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Wu AG, Madhavan G, Deakins K, Evans D, Hayward A, Pugh C, Stutts AC, Mustin L, Staubach KC, Sisson P, Coffey M, Lyren A, Lee GM, Gupta S, Pereira-Argenziano L, Priebe GP. Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative. JAMA Netw Open 2023; 6:e2346545. [PMID: 38060226 DOI: 10.1001/jamanetworkopen.2023.46545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
Importance Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates. Objective To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates. Design, Setting, and Participants This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023. Intervention A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018. Main Outcomes and Measures Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods. Results Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease. Conclusions and Relevance This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.
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Affiliation(s)
- Andrew G Wu
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Gowri Madhavan
- Center for Pediatric and Maternal Value, Stanford Medicine Children's Health, Palo Alto, California
| | - Kathy Deakins
- Pediatric Respiratory Care, University Hospitals (UH) Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Dana Evans
- Respiratory Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Now with Advocate Aurora Health, Downers Grove, Illinois
| | - Angela Hayward
- Infection Prevention Control, University of Wisconsin Hospital and Clinics, Madison
| | - Caitlin Pugh
- Nursing Quality, Monroe Carell Jr Vanderbilt Children's Hospital, Nashville, Tennessee
- Now with Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Laurie Mustin
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katherine C Staubach
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia Sisson
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maitreya Coffey
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne Lyren
- Case Western Reserve University School of Medicine, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Grace M Lee
- Department of Pediatrics, Infectious Disease, Stanford Medicine Children's Health, Palo Alto, California
| | - Sameer Gupta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, M Health Fairview Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Gregory P Priebe
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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Kimura S, Shimizu K, Matsuoka Y, Iwasaki T, Kanazawa T, Morimatsu H. An Assessment of the Practice of Neuromuscular Blockade and the Association Between Its Prophylactic Use and Outcomes Among Postoperative Pediatric Cardiac Patients. J Cardiothorac Vasc Anesth 2023; 37:980-987. [PMID: 36933990 DOI: 10.1053/j.jvca.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions. DESIGN A retrospective cohort study. SETTING At a tertiary teaching hospital. PARTICIPANTS Patients younger than 18, with congenital heart disease, who underwent cardiac surgery. INTERVENTIONS Commencement of NMBA infusion in the first 2 hours after surgery MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001). CONCLUSIONS Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease.
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Affiliation(s)
- Satoshi Kimura
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan.
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Yoshikazu Matsuoka
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
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Sick-Samuels AC, Priebe GP. Optimizing surveillance for pediatric ventilator-associated events-But are they preventable? Infect Control Hosp Epidemiol 2023; 44:175-177. [PMID: 35611848 PMCID: PMC9691785 DOI: 10.1017/ice.2022.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Anna C Sick-Samuels
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Gregory P Priebe
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Epidemiology and outcomes of ventilator-associated events in critically ill children: Evaluation of three different definitions. Infect Control Hosp Epidemiol 2023; 44:216-221. [PMID: 35506391 DOI: 10.1017/ice.2022.97] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Ventilator-associated pneumonia (VAP) is one of the most common healthcare-associated infections in pediatric intensive care units (PICUs), but its definite diagnosis remains controversial. The CDC Ventilator-Associated Event (VAE) module (validated in adults) constitutes a new approach for VAP surveillance. DESIGN We described epidemiological characteristics of PICU VAE cases, investigated possible risk factors, and evaluated 3 different sets of diagnostic VAE criteria. SETTING This study was conducted in a PICU in a tertiary-care general hospital in northern Greece during 2017-2019. PATIENTS The study included patients aged 35 days-16 years who received mechanical ventilation. METHODS From medical records, we retrieved epidemiological data, clinical data, and laboratory characteristics as well as ventilator settings for our analysis. We assessed "oxygen deterioration" for the tier 1 CDC VAE module using 3 sets of diagnostic criteria: (1) CDC adult VAE criteria [increase of daily minimum fraction of inspired oxygen (FiO2) ≥ 0.2 or positive end expiratory pressure (PEEP) ≥ 3 cmH2O for 2 days], (2) the US pediatric VAE criteria [increase of FiO2 ≥ 0.25 or mean airway pressure (MAP) ≥ 4 cmH2O for 2 days], and (3) the European pediatric VAE criteria (increase of FiO2 ≥ 0.2 or PEEP ≥ 2 cmH2O for 1 day or increase of FiO2 ≥ 0.15 and PEEP ≥ 1 cm H2O for 1 day). RESULTS Among 326 children admitted to the PICU, 301 received mechanical ventilation. The incidence rate according to the CDC adult VAE criteria was 4.7 per 1,000 ventilator days. For the US pediatric VAE criteria the incidence rate was 6 per 1,000 ventilator days. For the European pediatric VAE criteria the incidence rate was 9.7 per 1,000 ventilator days. These results revealed statistically significant correlation of all 3 algorithms with adverse outcomes, including mortality. CONCLUSIONS All VAE algorithms were associated with higher mortality rates. Our findings highlight the need for a unified pediatric VAE definition to improve preventive strategies.
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Schults JA, Charles K, Harnischfeger J, Erikson S, Burren J, Waak M, Blackwood B, Tume LN, Long D. Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice. Aust Crit Care 2022:S1036-7314(22)00090-X. [PMID: 36038459 DOI: 10.1016/j.aucc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES We aimed to (i) describe current weaning and extubation practices in children (protocols to identify weaning candidates, spontaneous breathing trials, and other aspects of care such as sedation weaning) and (ii) understand responsibilities for ventilation weaning decisions across Australia and New Zealand (ANZ). METHODS A cross-sectional survey of ANZ intensive care units who routinely intubate and ventilate children (<18 years) was conducted. We worked with the Australian and New Zealand Intensive Care Society Paediatric Study Group to identify units and potential respondents (senior nurse representative per unit) and to administer questionnaires. Survey questions (n = 35) examined current protocols, practices, unit staffing, and decision-making responsibilities for ventilation weaning and extubation. Open-ended questions examined respondents' experiences of weaning and extubation. RESULTS A senior nursing respondent from 18/22 intensive care units (82%) completed the survey. Across units, most used sedation assessment tools (88%), and less often, sedation weaning tools (55%). Spontaneous awakening protocols were not used; one unit (5%) reported the use of a spontaneous breathing protocol. Two respondents reported that ventilation weaning protocols (11%) were in use, with 44% of units reporting the use of extubation protocols. Weaning and extubation practices were largely perceived as medically driven, with qualitative data demonstrating a desire from most respondents for greater shared decision-making. CONCLUSION In ANZ, ventilation weaning and extubation practices are largely medically driven with variation in the use of protocols to support mechanical ventilation weaning and extubation in children. Our findings highlight the importance of future research to determine the impact of greater collaboration of the multidisciplinary team on weaning practices.
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Affiliation(s)
- Jessica A Schults
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Metro North Hospital and Health Service, Queensland, Australia; Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Queensland, Australia.
| | - Karina Charles
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Queensland, Australia
| | - Jane Harnischfeger
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Simon Erikson
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Juerg Burren
- University Children's Hospital Zurich, Switzerland
| | - Michaela Waak
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; Centre for Children's Health Research, the University of Queensland, Queensland, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Northern Ireland, UK
| | - Lyvonne N Tume
- School of Health & Society, University of Salford, Manchester, UK; Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Debbie Long
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
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Alriyami A, Kiger JR, Hooven TA. Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit. Neoreviews 2022; 23:e448-e461. [PMID: 35773508 DOI: 10.1542/neo.23-7-e448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
See Bonus NeoBriefs videos and downloadable teaching slides Intubated infants in the NICU are at risk of developing ventilator-associated pneumonia (VAP), a common type of health care-associated infection. The Centers for Disease Control and Prevention developed guidelines for diagnosing VAP in patients younger than 1 year, which include worsening gas exchange, radiographic findings, and at least 3 defined clinical signs of pneumonia. VAP in infants is treated with empiric antibiotics selected based on local resistance patterns and individualized patient data. Many NICUs have implemented prevention bundles in an effort to decrease VAP by ensuring the cleanest environment for intubated neonates (hand hygiene, sterile handling of equipment), positioning of infants to prevent gastric reflux, and constantly reevaluating for extubation readiness. Although these prevention bundle elements are intuitive and generally low risk, none are based on strong research support. This article reviews the epidemiology, pathogenesis, diagnosis, treatment, and prevention of VAP in NICU patients, focusing on recent evidence, highlighting areas of emerging research, and identifying persistent knowledge gaps.
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Affiliation(s)
- Ayesha Alriyami
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - James R Kiger
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas A Hooven
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Richard King Mellon Institute for Pediatric Research, Pittsburgh, PA
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Weinberger J, Cocoros N, Klompas M. Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention. Infect Dis Clin North Am 2021; 35:871-899. [PMID: 34752224 DOI: 10.1016/j.idc.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - Noelle Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Fluid Balance and Ventilator-Associated Events Among Patients Admitted to ICUs in China: A Nested Case-Control Study. Crit Care Med 2021; 50:307-316. [PMID: 34473657 PMCID: PMC8797004 DOI: 10.1097/ccm.0000000000005227] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Supplemental Digital Content is available in the text. Fluid therapy is an important component of intensive care management, however, optimal fluid management is unknown. The relationship between fluid balance and ventilator-associated events has not been well established. This study investigated the dose-response relationship between fluid balance and ventilator-associated events.
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Association between blood transfusion and ventilator-associated events: a nested case-control study. Infect Control Hosp Epidemiol 2021; 43:597-602. [PMID: 33993893 DOI: 10.1017/ice.2021.178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The association between blood transfusion and ventilator-associated events (VAEs) has not been fully understood. We sought to determine whether blood transfusion increases the risk of a VAE. DESIGN Nested case-control study. SETTING This study was based on a registry of healthcare-associated infections in intensive care units at West China Hospital system. PATIENTS 1,657 VAE cases and 3,293 matched controls were identified. METHODS For each case, 2 controls were randomly selected using incidence density sampling. We defined blood transfusion as a time-dependent variable, and we used weighted Cox models to calculate hazard ratios (HRs) for all 3 tiers of VAEs. RESULTS Blood transfusion was associated with increased risk of ventilator-associated complication-plus (VAC-plus; HR, 1.47; 95% CI, 1.22-1.77; P <.001), VAC-only (HR, 1.29; 95% CI, 1.01-1.65; P = .038), infection-related VAC-plus (IVAC-plus; HR, 1.78; 95% CI, 1.33-2.39; P < .001), and possible ventilator-associated pneumonia (PVAP; HR, 2.10; 95% CI, 1.10-3.99; P = .024). Red blood cell (RBC) transfusion was also associated with increased risk of VAC-plus (HR, 1.34; 95% CI, 1.08-1.65; P = .007), IVAC-plus (HR, 1.70; 95% CI, 1.22-2.36; P = .002), and PVAP (HR, 2.49; 95% CI, 1.17-5.28; P = .018). Compared to patients without transfusion, the risk of VAE was significantly higher in patients with RBC transfusions of >3 units (HR, 1.73; 95% CI, 1.25-2.40; P = .001) but not in those with RBC transfusions of 0-3 units. CONCLUSION Blood transfusions were associated with increased risk of all tiers of VAE. The risk was significantly higher among patients who were transfused with >3 units of RBCs.
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Sedation, Analgesia, and Neuromuscular Blockade: An Assessment of Practices From 2009 to 2016 in a National Sample of 66,443 Pediatric Patients Cared for in the ICU. Pediatr Crit Care Med 2020; 21:e599-e609. [PMID: 32195896 PMCID: PMC7483172 DOI: 10.1097/pcc.0000000000002351] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To describe the pharmaceutical management of sedation, analgesia, and neuromuscular blockade medications administered to children in ICUs. DESIGN A retrospective analysis using data extracted from the national database Health Facts. SETTING One hundred sixty-one ICUs in the United States with pediatric admissions. PATIENTS Children in ICUs receiving medications from 2009 to 2016. EXPOSURE/INTERVENTION Frequency and duration of administration of sedation, analgesia, and neuromuscular blockade medications. MEASUREMENTS AND MAIN RESULTS Of 66,443 patients with a median age of 1.3 years (interquartile range, 0-14.5), 63.3% (n = 42,070) received nonopioid analgesic, opioid analgesic, sedative, and/or neuromuscular blockade medications consisting of 83 different agents. Opioid and nonopioid analgesics were dispensed to 58.4% (n = 38,776), of which nonopioid analgesics were prescribed to 67.4% (n = 26,149). Median duration of opioid analgesic administration was 32 hours (interquartile range, 7-92). Sedatives were dispensed to 39.8% (n = 26,441) for a median duration of 23 hours (interquartile range, 3-84), of which benzodiazepines were most common (73.4%; n = 19,426). Neuromuscular-blocking agents were dispensed to 17.3% (n = 11,517) for a median duration of 2 hours (interquartile range, 1-15). Younger age was associated with longer durations in all medication classes. A greater proportion of operative patients received these medication classes for a longer duration than nonoperative patients. A greater proportion of patients with musculoskeletal and hematologic/oncologic diseases received these medication classes. CONCLUSIONS Analgesic, sedative, and neuromuscular-blocking medications were prescribed to 63.3% of children in ICUs. The durations of opioid analgesic and sedative medication administration found in this study can be associated with known complications, including tolerance and withdrawal. Several medications dispensed to pediatric patients in this analysis are in conflict with Food and Drug Administration warnings, suggesting that there is potential risk in current sedation and analgesia practice that could be reduced with practice changes to improve efficacy and minimize risks.
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Ventilator-associated Events in Children: Controversies and Research Needs. Pediatr Infect Dis J 2020; 39:e37-e39. [PMID: 32084110 DOI: 10.1097/inf.0000000000002576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Barriers to the adoption of ventilator-associated events surveillance and prevention. Clin Microbiol Infect 2019; 25:1180-1185. [DOI: 10.1016/j.cmi.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/28/2019] [Accepted: 03/28/2019] [Indexed: 12/12/2022]
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Variability in antimicrobial use in pediatric ventilator-associated events. Infect Control Hosp Epidemiol 2018; 40:32-39. [PMID: 30409233 DOI: 10.1017/ice.2018.264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs). DESIGN Descriptive retrospective cohort with nested case-control study. SETTING Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.PatientsChildren≤18 years ventilated for≥1 calendar day. METHODS We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria. RESULTS Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20-67%; PICU, 0-70%; and NICU, 0-43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test. CONCLUSIONS Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
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Ventilator-Associated Conditions: Are the New Definitions "Eliminating the Noise" or Ignoring Important Preconditions? Pediatr Crit Care Med 2018; 19:578-579. [PMID: 29863639 DOI: 10.1097/pcc.0000000000001541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Conflicting Paradigm of Ventilator-Associated Conditions. Pediatr Crit Care Med 2017; 18:1078-1079. [PMID: 29099453 PMCID: PMC5679393 DOI: 10.1097/pcc.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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