Hyperlacticaemia in children with status asthmaticus. The Stewart approach

BACKGROUND

Patients with status asthmaticus (SA) frequently present with lactic acidosis (LA). Our goal is to identify the nature of this LA using the Stewart physicochemical model and to identify the independent factors associated with LA in children with SA.

METHODS

Analytical study of a retrospective cohort using a nested case-control design. Twenty-eight episodes of SA in 24 children were included. Patients admitted to a paediatric intensive care unit (PICU) for SA over a 9-year period were recruited consecutively. Data were analysed using the Stewart model and the Strong Ion Calculator. Data were analysed using descriptive statistics and regression models were fitted within the general linear model.

RESULTS

Hyperlacticaemia (Lact[mM/L] = 3.905 [95% CI = 3.018-4.792]) and acidosis (pH = 7.294 [95% CI = 7.241-7.339]) were observed in 18 episodes (15 patients; 62.5%). According to the Stewart model, acidosis was caused by a decrease in strong ion difference. Initially, pCO2 was high (pCO2[mmHg] = 45.806 [95% CI = 37.314-54.298]) but the net unmeasured ion (NUI) component was normal (NUI = -4,461 [95% CI = -3.51 to -5.412]), and neither changed significantly over the clinical course. There was no need to determine pyruvate, as the NUI was normal and the LA was type B (non-hypoxic, lactate/pyruvate < 25). We observed a correlation (P = .023) between LA and intramuscular epinephrine administered on arrival at hospital, but not between LA and the cumulative dose of nebulized salbutamol.

CONCLUSIONS

Most patients with SA presented LA. The Stewart model confirmed that LA is not hypoxic, probably due to sympathomimetic-related glycolysis.

Paediatric intensive care 'do not do' recommendations in Spain: Selection by Delphi method

INTRODUCTION

Health care is not free of ineffective, unsafe or inefficient diagnostic and therapeutic practices. To address this, different scientific societies and health authorities have proposed 'do not do' recommendations (DNDRs). Our goal was the selection by consensus of a set of DNDRs for paediatric intensive care in Spain.

MATERIAL AND METHOD

The research was carried out in 2 phases: first, gathering potential DNDRs; second, selecting the most important ones, using the Delphi method, based on the prevalence of the practice to be modified, the severity of its potential risks and the ease with which it could be modified. Proposals and evaluations were both made by members of working groups of the Sociedad Española de Cuidados Intensivos Pediátricos (SECIP, Spanish Society of Paediatric Intensive Care), coordinated by email. The initial set of DNDRs was reduced based on the coefficient of variation (<80%) of the corresponding evaluations.

RESULTS

A total of 182 DNDRs were proposed by 30 intensivists. The 14 Delphi evaluators managed to pare down the initial set to 85 DNDRs and, after a second round, to the final set of 26 DNDRs. The care quality dimensions most represented in the final set are clinical effectiveness and patient safety.

CONCLUSIONS

This study allowed the selection by consensus of a series of recommendations to avoid unsafe, inefficient or ineffective practices in paediatric intensive care in Spain, which could be useful for improving the quality of clinical care in our field.

Level of discomfort in critically ill paediatric patients and its correlation with sociodemographic and clinical variables, analgosedation and withdrawal syndrome. COSAIP multicentre study (Phase 2)

INTRODUCTION

There are clinical and sociodemographic factors that have an impact on the comfort of the critically ill paediatric patient. The main aim of this study was to determine the level of discomfort of paediatric patients admitted to different national hospitals, and to analyse its correlation with sociodemographic and clinical variables, analgosedation, and withdrawal syndrome.

METHODS

An observational, analytical, cross-sectional, and multicentre study was conducted in five Spanish hospitals. The level of analgosedation was assessed once per shift over a 24 h period, using a BIS sensor, and pain with scales adapted to paediatric age population. The intensity of withdrawal syndrome was determined using the Withdrawal Assessment Tool (WAT-1) scale once per shift for 3 days. Discomfort level was simultaneously assessed using COMFORT Behaviour Scale-Spanish version (CBS-S).

RESULTS

A total of 261 critically ill paediatric patients with median age of 1.61 years (IQR = 0.35-6.55) were included. An overall discomfort score of 10.79 ± 3.7 was observed during morning compared to 10.31 ± 3.3 during the night. When comparing analgosedation and non-analgosedation groups, statistical differences were found in both shifts (χ²: 45.48; P = .001). At the same time, an association was observed (P < .001) between low discomfort scores and development of withdrawal syndrome development assessed with WAT-1.

CONCLUSIONS

As there is a percentage of the studied population with discomfort, specific protocols need to be developed, guided by valuated and clinically tested tools, like the COMFORT Behaviour Scale-Spanish version.

[Level of discomfort in critically ill paediatric patients and its correlation with sociodemographic and clinical variables, analgosedation and withdrawal syndrome. COSAIP multicentre study (Phase 2)]

INTRODUCTION

There are clinical and sociodemographic factors that have an impact on the comfort of the critically ill paediatric patient. The main aim of this study was to determine the level of discomfort of paediatric patients admitted to different national hospitals, and to analyse its correlation with sociodemographic and clinical variables, analgosedation, and withdrawal syndrome.

METHODS

An observational, analytical, cross-sectional, and multicentre study was conducted in five Spanish hospitals. The level of analgosedation was assessed once per shift over a 24h period, using a BIS sensor, and pain with scales adapted to paediatric age population. The intensity of withdrawal syndrome was determined using the Withdrawal Assessment Tool (WAT-1) scale once per shift for 3 days. Discomfort level was simultaneous assessed using COMFORT Behaviour Scale-Spanish version (CBS-S).

RESULTS

A total of 261 critically ill paediatric patients with median age of 1.61 years (IQR=0.35-6.55) were included. An overall discomfort score of 10.79±3.7 was observed during morning compared to 10.31±3.3 observed during the night. When comparing analgosedation and non-analgosedation groups, statistically differences were found in both shifts (χ2: 45.48; P=.001). At the same time, an association was observed (P<.001) between low discomfort scores and development of withdrawal syndrome development assessed with WAT-1.

CONCLUSIONS

As there is a percentage of the studied population with discomfort, specific protocols need to be developed, guided by valuated and clinically tested tools, like the COMFORT Behaviour Scale-Spanish version.

[Validation of a Therapeutic Intervention Scoring System (TISS-28) in critically ill children]

INTRODUCTION

There are numerous scales in intensive care units that are used to quantify the severity of patients. Most of them are very useful, although sometimes laborious to complete, thus limiting their use in usual practice. One of these scales, the Therapeutic Intervention Scoring System (TISS 76), has been validated in adult and paediatric units. Its simplified and updated version, the Simplified Therapeutic Intervention Scoring System (TISS 28), has not yet been validated in paediatric units. The aim of this study is to validate TISS 28, in order to have a simple and rapid scale.

MATERIAL AND METHOD

A prospective non-interventional observational study was conducted in a Paediatric Intensive Care Unit (PICU) of a university hospital. Data were collected from 935 consecutive patients admitted to the PICU over a 3-year period. These included the values of TISS 76 and TISS 28 during the first 4days of admission and the subsequent outcome of the patients.

RESULTS

The mean values of TISS 76 and TISS 28 for the first day of admission were 18.27 and 18.02, respectively. Values were higher in patients who had sequelae or died (17.58 versus 27.23 and 37.44, respectively for TISS 76 (P<.01); and 17.51 versus 23.80 and 33.44, respectively for TISS 28 (P<.01). A very good correlation was found between TISS 76 and TISS 28, with Pearson correlation and intraclass correlation coefficients> 0.9 (except for the 2nd day). The correlation equation for the overall 4 days was: TISS76=- 1.74+1.05×TISS28. TISS 28 was able to explain 82.4% of variability of TISS 76. The area under the curve with a confidence interval (CI) of 95% for the first day was 0.80 (0.73-0.87) for TISS 76, and 0.76 (0.67-0.84) for TISS 28.

CONCLUSIONS

On observing the results obtained, TISS 28 can replace TISS 26 in our PICU, without worsening the information provided. Being a reliable scale and easier to apply, its practical application could be useful.