Iatrogenic illness in pediatric critical care

Iatrogenic illness may be an important determinant of the need for pediatric intensive care. We prospectively evaluated consecutive admissions to a pediatric ICU (PICU) over two time periods totaling 6 months. Twenty-five (4.6%) admissions were necessitated by iatrogenic illnesses. Drug-induced conditions accounted for eight (32%) of the iatrogenic patients, and complications of medical-surgical acts accounted for 17 (68%). Diagnoses included six respiratory failures due to seizure medications, six chronic upper airway complications of neonatal intensive care, four posttonsillectomy and postadenoidectomy complications, two chronic postcardiac surgery complications, two cardiac catheterization complications, and five miscellaneous conditions. One (3.7%) patient with iatrogenic illness died. As a group, patients with iatrogenic illness were at a risk of dying similar to other patients. We conclude that iatrogenic illness is a significant cause of PICU admission.     

Iatrogenic developmental effects of pediatric intensive care.

Critically ill children in the pediatric intensive care environment are at particular risk for experiencing health care interventions that hinder them from progressing through their normal developmental milestones. Knowledge of the factors that influence iatrogenic developmental insults can help the nurse develop the skills and sensitivity to meet the complex needs of these children and their families.     

Immunosuppression in pediatric critical care patients

The pediatric critical care patient not only ranges in age, size, diagnosis, and outcome but also in immunologic capability and function. The neonate, once thought to be devoid of any immunological function, is relatively immunocompetent in some areas and immature in immunologic function in other areas. The newborn's impaired immune function is a reflection of immature and inexperienced cellular interrelations rather than the absence or immature function of a single cell line. The exact time that an infant/young child's immune system becomes mature is not definitive. The maturational process of the immune system is complex and unpredictably long. Although some components of a mature immune function occur quickly following birth (for example, colonization and secretory functions of the skin and mucous membranes), other components may take years and occur sometime before the child reaches puberty (for example, adult levels of IgG, IgD, IgA, and IgE). The critically ill infant and child have both developmental aspects of immunocompromise but also the PICU situational or clinical stressors that may impede immune function. The long-term impact of the situational stressors on the development of immune system is unknown. The PICU nurse should recognize that the critically ill child is vulnerable to immunocompromise, and provide assessment and intervention to provide optimal immune function by preventing infection and promoting host defenses.     

Unique solutions in pediatric critical care

This pediatric intensive care unit (PICU) functions as a part of a multidisciplinary adult ICU and has evolved into a unique health care setting. The Special Care Unit (SCU), which is the name for our ICU, serves a population of adult and pediatric patients, including trauma, open-heart surgery, medicine, surgery, and neurosurgery. All staff are expected to provide care for adults and children without regard to admitting diagnosis. In addition to meeting the critical care needs of this diverse pediatric population in the SCU, we provide a pediatric critical care ground transport program for critically ill children from outlying hospitals. Competency-based orientation tools were developed and are used to guide the orientation process. The tools identify the required knowledge base necessary for a staff member to adequately care for the adult and pediatric populations and track each staff member's progress through orientation. The model used to deliver care to adults and children in this setting is innovative. This model represents one solution to providing critical care to both the adult and pediatric population in today's era of health care redesign.     

Substance abuse and withdrawal in the critical care setting

Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. It is imperative for the critical care team to have a high index of suspicion for substance intoxication and withdrawal. This article reviews the epidemiology of substance use in this population and the treatment of common withdrawal syndromes. General principles regarding the management of substance withdrawal syndromes include general resuscitative measures, use of a symptom-triggered approach, and substitution of a long-acting replacement for the abused drug in gradual tapering dose. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.     

Ethical dilemmas in pediatric critical care.

Advances in the area of pediatric medicine during the past few years have presented ethical dilemmas for the physician to consider. This article discusses the ethical principles upon which clinical reasoning and judgments can be made.     

Ethical considerations in pediatric critical care research

Pediatric critical care nurses are exposed to research in the critical care environment on a routine basis and should be knowledgeable about the ethical considerations inherent in this process. The following discussion includes information that centers on the ethical issues of conducting research with children. First, children as a vulnerable population is explored, followed by selected ethical principles that pertain to research, the role of the technological imperative in research, the process of informed consent, and finally, nursing considerations.     

Regionalization of pediatric critical care.

It is evident that the field of pediatric critical care is evolving rapidly, but the prime issue remains the proper delivery of scarce and expensive resources to the most patients. In order to do so it is necessary to determine where current resources exist. This has been difficult to accomplish accurately on a national basis, although it may be possible on a regional level. To achieve the final goal of building organized systems of care, the special needs of the critically ill and injured child must be recognized. Models of regionalization will provide the basic structure for the development of these systems. The Model for a Pediatric Critical Care System proposed by the California Critical Care Coalition and District IX of the American Academy of Pediatrics should be readily applicable to any region. It is hoped that the information and examples provided in this article will provide some guidelines for those interested in promoting regionalization of pediatric critical care across the nation.     

赋予检验“危急值”专科特性的护理安全管理在肾内科的应用

目的：探讨赋予检验“危急值”专科特性的护理安全管理在肾内科的应用。方法：根据危急值项目频次结果确定专科护理安全关键点,建立标准培训课程对护士进行全员培训,完善专科护理指引,规范细节管理制度并进行持续质量改进。结果：174例危急值报告患者均得到及时有效处理,患者满意度提高。结论：赋予检验“危急值”专科特性的护理安全管理,能够厘清专科危急值的特点,快速有效提高护士的专科能力,给予护士临床工作明确的指引,最终有效保障病人的护理安全。     

Factors affecting consent in pediatric critical care research

Purpose  

Consent for research is a difficult and unpredictable process in pediatric critical care populations. The objectives of this study were to describe consent rates in pediatric critical care research and their association with patient, legal guardian, consent process, and study design-related factors.     

Iatrogenic pediatric hydroxocobalamin overdose

IntroductionHydroxocobalamin, a precursor molecule to vitamin B12, has emerged as the preferred empiric treatment for patients rescued from enclosed-space fires with concern for inhalational injury and potential concomitant cyanide toxicity. Limited data exist on the effects of hydroxocobalamin toxicity, particularly in pediatric patients.Case reportWe report a case of a healthy three-year old girl who was rescued from an apartment fire and electively intubated by prehospital providers. Due to concern for potential cyanide toxicity, she received 5 g (373 mg/kg) of intravenous hydroxocobalamin, an amount equivalent to one standard adult dose but over five times the appropriate weight-adjusted dose for this 13.4-kilogram child. On hospital arrival, patient was noted to have chromaturia and diffuse erythroderma without cutaneous burns. She was extubated 4 h after prehospital intubation and discharged home the following morning in good condition with persistent erythroderma. Skin color returned to normal within two days.DiscussionWe believe this to be the first reported case of iatrogenic pediatric hydroxocobalamin overdose for the treatment of suspected cyanide toxicity. Erythroderma and chromaturia are expected side effects of hydroxocobalamin, even at therapeutic levels. Along with minor airway burns, the only other finding was a transient and hemodynamically neutral bradycardia, which began shortly after prehospital intubation. As this bradycardia occurred prior to hydroxocobalamin administration, more likely culprits include vagal nerve stimulation from direct laryngoscopy, and sinoatrial muscarinic receptor stimulation caused by repeated doses of succinylcholine. In all, we were unable to appreciate any complications due to excess hydroxocobalamin administration.     

Computerized decision support in adult and pediatric critical care

Computerized decision support (CDS) is the most advanced form of clinical decision support available and has evolved with innovative technologies to provide meaningful assistance to medical professionals. Critical care clinicians are in unique environments where vast amounts of data are collected on individual patients, and where expedient and accurate decisions are paramount to the delivery of quality healthcare. Many CDS tools are in use today among adult and pediatric intensive care units as diagnostic aides, safety alerts, computerized protocols, and automated recommendations for management. Some CDS use have significantly decreased adverse events and improved costs when carefully implemented and properly operated. CDS tools integrated into electronic health records are also valuable to researchers providing rapid identification of eligible patients, streamlining data-gathering and analysis, and providing cohorts for study of rare and chronic diseases through data-warehousing. Although the need for human judgment in the daily care of critically ill patients has limited the study and realization of meaningful improvements in overall patient outcomes, CDS tools continue to evolve and integrate into the daily workflow of clinicians, and will likely provide advancements over time. Through novel technologies, CDS tools have vast potential for progression and will significantly impact the field of critical care and clinical research in the future.     

Burnout's syndrome in critical care nursing professionals

The concept of the "Burnout Syndrome" has come as a result of the chronic work-stress developed in workers involved in human services during their professional activity. The working conditions and the specific characteristics of the job developed at the Intensive Care Units by the nursing staff, involve a high risk for this group to acquire this syndrome.The main objective of this study is to assess the prevalence of the Burnout Syndrome in the nursing staff of the ICUs in different hospitals of the Alicante province, Spain, by means of the Malsach Burnout Inventory questionnaire. This questionnaire is self-administered and was handed to all the nursing staff at the ICUs in the University Hospitals of Alicante and Elche and in the Hospital Marina Baixa of Villajoyosa. form the total of 107 questionnaires, 83 proved to be valid. The average total of MBI was of 55.05, indicating low values of emotional tiredness, low depersonalisation, and an adequate level of personal accomplishment.     

End-of-life care in the pediatric intensive care unit: attitudes and practices of pediatric critical care physicians and nurses

OBJECTIVE: To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN: Cross-sectional survey. SETTING: A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS: Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.     

Iatrogenic Horner's syndrome

Recent reports appear to indicate that the incidence of iatrogenic Horner s Syndrome is increasing, perhaps due to an increased frequency of surgical procedures, anesthetic techniques, and vascular access methods applied to the cervical region. A case of Horner's syndrome, due to a malpositioned thoracostomy tube, is described and iatrogenic causes of Horner's syndrome are discussed.