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1.
L. Vogiatzi S. Ilia G. Sideri E. Vagelakoudi M. Vassilopoulou M. Sdougka G. Briassoulis I. Papadatos P. Kalabalikis L. Sianidou E. Roilides 《Intensive care medicine》2013,39(12):2188-2195
Purpose
To record the practices for prevention and management of invasive candidiasis in the PICU and investigate the epidemiology of candidiasis and its outcome nationwide.Methods
A multicenter national study among PICUs throughout Greece. A questionnaire referring to local practices of prevention and management of candidemia was filled in, and a retrospective study of episodes that occurred during 5 years was conducted in all seven Greek PICUs.Results
Clinical practices regarding surveillance cultures, catheter replacement protocols and antibiotic use were similar, although the case mix differed. In all PICUs prophylactic antifungal treatment was administered in transplant and neutropenic oncology patients. Discrepancy existed between PICUs concerning the first-line antifungal agents and treatment duration of candidemia. Twenty-two candidemias were nationally recorded between 2005 and 2009 with a median incidence of 6.4 cases/1,000 admissions. Median age was 8.2 (0.3–16.6) years. Candida albicans was isolated in 45.4 % of episodes followed by Candida parapsilosis (22.7 %). Common findings were presence of central venous and urinary catheters as well as mechanical ventilation and administration of antibiotics with anti-anaerobic activity in almost all patients with candidemia. Total parenteral nutrition was administered to five (22.7 %) patients. Most of the patients had a chronic underlying disease; five were oncology patients, and two-thirds of those with candidemia were colonized with Candida spp. Lipid amphotericin B formulations were the predominant therapeutic choice (54.5 %). Thirty-day mortality was 18.2 %.Conclusion
This first national study adds information to the epidemiology of candidemia in critically ill children. In these special patients, candidemia has a relatively low incidence and tends toward non-albicans Candida preponderance. 相似文献2.
Katie Harron Angie Wade Berit Muller-Pebody Harvey Goldstein Roger Parslow Jim Gray John C. Hartley Quen Mok Ruth Gilbert 《Intensive care medicine》2013,39(6):1080-1087
Purpose
National monitoring of variation in the quality of infection control in paediatric intensive care units (PICUs) requires comparisons of risk-adjusted rates. To inform the development of a national monitoring system, we evaluated the effects of risk-adjustment and outcome definition on comparisons of blood-stream infection (BSI) rates in PICU, using linkage of risk-factor data captured by national audit (PICANet) with laboratory records of BSI.Methods
Admission data for two children’s hospitals 2003–2010 were extracted from PICANet and linked using multiple identifiers with laboratory BSI records. We calculated trends of PICU-acquired BSI, defined as BSI occurring between at least 2 days after admission until up to 2 days following discharge. In one PICU, we compared rates of all PICU-acquired BSI with clinically significant PICU-acquired BSI submitted to the national surveillance system.Results
Of 20,924 admissions, 1,428 (6.8 %) were linked to 1,761 PICU-acquired BSI episodes. The crude incidence rate-ratio for PICU-acquired BSI between PICUs was 1.15 [95 % confidence interval (CI) 1.05–1.26] but increased to 1.26 (1.14–1.39) after risk-adjustment. Rates of PICU-acquired BSI were 13.44 (95 % CI 12.60–14.28) per 1,000 bed-days at PICU 1 and 18.05 (95 % CI 16.80–19.32) at PICU 2. Of PICU-acquired BSI at PICU 2, 41 % was classified as clinically significant. Rates of PICU-acquired BSI decreased by 10 % per year between 2003 and 2010 for skin organisms and 8 % for non-skin organisms.Conclusions
Risk-adjustment and standardisation of outcome measures are essential for fair comparisons of BSI rates between PICUs. Linkage of risk-factor data and BSI surveillance is feasible and could allow national risk-adjusted monitoring. 相似文献3.
Matt S. Zinter Steven G. DuBois Aaron Spicer Katherine Matthay Anil Sapru 《Intensive care medicine》2014,40(10):1536-1544
Purpose
Up to 38 % of children with cancer require pediatric intensive care unit (PICU) admission within 3 years of diagnosis, with reported PICU mortality of 13–27 % far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes.Methods
We performed a retrospective multicenter analysis of 10,365 PICU admissions of cancer patients no greater than 21 years old among 112 PICUs between 1 January 2009 and 30 June 2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality.Results
After excluding scheduled perioperative admissions, cancer patients represented 4.2 % of all PICU admissions (10,365/246,346), had overall mortality of 6.8 % (708/10,365) vs. 2.4 % (5,485/230,548) in the general PICU population (RR = 2.9, 95 % CI 2.7–3.1, p < 0.001), and accounted for 11.4 % of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p < 0.001), rates of sepsis (27 vs 9 %, RR = 2.9, 95 % CI 2.6–3.1, p < 0.001), and mortality (9.6 vs 4.5 %, RR = 2.1, 95 % CI 1.8–2.5, p < 0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality.Conclusions
Children with cancer account for 4.2 % of PICU admissions and 11.4 % of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk stratification for closer monitoring and patient counseling. 相似文献4.
Julio A. Farias Analía Fernández Ezequiel Monteverde Nilda Vidal Pilar Arias María J. Montes Gabriela Rodríguez Mariela Allasia Maria E. Ratto Roxana Jaén Claudia Meregalli Karina Fiquepron Ana R. Calvo Alejandro Siaba Lidia Albano Rossana Poterala Pablo Neira Andrés Esteban 《Intensive care medicine》2010,36(6):1015-1022
Objective
To determine the epidemiological features, course, and outcomes of critically ill pediatric patients with Influenza A (H1N1) virus.Design
Prospective cohort of children in pediatric intensive care units (PICUs) due to Influenza A (H1N1) virus infection.Setting
Seventeen medical-surgical PICUs in tertiary care hospital in Argentina.Patients
All consecutive patients admitted to the PICUs with influenza A (H1N1) viral infection from 15 June to 31 July 2009.Measurements and main results
Of 437 patients with acute lower respiratory infection in PICUs, 147 (34%) were diagnosed with influenza A (H1N1) related to critical illness. The median age of these patients was 10 months (IQR 3–59). Invasive mechanical ventilation was used in 117 (84%) on admission. The rate of acute respiratory distress syndrome (ARDS) was 80% (118 of 147 patients). Initial non-invasive ventilation failed in 19 of 22 attempts (86%). Mortality at 28 days was 39% (n = 57). Chronic complex conditions (CCCs), acute renal dysfunction (ARD) and ratio PaO2/FiO2 at day 3 on MV were independently associated with a higher risk of mortality. The odds ratio (OR) for CCCs was 3.06, (CI 95% 1.36–6.84); OR for ARD, 3.38, (CI 95% 1.45–10.33); OR for PaO2/FiO2, 4 (CI 95% 1.57–9.59). The administration of oseltamivir within 24 h after admission had a protective effect: OR 0.2 (CI 95% 0.07–0.54).Conclusions
In children with ARDS, H1N1 as an etiologic agent confers high mortality, and the presence of CCCs in such patients increases the risk of death. 相似文献5.
Sandrine Essouri Marie Laurent Laurent Chevret Philippe Durand Emmanuelle Ecochard Vincent Gajdos Denis Devictor Pierre Tissières 《Intensive care medicine》2014,40(1):84-91
Purpose
Severe bronchiolitis is the leading cause of admission to the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (nCPAP) has become the primary respiratory support, replacing invasive mechanical ventilation (MV). Our objective was to evaluate the economic and clinical consequences following implementation of this respiratory strategy in our unit.Methods
This was a retrospective cohort analysis of 525 infants with bronchiolitis requiring respiratory support and successively treated during two distinct periods with invasive MV between 1996 and 2000, P1 (n = 193) and nCPAP between 2006 and 2010, P2 (n = 332). Costs were estimated using the hospital cost billing reports.Results
Patients’ baseline characteristics were similar between the two periods. P2 is associated with a significant decrease in the length of ventilation (LOV) (4.1 ± 3.5 versus 6.9 ± 4.6 days, p < 0.001), PICU length of stay (LOS) (6.2 ± 4.6 versus 9.7 ± 5.5 days, p < 0.001) and hospital LOS. nCPAP was independently associated with a shorter duration of ventilatory support than MV (hazard ratio 1.8, 95 % CI 1.5–2.2, p < 0.001). nCPAP was also associated with a significant decrease in ventilation-associated complications, and less invasive management. The mean cost of acute viral bronchiolitis-related PICU hospitalizations was significantly decreased, from 17,451 to 11,205 € (p < 0.001). Implementation of nCPAP led to a reduction of the total annual cost of acute viral bronchiolitis hospitalizations of 715,000 €.Conclusion
nCPAP in severe bronchiolitis is associated with a significant improvement in patient management as shown by the reduction in invasive care, LOV, PICU LOS, hospital LOS, and economic burden. 相似文献6.
Philippe A. Jouvet Valérie Payen France Gauvin Guillaume Emeriaud Jacques Lacroix 《Intensive care medicine》2013,39(5):919-925
Purpose
Duration of weaning from mechanical ventilation is decreased with the use of written protocols in adults. In children, the use of written protocols has not had such an impact.Methods and measurements
We conducted a single-center trial to assess the feasibility of conducting a multicenter randomized clinical trial comparing the duration of weaning from mechanical ventilation in those managed by a computer-driven explicit protocol versus usual care. Mechanically ventilated children aged between 2 and 17 years on pressure support and not receiving inotropes were included. After randomization, children were weaned either by usual care (n = 15) that was characterized by no protocolized decisions by attending physicians, or by a computer-driven protocol (Smartcare/PS?, Drager Medical) (n = 15). Weaning duration until first extubation was the primary outcome. For comparison, a Mann–Whitney U test was employed (p < 0.05).Results
Patients characteristics at inclusion were similar. The median duration of weaning was 21 h (range 3–142 h) in the SmartCare/PS? group and 90 h (range 4–552 h) in the usual care group, p = 0.007. The rate of reintubation within 48 h after extubation and the rate of noninvasive ventilation after extubation in the SmartCare/PS? and usual care groups were 2/15 versus 1/15 and 2/15 versus 2/15, respectively.Conclusions
A pediatric randomized trial on mechanical ventilation with a computerized protocol in North America is feasible. A computer-driven protocol that also manages children younger than 2 years old would help to decrease the number of PICU admissions screened in a multicentre trial on this topic. 相似文献7.
J. C. Montejo E. Miñambres L. Bordejé A. Mesejo J. Acosta A. Heras M. Ferré F. Fernandez-Ortega C. I. Vaquerizo R. Manzanedo 《Intensive care medicine》2010,36(8):1386-1393
Objective
To compare the effects of increasing the limit for gastric residual volume (GRV) in the adequacy of enteral nutrition. Frequency of gastrointestinal complications and outcome variables were secondary goals.Design
An open, prospective, randomized study.Setting
Twenty-eight intensive care units in Spain.Patients
Three hundred twenty-nine intubated and mechanically ventilated adult patients with enteral nutrition (EN).Interventions
EN was administered by nasogastric tube. A protocol for management of EN-related gastrointestinal complications was used. Patients were randomized to be included in a control (GRV = 200 ml) or in study group (GRV = 500 ml).Measurements and results
Diet volume ratio (diet received/diet prescribed), incidence of gastrointestinal complications, ICU-acquired pneumonia, days on mechanical ventilation and ICU length of stay were the study variables. Gastrointestinal complications were higher in the control group (63.6 vs. 47.8%, P = 0.004), but the only difference was in the frequency of high GRV (42.4 vs. 26.8%, P = 0.003). The diet volume ratio was higher for the study group only during the 1st week (84.48 vs. 88.20%) (P = 0.0002). Volume ratio was similar for both groups in weeks 3 and 4. Duration of mechanical ventilation, ICU length of stay or frequency of pneumonia were similar.Conclusions
Diet volume ratio of mechanically ventilated patients treated with enteral nutrition is not affected by increasing the limit in GRV. A limit of 500 ml is not associated with adverse effects in gastrointestinal complications or in outcome variables. A value of 500 ml can be equally recommended as a normal limit for GRV. 相似文献8.
Leteurtre S Grandbastien B Leclerc F Parslow R;Groupe Francophone de Réanimation et Urgences Pédiatriques;Paediatric Intensive Care Audit Network 《Intensive care medicine》2012,38(8):1372-1380
Objectives
To test the performance of PIM2 in French-speaking (FS) paediatric intensive care units (PICUs) and its relative performance when recalibrated using data from FS and Great Britain (GB) PICUs of different size.Methods
Consecutive admissions to 15 FS (n?=?5,602) and 31 GB PICUs (n?=?20,693) from June 2006 to October 2007 were included. The recalibrated PIM2 were applied to PICUs of different size within the FS and GB PICUs and between the two groups. PICU size was defined using number of admissions/month. Discrimination and calibration were evaluated using the area under the ROC curve (AUC) and the goodness-of-fit test, respectively. Logistic regression, funnel plots and standardized W scores were performed in the two groups and between different PICU sizes.Results
In FS PICUs, the original PIM2 had good discrimination (AUC?=?0.85) and moderate calibration (p?=?0.07). The recalibrated PIM2 scores had good calibration in FS (p?=?0.33) and moderate calibration in GB (p?=?0.06). Calibration was poor when the recalibrated FS PIM2 was applied to GB (p?=?0.02) but good when the GB recalibration was applied to the FS (p?=?0.36). Using the original PIM2 coefficients, calibration was poor in large units in both groups but improved following recalibration. There were no effects of PICU size on risk-adjusted mortality in GB and a significant effect in the FS PICUs with a minimum risk-adjusted mortality at about 35?admissions/month.Conclusion
The PIM2 score was valid in the FS population. The recalibration based on GB data could be applied to FS PICUs. Such recalibration may facilitate comparisons between countries. 相似文献9.
Idse H. E. Visser Jan A. Hazelzet Marcel J. I. J. Albers Carin W. M. Verlaat Karin Hogenbirk Job B. van Woensel Marc van Heerde Dick A. van Waardenburg Nicolaas J. G. Jansen Ewout W. Steyerberg 《Intensive care medicine》2013,39(5):942-950
Aim
To validate paediatric index of mortality (PIM) and pediatric risk of mortality (PRISM) models within the overall population as well as in specific subgroups in pediatric intensive care units (PICUs).Methods
Variants of PIM and PRISM prediction models were compared with respect to calibration (agreement between predicted risks and observed mortality) and discrimination (area under the receiver operating characteristic curve, AUC). We considered performance in the overall study population and in subgroups, defined by diagnoses, age and urgency at admission, and length of stay (LoS) at the PICU. We analyzed data from consecutive patients younger than 16 years admitted to the eight PICUs in the Netherlands between February 2006 and October 2009. Patients referred to another ICU or deceased within 2 h after admission were excluded.Results
A total of 12,040 admissions were included, with 412 deaths. Variants of PIM2 were best calibrated. All models discriminated well, also in patients <28 days of age (neonates), with overall higher AUC for PRISM variants (PIM = 0.83, PIM2 = 0.85, PIM2-ANZ06 = 0.86, PIM2-ANZ08 = 0.85, PRISM = 0.88, PRISM3-24 = 0.90). Best discrimination for PRISM3-24 was confirmed in 13 out of 14 subgroup categories. After recalibration PRISM3-24 predicted accurately in most (12 out of 14) categories. Discrimination was poorer for all models (AUC < 0.73) after LoS of >6 days at the PICU.Conclusion
All models discriminated well, also in most subgroups including neonates, but had difficulties predicting mortality for patients >6 days at the PICU. In a western European setting both the PIM2(-ANZ06) or a recalibrated version of PRISM3-24 are suited for overall individualized risk prediction. 相似文献10.
David T. Selewski Timothy T. Cornell Michael Heung Jonathan P. Troost Brett J. Ehrmann Rebecca M. Lombel Neal B. Blatt Kera Luckritz Sue Hieber Robert Gajarski David B. Kershaw Thomas P. Shanley Debbie S. Gipson 《Intensive care medicine》2014,40(10):1481-1488
Purpose
Acute kidney injury (AKI) occurs commonly in critically ill children and has been associated with increased mortality of up to 50 %. The Kidney Disease: Improving Global Outcomes (KDIGO) AKI working group has proposed a standardized definition of AKI. Utilizing routinely available clinical data, we evaluated the KDIGO AKI criteria and the relationship of AKI with relevant outcomes in a single center tertiary pediatric intensive care (PICU) and cardiac intensive care unit (CICU) population.Methods
The University of Michigan Pediatric Critical Care Database was probed for all discharges from the pediatric intensive care and cardiac intensive care units between July 2011 and October 2013 (N = 4,645). The KDIGO serum creatinine (SCr)-based criteria staged AKI with the modification that a minimum SCr of greater than 0.5 mg/dL was required to be classified as AKI. Exclusion: end-stage renal disease, new renal transplant, missing PRISM III data, or no measured Cr during intensive care unit (ICU) admission (N = 1,636).Results
AKI occurred in 737 (24.5 %, stage 1 = 193, stage 2 = 189, and stage 3 = 355) of 3,009 discharges (PICU N = 1,870, CICU N = 1,139) that included 2,415 patients. In multivariate analysis AKI was associated with increased ICU length of stay (LOS) in hours (stage I β = 42.2, p = 0.024, II β = 74.1, p = 0.003, III β = 215.8, p < 0.001). Multivariate analysis showed that AKI was associated with increased odds of ICU mortality (OR 3.4, 95 % CI 2.0–6.0) and increased length of mechanical ventilation among those requiring mechanical ventilation (β = 2.3 days, p < 0.001).Conclusions
Using the KDIGO criteria to define AKI, we observed a high prevalence of AKI among critically ill children. Worsening stages of AKI were associated with increased ICU LOS, and AKI was independently associated with prolonged mechanical ventilation and increased mortality. The KDIGO criteria describe clinically relevant AKI in a broad pediatric critical care population. 相似文献11.
Padmanabhan Ramnarayan Krishna Patel John Pappachan Jonathan Purday Peter Davis David Harrison Kathy Rowan 《Intensive care medicine》2013,39(11):2020-2027
Purpose
Despite centralisation of paediatric intensive care units (PICU) in the UK, children continue to be admitted to adult intensive care units (AICU). We aimed to analyse trends in the admission of children to AICUs over a 16-year period from 1996, and describe their case mix, outcome and resource use in a recent cohort (2009–2011).Methods
We extracted data from consecutive admissions of children (1996–2011) to AICUs from the Intensive Care National Audit and Research Centre Case Mix Programme Database. We studied case mix, outcome and resource use as well as regional, seasonal and temporal variations in admissions of children to AICU.Results
A total of 13,430 children were admitted to AICUs between 1996 and 2011 (representing 1.3 % of all admissions). This proportion decreased from 2.8 % in 1996 to 0.6 % in 2011. Crude mortality fell from 6.7 to 2.8 %, and the proportion transferred out to a PICU rose from 18.9 to 51.4 %. In recent years (2009–2011), half of the 2,320 admissions of children occurred in just three English Strategic Health Authorities. The median length of unit stay was 7.7 h (IQR 3.8–19.7) for survivors and 11.5 h (IQR 5.0–36.2) for non-survivors.Conclusions
The number of children admitted to AICUs in England, Wales and Northern Ireland has been steadily declining since 1996. In recent years, half of all children admitted to AICUs are transferred to PICU, usually following a short stay. The reasons for regional variation in paediatric admissions to AICUs, and the cause of death in the small number of children who die in AICUs, are unclear. 相似文献12.
13.
Introduction
Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial.Methods
The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed.Results
A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure.Conclusion
The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality. 相似文献14.
Luregn J. Schlapbach Jonas Schaefer Ann-Maree Brady Sara Mayfield Andreas Schibler 《Intensive care medicine》2014,40(4):592-599
Purpose
Optimal respiratory support for interhospital transport of critically ill children is challenging and has been scarcely investigated. High-flow nasal cannula (HFNC) therapy has emerged as a promising support mode in the paediatric intensive care unit (PICU), but no data are available on HFNC used during interhospital transport. We aimed to assess the safety of HFNC during retrievals of critically ill children and its impact on the need for invasive ventilation (IV).Methods
This was a retrospective, single-centre study of children under 2 years old transported by a specialized paediatric retrieval team to PICU. We compared IV rates before (2005–2008) and after introduction of HFNC therapy (2009–2012).Results
A total of 793 infants were transported. The mean transport duration was 1.4 h (range 0.25–8), with a mean distance of 205 km (2–2,856). Before introduction of HFNC, 7 % (n = 23) were retrieved on non-invasive ventilation (NIV) and 49 % (n = 163) on IV. After introduction of HFNC, 33 % (n = 150) were retrieved on HFNC, 2 % (n = 10) on NIV, whereas IV decreased to 35 % (n = 162, p < 0.001). No patients retrieved on HFNC required intubation during retrieval, or developed pneumothorax or cardiac arrest. Using HFNC was associated with a significant reduction in IV initiated by the retrieval team (multivariate OR 0.51; 95 % CI 0.27–0.95; p = 0.032).Conclusions
We report on a major change of practice in transport of critically ill children in our retrieval system. HFNC therapy was increasingly used and was not inferior to low-flow oxygen or NIV. Randomized trials are needed to assess whether HFNC can reduce the need for IV in interhospital transport of critically ill children. 相似文献15.
Vincenzo Squadrone Massimo Massaia Benedetto Bruno Filippo Marmont Michele Falda Carlotta Bagna Stefania Bertone Claudia Filippini Arthur S. Slutsky Umberto Vitolo Mario Boccadoro V. Marco Ranieri 《Intensive care medicine》2010,36(10):1666-1674
Purpose
Although chemotherapy and transplantation improve outcome of patients with hematological malignancy, complications of these therapies are responsible for a 20–50% mortality rate that increases when respiratory symptoms evolve into acute lung injury (ALI). The aim of this study is to determine the effectiveness of early continuous positive airway pressure (CPAP) delivered in the ward to prevent occurrence of ALI requiring intensive care unit (ICU) admission for mechanical ventilation.Methods
Patients with hematological malignancy presenting in the hematological ward with early changes in respiratory variables were randomized to receive oxygen (N = 20) or oxygen plus CPAP (N = 20). Primary outcome variables were need of mechanical ventilation requiring ICU admission, and intubation rate among those patients who required ICU admission.Results
At randomization, arterial-to-inspiratory O2 ratio in control and CPAP group was 282 ± 41 and 256 ± 52, respectively. Patients who received CPAP had less need of ICU admission for mechanical ventilation (4 versus 16 patients; P = 0.0002). CPAP reduced the relative risk for developing need of ventilatory support to 0.25 (95% confidence interval: 0.10–0.62). Among patients admitted to ICU, intubation rate was lower in the CPAP than in the control group (2 versus 14 patients; P = 0.0001). CPAP reduced the relative risk for intubation to 0.46 (95% confidence interval: 0.27–0.78).Conclusions
This study suggests that early use of CPAP on the hematological ward in patients with early changes in respiratory variables prevents evolution to acute lung injury requiring mechanical ventilation and ICU admission. 相似文献16.
Lahn D. Straney Archie Clements Jan Alexander Anthony Slater 《Intensive care medicine》2010,36(8):1410-1416
Purpose
To develop a measure of paediatric intensive care unit (PICU) efficiency and compare the efficiency of PICUs in Australia and New Zealand.Methods
Separate outcome prediction models for estimating clinical performance and resource usage were constructed using patient data from 20,742 admissions between 2005 and 2007. A standardised mortality ratio was calculated using a recalibrated Paediatric Index of Mortality 2 model. A random effects length of stay (LoS) prediction model was used to provide an indicator of unit-level variation in resource use. A modified Rapoport-Teres plot of risk-adjusted mortality versus unit mean LoS provided a visual representation of efficiency. To account for potential differences in admission threshold, the calculation of performance measures was repeated on patients receiving mechanical respiratory support and compared to those estimated for all patients.Results
The modified plot provides a useful tool for visualising ICU efficiency. Two units were identified as potentially inefficient with higher SMR and risk-adjusted mean LoS at the 95% level. One unit had a significantly lower SMR and significantly higher risk-adjusted mean LoS. The measures for both SMR and risk-adjusted mean LoS showed good agreement between all patients and those who received mechanical respiratory support.Conclusion
There is significant variation in efficiency among PICUs in Australia and New Zealand. Two units were designated as inefficient and one unit was considered to be effective at the expense of high resource use. Application of these methods may help to identify inefficiencies in units located in other countries or regions. 相似文献17.
Pedro Celiny R. Garcia Pablo Eulmesekian Ricardo G. Branco Augusto Perez Ana Sffogia Lorenzo Olivero Jefferson P. Piva Robert C. Tasker 《Intensive care medicine》2010,36(1):116-122
Objective
External validation of the paediatric logistic organ dysfunction (PELOD) score in two paediatric intensive care units (PICU) in South America.Methods
Prospective observational cohort study including all PICU admissions from July 2003 to December 2004 in Porto Alegre, Brazil, and from January 2004 to December 2004 in Buenos Aires, Argentina. The data collected included demographic variables, diagnosis, need for mechanical ventilation, length of PICU stay and mortality, and the 12 variables in the PELOD score. For each PELOD score variable, the worst daily value and the worst value of the whole PICU stay were used for the daily PELOD (dPELOD) and PELOD scores, respectively.Results
A total of 1,476 admissions (51.3% from Argentina and 48.7% from Brazil) were analysed. Observed and predicted mortality were, respectively, 4.7% and 6.6%, with a standardized mortality ratio of 0.72. The score showed excellent discrimination capacity, with an area under the receiver operator characteristic (ROC) curve of 0.93 (0.88–0.98). The dPELOD score on days 1–5 also showed good discrimination capacities, with areas under the ROC curve >0.85. However, PELOD and dPELOD scores showed poor calibration with the Hosmer–Lemeshow test (chi-square 72.3, p < 0.001). This poor calibration was explained by a deficiency in the PELOD score where it fails to identify two risk intervals; 3.1–16.2% and 40–80%.Conclusions
The PELOD score is reproducible, has excellent discrimination, but over-predicts mortality and has poor calibration. Although the lack of calibration may not invalidate the score, the PELOD score is a discontinuous variable and we advise careful consideration when using it as a surrogate endpoint in clinical trials. 相似文献18.
Sachin Sud Jan O. Friedrich Paolo Taccone Federico Polli Neill K. J. Adhikari Roberto Latini Antonio Pesenti Claude Guérin Jordi Mancebo Martha A. Q. Curley Rafael Fernandez Ming-Cheng Chan Pascal Beuret Gregor Voggenreiter Maneesh Sud Gianni Tognoni Luciano Gattinoni 《Intensive care medicine》2010,36(4):585-599
Background
Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.Objective
To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO2)/inspired fraction of oxygen (FiO2) <100 mmHg] compared with moderate hypoxemia (100 mmHg ≤ PaO2/FiO2 ≤ 300 mmHg).Design
Systematic review and meta-analysis.Data Sources
Electronic databases (to November 2009) and conference proceedings.Methods
Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO2/FiO2 <100 mmHg. Meta-analyses used study-level random-effects models.Results
Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO2/FiO2 <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74–0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO2/FiO2 ≥100 mmHg (RR 1.07, 95% CI 0.93–1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO2/FiO2 thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27–39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16–1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24–2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02–9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.Conclusions
Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients. 相似文献19.
Shime N Kawasaki T Saito O Akamine Y Toda Y Takeuchi M Sugimura H Sakurai Y Iijima M Ueta I Shimizu N Nakagawa S 《Intensive care medicine》2012,38(7):1191-1197
Purpose
To assess the incidence, background, outcome and risk factors for death of severe sepsis in Japanese paediatric intensive care units (PICUs).Methods
A data analysis of a prospective, multicentre, 3-year case registry from nine medical-surgical Japanese PICUs. Children with severe sepsis, aged 0–15?years, who were consecutively admitted to the participating PICUs from 1 January 2007 to 31 December 2009 were enrolled. The incidence, background, causative pathogens or infective foci, outcome and risk factors for death caused by severe sepsis were analysed.Results
One hundred forty-one cases were registered. After the exclusion of 14 patients because of incomplete data or inappropriate entry, 127 patients were eligible for the analysis. There were 60 boys and 67 girls, aged 23 [5–68] (median [IQR]) months and weighed 10 [5.5–16.5]?kg. The incidence was 1.4?% of total PICU admissions. Sepsis was community-acquired in 35?%, PICU-acquired in 37?% and acquired in hospital general wards in 28?%. Methicillin-resistant Staphylococcus aureus was the most frequent pathogen. The crude 28-day mortality was 18.9?%, comparable to the mean PIM-2 predicted mortality (17.7?%). The mortality rate in patients with shock was significantly increased to 28?% compared to those without shock (5?%). The presences of existing haematological disorders (OR 8.97, 95?% CI, 1.56–51.60) and shock (OR 5.35, 1.04–27.44) were significant factors associated with mortality by multivariate analysis.Conclusions
The mortality from severe sepsis/septic shock in Japanese PICUs was?~19?%. Haematological disorders and presence of shock were associated with death. 相似文献20.
Lylia Touat Clément Fournier Philippe Ramon Julia Salleron Alain Durocher Saad Nseir 《Intensive care medicine》2013,39(4):575-582