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Baloglu O, Flagg LK, Suleiman A, Gupta V, Fast JA, Wang L, Worley S, Agarwal HS. Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients. J Pediatr Intensive Care 2024; 13:7-17. [PMID: 38571992 PMCID: PMC10987226 DOI: 10.1055/s-0041-1735873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022] Open
Abstract
Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.
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Affiliation(s)
- Orkun Baloglu
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Lauren K. Flagg
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Ahmad Suleiman
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Vedant Gupta
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Jamie A. Fast
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
| | - Hemant S. Agarwal
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
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Tasker RC. Editor's Choice Articles for December. Pediatr Crit Care Med 2023; 24:983-986. [PMID: 38055000 DOI: 10.1097/pcc.0000000000003396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Miranda M, Ray S, Boot E, Inwald D, Meena D, Kumar R, Davies P, Rivero-Bosch M, Sturgess P, Weeks C, Holliday K, Cuevas-Asturias S, Donnelly P, Elsaoudi A, Lillie J, Nadel S, Tibby S, Mitting R. Variation in Early Pediatric Intensive Care Management Strategies and Duration of Invasive Mechanical Ventilation for Acute Viral Bronchiolitis in the United Kingdom: A Retrospective Multicenter Cohort Study. Pediatr Crit Care Med 2023; 24:1010-1021. [PMID: 37493464 DOI: 10.1097/pcc.0000000000003333] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVES Management of mechanically ventilated patients with bronchiolitis is not standardized and duration of mechanical ventilation has been shown to vary widely between centers. The aim of this study was to examine practice in a large number of U.K. PICUs with a view to identify if early management choices relating to fluid prescription, sedative agent use, and endotracheal tube (ETT) placement were associated with differences in duration of invasive mechanical ventilation (IMV). DESIGN Retrospective multicenter cohort study. Primary outcome was duration of IMV. A hierarchical gamma generalized linear model was used to test for associations between practice variables (sedative and neuromuscular blocking agents, route of endotracheal intubation at 24 hr and fluid balance at 48 hr) and duration of IMV after adjustment for known confounders. SETTING Thirteen U.K. PICUs. Duration of 2 months between November and December 2019. PATIENTS Three hundred fifty infants receiving IMV for bronchiolitis. Excluded were patients receiving long-term ventilation, extracorporeal life support, or who died before separation from IMV. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After adjustment for confounders, several variables were associated with an increase in the geometric mean duration of IMV (expressed as a percentage) including: nasal ETT use, 16% (95% CI, 1-32%); neuromuscular blockade use, 39% (95% CI, 21-61%); and fluid balance at 48 hr, 13% per 100 mL/kg positive fluid balance (95% CI, -1% to 28%). The association of sedative use varied with class of agent. The use of an alpha-2 agonist alone was associated with a reduction in duration of IMV by 19% in relation to no sedative agent (95% CI, -31 to -5%), whereas benzodiazepine uses alone or with alpha-2 agonist in combination were similar to using neither agent. CONCLUSIONS Early management strategies for bronchiolitis were associated with the duration of IMV across U.K. centers after adjustment for confounders. Future work should prospectively assess the impact of fluid restriction, route of endotracheal intubation, and alpha-2 agonist use on duration of IMV in infants with bronchiolitis, with the aim of reducing seasonal bed pressure.
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Affiliation(s)
- Mariana Miranda
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Samiran Ray
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Elizabeth Boot
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - David Inwald
- Pediatric Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Daleep Meena
- Pediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ramesh Kumar
- Pediatric Intensive Care Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Patrick Davies
- Pediatric Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Maria Rivero-Bosch
- Pediatric Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Philippa Sturgess
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Charlotte Weeks
- Pediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Kathryn Holliday
- Pediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Sofia Cuevas-Asturias
- Pediatric Intensive Care Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Peter Donnelly
- Pediatric Intensive Care Unit, The Royal Hospital For Children, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Ahmed Elsaoudi
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jon Lillie
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Simon Nadel
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Paediatrics and Child Health, Imperial College, London, United Kingdom
| | - Shane Tibby
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Rebecca Mitting
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
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Straube TL, Rotta AT. Sedation, Relaxation, and a Tube in the Nose: Which Are Associated With Longer Mechanical Ventilation Woes? Early Management Strategies and Outcomes in Critical Bronchiolitis. Pediatr Crit Care Med 2023; 24:1086-1089. [PMID: 38055002 DOI: 10.1097/pcc.0000000000003361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Tobias L Straube
- Both authors: Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC
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Robino C, Toncelli G, Sorrentino LA, Fioccola A, Tedesco B, Giugni C, L'Erario M, Ricci Z. Fluid balance in critically ill children with lower respiratory tract viral infection: a cohort study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:10. [PMID: 37386553 DOI: 10.1186/s44158-023-00093-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/18/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Increasing evidence has associated positive fluid balance of critically ill patients with poor outcomes. The aim of this study was to explore the pattern of daily fluid balances and their association with outcomes in critically ill children with lower respiratory tract viral infection. METHODS A retrospective single-center study was conducted, in children supported with high-flow nasal cannula, non-invasive ventilation, or invasive ventilation. Median (interquartile range) daily fluid balances, cumulative fluid overload (FO) and peak FO variation, indexed as the % of admission body weight, over the first week of Pediatric Intensive Care Unit admission, and their association with the duration of respiratory support were assessed. RESULTS Overall, 94 patients with a median age of 6.9 (1.9-18) months, and a respiratory support duration of 4 (2-7) days, showed a median (interquartile range) daily fluid balance of 18 (4.5-19.5) ml/kg at day 1, which decreased up to day 3 to 5.9 (- 14 to 24.9) ml/kg and increased to 13 (- 11 to 29.9) ml/kg at day 7 (p = 0.001). Median cumulative FO% was 4.6 (- 0.8 to 11) and peak FO% was 5.7 (1.9-12.4). Daily fluid balances, once patients were stratified according to the respiratory support, were significantly lower in those requiring mechanical ventilation (p = 0.003). No correlation was found between all examined fluid balances and respiratory support duration or oxygen saturation, even after subgroup analysis of patients with invasive mechanical ventilation, or respiratory comorbidities, or bacterial coinfection, or of patients under 1 year old. CONCLUSIONS In a cohort of children with bronchiolitis, fluid balance was not associated with duration of respiratory support or other parameters of pulmonary function.
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Affiliation(s)
- Chiara Robino
- Department of Anesthesia and Critical Care, Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Guido Toncelli
- Department of Anesthesia and Critical Care, Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Laura Arianna Sorrentino
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Antonio Fioccola
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Brigida Tedesco
- Department of Anesthesia and Critical Care, Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Cristina Giugni
- Department of Anesthesia and Critical Care, Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Manuela L'Erario
- Department of Anesthesia and Critical Care, Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Zaccaria Ricci
- Department of Anesthesia and Critical Care, Pediatric Intensive Care Unit, Meyer Children's University Hospital, IRCCS, Florence, Italy.
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.
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Ortmann LA, Nabower A, Cullimore ML, Kerns E. Antibiotic use in nonintubated children with bronchiolitis in the intensive care unit. Pediatr Pulmonol 2023; 58:804-810. [PMID: 36440528 DOI: 10.1002/ppul.26256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Antibiotic use may shorten mechanical ventilation duration and length of stay for patients with bronchiolitis that require intubation. The goals of this study were to describe antibiotic use in previously healthy children with bronchiolitis admitted to the intensive care unit (ICU) for noninvasive respiratory support and to describe associations of early antibiotic use with clinical outcomes. METHODS The Pediatric Health Information Systems database was queried for children <2 years of age without significant comorbidities admitted to the ICU for bronchiolitis. Children requiring mechanical ventilation on the first ICU day were excluded. Two groups were analyzed: those patients receiving antibiotics on the first day of their ICU stay (early antibiotics), and those receiving no antibiotics on their first ICU day (no antibiotics). Primary outcome was the length of ICU stay. RESULTS A total of 11,029 admissions met criteria, 2522 (22.9%) in the early antibiotic group, and 8507 (77.1%) in the no antibiotic group. The use of early antibiotics varied by center from 10% to 54%. In multivariate analysis, the early antibiotic group had similar ICU length of stay compared to the no antibiotic group (relative risk, RR [95% confidence interval, CI] 1.01 [0.98-1.05]). For patients on noninvasive ventilation, the first ICU day early antibiotics did not impact ICU length of stay (RR [95% CI] 0.97 [0.92-1.02]) or need for intubation (RR [95% CI] 1.11 [0.77-1.58]). CONCLUSION Early antibiotic use was common with significant variation between centers. Early antibiotic use was not associated with improved clinical outcomes in children admitted to the ICU for noninvasive respiratory support for bronchiolitis.
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Affiliation(s)
- Laura A Ortmann
- Children's Hospital & Medical Center, Omaha, Nebraska, USA
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Aleisha Nabower
- Children's Hospital & Medical Center, Omaha, Nebraska, USA
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Melissa L Cullimore
- Children's Hospital & Medical Center, Omaha, Nebraska, USA
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ellen Kerns
- Children's Hospital & Medical Center, Omaha, Nebraska, USA
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Bem RA, van Woensel JBM. Toward Standardized Supportive Care During Invasive Mechanical Ventilation for Bronchiolitis: Time to Bundle Up for the Winter? Pediatr Crit Care Med 2021; 22:323-325. [PMID: 33657613 DOI: 10.1097/pcc.0000000000002644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Reinout A Bem
- All authors: Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
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