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Gladen KM, Tellez D, Napolitano N, Edwards LR, Sanders RC, Kojima T, Malone MP, Shults J, Krawiec C, Ambati S, McCarthy R, Branca A, Polikoff LA, Jung P, Parsons SJ, Mallory PP, Komeswaran K, Page-Goertz C, Toal MC, Bysani GK, Meyer K, Chiusolo F, Glater-Welt LB, Al-Subu A, Biagas K, Hau Lee J, Miksa M, Giuliano JS, Kierys KL, Talukdar AM, DeRusso M, Cucharme-Crevier L, Adu-Arko M, Shenoi AN, Kimura D, Flottman M, Gangu S, Freeman AD, Piehl MD, Nuthall GA, Tarquinio KM, Harwayne-Gidansky I, Hasegawa T, Rescoe ES, Breuer RK, Kasagi M, Nadkarni VM, Nishisaki A. Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020). Pediatr Crit Care Med 2024; 25:147-158. [PMID: 37909825 PMCID: PMC10841296 DOI: 10.1097/pcc.0000000000003387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children. DESIGN/SETTING Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020. PATIENTS Critically ill children, 0 to 17 years old, undergoing TI in PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002). CONCLUSIONS In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.
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Affiliation(s)
- Kelsey M Gladen
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - David Tellez
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lauren R Edwards
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE
| | - Ronald C Sanders
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Matthew P Malone
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Justine Shults
- Department of Biostatistics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Conrad Krawiec
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA
| | - Shashikanth Ambati
- Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, NY
| | - Riley McCarthy
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Aline Branca
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Lee A Polikoff
- Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School at Brown University, Providence, RI
| | - Philipp Jung
- Department of Pediatrics, University Children's Hospital, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Simon J Parsons
- Department of Pediatrics, Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, AB, Canada
| | | | | | - Christopher Page-Goertz
- Pediatric Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Megan C Toal
- Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - G Kris Bysani
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX
| | - Keith Meyer
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Herber Wertheim College of Medicine Florida International University, Miami, FL
| | - Fabrizio Chiusolo
- Anesthesia and Critical Care Medicine, ARCO, Bambino Gesú Children's Hospital, Rome, Italy
| | - Lily B Glater-Welt
- Division of Pediatric Critical Care, Cohen Children's Medical Center of New York, Queens, NY
| | - Awni Al-Subu
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Katherine Biagas
- Pediatric Critical Care Medicine, Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Michael Miksa
- Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - John S Giuliano
- Department of Pediatrics, Section of Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Krista L Kierys
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | - Andrea M Talukdar
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE
| | | | - Laurence Cucharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Michelle Adu-Arko
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Asha N Shenoi
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Dai Kimura
- Critical Care Medicine, Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL
| | - Molly Flottman
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Shantaveer Gangu
- Critical Care Medicine, Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL
| | - Ashley D Freeman
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA
| | - Mark D Piehl
- Pediatric Critical Care Medicine, Department of Pediatrics, WakeMed Children's Hospital, Raleigh, NC
| | - G A Nuthall
- Pediatric Critical Care, Department of Pediatrics, Starship Children's Hospital, Auckland, New Zealand
| | - Keiko M Tarquinio
- Pediatric Critical Care Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ilana Harwayne-Gidansky
- Pediatric Critical Care Medicine, Department of Pediatrics, Bernard and Millie Duker Children's Hospital, Albany, NY
| | - Tatsuya Hasegawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Erin S Rescoe
- Division of Pediatric Critical Care, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY
| | - Ryan K Breuer
- Division of Critical Care Medicine, John R. Oishei Children's Hospital, Buffalo, NY
| | - Mioko Kasagi
- Pediatric Critical Care and Emergency Medicine, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Capone CA, Emerson B, Sweberg T, Polikoff L, Turner DA, Adu‐Darko M, Li S, Glater‐Welt LB, Howell J, Brown CA, Donoghue A, Krawiec C, Shults J, Breuer R, Swain K, Shenoi A, Krishna AS, Al‐Subu A, Harwayne‐Gidansky I, Biagas KV, Kelly SP, Nuthall G, Panisello J, Napolitano N, Giuliano JS, Emeriaud G, Toedt‐Pingel I, Lee A, Page‐Goertz C, Kimura D, Kasagi M, D'Mello J, Parsons SJ, Mallory P, Gima M, Bysani GK, Motomura M, Tarquinio KM, Nett S, Ikeyama T, Shetty R, Sanders RC, Lee JH, Pinto M, Orioles A, Jung P, Shlomovich M, Nadkarni V, Nishisaki A. Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS). Acad Emerg Med 2022; 29:406-414. [PMID: 34923705 DOI: 10.1111/acem.14431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/23/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. METHODS Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. RESULTS A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. CONCLUSIONS While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.
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Affiliation(s)
- Christine A. Capone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Beth Emerson
- Department of Pediatrics Yale University School of Medicine New Haven Connecticut USA
| | - Todd Sweberg
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Lee Polikoff
- Division of Critical Care Medicine, Department of Pediatrics The Warren Alpert Medical School of Brown University Providence Rhode Island USA
| | - David A. Turner
- Division of Pediatric Critical Care, Department of Pediatrics Duke Children's Hospital and Health Center Durham North Carolina USA
| | - Michelle Adu‐Darko
- Division of Pediatric Critical Care Medicine Department of Pediatrics University of Virginia Children's Hospital Charlottesville Virginia USA
| | - Simon Li
- Department of Pediatrics Robert Wood Johnson University New Brunswick New Jersey USA
| | - Lily B. Glater‐Welt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Joy Howell
- Pediatric Critical Care Medicine Department of Pediatrics New York Presbyterian Hospital/Weill Cornell Medical Center New York New York USA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Aaron Donoghue
- Division of Emergency Medicine Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Penn State Health Children's Hospital Hershey Pennsylvania USA
| | - Justine Shults
- Division of Biostatistics Department of Biostatistics and Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Ryan Breuer
- Department of Pediatrics John R. Oishei Children's Hospital Buffalo New York USA
| | - Kelly Swain
- Pediatric and Cardiac Critical Care Duke University Medical Center Durham North Carolina USA
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Ashwin S. Krishna
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Awni Al‐Subu
- Division of Pediatric Critical Care Medicine Department of Pediatrics UW Health American Family Children's Hospital University of Wisconsin‐Madison Madison Wisconsin USA
| | - Ilana Harwayne‐Gidansky
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Katherine V. Biagas
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Serena P. Kelly
- Department of Pediatrics Oregon Health & Science University Doernbecher Children's Hospital Portland Oregon USA
| | - Gabrielle Nuthall
- Pediatric Critical Care Medicine Starship Children's Hospital Auckland New Zealand
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Natalie Napolitano
- Respiratory Care Department The Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Guillaume Emeriaud
- Pediatric Critical Care Medicine CHU Sainte Justine Université de Montréal Montreal Quebec Canada
| | - Iris Toedt‐Pingel
- Division of Pediatric Critical Care University of Vermont Children's Hospital Burlington Vermont USA
| | - Anthony Lee
- Division of Critical Care Medicine Nationwide Children's Hospital Ohio State University College of Medicine Columbus Ohio USA
| | | | - Dai Kimura
- Department of Pediatrics University of Tennessee Health Science Center Le Bonheur Children's Hospital Memphis Tennessee USA
| | - Mioko Kasagi
- Pediatric Critical Care & Emergency Medicine Tokyo Metropolitan Children's Medical Center Tokyo Japan
| | - Jenn D'Mello
- Section of Pediatric Emergency Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Simon J. Parsons
- Section of Critical Care Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Palen Mallory
- Department of Pediatrics Duke University Durham North Carolina USA
| | - Masafumi Gima
- Critical Care Medicine National Center for Child Health and Development Tokyo Japan
| | | | - Makoto Motomura
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine Department of Pediatrics Emory University School of Medicine Children's Healthcare of Atlanta Egleston Georgia USA
| | - Sholeen Nett
- Section of Pediatric Critical Care Medicine Children's Hospital at Dartmouth, Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire USA
| | - Takanari Ikeyama
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Rakshay Shetty
- Department of Pediatrics Rainbow Children's Hospital Bangalore India
| | - Ronald C. Sanders
- Section of Critical Care University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Jan Hau Lee
- Children's Intensive Care Unit KK Women's and Children's Hospital Singapore Singapore
| | - Matthew Pinto
- Pediatric Critical Care Medicine Maria Fareri Children's Hospital Valhalla New York USA
| | - Alberto Orioles
- Division of Critical Care Children's Hospitals and Clinics of Minnesota Minneapolis Minnesota USA
| | - Philipp Jung
- Paediatric Department University Hospital Schleswig‐Holstein Campus Lübeck Germany
| | - Mark Shlomovich
- Division of Pediatric Critical Care Medicine Albert Einstein College of Medicine Children's Hospital at Montefiore Bronx New York USA
| | - Vinay Nadkarni
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Akira Nishisaki
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
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Nishisaki A, Lee A, Li S, Sanders RC, Brown CA, Rehder KJ, Napolitano N, Montgomery VL, Adu-Darko M, Bysani GK, Harwayne-Gidansky I, Howell JD, Nett S, Orioles A, Pinto M, Shenoi A, Tellez D, Kelly SP, Register M, Tarquinio K, Simon D, Krawiec C, Shults J, Nadkarni V. Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators. Crit Care Med 2021; 49:250-260. [PMID: 33177363 DOI: 10.1097/ccm.0000000000004725] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. DESIGN Multicenter time-series study. SETTING PICUs in the United States. PATIENTS All patients received tracheal intubations in ICUs. INTERVENTIONS We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. MEASUREMENTS AND MAIN RESULTS The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). CONCLUSIONS Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.
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Affiliation(s)
- Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anthony Lee
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kyle J Rehder
- Division of Pediatric Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Vicki L Montgomery
- Division of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY
| | - Michelle Adu-Darko
- Division of Critical Care, Children's Hospital of the University of Virginia, Charlottesville, VA
| | - G Kris Bysani
- Pediatric Critical Care Medicine, Pediatric Acute Care Associates of North Texas PLLC, Medical City Children's Hospital, Dallas, TX
| | | | - Joy D Howell
- Department of Pediatrics, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Sholeen Nett
- Division of Pediatric Critical Care, Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Alberto Orioles
- Division of Critical Care, Children's Hospital and Clinics of Minnesota, Minneapolis, MN
| | - Matthew Pinto
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Maria Fareri Children's Hospital, Valhalla, NY
| | - Asha Shenoi
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY
| | - David Tellez
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Serena P Kelly
- Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Portland, OR
| | - Melinda Register
- Department of Respiratory Therapy, Children's Healthcare of Atlanta, Atlanta, GA
| | - Keiko Tarquinio
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta GA
| | - Dennis Simon
- Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Conrad Krawiec
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA
| | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Watson RS, Asaro LA, Hutchins L, Bysani GK, Killien EY, Angus DC, Wypij D, Curley MAQ. Risk Factors for Functional Decline and Impaired Quality of Life after Pediatric Respiratory Failure. Am J Respir Crit Care Med 2019; 200:900-909. [PMID: 31034245 PMCID: PMC6812438 DOI: 10.1164/rccm.201810-1881oc] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 04/24/2019] [Indexed: 11/16/2022] Open
Abstract
Rationale: Poor outcomes of adults surviving critical illness are well documented, but data in children are limited.Objectives: To identify factors associated with worse postdischarge function and health-related quality of life (HRQL) after pediatric acute respiratory failure.Methods: We assessed functional status at baseline, discharge, and 6 months after pediatric ICU discharge and HRQL 6 months after discharge in 2-week- to 17-year-olds mechanically ventilated for acute respiratory failure in the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) trial. We assessed HRQL via Infant and Toddler Quality of Life Questionnaire-97 (<2 yr old) or Pediatric Quality of Life Inventory (≥2 yr old). We categorized patients with normal baseline function as having impaired HRQL if scores were greater than 1 SD below mean norms for Infant and Toddler Quality of Life Questionnaire-97 growth and development or Pediatric Quality of Life Inventory total score.Measurements and Main Results: One-fifth (n = 192) of 949 patients declined in function from baseline to postdischarge; 20% (55/271) had impaired growth and development; 19% (64/343) had impaired HRQL. In multivariable analyses, decline in function was associated with baseline impaired function, prematurity, cancer, respiratory failure etiology, ventilation duration, and clonidine (odds ratio [OR] = 2.14; 95% confidence interval [CI] = 1.22-3.76). Independent predictors of impaired growth and development included methadone (OR = 2.27; 95% CI = 1.18-4.36) and inadequate pain management (OR = 2.94; 95% CI = 1.39-6.19). Impaired HRQL was associated with older age, non-white or Hispanic race, cancer, and inadequate sedation management (OR = 3.15; 95% CI = 1.74-5.72).Conclusions: Postdischarge morbidity after respiratory failure is common and associated with admission factors, exposure to critical care therapies, and pain and sedation management.
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Affiliation(s)
- R Scott Watson
- Department of Pediatrics, University of Washington, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Larissa Hutchins
- Department of Patient Care Services, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - G Kris Bysani
- Medical City Children's Hospital, Dallas, Texas
- Pediatric Acute Care Associates of North Texas, Dallas, Texas
| | - Elizabeth Y Killien
- Department of Pediatrics, University of Washington, Seattle, Washington
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Martha A Q Curley
- School of Nursing and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
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5
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Natale JE, Lebet R, Joseph JG, Ulysse C, Ascenzi J, Wypij D, Curley MAQ, Wypij D, Allen GL, Angus DC, Asaro LA, Ascenzi JA, Bateman ST, Borasino S, Bowens CD, Bysani GK, Cheifetz IM, Cowl AS, Dodson BL, Faustino EVS, Fineman LD, Flori HR, Franck LS, Gedeit RG, Grant MJC, Harabin AL, Haskins-Kiefer C, Hertzog JH, Hutchins L, Kirby AL, Lebet RM, Matthay MA, McLaughlin GE, Natale JE, Oren PP, Polavarapu N, Schneider JB, Schwarz AJ, Shanley TP, Simone S, Singer LP, Sorce LR, Truemper EJ, Vander Heyden MA, Watson RS, Wells CR. Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial. J Pediatr 2017; 184:204-208.e1. [PMID: 28410087 DOI: 10.1016/j.jpeds.2017.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/05/2017] [Accepted: 02/02/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their child's participation in a multisite pediatric critical care clinical trial. STUDY DESIGN We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31-center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. RESULT Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non-Hispanic White (White), non-Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56-2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10-1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37-3.36, P < .001). CONCLUSIONS Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their child's participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. TRIAL REGISTRATION ClinicalTrials.gov: NCT00814099.
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Affiliation(s)
- Joanne E Natale
- Department of Pediatrics, University of California, Davis, CA.
| | - Ruth Lebet
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jill G Joseph
- Betty Irene Moore School of Nursing, University of California, Davis, CA
| | - Christine Ulysse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Judith Ascenzi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children's Hospital, Baltimore, MD
| | - David Wypij
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA; Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Critical Care and Cardiovascular Nursing, Boston Children's Hospital, Boston, MA
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Torres A, Skender KM, Wohrley JD, Aldag JC, Raff GW, Bysani GK, Geiss DM. Pulse Oximetry in Children with Congenital Heart Disease: Effects of Cardiopulmonary Bypass and Cyanosis. J Intensive Care Med 2016; 19:229-34. [PMID: 15296623 DOI: 10.1177/0885066604263819] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this prospective, observational study with consecutive sampling was to assess the reliability, bias, and precision of Nellcor N-395 (N) and Masimo SET Radical (M) pulse oximeters in children with cyanotic congenital heart disease and children with congenital heart disease recovering from cardiopulmonary bypass-assisted surgery admitted to a cardiovascular operating suite and pediatric intensive care unit at a tertiary care community hospital. Forty-six children with congenital heart disease were studied in 1 of 2 groups: (1) those recovering from cardiopulmonary bypass with a serum lactic acid > 2 mmol/L, and (2) those with co-oximetry measured saturations (SaO 2) < 90% and no evidence of shock. Measurements of SaO 2 of whole blood were compared to simultaneous pulse oximetry saturations (SpO 2). Data were analyzed to detect significant differences in SpO 2 readout failures between oximeters and average SpO 2 - SaO 2 ± 1 SD for each oximeter. A total of 122 SaO 2 measurements were recorded; the median SaO 2 was 83% (57 - 100%). SpO 2 failures after cardiopulmonary bypass were 41% (25/61) for N versus 10% (6/61) for M ( P < .001). There was a significant difference in bias (ie, average SpO 2 - SaO 2) and precision (± 1 SD) between oximeters (N, 1.1 ± 3.3 vs M, -0.2 ± 4.1; P < .001) in the postcardiopulmonary bypass group but no significant difference in bias and precision between oximeters in the cyanotic congenital heart disease group (N, 2.9 ± 4.6 vs M, 2.8 ± 6.2; P = .848). The Nellcor N-395 pulse oximeter failed more often immediately after cardiopulmonary bypass than did the Masimo SET Radical pulse oximeter. SpO2 measured with both oximeters overestimated SaO2 in the presence of persistent hypoxemia.
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Affiliation(s)
- Adalberto Torres
- University of Illinois College of Medicine at Peoria, Illinois, USA.
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Sanders RC, Nett ST, Davis KF, Parker MM, Bysani GK, Adu-Darko M, Bird GL, Cheifetz IM, Derbyshire AT, Emeriaud G, Giuliano JS, Graciano AL, Hagiwara Y, Hefley G, Ikeyama T, Jarvis JD, Kamat P, Krishna AS, Lee A, Lee JH, Li S, Meyer K, Montgomery VL, Nagai Y, Pinto M, Rehder KJ, Saito O, Shenoi AN, Taekema HC, Tarquinio KM, Thompson AE, Turner DA, Nadkarni VM, Nishisaki A. Family Presence During Pediatric Tracheal Intubations. JAMA Pediatr 2016; 170:e154627. [PMID: 26954533 DOI: 10.1001/jamapediatrics.2015.4627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated. OBJECTIVE To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs. EXPOSURES Family presence and no FP during TI in the PICU. MAIN OUTCOMES AND MEASURES The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level. RESULTS A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders. CONCLUSIONS AND RELEVANCE Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.
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Affiliation(s)
- Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock
| | - Sholeen T Nett
- Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Katherine Finn Davis
- Center for Pediatric Nursing Research and Evidence Based Practice, Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Margaret M Parker
- Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, New York
| | - G Kris Bysani
- Pediatric Acute Care Associates of North Texas PLLC, Medical City Children's Hospital, Dallas
| | | | - Geoffrey L Bird
- Division of Cardiac Critical Care Medicine, Department of Pediatrics and Anesthesia/Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ira M Cheifetz
- Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | | | | | | | - Ana Lia Graciano
- Pediatric Critical Care Medicine, Children's Hospital of Central California, Fresno
| | | | - Glenda Hefley
- Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock
| | | | - J Dean Jarvis
- Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
| | - Ashwin S Krishna
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington
| | - Anthony Lee
- Nationwide Children's Hospital, Ohio State University, Columbus
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Singapore
| | - Simon Li
- Pediatric Intensive Care Unit, Maria Fareri Children's Hospital, Westchester, New York
| | - Keith Meyer
- Division of Critical Care Medicine, Miami Children's Hospital, Miami, Florida
| | - Vicki L Montgomery
- Division of Critical Care, Department of Pediatrics, University of Louisville and Kosair Children's Hospital, Louisville, Kentucky
| | - Yuki Nagai
- Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Matthew Pinto
- Pediatric Intensive Care Unit, Maria Fareri Children's Hospital, Westchester, New York
| | - Kyle J Rehder
- Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Osamu Saito
- Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Asha N Shenoi
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington
| | | | - Keiko M Tarquinio
- Critical Care Medicine, Rhode Island/Hasbro Children's Hospital, Providence
| | - Ann E Thompson
- Critical Care Medicine and Pediatrics, Pittsburgh Children's Hospital, Pittsburgh, Pennsylvania
| | - David A Turner
- Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
BACKGROUND/PURPOSE Hospital mortality rate among children with hypoplastic left heart syndrome (HLHS) after cardiac repair is well documented, but comparable data after noncardiac, surgical procedures are unknown. The authors hypothesized an increasing number of noncardiac procedures were being performed on children with HLHS, less than 2 years of age, from 1988 to 1997, and that these procedures were associated with a substantial mortality rate. METHODS A retrospective review of hospital discharge data for 2,457 children less than 2 years of age with HLHS for 1988 through 1997 was performed. The authors examined the outcomes of HLHS children undergoing only noncardiac surgical procedures during their hospital stay. Differences in hospital mortality rates between 1988 through 1992 versus 1993 through 1997 were assessed using the Chi2 square statistic. RESULTS Nineteen percent of the 147 children with HLHS undergoing noncardiac, surgical procedures died (95% CI, 13% to 25%). Comparing the 2 study periods, there was no significant change in outcome among HLHS children undergoing noncardiac, surgical procedures (78% v. 83%; P >.1). There was no significant difference in the percentage of hospital discharges with noncardiac, surgical procedures performed per year. CONCLUSIONS Although children with HLHS were not undergoing an increase in the number of noncardiac surgical procedures performed annually, even minor surgical procedures were associated with considerable mortality. Outcomes after noncardiac surgery in high-risk children with congenital heart disease warrant further investigation.
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Affiliation(s)
- Adalberto Torres
- Division of Critical Care, Department of Pediatrics, University of Illinois College of Medicine and Children's Hospital of Illinois at St Francis Medical Center, Peoria, IL 61637, USA
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9
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Bysani GK, Rucoba RJ, Noah ZL. Treatment of hydrocarbon pneumonitis. High frequency jet ventilation as an alternative to extracorporeal membrane oxygenation. Chest 1994; 106:300-3. [PMID: 8020296 DOI: 10.1378/chest.106.1.300] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A child presented with hydrocarbon ingestion leading to pneumonitis and adult respiratory distress syndrome (ARDS). Treatment with conventional ventilation in this child led to very high pressures and pulmonary air leaks. Treatment with high frequency jet ventilation (HFJV) resulted in less barotrauma, resolution of air leak, and clinical improvement. Thus, HFJV is an acceptable alternative to both conventional ventilation and extracorporeal membrane oxygenation in the treatment of hydrocarbon pneumonitis leading to ARDS.
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Affiliation(s)
- G K Bysani
- Department of Pediatrics, Children's Memorial Hospital, Chicago
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Abstract
Reactive oxygen species are a major cause of damage occurring in ischemic tissue after reperfusion. During reperfusion transitional metals such as iron are required for reactive oxygen species to mediate their major toxic effects. Xanthine oxidase is an important source of reactive oxygen species during ischemia-reperfusion injury, but not in all organs or species. Because cytochrome P-450 enzymes are an important pulmonary source of superoxide anion (O2-.) generation under basal conditions and during hyperoxia, and provide iron catalysts necessary for hydroxyl radical (.OH) formation and propagation of lipid peroxidation, we postulated that cytochrome P-450 might have a potential role in mediating ischemia-reperfusion injury. In this report, we explored the role of cytochrome P-450 enzymes in a rabbit model of reperfusion lung injury. The P-450 inhibitors 8-methoxypsoralen, piperonyl butoxide, and cimetidine markedly decreased lung edema from transvascular fluid flux. Cimetidine prevented the reperfusion-related increase in lung microvascular permeability, as measured by movement of 125I-albumin from the vascular space into lung water and alveolar fluid. P-450 inhibitors also prevented the increase in lung tissue levels of thiobarbituric acid reactive products in the model. P-450 inhibitors did not block enhanced O2-. generation by ischemic reperfused lungs, measured by in vivo reduction of succinylated ferricytochrome c in lung perfusate, but did prevent the increase in non-protein-bound low molecular weight chelates of iron after reperfusion. Thus, cytochrome P-450 enzymes are not likely a major source of enhanced O2-. generation, but serve as an important source of iron in mediating oxidant injury to the rabbit lung during reperfusion. These results suggest an important role of cytochrome P-450 in reperfusion injury to the lung and suggest potential new therapies for the disorder.
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Affiliation(s)
- G K Bysani
- Division of Pediatric Critical Care, University of Tennessee, Memphis
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11
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Abstract
The specific binding of radiolabeled polymyxin B (PmB) to rat alveolar macrophages was investigated. PmB retained its ability to inhibit lipopolysaccharide-induced tumor necrosis factor production by macrophages as long as one of five amino groups on PmB was unbound. Binding was saturable and temperature- and time-dependent, reaching steady state by 30 min at 37 degrees C and by 18 h at 4 degrees C. Macrophages had approximately 1.6 X 10(7) (Kd = 0.28 nM) PmB binding sites per cell. Lipid A had no appreciable effect on the number of sites. Binding did not occur to rat platelets, L929 fibroblast cells, a rat thymoma cell line, or precursor monocytic and myeloid cell lines. Precursor cells activated with 12-O-tetradecanoylphorbol-13-acetate acquired binding similar to that seen in alveolar macrophages, but L929 fibroblasts did not. Binding sites were sensitive to trypsin but not to phospholipase C. PmB may interact with specific binding sites involved in lipopolysaccharide-induced activation, production, or release of tumor necrosis factor by macrophages, inhibiting the effects of lipopolysaccharide on macrophages.
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Affiliation(s)
- G K Bysani
- Cardiopulmonary-Critical Care Division, St. Jude Children's Research Hospital, Memphis
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12
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Kennedy TP, Michael JR, Hoidal JR, Hasty D, Sciuto AM, Hopkins C, Lazar R, Bysani GK, Tolley E, Gurtner GH. Dibutyryl cAMP, aminophylline, and beta-adrenergic agonists protect against pulmonary edema caused by phosgene. J Appl Physiol (1985) 1989; 67:2542-52. [PMID: 2558103 DOI: 10.1152/jappl.1989.67.6.2542] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Phosgene is a toxic oxidant gas that causes the adult respiratory distress syndrome in exposed workers. Phosgene exposure markedly increased lung weight gain in buffer-perfused isolated rabbit lungs (31 +/- 5 g over 60 min after phosgene vs. 7.7 +/- 1.2 in control lungs, P less than 0.01) and markedly increased the lung leak index for 125I-albumin (0.28 +/- 0.03 after phosgene vs. 0.02 +/- 0.01 in control lungs, P less than 0.01). Pretreatment with dibutyryl adenosine 3',5' -cyclic monophosphate (DBcAMP), aminophylline, or terbutaline plus isoproterenol prevented the increase in lung weight caused by phosgene (31 +/- 5 g phosgene, 11.7 +/- 2.8 DBcAMP, 7.5 +/- 2.5 aminophylline, 6.1 +/- 1 terbutaline and isoproterenol, 6.1 +/- 1.2 control + aminophylline, and 7.7 +/- 1.2 control; all treatments were P less than 0.01 vs. the untreated phosgene group and not significantly different from control lungs). Pretreatment with aminophylline prevented the increase in lung leak index for 125I-albumin (0.28 +/- 0.03 after phosgene vs. 0.06 +/- 0.02 in aminophylline-treated lungs, P less than 0.01). Posttreatment with aminophylline and terbutaline also prevented the increase in lung weight caused by phosgene. These results indicate that phosgene dramatically increases the movement of fluid and protein across the pulmonary vasculature and that treatment with DBcAMP, aminophylline, terbutaline, or isoproterenol markedly reduces the pulmonary edema caused by phosgene.
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Affiliation(s)
- T P Kennedy
- Division of Pulmonary Medicine, University of Tennessee Center for Health Sciences, Memphis 38101
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13
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Stokes DC, Shenep JL, Fishman M, Hildner WK, Bysani GK, Rufus K. Polymyxin B prevents lipopolysaccharide-induced release of tumor necrosis factor-alpha from alveolar macrophages. J Infect Dis 1989; 160:52-7. [PMID: 2543712 DOI: 10.1093/infdis/160.1.52] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Polymyxin B (PmB) blocks many of the toxic effects of lipopolysaccharide by mechanisms that are not yet understood. The production of tumor necrosis factor-alpha (TNF-alpha) by isolated rat alveolar macrophages in response to lipopolysaccharide and macrophage-activating factor was blocked by PmB at concentrations of 100, 10, and 1 micrograms/ml. Gentamicin enhanced rather than inhibited TNF production at the 100-micrograms/ml concentrations and had no effect at low concentration. Similar inhibitory effects were induced by PmB in an in vivo model in which rat macrophage TNF production was stimulated by intratracheally injected lipopolysaccharide. Because many of the effects of lipopolysaccharide are mediated by TNF, this inhibition provides a mechanism to explain the protection afforded by PmB against lipopolysaccharide-induced toxicity.
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Affiliation(s)
- D C Stokes
- Cardiopulmonary Division, St. Jude Children's Research Hospital, Memphis, TN 38101-0318
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