Showing papers in "Pediatric Critical Care Medicine in 2008"

Parents' perspectives on physician-parent communication near the time of a child's death in the pediatric intensive care unit.

Abstract: Objective: Communicating bad news about a child’s illness is a difficult task commonly faced by intensive care physicians. Greater understanding of parents’ scope of experiences with bad news during their child’s hospitalization will help physicians communicate more effectively. Our objective is to describe parents’ perceptions of their conversations with physicians regarding their child’s terminal illness and death in the pediatric intensive care unit (PICU). Design: A secondary analysis of a qualitative interview study. Setting: Six children’s hospitals in the National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Participants: Fifty-six parents of 48 children who died in the PICU 3–12 months before the study. Interventions: Parents participated in audio recorded semistructured telephone interviews. Interviews were analyzed using established qualitative methods. Measurements and Main Results: Of the 56 parents interviewed, 40 (71%) wanted to provide feedback on the way information about their child’s terminal illness and death was communicated by PICU physicians. The most common communication issue identified by parents was the physicians’ availability and attentiveness to their informational needs. Other communication issues included honesty and comprehensiveness of information, affect with which information was provided, withholding of information, provision of false hope, complexity of vocabulary, pace of providing information, contradictory information, and physicians’ body language. Conclusions: The way bad news is discussed by physicians is extremely important to most parents. Parents want physicians to be accessible and to provide honest and complete information with a caring affect, using lay language, and at a pace in accordance with their ability to comprehend. Withholding prognostic information from parents often leads to false hopes and feelings of anger, betrayal, and distrust. Future research is needed to investigate whether the way bad news is discussed influences psychological adjustment and family functioning among bereaved parents. (Pediatr Crit Care Med 2008; 9:2–7)

The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients.

Abstract: Objective To develop and test the validity and reliability of the Withdrawal Assessment Tool - Version 1 (WAT-1) for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients.

Alterations in glucose homeostasis in the pediatric intensive care unit: Hyperglycemia and glucose variability are associated with increased mortality and morbidity.

Abstract: Objectives:Critically ill patients with alterations in glucose equilibrium may experience adverse outcomes. We sought to describe the distribution of blood glucose values in the absence of insulin therapy and to evaluate the association of hyperglycemia, hypoglycemia, and glucose variability with mo

A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure.

Abstract: Outcomes:To compare the benefits of noninvasive ventilation (NIV) plus standard therapy vs. standard therapy alone in children with acute respiratory failure; assess method effectiveness in improving gas exchange and vital signs; and assess method safety.Design:Prospective, randomized, controlled st

The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: a randomized, controlled open study.

Abstract: Objectives:Hypotonic fluids are widely used in pediatrics. Several articles have reported the risk of iatrogenic hyponatremia secondary to this practice. We primarily intend to determine whether the use of isotonic fluids prevents hyponatremia and, secondly, whether these fluids increase the inciden

Correlation of abdominal site near-infrared spectroscopy with gastric tonometry in infants following surgery for congenital heart disease.

Abstract: Objective:Splanchnic oximetry, as measured by near-infrared spectroscopy (NIRS), correlates with gastric tonometry as a means of assessing regional (splanchnic) oxygenation and perfusion.Design:Prospective, data-gathering study.Setting:Pediatric cardiac intensive care unit in a tertiary care childre

Worsening renal function in children hospitalized with decompensated heart failure: evidence for a pediatric cardiorenal syndrome?

Abstract: Objectives: The purpose of this study was to determine the incidence of renal insufficiency in children hospitalized with acute decompensated heart failure and whether worsening renal function is associated with adverse cardiovascular outcome. Design: Prospective observational cohort study. Setting: Single-center children’s hospital. Patients: All pediatric patients from birth to age 21 yrs admitted to our institution with acute decompensated heart failure from October 2003 to October 2005. Interventions: None. Measurements and Main Results: Acute decompensated heart failure was defined as new-onset or acute exacerbation of heart failure signs or symptoms requiring hospitalization and inpatient treatment. We required that heart failure be attributable to ventricular dysfunction only. Worsening renal function was defined as an increase in serum creatinine by >0.3 mg/dL during hospitalization. Sixty-three patients (35 male, 28 female) comprised 73 patient hospitalizations. Median age at admission was 10 yrs (range 0.1‐20.3 yrs). Median serum creatinine at admission was 0.6 mg/dL (range 0.2‐3.5 mg/dL), and median creatinine clearance was 103 mL/min/1.73 m 2 (range 22‐431 mL/min/1.73 m 2 ). Serum creatinine increased during 60 of 73 (82%) patient hospitalizations (median increase 0.2 mg/dL, range 0.1‐2.7 mg/dL), and worsening renal function occurred in 35 of 73 (48%) patient hospitalizations. Clinical variables associated with worsening renal function included admission serum creatinine (p .009) and blood urea nitrogen (p .04) and, during hospitalization, continuous infusions of dopamine (p .028) or nesiritide (p .007). Worsening renal function was independently associated with the combined end point of in-hospital death or need for mechanical circulatory support (adjusted odds ratio 10.2; 95% confidence interval 1.7‐61.2, p .011). Worsening renal function was also associated with longer observed length of stay (33 30 days vs. 18 25 days, p < .03). Conclusions: These data suggest that an important cardiorenal interaction occurs in children hospitalized for acute decompensated heart failure. Renal function commonly worsens in such patients and is associated with prolonged hospitalization and in-hospital death or the need for mechanical circulatory assistance. (Pediatr Crit Care Med 2008; 9:279‐284)

Changes in outcomes (1996-2004) for pediatric oncology and hematopoietic stem cell transplant patients requiring invasive mechanical ventilation.

Abstract: Objective:To assess the following hypotheses regarding mechanically ventilated pediatric oncology patients, including those receiving hematopoietic stem cell transplant (HSCT) and those not receiving HSCT: 1) outcomes are more favorable for nontransplant oncology patients than for those requiring HS

Pediatric tracheostomies: a recent experience from one academic center.

Abstract: Objectives:To describe the indications, surgical timing, length of stay, hospital charges, and discharge disposition of pediatric tracheostomy patients.Design:Retrospective case series.Setting:Large urban academic pediatric hospital.Patients:Seventy children and adolescents undergoing tracheostomy p

Do outcomes vary according to the source of admission to the pediatric intensive care unit

Abstract: Objective: To examine associations between mortality, length of stay, and the sources of admission to tertiary pediatric intensive care. Design: A retrospective analysis of prospectively collected data. Setting: A tertiary medical center with a 16-bed medical-surgical intensive care unit and a 15-bed cardiac pediatric intensive care unit (PICU). Patients: All admissions from July 1, 1998, through June 30, 2004. Multivariable regression methods compared length of stay and mortality between the sources of PICU admission, controlling for multiple variables, including severity of illness. Interventions: None. Measurements and Main Results: Of 8,897 eligible admissions, 74% were directly from the study hospital’s emergency department or operating rooms, while 26% were from indirect sources, including the study hospital’s wards (11%) or interhospital transfer from either non-PICU (12%) or PICU settings (3%). Compared with emergency department admissions, ward admissions had higher odds of mortality (odds ratio 1.65, 95% confidence interval 1.08–2.51), transfer admissions from non-PICU settings did not have elevated odds of mortality (odds ratio 0.80, 95% confidence interval 0.51–1.25), and inter-PICU transfer admissions had higher odds of mortality (odds ratio 1.43, 95% confidence interval 0.80–2.56), although not reaching statistical significance. Compared with emergency department admissions, ward admissions stayed almost 4 days longer in the PICU, while interhospital transfer admissions from non-PICU and PICU settings stayed 2 and 6 days longer, respectively. Conclusions: Outcomes of tertiary pediatric intensive care vary significantly by source of admission. Strategies aimed at reduction of mortality at the tertiary PICU should target transfer admissions from the hospital’s wards and from PICUs of other hospitals.

A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice.

Abstract: Objective:To provide a comprehensive, evidence-based review of pediatric endotracheal suctioning: effects, indications, and clinical practice.Methods:PubMed, Cumulative Index of Nursing and Allied Health Literature, and PEDro (Physiotherapy Evidence Database) electronic databases were searched for E

Procalcitonin and C-reactive protein as markers of bacterial infection in critically ill children at onset of systemic inflammatory response syndrome.

Abstract: OBJECTIVE To compare the accuracy of procalcitonin and C-reactive protein as diagnostic markers of bacterial infection in critically ill children at the onset of systemic inflammatory response syndrome (SIRS). DESIGN Prospective cohort study. SETTING Tertiary care, university-affiliated pediatric intensive care unit (PICU). PATIENTS Consecutive patients with SIRS. INTERVENTIONS From June to December 2002, all PICU patients were screened daily to include cases of SIRS. At inclusion (onset of SIRS), procalcitonin and C-reactive protein levels as well as an array of cultures were obtained. Diagnosis of bacterial infection was made a posteriori by an adjudicating process (consensus of experts unaware of the results of procalcitonin and C-reactive protein). Baseline and daily data on severity of illness, organ dysfunction, and outcome were collected. MEASUREMENTS AND MAIN RESULTS Sixty-four patients were included in the study and were a posteriori divided into the following groups: bacterial SIRS (n = 25) and nonbacterial SIRS (n = 39). Procalcitonin levels were significantly higher in patients with bacterial infection compared with patients without bacterial infection (p = .01). The area under the receiver operating characteristic curve for procalcitonin was greater than that for C-reactive protein (0.71 vs. 0.65, respectively). A positive procalcitonin level (>or=2.5 ng/mL), when added to bedside clinical judgment, increased the likelihood of bacterial infection from 39% to 92%, while a negative C-reactive protein level (<40 mg/L) decreased the probability of bacterial infection from 39% to 2%. CONCLUSIONS Procalcitonin is better than C-reactive protein for differentiating bacterial from nonbacterial SIRS in critically ill children, although the accuracy of both tests is moderate. Diagnostic accuracy could be enhanced by combining these tests with bedside clinical judgment.

Cerebral edema in diabetic ketoacidosis.

Abstract: Objective: To review the causes of cerebral edema in diabetic ketoacidosis (CEDKA), including pathophysiology, risk factors, and proposed mechanisms, to review the diagnosis, treatment, and prognosis of CEDKA and the treatment of diabetic ketoacidosis as it pertains to prevention of cerebral edema. Data Source: A MEDLINE search using OVID was done through 2006 using the search terms cerebral edema and diabetic ketoacidosis. Results of Search: There were 191 citations identified, of which 150 were used. An additional 42 references listed in publications thus identified were also reviewed, and two book chapters were used. Study Selection: The citations were reviewed by the author. All citations identified were used except 25 in foreign languages and 16 that were duplicates or had inappropriate titles and/or subject matter. Of the 194 references, there were 21 preclinical and 40 clinical studies, 35 reviews, 15 editorials, 43 case reports, 29 letters, three abstracts, six commentaries, and two book chapters. Data Synthesis: The data are summarized in discussion. Conclusions: The causes and mechanisms of CEDKA are unknown. CEDKA may be due as much to individual biological variance as to severity of underlying metabolic derangement of the child's state and/or treatment risk factors. Treatment recommendations for CEDKA and diabetic ketoacidosis are made taking into consideration possible mechanisms and risk factors but are intended as general guidelines only in view of the absence of conclusive evidence.

Outcome and prognostic factors in neonates with septic shock

Abstract: Objective:Few accurate data are available on the outcome of septic shock in the neonatal period. The objective was to describe outcome and to determine variables associated with death or adverse outcome in neonates with septic shock.Design:Retrospective cohort study.Setting:A tertiary neonatal inten

Surgery-related posttraumatic stress disorder in parents of children undergoing cardiopulmonary bypass surgery: a prospective cohort study.

Abstract: Objective:We aimed at evaluating surgery-related posttraumatic stress disorder (PTSD) in parents of children undergoing cardiopulmonary bypass surgery. Risk factors for parental PTSD symptoms were explored.Design:A prospective cohort study was performed assessing PTSD symptoms immediately after disc

Glucose control, organ failure, and mortality in pediatric intensive care

Abstract: In ventilated children, to determine the prevalence of hyperglycemia, establish whether it is associated with organ failure, and document glycemic control practices in Australasian pediatric intensive care units (PICUs). Prospective inception cohort study. All nine specialist PICUs in Australia and New Zealand. Children ventilated > 12 hrs excluding those with diabetic ketoacidosis, on home ventilation, undergoing active cardiopulmonary resuscitation on admission, or with do-not-resuscitate orders. None. All blood glucose measurements for up to 14 days, clinical and laboratory values needed to calculate Paediatric Logistic Organ Dysfunction (PELOD) scores, and insulin use were recorded in 409 patients. Fifty percent of glucose measurements were > 6.1 mmol/L, with 89% of patients having peak values > 6.1 mmol/L. The median time to peak blood glucose was 7 hrs. Hyperglycemia was defined by area under the glucose-time curve > 6.1 mmol/L above the sample median. Thirteen percent of hyperglycemic subjects died vs. 3% of nonhyperglycemic subjects. There was an independent association between hyperglycemia and a PELOD score > or = 10 (odds ratio 3.41, 95% confidence interval 1.91-6.10) and death (odds ratio 3.31, 95% confidence interval 1.26-7.7). Early hyperglycemia, defined using only glucose data in the first 48 hrs, was also associated with these outcomes but not with PELOD > or = 10 after day 2 or with worsening PELOD after day 1. Five percent of patients received insulin. Hyperglycemia is common in PICUs, occurs early, and is independently associated with organ failure and death. However, early hyperglycemia is not associated with later or worsening organ failure. Australasian PICUs seldom use insulin.

Energy expenditure and caloric and protein intake in infants following the Norwood procedure.

Abstract: OBJECTIVES Cardiopulmonary bypass in infants results in a hypermetabolic response. Energy requirements of these patients have not been well studied. We assessed energy expenditure and caloric and protein intake during the first 3 days following the Norwood procedure. DESIGN Clinical investigation. SETTING Children's hospital. PATIENTS Seventeen infants (15 boys, age 4-92 days, median 7 days). INTERVENTIONS VO2 and VCO2 were continuously measured using respiratory mass spectrometry in 17 infants for the first 72 hrs following the Norwood procedure. The respiratory quotient was determined as VCO2/VO2. Energy expenditure was calculated using the modified Weir equation. Measurements were collected at 2- to 4-hr intervals. The mean values in the first 8 hrs, hours 8-32, hours 32-56, and the last 16 hrs were used as representative values for postoperative days 0, 1, 2, and 3. Total caloric and protein intakes were recorded for each day. MEASUREMENTS AND MAIN RESULTS Energy expenditure, VO2, and VCO2 were initially high; declined rapidly during the first 8 hrs; and were maintained relatively stable in the following hours (p < .0001). Respiratory quotient showed a significant linear increase over the 72 hrs (p = .002). Energy expenditure on days 0, 1, 2, and 3 was 43 +/- 11, 39 +/- 8, 39 +/- 8, and 41 +/- 6 kcal/kg/day, respectively. Total caloric intake was 3 +/- 1, 14 +/- 5, 31 +/- 16, and 51 +/- 16 kcal/kg/day. Protein intake was 0, 0.2 +/- 0.2, 0.6 +/- 0.5, and 0.9 +/- 0.5 g/kg/day on days 0, 1, 2, and 3, respectively. CONCLUSIONS Infants exhibit a hypermetabolic response immediately following the Norwood procedure. Caloric and protein intake was inadequate to meet energy expenditure during the first 2 days after surgery. Further studies are warranted to examine the effects of caloric and protein supplementation on postoperative outcomes in infants after cardiopulmonary bypass.

Candida colonization and candidemia in a pediatric intensive care unit.

Abstract: Objective: To evaluate role of Candida colonization in development of candidemia and to identify risk factors associated with Candida colonization and candidemia in children treated for severe sepsis or septic shock in a pediatric intensive care unit (PICU) for >5 days. Design: Prospective observational. Setting: PICU of a tertiary care teaching hospital. Subjects: Of 186 children, aged 1 month to 14 yrs, consecutively admitted to PICU for severe sepsis or septic shock, 65 patients having a stay of >5 days. Interventions: Clinical and demographic data at admission and variables likely to influence Candida colonization were recorded. Oropharyngeal, rectal, and skin (groin) swabs were taken on days 0, 2, 5, and 7 of admission. Blood for fungal culture (two samples 48 hrs apart) was obtained if a patient developed signs of sepsis. The yeast growth was identified by conventional methods. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and multivariate logistic regression analysis was conducted. Measurements and Main Results: Colonization by Candida species occurred in 45 (69%) patients. Oropharyngeal (52%) and rectal (43%) colonization was more common than skin (34%) colonization. The colonizing species were C. tropicalis (34.2%), C. parapsilosis (28.8%), C. albicans (14.4%), and others. Use of central venous catheters was the only independent predictor of colonization on multivariate logistic regression (OR 4.1; 95% CI 1.01–17.1). Twenty (30.2%) patients developed candidemia; 18 (90%) of them were colonized, 15 (75%) with the same Candida species. Independent predictors of candidemia on multivariate stepwise logistic regression analysis were presence of colonization (OR 5.1; 95% CI 1.01–25.6, p = .048) and Pediatric Risk of Mortality score (OR 1.3; 95% CI 1.02–1.6, p = .034). Conclusions: Monitoring for colonization with Candida species in children undergoing treatment for severe sepsis or sepsis shock in PICU for >5 days may offer opportunity for early intervention for prevention of candidemia.

Effect of inhaled hydrogen sulfide on metabolic responses in anesthetized, paralyzed, and mechanically ventilated piglets.

Abstract: Objective:Induced hypometabolism may improve the balance between oxygen delivery and consumption and may help sustain tissue viability in critically ill patients with low cardiac output state. Inhaled hydrogen sulfide (H2S) has been shown to induce a suspended animation-like state in mice with a 90%

Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality.

Abstract: Objective:Few data exist on successes at reducing pediatric catheter-associated bloodstream infections (CA-BSI). The objective was to eradicate CA-BSI with a multifaceted pediatric-relevant intervention proven effective in adult patients.Design:Prospective cohort of pediatric intensive care (PICU) p

Pediatric organ donation: what factors most influence parents' donation decisions?

Abstract: Objective:To identify factors that influence parents’ decisions when asked to donate a deceased child’s organs.Design:Cross-sectional design with data collection via structured telephone interviews.Setting:One organ procurement organization in the Southeastern United States.Participants:Seventy-four

Exploring parents' environmental needs at the time of a child's death in the pediatric intensive care unit.

Abstract: Objective:Many childhood deaths in the United States occur in intensive care settings. The environmental needs of parents experiencing their child’s death in a pediatric intensive care unit must be understood to design facilities that comfort at the time of death and promote healing after loss. The

Combination of recombinant human growth hormone and propranolol decreases hypermetabolism and inflammation in severely burned children.

Abstract: OBJECTIVE Recombinant human growth hormone (rhGH) is a salutary modulator of posttraumatic metabolic responses. However, rhGH administration is associated with deleterious side effects, such as hyperglycemia, increased free fatty acids, and triglycerides, which limit its use. Administration of beta-blocker attenuates cardiac work and resting energy expenditure after severe thermal injury and improves fat metabolism and insulin sensitivity. Therefore, the combination of rhGH plus propranolol appears ideal. The aim of the present study was to determine whether rhGH plus propranolol improves hypermetabolism and the inflammatory and acute phase response after severe burn without causing adverse side effects. DESIGN Prospective randomized control trial. SETTING Shriners Hospitals for Children. PATIENTS Fifteen pediatric patients with burns > 40% total body surface area, 0.1-16 yrs of age, admitted within 7 days after burn. Fifteen children were matched for burn size, age, gender, inhalation injury, and infection and served as controls. INTERVENTIONS Patients in the experimental group received rhGH (0.2 mg/kg/day) and propranolol (to decrease heart rate by 15%) for > or = 15 days. MEASUREMENTS AND MAIN RESULTS Outcome measurements included resting energy expenditure, body composition, acute phase proteins, and cytokines. Both cohorts were similar in age, burn size, gender, and accompanying injuries. Percent predicted resting energy expenditure significantly decreased in patients receiving rhGH/propranolol (Delta -5% +/- 8%) compared with controls (Delta +35% +/- 20%) (p < .05). rhGH/propranolol administration significantly decreased serum C-reactive protein, cortisone, aspartate aminotransferase, alanine aminotransferase, free fatty acids, interleukin-6, interleukin-8, and macrophage inflammatory protein-1beta when compared with controls, while growth hormone/propranolol increased serum insulin-like growth factor-I, insulin-like growth factor binding protein-3, growth hormone, prealbumin, and interleukin-7 when compared with placebo (p < .05). CONCLUSIONS rhGH in combination with propranolol attenuates hypermetabolism and inflammation without the adverse side effects found with rhGH therapy alone.

Dexmedetomidine as the primary sedative during invasive procedures in infants and toddlers with congenital heart disease

Abstract: throughout their procedure. Dexmedetomidine was used as the primary sedative agent during the procedure with additional sedation provided with low dose ketamine for patient movement in three of the six patients. The average dexmedetomidine dose used was 1.5 g/kg (1–3 g/kg). An additional low dose of ketamine, 0.7 mg/kg (0.3–1.5 mg/kg), was used in 50% of the patients. All patients breathed spontaneously without significant desaturation throughout the procedure, and although there was a trend toward lower blood pressure and heart rate, all patients remained warm and well perfused. Each of the six procedures was successfully completed without any associated complications. Conclusions: Our experience suggests that invasive procedures can be successfully performed in spontaneously breathing infants and toddlers with congenital heart disease using dexmedetomidine alone or in combination with low dose ketamine. (Pediatr Crit Care Med 2008; 9:612– 615)

Extracorporeal life support for severe respiratory failure in children with immune compromised conditions.

Abstract: Objectives:To examine a large cohort of children treated with extracorporeal life support (ECLS) for severe respiratory failure to investigate the hypothesis that patients with an immune compromise condition (ICC) would have reduced survival to hospital discharge compared with patients without this

A protocolized approach to identify and manage hyperglycemia in a pediatric critical care unit

Abstract: Introduction:Hyperglycemia is a risk factor for poor outcome in critically ill patients, and glycemic control may decrease morbidity and mortality in adults. There is limited information regarding hyperglycemia and its control in pediatric intensive care.Objective:To determine prevalence and risk fa

Assessment of cardiac output in children: a comparison between the pressure recording analytical method and Doppler echocardiography.

Abstract: Objective:To assess cardiac output in pediatric patients with the pressure recording analytical method (PRAM) and the Doppler echocardiography method. PRAM derives cardiac output from beat-by-beat analysis of the arterial pressure profile (systolic and diastolic phase) in the time domain.Design:A pr

The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients.

Abstract: Objective: Endotracheal tube air leak pressures are used to predict postextubation upper airway compromise such as stridor, upper airway obstruction, or risk of reintubation. To determine whether the absence of an endotracheal tube air leak (air leak test ≥30 cm H2O) measured during the course of mechanical ventilation predicts extubation failure in infants and children. Design: Prospective, blinded cohort. Setting: Multidisciplinary pediatric intensive care unit of a university hospital. Patients: Patients younger than or equal to 18 yrs and intubated ≥24 hrs. Interventions: The pressure required to produce an audible endotracheal tube air leak was measured within 12 hrs of intubation and extubation. Unless prescribed by the medical care team, patients did not receive neuromuscular blocking agents during air leak test measurements. Measurements and Main Results: The need for reintubation (i.e., extubation failure) was recorded during the 24-hr postextubation period. Seventy-four patients were enrolled resulting in 59 observed extubation trials. The extubation failure rate was 15.3% (9 of 59). Seven patients were treated for postextubation stridor. Extubation failure was associated with a longer median length of ventilation, 177 vs. 78 hrs, p = 0.03. Extubation success was associated with the use of postextubation noninvasive ventilation (p = 0.04). The air leak was absent for the duration of mechanical ventilation (i.e., ≥30 cm H2O at intubation and extubation) in ten patients. Absence of the air leak did not predict extubation failure (negative predictive value 27%, 95% confidence interval 6–60). The air leak test was ≥30 cm H2O before extubation in 47% (28 of 59) of patients yet 23 patients extubated successfully (negative predictive value 18%). Conclusions: An endotracheal tube air leak pressure ≥30 cm H2O measured in the nonparalyzed patient before extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube. (Pediatr Crit Care Med 2008; 9:490–496)

Serial blood lactate levels as a predictor of mortality in children after cardiopulmonary bypass surgery.

Abstract: Objective:To assess the role of serial lactate levels in determining outcome after cardiopulmonary bypass surgery in children.Design:Analysis of retrospectively collected data.Setting:Cardiac intensive care unit of a tertiary care children's hospital.Patients:Patients were 129 children who underwent

Critical heart disease in the neonate: Presentation and outcome at a tertiary care center

Abstract: Objective:To define the modes of presentation, incidence of major organ dysfunction, predictors of hospital mortality, and adverse outcomes in neonates with critical heart disease admitted to a tertiary care center.Design:Retrospective chart review.Setting:A tertiary care pediatric cardiac intensive