COMBINED NONINVASIVE VENTILATION AND MECHANICAL IN-EXSUFFLATOR IN THE TREATMENT OF PEDIATRIC ACUTE NEUROMUSCULAR RESPIRATORY FAILURE
Chen T, Hsu J, Wu J, Dai Z, Chen C, Liang W, Yang S, Jong Y. Pediatr Pulmonol. 2014;49:589-596.
In this prospective study, the researchers aimed to evaluate the efficacy and complications of combined noninvasive ventilation (NIV) and assisted coughing by mechanical in-exsufflator (MIE) in children who have neuromuscular disease with acute respiratory failure (ARF) in the pediatric intensive care unit (n = 15). The authors defined treatment success as freedom from tracheal intubation during the hospital stay. Physiologic indices were recorded before and at 12 and 24 hours after the use of the NIV/MIE. Indices included Pao2, Paco2, pH, and Pao2/Fio2.
Combined NIV/MIE was used in '15 patients with 16 cases of ARF. Treatment success was achieved in 12 cases including 6 cases that demanded "do not intubate." Acute respiratory failure was related to a diagnosis of pneumonia. In the success group, hypercapia and acidosis improved after use of NIV/MIE after 24 hours. There was no mortality reported in this cohort. Patients were reported to tolerate the NIV/MIE well, with transient skin pressures sores in 5 cases. The researchers concluded that combined NIV/MIE is a safe and effective approach to rapidly improve physiologic indices and decrease the need for intubation in neuromuscular disease patients with ARF and as an alternative for those refusing intubation.
PEDIATRIC LIVER LACERATIONS AND INTENSIVE CARE: EVALUATION OF ICU TRIAGE STRATEGIES
Fremgen HE, Bratton SL, Metzger RR, Barnhard DC. Pediatr Crit Care Med. 2014;15(4):e183-e191.
On this retrospective cohort study, the authors sought to compare pediatric intensive care unit (PICU) admissions criteria following blunt traumatic liver laceration based on computed tomography grade and/or physiologic instability with actual practice to improve efficiency of PICU admission. Patient with a grade 3 to 6 liver laceration (n=171) aged 1 month to 17 years were included in the study.
The authors collected preadmission signs of physiologic instability, liver computed tomography grading, and outcomes including length of stay and packed red blood cell (PRBC) transfusion after admission to the PICU admission. Two patients died before PICU admission, and 5 died after PICU admission. Of 169 patients, 52 (31%) were initially admitted to the inpatient ward, 5% received surgical care, 20% received PRBCs emergently for shock, and 5% received their first PRBC transfusion after admission. Among PICU patients, transfusion for hemorrhagic shock was significantly associated with more severe injury score. Sixty percent of the PICU patients were not transfused.
The authors conclude that children with isolated abdominal injury and no physiologic instability can generally be treated without PICU admission. Adding grade more than or equal to 4 to usual PICU admission criteria resulted in excessive admission of stable patients.