Detecting pediatric delirium: development of a rapid observational assessment tool

Objective

Development of a novel screening tool for the detection of delirium in pediatric intensive care unit (PICU) patients of all ages by comparison with psychiatric assessment based on the reference standard Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria.

Methods

This was a prospective blinded pilot study investigating the feasibility of the Cornell Assessment of Pediatric Delirium (CAP-D) performed in a PICU at a university hospital. Fifty patients, ages 3?months to 21?years, admitted to the PICU over a 6-week period were included. No interventions were performed.

Results

After informed consent was obtained, two study teams independently assessed for delirium by completing the CAP-D and by conducting psychiatric evaluation based on the DSM-IV criteria. Concordance between the CAP-D and DSM-IV criteria was excellent, at 97%. Prevalence of delirium in this sample was 29%.

Conclusion

The CAP-D may be a valid screen for identification of delirium in PICU patients of all ages. Further studies are required to explore its validity, inter-rater reliability, and feasibility of use as a nursing screen.     

Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatment

Background

The mortality for children with prolonged stay in pediatric intensive care units (PICU) is much higher than overall mortality. The incidence of withdrawal or limitation of therapy in this group is unknown.

Purpose

To assess mortality and characteristics of children admitted for ≥28 days to our ICU, and to describe the extent to which limitations of care were involved in the terminal phase preceding death.

Methods

For the period 2003 to 2005 clinical data were collected retrospectively for children with prolonged stay (defined as ≥28 days) in a medical/surgical PICU of a university children’s hospital.

Results

In the PICU, 4.4% of the children (116/2,607, equal gender, mean age 29 days) had a prolonged stay. Median (range) stay was 56 (28–546) days. These children accounted for 3% of total admissions and occupied 63% of total admission days. Mortality during admission for this group was five times higher (22%) than the average PICU mortality rate of 4.6%. Withdrawal or limitation of therapy preceded 70% of deaths.

Conclusions

Children with prolonged stay in the PICU have a significantly high risk of mortality. Death is typically preceded by limitation of care.     

Vitamin?D status in critically ill children

Background

Hypovitaminosis?D is an independent risk factor for cardiovascular disease, muscle weakness, impaired metabolism, immune dysfunction, and compromised lung function. Hypovitaminosis?D is common in critically ill adults and has been associated with adverse outcomes. The prevalence of hypovitaminosis?D and its significance in critically ill children are unclear.

Methods

We performed a prospective study to determine the prevalence of hypovitaminosis?D in 316 critically ill children, and examined its association with physiological and biochemical variables, length of pediatric intensive care unit (PICU) stay, and hospital mortality.

Results

The prevalence of hypovitaminosis?D [25(OH)D₃ <50?nmol/L] was 34.5?%. Hypovitaminosis?D was more common in postoperative cardiac patients than in general medical ICU patients (40.5 versus 22.6?%, p?=?0.002), and the cardiac patients had a higher inotrope score [2.5 (1.9–3.3) versus 1.4 (1.1–1.9), p?=?0.006]. Additionally, ionized calcium within the first 24?h was lower in patients with 25(OH)D₃ <50?nmol/L [1.07 (0.99–1.14)?mmol/L] compared with patients with normal vitamin?D₃ [1.17 (1.14–1.19)?mmol/L, p?=?0.02]. Hypovitaminosis?D was not associated with longer PICU stay or increased hospital mortality.

Conclusions

Hypovitaminosis?D is common in critically ill children, and is associated with higher inotropes in the postoperative cardiac population, but not with PICU length of stay or hospital survival.     

Deutscher Schmerzkongress 2012 aus medizindidaktischer Sicht

Background

Professionals in the medical field are expected to participate in continuing medical education in the sense of lifelong learning. The authors took this occasion to evaluate the most important national convention in pain medicine concerning its role in medical education.

Material and methods

The participants of the 37th German Pain Congress (17–20 October 2012 in Mannheim) were asked to complete a questionnaire concerning content and design of the convention. The aim of this study was to analyze the distribution of different physician competencies in the program. For this purpose the congress program was analyzed with respect to the various medical role models as defined in the Canadian medical education directions for specialists (CanMEDS) framework.

Results

The participants considered the quality of the different sessions of the German Pain Congress to be good. The poster sessions were considered to be the second most important educational format in the congress following the live sessions. Concerning the content of the congress the participants wished more emphasis on the role of interprofessional partners, such as nursing and psychotherapy. The CanMEDS physician roles of manager, communicator, health advisor and professional paragon were underrepresented in the congress program in this study.

Conclusion

Regarding content and educational value, the congress design could benefit from additional Praktikerseminaren (practical seminars). The role of interprofessional partners should be more emphasized. In addition the program could become more attractive through a more balanced distribution of the CanMEDS roles.     

In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial

Purpose

Particulate contamination due to infusion therapy carries a potential health risk for intensive care patients.

Methods

This single-centre, prospective, randomized controlled trial assessed the effects of filtration of intravenous fluids on the reduction of complications in critically ill children admitted to a pediatric intensive care unit (PICU). A total of 807 subjects were randomly assigned to either a control (n?=?406) or filter group (n?=?401), with the latter receiving in-line filtration. The primary endpoint was reduction in the rate of overall complications, which included the occurrence of systemic inflammatory response syndrome (SIRS), sepsis, organ failure (circulation, lung, liver, kidney) and thrombosis. Secondary objectives were a reduction in the length of stay on the PICU and overall hospital stay. Duration of mechanical ventilation and mortality were also analyzed.

Findings

Analysis demonstrated a significant reduction in the overall complication rate (n?=?166 [40.9?%] vs. n?=?124 [30.9?%]; P?=?0.003) for the filter group. In particular, the incidence of SIRS was significantly lower (n?=?123 [30.3?%] vs. n?=?90 [22.4?%]; P?=?0.01). Moreover the length of stay on PICU (3.89 [95?% confidence interval 2.97?4.82] vs. 2.98 [2.33?3.64]; P?=?0.025) and duration of mechanical ventilation (14.0 [5.6?22.4] vs. 11.0 [7.1?14.9] h; P?=?0.028) were significantly reduced.

Conclusion

In-line filtration is able to avert severe complications in critically ill patients. The overall complication rate during the PICU stay among the filter group was significantly reduced. In-line filtration was effective in reducing the occurrence of SIRS. We therefore conclude that in-line filtration improves the safety of intensive care therapy and represents a preventive strategy that results in a significant reduction of the length of stay in the PICU and duration of mechanical ventilation (ClinicalTrials.gov number: NCT00209768).     

Early change in blood glucose concentration is an indicator of mortality in critically ill children

Objective

Hyperglycaemia is associated with increased mortality in critically ill patients. A number of studies have highlighted an association between increased variability of blood glucose (BG) concentration and mortality, supporting a survival disadvantage if BG homeostasis is lost. By exploring the longitudinal BG profile of individual children over time, this study investigates the importance of intact homeostasis early after admission to the paediatric intensive care unit (PICU).

Design, setting, and patients

Retrospective single-centre observational study in a large multi-specialty PICU in the UK. Children admitted between August 2003 and February 2006 were included unless they met exclusion criteria. Data were merged from the PICU clinical database and blood gas analyser database by means of a unique PICU identifier. BG was measured frequently on a blood gas analyser (Bayer Rapidlink). Primary outcome was 100-day mortality. BG parameters were investigated for possible associations with mortality.

Measurements and main results

A total of 1,763 patients were included (median age 1.1?years; IQR 0.1?C5.8). Although admission BG was not associated with mortality, a survival advantage was found in children who showed a reduction in BG on day 1 relative to the admission BG value (p?<?0.001). This remained statistically significant (p?=?0.007) after adjusting for severity of illness.

Conclusions

This study supports an association between early BG profile and mortality in children admitted to PICU, with increased survival in those who demonstrate a fall in BG on day 1 relative to PICU admission. These findings are consistent with a survival advantage of intact BG homeostasis.     

The relationship between blood lactate concentration, the Paediatric Index of Mortality 2 (PIM2) and mortality in paediatric intensive care

Introduction

Blood lactate concentration predicts mortality in neonates, infants, children and adults, with evidence that it has better predictive power than other markers of acid–base status such as absolute base excess or pH.

Objective

To investigate whether blood lactate concentration on admission predicts mortality in paediatric intensive care and if its addition can improve the performance of the Paediatric Index of Mortality?2 (PIM2) mortality prediction score.

Design and setting

Retrospective cohort study in one 20-bed UK paediatric intensive care unit (PICU) using data from the PICU clinical and blood gas analyser databases between 2006 and 2010. Only cases with a blood lactate concentration measured at the same time as the PIM2 variables were included. Logistic regression was used to assess if blood lactate concentration predicted mortality independently of PIM2, adjusting for potential confounders, and if it could replace absolute base excess in the PIM2 model.

Results

There were 155 deaths amongst 2,380 admissions (6.5?%). Admission lactate in non-survivors was higher than in survivors (mean [standard deviation, SD]) 6.6 [5.6] versus 3.0 [2.5]?mmol/l, had a positive association with mortality [adjusted odds ratio (OR) for death per unit (mmol/l)] increase 1.11 [95?% confidence interval (CI) 1.06–1.16; p?<?0.001] and significantly improved the model fit of PIM2 when it replaced absolute base excess (p?<?0.001).

Conclusions

PICU admission blood lactate concentration predicts mortality independently of PIM2. Given the limitations of this study, a prospective multi-centre evaluation is required to establish whether it should be added to the PIM2 model with or without replacement of base excess.     

Cardiogoniometry as a diagnostic tool in patients with acute coronary syndromes: results of the CGM@ACS trial

Background

Cardiogoniometry (CGM) is a novel electrocardiac method utilising computer-assisted three-dimensional information on cardiac potentials.

Objective

To investigate the potential of CGM in discriminating non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and relevant coronary stenosis upon hospital admission by prospectively comparing its sensitivity, specificity and accuracy against those of a single troponin test and a 12-lead ECG performed on admission

Design

A multicenter prospective observational trial.

Setting

Eight interventional cardiac centres in Germany.

Patients

A cohort of 216 patients (mean age 67?years, 34.7?% female) who presented with acute chest pain or dyspnoea without ST-segment elevation and were scheduled for coronary angiography within 72?h of admission.

Intervention

Pre-angiography screening by CGM, troponin test, 12-lead ECG

Main outcome measures

ECG, troponin and CGM on admission compared with final diagnosis of NSTE-ACS or relevant diameter stenosis ≥70?% verified by an independent review board and an angiographic core laboratory.

Results

NSTE-ACS was finally confirmed in 162 cases, whereas the remaining 54 cases without proof of NSTE-ACS served as controls. Diagnostic sensitivity for NSTE-ACS was 28, 50 and 69?% and specificity 78, 96 and 54?% for first ECG, serial troponin and first CGM, respectively. Accuracy was 40, 62 and 65?%. The sensitivity of the tests to detect relevant coronary stenosis (n?=?126) was 32, 53 and 74?%, respectively. The sensitivity of CGM to detect NSTE-ACS (65?%) or relevant stenosis (71?%) was high even in patients with normal troponin and ECG.

Conclusions

CGM can detect NSTE-ACS at first medical contact. CGM in conjunction with traditional markers, 12-lead ECG and troponin may effectively aid early decision making in patients presenting with acute chest pain.