Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Best Evidence
Year : 2019 | Volume : 6 | Issue : 3 | Page : 76 - 80

Journal Scan

Vinayak Patki1

1Chief consultant, Advanced Pediatric Critical Care Centre, Wanless Hospital, Miraj, Maharashtra, India

Correspondence Address:

Dr. Vinayak Patki,
MB, DNB, FCCP, FIAP,FICCM,FCCM. Chief consultant, Advanced Pediatric Critical Care Centre and Head, Dept of Pediatrics, Wanless Hospital, Miraj, 416101, Maharashtra, India.
Mob.: +919822119314, Email : patkivinayak@gmail.com
Received:15-May-19/ Accepted:27-May-19/Published Online:05-Jun-19

Source of Funding:None Conflict of Interest:None

DOI:10.21304/2019.0603.00510


1. 23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children: A 10-Year Retrospective Analysis.
Wu AG, Samadani U, Slusher TM, Zhang L, Kiragu AW.Pediatr Crit Care Med. 2019 May;20(5):466-473. doi: 10.1097/ PCC.0000000000001867.
Objective :
To explore the effect of 23.4% hypertonic saline for management of elevated intracranial pressure in children admitted to our institution for severe traumatic brain injury.

Design :
Single-center, retrospective medical chart analysis.

Setting :
A PICU at a level 1 pediatric trauma center in the United States.

Patients :
Children admitted for severe traumatic brain injury from 2006 to 2016 who received 23.4% hypertonic saline and whose intracranial pressures were measured within 5 hours of receiving 23.4% hypertonic saline.

Interventions: None.

Measurements and Main Results:
Over the 10-year period, 1,587 children were admitted for traumatic brain injury, 155 of whom were deemed severe per this study’s criteria. Forty of these children received at least one dose of hypertonic saline, but 14 were excluded for insuffi cient intracranial pressure data. Among the remaining 26 children, one hundred one 23.4% hypertonic saline boluses were used in the analysis. Use of 23.4% hypertonic saline was associated with a decrease in intracranial pressure of approximately 7 mm Hg, both within 1 hour after the bolus (p < 0.01) and 4 hours after the bolus (p < 0.01) when compared with the intracranial pressure measured within 1 hour before the hypertonic saline bolus. These effects remained signifi cant after adjusting for Functional Status Scale score and CT Marshall scores. There was no statistically signifi cant association between adjunctive therapies, such as antiepileptics and analgesics, and changes in intracranial pressure. There was no laboratory evidence of hyperkalemia or renal injury after use of 23.4% hypertonic saline. Across all hospitalizations, 65% of the study population demonstrated an abnormally elevated creatinine at least once, but only three episodes of acute kidney injury occurred in total, all before hypertonic saline administration. Eight of the 26 children in this analysis died during their hospitalization. The Functional Status Scale scores ranged from 6 to 26 with a mean of 12.2 and SD of 5.7.

Conclusions:
Use of 23.4% hypertonic saline with children admitted for severe traumatic brain injury is associated with a statistically signifi cant decrease in intracranial pressure within 1 hour of use.

R eviewer’s Comments:
This study’s results suggest that administration of 23.4% HTSin children hospitalized for severe TBI is associated with a signifi cant decrease in ICP within 1 hour. The importance of considering 23.4% HTS use in TBI lies in its smaller volume requirement compared with other hyperosmolar agents.Indeed, usually the volume of a dose of 3% HTS is up to 150 mL compared with a maximum volume of 30 mL for a dose of 23.4% HTS. In this study, no clear pattern was observed between the net fl uid balance and the number of 23.4% HTS boluses received. Concerns have been raised about adverse effects due to hyperosmolar agents including coagulopathies, AKI, hypernatremia, and abnormal serum potassium levels. But 23.4% HTS, have demonstrated safety in their use. But because risk of AKI in children, this population should be monitored very closely when using this intervention. There are a few key limitations to our study. First, retrospective design of this study, Second, study population was small and limited for analytical exploration. More number of multicentred, prospective randomised trails are needed on use of 23.4% HTS in severe TBI patients.

2. Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study.
da Silva PSL, de Aguiar VE, Fonseca MCM.Pediatr Crit Care Med. 2019 Apr 20(4):365-371. doi: 10.1097/ PCC.0000000000001817

Objectives:
Tracheal suctioning is a routine procedure in mechanically ventilated children. However, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning.

Design:
Prospective randomized controlled crossover study.

Setting:
PICU of a tertiary hospital.

Patients:
Eleven patients with severe head trauma (Glasgow Coma Scale score 4-8).

Interventions:
Lidocaine (1.5 mg/kg) or saline solution was endotracheally instilled before a standardized tracheal suctioning maneuver. Each patient received both treatments in a crossover design. Cerebral hemodynamic and systemic and ventilatory effects were assessed at four time points: in baseline (T0), within 2 minutes (T1), 5 minutes (T2), and 15 minutes after tracheal instillation (T3). The 2-minute time interval around tracheal suctioning was used to assess each treatment effi cacy

Measurements and Main Results:
The time course of intracranial pressure was different throughout the study in both treatment groups, with a signifi cant increase of intracranial pressure from 14.82 ± 3.48 to 23.27 ± 9.06 with lidocaine (p = 0.003) and from 14.73 ± 2.41 to 30.45 ± 13.14 with saline (p = 0.02). The mean variation in intracranial pressure immediately after tracheal suctioning was smaller with lidocaine instillation than saline (8.45 vs 15.72 mm Hg; p = 0.006). Patients treated with lidocaine returned to baseline intracranial pressure value at 5 minutes after tracheal suctioning whereas those receiving saline solution returned to baseline intracranial pressure value at 15 minutes. Although, patients treated with lidocaine had no signifi cant hemodynamic changes, patients receiving saline solution experienced a higher mean value of mean arterial pressure (99.36 vs 81.73 mm Hg; p = 0.004) at T1.

Conclusions:
This preliminary study showed that tracheal lidocaine instillation can attenuate increase in intracranial pressure induced by tracheal suctioning and favor a faster return to the intracranial pressure baseline levels without signifi cant hemodynamic and ventilatory changes.

Reviewer’s Comme nts:
Prevention of cerebral ischemia and treatment of acute intracranial hypertension are the primary goals in patients with traumatic brain injury.Tracheal suctioning(TS) is an essential procedure in intubated patients to reduce morbidity associated with invasive ventilation. In the present study, they found that TS was associated witha transient increase in ICP, but when patients received lidocaine compared with when they received the saline solution they experienced a smaller increase in their ICP. Although lidocaine instillation was notable to prevent ICP increase after TS, its use had a signifi cant impact, blunting the increase in ICP as compared with saline solution. Authors also found that this signifi cant effect of lidocaine on ICP increase caused by TS was persistent over time.This study has some limitations. First, they did not measurethe plasma concentration of lidocaine after its tracheal instillation. Second, they used a single administration of tracheal lidocaine and the sample size was relatively small because of very strict application of inclusion criteria.Even though neither, lidocaine nor saline solution prevented ICP increase after TS, the use of tracheal lidocaine can minimize ICP changes due toTS procedure. Further studies in children are required to confi rm these results.

3. Mortality of Critically Ill Children Requiring Continuous Renal Replacement Therapy: Effect of Fluid Overload, Underlying Disease, and Timing of Initiation.
Cortina G, McRae R, Hoq M, Donath S, Chiletti R, Arvandi M, Gothe RM, Joannidis M, Butt W.Pediatr Crit Care Med. 2019 Apr;20(4):314-322. doi: 10.1097/ PCC.0000000000001806.

Objective:
To identify risk factors associated with mortality in critically ill children requiring continuous renal replacement therapy.

Design:
Retrospective observational study based on a prospective registry.

Setting:
Tertiary and quaternary referral 30-bed PICU.

Patients:
Critically ill children undergoing continuous renal replacement therapy were included in the study.

Interventions:
Continuous renal replacement therapy.

Measurements and Main Results:
Overall mortality was 36% (n = 58) among the 161 patients treated with continuous renal replacement therapy during the study period and was signifi cantly higher in patients on extracorporeal membrane oxygenation (47.5%, 28 of 59) than in patients not requiring extracorporeal membrane oxygenation (28.4%, 29 of 102; p = 0.022). According to the admission diagnosis, we found the highest mortality in patients with onco-hematologic disease (77.8%) and the lowest in patients with renal disease (5.6%). Based on multivariate logistic regression analysis, the presence of higher severity of illness score at admission (adjusted odds ratio, 1.49; 95% CI, 1.18-1.89; p < 0.001), onco-hematologic disease (odds ratio, 17.10; 95% CI, 4.10-72.17; p < 0.001), fl uid overload 10%-20% (odds ratio, 3.83; 95% CI, 1.33-11.07; p = 0.013), greater than 20% (odds ratio, 15.03; 95% CI, 4.03-56.05; p < 0.001), and timing of initiation of continuous renal replacement therapy (odds ratio, 1.01; 95% CI, 1.00-1.01; p = 0.040) were independently associated with mortality. In our population, the odds of dying increases by 1% for every hour of delay in continuous renal replacement therapy initiation from ICU admission.

Conclusions:
Mortality in children requiring continuous renal replacement therapy remains high and seems to be related to the underlying disease, the severity of illness, and the degree of fl uid overload. In critically ill children at high risk for developing acute kidney injury and fl uid overload, earlier initiation of continuous renal replacement therapy might result in decreased mortality.

Reviewer’s Comments:
Continuous renal replacement therapy (CRRT) is used in the management of critically ill children with acute kidney injury (AKI), fl uid overload (FO), and multipleorgan dysfunction syndrome (MODS), although in the last decade has become safer due to technological advances, the mortality of children requiring CRRT remains high. Highlight of this study is, it provides a representative cross-section of alarge and heterogeneous pediatric ICU population receiving CRRT including patients on ECMO. Overall mortality of 36% are among the lowest published studies. Authors founda signifi cant association between %FO and outcome. Patients with greater than 20% FO had a higher mortalityrate than did those with FO less than 10%. The timeliness of CRRT initiation is still controversial in the literature. The American College of Critical Care Medicine practice guidelines for pediatric and neonatal septic shock proposes (after initial fl uid resuscitation) a threshold of 10% FO for starting diuretics or CRRT in patients unable to maintain anegative or even fl uid balance. Authors found that the use of diuretics was associated with increased mortality and diureticuse seemed to delay initiation of CRRT. The use of CRRT in patients on ECMO has not been found to impact mortality and was not independently associated withmortality in this study. Limitations of study includes, it is a single-centre retrospective analysis, the study population is heterogeneous with smaller sub-populations, makes it diffi cult to draw general conclusions from the associations and the method of calculating FO, which uses only the fl uid from ICU admission to the start of CRRT. Prospective multi centre trials for further evaluation of the effect of timing of initiation of CRRT on outcome in the PICU population is needed.

4. Parental Perceptions of Displayed Patient Data in a PICU: An Example of Unintentional Empowerment.
Asan O, Scanlon MC, Crotty B, Holden RJ, Flynn KE.Pediatr Crit Care Med. 2019 May;20(5):435-441. doi: 10.1097/PCC.0000000000001895.

Objectives:
To explore the perceptions of parents of pediatric patients in a PICU regarding real-time open electronic health record data displayed in patient rooms.
Design:
Cross-sectional qualitative interview study. Setting: PICU in a large Midwestern tertiary-care children’s hospital.

Subjects:
Parents of patients in a PICU (n = 33).

Measurements and Main Results:
Qualitative data were collected through in-person semi-structured, individual, and small-group interviews. Data were collected from March 2016 to July 2016, with approval from the study hospital’s institutional review board. Data were analyzed using inductive thematic analysis. Results included positive effects of accessing real-time open electronic health record data on family empowerment, situation awareness, potential error detection, understanding of medical data, and facilitating discussions during rounds. Concerns were reported regarding privacy of information as well as potential misinterpretation of displayed data. We identifi ed several ways to improve this collaborative technology to make it more family-centered.

Conclusions:
This study suggests that a new health information technology system providing continuous access to open electronic health record data may be an effective way to empower and engage parents in the PICU, but potential drawbacks were also noted. The results also provide insights into the collaborative use of health information technology in the PICU setting.

Reviewer’s Comme nts:
Health information technology (IT) can enable patients and families to be more involved in the care process, facilitating care that is more coordinated and patient and family-centered. This may be the fi rst study to explore the perception of families on a parent-facing technology that provides real-time EHR data in PICU. Their fi ndings reveal that show allowing continuous access to parents might contribute to increased family empowerment and family-centered care. The large customizable interactive monitor (LCIM) is a fl at-panel touchscreen monitor that displays data from the patient’s real-time open electronic health record HER used in this study, providing data to patients, families, and professional staff. In addition to enabling transparency, LCIM can engagepatients by serving as a conversational aid. LCIM helped parents “pre-round” or prepare questions for rounds, as well asserving as a common platform for conversations with clinical staff. But the lack of orientation for both providers and parents can signifi cantly affect the use of such technologies and there is possibility of misinterpretation of displayed information. To address issues related to information interpretation, tools could be built with the technology to assist parents with understanding the data and using the local language of the parents. Further large scale studies on these kind of innovative technologies are required to implement their routine use in PICUs.

5. The Association of Hospital Rate of Delayed Epinephrine Administration With Survival to Discharge for Pediatric Nonshockable In-Hospital Cardiac Arrest.
Raymond TT, Praestgaard A, Berg RA, Nadkarni VM, Parshuram CS; American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Pediatr Crit Care Med. 2019 May;20(5):405-416. doi: 10.1097/PCC.0000000000001863

Objectives:
To evaluate the variation of hospital rates of delayed epinephrine administration in pediatric patients with nonshockable in-hospital cardiac arrest, and the association of those rates with event, 24-hour, and overall survival to hospital discharge.

Design:
A retrospective evaluation was performed. Delayed epinephrine was defi ned as greater than 5 minutes between the time the need for chest compressions was identifi ed and epinephrine was administered. The main outcome was the association of hospital rate of delayed epinephrine administration with survival to hospital discharge. Secondary outcomes were event and 24-hour survival. Evaluation used hierarchical logistic regression and included 13 patient/event-level and seven hospital-level factors.

Setting:
Hospitals with greater than 6 months data in the American Heart Association’s Get With the Guidelines-Resuscitation registry (2000-2016) and greater than or equal to fi ve total pediatric cardiac arrests with nonshockable rhythm.

Patients:
Children less than 18 years old with index nonshockable in-hospital cardiac arrest treated with greater than or equal to one epinephrine dose.

Interventions:None.

Measurements and Main Results:
One-thousand four-hundred sixty-two patients at 69 hospitals were included: 218 patients (14.9%) had epinephrine delay rates ranging from 0% to 80% of events (median, 15.6%; interquartile range, 7-25%). The median and interquartile range of hospital level delay was 16% (7-25%). Patient/event-level predictors of delayed epinephrine were asystole (odds ratio, 1.54 [95% CI, 1.10-2.16]) and insertion of an endotracheal tube (odds ratio, 1.86 [95% CI, 1.27-2.73]). Hospital size less than 200 compared with greater than or equal to 500 beds (odds ratio, 3.07 [95% CI, 1.22-7.73]) and ICU location (odds ratio, 0.51 [95% CI, 0.36-0.74]) were associated with epinephrine delay rates. After adjustment, increasing quartiles of epinephrine delay were associated with lower patient and hospital-level return of spontaneous circulation (p = 0.019, p = 0.006) and 24-hour survival (p = 0.018, p = 0.002) respectively, but not survival to discharge (p = 0.20, p = 0.24).

Conclusions:
Delayed epinephrine administration following pediatric nonshockable in-hospital cardiac arrest varies signifi cantly between hospitals. Hospitals with higher rates of delayed epinephrine administration had worse patient and hospitallevel outcomes after adjusting for multiple patientand hospital-level factors. Delayed epinephrine administration may directly contribute to increased mortality risk and/or may be a marker of unmeasured elements of hospital resuscitation performance.

Reviewer’s Comments:
An initial rhythm of pulseless electrical activityor asystole (i.e., nonshockable rhythm) is most common and is associated with signifi cant mortality. The most recent 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care by the “International Liaison stated that it is reasonable to consider administering a 0.01 mg/ kg dose of IV/intraosseous epinephrine every 3–5 minutes during pediatric cardiac arrest. In this large, multicenter registry of pediatric Intra Hospital Cardiac Arress, authors found that there was large variation in the timely administration of epinephrine for patients with an initial nonshockable rhythm of pulseless electric activity or asystole, with overall hospital rates of delayed epinephrine ranging from 0% to 80%. Differences across hospitals explained a substantial degree of the variation in rates of delayed epinephrine administration, but few facility characteristics were found to explain this variation. Asystole and insertion of an endotracheal tube were the only patient/event-level predictors of delayed epinephrine administration. Limitations of this study,First, the data are observational, and the possibility of unmeasured confounding factors. Second, they excluded a small number of patients based on missing values for covariates, time to epinephrine or the outcomes which could have affected interpretation, and third though the model was adjusted for several patients, they did not have information on hospital factors such as staffi ng ratios, presence of around-the-clock intensivists in critical care units, and use of mock codes etc.