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Du Pont-Thibodeau G, Li SYH, Ducharme-Crevier L, Jutras C, Pantopoulos K, Farrell C, Roumeliotis N, Harrington K, Thibault C, Roy N, Shah A, Lacroix J, Stanworth SJ. Iron Deficiency in Anemic Children Surviving Critical Illness: Post Hoc Analysis of a Single-Center Prospective Cohort in Canada, 2019-2022. Pediatr Crit Care Med 2024; 25:344-353. [PMID: 38358779 DOI: 10.1097/pcc.0000000000003442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Many children leave the PICU with anemia. The mechanisms of post-PICU anemia are poorly investigated, and treatment of anemia, other than blood, is rarely started during PICU. We aimed to characterize the contributions of iron depletion (ID) and/or inflammation in the development of post-PICU anemia and to explore the utility of hepcidin (a novel iron marker) at detecting ID during inflammation. DESIGN Post hoc analysis of a single-center prospective study (November 2019 to September 2022). SETTING PICU, quaternary center, Canada. PATIENTS Children admitted to PICU with greater than or equal to 48 hours of invasive or greater than or equal to 96 hours of noninvasive ventilation. We excluded patients with preexisting conditions causing anemia or those admitted after cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Hematological and iron profiles were performed at PICU discharge on 56 participants of which 37 (37/56) were diagnosed with anemia. Thirty-three children (33/56; 59%) were younger than 2 years. Median Pediatric Logistic Organ Dysfunction score was 11 (interquartile range, 6-16). Twenty-four of the 37 anemic patients had repeat bloodwork 2 months post-PICU. Of those, four (4/24; 16%) remained anemic. Hematologic profiles were categorized as: anemia of inflammation (AI), iron deficiency anemia (IDA), IDA with inflammation, and ID (low iron stores without anemia). Seven (7/47; 15%) had AI at discharge, and one had persistent AI post-PICU. Three patients (3/47; 6%) had IDA at discharge; of which one was lost to follow-up and the other two were no longer anemic but had ID post-PICU. Eleven additional patients developed ID post-PICU. In the exploratory analysis, we identified a diagnostic cutoff value for ID during inflammation from the receiver operating characteristic curve for hepcidin of 31.9 pg/mL. This cutoff would increase the detection of ID at discharge from 6% to 34%. CONCLUSIONS The burden of ID in children post-PICU is high and better management strategies are required. Hepcidin may increase the diagnostic yield of ID in patients with inflammation.
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Affiliation(s)
| | - Shu Yin Han Li
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | | | - Camille Jutras
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Kostas Pantopoulos
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Catherine Farrell
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Nadia Roumeliotis
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Karen Harrington
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Céline Thibault
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Noémi Roy
- Department of Hematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Akshay Shah
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Simon J Stanworth
- Department of Hematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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Thibault C, Pont-Thibodeau GD, MacDonald S, Jutras C, Metras MÉ, Harrington K, Toledano B, Roumeliotis N, Farrell C, Lacroix J, Ducharme-Crevier L. Two months outcomes following delirium in the pediatric intensive care unit. Eur J Pediatr 2024:10.1007/s00431-024-05491-w. [PMID: 38520519 DOI: 10.1007/s00431-024-05491-w] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 03/25/2024]
Abstract
The lasting consequences of delirium in children are not well characterized. This study aimed to compare the two-month outcomes in pediatric intensive care unit (PICU) survivors according to the presence of delirium. Post-hoc analysis of a single-center prospective study of mechanically ventilated (invasive ventilation or non-invasive ventilation) children followed at the CHU Sainte-Justine PICU follow-up clinic two months after PICU discharge, between October 2018 and August 2022. Delirium was defined as one or more Cornell Assessment of Pediatric Delirium (CAPD) scores ≥ 9. Primary outcome was survivors' quality of life and secondary outcomes were sleep and posttraumatic stress and anxiety and depression in parents. Multivariable linear and logistic regression models assessed the independent associations between delirium and outcomes while adjusting for age, sex, comorbidity, diagnosis, severity of illness, PICU length of stay, and invasive mechanical ventilation. Of the 179 children included over a 47 month-period, 117 (65.4%) had delirium. Children with delirium were more commonly intubated (91.5% vs. 30.7%, p < 0.001) and had higher PELOD-2 scores (10 vs. 4, p < 0.001). On multivariable analysis, delirium was associated with a decreased quality of life at 2.3 months post discharge (p = 0.03). The severity of the delirium episode (higher scores of CAPD) was associated with a higher likelihood of sleep disturbances (OR 1.13, p = 0.01) and parental anxiety (OR 1.16, p = 0.01), in addition to lower quality of life (p = 0.03).Conclusions: Two months following their PICU stay, children with delirium had a lower quality of life, suggesting a lasting effect of delirium on children and their families.
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Affiliation(s)
- Celine Thibault
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Simon MacDonald
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Camille Jutras
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Marie-Élaine Metras
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, Québec, Canada
| | - Karen Harrington
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Baruch Toledano
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Catherine Farrell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal. Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Québec, H3T 1C5, Canada.
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3
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Ducharme-Crevier L, Furlong-Dillard J, Jung P, Chiusolo F, Malone MP, Ambati S, Parsons SJ, Krawiec C, Al-Subu A, Polikoff LA, Napolitano N, Tarquinio KM, Shenoi A, Talukdar A, Mallory PP, Giuliano JS, Breuer RK, Kierys K, Kelly SP, Motomura M, Sanders RC, Freeman A, Nagai Y, Glater-Welt LB, Wilson J, Loi M, Adu-Darko M, Shults J, Nadkarni V, Emeriaud G, Nishisaki A. Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU). Intensive Care Med Paediatr Neonatal 2024; 2:7. [PMID: 38404646 PMCID: PMC10891187 DOI: 10.1007/s44253-024-00035-4] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/09/2024] [Indexed: 02/27/2024]
Abstract
Background Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted. Methods We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO2 > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI. Results A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759). Conclusion In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte-Justine Université de Montréal, Montréal, QC H3T 1C5 Canada
| | - Jamie Furlong-Dillard
- Department of Pediatric Critical Care, Norton Children's Hospital, University of Louisville, Louisville, KY USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Matthew P Malone
- Division of Critical Care Medicine, Department of Pediatrics, The University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR USA
| | - Shashikanth Ambati
- Division of Pediatric Critical Care, Department of Pediatrics, Albany Medical Center, Albany, NY USA
| | - Simon J Parsons
- Section of Critical Care Medicine, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB Canada
| | - Conrad Krawiec
- Pediatric Critical Care, Department of Pediatrics, College of Medicine, Penn State Health Children's Hospital, Hershey, PA USA
| | - Awni Al-Subu
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI USA
| | - Lee A Polikoff
- Division of Pediatric Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA USA
| | - Keiko M Tarquinio
- College of Health Professions, the Medical University of South Carolina, Charleston, SC USA
| | - Asha Shenoi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Kentucky School of Medicine, Lexington, KY USA
| | - Andrea Talukdar
- Pediatric Critical Care, Medical Center/Children's Hospital and Medical Center of Omaha, University of Nebraska, Omaha, NE USA
| | - Palen P Mallory
- Division of Pediatric Critical Care Medicine, Duke University, Durham, NC USA
| | - John S Giuliano
- Department of Pediatrics (Critical Care Medicine), Yale University School of Medicine, New Haven, CT USA
| | - Ryan K Breuer
- Division of Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital, Buffalo, NY USA
| | - Krista Kierys
- Pediatric Intensive Care Unit, Penn State Health, Philadelphia, PA USA
| | - Serena P Kelly
- Division of Pediatric Critical Care, OHSU Doernbecher Children's Hospital, Portland, OR USA
| | - Makoto Motomura
- Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Obu, Aichi Japan
| | - Ron C Sanders
- Section of Critical Care, Department of Pediatrics, UAMS/Arkansas Children's Hospital, Little Rock, AR USA
| | - Ashley Freeman
- Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Georgia at the Medical College of Georgia, Augusta, GA USA
| | - Yuki Nagai
- Division of Pediatric Critical Care Medicine, Kobe Children's Hospital, Kobe, Hyogo Japan
| | - Lily B Glater-Welt
- Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York/Northwell, Queens, NY USA
| | - Joseph Wilson
- Pediatric Critical Care Medicine, University of Louisville, Louisville, KY USA
| | - Mervin Loi
- Department of Pediatric Subspecialties, Children's Intensive Care Unit KK Women's and Children's Hospital, Singapore, Singapore
| | - Michelle Adu-Darko
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia Hospital, Charlottesville, VA USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA USA
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte-Justine Université de Montréal, Montréal, QC H3T 1C5 Canada
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA USA
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Loi MV, Lee JH, Huh JW, Mallory P, Napolitano N, Shults J, Krawiec C, Shenoi A, Polikoff L, Al-Subu A, Sanders R, Toal M, Branca A, Glater-Welt L, Ducharme-Crevier L, Breuer R, Parsons S, Harwayne-Gidansky I, Kelly S, Motomura M, Gladen K, Pinto M, Giuliano J, Bysani G, Berkenbosch J, Biagas K, Rehder K, Kasagi M, Lee A, Jung P, Shetty R, Nadkarni V, Nishisaki A. Ketamine Use in the Intubation of Critically Ill Children with Neurological Indications: A Multicenter Retrospective Analysis. Neurocrit Care 2024; 40:205-214. [PMID: 37160847 DOI: 10.1007/s12028-023-01734-0] [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] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/10/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Ketamine has traditionally been avoided for tracheal intubations (TIs) in patients with acute neurological conditions. We evaluate its current usage pattern in these patients and any associated adverse events. METHODS We conducted a retrospective observational cohort study of critically ill children undergoing TI for neurological indications in 53 international pediatric intensive care units and emergency departments. We screened all intubations from 2014 to 2020 entered into the multicenter National Emergency Airway Registry for Children (NEAR4KIDS) registry database. Patients were included if they were under the age of 18 years and underwent TI for a primary neurological indication. Usage patterns and reported periprocedural composite adverse outcomes (hypoxemia < 80%, hypotension/hypertension, cardiac arrest, and dysrhythmia) were noted. RESULTS Of 21,562 TIs, 2,073 (9.6%) were performed for a primary neurological indication, including 190 for traumatic brain injury/trauma. Patients received ketamine in 495 TIs (23.9%), which increased from 10% in 2014 to 41% in 2020 (p < 0.001). Ketamine use was associated with a coindication of respiratory failure, difficult airway history, and use of vagolytic agents, apneic oxygenation, and video laryngoscopy. Composite adverse outcomes were reported in 289 (13.9%) Tis and were more common in the ketamine group (17.0% vs. 13.0%, p = 0.026). After adjusting for location, patient age and codiagnoses, the presence of respiratory failure and shock, difficult airway history, provider demographics, intubating device, and the use of apneic oxygenation, vagolytic agents, and neuromuscular blockade, ketamine use was not significantly associated with increased composite adverse outcomes (adjusted odds ratio 1.34, 95% confidence interval CI 0.99-1.81, p = 0.057). This paucity of association remained even when only neurotrauma intubations were considered (10.6% vs. 7.7%, p = 0.528). CONCLUSIONS This retrospective cohort study did not demonstrate an association between procedural ketamine use and increased risk of peri-intubation hypoxemia and hemodynamic instability in patients intubated for neurological indications.
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Affiliation(s)
- Mervin V Loi
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore.
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Palen Mallory
- Department of Pediatric Critical Care Medicine, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biostatistics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Conrad Krawiec
- Departments of Pediatric Critical Care Medicine and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Asha Shenoi
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Lee Polikoff
- Department of Pediatric Critical Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Sanders
- Division of Critical Care Medicine, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Megan Toal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Aline Branca
- Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lily Glater-Welt
- Department of Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Ryan Breuer
- Division of Critical Care Medicine, Department of Pediatrics, John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - Simon Parsons
- Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, Canada
| | - Ilana Harwayne-Gidansky
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - Serena Kelly
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Oregon Health and Science University Doernbecher Children's Hospital, Portland, OR, USA
| | - Makoto Motomura
- Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Kelsey Gladen
- Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Pinto
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - John Giuliano
- Section of Pediatric Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Gokul Bysani
- Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, USA
| | - John Berkenbosch
- Department of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Katherine Biagas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY, USA
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC, USA
| | - Mioko Kasagi
- Division of Pediatric Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Anthony Lee
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Rakshay Shetty
- Pediatric Intensive Care, Rainbow Children's Hospital, Bengaluru, India
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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MacDonald S, Du Pont-Thibodeau G, Thibault C, Jutras C, Roumeliotis N, Farrell C, Ducharme-Crevier L. Outcomes of patients supported by mechanical ventilation and their families two months after discharge from pediatric intensive care unit. Front Pediatr 2024; 12:1333634. [PMID: 38362003 PMCID: PMC10867956 DOI: 10.3389/fped.2024.1333634] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction The outcomes of children undergoing mechanical ventilation (MV) in a Pediatric Intensive Care Unit (PICU) remain poorly characterized and increasing knowledge in this area may lead to strategies that improve care. In this study, we reported the outcomes of children receiving invasive mechanical ventilation (IMV) and/or non-invasive ventilation (NIV), 2 months after PICU discharge. Methods This is a post-hoc analysis of a single-center prospective study of PICU children followed at the PICU follow-up clinic at CHU Sainte-Justine. Eligible children were admitted to the PICU with ≥2 days of IMV or ≥4 days of NIV. Two months after PICU discharge, patients and families were evaluated by physicians and filled out questionnaires assessing Quality of life (Pediatric Quality of Life Inventory™), development milestones (Ages and Stages Questionnaire), and parental anxiety and depression (Hospital Anxiety and Depression Scale). Results One hundred and fifty patients were included from October 2018 to December 2021; 106 patients received IMV (±NIV), and 44 patients received NIV exclusively. Admission diagnoses differed between groups, with 30.2% of patients in the IMV group admitted for a respiratory illness vs. 79.5% in the NIV group. For the entire cohort, QoL scores were 78.1% for the physical domain and 80.1% for the psychological domain, and were similar between groups. Children with a respiratory illness exhibited similar symptoms at follow-up whether they were supported by IMV vs. NIV. For developmental outcomes, only 22.2% of pre-school children had normal scores in all ASQ domains. In the entire cohort, symptoms of anxiety were reported in 29.9% and depression in 24.6 of patients. Conclusions PICU survivors undergoing mechanical ventilation, and their families, experienced significant morbidities 2 months after their critical illness, whether they received IMV or NIV. Children with respiratory illness exhibited a higher prevalence of persistent respiratory difficulties post PICU, whether they underwent IMV or NIV. Patients' quality of life and parental symptoms of anxiety and depression did not differ according to the type of respiratory support. These findings justify the inclusion of patients receiving NIV in the PICU in follow-up assessments as well as those receiving IMV.
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Affiliation(s)
| | | | | | | | | | | | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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Lamoureux AA, Ducharme-Crevier L, Lacelle-Webster F, Jouvet P, Boivin J, Lavoie A, Rossignol E. Pediatric Delirium: An Overlooked Diagnosis? Pediatr Neurol 2023; 145:48-53. [PMID: 37271057 DOI: 10.1016/j.pediatrneurol.2023.04.001] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 02/03/2023] [Accepted: 04/02/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Delirium is well-recognized in adult inpatient care. However, it is often overlooked in children, being mistaken for pain, anxiety, or age-appropriate agitation. METHODS To assess the impact of a formal teaching session on the diagnostic rates and management of pediatric delirium (PD) in a tertiary care center, we conducted a retrospective chart review of all hospitalized children diagnosed with PD between August 2003 and August 2018 at the CHU Sainte-Justine (Montreal, Canada). Diagnostic incidence and management were compared before (2003 to 2014) and after (2015 to 2018) a formal teaching session provided to pediatric residents, staff pediatricians, and intensive care physicians in December 2014. RESULTS The two cohorts displayed similar demographics, PD symptomatology, PD duration (median: 2 days), and hospital stay duration (median: 11.0 and 10.5 days). However, we saw a major increase in diagnosis frequency after 2014 (from 1.84 to 7.09 cases/year). This increased diagnostic rate was most striking in the pediatric intensive care unit setting. Although symptomatic treatment with antipsychotics and alpha-2 agonists was similar between the two cohorts, patients diagnosed after 2014 were more often weaned from offending medications (benzodiazepines, anesthetics, and anticholinergics). All patients recovered fully. CONCLUSIONS Formal teaching on the symptoms and management of PD was associated with an increase in diagnostic rate and an improved management of PD in our institution. Larger studies are required to assess standardized screening tools that may further enhance diagnostic rates and improve care for children with PD.
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Affiliation(s)
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Fanny Lacelle-Webster
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Department of Pediatrics, CHU Sherbrooke, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Philippe Jouvet
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Johanne Boivin
- Department of Psychiatry, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Annie Lavoie
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada; Department of Pharmacy, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Elsa Rossignol
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Department of Neurosciences, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada.
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7
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Jutras C, Sauthier M, Tucci M, Trottier H, Lacroix J, Robitaille N, Ducharme-Crevier L, Du Pont-Thibodeau G. Prevalence and determinants of anemia at discharge in pediatric intensive care survivors. Transfusion 2023; 63:973-981. [PMID: 36907652 DOI: 10.1111/trf.17309] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/06/2022] [Accepted: 01/11/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Restrictive transfusion practices are increasingly being followed in pediatric intensive care units (PICU); consequently, more patients are discharged anemic from PICU. Given the possible impact of anemia on long-term neurodevelopmental outcomes, we aim to describe the epidemiology of anemia at PICU discharge in a mixed (pediatric and cardiac) cohort of PICU survivors and to characterize risk factors for anemia. STUDY DESIGN AND METHODS We performed a retrospective cohort study in the PICU of a multidisciplinary tertiary-care university-affiliated center. All consecutive PICU survivors for whom a hemoglobin level was available at PICU discharge were included. Baseline characteristics and hemoglobin levels were extracted from an electronic medical records database. RESULTS From January 2013 to January 2018, 4750 patients were admitted to the PICU (97.1% survival); discharge hemoglobin levels were available for 4124 patients. Overall, 50.9% (n = 2100) were anemic at PICU discharge. Anemia at PICU discharge was also common in the cardiac surgery population (53.3%), mainly in acyanotic patients; only 24.6% of cyanotic patients were anemic according to standard definitions of anemia. Cardiac surgery patients were transfused more often and at higher hemoglobin levels than medical and non-cardiac surgery patients. Anemia at admission was the strongest predictor of anemia at discharge (odds ratios (OR): 6.51, 95% confidence interval (CI:5.40;7.85)). DISCUSSION Half of PICU survivors are anemic at discharge. Further studies are required to determine the course of anemia after discharge and to ascertain whether anemia is associated with adverse long-term outcomes.
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Affiliation(s)
- Camille Jutras
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Michaël Sauthier
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marisa Tucci
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Helen Trottier
- Public Health School, Université de Montréal and Research Center, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Nancy Robitaille
- Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada.,Public Health School, Université de Montréal and Research Center, CHU Sainte-Justine, Montréal, Québec, Canada.,Héma-Québec, Montréal, Québec, Canada
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8
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Martin S, Du Pont-Thibodeau G, Seely AJE, Emeriaud G, Herry CL, Recher M, Lacroix J, Ducharme-Crevier L. Heart Rate Variability in Children with Moderate and Severe Traumatic Brain Injury: A Prospective Observational Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1759877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AbstractThe aim of this study was to assess the feasibility of continuous monitoring of heart rate variability (HRV) in children with traumatic brain injury (TBI) hospitalized in a pediatric intensive care unit (PICU) and collect preliminary data on the association between HRV, neurological outcome, and complications. This is a prospective observational cohort study in a tertiary academic PICU. Children admitted to the PICU ≤24 hours after moderate or severe TBI were included in the study. Children suspected of being brain dead at PICU entry or with a pacemaker were excluded. Children underwent continuous monitoring of electrocardiographic (ECG) waveforms over 7 days post-TBI. HRV analysis was performed retrospectively, using a standardized, validated HRV analysis software (CIMVA). The occurrence of medical complications (“event”: intracranial hypertension, cerebral hypoperfusion, seizure, and cardiac arrest) was prospectively documented. Outcome of children 6 months post-TBI was assessed using the Glasgow Outcome Scale – Extended Pediatric (GOS-E Peds). Fifteen patients were included over a 20-month period. Thirteen patients had ECG recordings available and 4 had >20% of missing ECG data. When ECG was available, HRV calculation was feasible (average 88%; range 70–97%). Significant decrease in overall HRV coefficient of variation and Poincaré SD2 (p < 0.05) at 6 hours post–PICU admission was associated with an unfavorable outcome (defined as GOS-E Peds ≥ 3, or a deterioration of ≥2 points over baseline score). Several HRV metrics exhibited significant and nonsignificant variation in HRV during event. This study demonstrates that it is feasible to monitor HRV in the PICU provided ECG data are available; however, missing ECG data are not uncommon. These preliminary data suggest that altered HRV is associated with unfavorable neurological outcome and in-hospital medical complications. Larger prospective studies are needed to confirm these findings and to explore if HRV offers reliable and clinically useful prediction data that may help clinical decision making.
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Affiliation(s)
- Sophie Martin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Andrew J. E. Seely
- Thoracic Surgery & Critical Care Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Guillaume Emeriaud
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Morgan Recher
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
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9
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François T, Sauthier M, Charlier J, Dessureault J, Tucci M, Harrington K, Ducharme-Crevier L, Al Omar S, Lacroix J, Du Pont-Thibodeau G. Impact of Blood Sampling on Anemia in the PICU: A Prospective Cohort Study. Pediatr Crit Care Med 2022; 23:435-443. [PMID: 35404309 DOI: 10.1097/pcc.0000000000002947] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Fifty percent of children are anemic after a critical illness. Iatrogenic blood testing may be a contributor to this problem. The objectives of this study were to describe blood sampling practice in a PICU, determine patient factors associated with increased sampling, and examine the association among blood sampling volume, anemia at PICU discharge, and change in hemoglobin from PICU entry to PICU discharge. DESIGN Prospective observational cohort study. SETTING PICU of Sainte-Justine University Hospital. PATIENTS All children consecutively admitted during a 4-month period. MEASUREMENTS AND MAIN RESULTS Four hundred twenty-three children were enrolled. Mean blood volume sampled was 3.9 (±19) mL/kg/stay, of which 26% was discarded volume. Children with central venous or arterial access were sampled more than those without access (p < 0.05). Children with sepsis, shock, or cardiac surgery were most sampled, those with a primary respiratory diagnosis; the least (p < 0.001). We detected a strong association between blood sample volume and mechanical ventilation (H, 81.35; p < 0.0001), but no association with severity of illness (Worst Pediatric Logistic Organ Dysfunction score) (R, -0.044; p = 0.43). Multivariate analysis (n = 314) showed a significant association between the volume of blood sampled (as continuous variable) and anemia at discharge (adjusted OR, 1.63; 95% CI, 1.18-2.45; p = 0.003). We lacked power to detect an association between blood sampling and change in hemoglobin from PICU admission to PICU discharge. CONCLUSIONS Diagnostic blood sampling in PICU is associated with anemia at discharge. Twenty-five percent of blood losses from sampling is wasted. Volumes are highest for patients with sepsis, shock, or cardiac surgery, and in patients with vascular access or ventilatory support.
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Affiliation(s)
- Tine François
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Michaël Sauthier
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Julien Charlier
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Jessica Dessureault
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Marisa Tucci
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Karen Harrington
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Laurence Ducharme-Crevier
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Sally Al Omar
- Centre de Recherche, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
| | - Geneviève Du Pont-Thibodeau
- Department of Pediatrics, Pediatric Intensive Care Unit, Sainte-Justine University Health Centre, Université de Montréal, Montreal, QC, Canada
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10
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Barcat L, Pont-Thibodeau GD, Jutras C, Harrington K, MacDonald S, Ducharme-Crevier L. Impact of the Covid-19 Pandemic on Children and Families in PICU Follow-Up Clinic. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1747927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThe novel coronavirus disease 2019 (COVID-19) pandemic disrupted the lives of many families, especially those of children with chronic health problems. Little is known about the impact of this pandemic on the health and well-being of critically ill children and their families after their discharge from pediatric intensive care unit (PICU) hospitalization. This study describes the repercussions of the COVID-19-related lockdown on the physical and psychological wellbeing, quality of life, and access to resources of PICU survivors and their families. This was a prospective cohort study of children and families followed at the Centre Hospitalier Universitaire Ste-Justine PICU follow-up clinic from October 2018 to February 2020. Families were contacted by phone to complete validated questionnaires (Pediatric Quality of Life Inventory, Hospital Anxiety and Depression Scale) and to evaluate the impact of the COVID-19 pandemic on their access to medical care and extrafamilial support. Fifty-five families were contacted between November and December 2020. Quality of life scores were 88.1 ± 16.9 and 83.8 ± 13.9 for physical and psychosocial aspects, respectively. Symptoms of anxiety and depression were detected in 23.6 and 3.6% of respondent parents, respectively. A significant proportion of families reported canceled or delayed health care appointments (65.5%) and difficulty with medication access (12.7%). Twenty-five families (45.5%) reported a significant decrease in income. We could not identify any statistically significant predictors for lower quality of life scores. Difficulty accessing medical care was associated with higher symptoms of anxiety and/or depression in parents on multivariate analysis (p = 0.02). In conclusion, the COVID-19 pandemic has had a significant negative impact on PICU survivors' access to medical resources and extrafamilial support.
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Affiliation(s)
- Lucile Barcat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte Justine, Université de Montréal. Montréal, Québec, Canada
| | - Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte Justine, Université de Montréal. Montréal, Québec, Canada
| | - Camille Jutras
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte Justine, Université de Montréal. Montréal, Québec, Canada
| | - Karen Harrington
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte Justine, Université de Montréal. Montréal, Québec, Canada
| | - Simon MacDonald
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte Justine, Université de Montréal. Montréal, Québec, Canada
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte Justine, Université de Montréal. Montréal, Québec, Canada
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11
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Martin S, Feder J, Ducharme-Crevier L, Savy N, Emeriaud G. Diaphragm electrical activity target during NAVA: One size may not fit all. Pediatr Pulmonol 2022; 57:1358-1360. [PMID: 35146954 DOI: 10.1002/ppul.25856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Sophie Martin
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Joshua Feder
- Department of Pediatrics, Pediatric Intensive Care Unit, Montreal Children's Hospital, McGill University, Montreal, Québec, Canada
| | - Laurence Ducharme-Crevier
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Nadia Savy
- Pôle Femmes-Mères-Enfants, Pediatric Intensive Care Unit, Hôpital Estaing, CHU Clermont-Ferrand, Clermont Ferrand, France
| | - Guillaume Emeriaud
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
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12
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Cloedt LD, Benbouzid K, Lavoie A, Metras MÉ, Lavoie MC, Harakat S, Harrington K, Ducharme-Crevier L. The Impact of Implementing a “Pain, Agitation, and Delirium Bundle” in a Pediatric Intensive Care Unit: Improved Delirium Diagnosis. J Pediatr Intensive Care 2021; 11:233-239. [DOI: 10.1055/s-0041-1723037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/24/2020] [Indexed: 10/22/2022] Open
Abstract
AbstractDelirium is associated with significant negative outcomes, yet it remains underdiagnosed in children. We describe the impact of implementing a pain, agitation, and delirium (PAD) bundle on the rate of delirium detection in a pediatric intensive care unit (PICU). This represents a single-center, pre-/post-intervention retrospective and prospective cohort study. The study was conducted at a PICU in a quaternary university-affiliated pediatric hospital. All patients consecutively admitted to the PICU in October and November 2017 and 2018. Purpose of the study was describe the impact of the implementation of a PAD bundle. The rate of delirium detection and the utilization of sedative and analgesics in the pre- and post-implementation phases were measured. A total of 176 and 138 patients were admitted during the pre- and post-implementation phases, respectively. Of them, 7 (4%) and 44 (31.9%) were diagnosed with delirium (p < 0.001). Delirium was diagnosed in the first 48 hours of PICU admission and lasted for a median of 2 days (interquartile range [IQR]: 2–4). Delirium diagnosis was higher in patients receiving invasive ventilation (p < 0.001). Compliance with the PAD bundle scoring was 79% for the delirium scale. Score results were discussed during medical rounds for 68% of the patients in the post-implementation period. The number of patients who received opioids and benzodiazepines and the cumulative doses were not statistically different between the two cohorts. More patients received dexmedetomidine and the cumulative daily dose was higher in the post-implementation period (p < 0.001). The implementation of a PAD bundle in a PICU was associated with an increased recognition of delirium diagnosis. Further studies are needed to evaluate the impact of this increased diagnostic rate on short- and long-term outcomes.
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Affiliation(s)
- Lise D. Cloedt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Annie Lavoie
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | - Marie-Élaine Metras
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | - Marie-Christine Lavoie
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | - Samira Harakat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | - Karen Harrington
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, Québec, Canada
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13
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Choong K, Zorko DJ, Awojoodu R, Ducharme-Crevier L, Fontela PS, Lee LA, Guerguerian AM, Garcia Guerra G, Krmpotic K, McKelvie B, Menon K, Murthy S, Sehgal A, Weiss MJ, Kudchadkar SR. Prevalence of Acute Rehabilitation for Kids in the PICU: A Canadian Multicenter Point Prevalence Study. Pediatr Crit Care Med 2021; 22:181-193. [PMID: 33116069 DOI: 10.1097/pcc.0000000000002601] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs. DESIGN National 2-day point prevalence study. SETTING Thirteen PICUs across Canada. PATIENTS Children with a minimum 72-hour PICU length of stay on the allocated study day. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Outcomes of interest were the prevalence and nature of mobilization activities, rehabilitation resources, adverse events, and factors associated with out-of-bed mobility and therapist-provided mobility. Two PICUs (15%) had early mobilization practice guidelines, and one PICU (8%) reported a formal process for engaging families in the mobilization of patients. The prevalence of mobilization was 110 of 137 patient-days (80%). The commonest activity was out-of-bed mobility (87/137; 64% patient-days); there was no active mobilization on 46 patient-days (34%). Therapists provided mobility on 33% of patient-days. Mobility was most commonly facilitated by nurses (74% events) and family (49% events). Family participation was strongly associated with out-of-bed mobility (odds ratio 6.4; p = 0.001). Intubated, mechanically ventilated patients were mobilized out-of-bed on 18 of 50 patient-days (36%). However, the presence of an endotracheal tube, vasoactive infusions, and age greater than or equal to 3 years were independently associated with not being mobilized out-of-bed. Barriers were reported on 58 of 137 patient-days (42%), and adverse events occurred in 22 of 387 mobility events (6%). CONCLUSIONS Mobilization is common and safe, and the majority of children in Canadian PICUs are being mobilized out-of-bed, even when mechanically ventilated. Family engagement in PICU-based rehabilitation is increasing. This study provides encouraging evidence that common barriers can be overcome in order to safely mobilize children in PICUs.
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Affiliation(s)
- Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - David J Zorko
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Ronke Awojoodu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Laurie A Lee
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Anne-Marie Guerguerian
- Departments of Critical Care Medicine and Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Kristina Krmpotic
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Brianna McKelvie
- Department of Pediatrics, Western University, London, ON, Canada
| | - Kusum Menon
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Kingston Health Science Center, Queen's University, Kingston, ON, Canada
| | - Matthew J Weiss
- Department of Pediatrics, Université Laval Faculté de Médecine, Québec, QC, Canada
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Press CA, Kirschen M, LaRovere K, Risen S, Guilliams KP, Chung M, Griffith J, Erklauer J, Peariso K, Ducharme-Crevier L, Shah SS, Hall M, Wainwright MS. Variation in Treatment and Outcomes of Children With Acute Disseminated Encephalomyelitis. Hosp Pediatr 2020; 10:159-165. [PMID: 31996356 DOI: 10.1542/hpeds.2019-0129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/10/2023]
Abstract
OBJECTIVES To characterize variation in treatments and outcomes of pediatric patients admitted to children's hospitals with acute disseminated encephalomyelitis (ADEM). METHODS In this retrospective cohort study, we used data from the Pediatric Health Information System. Children >30 days old who were hospitalized from 2010 to 2015 with ADEM were included. Variables analyzed were treatments and admission to an ICU. Primary outcomes were discharge disposition and readmissions for relapses (ADEM readmissions) or for continued comorbidities (non-ADEM readmissions). RESULTS A total of 954 patients with ADEM had 1117 admissions. Treatments included steroids (80%), immunoglobulin (22%), and plasmapheresis (6.6%); 15% of admissions included none of these treatments. Treatments varied by center (P < .001). Thirty-four percent of admissions included ICU admission, which was associated with an increased number and duration of treatments (P < .01). The discharge disposition was home in 85% of admissions; home with health services, rehab facility, or other in 13.6%; and mortality in 1.4%. Twelve percent (117 of 954) of patients had >1 admission for ADEM. Treatment choice and ICU stay were not associated with ADEM readmissions. Sixteen percent (181 of 1101) of ADEM admissions had a non-ADEM readmission within 90 days. Prolonged ICU hospitalization was associated with non-ADEM readmission (adjusted odds ratio 1.9; P = .017) and decreased likelihood of discharge from the hospital to home (adjusted odds ratio 0.1; P < .001). After adjusting for ICU duration, treatment choice and duration were not associated with non-ADEM readmission or hospital disposition. CONCLUSIONS Significant variation in ADEM treatment exists across centers. Admission to an ICU for ADEM was associated with increased immunotherapy, additional health services at discharge, and readmission for diagnoses other than ADEM.
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Affiliation(s)
- Craig A Press
- University of Colorado and Children's Hospital Colorado, Aurora, Colorado;
| | | | | | - Sarah Risen
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Kristin P Guilliams
- School of Medicine, Washington University in St Louis and St Louis Children's Hospital, St Louis, Missouri
| | | | - Jennifer Griffith
- School of Medicine, Washington University in St Louis and St Louis Children's Hospital, St Louis, Missouri
| | - Jennifer Erklauer
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Katrina Peariso
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Samir S Shah
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas; and
| | - Mark S Wainwright
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington
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15
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De Cloedt L, Harrington K, Du Pont-Thibodeau G, Ducharme-Crevier L. Traduction et validation de l’échelle d’évaluation du delirium pédiatrique de Cornell en version française. Méd Intensive Réa 2019. [DOI: 10.3166/rea-2019-0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objectif : Le delirium est commun chez les patients de soins intensifs pédiatriques (SIP), mais sous-reconnu par les cliniciens en l’absence d’une échelle de dépistage de delirium pédiatrique. L’objectif de cette étude était donc de traduire et de valider l’échelle d’évaluation du delirium pédiatrique de Cornell en version française.
Patients et méthodes : Pour la traduction, la méthode reconnue de rétrotraduction a été utilisée. L’échelle Cornell Assessment of Pediatric Delirium a été traduite de l’anglais vers le français par une traductrice et un médecin francophones. Les deux versions ont été mises en commun et harmonisées, puis cette version a été rétrotraduite en anglais par un médecin anglophone. Cette traduction a ensuite été comparée à la version source par les auteurs originaux qui ont pprouvé la traduction. La version française finale de l’échelle a été validée sur 25 patients admis dans notre unité médicochirurgicale de SIP de 32 lits. Chaque patient a été évalué de manière indépendante par deux infirmières. La reproductibilité interobservateur a été mesurée par un coefficient de Kappa.
Résultats : Cinquante mesures ont été obtenues au cours des 25 évaluations. La concordance interobservateur était presque parfaite, avec un coefficient de Kappa de 0,92. Le temps médian nécessaire pour compléter l’échelle était de 51 secondes.
Conclusion : La version française de l’échelle d’évaluation du delirium pédiatrique de Cornell est valide et reproductible dans un milieu de SIP.
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Abstract
Acute hyperammonemia may induce a neurologic impairment leading to an acute life-threatening condition. Coma duration, ammonia peak level, and hyperammonemia duration are the main risk factors of hyperammonemia-related neurologic deficits and death. In children, hyperammonemia is mainly caused by severe liver failure and inborn errors of metabolism. In an acute setting, obtaining reliable plasma ammonia levels can be challenging because of the preanalytical difficulties that need to be addressed carefully. The management of hyperammonemia includes 1) identification of precipitating factors and cerebral edema presence, 2) a decrease in ammonia production by reducing protein intake and reversing catabolism, and 3) ammonia removal with pharmacologic treatment and, in the most severe cases, with extracorporeal therapies. In case of severe coma, transcranial Doppler ultrasound could be the method of choice to noninvasively monitor cerebral blood flow and titrate therapies.
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Affiliation(s)
- Nadia Savy
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada,
| | - David Brossier
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Caen, Caen, France
| | | | | | | | - Philippe Jouvet
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada,
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17
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Mortamet G, Larouche A, Ducharme-Crevier L, Fléchelles O, Constantin G, Essouri S, Pellerin-Leblanc AA, Beck J, Sinderby C, Jouvet P, Emeriaud G. Patient-ventilator asynchrony during conventional mechanical ventilation in children. Ann Intensive Care 2017; 7:122. [PMID: 29264742 PMCID: PMC5738329 DOI: 10.1186/s13613-017-0344-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/13/2017] [Indexed: 11/22/2022] Open
Abstract
Background We aimed (1) to describe the characteristics of patient–ventilator asynchrony in a population of critically ill children, (2) to describe the risk factors associated with patient–ventilator asynchrony, and (3) to evaluate the association between patient–ventilator asynchrony and ventilator-free days at day 28. Methods In this single-center prospective study, consecutive children admitted to the PICU and mechanically ventilated for at least 24 h were included. Patient–ventilator asynchrony was analyzed by comparing the ventilator pressure curve and the electrical activity of the diaphragm (Edi) signal with (1) a manual analysis and (2) using a standardized fully automated method. Results Fifty-two patients (median age 6 months) were included in the analysis. Eighteen patients had a very low ventilatory drive (i.e., peak Edi < 2 µV on average), which prevented the calculation of patient–ventilator asynchrony. Children spent 27% (interquartile 22–39%) of the time in conflict with the ventilator. Cycling-off errors and trigger delays contributed to most of this asynchronous time. The automatic algorithm provided a NeuroSync index of 45%, confirming the high prevalence of asynchrony. No association between the severity of asynchrony and ventilator-free days at day 28 or any other clinical secondary outcomes was observed, but the proportion of children with good synchrony was very low. Conclusion Patient–ventilator interaction is poor in children supported by conventional ventilation, with a high frequency of depressed ventilatory drive and a large proportion of time spent in asynchrony. The clinical benefit of strategies to improve patient–ventilator interactions should be evaluated in pediatric critical care.
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Affiliation(s)
- Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,INSERM U 955, Equipe 13, Créteil, France.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Alexandrine Larouche
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Laurence Ducharme-Crevier
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Olivier Fléchelles
- Pediatric Intensive Care Unit, CHU Fort-de-France, Fort-de-France, France
| | - Gabrielle Constantin
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Sandrine Essouri
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada. .,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.
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18
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Abstract
In this review on respiratory assistance, we aim to discuss the following recent advances: the optimization and customization of mechanical ventilation, the use of high-frequency oscillatory ventilation, and the role of noninvasive ventilation. The prevention of ventilator-induced lung injury and diaphragmatic dysfunction is now a key aspect in the management of mechanical ventilation, since these complications may lead to higher mortality and prolonged length of stay in intensive care units. Different physiological measurements, such as esophageal pressure, electrical activity of the diaphragm, and volumetric capnography, may be useful objective tools to help guide ventilator assistance. Companies that design medical devices including ventilators and respiratory monitoring platforms play a key role in knowledge application. The creation of a ventilation consortium that includes companies, clinicians, researchers, and stakeholders could be a solution to promote much-needed device development and knowledge implementation.
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Affiliation(s)
- Nicolas Nardi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | | | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
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19
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Ducharme-Crevier L, Mills MG, Mehta PM, Smith CM, Wainwright MS. Use of Transcranial Doppler for Management of Central Nervous System Infections in Critically Ill Children. Pediatr Neurol 2016; 65:52-58.e2. [PMID: 27743745 DOI: 10.1016/j.pediatrneurol.2016.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 03/05/2016] [Revised: 08/26/2016] [Accepted: 08/28/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The primary objective of this study was to characterize changes in cerebral blood flow measured using transcranial Doppler in children with central nervous system infections. We hypothesized that children with central nervous system infections have abnormal cerebral blood flow, associated with a greater frequency of complications and poor neurological outcome. METHODS We conducted a single-center, retrospective study of children admitted to the neonatal or pediatric intensive care unit with central nervous system infection and undergoing transcranial Doppler as part of routine care between March 2011 and July 2015. RESULTS A total of 20 children with central nervous system infection underwent 35 transcranial Dopplers. The mean age was 8.2 ± 6.3 years, including 12 boys and eight girls. The most common infection was meningitis (n = 11, 55%), with the remainder comprising encephalitis (15%), meningoencephalitis (20%), and abscess or empyema (10%). Bacterial (n = 10, 50%) and viral (n = 6) sources were common with only one (5%) fungal infection and three (15%) unknown but presumed viral etiology. The patients underwent transcranial Doppler 4 ± 9 days after intensive care unit admission. Mean cerebral blood flow velocities were overall increased compared with reference values for age (healthy children and critically ill children) mostly because of hyperemia (n = 21, 60%) and vasospasm (6%). Hypoperfusion (cerebral blood flow velocity <1 S.D. of normal value) in at least one vessel was associated with morbidity (intubation, vasoactive medications, neurosurgery, cardiac arrest) (P = 0.04) and mortality (P = 0.03). Two patients had increased intracranial pressure and hyperventilation was safely achieved with transcranial Doppler monitoring to avoid ischemia. Serial transcranial Dopplers were used to guide blood pressure management. CONCLUSIONS Transcranial Doppler can be used in children with central nervous system infection as a tool to assess cerebral blood flow. In this retrospective study, cerebral hypoperfusion was associated with increased morbidity and mortality. If transcranial Doppler is to guide medical therapy and management of cerebral blood flow in children with central nervous system infections, these results will need to be validated in prospective studies with a more homogenous population of children with encephalitis or meningitis.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michele G Mills
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Priya M Mehta
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig M Smith
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark S Wainwright
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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20
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Broomall E, McBride ME, Deal BJ, Ducharme-Crevier L, Shaw A, Mazwi M, Backer CL, Mongé MC, Costello J, Marino BS, DeFreitas A, Wainwright MS. Posterior Circulation Ischemia or Occlusion in Five Adults With Failing Fontan Circulation. Ann Thorac Surg 2016; 101:2315-20. [PMID: 27016841 DOI: 10.1016/j.athoracsur.2016.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Received: 04/16/2015] [Revised: 11/24/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Palliative procedures performed before the Fontan procedure may require ligation of the subclavian arteries, thereby affecting flow to the vertebral arteries. In adults with functionally univentricular heart disease, the implications of altered brainstem vascular anatomy for perioperative management of failing Fontan circulation are not known. METHODS We identified abnormal posterior circulation anatomy in an adult patient with failing Fontan circulation who experienced a brainstem stroke after Fontan conversion. We then changed our clinical practice to include detailed preoperative neurologic evaluation of adults with univentricular heart disease and failing Fontan circulation. Here, we report the clinical and neuroimaging findings in 5 consecutive patients before and after this change in practice. RESULTS Five patients ages 28 to 42 years had Fontan procedures performed in childhood, and underwent either Fontan conversion or cardiac transplantation. Patient 1 experienced an episode of decreased cerebral perfusion pressure on postoperative day 3, and experienced an ischemic brainstem stroke causing transient locked-in syndrome. A change in practice was made, and patients 2, 3, and 4 were evaluated preoperatively by the neurocritical care service. These patients then had higher target blood pressures perioperatively and no neurologic injury. Patient 5 was evaluated for symptoms consistent with subclavian steal. Neuroimaging in 3 patients was abnormal, with atrophic vertebral arteries, an occluded vertebral artery, and retrograde perfusion of a vertebral artery. CONCLUSIONS In adults with failing Fontan circulation there is a potential for neurologic complications as a result of venous congestion with elevated central venous pressures, and aberrant posterior circulation. The patient's history and brain imaging may be used to identify at-risk patients and to tailor perioperative management during Fontan conversion or heart transplantation to mitigate the risk for brainstem ischemia.
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Affiliation(s)
- Eileen Broomall
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary E McBride
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Barbara J Deal
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Laurence Ducharme-Crevier
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexandra Shaw
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mjaye Mazwi
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carl L Backer
- Department of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael C Mongé
- Department of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Costello
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew DeFreitas
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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21
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Abstract
Investigators from University of Melbourne, Australia, studied Pressure-Reactivity Index (PRx) and optimal Cerebral Perfusion Pressure (CPP) in 36 children aged between 6 months and 16 years treated for traumatic brain injury (TBI) at the Royal Children's Hospital, Melbourne, from 2007 to 2013.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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22
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Abstract
Investigators from the University of California performed a case-control study of the association of stroke with congenital heart disease (CHD) within a population of 2.5 million children in Northern California.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark S Wainwright
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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23
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Larouche A, Massicotte E, Constantin G, Ducharme-Crevier L, Essouri S, Sinderby C, Beck J, Emeriaud G. Tonic diaphragmatic activity in critically ill children with and without ventilatory support. Pediatr Pulmonol 2015; 50:1304-12. [PMID: 25940232 DOI: 10.1002/ppul.23182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 07/10/2014] [Revised: 01/27/2015] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Infants have to actively maintain their end expiratory lung volume (EELV). In mechanically ventilated infants, the diaphragm stays activated until the end of expiration (tonic activity), contributing to EELV maintenance. It is unclear whether tonic activity compensates for the lack of laryngeal braking due to intubation or if it is normally present. OBJECTIVE To determine if tonic diaphragm activity remains after extubation in infants, and if it can be observed in older children. METHODS Prospective observational study of pediatric patients ventilated for >24 hr. Diaphragm electrical activity (EAdi) was recorded using a specific nasogastric catheter during four periods: (i) the acute phase, (ii) pre-extubation, (iii) post-extubation, and (iv) at PICU discharge. Tonic EAdi was defined as the EAdi in the last quartile of expiration. RESULTS Fifty-five patients, median age 10 months (Interquartile range: 1-48) were studied. In infants (<1 year, n = 28), tonic EAdi was always present, and represented 33% (22-43) of inspiratory EAdi at PICU discharge. No significant change was observed between pre- and post-extubation periods. In older patients (n = 27), tonic activity was negligible as a whole, but 10 patients exhibited significant tonic EAdi at one time-point during PICU stay. Bronchiolitis was the only independent factor associated with tonic EAdi. CONCLUSIONS In infants, tonic EAdi remains involved in ventilatory control after extubation and restoration of laryngeal braking. Tonic EAdi may play a pathophysiological role in bronchiolitis and it can be reactivated in older patients. The interest of tonic EAdi as a tool to titrate mechanical ventilation warrants further evaluation.
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Affiliation(s)
- Alexandrine Larouche
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Erika Massicotte
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Gabrielle Constantin
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Sandrine Essouri
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada.,Pediatric Intensive Care Unit, CHU Kremlin Bicêtre, Université Paris Sud, Le Kremlin Bicêtre, France
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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24
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Ducharme-Crevier L, Pettersen G, Emeriaud G. Vasospasm After Pediatric Traumatic Brain Injury: A Difficult Diagnosis. Crit Care Med 2015; 43:e467-8. [PMID: 26376271 DOI: 10.1097/ccm.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Emeriaud G, Larouche A, Ducharme-Crevier L, Massicotte E, Fléchelles O, Pellerin-Leblanc AA, Morneau S, Beck J, Jouvet P. Evolution of inspiratory diaphragm activity in children over the course of the PICU stay. Intensive Care Med 2014; 40:1718-26. [PMID: 25118865 DOI: 10.1007/s00134-014-3431-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/30/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE Diaphragm function should be monitored in critically ill patients, as full ventilatory support rapidly induces diaphragm atrophy. Monitoring the electrical activity of the diaphragm (EAdi) may help assess the level of diaphragm activity, but such monitoring results are difficult to interpret because reference values are lacking. The aim of this study was to describe EAdi values in critically ill children during a stay in the pediatric intensive care unit (PICU), from the acute to recovery phases, and to assess the impact of ventilatory support on EAdi. METHODS This was a prospective longitudinal observational study of children requiring mechanical ventilation for ≥24 h. EAdi was recorded using a validated method in the acute phase, before extubation, after extubation, and before PICU discharge. RESULTS Fifty-five critically ill children were enrolled in the study. Median maximum inspiratory EAdi (EAdimax) during mechanical ventilation was 3.6 [interquartile range (IQR) 1.2-7.6] μV in the acute phase and 4.8 (IQR 2.0-10.7) μV in the pre-extubation phase. Periods of diaphragm inactivity (with no detectable inspiratory EAdi) were frequent during conventional ventilation, even with a low level of support. EAdimax in spontaneous ventilation was 15.4 (IQR 7.4-20.7) μV shortly after extubation and 12.6 (IQR 8.1-21.3) μV before PICU discharge. The difference in EAdimax between mechanical ventilation and post-extubation periods was significant (p < 0.001). Patients intubated mainly because of a lung pathology exhibited higher EAdi (p < 0.01), with a similar temporal increase. CONCLUSIONS This is the first systematic description of EAdi evolution in children during their stay in the PICU. In our patient cohort, diaphragm activity was frequently low in conventional ventilation, suggesting that overassistance or oversedation is common in clinical practice. EAdi monitoring appears to be a helpful tool to detect such situations.
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Affiliation(s)
- Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada,
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26
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Ducharme-Crevier L, Emeriaud G, Beck J, Jouvet P. 436. Crit Care Med 2012. [DOI: 10.1097/01.ccm.0000424654.19702.a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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