Adverse occurrences in the pediatric intensive care unit

Integrating the Institute of Medicine's six quality aims into pediatric critical care: relevance and applications

The Institute of Medicine's report Crossing the Quality Chasm recommends "six aims for improvement." The aims are safety, effectiveness, equity, timeliness, patient-centeredness, and efficiency. This review focuses on the quality of care information relevant to the Institute of Medicine's six aims to assess their relevance, potential impact, and affect on pediatric critical care practice. It is concluded that if the care for pediatric intensive care patients is to be fundamentally improved, an understanding of the current care environment, the existing evidence base, the opportunities for improvement, and the documentation of the improvements needs to be realized. The Institute of Medicine's six aims provide a useful framework to advance the quality of care in this pediatric subspecialty and perhaps others.

Incidence and prevalence of pressure ulcers in children

OBJECTIVE

To determine the incidence and prevalence of pressure ulcers in children.

DESIGN

National survey mailed to 234 members of 4 pediatric-specific health care databases.

PARTICIPANTS

A total of 55 questionnaires were returned (25% return rate). Fifty-one of the questionnaires were suitable for obtaining prevalence data and 40 were suitable for obtaining incidence data.

RESULTS

The pressure ulcer incidence rate was 0.29% and the prevalence rate for 1998 was 0.47%. Many of the contributing factors cited by participants mirrored those seen in adult patients with pressure ulcers.

CONCLUSION

Under the National Institutes of Health guidelines, children can be excluded from pressure ulcer studies that include subjects above age 21 because of the rarity of pressure ulcer development in the pediatric population. However, separate pediatric pressure ulcer studies should be conducted to determine best-practice models for children with pressure ulcers.

Needs of the critically ill child: a review of the literature and report of a modified Delphi study

There has been a wealth of guidance from both policy-makers (Department of Health, (DoH) 1991, DoH 1997a, DoH 1997b) and other interested parties (Audit Commission 1993, British Paediatric Association 1993, Paediatric Intensive Care Society 1992) regarding how and where care should be provided for critically ill children. Latest recommendations indicate that designated general ICUs will continue to provide care for children requiring life support and that all general ICUs will need to initiate such care (DoH 1997a). The literature relating to how nurses identify and act on the needs of the critically ill child has been anecdotal in nature (Green 1991, Purcell 1993), whilst published studies focus on comparing outcomes (Pollock et al 1991) and addressing the needs of parents (Farrell & Frost 1992, Kasper & Nyamathi 1988). This paper explores the literature regarding the needs of the critically ill child, incorporating the role of parents and previous studies exploring needs. The findings of a modified Delphi study exploring the needs of the critically ill child are also outlined.

Autopsies and the pediatric intensive care unit

The pediatric autopsy can provide great benefits to families at a time when their world is falling apart. It can be invaluable in the processing of grief that families endure, helping them to plan their future. Autopsy results not only provide information but may also provide consolation by giving the family the opportunity to discuss the disease process that resulted in death. Autopsy results also provide information regarding the future and reassurance that appropriate care was given. Failure to perform a postmortem examination denies the family and the clinician knowledge regarding mechanisms of disease, confirmation or inclusion of unsuspected diagnoses, and the presence of iatrogenic complications. This missed information can be both informative to the current family's situation and potentially therapeutic in future cases. If death is the final chapter of life, then the physician's responsible relationship with the parents of the deceased patient should not end until a conference takes place several weeks or months after the child's death. The results of the postmortem examination provide a beginning point for discussion regarding the child's illness and death, the parents responses and coping, and the opportunity to help the family make sense of and bring closure to one of life's greatest crises.

Pneumomyocardium: an unusual complication of barotrauma

We report a 22-day-old infant who developed Staphylococcus aureus pneumonia with abscesses, pneumatoceles, and sepsis at 10 days of life. Mechanical ventilation was complicated by pneumothorax. At autopsy, a collection of air was found in the interventricular septum of the heart, a lesion we have termed pneumomyocardium. No hemorrhage, inflammatory infiltrate, organisms, or necrotic debris was found on the edge of the area of interstitial emphysema in the heart. We believe that the pneumomyocardium arose as a consequence of barotrauma.

Incidence and duration of total occlusion of the radial artery in newborn infants after catheter removal

The incidence and duration of total occlusion of the radial artery after catheter removal was determined using repeated Doppler flow measurements. Thirty-two newborn infants with birthweights ranging from 945 g to 3890 g (median 1935 g) and gestational age ranging from 26 to 40 weeks (median 32 weeks) were studied. In 20 out of 32 infants (63%), complete occlusion of the radial artery occurred. The number of occlusions were not related to birthweight, gestational age or duration of cannulation. In all infants, blood flow in the radial artery resumed within 1-29 days after catheter removal. The duration of occlusion was directly related to the duration of cannulation and inversely related to birthweight. This study demonstrates a high frequency of total occlusion of the radial artery in newborn infants after percutaneous radial artery cannulation. In the majority of infants with a radial artery catheter, blood flow to the tissue distal to the cannulation site is dependent solely on the existence of an adequate arterial palmar collateral circulation.