Upper gastrointestinal bleeding in the pediatric intensive care unit: clinically important but questionably preventable.
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Comment↗
Biomedical subjects
A G Randolph
Publications and source records attributed to A G Randolph.
Ribavirin for respiratory syncytial virus infection of the lower respiratory tract.
OBJECTIVES: Respiratory syncytial virus (RSV) is a common cause of pneumonia in infants. Ribavirin is the only antiviral therapy available against RSV. The objective of this review was to assess the effects of aerosolized ribavirin for infants with RSV lower respiratory tract infection. SEARCH STRATEGY: We searched MEDLINE from 1975 to 1999, we scanned reference lists of articles, and we contacted experts in the field. SELECTION CRITERIA: Randomized trials comparing ribavirin with placebo in infants and children with RSV infection and lower respiratory tract infection. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed trial quality. Unpublished data were requested from authors when necessary. MAIN RESULTS: Ten trials were included. All trials enrolled infants below the age of six months. In four trials with 158 patients, mortality with ribavirin was 5.8% compared with 9.7% with placebo (odds ratio 0.58, 95% confidence interval 0.18 to 1.85). In three trials with 116 patients the probability of respiratory deterioration with ribavirin was 7.1% compared with 18.3% with placebo (odds ratio 0.37, 95% confidence interval 0.12 to 1.18). In three studies with 104 patients the weighted mean difference in days of hospitalization was 1.9 fewer days with ribavirin (95% confidence interval +0.9 to -4.6) and the difference in days of ventilation was 1.2 fewer days with ribavirin (95% confidence interval -0.2 to -3.4). REVIEWER'S CONCLUSIONS: Trials of ribavirin for RSV lack sufficient power to provide reliable estimates of the effects. The cumulative results of three small trials show that ribavirin reduces length of mechanical ventilator support and may reduce days of hospitalization. A large randomized controlled trial of ribavirin for ventilated and other high-risk patients is indicated.
Antiviral Agents↗
Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults.
BACKGROUND: Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Corticosteroids, however, may be associated with adverse effects ranging from hypertension to hyperglycemia, and a more systematic assessment of the efficacy of this therapy is indicated prior to widespread adoption of this practice OBJECTIVES: To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults. SEARCH STRATEGY: Controlled trials were identified through MEDLINE, EMBASE and CINAHL. Bibliographies of all identified trials were examined, and authors of included trials were contacted to confirm the methodology and identify other potentially relevant trials. SELECTION CRITERIA: Any randomized controlled trial that compared administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit. DATA COLLECTION AND ANALYSIS: Data from the included studies were extracted independently by two reviewers. The main outcome was the rate of tracheal re-intubation after extubation. The incidence of stridor was examined as a secondary outcome. Subgroup analysis was predetermined to compare preventative use of steroids before extubation and therapeutic use following extubation. Neonates, pediatric patients, and adults were compared separately. A random effects model was used throughout. Methodologic quality of trials was assessed independently by the two reviewers. MAIN RESULTS: Of 251 studies identified, only seven met the criteria for inclusion; three in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post-extubation stridor; the remaining one concerned treatment of existing post-extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). Prophylactic intervention tended to decrease re-intubation rates among neonates and children, but did not reach statistical significance (neonates RR=0.1, 95% CI 0.01, 1.68; children RR=0.49, 95% CI 0.01, 19.65). Post-extubation stridor was reduced in children (n=216: RR=0.53, 95% CI 0.28, 0.97) but not in neonates. In the neonatal studies, a lower re-intubation rate was seen only in high risk patients treated with multiple doses of steroids around the time of extubation. In three adult studies (total n=1047), no difference in post-extubation stridor (RR=0.86, 95% CI 0.57, 1.30) or re-intubation rates (RR=0.95, 95% CI 0.52, 1.72) was detected. Side effects were reported seldomly and could not be aggregated. REVIEWER'S CONCLUSIONS: In neonates, there is a trend towards a reduced incidence of re-intubation in neonates receiving prophylactic dexamethasone prior to extubation. In children, prophylactic administration of dexamethasone prior to elective extubation reduces the incidence of post-extubation stridor, but the evidence is insufficient to conclude that rates of re-intubation are reduced. In adults, corticosteroids do not appear to reduce the need for re-intubation.
Adrenal Cortex Hormones↗
Users' Guides to the Medical Literature: XVIII. How to use an article evaluating the clinical impact of a computer-based clinical decision support system.
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Decision Making, Computer-Assisted↗
Reorganizing the delivery of intensive care may improve patient outcomes.
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Hospital Mortality↗
Variability in physician opinion on limiting pediatric life support.
OBJECTIVE: We conducted this study to investigate how physicians in a pediatric intensive care unit (ICU) currently make decisions to withdraw and withhold life support. Consultation with the patient's primary caregiver often precedes decisions about withdrawal and limitation of life support in chronically ill patients. In these scenarios, the patient's primary caregiver was the pediatric oncologist. To evaluate the influence of subspecialty training, we compared the attitudes of the pediatric intensivists and the oncologists using scenarios describing critically ill oncology patients. DESIGN: Cross-sectional survey. Each physician was randomly assigned 4 of 8 potential case scenarios. SETTING: A total of 29 American pediatric ICUs. PARTICIPANTS: Pediatric intensive care and oncology attendings and fellows. INTERVENTION: Systematic manipulation of patient characteristics in two hypothetical case scenarios describing 6-year-old female oncology patients presenting to the ICU after the institution of mechanical ventilator support for acute respiratory failure. Cases 1 through 4 described a patient who, before admission, had a 99% projected 1-year probability of survival from her underlying cancer and suffered from severe neurologic disabilities. Cases 5 through 8 described a patient who was neurologically normal before admission and had a <1% chance of surviving longer than 1 year because of her underlying cancer. Each physician was randomly assigned 2 cases from cases 1 through 4 and 2 cases from cases 5 through 8. Within each of these case scenarios, parental preferences (withdraw or advance support or look for guidance from the caregivers) and probability of survival (5% vs 40%) were manipulated. Before distribution, the survey instrument was pilot-tested and underwent a rigorous assessment for clinical sensibility. PRIMARY OUTCOME MEASURES: Physicians ratings of the importance of 10 factors considered in the decision to withdraw life support, and their decisions about the appropriate level of care to provide. Respondents were offered five management options representing five levels of care: 1) discontinue inotropes and mechanical ventilation but continue comfort measures; 2) discontinue inotropes and other maintenance therapy but continue mechanical ventilation and comfort measures; 3) continue with current management but add no new therapeutic intervention; 4) continue with current management, add additional inotropes, change antibiotics and the like as needed, but do not start dialysis; and 5) continue with full aggressive management and plan for dialysis if necessary. Respondents also were asked whether they would obtain an ethics consultation. RESULTS: A total of 270 physicians responded to our survey (165 of 198 potentially eligible pediatric intensivists and 105 of 178 pediatric oncologists for response rates of 83% and 59%, respectively). The respondents considered the probability of ICU survival and the wishes of the parents regarding the aggressiveness of care most important in the decision to limit life-support interventions. No clinically important differences were found when the responses of oncologists were compared with those of intensivists. In six of eight possible scenarios, the same level of intensity of care was chosen by less than half of all respondents. In three scenarios, >/=10% of respondents chose full aggressive management as the most appropriate level of care, whereas another >/=10% chose comfort measures only when viewing the same scenario. The most significant respondent factors affecting choices were professional status (attending vs fellow) and the self-rated importance of functional neurologic status. The majority of respondents (83%) believed that the intensive care and the oncology staff were usually in agreement at their institution about the level of intervention to recommend to the parents. (ABSTRACT TRUNCATED)
Child↗
Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials.
OBJECTIVE: To evaluate the effect of heparin on duration of catheter patency and on prevention of complications associated with use of peripheral venous and arterial catheters. DESIGN: Critical appraisal and meta-analysis of 26 randomised controlled trials that evaluated infusion of heparin intermittently or continuously. Thirteen trials of peripheral venous catheters and two of peripheral arterial catheters met criteria for inclusion. MAIN OUTCOME MEASURES: Data on the populations, interventions, outcomes, and methodological quality. RESULTS: For peripheral venous catheters locked between use flushing with 10 U/ml of heparin instead of normal saline did not reduce the incidence of catheter clotting and phlebitis or improve catheter patency. When heparin was given as a continuous infusion at 1 U/ml the risk of phlebitis decreased (relative risk 0.55; 95% confidence interval 0.39 to 0.77), the duration of patency increased, and infusion failure was reduced (0.88; 0.72 to 1.07). Heparin significantly prolonged duration of patency of radial artery catheters and decreased the risk of clot formation (0.51; 0.42 to 0.61). CONCLUSIONS: Use of intermittent heparin flushes at doses of 10 U/ml in peripheral venous catheters locked between use had no benefit over normal saline flush. Infusion of low dose heparin through a peripheral arterial catheter prolonged the duration of patency but further study is needed to establish its benefit for peripheral venous catheters.
Adolescent↗
Evaluation of compliance with a computerized protocol: weaning from mechanical ventilator support using pressure support.
STUDY OBJECTIVES: To use a computerized consultation system to evaluate the feasibility of a mechanical ventilator weaning protocol which used the rapid shallow breathing index to guide adjustments in pressure support. A program to monitor user compliance and reasons for noncompliance was built into the computerized consultation system. METHODS: A total of nine critically ill patients (ten weaning episodes) were enrolled in the protocol. The respiratory therapists performed routine computer charting in the electronic database. They accepted or declined the explicit instructions generated by the computerized protocol and displayed on the bedside terminal. The consultation program monitored whether accepted instructions were implemented by the user. RESULTS: Patient's therapy was controlled by protocol for a total of 1075 h (mean 108 h, range 4 to 339 h) and 94.8% (1321/1394) of instructions were followed by the clinical staff. Of the 42 instructions clinical staff refused to follow, 23 (55%) were extubation instructions. There were 52 (3.7%) incorrect instructions generated with 24 software errors, 21 errors in underlying logic, and seven user misunderstanding errors. CONCLUSIONS: A high level of user compliance with this protocol was achieved. The methods described herein to monitor compliance and reasons for noncompliance within a protocol are reusable in the domain of mechanical ventilation and possibly in other domains.
Evaluation Studies as Topic↗
An evidence-based approach to central venous catheter management to prevent catheter-related infection in critically ill patients.
A systematic search of the literature yielded 102 randomized controlled trials of interventions aimed at reducing central venous catheter-related infections in critically ill patients. The process of critically appraising these trials has begun and clinicians have performed meta-analyses of the data in some areas. There are three main components to the production of evidence-based guidelines in this area: identification of effective interventions, comparison of the relative merit of effective interventions aimed at the source of infection, and assessment of the applicability of the evidence to diverse sub-populations of critically ill patients.
Anticoagulants↗
Prognosis in the intensive care unit: finding accurate and useful estimates for counseling patients.
OBJECTIVES: Counseling critically ill patients and their families about what the future is likely to hold requires accurate prognostic information. Our goal is to teach clinicians how to find and critically appraise prognostic studies that examine homogeneous populations. CLINICAL EXAMPLE: An article describing the outcomes of a group of children who are in a prolonged, persistent vegetative state. RECOMMENDATIONS: The validity of prognostic studies is increased when: a) the sample of patients is representative; b) patients are homogeneous with respect to prognostic risk; c) follow-up is sufficient to minimize the possibility that the missing patients could alter the interpretation of the results; and d) health outcomes are evaluated, using objective and unbiased criteria. The likelihood of these outcomes over time and the precision around these probability estimates should be easily understandable. Before using the results of these studies to counsel patients and families, practitioners should ensure that the patients in the study and their management are similar to the patient in question, and that follow-up of the subjects is sufficiently long. CONCLUSIONS: The criteria outlined in this article may assist clinicians in interpreting articles describing the prognosis of patients with similar clinical conditions.
Adolescent↗
Understanding articles comparing outcomes among intensive care units to rate quality of care. Evidence Based Medicine in Critical Care Group.
OBJECTIVES: Comparisons of risk-adjusted outcomes among intensive care units (ICUs) is a relatively new but rapidly expanding area of ICU health services research. By investigating those factors that lead ICUs to have patient outcomes that differ from the average, the overall quality of care across ICUs may be improved. Our goal is to teach clinicians how to evaluate these types of articles. CLINICAL EXAMPLE: An article describing the development and application of an index used to assess the clinical performance and cost-effectiveness of 25 ICUs. RECOMMENDATIONS: Valid comparisons of the outcomes among ICUs are made when: a) the outcome measures are accurate and comprehensive; b) the ICUs being compared serve similar patients; c) the sampling of patients is sufficient and unbiased; d) appropriate risk adjustment is undertaken by applying a valid model to reliably collected data; and e) the comparisons focus on care delivered in the ICU. To evaluate the results of the study, clinicians must evaluate how confident they are that the outcome differences being described are clinically important. Before changes in ICU policy are made based on these outcome differences, it is important to clarify which factors might have resulted in these extreme outcomes and whether these results are applicable in the ICU population that will see the impact of the changes. CONCLUSION: The potential for misinterpretation of outcome performance ratings may decrease if articles describing outcome differences are evaluated, using the criteria outlined in this article.
Evidence-Based Medicine↗
Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials.
OBJECTIVE: To evaluate the efficacy of tunneling short-term central venous catheters to prevent catheter-related infections. DATA SOURCES: MEDLINE, EMBASE, conference proceedings, citation review of relevant primary and review articles, personal files, and contact with expert informants. STUDY SELECTION: From a pool of 225 randomized, controlled trials of venous and arterial catheter management, we identified 12 relevant trials and included seven of these trials in the analysis. DATA EXTRACTION: In duplicate, independently, we abstracted data on the population, intervention, outcomes, and methodologic quality. DATA SYNTHESIS: Tunneling decreased bacterial colonization of the catheter by 39% (relative risk of 0.61; 95% confidence interval [CI] of 0.39 to 0.95) and decreased catheter-related sepsis with bacteriologic confirmation by 44% (relative risk of 0.56; 95% CI of 0.31 to 1) in comparison with standard placement. The majority of the benefit in the decreased rate of catheter-sepsis came from one trial at the internal jugular site (relative risk of 0.30, 95% CI of 0.10 to 0.89) and the reduction in risk was not significant when the data from five subclavian catheter trials were pooled (relative risk of 0.71, 95% CI of 0.36 to 1.43). Tunneling was not associated with increased risk of mechanical complications from placement or technical difficulties during placement. However, this outcome was not rigorously evaluated. CONCLUSIONS: Tunneling decreases central venous catheter-related infections. However, current evidence does not support routine tunneling until its efficacy is evaluated at different placement sites and relative to other interventions.
Bacteremia↗
Understanding articles describing clinical prediction tools. Evidence Based Medicine in Critical Care Group.
OBJECTIVES: Clinical prediction rules and models are developed by applying statistical techniques to find combinations of predictors that categorize a heterogeneous group of patients into subgroups of risk. Our goal is to teach clinicians how to evaluate the validity, results, and applicability of articles describing clinical prediction tools. CLINICAL EXAMPLE: An article describing a rule to predict the need for intensive care unit care admission in patients presenting to the emergency room with chest pain. RECOMMENDATIONS: Valid clinical prediction tools are developed by completely following up a representative group of patients, by evaluating all potential predictors and testing the independent contribution of each predictor variable, and by ensuring that the outcomes were independent of the predictors. To evaluate the results of an article describing a clinical prediction tool, clinicians need to know what the prediction tool is, how well it categorizes patients into different levels of risk, and what the confidence intervals are around the risk estimates. Valid prediction tools are not applicable in every patient population. Before patient care application, the clinician should ensure that the tool maintains its prediction power in a new sample of patients, that the patients are similar to patients used to test the tool, and that the tool has been shown to improve clinical decision-making. CONCLUSIONS: There has been an increase in the development and validation of clinical prediction rules and models. It is important to evaluate the validity and reliability of these prediction tools before application.
APACHE↗
Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials.
OBJECTIVE: To evaluate the effect of heparin on thrombus formation and infection associated with use of central venous and pulmonary artery catheters. DATA SOURCES: We used MEDLINE, EMBASE, citation review of relevant primary and review articles, personal files, and contact with expert informants. STUDY SELECTION: Fourteen randomized controlled trials evaluating prophylactic doses of heparin or heparin bonding were included. DATA EXTRACTION: In duplicate, independently, we abstracted data on the population, intervention, outcome, and methodologic quality. DATA SYNTHESIS: Prophylactic heparin decreases catheter-related venous thrombosis (relative risk [RR], 0.43; 95% confidence interval [CI], 0.23, 0.78) and bacterial colonization (RR, 0.18; 95% CI, 0.06, 0.60) of central venous catheters and may decrease catheter-related bacteremia (RR, 0.26; 95% CI, 0.07, 1.03). Heparin bonding decreases the risk of pulmonary artery catheter clot formation within 24 h (RR, 0.08; 95% CI, 0.02, 0.37). CONCLUSIONS: Heparin administration effectively reduces thrombus formation and may reduce catheter-related infections in patients who have central venous and pulmonary artery catheters in place. Cost-effectiveness comparisons of unfractionated heparin, low molecular weight heparin, and warfarin are needed.
Adult↗
Potential for meeting clinician information requirements in an intensive care unit (ICU) via the web.
OBJECTIVE: A web interface allows ICU-oriented information to be accessed from other patient care areas and clinical applications, optimizing information integration in the hospital. In preparation for installation of a web-enabled bedside patient charting application, we attempted to maximize the percentage of our ICU-information requirements that could be met via the web and designed a web interface for accessing this information. DESIGN: A comprehensive inventory of the information needs of our ICU was made by taking an inventory of existing paper and electronic documents, manuals, handouts, patient chart elements, and clinician communication about patients. We then designed a web site, created web-based prototype applications, and linked to hospital web applications. MEASUREMENTS: Before and after implementation of the web site, each category of requirements that were identified were marked as available, partially available, or unavailable via the web. RESULTS: After implementation of the ICU web site, 56.3% of identified information category requirements (+18.3%) were available via the web, 23.9% were partially available (+4.2%) and 19.8% were still unavailable (-22.5%). Implementation of the web-enabled bedside charting application would increase the percentage of information categories available via the web to 73.2% (+16.9%) and 18.3% of required information would be partially web-accessible. CONCLUSIONS: The majority of information required by clinicians in an ICU can be made accessible via the web if a systematic approach is taken to identify needs and to develop or link to applications and web pages to meet these needs.
Evaluation Studies as Topic↗
Paediatric index of mortality (PIM): do we need another paediatric mortality prediction score?
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Child, Preschool↗
Factors explaining variability among caregivers in the intent to restrict life-support interventions in a pediatric intensive care unit.
OBJECTIVE: To explore patient-related factors which influence the decisions of pediatric intensive care unit (ICU) caregivers to restrict life-support interventions. DESIGN: Cross-sectional survey. SETTING: A university-affiliated pediatric ICU. SUBJECTS: All physicians and nurses caring for oncology or cardiology ICU patients. INTERVENTIONS: Seven patient characteristics were systematically presented in 16 theoretical case scenarios. MEASUREMENTS AND MAIN RESULTS: Individual linear regression models were constructed for each participant by calculating the importance caregivers placed on seven patient characteristics when deciding about starting intravenous vasopressors, performing chest compressions, and withdrawing life support. We compared the numerical and descriptive (very low, low, moderate, high) probability of survival. We surveyed 86 caregivers and 56 (65%) responded. The most important factors influencing decisions were family preferences (76% of decisions), followed by probability of survival (50%), and functional status (47%). There was marked variability among respondents in 38 (79%)/48 of the questions; 20% to 50% of caregivers chose opposing directions of patient management when they were asked to indicate the likelihood that they would perform a specific life-support intervention. The same term was never used by all respondents to describe the probability of survival for a scenario. CONCLUSION: Critically ill children and their families could face markedly different attitudes about the restriction of life-support interventions, depending on which nurses and physicians are involved in their care.
Activities of Daily Living↗
Ribavirin for respiratory syncytial virus lower respiratory tract infection. A systematic overview.
OBJECTIVE: To systematically review the evidence evaluating the efficacy of aerosolized ribavirin for the treatment of infants with respiratory syncytial virus lower respiratory tract infection. DESIGN: A computerized search of MEDLINE from 1975 to the present, a review of the reference lists of each retrieved article, and contact with experts. PATIENTS: infants with documented respiratory syncytial virus lower respiratory tract infection who were the subjects of 8 double-blind randomized placebo-controlled trials. METHODS: Two independent reviewers assessed study quality and extracted data on the study populations, the drug regimens, and clinically relevant outcome measurements. RESULTS: Ribavirin does not significantly reduce mortality rate (relative risk [RR] = 0.42, 95% confidence interval [CI] = 0.13, 1.44) or lower the probability of respiratory deterioration (RR = 0.42, 95% CI = 0.16, 1.34) when meta-analysis is used to pool the outcomes of 3 trials, although strong trends in the direction of benefit are present. No study found ribavirin to shorten length of hospitalization. Results on length of ventilation and oxygen supplementation are conflicting. CONCLUSIONS: Use of ribavirin in infants with respiratory syncytial virus lower respiratory tract infection is not supported by evidence of significant benefit. However, previous studies lack sufficient power to rule out a potential reduction in mortality rate or respiratory deterioration. A large randomized controlled trial of ribavirin for ventilated and other high-risk patients is needed.
Antiviral Agents↗