Journal of Pediatric Intensive Care - Volume 3, issue 1

Authors: Manoach, Seth

Article Type: Other

DOI: 10.3233/PIC-14085

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 1-7, 2014

Authors: Wheeler, Derek S. | Bigham, Michael T. | Lahni, Patrick M. | Giuliano Jr, John S. | Nelson, David P. | Manning, Peter B. | Wong, Hector R.

Article Type: Research Article

Abstract: The heat shock response, also frequently referred to as the stress response, is an ancient, highly conserved, endogenous cellular defense mechanism characterized by the rapid upregulation of a specific class of proteins known collectively as heat shock proteins, or stress proteins. The 70 kDa family of heat shock proteins are highly inducible and have been shown to possess important immunomodulatory effects in both the intracellular and extracellular compartments. In the current prospective translational study, we measured extracellular (i.e. plasma) levels of heat shock protein 72 (Hsp72) in 49 children undergoing cardiopulmonary bypass (CPB) for either palliation or repair of congenital …heart disease. There was a significant and transient increase (less than 24 h) in extracellular Hsp72 levels following CPB. Extracellular Hsp72 levels significantly correlated with levels of the pro-inflammatory cytokines interleukin (IL)-6 and IL-8, as well as the anti-inflammatory cytokine, IL-10. In addition, plasma Hsp72 levels correlated with troponin-I levels, a marker of myocardial injury. Increased extracellular Hsp72 levels at 6 h following CPB were independently associated with increased length of stay in the cardiac intensive care unit. Importantly, the source of extracellular Hsp72 does not appear to be cardiomyocytes. However, the mechanism of release and clinical relevance of the increase in extracellular Hsp72 need to be further delineated. Show more

Keywords: Heat shock proteins, danger signals, stress proteins, alarmins, cardiopulmonary bypass, congenital heart disease, extracellular Hsp72

DOI: 10.3233/PIC-14083

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 9-16, 2014

Authors: Hansen, Gregory | Kesselman, Murray S. | Koll, Jordan

Article Type: Research Article

Abstract: There is no consensus on how effective patient handover in the pediatric intensive care unit should occur. Complex patients with rapidly moving clinical trajectories are difficult to summarize and comprehend. We aimed to redesign our current handover instrument to encourage higher-level cognitive interactions, questioning and understanding for pediatric residents. Through an iterative process with five pediatric intensive care unit intensivists, the current hardcopy handover tool was reviewed and compared to other formats published in medical and non-medical domains. Several handover formats on the iPad were created and proposed, but continual feedback from intensive care unit physicians led to a selection, …and further revisions were made. A mock handover with completed data fields allowed pediatric residents to provide the final feedback in both a semi-structured group review and a survey with responses on a 1–5 Likert scale (1 = strongly disagree; 2 = disagree; 3 = neither agree or disagree; 4 = agree; 5 = strongly agree). A novel two-axis data grid combining the ‘systems’ and ‘problem list’ approach was developed, with read back prompts, and off the shelf applications such as “burn notices”. Residents found ease with the organizational format (4.0 ± 0.67 Likert scale response) and the transition to the iPad device (4.3 ± 0.67). Improving physician handovers may be achieved efficiently and economically through physician led iterative processes. Pediatric residents were at ease when the novel handover was combined with newer iPad technologies and applications. Show more

Keywords: Intensive care units, pediatric, patient handoff, computers, handheld

DOI: 10.3233/PIC-14081

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 17-22, 2014

Authors: Standage, Stephen W. | Lahni, Patrick M. | Ma, William | Kernie, Steven G. | Wong, Hector R. | Wheeler, Derek S.

Article Type: Research Article

Abstract: Extracellular heat shock protein 72 (Hsp72) is an endogenous danger signal and potential biomarker for critical illness in children. We hypothesized that elevated levels of extracellular Hsp72 in the cerebrospinal fluid (CSF) of children with suspected meningitis could predict bacterial meningitis. We measured extracellular Hsp72 levels in the CSF of 31 critically ill children with suspected meningitis via a commercially available enzyme-linked immunosorbent assay. Fourteen had bacterial meningitis based on CSF pleocytosis and bacterial growth in either blood or CSF culture. Seventeen children with negative cultures comprised the control group. CSF Hsp72 was significantly elevated in children with bacterial meningitis …compared to controls. Importantly, CSF Hsp72 levels did not correlate with the CSF white blood cell count. On receiver operator characteristic analysis, using a cut-off of 8.1 ng/mL, CSF Hsp72 has a sensitivity of 79% and a specificity of 94% for predicting bacterial meningitis. We therefore conclude that CSF extracellular Hsp72 levels are elevated in critically ill children with bacterial meningitis versus controls. Hsp72 potentially offers clinicians improved diagnostic information in distinguishing bacterial meningitis from other processes. Show more

Keywords: Heat shock proteins, danger signals, stress proteins, meningitis, infection, cerebrospinal fluid, biomarker, extracellular fluid

DOI: 10.3233/PIC-14080

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 23-28, 2014

Authors: Bafaqih, Hind | Almohaimeed, Suliman | Thabet, Farah | Alhejaili, Abdulrahman | Alarabi, Reda | Zolaly, Mohammed | Baqais, Khalid | Kasim, Khaled | Chehab, May

Article Type: Research Article

Abstract: The utility of daily routine chest X-rays (CXRs) in mechanically ventilated patients in intensive care units is still controversial. The present study compared the diagnostic, therapeutic and outcome efficacy between daily routine and non-routine (clinically indicated) CXRs in children patients in pediatric intensive care unit (PICU). A prospective randomized study conducted in tertiary center 18-bed PICU, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia. The study selected 52 children, who were mechanically intubated for at least 48 hr. The children were randomized to receive either routine (29 patients) or non-routine (23 patients) CXRs and were followed until extubation or death. …Demographic and outcome data were collected and analyzed as appropriate. Although children in the non-routine group received fewer CXRs, the lengths of stay (LOS) in intensive care unit and hospital and mortality rate were nearly the same compared with routine group. The percentage of CXRs with new findings was higher in the non-routine group (83%; 53 CXRs) compared to that in the routine group (69%; 156 CXRs) with an odds ratio (OR) of 2.10 (95% confidence interval [CI] = 0.60–8.11). Also, the percentage of CXRs with new findings that result in intervention was higher in non-routine group (78% vs. 69%; OR = 1.60; 95% CI = 0.50–5.70). The daily routine CXRs was not associated with a reduced effect on length of stay in PICU and hospital or mortality and it does not seem to add any advantages over non-routine CXRs in PICU. Large multicenter studies are needed to confirm these results. Show more

Keywords: Daily routine, chest X-ray, children, intensive care unit, mechanical ventilation

DOI: 10.3233/PIC-14082

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 29-34, 2014

Authors: Schloss, Brian | Naguib, Aymen | Bissonnette, Bruno | Winch, Peter | Rice, Julie | Galantowicz, Mark | Miao, Yongjie | Tobias, Joseph D.

Article Type: Research Article

Abstract: The aim of this study was to evaluate the response of pleth variability index (PVI) to phlebotomy in anesthetized children prior to surgery for congenital heart disease. After induction of general anesthesia and prior to surgical incision, approximately 10 mL/kg of blood was removed from 40 mechanically ventilated children over a 5–10 min period. The PVI was continuously monitored. Additionally, the volume of crystalloid required to ensure hemodynamic and near infrared spectroscopy stability was recorded. There was no difference between the pre-phlebotomy PVI (13% ± 6.2) and the post-phlebotomy PVI (16.4% ± 9.6) (P = 0.55). Patients who had a …starting PVI ≤14% had a significant increase in PVI after phlebotomy from 9.1% ± 3 to 14.3% ± 7.2 (P = 0.0014). Although, patients with a pre-phlebotomy PVI of >14% required more crystalloid replacement (11 ± 9.4 mL/kg) than those with a PVI ≤14% (5.3 ± 4.7 mL/kg), this was not significant (P = 0.06). In patients who received less crystalloid replacement during phlebotomy, PVI did show a significant increase. Additionally, the data suggests that patients with a pre-phlebotomy PVI >14% required greater fluid replacement than those with a PVI < 14%. Further research is needed to better delineate the utility of PVI in this unique group of patients. Show more

Keywords: Pleth variability index, fluid responsiveness, plethysmography

DOI: 10.3233/PIC-14084

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 35-40, 2014

Authors: Edwards-Richards, Alcia | Defreitas, Marissa | Katsoufis, Chryso | Jeyapalan, Asumthia | Nares, Michael | Abitbol, Carolyn L.

Article Type: Research Article

Abstract: Familial hemophagocytic lymphohistiocytosis is a rare, life-threatening disorder characterized by impaired cytotoxicity, hypercytokinemia and immune-mediated organ injury. We report a 7-week-old male of consanguineous parents who presented with fever, pancytopenia and multi-organ failure. Elevated inflammatory markers and hypercytokinemia led to the diagnosis of familial hemophagocytic lymphohistiocytosis, which was confirmed with genetic testing. With the fulminant multiorgan failure, therapeutic plasma exchange was instituted, using the Prismaflex® platform, followed by standard chemo-immunotherapy. There was dramatic reversal of the multi-organ failure and stabilization of the coagulopathy with this neo-adjuvant therapy. Thereafter, he was maintained in clinical remission with chemo-immunotherapy for 3 mo …while awaiting stem cell transplantation. Show more

Keywords: Therapeutic plasma exchange, hemophagocytic lymphohistiocytosis, multi-organ failure, continuous renal replacement therapy

DOI: 10.3233/PIC-14079

Citation: Journal of Pediatric Intensive Care, vol. 3, no. 1, pp. 41-44, 2014