DESIGN: Case report.

SETTING: Pediatric critical care unit.

PATIENT: A 4-yr-old girl with severe reactive airways disease.

INTERVENTIONS: The use of weakening doses of cisatracurium to assist in weaning from mechanical ventilation in the setting of withdrawal symptoms following the extended use of inhaled isoflurane.

MEASUREMENTS AND MAIN RESULTS: Despite treatment with mechanical ventilation, intravenous corticosteroids, and bronchodilators for status asthmaticus, the patient required inhaled isoflurane. She became tolerant to isoflurane over an extended period of time; her tolerance was associated with a specific withdrawal syndrome, with the development of choreoathetoid movements resulting in poor pulmonary coordination and agitation. Conventional medical treatment of withdrawal failed. Finally, by using an infusion of cisatracurium at weakening doses to assist in the control of these choreoathetoid movements, the isoflurane and ventilator support were weaned.

CONCLUSIONS: Weakening doses of cisatracurium may be used safely to control unpleasant motor symptoms secondary to tolerance of isoflurane. This may have a use in other circumstances where agitation in mechanically ventilated patients is not due to pain or anxiety.

OBJECTIVES: The goals of this study were to determine: 1) the prevalence of symptomatic buprenorphine exposure in children <3 yrs of>age; 2) the severity of toxicity associated with such exposures; and 3) effective clinical interventions.

METHODS AND MAIN RESULTS: A retrospective case review was performed on records from the pediatric intensive care unit at an academic medical center located in the northeastern United States. Unintentional buprenorphine/naloxone exposure (n = 9) accounted for the largest single fraction of toxic ingestions among patients younger than 3 yrs within the study period (9/33, 27%). All exposures occurred at the child's place of residence (n = 9, 100%). Clinical signs of opioid toxicity were evident in all nine cases, with the most common symptom being drowsiness or lethargy (n = 9, 100%), followed by miosis (n = 6, 67%) and respiratory depression (n = 5, 56%). Six patients were effectively treated with naloxone (n = 6, 67%).

CONCLUSIONS: The increased use and similarity to candy of the current formulation of buprenorphine pose a special risk to children, especially toddlers. Buprenorphine exposure in children <3 yrs old can cause significant opioid toxidrome. Naloxone is an effective agent for reversal of>symptoms; however, given buprenorphine's high affinity and long action, higher doses or continuous infusion may be required. Adults on buprenorphine should be educated on the risks posed to young children in their household and the appropriate storage of medication.

DATA SOURCES: Review of the literature, including PubMed, citations from relevant articles, and some articles that have been particularly relevant in adult critical care practice regarding packed red blood cell transfusion.

CONCLUSIONS: The use of packed red blood cell transfusions is common in the pediatric intensive care unit setting. However, until recently there have been little data to guide providers in this practice. Studies in adult intensive care units have shown less favorable outcomes in patients who received packed red blood cell transfusions. This has led to renewed questioning of the practice of packed red blood cell transfusion in critically ill pediatric patients. New data indicate that using a hemoglobin transfusion threshold of >7 g/dL does not yield improved outcomes. Furthermore, smaller studies have suggested that pediatric intensive care unit patients may be at an increased risk for morbidity and mortality when undergoing transfusion.

DESIGN: Prospective observational study, single-center tertiary children's hospital.

SETTING: Pediatric intensive care unit.

PATIENTS: A total of 63 patients admitted to the pediatric intensive care unit for >48 hrs from 2004 to 2005.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Phlebotomy resulted in a mean blood volume loss of 2.5 +/- 1.4 mL per draw, 7.1 +/- 5.3 mL per day, and 34 +/- 37 mL per pediatric intensive care unit stay, of which 1.4 +/- 1.1 mL per draw, 3.8 +/- 3.6 mL per day, and 23 +/- 31 mL per pediatric intensive care unit stay were discarded as excess. This excess represents 210% +/- 174% of the volume requested by the laboratory and a 110% overdraw. Blood drawn from central venous catheters had significantly greater overdraw volumes, 254% +/- 112%, compared to those of arterial, 168% +/- 44%, and peripheral intravenous catheters, 143% +/- 39%, p < .001. Blood draws sent for one test had an associated overdraw of 278% +/- 81%, compared to draws sent for two, 168% +/- 48%, three 173% +/- 4%, and four or greater tests 55% +/- 5%, p < .001. Patients <10 kg had significantly greater mean volumes of blood loss/kg/day compared to patients >/= 10 kg, p < .001.

CONCLUSION: Blood drawn in excess of phlebotomy requirements exceeds the blood volume loss drawn for phlebotomy by two fold. Using indwelling catheters for phlebotomy often requires a discard volume to be drawn before obtaining the laboratory sample. Consolidating phlebotomy tests and using a closed system may decrease the amount of blood overdrawn and minimize overall phlebotomy-induced blood loss.

DESIGN: Prospective, double-blind, randomized trial.

SETTING: Pediatric intensive care unit in a tertiary care children's hospital.

PATIENTS: Seventy-eight patients, 74 of whom had been receiving infusions of both fentanyl and midazolam, were randomized. Forty-one patients were randomized to the low-dose methadone group and 37 were randomized to the high-dose methadone group. Sixty patients successfully completed the trial, 34 were in the low-dose methadone group, and 26 were in the high-dose methadone group.

INTERVENTIONS: Patients were randomized to receive methadone either at a starting dose of 0.1 mg/kg/dose (low-dose methadone group) or at a starting dose based on both the patient's weight and the most recent fentanyl infusion rate (high-dose methadone group). In each group, methadone was administered every 6 hrs for the first 24 hrs and then every 12 hrs for the second 24 hrs. The methadone was then decreased to once daily and tapered off over the next 10 days. Patients were monitored for withdrawal symptoms using the Modified Narcotic Withdrawal Score.

MEASUREMENTS AND MAIN RESULTS: The percentage of patients who successfully completed the 10-day methadone taper was the same in the low-dose methadone group as in the high-dose methadone group (56% vs. 62%; p = .79). Patients that failed to complete the assigned methadone taper had a greater total fentanyl dose and longer pediatric intensive care unit length of stay compared to patients who completed the assigned methadone taper.

CONCLUSIONS: Patients who received infusions of fentanyl for at least 5 days were just as likely to complete a low-dose methadone taper as a high-dose methadone taper. Because of the risks of both withdrawal and oversedation with any fixed methadone schedule, the methadone dose must be adjusted according to each patient's response.

METHODS: Prospective, observational study conducted in 30 North American centers, in consecutive patients aged <18 years with a stay>or= 48 hours in a PICU. The primary outcome measure was the incidence of multiple organ dysfunction syndrome after transfusion. The secondary outcomes were 28-day mortality and PICU length of stay. Odds ratios were adjusted for gender, age, number of organ dysfunctions at admission, total number of transfusions, and total dose of transfusion, using a multiple logistic regression model.

RESULTS: The median length of storage was 14 days in 296 patients with documented length of storage. For patients receiving blood stored >or= 14 days, the adjusted odds ratio for an increased incidence of multiple organ dysfunction syndrome was 1.87 (95% CI 1.04;3.27, P = 0.03). There was also a significant difference in the total PICU length of stay (adjusted median difference +3.7 days, P < 0.001) and no significant change in mortality.

CONCLUSIONS: In critically ill children, transfusion of red blood cell units stored for >or= 14 days is independently associated with an increased occurrence of multiple organ dysfunction syndrome and prolonged PICU stay.

Design: This is a critical appraisal of the randomized, doubleblind, placebo-controlled trial: Koeman M, van der Ven AJ, Hak E, et al: Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006; 173:1348 –1355.

Findings: This review finds that the study was adequately designed to examine the use of CHX in prevention of VAP. Patients were randomized and follow-up was complete. The results showed that the risk of early VAP (defined as within 48–96 hours) was reduced by 65% (hazards ratio 0.35, 95% confidence interval 0.16–0.79) for those treated with CHX and 55% (hazards ratio 0.45, 95% confidence interval 0.22– 0.93) for those treated with CHX/colistin compared with placebo. Intensive care unit (ICU) mortality, duration of mechanical ventilation, and lengths of ICU/ hospital stay were comparable for all three groups.

Conclusions: It is unclear whether the use of CHX as an oral decontaminant will be applicable to the pediatric intensive care unit population because the study was performed on adults with multiple comorbidities. It appears that the benefits of using CHX to prevent VAP outweigh the risks. But since the duration of ventilation and lengths of ICU/hospital stay were equivalent in each of the three groups, the use of CHX does not seem to impact morbidity and mortality. (Pediatr Crit Care Med 2009; 10:242–245)