Antithrombin activity and central venous catheter-associated thrombosis in critically ill children at high risk of bleeding

BACKGROUND

Normalization of antithrombin activity may prevent catheter-associated thrombosis in critically ill children at high risk of bleeding.

OBJECTIVES

To characterize the temporal pattern of antithrombin activity, assess its association with catheter-associated thrombosis and clinically relevant bleeding, and evaluate its relationship with thrombin generation in these children.

METHODS

In this prospective cohort study, critically ill children <18 years old at high risk of bleeding with central venous catheter were eligible. Antithrombin activity and thrombin generation were measured from platelet-poor plasma and after in vitro antithrombin supplementation. Systematic surveillance ultrasound was performed to diagnose thrombosis. Children were followed for bleeding.

RESULTS

We enrolled 8 infants (median age: 0.2 years, IQR: 0.2, 0.3 years) and 72 older children (median age: 14.3 years, IQR: 9.1, 16.1 years). Mean antithrombin on the day of catheter insertion was 64 IU/dL (SD: 32 IU/dL) in infants and 83 IU/dL (SD: 35 IU/dL) in older children. Antithrombin normalized by the day of catheter removal. Thrombosis developed in 27 children, while 31 children bled. Thrombosis (regression coefficient: 0.008, 95% CI: -0.01, 0.03) and bleeding (regression coefficient: -0.0007, 95% CI: -0.02, 0.02) were not associated with antithrombin. Antithrombin was not correlated with in vivo change in endogenous thrombin potential (correlation coefficient: -0.07, 95% CI: -0.21, 0.08). In vitro supplementation reduced endogenous thrombin potential (correlation coefficient: -0.78; 95% CI: -0.95, -0.23).

CONCLUSION

These findings may not support normalization of antithrombin activity to prevent catheter-associated thrombosis in critically ill children at high risk of bleeding.

Measuring Social Health Following Pediatric Critical Illness: A Scoping Review and Conceptual Framework

OBJECTIVE

Social health is an important component of recovery following critical illness as modeled in the pediatric Post-Intensive Care Syndrome framework. We conducted a scoping review of studies measuring social outcomes (measurable components of social health) following pediatric critical illness and propose a conceptual framework of the social outcomes measured in these studies.

DATA SOURCES

PubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane Registry.

STUDY SELECTION

We identified studies evaluating social outcomes in pediatric intensive care unit (PICU) survivors or their families from 1970-2017 as part of a broader scoping review of outcomes after pediatric critical illness.

DATA EXTRACTION

We identified articles by dual review and dual-extracted study characteristics, instruments, and instrument validation and administration information. For instruments used in studies evaluating a social outcome, we collected instrument content and described it using qualitative methods adapted to a scoping review.

DATA SYNTHESIS

Of 407 articles identified in the scoping review, 223 (55%) evaluated a social outcome. The majority were conducted in North America and the United Kingdom, with wide variation in methodology and population. Among these studies, 38 unique instruments were used to evaluate a social outcome. Specific social outcomes measured included individual (independence, attachment, empathy, social behaviors, social cognition, and social interest), environmental (community perceptions and environment), and network (activities and relationships) characteristics, together with school and family outcomes. While many instruments assessed more than one social outcome, no instrument evaluated all areas of social outcome.

CONCLUSIONS

The full range of social outcomes reported following pediatric critical illness were not captured by any single instrument. The lack of a comprehensive instrument focused on social outcomes may contribute to under-appreciation of the importance of social outcomes and their under-representation in PICU outcomes research. A more comprehensive evaluation of social outcomes will improve understanding of overall recovery following pediatric critical illness.

Acute Care Pediatric Nurse Practitioner: The 2014 Practice Analysis

INTRODUCTION

Practice research serves as the certification framework for validating advanced practice roles and updating national qualifying examinations. This national study describes the current practice of the acute care pediatric nurse practitioner (AC PNP) to inform an update of the Certified Pediatric Nurse Practitioner-Acute Care (CPNP-AC) examination content outline.

METHOD

A descriptive analysis was performed of the responses of 319 pediatric nurse practitioners, practicing in an acute care role, who completed a practice survey in 2014.

RESULTS

Respondents were primarily White women with a mean age of 40 years; 75% had been formally educated as AC PNPs, compared with 48% in 2009. Regional practice was most heavily concentrated in the Southeast (28%) and Midwest (27%). Most respondents (81%) practiced in urban areas. Respondents reported spending 75% of practice time in inpatient settings. The most frequently cited areas of practice were critical care (36%), followed by emergency department (9%) and subspecialty practices.

DISCUSSION

This third analysis of AC PNP practice 10 years after initiation of the CPNP-AC certification examination demonstrates changes in clinical practice and educational preparation.

Pediatric Toxicology: Emerging Trends

Poisoning represents one of the most common medical emergencies encountered worldwide and is especially problematic for children, who constitute the population that is most vulnerable and at risk for unintentional and preventable poisonings. The scope of toxic substances involved in poisoning is very broad, requiring health care providers to have an extensive knowledge of signs and symptoms of poisoning, as well as specific therapeutic interventions and antidotes. New synthetic and herbal substances have emerged that have resulted in significant poisoning morbidity and mortality in the pediatric population.

Responding to pediatric poisoning

Make sure you know how to act quickly if a child ingests a toxic substance and what to teach parents to prevent accidental poisonings.

Pediatric poisonings: recognition, assessment, and management

Poisoning represents one of the most common medical emergencies encountered in young children in the United States, and accounts for a significant proportion of emergency room visits for the adolescent population. Poisoning is a significant and persistent cause of morbidity and mortality in children and adolescents. The scope of toxic substances involved in poisoning is broad, and requires health care providers to have an extensive knowledge of signs and symptoms of poisoning and specific therapeutic interventions and antidotes. Most children who ingest poisons suffer no harm; however, health care providers must recognize, assess, and manage those exposures that are most likely to cause serious injury, illness, or death and initiate appropriate management to minimize the physical injury that may occur.

Nurse Practitioners in Pediatric Critical Care

The nurse practitioner in pediatric critical care is a distinct advanced practice nursing role that has seen a tremendous increase in development and implementation over the past 10 years. There is a paucity of literature on this unique and valuable role. A total of 74 nurse practitioners practicing in pediatric critical care were surveyed. Part I of the survey solicited descriptive information of the nurse practitioner including background, work environment, reporting structure, and salary. The respondents also identified their role responsibilities that included direct patient management, nursing and medical education, coordination of care, research, and consultation. Part II of the questionnaire addressed skill level and need for supervision for technical procedures and leadership activities. These respondents described expert or proficient skill levels for the majority of technical procedures (ie, lumbar puncture, central line placement) and leadership activities (ie, discharge planning, participation in medical rounds). This is the first published report to delineate the role of the nurse practitioner in pediatric critical care based on responses from a national survey.

Continuous ambulatory peritoneal dialysis in diabetes mellitus. The risks and benefits of intraperitoneal insulin

14 insulin-dependent diabetic patients completed 122 patient months on continuous ambulatory peritoneal dialysis (CAPD), using only intraperitoneal insulin for glucose control. Survival was 70% at 1 year, in this relatively high-risk group, several members of which had been refused other modalities of treatment. Blood glucose control, using approximately 111 units of regular insulin per day intraperitoneally, was improved over pre-CAPD control, as assessed by monthly blood glucose determinations and Hgb A1c measurements. Pre-CAPD random blood glucose values fell in 13 of 14 from a mean of 367 +/- 42 to 207 +/- 15 mg/dl during CAPD. Mean pre-CAPD Hgb A1c levels were 14.2% with a fall to 10.5-11.4% during CAPD. The intraperitoneal insulin dose represented approximately 3.5 times the pre-CAPD total daily subcutaneous dose of insulin, and no patient required less than approximately twice the pre-CAPD insulin dose. Peritonitis rates were no different when compared to the general nondiabetic population on CAPD (269 patient months), and complicated episodes tended to be less frequent in diabetic patients. Intraperitoneal insulin administration is an effective means of controlling blood sugar in diabetics on CAPD, and does not increase the risk of infection.

Acute bowel obstruction: an unusual complication of chronic peritoneal dialysis

Two cases of acute small bowel obstruction complicating continuous ambulatory peritoneal dialysis (CAPD) are presented. In both patients, bowel herniation was through the peritoneal opening around the dialysis catheter. Both patients had sudden onset of symptoms and required an operation to relieve the obstruction. The second patient is now again on CAPD and has had no further problems. This complication of CAPD has not been previously described, and should be considered in the differential diagnosis of acute bowel obstruction in these patients. It does not, however, preclude continuing CAPD after appropriate therapy.

Longitudinal comparison of intermittent versus continuous ambulatory peritoneal dialysis, in the same patients

Twelve patients who had been on intermittent peritoneal dialysis (IPD) for an average of 18.3 months each, were switched to continuous ambulatory peritoneal dialysis (CAPD). CAPD experience is now 118 patient months (average 9.8 months per patient), and ten patients remain on CAPD. Serum chemistries reflected the change to continuous dialysis with a fall in serum creatinine, potassium, uric acid, phosphate, and BUN. The total CO2 rose markedly, indicating prevention of the recurrent metabolic acidosis experienced in IPD. Serum phosphate fell significantly into the normal range. Serum calcium rose slightly in six patients and significantly in three others. Serum alkaline phosphatase activity rose in seven patients, without development of clinical evidence of bone disease. Mean hematocrit values were higher in most patients of CAPD, but fell again after one year. The transient nature of the rise in hematocrit suggests that improved volume control, as reflected in blood pressure changes, may play a role in the frequently reported increase in hematocrit on CAPD. Despite an increase in peritonitis rate (one infection per 5.9 patient months on CAPD, versus one per 12.2 patient months on IPD), CAPD offers several distinct advantages over IPD, especially in control of uremic acidosis, phosphate retention, blood pressure and fluid management, as well as an overall improvement in physical and psychosocial well-being.