[Show abstract][Hide abstract] ABSTRACT: Background: Aminophylline, an established bronchodilator, is also purported to be an effective diuretic and anti-inflammatory agent. However, the data to support these contentions are scant. We conducted a prospective, open-label, single arm, single center study to assess the hypothesis that aminophylline increases urine output and decreases inflammation in critically ill children. Methods: Children less than 18 years of age admitted to the pediatric intensive care unit who were prescribed aminophylline over a 24-h period were eligible for study. The use and dosing of aminophylline was independent of the study and was at the discretion of the clinical team. Data analyzed consisted of demographics, diagnoses, medications, and markers of pulmonary function, renal function, and inflammation. Data were collected at baseline and at 24-h after aminophylline initiation with primary outcomes of change in urine output and inflammatory cytokine concentrations. Results: Thirty-five patients were studied. Urine output increased significantly with aminophylline use [median increase 0.5 mL/kg/h (IQR: -0.3, 1.3), p = 0.05] while blood urea nitrogen and creatinine concentrations remained unchanged. Among patients with elevated C-reactive protein concentrations, levels of both interleukin-6 (IL-6) and IL-10 decreased at 24 h of aminophylline therapy. There were no significant differences in pulmonary compliance or resistance among patients invasively ventilated at both time points. Side effects of aminophylline were detected in 7 of 35 patients. Conclusion: Although no definitive conclusions can be drawn from this study, aminophylline may be a useful diuretic and effective anti-inflammatory medication in critically ill children. Given the incidence of side effects, the small sample size and the uncontrolled study design, further study is needed to inform the appropriate use of aminophylline in these children.
[Show abstract][Hide abstract] ABSTRACT: Objective. To assess the impact of a locally applied vibrating device on outpatient venipuncture in children. Method. A retrospective review of survey data collected prospectively as part of a quality improvement project. Both patients and phlebotomists were surveyed. The sample consisted of 64 children aged 4 to 18 years (29 prior to the implementation of the vibrating device and 35 afterward) and 7 phlebotomists. Results. Prior to the use of the vibrating device, 17 children (59%) indicated that they wished something had been done to decrease venipuncture pain. Eighty percent of the cohort that used the vibrating device indicated that they would like it used for future procedures. Children with previous venipuncture experiences appeared to benefit most from use of the vibrating technique. The phlebotomists reported that vibration made the procedure easier in 81% of the cases; none reported that it complicated the procedure. Conclusions. Locally applied vibration appears to be a well-accepted technique to minimize pediatric venipuncture discomfort that may facilitate completion of the procedure.
[Show abstract][Hide abstract] ABSTRACT: Our previous studies in children with acute lung injury/acute respiratory distress syndrome demonstrated improved outcomes with exogenous surfactant (calfactant) administration. Sample sizes in those studies were small, however, and the subject populations heterogeneous, thus making recommendations tenuous.
To investigate the efficacy of surfactant administration in a larger, more homogenous population of children with lung injury/acute respiratory distress syndrome due to direct lung injury.
Masked, randomized, placebo-controlled trial in 24 children's hospitals in six different countries.
Children 37 weeks postconception to 18 years old with lung injury/acute respiratory distress syndrome due to direct lung injury were randomized to receive up to three doses of 30 mg/cm height of surfactant (calfactant) versus placebo (air) within 48 hours of intubation and initiation of mechanical ventilation. The primary outcome was mortality at 90 days. Ventilator-free days, changes in oxygenation, and adverse events were also assessed.
The study was stopped at the sponsor's request after the second interim analysis for presumed futility. A total of 110 subjects were enrolled, with consent withdrawn from one whose data are unavailable. There were no significant differences between groups except in hospital-free days (10.4 ± 7.8 placebo vs 6.4 ± 7.8 surfactant; p = 0.01). Overall 90-day mortality was 11% (seven surfactant, five placebo). No immediate improvement in oxygenation was associated with surfactant administration.
Surfactant did not improve outcomes relative to placebo in this trial of children with direct lung injury/acute respiratory distress syndrome. Differences in concentration of the surfactant, failure to recruit the lung during surfactant administration, or using two rather than four position changes during administration are possible explanations for the difference from previous studies. Exogenous surfactant cannot be recommended at this time for children with direct lung injury/acute respiratory distress syndrome.
Pediatric Critical Care Medicine 07/2013; · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The treatment of pulmonary arterial hypertension (PAH) associated with chronic lung disease of infancy (CLDI) is becoming commonplace. However, an optimal approach to the monitoring of this treatment has not been clearly established, and data suggest that such therapy may not be without risk. This study assessed the feasibility and safety of pulmonary artery catheter (PAC) placement and its role in the management of PAH associated with CLDI. The medical records of 12 infants with CLDI requiring chronic mechanical ventilation who underwent PAC monitoring were reviewed. Data analyzed included demographics, hemodynamic data, PAH pharmacological therapy, respiratory support, echocardiographic data, sedation level, complications related to PAC use, and mortality. In this analysis, PAC placement and monitoring was found to be feasible, appeared safe, and was associated with the ability to wean inspired oxygen, decrease sedation, and titrate PAH therapy without untoward effect. However, no definitive conclusions can be drawn from this report given its small sample size and uncontrolled, retrospective design. It is hoped that these data will renew interest in PAC monitoring for CLDI and foster prospective study where its true value can be ascertained.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE:: We investigated the short-term and 1-yr clinical outcomes of 129 children who received intensive cardiopulmonary support during hematopoietic stem cell transplant. Intensive cardiopulmonary support was defined as receiving at least one of the following interventions: continuous positive pressure ventilation, dopamine infusion greater than or equal to 10 mcg/kg/min, or the use of any other vasoactive infusion. Duration of intensive cardiopulmonary support, survival to hospital discharge, and predictors of these outcome variables were compared with 387 hematopoietic stem cell transplant patients who did not receive intensive support during the same period. We also report the 1-yr survival; presence of chronic graft-versus-host disease; and renal, cardiac, and pulmonary function for all patients. DESIGN:: A multicenter retrospective cohort study. SETTING:: The ICU and hematopoietic stem cell transplant unit of nine pediatric tertiary care centers. PATIENTS:: Children undergoing hematopoietic stem cell transplant who required intensive cardiopulmonary support. INTERVENTIONS:: None. RESULTS:: Predictors of the need for intensive support included unrelated donor allogeneic transplant, glomerular filtration rate less than 85 mL/min/1.73 m, and nonmalignant disease as the indication for transplant. The survival to discontinuation of intensive support for all patients was 62% and 58% for patients who received invasive mechanical ventilatory support. The duration of mechanical ventilation was not predictive of survival. Predictors of intensive support mortality included macroscopic bleeding, engraftment, and pediatric logistic organ dysfunction score greater than one in two domains. Survival to hospital discharge was 50% for the intensive support group and 99% for the nonintensive support group. Overall 1-yr survival was 40% in the intensive support population and 65% in the nonintensive support group. There were no significant differences in the survival, rates of chronic graft-versus-host disease, creatinine, forced expiratory volume in 1-min, cardiac shortening fraction, or performance status in intensive and nonintensive support patients who survived to hospital discharge. CONCLUSION:: Intensive cardiopulmonary support plays an important and potentially life-saving role in the care of pediatric stem cell transplant patients. Survivors of intensive support do not have compromised 1-yr survival or organ function compared with children who did not receive intensive support.
Pediatric Critical Care Medicine 02/2013; · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Palliative care for children and adolescents with cancer includes interventions that focus on the relief of suffering, optimization of function, and improvement of quality of life at any and all stages of disease. This care is most effectively provided by a multidisciplinary team. Nurses perform an integral role on that team by identifying symptoms, providing care coordination, and assuring clear communication. Several basic tenets appear essential to the provision of optimal palliative care. First, palliative care should be administered concurrently with curative therapy beginning at diagnosis and assuming a more significant role at end of life. This treatment approach, recommended by many medical societies, has been associated with numerous benefits including longer survival. Second, realistic, objective goals of care must be developed. A clear understanding of the prognosis by the patient, family, and all members of the medical team is essential to the development of these goals. The pediatric oncology nurse is pivotal in developing these goals and assuring that they are adhered to across all specialties. Third, effective therapies to prevent and relieve the symptoms of suffering must be provided. This can only be accomplished with accurate and repeated assessments. The pediatric oncology nurse is vital in providing these assessments and must possess a working knowledge of the most common symptoms associated with suffering. With a basic understanding of these palliative care principles and competency in the core skills required for this care, the pediatric oncology nurse will optimize quality of life for children and adolescents with cancer.
Clinical medicine insights. Pediatrics. 01/2012; 6:75-88.
[Show abstract][Hide abstract] ABSTRACT: To describe goals of care for children with complex, life-limiting conditions and to assess the variables that may influence these goals.
Goals of care were elicited from the parents and children with complex, life-limiting conditions during initial palliative care consultation. Data abstracted included: diagnoses, demographics, time from diagnosis until initial palliative care consult, spirituality status, resuscitative status, and disposition at discharge. Goals of care were categorized into one of four quality-of-life domains: 1) physical health and independence, 2) psychological and spiritual, 3) social, and 4) environment. Summary statistics were prepared and comparisons were made between the four categories of goals. Descriptive statistics were utilized to explore potential associations with a decision to pursue full medical support.
One hundred and forty goals of care were obtained from 50 patients/parents. The median patient age was 4.6 years. Thirty-seven patients had significant cognitive delay/impairment. Neuromuscular disorders accounted for more than half of the diagnoses. Forty-nine patients identified at least one goal pertaining to physical health and independence. This was significantly more than any other category (p < 0.0001). Thirty-three of the 50 patients (66%) opted for full medical support at the time of initial consult.
Children with complex, life-limiting conditions and their families referred to a palliative care service commonly verbalize goals related to health maintenance and independence. Anticipating this expectation may foster communication and improve patient care.
Journal of palliative medicine 03/2011; 14(5):607-13. · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although potentially curative, hematopoietic SCT (HSCT) is associated with significant morbidity. To improve outcomes, multicenter studies of critical illness in this patient population appear needed. To assist in the design of such studies, a survey was conducted to identify variations in care provided to critically ill pediatric HSCT patients. A survey was conducted of the highest volume pediatric HSCT centers in the United States (n=30) and Canada (n=4). One pediatric critical care medicine (PCCM) physician and one pediatric HSCT physician were surveyed at each institution. Analysis consisted of descriptive statistics. Thirty-three (29 United States/4 Canada) of 34 institutions responded. Although most HSCT units permit fluid boluses and nearly half permit some dose of dopamine, high-dose dopamine and other vasoactive infusions are rarely allowed there. Six institutions (21%) permit non-invasive ventilation on the HSCT unit. Criterion for PCCM consultation and therapies implemented before intubation vary significantly. High-frequency oscillatory ventilation and renal replacement therapy are commonly used for lung injury in patients failing conventional therapy. Variability exists in the location and type of therapy critically ill pediatric HSCT patients receive. Understanding this variability will help facilitate the design of clinical trials.
Bone marrow transplantation 02/2011; 46(2):227-31. · 3.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the long-term benefits of continuous renal replacement therapy (CRRT) in this patient population and to analyze factors associated with survival. Hematopoietic stem cell transplantation is being utilized as curative therapy for a variety of disorders. However, organ dysfunction is commonly associated with this therapy. Continuous renal replacement therapy (CRRT) is increasingly being used in the treatment of this multiorgan dysfunction.
Retrospective cohort study.
A free-standing, tertiary care, pediatric oncology hospital.
Twenty-nine allogeneic hematopoietic stem cell transplantation patients who underwent 33 courses of CRRT in the intensive care unit between January 2003 and December 2007.
Cox proportional hazards regressions models were used to examine the relationship between demographic and clinical variables and length of survival.
The median length of survival post CRRT initiation was 31 days; only one patient survived >6 mos. Factors associated with increased risk of death included: higher bilirubin and blood urea nitrogen levels before and at 48 hrs into CRRT, lower Pao2/Fio2 ratios at 48 hrs of CRRT, and higher C-reactive protein levels, as well as lower absolute neutrophil counts at CRRT end.
In this single-center study, CRRT was not associated with long-term survival in pediatric allogeneic hematopoietic stem cell transplantation patients. Clinical data exist, both before and during CRRT, that may be associated with length of survival. Lower C-reactive protein levels at CRRT end were associated with longer survival, suggesting that the ability to attenuate inflammation during CRRT may afford a survival advantage. These findings require confirmation in a prospective study.
Pediatric Critical Care Medicine 05/2010; 11(6):699-706. · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Aminophylline is a well established bronchodilator with reported diuretic effects. Limited data suggest it may also exert anti-inflammatory effects. We conducted a prospective, uncontrolled observational trial of aminophylline to assess its anti-inflammatory effects.
All patients prescribed aminophylline in our PICU from March 2007 through March 2008 were screened for inclusion. All patients who consented to the study had a C-reactive protein (CRP) level measured just prior to the initiation of aminophylline. Patients with a CRP level > 1.5 mg/dL were defined as having inflammatory disease and had cytokine analysis performed at baseline and 24 hours after the start of aminophylline. Cytokine analysis was performed by Rules Based Medicine Laboratories using 90-plex luminex technology. The use of aminophylline was at the discretion of the clinical team with intermittent dosing and goal trough levels of 4-8 mcg/mL. Data was analyzed using non-parametric testing. Subgroup analysis was also performed on patients with RSV infections or severe sepsis.
36 patients received aminophylline during the time period and consented to participation in the study. 19 of these patients had CRP levels > 1.5 mg/dL and underwent cytokine analysis. Diagnoses for the 19 patients included RSV respiratory infection (N=6), severe sepsis (N=5), near drowning (N=2), and one each of a variety of other diagnoses for the remaining six. CRP values ranged from 1.7 to > 27 mg/dL (IQR 5.4 to 24.2 mg/dL). IL-6 levels at 24 hours decreased from baseline (median 27.0 vs 9.4 pg/mL, p < 0.0001). Baseline IL-8 levels also differed from 24 hour levels (median 89.0 vs 64.0 pg/mL, p = 0.05). TNF alpha concentrations did not change over time. Among the RSV patients, IL-6 levels decreased from baseline (median 23.0 vs 4.0 pg/mL, p = 0.03), as did IL-8 levels (median 88.5 vs 68.0 pg/mL, p = 0.03). There was no difference in TNF alpha levels. The severe sepsis group also experienced a decrease in IL-6 levels, that did not attain statistical significance (p = 0.13). IL-8 and TNF-alpha concentrations were unchanged among this subset.
In this pilot study, aminophylline appeared to have an anti-inflammatory effect. These data support a controlled trial of the anti-inflammatory effects of aminophylline among critically ill children, and perhaps, identify a patient population to target for such study.
2009 American Academy of Pediatrics National Conference and Exhibition; 10/2009
[Show abstract][Hide abstract] ABSTRACT: To assess the impact of calfactant (a modified natural bovine lung surfactant) in immunocompromised children with acute lung injury and to determine the number of patients required for a definitive clinical trial of calfactant in this population.
Post hoc analysis of data from a previous randomized, control trial.
Tertiary care pediatric intensive care units.
All children, defined as immunocompromised, enrolled in a multicenter, masked, randomized, control trial of calfactant for acute lung injury conducted between July 2000 and July 2003.
Patients received either an intratracheal instillation of calfactant or an equal volume of air placebo in a protocolized manner.
Eleven of 22 (50%) calfactant-treated patients died when compared with 18 of 30 (60%) placebo patients (absolute risk reduction 10.0%, 95% confidence interval [CI] -17.3, 37.3). Among the 23 patients with an initial oxygen index (OI) >/=13 and </=37, 44% (4 of 9) of calfactant-treated patients died in comparison with 71% (10 of 14) of placebo (absolute risk reduction 27.0%, 95% CI -13.2, 67.2). Only 33% (3 of 9) of calfactant patients died before intensive care discharge in comparison with 71% (10 of 14) of placebo (absolute risk reduction 38.1%, 95% CI -0.7, 76.9). Calfactant therapy was associated with improved oxygenation in these 23 patients. Using an OI entry criterion of (13 </= OI </= 37), stratifying on the presence of hematopoietic stem cell transplantation, and accepting the 27% difference in mortality observed in this analysis, 63 patients would be required in each arm of a randomized, control trial to demonstrate a significant effect of calfactant on mortality in this patient population assuming a two-sided alpha of 0.05 and a power of 0.85.
These preliminary data suggest a potential benefit of calfactant in this high-risk population. A clinical trial powered to appropriately assess these findings seems warranted and feasible.
Pediatric Critical Care Medicine 09/2008; 9(5):459-64. · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the following hypotheses regarding mechanically ventilated pediatric oncology patients, including those receiving hematopoietic stem cell transplant (HSCT) and those not receiving HSCT: 1) outcomes are more favorable for nontransplant oncology patients than for those requiring HSCT; 2) outcomes have improved for both populations over time; and 3) there are factors available during the time of mechanical ventilation that identify patients with a higher likelihood of dying.
Free-standing, tertiary care, pediatric hematology oncology hospital.
All patients requiring invasive mechanical ventilation with a diagnosis of cancer or following HSCT from January 1996 to December 2004.
Bivariate and multivariate analysis. Dates of admission were grouped into time periods for analysis: 1996-1998, 1999-2001, and 2002-2004.
There were 401 courses of mechanical ventilation (329 patients) analyzed. Forty-five percent of HSCT admissions (92 of 206) vs. 75% of non-HSCT oncology admissions (146 of 195) were extubated and discharged from the pediatric intensive care unit (p < .0001). Twenty-five percent of HSCT vs. 60% of non-HSCT admissions survived 6 months (p < .0001). Among admissions with an abnormal chest radiograph and a PaO2/FiO2 ratio <200, pediatric intensive care unit survival increased for each successive time period, with 45% of HSCT and 83% of non-HSCT admissions surviving during 2002-2004. In multivariate analysis of all study patients, Pediatric Risk of Mortality scores on the day of intubation, allogeneic HSCT, cardiovascular failure, hepatic failure, neurologic failure, a previous course of mechanical ventilation within 6 months, and the time period intubated were associated with mortality. With the exception of time period, these same variables were associated with mortality in multivariate analysis of only HSCT patients.
HSCT patients who require mechanical ventilation have worse outcomes than non-HSCT oncology patients. Outcomes for both groups have improved over time. Allogeneic transplant, higher Pediatric Risk of Mortality scores, need for repeated mechanical ventilation, and concomitant organ system dysfunction are risk factors for death.
Pediatric Critical Care Medicine 05/2008; 9(3):270-7. · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: When anesthetizing a patient with an anterior mediastinal mass, sudden hypoxaemia and cardiovascular collapse may result from compression of a large airway or vascular structure in the mediastinum. We report the case of a pediatric cancer patient with an anterior mediastinal mass, who developed sudden and fatal hypoxaemia and cardiovascular collapse in the hours following sedation. A massive pulmonary thromboembolism was diagnosed at autopsy. We suggest that pulmonary embolism should be considered in the differential diagnosis when a patient with a mediastinal mass develops perioperative hypoxaemia, cardiovascular collapse, or both.
[Show abstract][Hide abstract] ABSTRACT: We present the radiological and clinical aspects of a patient with advanced-stage Burkitt lymphoma who presented with an acute abdomen complicated by abdominal compartment syndrome.