Life-threatening arrhythmias in the intensive care unit

Symptomatic arrhythmias are frequently observed in the intensive care unit and often lead to significant hemodynamic compromise because of the presence of multisystem disease. In particular, prompt evaluation of patients with tachycardia is critical because treatment depends on the accurate diagnosis of the arrhythmia mechanism. The electrocardiogram remains the most important diagnostic tool for the evaluation of both wide complex and narrow complex tachycardia. For wide complex tachycardia, evaluation of the atrioventricular relationship and QRS morphology are critical, and for narrow QRS complex tachycardias, evaluation focuses on identification of the location and morphology of P waves. Bradycardia can arise from sinus node dysfunction or atrioventricular conduction block.     

Outcome of cardiopulmonary resuscitation in a pediatric cardiac intensive care unit

OBJECTIVE: To determine the eventual outcome of children with heart disease who had cardiopulmonary resuscitation (CPR) in a specialized pediatric cardiac intensive care unit (CICU), and to define the influence of any prearrest variables on the outcome. DESIGN: A retrospective review of patients' medical records. SETTING: A pediatric CICU of a tertiary pediatric teaching hospital. PATIENTS AND METHODS: Patients were all children who presented with cardiopulmonary arrest and who were administered CPR in the pediatric CICU between June 1995 and June 1997. Prearrest variables such as age, diagnosis, prior cardiac surgery, and inotropic support with epinephrine, as well as cause of arrest, were evaluated. MEASUREMENTS AND MAIN RESULTS: Thirty-two patients, ranging in age from 1 day to 21 yrs (median, 1 month), satisfied criteria for inclusion in the study group. These 32 patients had a total of 38 episodes of cardiopulmonary arrest. Twenty-five of these patients (78%) had cardiac surgery before arrest. Inotropic support with continuous infusion of epinephrine was being administered at the time of arrest in 18 of 38 (47%) arrests. These prearrest variables did not influence outcome of CPR. Of the 38 episodes of CPR, 24 episodes (63%) were successful, with 20 episodes resulting in return of spontaneous circulation and four patients being successfully placed on mechanical cardiopulmonary support. Fourteen children, including all four patients who were rescued with mechanical cardiopulmonary support, survived to discharge. At 6-month follow-up, 11 patients were still alive, with three having neurologic impairment. CONCLUSIONS: After cardiopulmonary resuscitation in this pediatric CICU, the rate of success was 63% and the rate of survival was 42%. Prior cardiac surgery and use of epinephrine before arrest did not influence the outcome of CPR. The availability of effective mechanical cardiopulmonary support can improve the outcome of CPR.     

Vasopressin in the cardiac surgery intensive care unit.

Although nearly 10% of patients experience profound vasodilatory shock after cardiopulmonary bypass, some patients remain refractory to traditional resuscitation. Among this subset are patients who have inappropriately low levels of endogenous vasopressin. Thus, vasopressin replacement is an intuitively attractive intervention. The purposes of this review are to outline the pathophysiology of vasodilatory shock after cardiopulmonary bypass, to discuss the physiological role of endogenous vasopressin, to explore the clinical basis for vasopressin replacement, and to review the pharmacology and dosing guidelines.     

环丙沙星在PICU重症感染中的应用

目的　评价环丙沙星治疗小儿重症感染的有效性和安全性。方法　收集北京儿童医院儿童加强医疗病房 (PICU)重症感染患儿 2 6例 ,环丙沙星用量 10～ 2 0mg·kg-1·d-1,静脉给药 ,疗程 4～ 31d (11± 7)d。结果　用药前培养菌对环丙沙星的敏感率为 10 0 %。用药 5天后6例培养出 7株耐药菌 ,耐药菌发生率占 2 3 1% (6 / 2 6 )。其中 4例环丙沙星治疗无效改换敏感抗生素。继发霉菌感染者 4例 ,占 15 4% (4 / 2 6 ) ,2例死于霉菌败血症。本组患儿治愈 11例 ,好转出院 6例 ,无效 9例 ,总有效率为 6 5 4% (17/ 2 6 )。耐药菌株出现和霉菌感染是治疗失败的主要原因。仅 1例患儿治疗过程中出现皮疹 ,副作用发生率为 3 8% (1/ 2 6 )。结论　环丙沙星是治疗儿童严重感染的一种相对安全有效的药物     

Long-stay patients in the pediatric intensive care unit

OBJECTIVE: Length of stay in the pediatric intensive care unit (PICU) is a reflection of patient severity of illness and health status, as well as PICU quality and performance. We determined the clinical profiles and relative resource use of long-stay patients (LSPs) and developed a prediction model to identify LSPs for early quality and cost saving interventions. DESIGN: Nonconcurrent cohort study. SETTING: A total of 16 randomly selected PICUs and 16 volunteer PICUs. PATIENTS: A total of 11,165 consecutive admissions to the 32 PICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: LSPs were defined as patients having a length of stay greater than the 95th percentile (>12 days). Logistic regression analysis was used to determine which clinical characteristics, available within the first 24 hrs after admission, were associated with LSPs and to create a predictive algorithm. Overall, LSPs were 4.7% of the population but represented 36.1% of the days of care. Multivariate analysis indicated that the following factors are predictive of long stays: age <12 months, previous ICU admission, emergency admission, no CPR before admission, admission from another ICU or intermediate care unit, chronic care requirements (total parenteral nutrition and tracheostomy), specific diagnoses including acquired cardiac disease, pneumonia, and other respiratory disorders, having never been discharged from the hospital, need for ventilatory support or an intracranial catheter, and a Pediatric Risk of Mortality III score between 10 and 33. The performance of the prediction algorithm in both the training and validation samples for identifying LSPs was good for both discrimination (area under the receiver operating characteristics curve of 0.83 and 0.85, respectively), and calibration (goodness of fit, p = .33 and p = .16, respectively). LSPs comprised from 2.1% to 8.1% of individual ICU patients and occupied from 15.2% to 57.8% of individual ICU bed days. CONCLUSIONS: LSPs have less favorable outcomes and use more resources than non-LSPs. The clinical profile of LSPs includes those who are younger and those that require chronic care devices. A predictive algorithm could help identify patients at high risk of prolonged stays appropriate for specific interventions.     

Bronchopulmonary dysplasia in the pediatric intensive care unit

Bronchopulmonary dysplasia (BPD) is an important cause of chronic respiratory disease in infants and children. Infants with BPD are frequently readmitted to the hospital during the first 2 years of life usually because of infectious exacerbations of their chronic lung disease. This article is a review of the multisystem pathology of BPD and therapeutic approaches to the management of these infants in the PICU.     

Oncological emergencies in the pediatric intensive care unit

The overall 5-year survival rate of children with cancer has now reached 77%, an increase of about 45% in the past 25 years. Newer therapies, including hematopoietic cell transplantation and cutting edge chemotherapeutics evolving in the form of molecular and biological cell targeted agents, are being researched and developed and are responsible for the change in survival rates over time. Also, despite the national trend toward hospice and palliative care, children with chronic and life threatening illnesses, continue to die in the hospital setting, often in the intensive care unit. Previous studies of children with complications of cancer and its therapy document poor outcomes among those who do require intensive care. These trends are changing, however, currently leaving a hopeful, optimistic view of the outcome in children with cancer complications admitted to the pediatric intensive care unit. It is imperative that nurses and intensive care staff understand pediatric cancer and its potential emergent consequences in order to respond to the symptoms of life threatening events.     

Molecular genetics in the pediatric intensive care unit

Molecular genetics and genomics have become highly relevant tools in the field of pediatric critical care medicine. The most immediate examples involve the use of molecular genetics as routine diagnostic tests (eg, detection of herpes simplex virus by PCR). Perhaps the most exciting and promising examples involve the research efforts based in these fields, which hold the potential to gain novel insight regarding the complex mechanisms involved in critical illness. Ultimately, the generation of more comprehensive and fundamental knowledge can lead to the design of more effective and specific therapeutic strategies.     

Effectiveness of a simulation-based educational program in a pediatric cardiac intensive care unit

Optimal staff performance of resuscitation skills is best achieved through regular effective training. However, providing this teaching in a busy high-acuity pediatric cardiac intensive care unit (ICU) had become a challenge due to time and logistical constraints. A program to effectively and efficiently teach ICU nurses the skills necessary in patient resuscitation was developed using simulation training to better meet staff learning needs. Training via simulation provides an ideal learning environment with hands-on experience with the roles required in patient resuscitation. A simulation training program incorporating simulation training was developed for ICU nursing staff. All staff nurses in the ICU were required to attend over a year's time. The program involved mock resuscitation scenarios in which participants performed various resuscitation roles, followed by video review and group debriefing. All participants completed a survey prior to and immediately following participation in the training and again at 1 year. Data collected included self-report of knowledge, skill, and comfort related to patient resuscitation. Data revealed statistically significant improvement in scores pre and post training and at 1 year for self-reported knowledge, skills, and comfort related to resuscitation. Nursing staff reported that simulation training in resuscitation skills was helpful and positively impacted their knowledge, comfort, and skills. Feedback from nursing staff continues to be very positive, and performance of actual resuscitations on the unit has improved anecdotally.     

Implementing evidence-based nursing practice in the pediatric intensive care unit.

With the widespread use of central venous catheters in children, the incidence of catheter-related bloodstream infections (CR-BSIs) is increasing. Current evidence-based practice strategies to decrease CR-BSIs include using maximum barrier techniques during insertion, practicing good hand hygiene, performing skin antisepsis with 2% chlorhexidine, using a chlorhexidine-impregnated patch (CIP) covered by a semipermeable polyurethane dressing, and promptly removing catheters when no longer needed. Implementation of evidence-based practice bundles, along with monthly monitoring of infection surveillance, has resulted in significant decreases in the average rates of CR-BSIs per 1,000 catheter days in many pediatric intensive care units.     

Bowel management in the intensive care unit

The area of bowel care in the intensive care unit (ICU) is often overlooked in the holistic care of the critically ill individual. With the primary concern of optimising patients to preserve life the problem of bowel care has been given less priority. The guidelines included within this service improvement paper offer a simple approach to bowel care management with the use of an algorithm and visual display score to be used in conjunction with the algorithm. This was developed in the intensive care unit of the Royal Free Hospital, London and is presently in use.     

Pain management in the intensive care unit

Pain management is an essential component of quality care delivery for the critically ill patient. Because outcomes are difficult to predict in the intensive care unit (ICU), high-quality pain management and palliative therapy should be a goal for every patient. For those patients actively dying, palliation may be among the main benefits offered by the health care team. Appropriate palliation of pain begins with the use of effective strategies for recognizing, evaluating,and monitoring pain. Skill in pain management requires knowledge of both pharmacologic and nonpharmacologic therapies. This article focuses on expertise in the use of opiates to facilitate confident and appropriate pain therapy. To optimize palliative therapy, symptoms are best addressed by interdisciplinary care teams guided by models that acknowledge a continuum of curative therapies and palliative care.     

Use of hypothermia in the intensive care unit

Used for over 3600 years, hypothermia, or targeted temperature management (TTM), remains an ill defined medical therapy. Currently, the strongest evidence for TTM in adults are for out-of-hospital ventricular tachycardia/ventricular fibrillation cardiac arrest, intracerebral pressure control, and normothermia in the neurocritical care population. Even in these disease processes, a number of questions exist. Data on disease specific therapeutic markers, therapeutic depth and duration, and prognostication are limited. Despite ample experimental data, clinical evidence for stroke, refractory status epilepticus, hepatic encephalopathy, and intensive care unit is only at the safety and proof-of-concept stage. This review explores the deleterious nature of fever, the theoretical role of TTM in the critically ill, and summarizes the clinical evidence for TTM in adults.     

Use of albumin in the intensive care unit

Recent publications have renewed interest in albumin use in the ICU. Meta-analyses have been published that demonstrate the safety of albumin administration and even potential benefits. Hypoalbuminemia, which has long been considered a marker of disease, has been causally linked to the development of complications. Finally, advances have been made in our knowledge of the unique and potentially beneficial properties of albumin.