Bolus gastric feeds improve nutrition delivery to mechanically ventilated pediatric medical patients: Results of the COntinuous vs BOlus multicenter trial
Background: Comparison of bolus gastric feeding (BGF) vs continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated (MV) pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered.
Methods: Multicenter, prospective, randomized comparative effectiveness trial conducted in seven pediatric intensive care units (PICUs). Eligibility criteria included patients aged 1 month to 12 years who were intubated within 24 h of PICU admission, with expected duration of ventilation at least 48 h, and who were eligible to begin enteral nutrition within 48 h. Exclusion criteria included patients with acute or chronic gastrointestinal pathology or acute surgery.
Results: We enrolled 158 MV children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). Children in the BGF group were slightly older than those in the CGF; otherwise, the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group who achieved goal feeds. Time to goal feeds was shorter in the BGF group (hazard ratio 1.5 [CI 1.02-2.33]; P = 0.0387). Median percentage of target kilocalories (median kcal 0.78 vs 0.59; P ≤ 0.0001) and median percentage of protein delivered (median protein 0.77 vs 0.59; P ≤ 0.0001) was higher for BGF patients. There was no difference in serial oxygen saturation index between groups.
Conclusion: Our study demonstrated shorter time to achieve goal nutrition via BGF compared with CGF in MV pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations.
Ann-Marie Brown
Sharon Y Irving
Charlene Pringle
Christine Allen
Miraides F Brown
Sholeen Nett
Marcy N Singleton
Theresa A Mikhailov
Erik Madsen
Vijay Srinivasan
Heather Anthony
Michael L Forbes
The NutriNet and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
JPEN J Parenter Enteral Nutr
. 2022 Jul;46(5):1011-1021. doi: 10.1002/jpen.2305. Epub 2022 Jan 27.
2022
English
Key articles and guidelines for the pediatric clinical pharmacist from 2019 and 2020
Purpose: To summarize recently published research reports and practice guidelines deemed to be significantly impactful for pediatric pharmacy practice.
Summary: Our author group was composed of 8 board-certified pediatric pharmacists. Eight major themes were identified: critical care, hematology/oncology, medication safety, general pediatrics, infectious diseases, neurology/psychiatry, gastrointestinal/nutrition, and neonatology. The author group was assigned a specific theme(s) based on their practice expertise and were asked to identify articles using MEDLINE and/or searches of relevant journal articles pertaining to each theme that were published from January 2019 through December 2020 that they felt were "significant" for pediatric pharmacy practice. A final list of compiled articles was distributed to the authors, and an article was considered significant if it received a vote from 5 of the 8 authors. Thirty-two articles, including 16 clinical practice guidelines or position statements and 16 review or primary literature articles, were included in this review. For each of these articles, a narrative regarding its implications for pediatric pharmacy practice is provided.
Conclusion: Given the heterogeneity of pediatric patients, it is difficult for pediatric pharmacists to stay up to date with the most recent literature, especially in practice areas outside their main expertise. Over the last few years, there has been a significant number of publications impacting the practice of pediatric pharmacists. This review of articles that have significantly affected pediatric pharmacy practice may be helpful in staying up to date on key articles in the literature.
Kelly S Bobo
M Petrea Cober
Lea S Eiland
Melissa Heigham
Morgan King
Peter N Johnson
Jamie L Miller
Caroline M Sierra
Am J Health Syst Pharm
. 2022 Feb 18;79(5):364-384. doi: 10.1093/ajhp/zxab426.
2022
English
Evaluation of anticoagulation practice with new-onset atrial fibrillation in patients with sepsis and septic shock in medical intensive care unit: A retrospective observational cohort study.
severe sepsis; septic shock; atrial fibrillation; critical care; anticoagulation
Objective To investigate the anticoagulation practice in patients presenting with new-onset atrial fibrillation (NOAF) during sepsis and septic shock with one-year follow-up since discharge and to evaluate factors associated with the development of NOAF. Methods A retrospective observational cohort study was conducted using chart review in patients diagnosed with sepsis and septic shock. Results There was a total of 1132 patients diagnosed with sepsis and septic shock over a one-year period. Thirty-two patients were found to have NOAF in the setting of sepsis. Of this, eight (25%) patients were anticoagulated with warfarin and 14 (44%) patients were not anticoagulated during discharge. At one-year follow-up post-discharge, nine (29%) patients continued on warfarin and 16 (52%) patients remained not anticoagulated. Conclusion We found that the majority of patients who developed NOAF did not get anticoagulated at the time of discharge. A similar trend followed after one year of follow-up. Since proper treatment guidelines are not in place, these patients are at high risk for recurrent atrial fibrillation, stroke, transient ischemic attack, and death. (Copyright © 2020, Arunachalam et al.)
Arunachalam K;Kalyan SA;Jha K;Thakur L;Pond K
Cureus
2020
2020-08-25
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
journalArticle
<a href="http://doi.org/10.7759/cureus.10026" target="_blank" rel="noreferrer noopener">10.7759/cureus.10026</a>
Telepresent mechanical ventilation training versus traditional instruction: a simulation-based pilot study
critical care; education; telepresence; simulation; Health Care Sciences & Services; telementoring; mechanical ventilation; society; critical-care medicine; DASH
Background Mechanical ventilation is a complex topic that requires an in-depth understanding of the cardiopulmonary system, its associated pathophysiology and comprehensive knowledge of equipment capabilities. Introduction The use of telepresent faculty to train providers in the use of mechanical ventilation using medical simulation as a teaching methodology is not well established. The aim of this study was to compare the efficacy of telepresent faculty versus traditional in-person instruction to teach mechanical ventilation to medical students. Materials and methods Medical students for this small cohort pilot study were instructed using either in-person instruction or telementoring. Initiation and management of mechanical ventilation were reviewed. Effectiveness was evaluated by pre- and post-multiple choice tests, confidence surveys and summative simulation scenarios. Students evaluated faculty debriefing using the Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV). Results A 3-day pilot curriculum demonstrated significant improvement in the confidence (in person P<0.001; telementoring P=0.001), knowledge (in person P<0.001; telementoring P=0.022) and performance (in person P<0.001; telementoring P<0.002) of medical students in their ability to manage a critically ill patient on mechanical ventilation. Participants favoured the in-person curriculum over telepresent education, however, resultant mean DASH-SV scores rated both approaches as consistently to extremely effective. Discussion While in-person learners demonstrated larger confidence and knowledge gains than telementored learners, improvement was seen in both cases. Learners rated both methods to be effective. Technological issues may have contributed to students providing a more favourable rating of the in-person curriculum. Conclusions Telementoring is a viable option to provide medical education to medical students on the fundamentals of ventilator management at institutions that may not have content experts readily available.
Ciullo A; Yee J; Frey J A; Gothard M D; Benner A; Hammond J; Ballas D; Ahmed R A
Bmj Simulation & Technology Enhanced Learning
2019
2019-01
Journal Article or Conference Abstract Publication
<a href="http://doi.org/10.1136/bmjstel-2017-000254" target="_blank" rel="noreferrer noopener">10.1136/bmjstel-2017-000254</a>
Beyond NIPPV: HVNI Expands Potential Treatment Options For Acute Decompensated Heart Failure
Acute decompensated heart failure; Critical care; Emergency medicine; High flow nasal cannula; Non-invasive positive-pressure ventilation
Haywood Steven T; Volakis Leonithas I; Whittle Jessica S
The American Journal of Emergency Medicine
2019
2019-05
<a href="http://doi.org/10.1016/j.ajem.2019.05.021" target="_blank" rel="noreferrer noopener">10.1016/j.ajem.2019.05.021</a>
Lean Six Sigma: Trimming the fat! Effectively managing precious resources*.
Female; Male; Intensive Care Units; Critical Care; Human; Outcome Assessment; Pediatric; Systems Analysis; Patient Rounds – Administration
Besunder JB; Super DM
Critical care medicine
2012
2012-02
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/ccm.0b013e3182372bd4" target="_blank" rel="noreferrer noopener">10.1097/ccm.0b013e3182372bd4</a>
Fluid Overload in Critically Ill Children.
acute kidney injury; critical care; fluid overload; intensive care; pediatric nephrology
Background: A common practice in the management of critically ill patients is fluid resuscitation. An excessive administration of fluids can lead to an imbalance in fluid homeostasis and cause fluid overload (FO). In pediatric critical care patients, FO can lead to a multitude of adverse effects and increased risk of morbidity. Objectives: To review the literature highlighting impact of FO on a multitude of outcomes in critically-ill children, causative vs. associative relationship of FO with critical illness and current pediatric fluid management guidelines. Data Sources: A literature search was conducted using PubMed/Medline and Embase databases from the earliest available date until June 2017. Data Extraction: Two authors independently reviewed the titles and abstracts of all articles which were assessed for inclusion. The manuscripts of studies deemed relevant to the objectives of this review were then retrieved and associated reference lists hand-searched. Data Synthesis: Articles were segregated into various categories namely pathophysiology and sequelae of fluid overload, assessment techniques, epidemiology and fluid management. Each author reviewed the selected articles in categories assigned to them. All authors participated in the final review process. Conclusions: Recent evidence has purported a relationship between mortality and FO, which can be validated by prospective RCTs (randomized controlled trials). The current literature demonstrates that "clinically significant" degree of FO could be below 10%. The lack of a standardized method to assess FB (fluid balance) and a universal definition of FO are issues that need to be addressed. To date, the impact of early goal directed therapy and utility of hemodynamic parameters in predicting fluid responsiveness remains underexplored in pediatric resuscitation.
Raina Rupesh; Sethi Sidharth Kumar; Wadhwani Nikita; Vemuganti Meghana; Krishnappa Vinod; Bansal Shyam B
Frontiers in pediatrics
2018
1905-07
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.3389/fped.2018.00306" target="_blank" rel="noreferrer noopener">10.3389/fped.2018.00306</a>
From the street to the ICU: a review of pediatric emergency medical services and critical care transport.
Critical care; emergency medical services (EMS); modern medicine; pediatrics
Emergency medical services and critical care transport teams are relatively new parts of the American healthcare delivery system. Although most healthcare providers regularly interact with these groups and rely upon their almost ubiquitous availability, few know how these services developed or what sort of infrastructure currently exists to maintain them. This article provides a focused overview of the history and present practices of both emergency medical services and critical care transport teams, with a concentrated look at the implementation of these services in the pediatric population. Within this context, we also consider current challenges and future opportunities for both groups and conclude with ways to become involved in the improvement of out-of-hospital pediatric critical care.
Lee Sang Hoon; Schwartz Hamilton P; Bigham Michael T
Translational pediatrics
2018
2018-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.21037/tp.2018.09.04" target="_blank" rel="noreferrer noopener">10.21037/tp.2018.09.04</a>
Admission to the Intensive Care Unit is Associated With Changes in the Oral Mycobiome.
*Intensive Care Units; 80 and over; Adult; Aged; Candida albicans; Candida Albicans; Candida albicans/*isolation & purification; Candidiasis; critical care; Critical Care; Cross Infection/microbiology/prevention & control/*transmission; Female; Human; Humans; Length of Stay; Male; Middle Aged; mycobiome; Mycobiome/*immunology; Mycological Typing Techniques; Mycoses; Oral Health; Oral/microbiology/prevention & control/*transmission; Prospective Studies; Risk Factors; United States/epidemiology; Young Adult
A prospective exploratory study was conducted to characterize the oral mycobiome at baseline and determine whether changes occur after admission to the intensive care unit (ICU). We found that ICU admission is associated with alterations in the oral mycobiome, including an overall increase in Candida albicans.
Watkins Richard R; Mukherjee Pranab K; Chandra Jyotsna; Retuerto Mauricio A; Guidry Chrissy; Haller Nairmeen A; Paranjape Charudutt; Ghannoum Mahmoud A
Journal of intensive care medicine
2017
2017-05
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/0885066615627757" target="_blank" rel="noreferrer noopener">10.1177/0885066615627757</a>
Critical Care Transport: How Perilous the Trip.
*Critical Care; Critical Care; Critical Care Family Needs Inventory; Humans
Bigham Michael T; Brilli Richard J
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
2016
2016-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/PCC.0000000000000927" target="_blank" rel="noreferrer noopener">10.1097/PCC.0000000000000927</a>
Awake aortic aneurysm repair in patients with severe pulmonary disease.
*Consciousness; Abdominal/*surgery; Administration; Aged; Albuterol/administration & dosage/therapeutic use; Anesthesia; Aortic Aneurysm; Blood Loss; Bronchodilator Agents/administration & dosage/therapeutic use; Critical Care; Epidural; Forced Expiratory Volume/physiology; General; Home Care Services; Hospitalization; Humans; Hypnotics and Sedatives/administration & dosage; Iliac Aneurysm/*surgery; Inhalation; Intravenous; Length of Stay; Lung Diseases/*complications/drug therapy/therapy; Oxygen Inhalation Therapy; Retroperitoneal Space; Retrospective Studies; Risk Factors; Safety; Steroids/administration & dosage/therapeutic use; Surgical; Theophylline/administration & dosage/therapeutic use; Time Factors; Vital Capacity/physiology
BACKGROUND: We report the use of retroperitoneal aortic aneurysm repair utilizing exclusive regional anesthesia (no intubation or inhalation anesthetic) in high pulmonary risk patients. METHODS: Six patients were retrospectively reviewed. Pulmonary disease was diagnosed by clinical history and pulmonary function tests. Patients received intravenous sedation and regional anesthesia. Retroperitoneal aortoiliac aneurysm repair was performed. RESULTS: All patients used inhaled steroids and albuterol. Three required theophylline and home oxygen. FEV1 = 23% +/- 5% predicted, FVC = 34% +/- 5% predicted, and PO2 = 62 +/- 2 mm Hg. Operative time was 247 +/- 25 minutes. Blood loss was 840 +/- 479 mL. Five of six patients (83%) tolerated awake aneurysm repair and had intensive care unit stays of 2.4 +/- 0.6 days, and postoperative hospital stays of 8.2 +/- 1.8 days. One patient was converted to general anesthesia and had a prolonged hospital stay. CONCLUSIONS: With thorough patient communication, awake retroperitoneal aortic aneurysm repair can be safely performed in select patients with severe pulmonary disease.
McGregor W E; Koler A J; Labat G C; Perni V; Hirko M K; Rubin J R
American journal of surgery
1999
1999-08
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/s0002-9610(99)00153-1" target="_blank" rel="noreferrer noopener">10.1016/s0002-9610(99)00153-1</a>
Hematologic counts as predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.
*Blood Cell Count; *Inflammation; *Intracranial vasospasm; *Subarachnoid hemorrhage; *Transcranial Doppler sonography; Anemia/blood/diagnosis; Brain Ischemia/blood/complications/*diagnosis/epidemiology; Cerebrovascular Circulation/physiology; Critical Care; Databases; Doppler; Factual; Female; Humans; Leukocytosis/blood/diagnosis; Logistic Models; Male; Middle Aged; Models; Odds Ratio; Ohio/epidemiology; Sensitivity and Specificity; Subarachnoid Hemorrhage/*complications/diagnostic imaging; Theoretical; Transcranial; Ultrasonography
PURPOSE: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality, but currently no single clinical method or ancillary test can reliably predict which subset of patients will develop delayed cerebral ischemia (DCI). The aim of this study was to find hematologic derangements and clinical factors present during the first 7 days after bleeding that could help identify patients at risk for development of DCI. MATERIALS AND METHODS: Databank analysis of patients with SAH admitted between 2010 and 2012 in a single center. Data from demographics, imaging, laboratory, and clinical factors were collected. Statistical testing was conducted to test for association to the outcome, and multivariate logistic regression was used to design a predictive model. RESULTS: Of 55 patients, 14 developed DCI (25%). Anemia and leukocytosis on the third day after bleeding were significantly correlated with the outcome (for anemia: P\textless.032; confidence interval, 1.12-15.16; odds ratio, 4.12; for leukocytosis: P\textless.046; confidence interval, 1.03-26.13; odds ratio, 5.18). Anemia and leukocytosis were still statistically significant after adjustment for age, sex, modified Fisher scale, and Hunt-Hess scale. CONCLUSION: The presence of leukocytosis and anemia during the third day after SAH was statistically correlated with the occurrence of DCI.
Da Silva Ivan Rocha Ferreira; Gomes Joao Antonio; Wachsman Ari; de Freitas Gabriel Rodriguez; Provencio Jose Javier
Journal of critical care
2017
2017-02
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.jcrc.2016.09.011" target="_blank" rel="noreferrer noopener">10.1016/j.jcrc.2016.09.011</a>