P Jouvet

Université de Montréal, Montréal, Quebec, Canada

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Publications (106)424.29 Total impact

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    ABSTRACT: Supportive care as a bridge to transplant or recovery remains challenging in children suffering from acute liver failure (ALF). We report our experience in children using the Molecular Absorbent Recirculating System (MARS®). Retrospective data from children receiving therapy using MARS® from October 2009 to October 2012 were included in this single-center retrospective study. Patient characteristics, clinical presentation and complications of ALF, clinical and biological data before and after each MARS® session, technical modalities and adverse events were recorded. A total of six children underwent 17 MARS® sessions during the study period. Two adolescents were treated with the adult filter MARSFLUX® and four infants were treated with the MiniMARS® filter. The mean PEdiatric Logistic Dysfunction (PELOD) score at admission was 19 (range 11-33). All patients were mechanically ventilated, and four had acute kidney injury. The neurological course improved in one case, judged as stable in two cases and worsened in one case; data were unavailable in two cases. Mean serum ammonia levels decreased significantly following treatment with MARS® from an initial 89 ± 29 to 58 ± 35 mcmol/L (p = 0.02). No other significant biological improvement was observed. Hemodynamic status improved/remained unchanged in the adolescent group, but in the infants four of the seven sessions were poorly tolerated and two sessions were aborted. Three patients died, two were successfully transplanted and one recovered without transplantation. In our experience, treatment with MARS® is associated with encouraging results in adolescents, but it needs modification for very sick infants to improve tolerance.
    Pediatric Nephrology 12/2013; · 2.94 Impact Factor
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    ABSTRACT: BACKGROUND: Automated closed loop systems may improve adaptation of the mechanical support to a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. OBJECTIVES: To compare the duration of weaning from mechanical ventilation for critically ill ventilated adults and children when managed with automated closed loop systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); MEDLINE (OvidSP) (1948 to August 2011); EMBASE (OvidSP) (1980 to August 2011); CINAHL (EBSCOhost) (1982 to August 2011); and the Latin American and Caribbean Health Sciences Literature (LILACS). In addition we received and reviewed auto-alerts for our search strategy in MEDLINE, EMBASE, and CINAHL up to August 2012. Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. SELECTION CRITERIA: We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an intensive care unit (ICU). DATA COLLECTION AND ANALYSIS: Two authors independently extracted study data and assessed risk of bias. We combined data into forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria. MAIN RESULTS: Pooled data from 15 eligible trials (14 adult, one paediatric) totalling 1173 participants (1143 adults, 30 children) indicated that automated closed loop systems reduced the geometric mean duration of weaning by 32% (95% CI 19% to 46%, P = 0.002), however heterogeneity was substantial (I(2) = 89%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (43%, 95% CI 8% to 65%, P = 0.02) and Smartcare/PS™ (31%, 95% CI 7% to 49%, P = 0.02) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (17%, 95% CI 8% to 26%) and ICU length of stay (LOS) (11%, 95% CI 0% to 21%). There was no difference in mortality rates or hospital LOS. Overall the quality of evidence was high with the majority of trials rated as low risk. AUTHORS' CONCLUSIONS: Automated closed loop systems may result in reduced duration of weaning, ventilation, and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.
    Cochrane database of systematic reviews (Online) 06/2013; 6:CD009235. · 5.70 Impact Factor
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    ABSTRACT: Canada was one of the first countries affected by the 2009 influenza H1N1 pandemic with two waves - one from May to June and one from October to December. The 2009 influenza H1N1 pandemic had many unique features when compared with seasonal influenza, including the following: more than half of the affected people were children; asthma was the most significant risk factor for hospital admission; and Aboriginal and pregnant women had a higher risk of hospital admission and complications. Antiviral therapy was widely used but data did not show any effect on the pediatric population. Outbreak spread was possibly promoted from child-child and child-adult contact, and therefore the vaccination campaign targeted the pediatric population and achieved good coverage among young children (57%). Vaccination efficacy was difficult to test because of the vaccination delay. Improvement in models of prevention and treatment are urgently needed to prepare for the possible future pandemics.
    Expert Review of Anticancer Therapy 06/2013; 11(6):555-63. · 3.22 Impact Factor
  • Marc Wysocki, Philippe Jouvet, Samir Jaber
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    ABSTRACT: Mechanical ventilation is a sophisticated technique with very narrow therapeutic ranges i.e. highly efficient and able to keep alive the most severe patients, but with considerable side effects and unwanted complications if not properly and timely used. Computerized protocols, closed loop systems, decision support, all terms which need to be defined, may help making mechanical ventilation safer and more efficient. The present paper will provide a short overview on technical and engineering considerations regarding closed loop controlled ventilation as well as tangible clinical evidences supporting the previous statement.
    International Journal of Clinical Monitoring and Computing 04/2013;
  • Neal J Thomas, Philippe Jouvet, Douglas Willson
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    ABSTRACT: OBJECTIVE:: To describe the planned aims and methodology of the Pediatric Acute Lung Injury Consensus Conference. DESIGN:: Consensus conference of experts in pediatric acute lung injury. METHODS:: A panel of 26 experts in pediatric acute lung injury will meet over the course of one year to develop a better taxonomy to define pediatric acute lung injury, specifically predisposing factors, etiology, and pathophysiology. A modified Delphi approach that emphasizes strong professional agreement will be utilized. RESULTS:: The Pediatric Acute Lung Injury Consensus Conference will aim for consensus development on the following topics related to pediatric acute lung injury: 1) definition, incidence, and epidemiology; 2) comorbidities and severity; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive support and ventilation; 8) extracorporeal support; and 9) morbidity and long-term outcomes. CONCLUSIONS:: The importance of this effort for improving care and guiding future research in pediatric acute lung injury is clear. Despite the many epidemiologic, interventional, and outcome studies undertaken by pediatric intensivists worldwide, our understanding of this disease process is limited, and morbidity and mortality remain unacceptably high. By consolidating the knowledge and expertise of the leaders of the field of pediatric acute lung injury, we hope to develop a framework for future progress.
    Pediatric Critical Care Medicine 02/2013; · 2.35 Impact Factor
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    ABSTRACT: ABSTRACT PURPOSE: Although secondary infections are recognized as a cause of morbidity and mortality in seasonal influenza, their frequency, characteristics and associated clinical outcomes in Influenza A (H1N1)-related critical illness are unknown. METHODS: In a prospective cohort of adult patients admitted to Canadian Intensive Care Units (ICUs) with H1N1 infection, the frequency and associated clinical outcomes of prevalent (culture taken within 72 hours of ICU admission) and ICU-acquired (culture taken after 72 hours from ICU admission) positive bacterial cultures were determined. RESULTS: Among 681 patients the mean age was 47.9 years (standard deviation [SD] 15.1), APACHE II was 21.0 (9.9) and 573 (84.0%) were invasively mechanical ventilated (MV). Positive cultures were obtained in 259 (38.0 %): 77 (29.7%) prevalent; 115 (44.4%) ICU-acquired; 40 (15.4%) had both; culture date was unavailable in 27 (10.4%). The most common bacterial organisms isolated were coagulase negative staphylococci, Staphylococcus aureus, Pseudomonas sp. and Streptococcus pneumoniae. Antibiotics were prescribed in 661 (97.1%) with 3.8 (1.9) prescriptions per patient. Patients with any positive culture had longer days of MV [mean(SD); 15.2 (10.7) vs. 10.7 (9.0), p< 0.0001], ICU stay [median(IQR);18.2 (12.5) vs. 10.8 (9.0) days, p< 0.0001], hospitalization [median(IQR); 30.7 (20.7) vs. 19.2 (17.4) days, p< 0.0001] and a trend towards increased hospital mortality (25.1% vs. 19.9%, p = 0.15). Patients with ICU-acquired positive cultures had worse outcomes compared to those with positive prevalent cultures or who were culture negative. CONCLUSION: Culture-based evidence of secondary infections commonly complicates Influenza A(H1N1)-related critical illness and is associated with worse clinical outcomes despite nearly ubiquitous antibiotic administration.
    Chest 02/2013; · 5.85 Impact Factor
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    ABSTRACT: 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.
    European Journal of Intensive Care Medicine 01/2013; · 5.17 Impact Factor
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    ABSTRACT: Mechanical ventilation is a very effective therapy, but with many complications. Simulators are used in many fields, including medicine, to enhance safety issues. In the intensive care unit, they are used for teaching cardiorespiratory physiology and ventilation, for testing ventilator performance, for forecasting the effect of ventilatory support, and to determine optimal ventilatory management. They are also used in research and development of clinical decision support systems (CDSSs) and explicit computerized protocols in closed loop. For all those reasons, cardiorespiratory simulators are one of the tools that help to decrease mechanical ventilation duration and complications. This paper describes the different types of simulators described in the literature for physiologic simulation and modeling of the respiratory system, including a new simulator (SimulResp), and proposes a validation process for these simulators.
    Critical care research and practice 01/2013; 2013:943281.
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    ABSTRACT: OBJECTIVE:: To prospectively evaluate relationships among serum cytokine levels, innate immune responsiveness, and mortality in a multicenter cohort of critically ill children with influenza infection. DESIGN:: Prospective, multicenter, observational study. SETTING:: Fifteen pediatric ICUs among members of the Pediatric Acute Lung Injury and Sepsis Investigators network. PATIENTS:: Patients ≤18 yrs old admitted to a PICU with community-acquired influenza infection. A control group of outpatient children was also evaluated. INTERVENTIONS:: ICU patients underwent sampling within 72 hrs of ICU admission for measurement of a panel of 31 serum cytokine levels and quantification of whole blood ex vivo lipopolysaccharide-stimulated tumor necrosis factor-α production capacity using a standardized stimulation protocol. Outpatient control subjects also underwent measurement of tumor necrosis factor-α production capacity. MEASUREMENTS AND MAIN RESULTS:: Fifty-two patients (44 survivors, eight deaths) were sampled. High levels of serum cytokines (granulocyte macrophage colony-stimulating factor, interleukin-6, interleukin-8, interferon-inducible protein-10, monocyte chemotactic protein-1, and macrophage inflammatory protein-1α) were associated with mortality (p < 0.0016 for each comparison) as was the presence of secondary infection with Staphylococcus aureus (p = 0.007), particularly methicillin-resistant S. aureus (p < 0.0001). Nonsurvivors were immunosuppressed with leukopenia and markedly reduced tumor necrosis factor-α production capacity compared with outpatient control subjects (n = 21, p < 0.0001) and to ICU survivors (p < 0.0001). This association remained after controlling for multiple covariables. A tumor necrosis factor-α response <250 pg/mL was highly predictive of death and longer duration of ICU stay (p < 0.0001). Patients with S. aureus coinfection demonstrated the greatest degree of immunosuppression (p < 0.0001). CONCLUSIONS:: High serum levels of cytokines can coexist with marked innate immune suppression in children with critical influenza. Severe, early innate immune suppression is highly associated with both S. aureus coinfection and mortality in this population. Multicenter innate immune function testing is feasible and can identify these high-risk children.
    Critical care medicine 12/2012; · 6.37 Impact Factor
  • Douglas F Willson, Neal J Thomas, Philippe A Jouvet
    Pediatric Critical Care Medicine 11/2012; 13(6):691-2. · 2.35 Impact Factor
  • Olivier Flechelles, Philippe Jouvet
    Pediatric Critical Care Medicine 11/2012; 13(6):690-1. · 2.35 Impact Factor
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    ABSTRACT: INTRODUCTION: The present study is a pilot prospective safety evaluation of a new closed loop computerised protocol on ventilation and oxygenation in stable, spontaneously breathing children weighing more than 7 kg, during the weaning phase of mechanical ventilation. METHODS: Mechanically ventilated children ready to start the weaning process were ventilated for five periods of 60 minutes in the following order: pressure support ventilation, adaptive support ventilation (ASV), ASV plus a ventilation controller (ASV-CO2), ASV-CO2 plus an oxygenation controller (ASV-CO2-O2) and pressure support ventilation again. Based on breath-by-breath analysis, the percentage of time with normal ventilation as defined by a respiratory rate between 10 and 40 breaths/minute, tidal volume > 5 ml/kg predicted body weight and end-tidal CO2 between 25 and 55 mmHg was determined. The number of manipulations and changes on the ventilator were also recorded. RESULTS: Fifteen children, median aged 45 months, were investigated. No adverse event and no premature protocol termination were reported. ASV-CO2 and ASV-CO2-O2 kept the patients within normal ventilation for, respectively, 94% (91 to 96%) and 94% (87 to 96%) of the time. The tidal volume, respiratory rate, peak inspiratory airway pressure and minute ventilation were equivalent for all modalities, although there were more automatic setting changes in ASV-CO2 and ASV-CO2-O2. Positive end-expiratory pressure modifications by ASV-CO2-O2 require further investigation. CONCLUSION: Over the short study period and in this specific population, ASV-CO2 and ASV-CO2-O2 were safe and kept the patient under normal ventilation most of the time. Further research is needed, especially for positive end-expiratory pressure modifications by ASV-CO2-O2. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01095406.
    Critical care (London, England) 05/2012; 16(3):R85. · 4.72 Impact Factor
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    ABSTRACT: Background:Neurally Adjusted Ventilatory Assist (NAVA) is a mode of ventilation controlled by the electrical activity of the diaphragm (Edi). The aim was to evaluate patient-ventilator interaction in infants during NAVA compared to conventional ventilation.Methods:Infants were successively ventilated with NAVA, pressure control (PCV) and pressure support (PSV). Edi and ventilator pressure (Pvent) waveforms were compared and their variability was assessed by coefficients of variation (CV).Results:Ten patients (mean age 4.3±2.4 months and weight 5.9±2.2 kg) were studied. In PCV and PSV, 4±4.6% and 6.5±7.7% of the neural efforts failed to trigger the ventilator. This did not occur during NAVA. Trigger delays were shorter with NAVA compared to PCV and PSV (93±20ms vs 193±87ms, and 135±29ms). During PCV and PSV, the ventilator cycled off before end of neural inspiration in 12±13% and 21±19% of the breaths (0±0% during NAVA). During PCV and PSV, 24±11% and 25±9% of the neural breath cycle was asynchronous with the ventilator compared to 11±3% with NAVA. A large variability was observed for Edi in all modes, which was transmitted into Pvent during NAVA (CV: 24±8%), and not in PCV (CV 2±1%) or PSV (2±2%).Conclusions:NAVA improves patient-ventilator interaction and delivers adequate ventilation with variable pressure in infants.
    Pediatric Research 05/2012; · 2.67 Impact Factor
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    ABSTRACT: Acute kidney injury (AKI) affects 5% of critically ill hospitalized children and is a risk factor for increased morbidity and mortality. The current review focuses on new definitions of acute kidney injury, standardized to reflect the entire spectrum of the disease, as well as on ongoing research to identify early biomarkers of kidney injury. Its also provides an overview of current practice and available therapies, with emphasis on new strategies for the prevention and pharmacological treatment of diarrhea-associated hemolytic uremic syndrome. Furthermore, a decision-making algorithm is presented for the use of renal replacement therapies in critically ill children with AKI.
    Minerva pediatrica 04/2012; 64(2):121-33. · 0.64 Impact Factor
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    Philippe Jouvet, Patrice Hernert, Marc Wysocki
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    ABSTRACT: Mechanical ventilation can be perceived as a treatment with a very narrow therapeutic window, i.e., highly efficient but with considerable side effects if not used properly and in a timely manner. Protocols and guidelines have been designed to make mechanical ventilation safer and protective for the lung. However, variable effects and low compliance with use of written protocols have been reported repeatedly. Use of explicit computerized protocols for mechanical ventilation might very soon become a "must." Several closed loop systems are already on the market, and preliminary studies are showing promising results in providing patients with good quality ventilation and eventually weaning them faster from the ventilator. The present paper defines explicit computerized protocols for mechanical ventilation, describes how these protocols are designed, and reports the ones that are available on the market for children.
    Annals of intensive care. 12/2011; 1(1):51.
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    ABSTRACT: Invasive mechanical ventilation, if prolonged, may lead to high morbidity and mortality. To determine the incidence rate and early risk factors for prolonged acute invasive mechanical ventilation in children. Retrospective longitudinal cohort study over a 1-yr period. All consecutive episodes of invasive mechanical ventilation in the pediatric intensive care units of Sainte-Justine Hospital (Montreal, Canada) were included. Risk factors for long (≥96 hrs) vs. short (<96 hrs) duration of ventilation were determined by logistic regression. None. Among the 360 episodes of invasive ventilation, 36% had a length of ≥96 hrs. Following multivariate analysis, significant risk factors for prolonged acute invasive mechanical ventilation were age of <12 months (odds ratio 3.27, 95% confidence interval 1.90-5.63), Pediatric Risk of Mortality score of ≥15 at admission (odds ratio 3.41, 95% confidence interval 1.31-8.89), mean airway pressure of ≥13 cm H(2)O on day 1 (odds ratio 5.92, 95% confidence interval 3.08-11.36), use of continuous intravenous sedation on day 1 (odds ratio 1.75, 95% confidence interval 1.00-3.05), and use of noninvasive ventilation before intubation (odds ratio 6.56, 95% confidence interval 1.99-21.63). Among the risk factors identified, the use of noninvasive ventilation and continuous intravenous sedation on the first day of ventilation are the only two interventions that were associated with prolonged acute invasive mechanical ventilation. Further research is needed to study the impact of sedation protocols on the duration of mechanical ventilation in children.
    Pediatric Critical Care Medicine 07/2011; 13(2):152-7. · 2.35 Impact Factor
  • Philippe Jouvet, Guillaume Emeriaud
    Pediatric Critical Care Medicine 07/2011; 12(4):467-8. · 2.35 Impact Factor
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    ABSTRACT: Hyperammonemia results from reduction of hepatocyte function or enzyme of urea cycle deficiency. Hyperammonemia contributes to cerebral edema that may lead to cerebral herniation. The threshold of toxicity of ammonemia is unknown. We conducted a retrospective observational study in our pediatric intensive care unit. All children who developed hyperammonemia from January 2000 to April 2009 were included. Clinical and laboratory data at admission, specific treatments implemented, and ammonemias the first 7 days after inclusion were collected. The outcome assessed was 28 day mortality. Risk of mortality was estimated by a logistic regression model. Ninety patients with liver failure (63.3%) and primary or secondary urea cycle defect (23.3%) were included. Patients with urea cycle defects were more likely to receive ammonia scavengers than patients with liver failure (47.6% versus 3.5%). The 28 day mortality rate was 31.1%. Risk of mortality increased according to the ammonemia within 48 h: odds ratio 1.5, 1.9, 3.3, 2.4 for ammonemia above 100, 150, 200, and 300 μmol/L, respectively. Peak ammonemia ≥200 μmol/L within the first 48 h was an independent risk factor for mortality, with greater risk found in liver failure than in urea cycle defect. Our study identifies a threshold of exposure to ammonia (≥200 μmol/L) above which mortality increases significantly, especially in liver failure. Specific treatments of hyperammonemia are rarely used in liver failure when compared with urea cycle defect even though use of ammonia scavengers may help to decrease ammonemia.
    Journal of Hepatology 05/2011; 56(1):123-8. · 9.86 Impact Factor
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    ABSTRACT: Severe hyperammonemia (hyperNH3) in neonatal cardiac failure after cardiac surgery is rare. We report a case of a 2470-g female infant born at the week 37 of gestation with complex congenital heart disease (truncus arteriosus type III, interrupted aortic arch and tricuspid valve insufficiency) and hemodynamically non-significant intrahepatic arterio-venous malformation. She developed hyperNH3 (highest NH3 blood level: 467 µmol/L) without severe liver failure (INR of 1.9). The origin of the hyperNH3 was multifactorial including limited capacity of liver detoxification function due to congenital porto-caval shunt, liver ischemia, excessive protein intake and increased protein catabolic rate. HyperNH3 treatment partially succeeded in decreasing ammonia level and included discontinuation of protein intake, administration of phenylacetate and sodium benzoate. This case highlights the fact that NH3 detoxification by the liver has limitations for a neonate with multifactorial causes that decrease liver perfusion.
    Minerva anestesiologica 05/2011; 77(5):554-7. · 2.82 Impact Factor
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    ABSTRACT: To investigate the possibility of pediatric intensive care unit shortfalls, using pandemic models for a range of attack rates and durations. The emergence of the swine origin pH1N1 virus has led to concerns about shortfalls in our ability to provide pediatric ventilation and critical care support. Modeling of pediatric intensive care demand based on pH1N1 predictions using simulation techniques. Simulation laboratory. None. None. Data collected during the first wave of the pH1N1 in children in Canada were applied to several second wave pandemic models to explore potential pediatric intensive care unit ventilatory demands for Canada and to investigate the impact of vaccination upon these demands. In almost all cases studied, even for relatively low attack rates of 15%, significant pediatric intensive care unit shortages would be expected to occur. Vaccination strategies targeting 50% of the population significantly reduced demand, but shortages may still be expected. Although shortfalls can occur in all provinces, Ontario and British Columbia may experience the greatest supply-demand difference, even at low attack rates. Reducing the attack rate among children, whether through vaccination or additional measures, such as social distancing, will be critical to ensure sufficient pediatric intensive care unit capacity for continued pediatric care.
    Pediatric Critical Care Medicine 03/2011; 12(2):e51-7. · 2.35 Impact Factor

Publication Stats

1k Citations
424.29 Total Impact Points


  • 2005–2013
    • Université de Montréal
      • Department of Pediatrics
      Montréal, Quebec, Canada
  • 2011
    • Centre Hospitalier Universitaire de Québec (CHUQ)
      Québec, Quebec, Canada
  • 2007–2011
    • CHU Sainte-Justine
      Montréal, Quebec, Canada
  • 2010
    • University of Toronto
      • Division of Critical Care Medicine
      Toronto, Ontario, Canada
  • 2006
    • Université René Descartes - Paris 5
      Lutetia Parisorum, Île-de-France, France
    • Government of Quebec
      Québec, Quebec, Canada
  • 1999
    • Imperial College London
      Londinium, England, United Kingdom