Influence of a dedicated paediatric cardiac intensive care unit on patient outcomes

Background: The impact of a designated intensive care unit (ICU) for postoperative cardiac care in children is not clear. In our hospital (in the USA), we started a new Paediatric Cardiac Surgery programme 5 years ago, in September 2004. During the first 2 years of the programme, postoperative care was accomplished within the general paediatric ICU (PICU or c‐ICU). Subsequently, in September 2006, a dedicated cardiac ICU (d‐ICU) was established. We looked at our experience during these two periods to determine whether the designation of a separate ICU affected outcomes for these children. Design and Methods: We obtained Institutional Review Board (IRB) approval to review the medical records for all postoperative cardiac admissions to the ICU during the first 4 years of the programme (September 2004–September 2008). Variables collected included age, gender, diagnosis, type of cardiac surgery, Risk Adjustment for Congenital Cardiac Surgery, version 1 (RACHS‐1) classification, ventilator use, hospital stay, invasive line infections, ventilator‐related infections, wound infections, need for cardiopulmonary support, return to the operating room, re‐exploration of the chest, delayed sternal closure, accidental extubations, re‐intubation and mortality rates. These variables were summed and compared for the combined PICU and the dedicated paediatric cardiac ICU. Results: There were 199 cases performed in the first 2 years compared with 244 in the following 2 years. We saw a statistically insignificant increase in the number and complexity of cases during the second period (p = 0·08). However, morbidity declined as evidenced by the decrease in wound infection (p < 0·001) and need for chest re‐exploration (p < 0·001). In addition, mortality declined from 7 of 199 (3·5%) to 2 of 244 (0·8%). p < 0·04 and less children required resuscitation (p < 0·01). Conclusions: We believe the designation of a specific area for postoperative cardiac care was instrumental in the growth and development of our cardiac programme. This rapid change accomplished several crucial elements that lead to accelerated improvement in patient care and a decline in morbidity and mortality.     

Ventilator-associated pneumonia in paediatric intensive care: a literature review

Background: Ventilator‐associated pneumonia (VAP) has been identified as the most common nosocomial infection in intensive care units (ICUs) with associated health and financial costs. To date, more research has been carried out in adult ICUs than in paediatric units, thus prompting a review and investigation of the implications for paediatric practice. Aims: To identify relevant paediatric literature surrounding VAP and use this in association with research carried out in the adult environment to establish the implications of VAP and possible management strategies. Search strategies: A literature search was undertaken using databases within DialogDatastar to identify the extent to which VAP has been researched in both paediatric and adult centres. This information was used to try and gain a clearer concept of the impact and management of VAP in the paediatric setting. Key words and combinations included VAP, intensive care, paediatric, antibiotics, positioning, suction, economics, management, nosocomial and morbidity and mortality. Results of analysis: Despite the documented significance of VAP in terms of its financial and health implications, discrepancies and inconsistencies exist surrounding the identification and treatment of VAP. This is reflected in paediatric centres by a dearth of literature on the subject and the lack of a national standard as to the management and prevention of VAP. Inappropriate management of VAP plays an important role in the development and spread of multiresistant bacteria within hospitals. Conclusions: While inadequate paediatric research exists, extrapolating from adult research suggests that the financial and health costs of VAP are substantial and can be reduced by introducing simple low‐cost measures. Such measures include improving education surrounding VAP and its implications and making small changes in practice to improve and maintain oral hygiene standards. Implications: With a growing cohort of paediatric patients requiring short‐ and long‐term ventilation, progress must be made in identifying the extent and impact of VAP in paediatric ICUs and among the community ventilated patients. This will require changes in practice and attitudes towards VAP for which an appropriate knowledge base would need to be established using audit and research. These issues are particularly relevant in the current environment given the links with multiresistant strains of bacteria within hospitals and the community.     

Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study

Background

Hand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge.

Children with human immunodeficiency virus admitted to a paediatric intensive care unit in the United Kingdom over a 10-year period

Objective There is little published experience regarding the outcome of children with human immunodeficiency virus (HIV) infection treated on a paediatric intensive care unit (PICU). We describe the outcome of children with HIV infection in our hospital over a 10-year period.Method We performed a retrospective analysis of all children with HIV infection admitted to our PICU between August 1992 and July 2002. Their ages ranged from 2 months to 11 years (median 4 months). Information collected included demographic data, clinical presentation, investigations, treatment and outcome.Results There were 42 children with HIV infection admitted to PICU during the study period, with 66 admission episodes. Sixteen (38%) children died in PICU, and 26 (62%) survived their last PICU admission. Of these, 5 died at a later date (between 1 and 32 months after discharge from PICU) and 21 survived to the time of reporting. The most frequent reason for PICU admission was respiratory failure, due either to Pneumocystis carinii pneumonia (45% of admissions) or to other respiratory pathogens (32%). Over 80% of current survivors had good outcomes in terms of growth and development; 6 children had evidence of spastic diplegia.Conclusions Although there is significant mortality among children with HIV infection admitted to PICU, many of them survive their admission, and over 80% of the survivors have good outcomes with the currently available highly active anti-retroviral therapy. This provides evidence that intensive care treatment is appropriate for this group of patients in the United Kingdom.     

Pushing boundaries in paediatric intensive care: training as a paediatric retrieval nurse practitioner

Traditionally in the UK, the transportation of the critically ill child to a paediatric intensive care unit has been carried out by a medically led team of doctors and nurses. However, in countries such as the USA and Canada, appropriately trained nurse practitioners have proven to be competent in the transportation of these vulnerable children. This nurse-led team model has also been shown to be successful in the speciality of neonatal care in the UK. The impact of changes in the National Health Service (NHS) has led to an increased demand for the transportation of the child requiring paediatric intensive or high-dependency care, the lifting of restrictions on nursing practice and the reduction of doctors' hours in keeping with the European Working Time Directive. This has led to one NHS Trust in the UK developing the role of paediatric retrieval nurse practitioners (RNP): nurses who lead the retrieval team. The purpose of this article is to describe a pilot initiative to develop the role of RNPs. The comprehensive process of recruitment, training and assessment of competency will be detailed. Personal reflection on the project will also explore the pertinent nursing issues around; role impact and definition, conflict and change management, communication, legislation and personal and professional growth. Recommendations for future initiatives will also be explored.     

Study of paediatric intensive care units in Spain

Objective: To describe the organisation of paediatric intensive care units in Spain and the medical assistance provided during 1996.¶Methods: A written questionnaire was sent to all the paediatric ICUs linked to or within the Spanish public health system.¶Results: Thirty-one of the 34 paediatric ICUs replied. All are medico-surgical units. Eighteen treat only paediatric patients, 12 paediatric and neonatal patients, and one paediatric and adult patients. Fifteen units have fewer than seven beds, eight have between 7 and 12 beds, and eight between 13 and 18 beds. Of the paediatric ICUs, 83.8 % are staffed by paediatricians specialised in paediatric intensive care. The mean number of on-call on site periods of duty for each member of the medical staff was 5.1 ± 1.7 per month. Thirty of the 31 units undertake paediatric resident training, 13 train residents specialising in paediatric intensive care and 12 participate in medical student training.¶In 1996 there were 9,585 admissions (309 ± 182 patients per ICU) signifying 35.3 ± 14 patients/bed. Of the patients, 65.9 % were medical and 34.1 % surgical. The mean duration of stay was 5.6 ± 2.1 days. The mortality rate was 5.4 ± 3.2 %. The main causes of death were multiple organ failure and brain death.¶Conclusions: In Spain, paediatric intensive care is principally performed by specialised paediatricians. Although the general results for 1996 are similar to those of other European countries, efficiency studies are necessary to plan and re-organise the paediatric intensive care units in Spain.     

Retrospective analysis of renal transplantation outcomes in children admitted to a paediatric intensive care unit in Brazil

Renal transplantation has been described as the main treatment for children with end-stage renal disease. Traditionally, infants and small children represented a high-risk group with poor allograft survival. However, studies conducted mainly in developed countries have been demonstrated improvements in allograft survival rates. The aim of this study was to identify demographic characteristics of recipients and kidney donors and to analyse the outcomes of children who received postoperative care following renal transplantation in one Paediatric Intensive Care Unit (PICU). This retrospective study was carried out in a university hospital in Brazil. The data were collected through reviewing the follow up of medical records of recipients and kidney donors between 1988 and 2002. Chi-square or Fisher exact tests were used to analyse differences in outcome between living and donor transplants, whereas Mann-Whitney and Kruskal-Wallis tests were used to compare differences in outcome by age groups and by the number of complications affecting recipients. A total of 44 children were admitted for renal transplantation. Within this group, the median age was 10.1(+/-3.2) years, 63.6% were men and 38% were non-Caucasians. In contrast, the donor group had a median age of 17.5(+/-12.5) years, of which 51.3% were male, 56.8% were Caucasian and 70.5% were cadaver donors. The average length of PICU stay was 31.4 h, with complications being identified in the majority of the transplanted children. The occurrence of four or more complications was significantly associated with acute rejection (p= 0.009). In conclusion, the main outcomes of this study were similar to those observed in developed countries, in terms of acute rejections (52.3%), dialysis resumption (31.8%), graft loss (29.5%), chronic rejections (9.1%) and death (4.5%). Complications during PICU stay were significantly linked to the occurrence of acute rejection.     

Five years experience with continuous extracorporeal renal support in paediatric intensive care

Continuous arterio-venous haemofiltration (CAVH) and continuous veno-venous haemofiltration (CVVH) were used as renal support in 52 critically ill infants and children with acute renal failure. The majority of the patients were on mechanical ventilation (90%) and needed vasopressor support (85%). Uraemia was satisfactorily controlled with both treatment modes. Post-treatment serum urea levels were not different between survivors (94±8.8 mg/dl) and non-survivors (99.5±8.8 mg/dl). There were significant differences between survivors and non-survivors in the mean arterial pressure (64.7±3.8 vs 48.0±2.2 mmHg,p<0.001), the number of organ system failures (2.9±0.16 vs 3.8±0.21,p<0.025), and the severity of illness assessed by the acute physiologic score for children (APSC 19.4±1.9 vs 26.3±1.9,p<0.01). The overall mortality was 48%. The mortality in the CVVH group (65%) was higher than in the CAVH group (40%). Death was significantly related to sepsis (p<0.005) and multiple system organ failure (p<0.005). A major complication during CAVH was one femoral artery thrombosis after 12 days of treatment. Technical problems were only observed during CVVH. CAVH and CVVH are safe and effective methods of continuous renal support for critically ill paediatric patients with multiple system organ failure. CAVH is simpler, needs no specially trained staff and seems to the ideal renal replacement system for critically ill infants.     

Family involvement in end-of-life care in a paediatric intensive care unit

End-of-life care (ELC) on a paediatric intensive care unit (PICU) is a fundamental aspect of clinical practice and yet often remains a highly emotive and challenging issue. Every year, many children die in PICU often following the withdrawal of life-sustaining treatment, and as health professionals we have a duty to provide ELC that meets the needs of the dying child and their family. To achieve this, there is a growing emphasis on incorporating parental views on withdrawal of intensive care especially in time and place. Home care of the dying child enables the child to die at home in familiar surroundings and with the people who love them the most. This service is essentially child centred and acknowledges the unique and pivotal position that parents have in their child's life by empowering them to have control over the time and place of death. This is a vitally important aspect of end-of-life in PICU and underpins the ethos of this area of practice. We present a series of case reviews of patients cared for within a 12-month period, where intensive care was withdrawn distant from the PICU environment and address the challenges and considerations surrounding this area of practice.     

Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature

Aims and objectives: This paper aims to critically review and analyse available literature to inform and advance patient care. Background: Withdrawal syndromes related to the routine administration of sedation and analgesia in paediatric intensive care unit (PICU) have been recognized since the 1990s. Common symptoms include tremors, agitation, inconsolable crying and sleeplessness. Search strategies: A critical review was undertaken to assess developments in this area. Four databases were searched using Ovid Online. These were Ovid Medline, CINAHL, BNI and Embase. Key terms included were ‘Paediatric’, ‘Sedation’, ‘Withdrawal’ and ‘Intensive care’. Inclusion and exclusion criteria: Articles from 1980 onwards were reviewed for their relevance to paediatric iatrogenic withdrawal. Additionally, seminal work from the 1970s was included. Because of the scarcity of literature, relevant editorials and opinion pieces were included. Results: A total of 2 232 586 papers resulted from keyword searches. Use of Boolean operators to combine terms reduced the number of results to 62. Exclusion criteria reduced the number of suitable papers to 20. Tracking reference lists yielded a further 18 papers. In total, 38 papers were retrieved examining 1375 patients. Four papers surveyed drug usage on PICU, 14 listed withdrawal symptoms, 4 described the frequency of withdrawal in the PICU population, 9 described risk factors, 4 presented or validated clinical tools and 14 describe treatment strategies. Conclusions: Withdrawal syndromes may affect 20% of exposed children and are related to infusion duration and total dose. Fifty‐one symptoms are described in the literature. Future studies need accurate, validated clinical tools to be effective. Risk factors, signs and symptoms have been identified, and validation studies must now take place. Relevance to clinical practice: Withdrawal syndromes continue to be widespread and difficult to diagnose. Awareness of their causes and treatments should influence clinical decisions at the bedside.     

How often do we perform painful and stressful procedures in the paediatric intensive care unit? A prospective observational study

Background

Adequate analgesia and sedation is crucial in critical care. There is little knowledge on the extent of painful and stressful procedures on children admitted to a paediatric intensive care unit (PICU) and its analgesic and/or sedative management.

Randomised controlled trial comparing cisatracurium and vecuronium infusions in a paediatric intensive care unit

Objective To evaluate and compare the efficacy, infusion rate and recovery profile of vecuronium and cisatracurium continuous infusion in critically ill children requiring mechanical ventilation.Design and setting Prospective, randomised, double-blind, single-centre study in critically ill children in a paediatric intensive care unit in a tertiary childrens hospital.Methods Thirty-seven children from 3 months to 16 years old (median 4.1 year) were randomised to receive either drug; those already receiving more than 6 h of neuromuscular blocking drugs were excluded. The Train-of-Four (TOF) Watch maintained neuromuscular blockade to at least one twitch in the TOF response. Recovery time was measured from cessation of infusion until spontaneous TOF ratio recovery of 70%.Results The cisatracurium infusion rate in nineteen children averaged 3.9±1.3 µg kg^–1 min^–1 with a median duration of 63 h (IQR 23–88). The vecuronium infusion rate in 18 children averaged mean 2.6±1.3 µg kg^–1 min^–1 with a median duration of 40 h (IQR 27–72). Median time to recovery was significantly shorter with cisatracurium (52 min, 35–73) than with vecuronium (123 min, 80–480). Prolonged recovery of neuromuscular function (>24 h) occurred in one child (6%) on vecuronium.Conclusions Recovery of neuromuscular function after discontinuation of neuromuscular blocking drug infusion in children is significantly faster with cisatracurium than vecuronium. Neuromuscular monitoring was not sufficient to eliminate prolonged recovery in children on vecuronium infusions.     

Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study

Objective To determine whether paediatric intensive care unit (PICU) admission is associated with greater psychiatric morbidity in children and parents as compared with general paediatric ward admissions.Design Retrospective cohort study.Setting Paediatric intensive care unit and two general paediatric wards of a London teaching hospital.Participants Children aged 5–18 years discharged from PICU (exposed cohort) and general paediatric wards (unexposed cohort) 6–12 months previously, together with their parents.Measurements and results Children: the Clinician Administered Post Traumatic Stress Disorder (PTSD) Scale for Children (CAPS-C), the Impact of Event Scale (IES), Strengths and Difficulties Questionnaire, Birleson Depression Scale, Revised Childrens Manifest Anxiety Scale, Child Somatization Inventory. Parents: IES, General Health Questionnaire, Beck Depression Inventory, Hospital Anxiety and Depression Scale. Thirty-five of 46 (76%) PICU-discharged families and 33 of 41 (80%) from general paediatric wards participated. Valid CAPS-C data were obtained for 19 PICU-admitted children and 27 children admitted only to the general paediatric ward; 4/19 (21%) of PICU-discharged children developed PTSD (compared with none of 27 ward admissions), p=0.02. PICU children had significantly more PTSD features of irritability and persistent avoidance of reminders of the admission. Parents of PICU children were more likely to screen positive for PTSD (9/33 (27%) compared with 2/29 (7%) parents of ward-admitted children), p=0.04. There were no significant differences between the groups for other measures of psychopathology.Conclusion Post traumatic stress disorder diagnosis and symptomatology is significantly more common in families where a child has been admitted to the PICU. Consideration should be given to providing psychological support for children and parents after PICU admission.     

Nurses as withdrawers of life sustaining treatment in paediatric intensive care

Background: Withdrawal of life saving medical treatment is a common modality of death within UK paediatric intensive care units (PICUs). The majority of treatment withdrawals are carried out by medical staff, usually the consultant in charge of the child's care. Aim: To assess current practice of experienced PICU nurses performing the key tasks in treatment withdrawal once the decision has been made and its legal implications. Design and Method: The study was divided into three chronologically successive phases. In phase 1, a 12‐item paper survey was circulated to nursing staff on a UK PICU. In phase 2, a three‐item survey regarding current practice was sent to nurse managers on 22 UK PICUs. In phase 3, analysis of legal issues related to nurses withdrawing treatment was undertaken. Results: Poor response rates to both surveys limited their value; however, they may stimulate discussion of the issue within nursing. Phase 1 received 15 of 100 (15%) responses; open‐ended questions highlighted practitioner concerns. Eight of twenty‐two (36%) responses for phase 2 showed no consistent approach to the issue nationally. Legal analysis indicated that the law was untested in this area and nurses would be advised to withdraw treatment only if following a documented medical plan. Risks of legal and regulatory action could be reduced by formulating clear guidelines. Conclusion: PICU nurses could potentially enact withdrawal, but discussion is needed to resolve uncertainties. Relevance to Clinical Practice: National Guidelines from within the PICU community could assist nurses participating in treatment withdrawal.     

The use of propofol sedation in a paediatric intensive care unit

Background: The aim of this study was to prospectively evaluate and report the experience of the use of continuous intravenous propofol sedation in a paediatric intensive care unit (PICU). Methods: All children younger than 16 years who were admitted to the PICU at a University Hospital for slightly more than a year and received propofol infusion were included prospectively and data were recorded before and within 6 h after completion of the propofol infusion. Results: A total of 174 out of 955 children (18·2%) received propofol infusion for sedation. The median age was 2 years 10 months (range: 2 months to 16 years), duration of propofol infusion 13 h (range: 1·6–179 h) and dose of propofol 2·9 mg/kg/h (range: 0·3–6·5 mg/kg/h). No one developed signs of the propofol infusion syndrome (PRIS). Neither dose >3 mg/kg/h, duration of infusion >48 h nor both were found to be related to adverse metabolic derangements or circulatory failure. Eight children increased their lactate concentration ≥1·8 mmol/L during propofol infusion. All had a favourable outcome. One child who had received propofol infusion for 10 h died, but this occurred 14 h after the infusion ceased and was without doubt attributed to a multiple organ failure not related to the propofol infusion. Conclusion: Propofol infusion was used in this population at low risk of PRIS with no metabolic or circulatory adverse effects. These findings indicate that the occurrence of adverse effects may not be directly related to dose or duration of infusion, but emphasizes the risk that sporadic factors may be involved, such as genetic mutations. Guidelines are presented.     

The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care

Aims and objectives: To evaluate the concurrent validity and reliability of the behavioural COMFORT and a modified version of the FLACC scale for assessment of pain and sedation in intubated and ventilated children and to evaluate the construct validity of the FLACC scale for assessment of pain. Background: Few instruments are available for assessment of pain/sedation in paediatric intensive care. Design: A prospective observational study was performed postoperatively in 40 children aged 0–10 years. Methods: Two trained nurses observed the child simultaneously and assessing COMFORT behavioural (COMFORT‐B) and FLACC scores. In comparison, two bedside nurses concurrently scored pain using an observational visual analogue scale (VAS_obs) and sedation using the Nurse Interpretation of Sedation (NIS) score: oversedated, adequately or insufficient sedated. In 20 additional patients, one nurse assessed FLACC scores before and after analgesics. Results: The majority of patients were <1 year. A moderate but significant correlation was found between each scale and both sedation and VAS_obs. COMFORT‐B differentiated better than FLACC between the three sedation levels. For those assessed to be in pain (VAS_obs > 3), both COMFORT‐B and FLACC scores were significantly different compared with VAS_obs < 3. The interrater reliability was high for COMFORT‐B and FLACC (kappa 0·71 and 0·63, respectively). For bedside nurses’ assessment of pain, the interrater reliability was high (kappa 0·63) but low for the level of sedation (kappa 0·20). After administration of analgesics, the FLACC median score decreased significantly from 5 to 0. Conclusions: The COMFORT‐B scale was a more reliable measure of children’s sedation than bedside subjective assessment and gives more substantial information about sedation than the FLACC scale. Concurrent validity for assessment of pain was supported for both scales. The modified FLACC showed construct validity for measuring pain. Relevance to clinical practice: The use of validated scales may improve the assessment and management of pain and sedation in intubated children.     

Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit

Objective To determine the incidence of end-of-life decisions in intensive care unit (ICU) patients.Design and setting Prospective data collection and questionnaire in a 31-bed medicosurgical ICU in a university hospital.Patients and participants All 109 ICU patients who died during a 3-month period (April–June 2001). Members of the ICU team were also invited to complete a questionnaire regarding the circumstances of each patients death. Cardiopulmonary resuscitation was performed in 21 of the patients; other mechanisms leading to death were brain death (n=19), refractory shock (n=17), and refractory hypoxemia (n=2). The decision was taken in the remaining 50 patients to withdraw (n=43) or withhold (n=7) therapy. Questionnaires were completed for 68 patients, by physician and nurse in 40 cases, physician only in 20 cases, and nurse only in 8 cases. Questionnaires were obtained for 34 of 50 patients for whom a decision was made to limit therapy.Results Respondents generally felt that the decision was timely (n=28, 82%), 5 (15%) felt the decision was too late, and one (3%) that the decision was made too soon, before the family could be informed.Conclusions Therapeutic limitations are frequent in patients dying in the ICU, with withdrawing more common than withholding life support. Generally members of the ICU staff were satisfied with the end-of-life decisions made.