Guidelines and levels of care for pediatric intensive care units

The practice of pediatric critical care medicine has matured dramatically during the past decade. These guidelines are presented to update the existing guidelines published in 1993. Pediatric critical care services are provided in level I and level II units. Within these guidelines, the scope of pediatric critical care services is discussed, including organizational and administrative structure, hospital facilities and services, personnel, drugs and equipment, quality monitoring, and training and continuing education.     

儿科重症监护病房临床标本中细菌的分布

重症感染性疾病伴全身炎症反应综合征(SIRS)是引起儿童多脏器功能衰竭及死亡的最主要因素。控制感染，合理应用抗菌药是治疗的关键，但对于危重患儿来讲，抗菌治疗常是在获得细菌培养结果之前的经验性治疗。因此，临床医生需了解当前当地有关细菌感染的流行病学和细菌药敏资料，才能合理应用抗菌药。我们对2000年5月至2003年2月从儿科重症监护病房(PICU)分离出的菌株进行分析。     

Continuous end-tidal carbon dioxide monitoring in pediatric intensive care units

Purpose

End-tidal carbon dioxide (ETCO₂) monitoring has a variety of clinical applications in critically ill pediatric patients. This study was designed to explore the current availability and utilization patterns for continuous ETCO₂ monitoring in pediatric intensive care units.

Methods

A Web-based survey was distributed to directors of all accredited pediatric critical care fellowship programs in the United States.

Results

Sixty-six percent of directors completed this survey. One hundred percent of directors had access to ETCO₂ monitoring for intubated patients and 57% for nonintubated patients. Eighty-three percent of respondents used ETCO₂ monitoring “always” or “often” for endotracheal tube confirmation. Fifty percent of respondents used ETCO₂ monitoring “always” or “often” for cardiopulmonary resuscitation, 38% for moderate sedation, and 5% for acid-base disturbances. All respondents who used ETCO₂ monitoring felt that it was easy to use. The most common reason for not using ETCO₂ monitoring was lack of availability (75%).

Conclusions

End-tidal carbon dioxide monitoring is widely available and used for intubated patients. However, it could be applied more frequently in other clinical situations in pediatric intensive care units.     

儿童重症监护室非计划性拔管现状调查及分析

目的描述非计划性拔管在儿童重症监护室的现状及原因。方法2008年1—12月上海某三级甲等儿科医院中3个重症监护室发生非计划性拔管的患儿共21例,根据意外事件报告单,对发生非计划性拔管的原因进行系统分析。结果患儿的年龄、患儿身体约束不当、镇静不足、胶布固定无效和护理人力不足是造成患儿非计划性拔管的高危因素。结论非计划性拔管率是重症监护质量的重要指标,建立一套有效的预防非计划性拔管标准包括有效约束、有效胶布固定、有效的镇静,合理护理人力配置以及提高护士的评估能力将有助于降低非计划性拔管发生率,提升重症监护室的护理品质。     

儿科气管插管非计划性拔管现况调查与分析

目的:描述气管插管非计划性拔管在某儿科医院发生现状,分析其原因并探讨对策。方法:前瞻性研究,采用方便抽样法,使用自行设计的非计划性拔管登记表对2010年10月至2011年6月上海市某三级甲等儿科医院三个重症监护室留置气管插管的患儿进行调查。结果:本次调查共收集247例有效记录,其中27例(10.9%)共发生33次非计划性拔管,按例次计算得出非计划性拔管率为11.2%,按置管日计算拔管率为1.77次/100个置管日,新生儿组的重新置管率为66.7%,普通患儿组的重新置管率为88.9%。当班护士年资、护理人力配置、患儿年龄、肢体约束情况、镇静剂的使用为非计划性拔管的影响因素。结论:加强对护士的培训、提高年轻护士的评估和预见能力、增加护理人力配置、合理使用镇静剂、有效的肢体约束均可以减少非计划性拔管的发生。     

镇静护理在儿科重症监护病房中的应用进展

作者从镇静的含义及分类、儿童使用镇静剂的影响因素、镇静的护理干预及护理人员在镇静中的角色等方面,对镇静在儿科重症监护病房中的应用及护理进展进行了综述.     

Medication errors in emergency rooms, intensive care units and pediatric wards

Medication safety is a major concern worldwide that directly relates to patient care quality and safety. Reducing medication error incidents is a critical medication safety issue. This literature review article summarizes medication error issues related specifically to three hospital units, namely emergency rooms (ERs), intensive care units (ICUs), and pediatric wards. Time constrains, lack of patient history details and the frequent need to use rapid response life-saving medications are key factors behind high ER medication error rates. Patient hypo-responsiveness, complex medication administration and frequent need to use high-alert medications are key factors behind high ICU medication error rates. Medication error in pediatric wards are often linked to errors made by nurses in calculating dosage based on patient body weight. This article summarizes the major types of medication errors reported by these three units in order to increase nurse awareness of medication errors and further encourage nurses to apply proper standard operational procedures to medication administration.     

Nutritional support in 111 pediatric intensive care units: a European survey

Objective To study current strategies in nutritional management of pediatric intensive care units (PICUs) in Europe, focusing on energy requirements.Design and setting Survey by a 35-item questionnaire sent to representatives of 242 PICUs in 28 countries. Addresses were obtained from national PICU associations and the members list of the European Society of Pediatric and Neonatal Intensive Care.Participants Staff members of 111 European PICUs (46%) from 24 countries.Measurements and results Predominantly physicians were reported to be responsible for nutritional support. In 73% of PICUs a multidisciplinary nutritional team was available. In most PICUs daily energy requirements were estimated using weight, age, predictive equations and correction factors. In 17% of PICUs energy expenditure was regularly measured by indirect calorimetry. Nutritional status was mostly assessed by weight, physical examination, and a wide range of biochemical blood parameters. Approximately 70% of PICUs used dedicated software for nutritional support. A similar percentage of PICUs regarded nutrition as a research topic and part of the residents training program.Conclusions Most European PICUs regard nutritional support as an important aspect of patient care, as shown by the presence of nutritional teams, software, research, and education. However, energy requirements of pediatric intensive care patient were based predominantly on estimations rather than on measurements.     

The impact of prematurity: a perspective of pediatric intensive care units

OBJECTIVE: To evaluate the relative resource use of pediatric intensive care unit (PICU) patients who had been born prematurely. DESIGN: Nonconcurrent cohort study. SETTING: Consecutive admissions to 16 voluntary PICUs. PATIENTS: A total of 431 formerly premature patients (FPP) and 5,319 nonpremature patients. INTERVENTIONS: None METHODS: Patients with a history of prematurity and a prematurity-related complication or an anatomical deformity were compared for demographic and resource requirements to a group of non-premature patients by a bivariable logistic regression analysis that controlled for age as a co-morbid factor. RESULTS: Compared with other patients, FPP were younger (34.9 +/- 2.2 months vs. 72.4 +/- 1.0 months; p < .001), readmitted to the PICU more often during the same hospitalization (11.1% vs. 5.5%; p < .001), used more chronic technologies (ventilators, gastrostomy tubes, tracheostomy tubes, and parenteral nutrition; 30.3% vs. 5.6%; p < .001), and had longer lengths of stay (5.98 +/-0.59 days vs. 3.56 +/- 0.12 days; p = .004). FPP had significantly higher use of ventilators (45.5% vs. 35.0%; p < .007) and lower use of arterial catheters (27.8% vs. 35.9%, p = .006) and central venous catheters (16.9% vs. 20.9%, p = .026) than nonprematures. The need for other PICU resources, including vasopressors, were similar. CONCLUSIONS: FPP used more chronic and acute care resources than patients who were not prematurely born. Continued improvements in neonatal care will influence change in many aspects of the health care system. This will also affect the delivery of care to the current patient base of the PICU.     

The epidemiology of acute respiratory distress syndrome in pediatric intensive care units in China

Objective  To assess the incidence of, predisposing factors for, and the rates and relative risks of mortality from acute respiratory distress syndrome (ARDS) in pediatric patients. Design  A prospective study in 12 consecutive months from 2004 to 2005 in 25 pediatric intensive care units (PICUs). Patients and setting  ARDS was diagnosed according to the 1994 American–European Consensus Conference definitions, applied to all severely ill admissions between 1 month and 14 years of age. The PICUs were in major municipalities and provincial cities, and half were university affiliated. Measurements and results  From a total of 12,018 admissions, 7,269 were severely ill. One hundred and five (1.44%) patients developed ARDS and 64 (61.0%) died, which accounts for 13.2%, of the total ICU death (n = 485, 6.7%) or a nine times relative risk of dying. The median age at onset of ARDS was 24 months and 40% were less than 12 month old. Median time from PICU admission to the onset of ARDS was 16 h, and in 63% <24 h. Pneumonia (55.2%) and sepsis (22.9%) were the major predisposing factors for ARDS. These were respectively 14 and 5 times as high a death rate as those of the severely ill patients without ARDS. Conclusions  ARDS has a high mortality in these Chinese PICUs, especially in those with pneumonia and sepsis, and adequate management including lung protective ventilation strategy is required. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Antifungal use in intensive care units

OBJECTIVES: To provide benchmarking data on antifungal use in intensive care units (ICUs), to analyse risk factors and to look for correlations with antibiotic use data and structure parameters. METHODS: Antimicrobial use data for 13 ICUs were obtained from computerized databases from January 2004 through June 2005. Antimicrobial usage density (AD) is expressed as daily defined doses/1000 patient-days. Correlations were calculated by the Spearman correlation or for binomic variables by the two-sided Wilcoxon test. A multivariate regression analysis was performed to identify independent risk factors for the outcome 'antifungal use'. RESULTS: Mean systemic antifungal drug use was 93.0, the range being between ADs of 18.9 and 232.2. ICUs treating transplant patients had a significantly higher mean antifungal usage at 152.9 compared with ICUs not treating transplant patients where the AD was 46.0. Fluconazole was the most frequently prescribed antifungal (mean AD 69.6) followed by amphotericin B (11.4) and voriconazole (6.2). Antifungal use correlated significantly with the consumption of quinolones, carbapenems and extended-spectrum penicillins, but not with total antibiotic use and not with the type of ICU or university status. In the multivariate linear regression analysis, two parameters, i.e. high quinolone use (P = 0.002) and ICUs which treat transplant patients (P = 0.027), were independent risk factors for a high level of antifungal use. CONCLUSIONS: Antifungal use was heterogeneous in German ICUs with the mean AD lying at 93. Benchmarking data might provide a useful method for assessing strategies that aim to reduce antifungal use in ICUs. However, data should be stratified for ICUs with and without transplant patients.