Ventilator-assoc PNA (J Pediatr 2009;154:582; Am J Infect Control 2006;34:84)
• Prevention strategies: Hand hygiene, HOB >30°, oral chlorhexidine bid, minimize narcotics, avoid unnecessary stress ulcer ppx (does not seem to ↑ VAP risk in PICU pts). Neuromusc blockers impair gastric emptying. Statistically significant ↓ VAP rate
Stress Ulcer (Pediatr Crit Care 2010;11:124; AACN Adv Crit Care 2007;18:158)
• Pathophysiology: Stress → splanchnic hypoperfusion → gastric mucosal breakdown and impaired gastric motility, leading to prolonged gastric acid exposure
• pH has significant, nonlinear correlation w/ stress ulcer occurrence and bleeding
• pH 7.0 protective, below w/ increased risk
• After bleed, 50% ↓ in clot stability when pH dec from 7.4 to 6.5 (Crit Care Med 2002;30:S351)
• Generally during 3rd–7th ICU d; can cause signif bleed (up to 4× inc mortality)
• Prophylaxis indicated for high risk: Sepsis, shock, operative procedure ≥3 hr, trauma/closed-head injury, status epilepticus, acute renal or hepatic failure, anticoagulation or coagulopathy, burns >35% BSA, concurrent steroids, parenteral nutrition (Crit Care Med 1992;20:1519)
• Regimens: Meta-analysis of available data failed to demonstrate ↓ mortality, ↓ ICU stay, ↓ rate HAP/VAP, ↓ rate ulcer, (Pediatr Crit Care 2010;11:124) did see ↓ erythema on EGD
• Proton pump inhib: Preferred (though no benefit to any specific drug in meta-analysis)
• Most potent (dose dependent, 99% achieve pH = 7), max effect not until 48 hr
• Risks: CYP450 metabolism, poss assoc w/ C. diff infxn, acute interstitial nephritis
• Histamine2-receptor antagonists
• Quicker onset of action but less effective. Maximum achievable gastric pH 4.0–5.0. After 24–48 hr, pH stabilizes at 3.0–4.0
• Risk of thrombocytopenia: Use PPI if Plt <50,000; cimetidine inh cytochrome P450
DVT Prophy (J Trauma 2010;68:52; J Pediatr Child Health 2010;46:288)
• See Pulmonary Embolism in Pulmonary section for details on treatment
• Incidence of DVT 10× lower for children compared to adults
• Major ICU risk factor is CVL (18–26% assoc w/ VTE in ICU). Others include prolonged immobility/paralysis, malignancy, sepsis, surgery/trauma, long-term TPN (up to 66%)
• Peak incidence: Infants w/ CVL & adolesc s/p surgery, prolonged immobilization
• Dx: U/S most often used, but has low sensitivity (30–80%)
• In ICU, a neg U/S does not rule out DVT. If high suspicion, treat until able to confirm w/ contrast CT or venogram (gold standard)
• Hypercoag workup recommended for all patients (same incidence as in adults)
• Prophy: EBM guidelines for ppx in long-term TPN use and complex cardiac patients w/ assoc procedures; extrapolation from adults difficult 2/2 diff in developmental hemostasis (varying levels/response of clotting cascade proteins) & pharmacokinetic/dynamic properties of anticoag agents in children
• Methods: TEDs or pneumoboots, rarely LMWH
• Pediatric evidence: No benefit of prophy in trauma pts <13 yo (J Trauma 2005;59:1345) or w/ warfarin in pedi-onc pts w/ CVL (Acta Paediatr 2006;95:1053)
• Bottom line: Consider prophylaxis for adult-sized patients w/ significant risk factors (long-term immobilization, CVC, malignancy)
Catheter-related Blood Stream Infections (Pediatrics 2011;128:1077)
• Central venous catheters associated w/ ↑ risk nosocomial blood stream infection
• Rate of CRBSI ↓ 56% w/ CVC care bundle (5.2/1,000 line d to 2.3/1,000 line d)
• In one study, rate ↓ from 11.94/1,000 catheter d to 3.05/1,000 w/ efforts to ↓ insertion time and decreased use of parenteral nutrition
• Controversy exists about safety of chlorhexidine skin prep in children, use only if >6 mo