Emission rates of bio-based building materials, a method description for qualifying and quantifying VOC emissions

Biobased insulation materials offer opportunities to use vapor-open building constructions. Such constructions allow direct interaction between the biobased material and the indoor environment. This interaction raises questions about indoor air quality concerning volatile organic compounds (VOCs). This study presents results for the VOC emissions from biobased materials. It consists of two parts: 1) qualification of VOC emissions (compounds) from several biobased and non-biobased building materials, and 2) quantification of VOC emissions (emission rate) from expanded cork (biobased), particle board (semi-biobased), and EPS insulation. By quantifying the emission rate, the exposure to the released VOC emissions at room temperature in a standardized room can be compared to health limit requirements. Gas chromatography and mass spectroscopy (GC-MS) is used to derive the individual VOC emissions and the Total Volatile Organic Compounds (TVOC) from these materials. For qualification, two different sampling techniques are used in which temperature is introduced as a variable to investigate its effect on the type of compounds emitted. For quantification, the toluene equivalent approach is compared to the group equivalent approach. From the analyses it is concluded that temperature has an effect on the type of VOC compounds emitted from (biobased) materials. Results from the quantification indicate that expanded cork and particle board emit no harmful substances at a level that can affect human health. For EPS insulation, elevated levels of benzene were found to exceed healthy limits. The toluene equivalent approach for quantifying the emission, generally, underestimates the rate as compared to the more accurate group equivalent approach.

What Do We Know About Pediatric Palliative Care Patients Consulting to the Pediatric Emergency Department?

OBJECTIVES

The objective of this study was to describe the characteristics of pediatric palliative care (PPC) patients presenting to a pediatric emergency department (ED) and these patients' ED visits.

METHODS

This retrospective chart review was conducted from April 1, 2007, to March 31, 2012, in a tertiary care pediatric university-affiliated hospital. Eligible patients had initial PPC consultations during the study period; all ED visits by these patients were included. Data were drawn from the ED's electronic data system and patient's medical chart.

RESULTS

A total of 290 new patients were followed by the PPC team, and 94 (32.4%) consulted the ED. Pediatric palliative care patients who consulted the ED had a median age of 7 years and baseline diagnoses of cancer (39.4%) or encephalopathy (27.7%). No patients died in the ED, but 36 (38.3%) died in hospital after an ED visit and 18 (19.1%) within 72 hours of admission. Pediatric palliative care patients consulted 219 times, with a median number of visits per patient of 2 (range, 1-8). They presented acutely ill as per triage scales. Reasons for consultation included respiratory distress/dyspnea (30.6%), pain (12.8%), seizure (11.4%), and fever (9.1%). Patients were often admitted to wards (61.2%) and the pediatric intensive care unit (7.3%). Two thirds (65.7%) of patients had signed an advanced care directive at the time of their visit. Discussions about goals of care occurred in 37.4% of visits.

CONCLUSIONS

Pediatric palliative care patients present to the ED acutely ill, often at their end of life, and goals of care are not always discussed. This is a first step toward understanding how to improve PPC patients' ED care.

Massive Hemorrhage Protocol Application and Teamwork Skills

OBJECTIVE

Massive hemorrhages (MHs) are rare but serious complications of pediatric trauma and obstetric cases. This study aimed to evaluate the impact of interprofessional simulation to improve adherence to a MH protocol (MHP), teamwork skills and confidence levels during a hemorrhagic crisis situation.Methods: This was a pre-post experimental study conducted at a tertiary care mother-child simulation center. Pediatric emergency and obstetric teams were submitted to simulated trauma and postpartum MH scenarios. Training consisted of two case scenarios followed by debriefing sessions and a lecture on the MHP. The primary outcome was adherence to MHP processes (checklist) measured prior to and 2 weeks following training sessions. Other outcomes were the measure of teamwork skills (Mayo High Performance Teamwork Scale) and confidence of the participants.

RESULTS

Sixty-two health care professionals were involved in eight interprofessional teams. Mean scores for adherence to the MHP improved from 19.1 in the pretraining phase to 25.8 in the posttraining phase (difference of 6.7; 95% confidence interval [CI] = 4.4 to 8.9). Mean scores pertaining to teamwork skills also improved significantly between pre- and posttraining phases (difference = 3.9; 95% CI = 1.5 to 6.4). Confidence questionnaires showed significant improvements in the posttraining phase (difference = 6.9; 95% CI = 5.3 to 8.3).

CONCLUSIONS

Targeted training involving simulation and protocol review improved participant adherence to MHP processes and teamwork skills. Confidence levels improved across all disciplines.

Interventions in the operating room for children near end of life: A multidisciplinary approach

INTRODUCTION

Pediatric surgeons are often involved in the management of severely or terminally ill patients. However, articles addressing their specific roles in the context of palliative care are almost inexistent. We sought to characterize the involvement of pediatric surgeons caring for children near end of life.

METHODS

Chart review of children who had a procedure under general anesthesia within 6months of their death over a five-year period at a tertiary children's hospital (excluding traumas and neonatology cases). In addition to demographic and clinical data, we recorded the aim of the procedures performed, the involvement of the palliative care service, and presence of DNAR orders.

RESULTS

The analysis included 83 patients (mean age: 8years). Forty-four children had more than one procedure (range 2-10). Pediatric palliative care service was involved in 66 cases (80%). A majority of patients had cancer (50%), and the most frequent cause of death was oncologic progression (46%). Ten patients died of a complication following their intervention. The aim of the procedure was palliative in 48 cases (29 for symptoms control and 19 to facilitate care), diagnostic in 16, and curative in 19. Forty-five procedures were performed urgently and 14 despite DNAR orders.

CONCLUSION

Surgeon involvement with children near end of life is not infrequent. The procedures performed are varied and can be categorized according to their aim. Lack of formal palliative care training by surgeons highlights the need for increased collaboration with palliative care services to provide children optimal care when they need it most.

LEVEL OF EVIDENCE

IV.

Survey highlights the need for specific interventions to reduce frequent conflicts between healthcare professionals providing paediatric end-of-life care

AIMS

This study explored how paediatric healthcare professionals experienced and coped with end-of-life conflicts and identified how to improve coping strategies.

METHODS

A questionnaire was distributed to all 2300 professionals at a paediatric university hospital, covering the frequency of end-of-life conflicts, participants, contributing factors, resolution strategies, outcomes and the usefulness of specific institutional coping strategies.

RESULTS

Of the 946 professionals (41%) who responded, 466 had witnessed or participated in paediatric end-of-life discussions: 73% said these had led to conflict, more frequently between professionals (58%) than between professionals and parents (33%). Frequent factors included professionals' rotations, unprepared parents, emotional load, unrealistic parental expectations, differences in values and beliefs, parents' fear of hastening death, precipitated situations and uncertain prognosis. Discussions with patients and parents and between professionals were the most frequently used coping strategies. Conflicts were frequently resolved by the time of death. Professionals mainly supported designating one principal physician and nurse for each patient, two-step interdisciplinary meetings - between professionals then with parents - postdeath ethics meetings, bereavement follow-up protocols and early consultations with paediatric palliative care and clinical ethics services.

CONCLUSION

End-of-life conflicts were frequent and predominantly occurred between healthcare professionals. Specific interventions could target most of the contributing factors.

Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria

BACKGROUND

The incidence of transfusion-associated circulatory overload (TACO) is not well known in children, especially in pediatric intensive care unit (PICU) patients.

STUDY DESIGN AND METHODS

All consecutive patients admitted over 1 year to the PICU of CHU Sainte-Justine were included after they received their first red blood cell transfusion. TACO was diagnosed using the criteria of the International Society of Blood Transfusion, with two different ways of defining abnormal values: 1) using normal pediatric values published in the Nelson Textbook of Pediatrics and 2) by using the patient as its own control and comparing pre- and posttransfusion values with either 10 or 20% difference threshold. We monitored for TACO up to 24 hours posttransfusion.

RESULTS

A total of 136 patients were included. Using the "normal pediatric values" definition, we diagnosed 63, 88, and 104 patients with TACO at 6, 12, and 24 hours posttransfusion, respectively. Using the "10% threshold" definition we detected 4, 15, and 27 TACO cases in the same periods, respectively; using the "20% threshold" definition, the number of TACO cases was 2, 6, and 17, respectively. Chest radiograph was the most frequent missing item, especially at 6 and 12 hours posttransfusion. Overall, the incidence of TACO varied from 1.5% to 76% depending on the definition.

CONCLUSION

A more operational definition of TACO is needed in PICU patients. Using a threshold could be more optimal but more studies are needed to confirm the best threshold.

Atypical juvenile presentation of GM2 gangliosidosis AB in a patient compound-heterozygote for c.259G > T and c.164C > T mutations in the GM2A gene

G_M2-gangliosidosis, AB variant is an extremely rare autosomal recessive inherited disorder caused by mutations in the GM2A gene that encodes G_M2 ganglioside activator protein (GM2AP). GM2AP is necessary for solubilisation of G_M2 ganglioside in endolysosomes and its presentation to β-hexosaminidase A. Conversely GM2AP deficiency impairs lysosomal catabolism of G_M2 ganglioside, leading to its storage in cells and tissues. We describe a 9-year-old child with an unusual juvenile clinical onset of G_M2-gangliosidosis AB. At the age of 3 years he presented with global developmental delay, progressive epilepsy, intellectual disability, axial hypertonia, spasticity, seizures and ataxia, but without the macular cherry-red spots typical for G_M2 gangliosidosis. Brain MRI detected a rapid onset of diffuse atrophy, whereas whole exome sequencing showed that the patient is a compound heterozygote for two mutations in GM2A: a novel nonsense mutation, c.259G > T (p.E87X) and a missense mutation c.164C > T (p.P55L) that was recently identified in homozygosity in patients of a Saudi family with a progressive chorea-dementia syndrome. Western blot analysis showed an absence of GM2AP in cultured fibroblasts from the patient, suggesting that both mutations interfere with the synthesis and/or folding of the protein. Finally, impaired catabolism of G_M2 ganglioside in the patient's fibroblasts was demonstrated by metabolic labeling with fluorescently labeled G_M1 ganglioside and by immunohistochemistry with anti-G_M2 and anti-G_M3 antibodies. Our observation expands the molecular and clinical spectrum of molecular defects linked to G_M2-gangliosidosis and suggests novel diagnostic approach by whole exome sequencing and perhaps ganglioside analysis in cultured patient's cells.

Hypotensive Reactions Associated with Platelet Transfusion Through Leukocyte Reduction Filters

This article reports a case of hypotensive reaction following platelet transfusion (PT) and presents a possible etiologic mechanism implicating negatively charged leukocyte reduction filters (LRFs) and angiotensin converting enzyme (ACE) inhibitors. A 14-year-old boy with acute lymphoblastic leukemia was admitted to the pediatric intensive care unit (PICU) for respiratory failure following bone marrow transplantation. He was being treated with ACE inhibitors and was hemodynamically stable. He received a PT with a negatively charged bedside LRF the day his ACE inhibitor dose was doubled. His blood pressure (BP) dropped from 106/65 to 75/45. The PT was stopped and his BP was stabilized with a bolus of cristalloid. The same PT was restarted using a macroaggregate filter and his BP remained stable. This reaction was characterized by severe and isolated hypotension. It occurred while using a negatively charged bedside LRF in a patient who had a recent increase in ACE inhibitor therapy. The reaction did not recur when the LRF was replaced by a macroaggregate filter. This case provides further evidence to support the hypothesis that the use of negatively charged LRF may lead to hypotensive transfusion reactions in some patients. Bradykinin, which is generated when plasma is exposed to a negatively charged surface, and whose metabolism is decreased by ACE inhibitors, may play a role in these reactions.

An Order Protocol for Respiratory Distress/Acute Pain Crisis in Pediatric Palliative Care Patients: Medical and Nursing Staff Perceptions

BACKGROUND

An order protocol for distress (OPD), including respiratory distress and acute pain crisis, has been established for pediatric palliative care patients at Sainte-Justine Hospital (SJH). After discussion with the patient/his or her family, the OPD is prescribed by the attending physician whenever judged appropriate. The OPD can then be initiated by the bedside nurse when necessary; the physician is notified after the first dose is administered.

OBJECTIVES

The study objectives were to evaluate the perceptions and experience of the medical/nursing staff towards the use of the OPD.

METHODS

A survey was distributed to all physicians/nurses working on wards with pediatric palliative care patients. Answers to the survey were anonymous, done on a voluntary basis, and after consent of the participant.

RESULTS

Surveys (258/548) were answered corresponding to a response rate of 47%. According to the respondents, the most important motivations in using the OPD were the desire to relieve patient's distress and the speed of relief of distress by the OPD; the most important obstacles were going against the patient's/his or her family's wishes and fear of hastening death. The respondents reported that the OPD was frequently (56%) or always (36%) effective in relieving the patient's distress. The respondents felt sometimes (16%), frequently (34%), or always (41%) comfortable in giving the OPD. They thought the OPD could never (12%), rarely (32%), sometimes (46%), frequently (8%), or always (1%) hasten death. Physicians were less favorable than nurses with the autonomy of bedside nurses to initiate the OPD before notifying the physician (p = 0.04). Overall, 95% of respondents considered that they would use the OPD in the future.

CONCLUSIONS

Data from this survey shows that respondents are in favor of using the OPD at SJH and find it effective. Further training as well as support for health care professionals are mandatory in such palliative care settings.

Incidence of hypotension and acute hypotensive transfusion reactions following platelet concentrate transfusions

BACKGROUND AND OBJECTIVES

Platelet concentrates (PCs) are associated with transfusion reactions involving hypotension, particularly bradykinin-mediated acute hypotensive transfusion reactions. This study aims to determine the incidence of hypotensive events and more specifically acute hypotensive transfusion reaction associated with PC transfusions. We also sought to ascertain whether these reactions are associated with elevated bradykinin levels.

MATERIALS AND METHODS

This is a prospective descriptive study of PCs administered at Sainte-Justine Hospital over 28 months. All PCs administered during this period were screened for hypotension through review of all transfusion-associated reaction reports (TARRs) sent to the blood bank. All residual PC bags were returned to the blood bank. TARRs associated with hypotension were reviewed by adjudicators that established the imputability of the PC transfusion to the reaction. Bradykinin levels were sampled in the first 168 PC bags returned to the blood bank. Levels were compared between PCs associated with hypotension and control PCs not associated with hypotension.

RESULTS

A total of 3672 PC bags were returned to the blood bank; 25 PCs were associated with hypotension. Adjudicators ascertained that five hypotensive events were imputable to PCs of which one was an acute hypotensive transfusion reaction (incidence: 0·03%). Bradykinin level in the latter PC was 10 pg/ml, whereas levels were 226·2 ± 1252 pg/ml in the 143 control PCs.

CONCLUSION

Our results show a low incidence of hypotension after PC transfusion. We identified only one acute hypotensive transfusion reaction. No correlation between bradykinin level and the occurrence of acute hypotensive reactions could be observed given that only one event was identified.

Weaning children from mechanical ventilation with a computer-driven protocol: a pilot trial

PURPOSE

Duration of weaning from mechanical ventilation is decreased with the use of written protocols in adults. In children, the use of written protocols has not had such an impact.

METHODS AND MEASUREMENTS

We conducted a single-center trial to assess the feasibility of conducting a multicenter randomized clinical trial comparing the duration of weaning from mechanical ventilation in those managed by a computer-driven explicit protocol versus usual care. Mechanically ventilated children aged between 2 and 17 years on pressure support and not receiving inotropes were included. After randomization, children were weaned either by usual care (n = 15) that was characterized by no protocolized decisions by attending physicians, or by a computer-driven protocol (Smartcare/PS™, Drager Medical) (n = 15). Weaning duration until first extubation was the primary outcome. For comparison, a Mann-Whitney U test was employed (p < 0.05).

RESULTS

Patients characteristics at inclusion were similar. The median duration of weaning was 21 h (range 3-142 h) in the SmartCare/PS™ group and 90 h (range 4-552 h) in the usual care group, p = 0.007. The rate of reintubation within 48 h after extubation and the rate of noninvasive ventilation after extubation in the SmartCare/PS™ and usual care groups were 2/15 versus 1/15 and 2/15 versus 2/15, respectively.

CONCLUSIONS

A pediatric randomized trial on mechanical ventilation with a computerized protocol in North America is feasible. A computer-driven protocol that also manages children younger than 2 years old would help to decrease the number of PICU admissions screened in a multicentre trial on this topic.

Transfusion-related acute lung injury in the Canadian paediatric population

BACKGROUND

The incidence of transfusion-related acute lung injury (TRALI) in adults is approximately one per 5000 transfusions. The Canadian Paediatric Surveillance Program undertook the present study to determine the incidence of TRALI in the paediatric population and to describe the characteristics and outcomes of children with TRALI.

METHODS

The present surveillance study was conducted over a three-year period.

RESULTS

Four TRALI cases were reported, yielding an incidence rate of 1.8 per 100,000 transfusions. The degree of severity varied: in two patients, only supplemental oxygen was necessary, while the other two required mechanical ventilation.

CONCLUSION

TRALI was reported much less often in the present study compared with adult studies; therefore, it needs to be determined whether TRALI occurs less frequently in children, or alternatively, whether TRALI is recognized less often in children. The possibility that neonates who undergo cardiac surgery are at greater risk of TRALI than other patients should be addressed in future studies.

Transient creatine phosphokinase elevations in children: a single-center experience

OBJECTIVES

To determine the etiologies and evolution of rhabdomyolysis in children.

STUDY DESIGN

We performed a retrospective study of patients with rhabdomyolysis who were seen in our tertiary care university-affiliated pediatric hospital. Patients in outpatient clinics, seen in the emergency department, or admitted from 2001 to 2002 were selected. With a standardized case report form, we collected predetermined data from each patient's chart.

RESULTS

A total of 130 patients with rhabdomyolysis were included in the study (male, 56%; mean age, 7.5 ± 5.9 years). The median elevation of creatine phosphokinase was 2207 IU/L (range, 1003 to 811 428 IU/L). The most frequent diagnoses were viral myositis (29, 22.3%), trauma (24, 18.4%), surgery (24, 18.4%), hypoxia (12 , 9.2%), and drug reaction (8, 6.2%). Metabolic myopathy was found only in one patient (0.8%). In 17 patients (13.1%), no definite diagnosis could be made.

CONCLUSIONS

Etiologies of rhabdomyolysis in children are varied and differ from those reported in adults. In most patients, rhabdomyolysis is benign and without recurrence. In our series, rhabdomyolysis was the initial symptom of a metabolic myopathy in only one patient.

Acute kidney injury is an independent risk factor for pediatric intensive care unit mortality, longer length of stay and prolonged mechanical ventilation in critically ill children: a two-center retrospective cohort study

Introduction

In adults, small (< 50%) serum creatinine (SCr) increases predict mortality. It is unclear whether different baseline serum creatinine (bSCr) estimation methods affect findings of acute kidney injury (AKI)-outcome associations. We characterized pediatric AKI, evaluated the effect of bSCr estimation approaches on AKI-outcome associations and evaluated the use of small SCr increases to predict AKI development.

Methods

We conducted a retrospective cohort database study of children (excluding postoperative cardiac or renal transplant patients) admitted to two pediatric intensive care units (PICUs) for at least one night in Montreal, QC, Canada. The AKI definition was based on the Acute Kidney Injury Network staging system, excluding the requirement of SCr increase within 48 hours, which was impossible to evaluate on the basis of our data set. We estimated bSCr two ways: (1) the lowest SCr level in the three months before admission or the average age- and gender-based norms (the standard method) or (2) by using average norms in all patients. Outcomes were PICU mortality and length of stay as well as required mechanical ventilation. We used multiple logistic regression analysis to evaluate AKI risk factors and the association between AKI and mortality. We used multiple linear regression analysis to evaluate the effect of AKI on other outcomes. We calculated diagnostic characteristics for early SCr increase (< 50%) to predict AKI development.

Results

Of 2,106 admissions (mean age ± SD = 5.0 ± 5.5 years; 47% female), 377 patients (17.9%) developed AKI (using the standard bSCr method) during PICU admission. Higher Pediatric Risk of Mortality score, required mechanical ventilation, documented infection and having a bSCr measurement were independent predictors of AKI development. AKI was associated with increased mortality (adjusted odds ratio (OR) = 3.7, 95% confidence interval (95% CI) = 2.1 to 6.4, using the standard bSCr method; OR = 4.5, 95% CI = 2.6 to 7.9, using normative bSCr values in all patients). AKI was independently associated with longer PICU stay and required mechanical ventilation. In children with no admission AKI, the initial percentage SCr increase predicted AKI development (area under the curve = 0.67, 95% CI = 0.60 to 0.74).

Conclusions

AKI is associated with increased mortality and morbidity in critically ill children, regardless of the bSCr used. Paying attention to small early SCr increases may contribute to early AKI diagnosis in conjunction with other new AKI biomarkers.

Association between length of storage of transfused red blood cells and multiple organ dysfunction syndrome in pediatric intensive care patients

BACKGROUND

The objective was to determine if there is an association between red blood cell (RBC) storage time and development of new or progressive multiple organ dysfunction syndrome (MODS) in critically ill children.

STUDY DESIGN AND METHODS

This was an analytic cohort analysis of patients enrolled in a randomized controlled trial, TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units; ISRCTN37246456), in which stable critically ill children were randomly assigned to a restrictive or liberal strategy. Transfused patients were analyzed using three different sliding time cutoffs (7, 14, and 21 days). Storage time for multiply transfused patients was defined according to the oldest unit transfused.

RESULTS

A total of 455 patients were retained (liberal, 310; restrictive, 145). Multivariate logistic regression was performed to determine independent associations. In the restrictive group, a maximum RBC storage time of more than 21 days was independently associated with new or progressive MODS (adjusted odds ratio [OR], 3.29; 95% confidence interval [CI], 1.21-9.04). The same association was found in the liberal group for a storage time of more than 14 days (adjusted OR, 2.50; 95% CI, 1.12-5.58). When the two groups were combined in a meta-analysis, a storage time of more than 14 days was independently associated with increased MODS (adjusted OR, 2.23; 95% CI, 1.20-4.15) and more than 21 days was associated with increased Pediatric Logistic Organ Dysfunction (PELOD) scores (adjusted mean difference, 4.26; 95% CI, 1.99-6.53) and higher mortality (9.2% vs. 3.8%).

CONCLUSION

Stable critically ill children who receive RBC units with storage times longer than 2 to 3 weeks may be at greater risk of developing new or progressive MODS.

Critical illness polyneuromyopathy in a child with severe demyelinating myelitis

We report a child presenting with severe demyelinating myelitis complicated with critical illness polyneuropathy. This previously healthy 8-month-old boy presented with acute superior limb weakness, absent tendon reflexes, and respiratory failure. Spinal magnetic resonance imaging showed an extensive cervical demyelinating lesion. Spinal cord trauma was suspected and high doses of dexamethasone were administered. Electromyography and nerve conduction studies showed absence of compound muscle action potentials and sural nerve sensory action potential, which was suggestive of a severe Guillain-Barré syndrome. However, intravenous immunoglobulins did not induce any improvement. Afterward, sural nerve biopsy showed a mild neuropathy, but muscle biopsy revealed abnormalities compatible with severe critical illness myopathy. After 5 months of evolution without improvement, the patient died following withdrawal of life support therapy. This case highlights the possible occurrence of critical illness polyneuromyopathy when treatment with corticosteroids are used in patients with acute demyelinating myelitis.

Acute combined central and peripheral nervous system demyelination in children

Reports of acute combined central and peripheral nervous system acquired inflammatory demyelination are rare in children. This study aimed to (1) define the clinical features and prognoses of patients with this entity; and (2) compare these patients with children presenting isolated acute central or peripheral nervous system demyelination. A retrospective chart review of 523 children with central or peripheral nervous system demyelination hospitalized between 1993-2006 was undertaken. Among these, 93 fulfilled criteria (clinical features and positive magnetic resonance imaging or electromyography/nerve conduction studies) for either acute central (n = 37; 39.8%) or peripheral (n = 43; 46%) nervous system demyelination, or a combination of the two (n = 13; 14%). Significant differences between groups were evident for age (median, 10 versus 7 versus 11 years, respectively; P = 0.047), admission to pediatric intensive care unit (8% versus 30% versus 58%, respectively; P = 0.001), length of hospital stay (median, 8 versus 9 versus 29 days, respectively; P < 0.001), treatment with steroids (52% versus 7% versus 75%, respectively; P < 0.001) and immunoglobulins (11% versus 81% versus 75%, respectively; P < 0.001), and poor evolution (3% versus 12% versus 54%, respectively; P = 0.002). This entity in children is not rare, and has a poorer outcome than isolated central or peripheral nervous system demyelination. Assessment is needed for a better understanding of risk factors, etiologies, management, and prognosis.

Multicenter comparative study of conventional mechanical gas ventilation to tidal liquid ventilation in oleic acid injured sheep

We performed a multicenter study to test the hypothesis that tidal liquid ventilation (TLV) would improve cardiopulmonary, lung histomorphological, and inflammatory profiles compared with conventional mechanical gas ventilation (CMV). Sheep were studied using the same volume-controlled, pressure-limited ventilator systems, protocols, and treatment strategies in three independent laboratories. Following baseline measurements, oleic acid lung injury was induced and animals were randomized to 4 hours of CMV or TLV targeted to "best PaO2" and PaCO2 35 to 60 mm Hg. The following were significantly higher (p < 0.01) during TLV than CMV: PaO2, venous oxygen saturation, respiratory compliance, cardiac output, stroke volume, oxygen delivery, ventilatory efficiency index; alveolar area, lung % gas exchange space, and expansion index. The following were lower (p < 0.01) during TLV compared with CMV: inspiratory and expiratory pause pressures, mean airway pressure, minute ventilation, physiologic shunt, plasma lactate, lung interleukin-6, interleukin-8, myeloperoxidase, and composite total injury score. No significant laboratories by treatment group interactions were found. In summary, TLV resulted in improved cardiopulmonary physiology at lower ventilatory requirements with more favorable histological and inflammatory profiles than CMV. As such, TLV offers a feasible ventilatory alternative as a lung protective strategy in this model of acute lung injury.

Lemierre Syndrome: Two Preschool Children with Cerebral Infarcts

We report two children who developed hemiparesis secondary to cerebral infarcts complicating Lemierre syndrome. The first case is a one-year-old patient who presented a left internal jugular vein thrombosis and a left carotid compression due to retropharyngeal cellulitis. The second case is a five-year-old girl who presented a left internal jugular vein and a right carotid artery thrombosis associated with an oropharyngeal cellulitis. Etiologic agents involved were Staphylococus aureus in the first case and Fusobacterium necrophorum in the second case.

These cases call for vigilance among physicians for this rare syndrome, its unusual presentation and its associated severe complications.

Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents

BACKGROUND

Peripherally inserted central catheters (PICC) in children and adolescents are being used with increasing frequency. We sought to determine the incidence and characterize risk factors of deep vein thrombosis associated with peripherally inserted central catheters in a pediatric population.

METHODS

We conducted a prospective study involving consecutive patients referred to the radiology department of a tertiary care university-affiliated hospital for insertion of a peripherally inserted central catheter. We included patients aged 18 years or less who weighed more than 2.5 kg and had a peripherally inserted central catheter successfully inserted in his or her arm between June 2004 and November 2005. The primary outcome was the occurrence of partial or complete deep vein thrombosis evaluated by clinical examination, ultrasonography and venous angiography.

RESULTS

A total of 214 patients (101 girls, 113 boys) were included in the study. Partial or complete deep vein thrombosis occurred in 20 patients, for an incidence of 93.5 per 1000 patients and 3.85 per 1000 catheter-days. Only 1 of the cases was symptomatic. In the univariable analyses, the only variable significantly associated with deep vein thrombosis was the presence of factor II mutation G20210A (odds ratio 7.08, 95% confidence interval 1.11-45.15, p = 0.04), a genetic mutation that increases the risk of a blood clot and that was present in 5 (2.3%) of the 214 patients.

INTERPRETATION

The incidence of deep vein thrombosis related to peripherally inserted central catheters in our study was lower than the incidence related to centrally inserted venous catheters described in the pediatric literature (11%-50%).

Transfusion strategies for patients in pediatric intensive care units

BACKGROUND

The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as judged by the outcome of multiple-organ dysfunction.

METHODS

In this noninferiority trial, we enrolled 637 stable, critically ill children who had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients to a threshold of 9.5 g per deciliter (liberal-strategy group).

RESULTS

Hemoglobin concentrations were maintained at a mean (+/-SD) level that was 2.1+/-0.2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7+/-0.4 and 10.8+/-0.5 g per deciliter, respectively; P<0.001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, -4.6 to 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other outcomes, including adverse events.

CONCLUSIONS

In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes. (Controlled-trials.com number, ISRCTN37246456 [controlled-trials.com].).

Risk factors of acute renal failure in critically ill children: A prospective descriptive epidemiological study

OBJECTIVE

Acute renal failure is a serious condition in critically ill patients, but little literature is available on acute renal failure in critically ill children. The aim of the study was to determine incidence rate, identify risk factors, and describe the clinical outcome of acute renal failure in the pediatric intensive care unit (PICU).

DESIGN

Prospective, descriptive study.

SETTING

A tertiary PICU.

PATIENTS

Patients were 1,047 consecutively admitted children over a 1-yr period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Acute renal failure was defined as doubling of baseline serum creatinine. A comparison between patients with acute renal failure and without acute renal failure was carried out, and the risk factors playing a significant role in the manifestation of acute renal failure were analyzed. There were 985 cases included in the study, with the incidence rate of acute renal failure in PICU being 4.5%. The most common PICU admission diagnoses in acute renal failure cases were hemolytic uremic syndrome (18.2%), oncologic pathologies (18.2%), and cardiac surgery (11.4%). Significant risk factors for acute renal failure following multivariate analysis were thrombocytopenia (odds ratio, 6.3; 95% confidence interval, 2.5, 16.2), age >12 yrs (odds ratio, 4.9; 95% confidence interval, 1.9, 13), hypoxemia (odds ratio, 3.2; 95% confidence interval, 1.3, 8.0), hypotension (odds ratio, 3.0; 95% confidence interval, 1.2, 7.5), and coagulopathy (odds ratio, 2.7; 95% confidence interval, 1.3, 5.6). The mortality rate was estimated to be higher in patients with acute renal failure compared with patients without acute renal failure (29.6% vs. 2.3%, p < .001).

CONCLUSIONS

Although not frequent in the PICU, acute renal failure is associated with a significant increase in mortality. The risk factors of acute renal failure are multiple and are often present before PICU admission. A multiple-center study is planned with the intention to confirm these results.

Acute transfusion reactions in the pediatric intensive care unit

BACKGROUND

Acute transfusion reactions (ATRs) are probably underdiagnosed in critically ill children because associated symptoms can frequently be attributed to the patient's underlying disease. This study was undertaken to determine the incidence, type, imputability, and severity of ATRs observed in a tertiary care pediatric intensive care unit (PICU).

STUDY DESIGN AND METHODS

All transfusions of labile blood product administered to consecutive patients admitted to our PICU, between February 2002 and February 2004, were prospectively recorded. For each transfusion, the bedside nurse recorded the patient's status before, during, and up to 4 hours after the transfusion, as well as the presence of any new sign or symptom suggesting an ATR. Three independent experts retrospectively reviewed all transfusion event reports and hospital charts. The presence, type, imputability, and severity of ATRs were adjudicated by consensus of two of three experts (Delphi method), with predefined criteria.

RESULTS

A total of 2509 transfusions were administered to 305 patients during the study. Forty transfusion events (1.6%) were confirmed to be ATRs by expert consensus: 24 febrile nonhemolytic, 6 minor allergic, 4 isolated hypotension, 3 bacterial contamination, 1 major allergic (anaphylactic shock), 1 TRALI, and 1 hemolytic reaction. Imputability of ATRs was probable or possible in 35 cases (88%). ATRs led to an immediate vital threat in 15 percent of cases.

CONCLUSION

Improved surveillance of transfusions given to PICU patients and better knowledge of these reactions by health care professionals should improve the safety of transfusions in the PICU.

Acceptable respiratory physiologic limits for children during weaning from mechanical ventilation

OBJECTIVE

The aim of this survey was to characterize the physiological limits considered appropriate during weaning from mechanical ventilation in children.

DESIGN

Two hundred twenty-two (222) intensivists from 63 pediatric intensive care units (PICUs) were asked to provide the limits they considered acceptable for respiratory rate (RR), tidal volume (V(T)) and end-tidal CO(2) (PetCO(2)) during weaning from mechanical ventilation of a 3-month-old, a 2-year-old and a 10-year-old patient.

SETTING

Pediatric intensivists working in Canada, France, Switzerland and Belgium.

PATIENTS

None.

INTERVENTIONS

None.

RESULTS

Ninety-seven intensivists (43%) from 49 PICUs responded to the survey. The median minimal RR (25th;75th percentile) was: 20 breaths per minute (bpm) (15;25) for the 3-month-old, 15 bpm (10;15) for the 2-year-old and 10 bpm (10;15) for the 10-year-old patient. The median maximal RR was 50 bpm (40;60) for the 3-month-old, 40 bpm (30;40) for the 2-year-old and 30 bpm (30;40) for the 10-year-old child. The median minimal V(T) was 5 ml/kg (4;6) for the 3-month-old and 2-year-old patients and 5 ml/kg (5;6) for the 10-year-old. The median maximal PetCO(2) was 55 mmHg (50;60) for the 3-month-old, 50 mmHg (45;50) for the 2-year-old and 50 mmHg (50;55) for the 10-year-old.

CONCLUSION

This survey indicated that acceptable weaning limits are broad, as stated by the responders. We need to organize and consolidate our thinking on weaning children from mechanical ventilation before guidelines can be established.

Systemic capillary leak syndrome presenting as recurrent shock

OBJECTIVE

To report a case of systemic capillary leak syndrome (SCLS) in a child.

DESIGN

Case report.

SETTING

Pediatric intensive care unit.

PATIENT

A 6-yr-old girl was admitted twice to the pediatric intensive care unit, at a 10-month interval, in severe shock with important edema.

RESULTS

The patient presented with acute symptoms of abdominal pain, vomiting, and syncope in the hour preceding the shock. During both episodes necessary management included aggressive intravenous fluid rehydration, mechanical ventilation, and use of inotropes/vasopressors. Suspicion of a lower limb fasciitis necessitated surgical exploration, but pathology reports were negative on both occasions revealing only subcutaneous tissue edema. The patient recovered within 24 hrs on both episodes. Investigation ruled out cardiogenic shock and septic shock due to bacterial etiology. On the first episode, a nasopharyngeal aspirate was positive for influenza A (H3N2) by both viral immunofluorescence and culture. The presumed diagnosis was toxic shock syndrome associated with influenza virus. On the second episode, all bacterial and virology cultures remained negative. Hypovolemic shock was suspected, but there was no history of dehydration, bleeding, or gastrointestinal losses (persistent vomiting or diarrhea). Noninfectious causes of hypovolemic shock with edema were ruled out, leading us to believe that she suffered from SCLS.

CONCLUSIONS

Although well described in the adult literature, there have been few reports of SCLS in pediatric patients. SCLS should be considered in the differential diagnosis of recurrent hypovolemic shock without identifiable cause. The only therapeutic intervention is to obtain vascular access when initial manifestations occur and give aggressive fluid reanimation.

Determinants of red blood cell transfusions in a pediatric critical care unit: A prospective, descriptive epidemiological study*

OBJECTIVE

To determine the incidence and to characterize the determinants of red blood cell transfusions in critically ill children.

DESIGN

Prospective, descriptive epidemiologic study.

SETTING

A single-center, multidisciplinary, tertiary care level, university-affiliated, pediatric intensive care unit (PICU).

PATIENTS

Critically ill children.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,047 consecutive admissions over a 1-yr period, 985 were retained for study. At least one transfusion was given in 139 cases (14%). Incidence rate of transfusion was 304 transfusions/1,000 cases. Possible determinants of red blood cell transfusions were identified and prospectively monitored during PICU stay until a first transfusion event (transfused cases) or up until the time of death or discharge from PICU (nontransfused cases). Four significant determinants of a first red blood cell transfusion event were retained in the multivariate analysis (odds ratio, 95% confidence interval, p): a hemoglobin level <9.5 g/dL during PICU stay (13.26, 8.04-21.88, p < .001), an admission diagnosis of cardiac disease (8.07, 5.14-14.65, p < .001), an admission Pediatric Risk of Mortality score >10 (4.83, 2.33-10.04, p < .001), and the presence of multiple organ dysfunction syndrome during the stay (2.06, 1.18-3.57, p = .01).

CONCLUSION

A significant proportion of critically ill children receive at least one red blood cell transfusion during their PICU stay. Presence of anemia, cardiac disease, severe critical illness, and multiple organ dysfunction syndrome are the most significant determinants of red blood cell transfusions in PICU.

The syndrome of amniotic fluid embolism: a potential contribution of bradykinin

OBJECTIVE

Amniotic fluid embolism is a potentially fatal complication of pregnancy; although several hypotheses have been formulated, the pathophysiology of this condition is not well known. An exaggerated release of bradykinin, which is activated by products of the amniotic fluid that enter the maternal circulation, could explain the symptoms that are present in amniotic fluid embolism. The objective of this study was to assess whether bradykinin is involved in amniotic fluid embolism.

STUDY DESIGN

The plasma bradykinin-generating capacity was measured serially in a patient who experienced amniotic fluid embolism.

RESULTS

The plasma bradykinin-generating capacity was found to be very low at the time of the initial clinical manifestations, which were characterized by severe hypotension, cardiorespiratory arrest, and coagulopathy.

CONCLUSION

This study suggests a potential role for bradykinin release in the pathophysiology of amniotic fluid embolism.

Cumulative influence of organ dysfunctions and septic state on mortality of critically ill children

The interaction between sepsis and multiple organ dysfunction syndrome is poorly defined in children. We analyzed by Cox regression models the cumulative influence of organ dysfunctions, using the pediatric logistic organ dysfunction (PELOD) score, and septic state (systemic inflammatory response syndrome or sepsis, severe sepsis, and septic shock) on mortality of critically ill children. We included 593 children (mortality rate: 8.6%) from three pediatric intensive care units; 514 patients had at least a systemic inflammatory response syndrome and 269 had two or more organ dysfunctions. Hazard ratio of death significantly increased with the severity of organ dysfunction, as estimated by the PELOD score, and the worst diagnostic category of septic state. Each increase of one unit in the PELOD score multiplied the hazard ratio by 1.096 (p < 0.0001); hazard ratio of diagnostic category was 9.039 (p = 0.031) for systemic inflammatory response syndrome or sepsis, 18.797 (p = 0.007) for severe sepsis and 32.572 (p < 0.001) for septic shock. Cumulative hazard ratio of death = (hazard ratio of PELOD score) x (hazard ratio of diagnostic category). We conclude that there is a cumulative accrual of the risk of death both with an increasing severity of organ dysfunction and an increasing severity of the diagnostic category of septic state.

Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis

A meta-analysis was performed to evaluate the accuracy of determination of procalcitonin (PCT) and C-reactive protein (CRP) levels for the diagnosis of bacterial infection. The analysis included published studies that evaluated these markers for the diagnosis of bacterial infections in hospitalized patients. PCT level was more sensitive (88% [95% confidence interval [CI], 80%-93%] vs. 75% [95% CI, 62%-84%]) and more specific (81% [95% CI, 67%-90%] vs. 67% [95% CI, 56%-77%]) than CRP level for differentiating bacterial from noninfective causes of inflammation. The Q value for PCT markers was higher (0.82 vs. 0.73). The sensitivity for differentiating bacterial from viral infections was also higher for PCT markers (92% [95% CI, 86%-95%] vs. 86% [95% CI, 65%-95%]); the specificities were comparable (73% [95% CI, 42%-91%] vs. 70% [95% CI, 19%-96%]). The Q value was higher for PCT markers (0.89 vs. 0.83). PCT markers also had a higher positive likelihood ratio and lower negative likelihood ratio than did CRP markers in both groups. On the basis of this analysis, the diagnostic accuracy of PCT markers was higher than that of CRP markers among patients hospitalized for suspected bacterial infections.

Ventilator-associated pneumonia in intubated children: comparison of different diagnostic methods

OBJECTIVES

To compare different methods for diagnosis of ventilator-associated pneumonia in intubated children.

DESIGN

Prospective epidemiologic study.

SETTING

Pediatric intensive care unit of a tertiary care university hospital.

PATIENTS

All consecutive pediatric intensive care unit patients <18 yrs of age with suspected ventilator-associated pneumonia.

INTERVENTIONS

For all patients, the following diagnostic methods were compared: 1) clinical data using Centers for Disease Control criteria; 2) blind protected bronchoalveolar lavage, evaluating quantitative cultures, bacterial index of >5, Gram stain, and presence of intracellular bacteria; and 3) nonquantitative cultures of endotracheal secretions. The reference standard used was clinical judgment of three independent experts (Delphi method) who retrospectively established by consensus the presence of ventilator-associated pneumonia based on clinical, microbiological, and radiologic data. Concordance between each diagnostic method and the reference standard was evaluated by concordance percentage and kappa score. Validity was evaluated using sensitivity, specificity, positive predictive value, negative predictive value, and global value.

RESULTS

A total of 30 patients were included in the study. According to the reference standard, ventilator-associated pneumonia occurred in 10 of 30 patients (33%). Bacterial index of >5 in bronchoalveolar secretions showed the best concordance compared with the reference standard (concordance, 83%; kappa, 0.61). Bacterial index of >5 also showed the best validity (sensitivity, 78%; specificity, 86%; positive predictive value, 70%; negative predictive value, 90%; global value, 90%). Intracellular bacteria and Gram stain from bronchoalveolar secretions were very specific (95% and 81%, respectively) but not sensitive (30% and 50%, respectively). Clinical criteria and endotracheal cultures were very sensitive (100% and 90%, respectively) but poorly specific (15% and 40%, respectively).

CONCLUSION

Our data show that the most reliable diagnostic method for ventilator-associated pneumonia is a bacterial index of >5, using blind protected bronchoalveolar lavage. Further studies should evaluate the validity of all these methods according to the gold standard (autopsy).

Naloxone for shock

BACKGROUND

There is pre-clinical evidence, involving several animal species, suggesting that opioid peptides play a role in the physiopathology of shock (endotoxic, hypovolemic, cardiogenic, spinal, anaphylactic). Many case reports have suggested that naloxone (an opiate antagonist) might be an effective treatment for shock in humans, but others have not supported such a point of view. This controversy led us to undertake a meta-analysis of the available evidence on the efficacy of naloxone as a treatment measure of shock in humans.

OBJECTIVES

To evaluate the effectiveness and safety of naloxone in human shock and to estimate the methodological quality of the clinical trials.

SEARCH STRATEGY

Computerized bibliographic search up to December 2002, review of references of all papers found on the subject and contact with primary investigators of eligible studies.

SELECTION CRITERIA

Randomized controlled trials evaluating naloxone in human shock, regardless of the patient's age (adult, child or neonate).

DATA COLLECTION AND ANALYSIS

Three independent reviewers extracted data on study design, intervention, outcome and methodological quality.

MAIN RESULTS

Three independent readers reviewed 80 human publications and selected six clinical trials. Overall agreement on study selection was perfect (concordance: 100%). This meta-analysis includes six studies involving 126 patients with septic, cardiogenic, hemorrhagic or spinal shock. Naloxone therapy was associated with statistically significant hemodynamic improvement (odds ratio 0.24; 95% confidence interval [95%CI] 0.09-0.68). The mean arterial pressure was significantly higher in the naloxone groups than in the placebo groups (weighted mean difference: +9.33 mmHg; 95%CI 7.07-11.59). No heterogeneity was found for this outcome. The death rate was lower in the naloxone group (odds ratio 0.59; 95%CI 0.21-1.67) but this was consistent with the play of chance. A significant heterogeneity for the latter outcome was detected (p<0.05).

REVIEWER'S CONCLUSIONS

Naloxone improves blood pressure, especially mean arterial blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined, and additional randomized controlled trials are needed to assess its usefulness.

Survey on transfusion practices of pediatric intensivists

OBJECTIVE

To describe the red blood cell transfusion practices of pediatric intensivists.

DESIGN

Cross-sectional self-administered survey.

SETTING

Pediatric intensive care units.

PATIENTS

Academic pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Scenario-based survey among English- or French-speaking intensivists from Canada, France, Belgium, or Switzerland, working in tertiary-care pediatric intensive care units. Respondents were asked to report their decisions regarding transfusion practice with respect to four scenarios: cases of bronchiolitis, septic shock, trauma, and the postoperative care of a patient with Fallot's tetrad. The response rate was 71% (163 of 230). The overall baseline hemoglobin transfusion threshold that would have prompted intensivists to transfuse a patient ranged from 7 to 13 g/dL (70-130 g/L) within almost all scenarios. There was a significant difference between scenarios of the average baseline hemoglobin transfusion thresholds (p < .0001). A low Pao2, a high blood lactate concentration, a high Pediatric Risk of Mortality score, active gastric bleeding, emergency surgery, and age (2 wks) were important determinants of red blood cell transfusion, whereas none of the respondents' personal characteristics were. The average volume of packed red blood cells transfused in the four scenarios did not differ significantly.

CONCLUSIONS

This survey documented a significant variation in transfusion practice patterns among pediatric critical care practitioners with respect to the threshold hemoglobin concentration for red blood cell transfusion. The volume of packed red blood cells given was not adjusted to the hemoglobin concentration.

Reproducibility of blind protected bronchoalveolar lavage in mechanically ventilated children

Blind protected bronchoalveolar lavage (BAL) could be an interesting tool in the diagnosis of ventilator-associated pneumonia in intubated children, but its reproducibility has never been evaluated. This study evaluates the reproducibility, feasibility, and safety of blind protected BAL in mechanically ventilated children. Two blind protected BAL were done, at a 2-hour interval, in 30 patients. The reproducibility of microbiologic and cytologic results was studied. A total of 60 BALs was analyzed. Bacterial growth was present in 26 of 60 BAL (43%). Reproducibility for the presence of bacteria on quantitative cultures was excellent (concordance, 93%; kappa [kappa], 0.86). Concordance for the type of bacteria isolated was 86% and for the number of bacteria was 79%. Reproducibility for the presence of neutrophils containing bacteria was perfect (concordance, 100%; kappa, 1) although only a few BALs had a positive result (8/60). Blind protected BAL was feasible in all patients and all samples were considered adequate for analysis. Complications were mostly benign and transitory except in two cases: one pneumothorax and one significant increase in intracranial pressure. Overall, blind protected BAL is a reproducible test in mechanically ventilated children, is easily feasible, and is usually well tolerated.

The impact of clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit

OBJECTIVE

To determine the clinical and economic impact attributable to upper gastrointestinal bleeding (UGIB) acquired in a pediatric intensive care unit (PICU).

DESIGN

Prospective case-control-within-cohort study.

SETTING

PICU at a university hospital.

PATIENTS

All consecutive patients over a 1-yr period.

METHODS

All UGIB (hematemesis or blood in gastric tube) were reported. A UGIB was qualified as clinically significant (CS-UGIB) if a panel of reviewers assessed that a complication (decreased hemoglobin concentration, transfusion, multiple organ dysfunction syndrome, surgery, or death) was attributed to it. A UGIB was qualified as clinically nonsignificant (NS-UGIB) if none of these complications was attributed to it. The Ø-UGIB group comprised patients without UGIB. Pairing between the three groups was done according to these criteria: death or survival, Pediatric Risk of Mortality Score on admission, respiratory failure, coagulopathy, and age. Data considered for the impact analysis was prospectively monitored during the stay in PICU. Costs were estimated in Canadian dollars (1999) as follows: costs of stay + medical staff + ventilation + red blood cell transfusions.

RESULTS

The cohort included 1006 admissions. Sixteen cases of CS-UGIB were paired to 13 cases of NS-UGIB and 32 cases of Ø-UGIB. Compared with the Ø-UGIB group and the NS-UGIB group, the CS-UGIB group showed a significantly (p < 0.05) higher rate of red blood cell transfusions, duration of ventilation, length of stay in PICU, and a lower hemoglobin level. There was no difference between the NS-UGIB group and the Ø-UGIB group. The cost analysis demonstrated a significant difference (p < 0.05) between the CS-UGIB group (20,062.67 Can dollars/patient per stay) and the other groups (NS-UGIB, 6104.77 Can dollars/patient per stay; Ø-UGIB, 5457.25 Can dollars/patient per stay).

CONCLUSION

This study demonstrates a significant clinical and economic impact of CS-UGIB in PICU, although no impact was detected for NS-UGIB. Further studies on the benefit of UGIB prophylaxis for critically ill children with risk factors for CS-UGIB are needed.

Hospitalizations for pediatric intoxication in Washington State, 1987-1997

BACKGROUND

Intoxication (or poisoning) that necessitates hospitalization remains an important source of morbidity in children.

OBJECTIVE

To determine changes, during an 11-year period (1987-1997), in the incidence of hospitalization due to intoxication among children in Washington State and circumstances of ingestion, agents used, hospital length of stay, charges, and mortality.

METHODS

A computerized database of all hospital discharges (Comprehensive Hospital Abstract Reporting System [CHARS] database) in Washington was used. Cases included all children younger than 19 years with a primary or secondary diagnosis for an intoxication or with an external cause of injury code (E code) for an intoxication from 1987 to 1997.

RESULTS

There were 7322 hospitalizations (45 per 100 000 children per year); the annual rate significantly decreased during the study period. Most patients (75%) were teenagers. Sixty-five percent were female. Pharmaceutical agents were used in 80% of cases. Analgesics were the most commonly used (34%), followed by antidepressants (12%) and psychotropic drugs (8%). Nonpharmaceutical agents were more prevalent in children younger than 12 years than in teenagers. Self-inflicted intoxication was the most frequent cause identified by E codes (47%). Median length of stay was 1 day, and median hospital charges were $2096. Mortality was low (0.2%) and did not change significantly over time.

CONCLUSIONS

Acute intoxication continues to be an important cause of hospitalization in children. The type of agent involved did not change significantly over time. Teenage girls continue as the highest risk group for suicide attempt from ingestions. Self-inflicted intoxications were associated with higher costs, length of stay, and readmissions. Although preventive measures and development of poison centers have contributed to decrease mortality from acute intoxication in children in the last 50 years, efforts need to be targeted toward suicide prevention, especially among teenage girls.