End-of-life issues in the paediatric intensive care unit

Recent changes in paediatrics with the growing provision of life-sustaining interventions in both complex and rare diseases have increased the prevalence of chronic and life-limiting conditions in children. This has, in turn, led to changes in the population of children cared for and, consequently, the modes of death in paediatric intensive care units. In many countries, children with chronic conditions now constitute a large proportion of both admissions to paediatric intensive care units and the deaths occurring there. Managing end-of-life decisions and care is an integral part of practice and constitutes an imperative skill for all professionals working in paediatric intensive care. The process of end-of-life care involves many uncertainties and ethical, legal, religious, cultural and social considerations. A child's death will always be a tragic and challenging experience, but the way it is managed can influence the impact it has on everyone involved. This article provides a review of the issues surrounding the end-of-life process for patients in paediatric intensive care units and explores the challenges and considerations involved in decision-making to withhold or withdraw life-sustaining therapy. We discuss the practicalities of managing and optimising end-of-life care within and beyond the paediatric intensive care unit and the different aspects that healthcare teams need to address before and after a child's death.     

Characteristics and outcome of long-stay patients in a paediatric intensive care unit: a case-control study

Aim: To identify differences in baseline characteristics and outcome between long-stay and other patients admitted to a paediatric intensive care unit with the same diagnosis. Methods: Over a period of 6 y, data of paediatric intensive care unit patients with a length of stay of 30 or more days (long-stay patients) and aged 1 to 18 y were retrospectively collected. Long-stay patients were matched with the next patient who was admitted to the paediatric intensive care unit with the same diagnosis. Evaluated characteristics on admission included: age, sex, presence of chronic morbidity, functional status, Pediatric Risk of Mortality score, presence of multiple organ system failure and complications during admission. Outcome (survival and functional status) was assessed 2.5 to 8.5 y after admission. Results: Of 19 long-stay patients identified, 15 could be matched with a control patient admitted with the same diagnosis. No significant difference in baseline characteristics was found between long-stay patients and the matched controls. The mean number of complications per long-stay patient was 2.9, compared to 1.2 per control patient (p = 0.02). Infection accounted for half of the complications. Mortality rate in long-stay patients was not higher than in the matched controls (36.8 vs 26.7%, p = 0.54). Paediatric intensive care unit stay did not change functional status in either long-stay patients or controls.

Conclusion: Long-stay patients in the paediatric intensive care unit had more complications, but baseline characteristics, mortality and functional outcome were not different from a control group admitted with the same diagnosis.     

Ventilator-associated pneumonia in a paediatric intensive care unit in a developing country with high HIV prevalence

Aim:   To obtain preliminary prevalence, aetiological and outcome data on South African paediatric patients with ventilator-associated pneumonia (VAP).
Methods:   Non-bronchoscopic bronchoalveolar lavage (BAL) specimens taken between January 2004 and September 2005 were prospectively recorded and related clinical data were retrospectively reviewed. VAP was defined as a new isolate on BAL and a modified Clinical Pulmonary Infection Score ≥5.
Results:   A total of 230 patients aged 3.9 (2.2–9.1) months (median interquartile range (IQR) ) underwent 309 BALs during 244 paediatric intensive care unit (PICU) admissions. Most patients (84%) were admitted with acute infectious diseases, with a 70% incidence of comorbidity. Thirty-three patients (14.3%) were HIV-exposed but uninfected and 58 (25.2%) were HIV-infected.
Of 172 BALs taken ≥48 h after intubation, 63 specimens from 55 patients fulfilled VAP criteria. Acinetobacter baumannii was the most common VAP pathogen, followed by Klebsiella pneumoniae , viruses, yeasts and Staphylococcus aureus.
Patients who developed VAP had a higher proportion of comorbid conditions (76% vs. 55%, P = 0.01) and reintubations (39% vs. 12%, P < 0.0001) when compared with non-VAP patients. Median (IQR) length of PICU stay was 12.5 (5–21) days versus 8 (5–14) days ( P = 0.03); and the risk adjusted PICU mortality was 1.38 versus 0.79 ( P = 0.002) in VAP versus non-VAP patients, respectively.
Conclusions:   VAP is associated with significant morbidity and mortality and may relate to the high incidence of comorbid conditions in this population. Primary VAP pathogens differ from developed countries.     

No resuscitation orders and withdrawal of therapy in French paediatric intensive care units

Objective: To determine the incidence of different modes of death in French paediatric intensive care units and to compare patients' characteristics, including a severity of illness score (Paediatric Risk of Mortality: PRISM score) and prior health status (Paediatric Overall Performance Category scale), according to the mode of death. Design: A 4-month prospective cohort study. Setting: Nine French multidisciplinary paediatric intensive care units. Patients: All patients who died in PICUs, except premature babies. Main results: Among 712 admissions, 13% patients died. Brain death was declared in 20%, failure of cardiopulmonary resuscitation occurred in 26%, do-not-resuscitate status was identified in 27%, and withdrawal of supportive therapy was noted in 27%. The PRISM score and the baseline Paediatric Overall Performance Category were not different between the four groups. Brain-dead patients were older than those in whom a do-not-resuscitate order and withdrawal of therapy were made (median age 81 vs 7 and 4 months). Conclusions: Decisions to limit or to withdraw supportive care were made for a majority of patients dying in French paediatric intensive care units. Chronic health evaluation and severity of illness index are not sufficient to describe dead-patient populations.     

Children with human immunodeficiency virus infection admitted to a paediatric intensive care unit in South Africa

BACKGROUND: Early data regarding the outcome of human immunodeficiency virus (HIV)-infected children in paediatric intensive care units (PICU) suggested mortality as high as 100%. Recent studies report mortality of 38%. Survival depends on the indication for admission. OBJECTIVES: To describe the prevalence, duration of stay, and outcome of HIV-infected patients in a single PICU over a 1-year period. Additional objectives included describing the indications for admission as well as the clinical and laboratory characteristics of HIV-infected infants and children requiring PICU admission. METHOD: Retrospective chart review of all children with serological proof of HIV admitted to PICU at Tygerberg Children's Hospital from 1 January to 31 December 2003. RESULTS: Of the 465 patients admitted, 47 (10%) were HIV-infected. For HIV-infected children the median age on admission was 4 months. The median duration of stay was 6 days, significantly longer than for the non-HIV group (p = 0.0001). Fifty-seven percent had advanced clinical and immunological disease. Seventeen died in PICU and four shortly afterwards, poor PICU outcome was significantly associated with HIV status (p = 0.001). Lower total lymphocyte count (p = 0.004) and higher gamma globulin level (p = 0.04) were paradoxically the only findings significantly associated with survival. Acute respiratory failure (ARF) accounted for 76% of admissions, including Pneumocystis jiroveci in 38%. Fifty-one percent had evidence of cytomegalovirus infection. CONCLUSIONS: HIV-infected children requiring PICU can survive despite the lack of availability of antiretroviral therapy.     

Adverse drug reactions in a paediatric intensive care unit

Adverse drug reactions (ADRs) were prospectively studied in critically ill infants and children. Seventy–six ADRs were reported in 63 patients out of a study group of 899 patients. The majority of the ADRs were mild (49), although 19 were of moderate severity and 8 were severe. Thirty–five ADRs required treatment or alteration in treatment. Midazolam, morphine, salbutamol, vecuronium, hydrocortisone and theophylline were the drugs most likely to cause an ADR. One–third of the ADRs were due to drugs used outside their product licence. The majority of the ADRs were reported by nurses (36) and pharmacists (30). We believe that it is possible to prospectively study drug toxicity in critically ill infants and children.     

Clinical experience with continuous intravenous sedation using midazolam and fentanyl in the paediatric intensive care unit

Twenty-four patients in a paediatric intensive care unit mostly undergoing cardiac surgery, received a midazolam dosage between 50–400 g/kg per hour as a continuous intravenous infusion partly in combination with fentanyl [0,5–2,5 g/kg per hour] for analgesia and sedation. The mean duration of midazolam infusion was 11.6 days (range 38h–40 days). Blood samples for the HPLC assay of serum midazolam concentration were taken and the clearance estimated. The efficiency of sedation in correlation to the midazolam concentration was evaluated by a clinical sedation score. Serum midazolam concentrations between 100–400 g/l were sufficient for sedation. Dosage had to be increased during therapy according to an increased midazolam clearance. The evaluation of the sedation score showed that sedation of artifically ventilated infants and young children can be established by continuous intravenous infusion of midazolam.Dedicated to the 65th birthday of Prof.Dr. Erich Gladtke     

Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt

Aim: To investigate the impact of different measures, implemented by clinical pharmacists, on prescribing error rates in a paediatric intensive care unit (PICU) in Cairo, Egypt. Methods: We performed a pre–post study of prescribing errors in a 12 bed PICU. We utilized a chart review method for the detection of prescribing errors. The rate and potential severity of prescribing errors were determined before and then after the implementation of the medication error reducing measures. These measures included the use of a new structured medication order chart, physician education, provision of dosing assists and physician performance feedback. Results: We evaluated 1417 medication orders for 139 patients preintervention and 1097 orders for 101 patients postintervention. Of preintervention orders, 1107 (78.1%) had at least one prescribing error. The intervention resulted in significant reduction in prescribing error rate to 35.2% postintervention (p < 0.001). The intervention resulted also in a significant reduction in the rate of potentially severe errors from 29.7% preintervention to 7% postintervention (p < 0.001) and the rate of potentially moderate errors from 39.8% preintervention to 24.2% postintervention (p < 0.001). Besides, rates of all types of prescribing errors were declined to different degrees as a result of the intervention. Conclusion: Clinical pharmacists’ activities, focusing on improving physician‐nurse communication, physician drug knowledge and awareness of errors, were shown effective in reducing the rate of prescribing errors and their potential severity in a PICU.     

Postmortem examinations in a statewide audit of neonatal intensive care unit admissions in Australia in 1992*

The objectives of the investigation were (i) to study infants registered in a statewide audit of tertiary neonatal intensive care units in New South Wales, Australia in 1992 and who died, and (ii) to examine postmortem rates, quality of postmortem reports and compare clinical cause of death with postmortem report. Death rates, data on clinical cause of death and postmortem status were collected prospectively as part of the routine audit. Postmortem reports were examined by LS. Fifteen percent of the cohort died and 43% had a postmortem examination. The postmortem rate was highest in the 28-36 week gestation group and in babies dying of pulmonary haemorrhage, intracranial haemorrhage or sudden infant death syndrome. Fewer than 50% of babies with a major congenital anomaly had a postmortem. The postmortem changed the major diagnosis in 10% of cases and added useful information in 17%. We conclude that postmortem examination should be an essential part of any audit of neonatal intensive care unit outcomes.     

Age is of influence on midazolam requirements in a paediatric intensive care unit

AIM: To test that age is of influence on midazolam requirements during prolonged mechanical ventilation in critically ill children. METHODS: Retrospective observational study of children (28 days-18 year) admitted between January 1st 2002 and January 1st 2005 who needed controlled mechanical ventilation for 5 days and initial sedation with midazolam were included. Exclusion criteria were psychomotor retardation, therapeutic use of midazolam, ventilator weaning within 5 days, kidney or liver failure. RESULTS: A total of 1186 children were admitted, of which 58 children were included. The children were divided into three age groups: 28 days-1 year (n = 28), 1-4 years (n = 16) and older than 4 years (n = 14). Within 2 days the children age 1-4 years received the maximum midazolam dosage (0.3 mg/kg/h). In addition, the mean total dose of midazolam was higher at all days for this age group. At day 5 none of the children between 1 and 4 years could be sedated with midazolam alone. CONCLUSIONS: Our data showed that children between 1 and 4 years needed higher doses of midazolam as compared to children who were younger and older. Furthermore, we observed that midazolam alone is a poor sedative for all age groups. The influence of and mechanisms for possible age related effects on midazolam requirements remain to be elucidated, as well as the position of midazolam as a first line drug for PICU sedation.     

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.     

Comparison of human metapneumovirus and respiratory syncytial virus in children admitted to a paediatric intensive care unit

Aim: To describe the clinical presentation and course of children admitted to the paediatric intensive care unit (PICU) with human metapneumovirus (hMPV) infection, and compare them with children admitted to the PICU with respiratory syncytial virus (RSV) infection. Methods: hMPV was identified by immunofluorescence in 22 children admitted to the PICU over a 16‐month period. The medical records of these children were reviewed retrospectively, and their clinical and laboratory data were compared with 66 children admitted to the PICU with positive tests for RSV over the same period. Results: Children admitted to the PICU with hMPV were significantly older than children with RSV (P= 0.003). Children with hMPV presented more commonly with pneumonia or pneumonitis (29% vs. 16%), and less commonly with bronchiolitis (43% vs. 68%) than RSV (P= 0.13). Invasive ventilation was required in 10 patients (48%) with hMPV, and non‐invasive ventilation was required in a further 5 (28%), similar to patients with RSV. Children with hMPV were more likely to have an underlying co‐morbidity (P= 0.11). Conclusions: Children admitted to the PICU with hMPV have a similar disease presentation and severity as children admitted with RSV, including some with extremely severe disease who require additional ventilatory or cardiovascular support. Children with hMPV are likely to be older than those with RSV, and more likely to present with pneumonia and less likely to present with bronchiolitis.     

Risk-stratified nosocomial infection surveillance in a neonatal intensive care unit: Report on 24 months of surveillance

Objective : To document the nosocomial infection rate in a single neonatal intensive care unit (NICU) in terms of patient workload and device utilization.
Methodology : Nosocomial infections have been identified and documented by the methodology described by the National Nosocomial Infection Surveillance System (NNIS), Centres for Disease Control, Atlanta. In addition, antibiotic usage has been surveyed in the NICU and standardized measures of patient exposure to antibiotics stratified by birthweight and gestational age have been described.
Results : Overall nosocomial infection rates compared favourably with the published NNIS figures at 6.2 infections per 100 admissions or 4.8 per 1000 patient days. Infection rates were significantly higher in lower birthweight groups. Device-related infection rates in each birthweight cohort were also very close to published figures and varied less with birthweight group. Antibiotic exposure averaged 12% of total admission days, less than previously published data.
Conclusions : The NNIS system is applicable to Australian NICU and provides an effective tool for monitoring infection episodes.     

Respiratory syncytial virus infection in infants admitted to paediatric intensive care units in London,and in their families

We carried out a study in five London paediatric intensive care units (PICUs), with the objectives of describing a cohort of infants with respiratory syncytial virus (RSV) infection, comparing hospital diagnosis with PCR results and investigating the spread of RSV in families. Eligible infants were under 5 months old and admitted betweem November 1998 and October 1999 with respiratory failure, apnoea and/or bradycardia or acute life threatening episodes (ALTE). We diagnosed RSV by PCR analysis of nasopharyngeal aspirate, and in contacts by PCR of pernasal swabs. Of the 137 eligible infants, 66% (91/137) were recruited; of these, 82% (75/91) had RSV, with 47% (35/75) diagnosed by hospital laboratory tests and 93% (70/75) by PCR. The median duration of ventilation was 4.4 days, the length of stay on PICU, 8.6 days, and the length of stay in hospital, 15.9 days. In most families (62%), the parents and siblings developed symptoms of RSV infection at the same time as the infant. When the index infant was a secondary case, primary cases occurred in both older siblings (16 families) and adults (11 families). Silent RSV infection occurred frequently amongst children and adults. RSV is under-diagnosed in PICUs. PCR increases the rate of diagnosis of RSV compared to routine hospital diagnostic methods. Young infants are most often infected at the same time as or before their parents and siblings, indicating that the source may be outside the household; vaccinating family members may not prevent RSV infection in infants.