Diagnostic value of pleural ultrasound to refine endotracheal tube placement in pediatric intensive care unit

Aim: To assess the diagnostic performance of a simplified lung point-of-care ultrasound (POCUS) to confirm the correct positioning of an endotracheal tube (ETT) in a pediatric intensive care unit (PICU) used to chest radiography (CXR), and to compare the time to obtain the ETT position between POCUS and CXR.Methods: We conducted a single-center prospective study in critically ill children requiring urgent endotracheal intubation. Esophageal tube malposition was first avoided using auscultation and end-tidal CO2. The ETT position was assessed with CXR and lung POCUS using the lung sliding sign on a pleural window. All of the investigators had to read guidelines and received 1-h training on the technical aspects of lung sliding. The primary objective was the accuracy of POCUS in confirming correct nonselective endotracheal intubation as compared with CXR.Results: A total of 71 patients were included from December 2016 to November 2018. CXR identified proper nonselective ETT placement in 43 of 71 (61%) patients, while the rate for selective intubation was 39%. The sensitivity and specificity of POCUS as compared with CXR were 77% and 68%, respectively. Median time to POCUS was significantly shorter than CXR (2 min to perform POCUS, 10 min to obtain radiographs, p<10−4).Conclusion: Pleural ultrasound, although faster than CXR, appears to be inadequate for identifying selective ETT after urgent intubation in a PICU less accustomed to this kind of ultrasound. In this heterogeneous and fragile population, timely POCUS may remain useful at the bedside as compared with auscultation, aiming at guiding optimal ETT placement and reducing respiratory complications, provided by trained physicians.     

Candidemia in a pediatric intensive care unit.

OBJECTIVE: To examine the incidence, epidemiology, and clinical characteristics of candidemia in a pediatric intensive care unit. DESIGN: Retrospective cohort study. SETTING: Pediatric intensive care unit of a tertiary care teaching and referral hospital in north India. SUBJECTS: All patients with candidemia from March 1993 to December 1996. INTERVENTIONS: Patient-related data were analyzed to study candidemia in relation to reason for fungal culture, underlying medical conditions, predisposing factors, Candida isolates, antimicrobial and antifungal treatment, and deaths. MEASUREMENTS AND MAIN RESULTS: Sixty-four patients with candidemia were identified. The Candida species isolated were Candida tropicalis (48.4%), C. albicans (29.7%), C. guillermondii (14.1%), C. krusei (6.3%), and C. glabrata (1.6%). Thirty-three patients were detected by a high-risk surveillance blood culture, whereas 31 patients were detected while undergoing septic workup. Sixteen (25%) patients were asymptomatic; they recovered without any antifungal therapy and without any sequelae. Of 48 symptomatic patients, 11 died before institution of antifungal therapy; 37 received oral itraconazole (10 mg.kg(-1).day(-1)). Seven (19%) of these 37 patients died. Those who recovered had sterile culture on average by day 14 (range, 4-30) and received the antifungal therapy on average for 24 days (range, 9-42 days). Overall mortality rate was 28.1%, and bivariate analysis showed significant association with Pediatric Risk of Mortality score (p =.0001), presence of symptoms (p =.003), isolation of nonalbicans Candida in general (p =.04) and C. tropicalis specifically (p =.001), and failure to give presumptive antifungal therapy (p =.055). On multivariate analysis, Pediatric Risk of Mortality score and isolation of C. tropicalis were the only significant predictors of mortality. CONCLUSIONS: Nonalbicans Candida accounted for 70% of candidemia in a pediatric intensive care unit. High-risk surveillance blood cultures aided diagnosis in about half the patients. Severity of illness and isolation of C. tropicalis were significant predictors of mortality.     

Oral itraconazole in treatment of candidemia in a pediatric intensive care unit

Objective: To examine efficacy of itraconazole in the treatment of candidemia in critically ill children.Methods: We studied retrospectively cases of candidemia seen consecutively in our Pediatric Intensive Care Unit (PICU) over three and half year.Candida isolates from those patients included.Candida albicans- 19, C.tropicalis-31,C. guillermondii- 9,C.krusei- 4 andC. glabrata-1Results: Of the 64 patients, 48 (75%) had symptoms suggestive of septicemia and 16 had no symptoms suggestive of septicemia. No antifungal therapy was given to asymptomatic patients; they recovered from candidemia without development of any sequelae. Of the 48 symptomatic patients 11 died before results of fungal culture became available and antifungal therapy could be started. Thirty seven patients were treated with itraconazole (10 mg/kg/day orally or through gastric tube). Seven (18.9 %) of 37 patients died, 3 within first week of antifungal therapy. Thirty (81%) patients recovered; microbiological cure was noted on average by day 14 (range 4–30 days). The mean ±SD duration of therapy in patients who responded was 24 ±7 days (range 21–42 days). None had any major side effect.Conclusion: We conclude that oral itraconazole may be effective in treatment of candidemia in children in a PICU where non-C.albicans Candida species constituted majority (70%) of allCandida isolates.     

The use of enteral naloxone to treat opioid-induced constipation in a pediatric intensive care unit.

OBJECTIVE: To describe the effects of enteral naloxone used to treat opioid-induced constipation in pediatric intensive care patients. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit. PATIENTS: Twenty-three patients who received opioid therapy and enteral naloxone in our institution from January 2003 to February 2004 were compared with a randomly sampled control group matched for age, weight, sex, and length of stay who received opioids but had not received enteral naloxone. INTERVENTIONS: None. MEASUREMENTS: Daily stool output, daily opiate usage, nutrition, adjuvant laxative use, and side effects were assessed. RESULTS: Patients stayed an average of 5 days (range, 0-13 days) in the pediatric intensive care unit before enteral administration of naloxone was instituted and received it for an average of 9 consecutive days (range, 3-30 days). Mean stool output for study patients before administration of enteral naloxone was 0.14 +/- 0.38 stools per day, whereas after its initiation it was 1.60 +/- 1.14 stools per day (p < .001). However, two patients developed significant opiate withdrawal symptoms after receiving enteral naloxone. The average stool output for control patients was 0.53 +/- 1.21 stools per day. CONCLUSIONS: Enteral naloxone may be effective in increasing stool output in opioid-induced constipation but carries the risk of introducing withdrawal symptoms. Further studies are needed to evaluate this agent for opioid-induced constipation in the intensive care unit.     

Infections in a pediatric intensive care unit

All infections occurring in a busy pediatric intensive care unit (PICU) from 1982 to 1984 were characterized by site, bacteriology, acquisition status, and outcome. Standard Centers for Disease Control criteria were employed. Nine hundred sixty-five patients were admitted to the PICU. Mortality was 3.4%. Two hundred twenty-one infections occurred in 180 patients. Infection rates were 23% and 6% for total and PICU-acquired infections, respectively. Infections of the central nervous system (n = 56), lower respiratory tract (n = 53), and genitourinary tract (n = 46) made up 70% of all infections. Haemophilus influenzae (n = 39) was the most commonly isolated pathogen. Staphylococcus aureus (20%) and Klebsiella-Enterobacter-Serratia (18.3%) were most commonly noted in PICU-acquired infections. Twenty infected patients (11.1%) died in the PICU. Lower respiratory tract infections (20.5%) were associated with the highest mortality. Both PICU-acquired and community-acquired infections were associated with similar mortalities. Infected patients in a PICU have a mortality approximately 300% higher than that seen in the overall PICU population. The data presented document the importance of infection and provide information against which similar units can gauge their infection status for quality-assurance purposes.     

Candida colonization and candidemia in a pediatric intensive care unit.

OBJECTIVE: To evaluate role of Candida colonization in development of candidemia and to identify risk factors associated with Candida colonization and candidemia in children treated for severe sepsis or septic shock in a pediatric intensive care unit (PICU) for >5 days. DESIGN: Prospective observational. SETTING: PICU of a tertiary care teaching hospital. SUBJECTS: Of 186 children, aged 1 month to 14 yrs, consecutively admitted to PICU for severe sepsis or septic shock, 65 patients having a stay of >5 days. INTERVENTIONS: Clinical and demographic data at admission and variables likely to influence Candida colonization were recorded. Oropharyngeal, rectal, and skin (groin) swabs were taken on days 0, 2, 5, and 7 of admission. Blood for fungal culture (two samples 48 hrs apart) was obtained if a patient developed signs of sepsis. The yeast growth was identified by conventional methods. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and multivariate logistic regression analysis was conducted. MEASUREMENTS AND MAIN RESULTS: Colonization by Candida species occurred in 45 (69%) patients. Oropharyngeal (52%) and rectal (43%) colonization was more common than skin (34%) colonization. The colonizing species were C. tropicalis (34.2%), C. parapsilosis (28.8%), C. albicans (14.4%), and others. Use of central venous catheters was the only independent predictor of colonization on multivariate logistic regression (OR 4.1; 95% CI 1.01-17.1). Twenty (30.2%) patients developed candidemia; 18 (90%) of them were colonized, 15 (75%) with the same Candida species. Independent predictors of candidemia on multivariate stepwise logistic regression analysis were presence of colonization (OR 5.1; 95% CI 1.01-25.6, p = .048) and Pediatric Risk of Mortality score (OR 1.3; 95% CI 1.02-1.6, p = .034). CONCLUSIONS: Monitoring for colonization with Candida species in children undergoing treatment for severe sepsis or sepsis shock in PICU for >5 days may offer opportunity for early intervention for prevention of candidemia.     

Establishing a new pediatric intensive care unit

Summary Pediatric intensive care is a collaborative practice of dedicated personnel, advanced technology and a diverse group of support services. Unit design must focus on current patient needs while envisioning the technological and clinical needs of the future. With insight and a cooperative effort, your design team can effectively transform ideas into a unit committed to the care of critically ill children.     

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

OBJECTIVE: To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated. DESIGN: Prospective, direct observation study. SETTING: A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center. PATIENTS: One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively. CONCLUSIONS: Our medication error rate was similar to that of previous pediatric ICU studies that used the direct observation method for reporting but higher than the rates in previous studies using other detection techniques such as voluntary incident reporting. Periodic direct observation and other ongoing data collection methods such as voluntary incident reporting have the potential to be complementary approaches to medication error and ADE detection.     

Nosocomial pneumonia in a pediatric intensive care unit

BACKGROUND: Nosocomial pneumonia (NP) is the second most common hospital acquired infection. Understanding the pattern of occurrence, risk factors and etiological agents of NP in a PICU, is essential for developing effective infection control measures. This prospective observational study was conducted in a PICU of a tertiary care teaching hospital, to determine the incidence, etiology and risk factors for NP. MATERIALS AND METHODS: Patients admitted to the PICU, over a period of 1 year who had endotracheal (ET) intubation, were enrolled consecutively into the study. Demographic details were recorded at the time of inclusion. Diagnosis of NP was based on CDC criteria (1988).Semiquantiative assay of endotracheal aspirate (ETA) with a colony count of > 10(5) cfu/mL was taken as evidence of infection. Colonisation was defined as isolation of organism with <10(5) cfu/mL. Age, nutritional status, number and duration of intubations, duration of mechanical ventilation, sedation, nasogastric feeding were the risk factors studied for development of NP. Intubation attempts of more than one were defined as reintubation. Risk factors found significant on univariate analysis, were subjected to multiple regression analysis to determine the most important predictors of NP. RESULTS: The study group comprised of 72 children with a median age of 3.7 years and boys: girls ratio of 1.9:1.Twenty two of 72 (30.5%) developed NP; the predominant isolates from ETA were Acinetobacter anitratus(12), Pseudomonas aeruginosa (5), Klebsiella sp(3) and Staphylococcus aureus and E.coli(1) each. Additionally 18(39%) had evidence of ET colonization, with Acinetobacter sp being the commonest 9(50%). Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP.On multiple regression analysis, reintubation was the only independent risk factor for NP(OR 0.72, 95%CI 0.55-0.94).Overall mortality was 21%(15/72);7(47%)of these deaths were secondary to NP. CONCLUSIONS: NP developed in nearly one third of the intubated patients; Gram negative organisms were the predominant etiological agents and associated with high mortality. Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP. On multiple regression analysis, reintubation was the only independent risk factor for NP.     

Accidental extubation in a pediatric intensive care unit

It is an on-going practice in the pediatric ICUs to obtain and to maintain a working artificial airway. Nevertheless this procedure bears not infrequent risks of accidental extubation (AE) which ranges in several services from 0.9 to 3.3 for each 100 days of intubation. The risk factors that are involved in AE are related to: sedation level, age-group, intubation path, and others. The purpose of the authors in this article was to observe the incidence of AE in their service and to compare the relative risk in the rate of AE among orotracheal and nasotracheal intubation population. A prospective study was taken during six months, in which every patients with artificial airway admitted at the PICU of the Santo Antonio Hospital in Porto Alegre (Brazil) was included except those with tracheostomy. The total number of cases were 673 patients-day with artificial airway, with an average of 3.7 patients with tracheal tube per day. In the period there were 18 AE, with a rate of 2.7 AE/ 100 days. The incidence rate of AE in the orotracheal group was 3.1% and 1.6% in the nasotracheal group with no statistically significant difference (p=0.6). The authors concluded that the pathway of intubation in their study does not carry any additional risk in the incidence of accidental extubation.     

Handwashing technique in a pediatric intensive care unit

A one-year prospective study of 454 patients in a pediatric intensive care unit was performed to determine whether the rate of breaks in handwashing technique was different between medical professionals and to determine whether these rates were altered by the use of the overgown. A handwashing break in technique was defined as not washing your hands after direct contact with either patients or support equipment before contact with another patient or departure from the unit. Ninety-four two-hour sessions were monitored by a research nurse during four cross-over periods of gown and no-gown use. Physicians did not wash their hands in 834 (79%) of 1056 contacts, nurses in 1073 (63%) of 1714 cases, occupational therapists in 21 (62%) of 34 cases, respiratory therapists in 269 (78%) of 346 cases, and radiology technicians in 59 (78%) of 76 cases. Nurses used significantly better technique when compared with physicians, respiratory therapists, and radiology technicians. Gown usage overall did not affect these breaks in handwashing technique rates. Physicians did not wash their hands 75% of the time when gowns were not used and 82% of the time when gowns were used. Handwashing rates were unaffected by gown use in all other professionals. Handwashing remains an important but neglected method of interrupting the transmission of hospital pathogens.     

Impact of inborn errors of metabolism on admission and mortality in a pediatric intensive care unit

The authors conducted a retrospective analysis of the patients admitted to a pediatric intensive care unit (PICU) during a five-year period, with specific focus on those with a suspected or confirmed diagnosis of inborn errors of metabolism (IEM), in order to ascertain the resources required to care for these patients. Medical records were reviewed for all admissions between January 1998 and December 2002 in a single metabolic referral center, and a subset of patients were identified with suspected IEM at admission or diagnosed IEM at hospital discharge. These patient charts were then further reviewed and the following information was extracted: IEM diagnosis, demographic data, biochemical characteristics at admission, need for mechanical ventilation, use of extracorporeal removal therapy, and outcome at PICU discharge. The study population comprised 70 patients (2.2% of all admissions during the study period) and included 33 neonates and 37 children aged >28 days. IEM diagnosis was known at the time of admission to the PICU in 9/33 of the neonates and 23/37 of the older children. Forty-three of the patients required invasive mechanical ventilation, while continuous extracorporeal removal therapy was used in 27 children. The median length of PICU stay was 3 days (range, 1 to 13 days) and 20 patients (28.6%) died. In conclusion, these observations show that inherited metabolic disease may be as frequent a primary diagnosis as septic shock in some PICUs. In neonates, these diseases are not usually diagnosed prior to PICU admission. Patients with IEM admitted to a PICU require aggressive support (including mechanical ventilation and extracorporeal removal therapies), and consume significant resources for relatively short PICU stays. These patients constitute a significant diagnostic and therapeutic challenge for pediatric intensivists.     

Noninvasive monitoring in the pediatric intensive care unit.

The best ICU monitors are physicians and nurses, who integrate all of the physiologic parameters of patients with the known pathophysiology of the disease process. Over-reliance on raw electronic data, with their inherent errors, jeopardizes the safe and efficient care of patients. Data must be interpreted in the context of the history, repetitive physical examinations, response to therapy, and a background of experience. New modalities and the application of artificial intelligence may facilitate the interpretation of data, but the role of the bedside medical practitioner remains as the heart of pediatric critical care.     

Coding and billing in the pediatric intensive care unit.

Physicians need to be proficient in their use of CPT codes and ICD-9 codes. They must participate actively and be knowledgeable of their billing process. An organized approach to coding and billing has been suggested by the American Academy of Pediatrics, as outlined in the following box. Physicians are ultimately responsible for any bill submitted in their name. Therefore, close scrutiny of the coding and billing procedures is paramount. Even if mistakes are made in the billing process beyond physicians' input, physicians still may be held responsible. If physicians do their own coding, the bills become more accurate, which can result in higher reimbursement. Physicians also should have a functional compliance plan in place, whether practicing in a large faculty group practice or practicing solo, with the ability to audit the coding and billing process and respond to variances if they are found. By being more involved in the process, physicians can have a more efficient billing system that avoids the potential for fraud and abuse and improves collections.