RESUMO
OBJECTIVE: To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children. DESIGN: Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling. METHODS: We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle-Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist. MAIN OUTCOME: The primary outcome measure was UE rates per 100 intubation days. RESULTS: We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was 'good' in 70%, and the remaining as 'fair' (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates. CONCLUSIONS: We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.
Assuntos
Extubação/métodos , Estado Terminal/terapia , Pacotes de Assistência ao Paciente/métodos , Extubação/estatística & dados numéricos , Criança , Humanos , Incidência , Unidades de Terapia Intensiva Pediátrica , Intubação Intratraqueal/métodos , Melhoria de Qualidade , Fatores de RiscoRESUMO
PURPOSE: Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs. METHODS: All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected. RESULTS: Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations. CONCLUSION: The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.
Assuntos
Extubação/efeitos adversos , Unidades de Terapia Intensiva Pediátrica , Intubação Intratraqueal/estatística & dados numéricos , Respiração Artificial/efeitos adversos , Desmame do Respirador/efeitos adversos , Extubação/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Tempo de Internação , Modelos Logísticos , Masculino , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Pneumonia Associada à Ventilação Mecânica/etiologia , Estudos Prospectivos , Fatores de Risco , Desmame do Respirador/métodosRESUMO
BACKGROUND AND AIMS: Although iatrogenic withdrawal syndrome (IWS) has been recognized in patients exposed to opioids and benzodiazepines, very few studies have used a validated tool for diagnosis and assessment of IWS in critically ill children. We sought to determine IWS rate, risk factors, and outcomes of IWS patients. METHODS: Prospective observational study conducted in a pediatric intensive care unit. A total of 137 patients (31 with IWS and 106 with no IWS) received a continuous infusion of fentanyl and midazolam for 3 or more days. The Sophia Observation withdrawal Symptoms scale was repeatedly applied when children were weaned off sedation/analgesia. RESULTS: The overall incidence of IWS was 22.6%. Of the 31 IWS patients, 6 showed IWS with less than 5 days sedation or analgesia. Logistic regression showed that the median peak dose of midazolam was associated with IWS development (odds ratio 1.4). Receiver-operating curve showed a cut-off value of 0.35âmg/kg/h for midazolam peak dose (sensitivity 96.7%, specificity 51%, positive predictive value 36.6%, and negative predictive value 98.2%), with area under the curve of 0.80. IWS patients had a longer time on mechanical ventilation, prolonged pediatric intensive care unit, and hospital stays, and required prolonged period to have drugs discontinued. CONCLUSIONS: Although length of sedation/analgesia for at least5 days has been widely proposed for monitoring IWS, our data suggest that initiating monitoring after 3 sedation days is highly recommended. In addition, patients requiring infusion rates of midazolam above 0.35âmg/kg/h should be considered at high risk for IWS.
Assuntos
Cuidados Críticos/métodos , Fentanila/efeitos adversos , Doença Iatrogênica/epidemiologia , Unidades de Terapia Intensiva Pediátrica , Midazolam/efeitos adversos , Síndrome de Abstinência a Substâncias/epidemiologia , Adolescente , Analgésicos Opioides/efeitos adversos , Benzodiazepinas/efeitos adversos , Brasil/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Masculino , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To update the state of knowledge on unplanned extubations (UEs) in neonatal ICUs. This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention. METHODS: The MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for relevant publications from January 1, 1950, through January 30, 2012. Fifteen articles were selected for data abstraction. The search strategy included the following key words: "unplanned extubation," "accidental extubation," "self extubation," "unintentional extubation," "unexpected extubation," "inadvertent extubation," "unintended extubation," "spontaneous extubation," "treatment interference," and "airway accident." Study quality was assessed using the Newcastle-Ottawa scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine's levels of evidence system. Studies with Newcastle-Ottawa scale score ≥ 5 that included appropriate statistical analysis were deemed of high methodological quality. RESULTS: The overall mean Newcastle-Ottawa scale score was 3.5. UE rates ranged from 0.14 to 5.3 UEs/100 intubation days, or 1% to 80.8%. Risk factors included restlessness/agitation (13-89%), poor fixation of endotracheal tube (8.5-31%), tube manipulation at the time of UE (17-30%), and performance of a patient procedure at bedside (27.5-51%). One study showed that every day on mechanical ventilation increased the UE risk 3% (relative risk 1.03, P < .001). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. The best method of endotracheal tube securement remains a controversial issue. CONCLUSIONS: Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and there is a lack of randomized clinical trials. Recommendations are proposed based on the current available literature.
Assuntos
Acidentes/estatística & dados numéricos , Extubação/estatística & dados numéricos , Respiração Artificial/efeitos adversos , Estudos de Coortes , Medicina Baseada em Evidências , Feminino , Humanos , Incidência , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Retratamento/métodos , Retratamento/estatística & dados numéricos , Fatores de Risco , Prevenção Secundária/métodos , Prevenção Secundária/estatística & dados numéricosRESUMO
OBJECTIVE: To evaluate the performance of the Transport Risk Index of Physiologic Stability (TRIPS) score at admission for early mortality prediction. METHODS: The study included all consecutive outborn infants admitted to a single neonatal intensive care unit (NICU) over a 3-year period. The data collected included demographic variables, 7-day NICU mortality, and severe (≥ grade 3) intraventricular hemorrhage (IVH), TRIPS score at admission, and Score for Neonatal Acute Physiology II (SNAP-II) and SNAP-Perinatal Extension-II (SNAPPE-II) scores. RESULTS: A total of 175 neonates were enrolled. TRIPS at admission discriminated 7-day mortality from survival with a receiver operating characteristic (ROC) area of 0.80, and predictive performance of TRIPS for severe IVH showed a ROC area of 0.67. The TRIPS had good calibration for all strata (p = 0.49). For gestational age (GA) >32 weeks, the area under the curve (AUC) for TRIPS was 0.71, whereas the AUC for GA ≤32 weeks was 0.99 for 7-day mortality. Predictive performance of TRIPS for 7-day mortality was similar to that of SNAP-II and SNAPPE-II. CONCLUSION: TRIPS score at admission had a good performance to discriminate high-risk patients for 7-day mortality, mainly infants with GA ≤32 weeks. TRIPS might be a useful triage tool if applied at the time of first contact with a transport service.
Assuntos
Doenças do Recém-Nascido/mortalidade , Unidades de Terapia Intensiva Neonatal , Transferência de Pacientes , Índice de Gravidade de Doença , Índice de Apgar , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Masculino , Estudos Prospectivos , Curva ROC , Triagem/métodosRESUMO
BACKGROUND: Repeat head computed tomography (CT) is standard practice for traumatic brain injury (TBI) at many centers. The few studies available in children remain unclear over the value of repeat CT within 24 hours to 48 hours of lesion in such patients. The purpose of the present study was to assess the value of repeat cranial CT in children presenting moderate or severe TBI. METHODS: A retrospective study performed within a pediatric intensive care unit between January 2000 and December 2006. All patients with moderate and severe TBI who survived the first 24 hours after admission were included. Clinical data collected included age, lesion mechanism, time between first and second CTs, disease severity score at admission, and Glasgow Coma Scale (GCS) both at admission and day of repeat CT. RESULTS: A total of 63 children were assessed whose mean age was 72 months (48-112). The time between the first and the second CT scans averaged 25.78 hours +/- 13.75 hours (range, 6-48 hours). The reasons for ordering repeat CT scans were divided as follows: follow-up (78%), neurologic deterioration (20.4%), and increased intracranial pressure (1.6%). The change on the follow-up CT scan was compared with the GCS score. The GCS score was improved in 66.6% of patients, remained the same in 15.9%, and worsened in 17.5%. The appearance on the CT scans was better, the same or worse in 41.3%, 34.9%, and 23.8% of patients, respectively. There was a significant association between GCS and changes in findings on repeat CT (OR = 34.5, confidence interval [5.98-199.04], p = 0.000009). The positive and negative predictive values were 82% and 89%, respectively. One patient with a worsened GCS required surgical intervention based on the repeat CT scan. CONCLUSION: An unchanged or improving neurologic examination in children sustaining moderate or severe TBI who are appropriately monitored may be adequate to exclude the possibility of neurosurgical intervention and, hence, repeat head CT scan.