Point-of-Care Ultrasound Measurement of Diaphragm Thickening Fraction as a Predictor of Successful Extubation in Critically Ill Children

2021 ◽  
Author(s):  
Swathy Subhash ◽  
Vasanth Kumar
Keyword(s):  
Mechanical Ventilation ◽  
Point Of Care ◽  
Neuromuscular Disorders ◽  
Spontaneous Breathing Trial ◽  
Invasive Mechanical Ventilation ◽  
Tertiary Care ◽  
Critically Ill Children ◽  
Ultrasound Measurement ◽  
Point Of Care Ultrasound ◽  
Diaphragm Function

AbstractVentilation-induced diaphragm dysfunction can delay weaning from mechanical ventilation. Identifying the optimal time for extubation has always been a challenge for intensivists. Diaphragm ultrasound is gaining immense popularity as a surrogate to measure diaphragm function. We attempted to assess the utility of diaphragm function in predicting extubation success using point-of-care ultrasound examination. We conducted a prospective observational study in a single-center tertiary care pediatric intensive care unit (PICU). All children aged between 1 month and 16 years admitted to the PICU and who underwent invasive mechanical ventilation for more than 24 hours were included in the study. Children who died during mechanical ventilation and those with conditions affecting diaphragm function like neuromuscular disorders, pneumothorax, chronic respiratory diseases, and intraabdominal hypertension were excluded from the study. Diaphragm thickening fraction (DTf) was measured during spontaneous breathing trial and correlated to predict extubation success. We found that DTf is an independent predictor of extubation success. DTf more than or equal to 20% was associated with extubation success with a positive predictive value of 85%. The area under the curve for DTf showed good accuracy.

scholarly journals Point-of-Care Respiratory Muscle Ultrasound in a Child with Medical Complexity

2021 ◽  
Author(s):  
Sigmund Kharasch ◽  
LAUREN SELAME ◽  
Helene Dumas ◽  
Hamid Shokoohi ◽  
Andrew Liteplo ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Adverse Effects ◽  
Point Of Care ◽  
Spontaneous Breathing Trial ◽  
Point Of Care Ultrasound ◽  
Lateral Abdominal Wall ◽  
High Resource ◽  
Weaning Failure ◽  
Medical Complexity ◽  
Expiratory Muscles

Point-of-care ultrasound of the diaphragm is a simple, noninvasive, dynamic bedside evaluation of diaphragm function that involves no ionizing radiation, does not require patient transport, and enables the serial evaluation of diaphragmatic function over time. Adverse effects on the diaphragm attributed to ventilator-induced diaphragm dysfunction include longer weaning times, ventilation time and weaning failure. Recent investigations of point-of-care ultrasound evaluating the expiratory muscles of the lateral abdominal wall have found similar adverse effects of mechanical ventilation on these important respiratory muscles resulting in weaning difficulty as well as impaired airway clearance. Children with medical complexity have significant chronic health conditions that may involve multisystem disease (congenital or acquired), high medical fragility, functional and psychosocial impairment, technology dependence (tracheostomies, mechanical ventilation, feeding tubes) and high resource utilization (frequent and/or prolonged hospitalizations). Weaning children dependent on mechanical ventilation is a common rehabilitation goal that has beneficial effects on the quality of life, ease of care, and functionality for transitioning to home care. We present a case of weaning difficulty in a child with medical complexity and the important role of point-of-care ultrasound in the evaluation of the diaphragm and expiratory muscles during a spontaneous breathing trial.

Peritoneal dialysis in critically ill children in resource-limited setting: A prospective cohort study

2020 ◽  
pp. 089686082097589
Author(s):  
Pallavi Choudhary ◽  
Virendra Kumar ◽  
Abhijeet Saha ◽  
Archana Thakur
Keyword(s):  
Mechanical Ventilation ◽  
Peritoneal Dialysis ◽  
Renal Impairment ◽  
Critically Ill ◽  
Tertiary Care ◽  
Kidney Injury ◽  
Pediatric Intensive Care ◽  
Renal Outcome ◽  
Severe Dengue ◽  
Critically Ill Children

Background: Peritoneal dialysis (PD) is easily available and simple lifesaving procedure in children with renal impairment. There is paucity of reports on efficacy of PD in critically ill children in presence of shock and those requiring mechanical ventilation. Methods: In this prospective observational study, efficacy and outcome of PD were evaluated in 50 critically ill children aged 1 month to 14 years admitted in pediatric intensive care unit of a tertiary care teaching hospital in India. Results: Indication of PD was acute kidney injury (AKI) in 66% of patients followed by chronic kidney disease with acute deterioration due to infectious complications in 34%. Bacterial sepsis was the most common cause of AKI (22%), others being malaria (14%) and severe dengue (12%). At initiation of PD, 26% of patients were in shock and 46% were mechanically ventilated. PD was effective and improvement in pH, bicarbonate, and lactate started within hours, with consistent improvement in estimated glomerular filtration rate by 24 h, which continued till the end of procedure, including the subgroup of patients with shock and mechanical ventilation. Total complications were seen in 14% and of which peritonitis was present in 4.0% of patients. Mortality was seen in 14% (7/50) of patients. Shock at initiation of PD (odds ratio (OR), 5.03; 95% confidence interval (CI), 0.95–26.69; p < 0.04) and requirement of mechanical ventilation (OR, 9.17; 95% CI, 1.01–83.10; p < 0.02) were associated with mortality. Conclusions: Acute PD in critically ill children with renal impairment is a lifesaving procedure. Treatment of shock with resuscitative measures and respiratory failure with mechanical ventilation, along with PD, resulted in favorable renal outcome.

scholarly journals Intensive care resources required to care for critically ill children with focal intracranial infections

2018 ◽  
Vol 22 (4) ◽  
pp. 453-461 ◽  
Author(s):  
Marlina E. Lovett ◽  
Zubin S. Shah ◽  
Melissa Moore-Clingenpeel ◽  
Eric Sribnick ◽  
Adam Ostendorf ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Chart Review ◽  
Sinus Thrombosis ◽  
Invasive Mechanical Ventilation ◽  
Retrospective Chart Review ◽  
Cerebral Venous Sinus Thrombosis ◽  
Critically Ill Children ◽  
Venous Sinus Thrombosis ◽  
Intracranial Infections ◽  
Vasoactive Medications

OBJECTIVEFocal intracranial infections such as intraparenchymal abscesses or localized infections in the epidural or subdural spaces are relatively rare infections associated with both morbidity and mortality in children. Although children with these infections frequently require surgical intervention, there is a paucity of literature describing the critical care resources required to manage these cases. This retrospective chart review was performed to evaluate the resources necessary to care for critically ill children with focal intracranial infections at the authors’ institution.METHODSThe authors performed a retrospective chart review of cases at their institution by using ICD-9/10 codes to identify children admitted to the pediatric intensive care unit (PICU) for either intracranial abscess or extradural and subdural abscess between 2006 and 2016. All notes, medication administration records, laboratory/imaging results, vital signs, microbiological data, and electroencephalogram results were reviewed. Data were extracted to determine the utilization of the following resources: mechanical ventilation, vasoactive medications, and intracranial pressure (ICP) monitoring. The presence of intracranial hypertension, cerebral edema, seizure, and cerebral venous sinus thrombosis were noted. Pediatric cerebral performance category (PCPC) score was determined based upon the neurological exam at discharge.RESULTSA total of 45 children met the inclusion criteria. Their median age was 9 years (IQR 3–14 years). The incidence of focal intracranial infections in children admitted to the PICU was 0.68/1000 PICU admissions in 2006 and 2.81/1000 admissions in 2016. Thirty-nine children (86.7%) underwent neurosurgical intervention. Twenty patients (44%) required invasive mechanical ventilation, 7 (15.6%) received vasoactive medications, and 11 (24%) had an ICP monitor. Clinical seizures were detected in 12 children, including 2 who had both clinical and subclinical seizures; 1 child had subclinical seizures only. Eight children (17.8%) developed cerebral venous sinus thrombosis. The median PCPC score was 1 (interquartile range [IQR] 1–3). The median PICU length of stay was 6.4 days (IQR 2.2–10.2 days). Children with seizures had a significantly longer hospital LOS than children without seizure.CONCLUSIONSIn this single-center, retrospective study, critical care needs for children with focal intracranial infections varied. Most frequently, patients required close neurological monitoring, and almost half required invasive mechanical ventilation. Future studies should focus on further elucidating the resources required to care for these children as well as detecting factors to identify those children most at risk for complications.

scholarly journals A study on symptoms of children mechanically ventilated in a paediatric intensive care unit of a minimum resource setting in tertiary care centre

2019 ◽  
Vol 6 (2) ◽  
pp. 574
Author(s):  
Korisipati Ankireddy ◽  
Aruna Jyothi K.
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Critically Ill ◽  
Tertiary Care ◽  
Limited Resource ◽  
Critically Ill Children ◽  
Invasive Ventilation ◽  
Ventilator Support ◽  
Mechanically Ventilated

Background: Mechanical ventilation, a lifesaving intervention in a critical care unit is under continuous evolution in modern era. Despite this, the management of children with invasive ventilation in developing countries with limited resources is challenging. The study analyses the clinical profile, indications, complications and duration of ventilator care in limited resource settings. Methods: A retrospective study of critically ill children mechanically ventilated in an intensive care unit of a tertiary care government hospital.   Results: A total of 120 children required invasive ventilation during the study period of 1 year. Infants constituted the majority (70%), and males (65%) were marginally more than female children (35%). Respiratory failure was the most common indication for invasive ventilation (55%). The major underlying etiology for invasive ventilation was bronchopneumonia associated with septic shock (30%); and the same also required a prolonged duration of ventilation of >72 hours (35%). Prolonged ventilator support of >72 hours predisposed to more complications as well as a prolonged hospital stay of >2 weeks and above, which was statistically significant. Upper lobe atelectasis (50%) and ventilator associated pneumonia (25%) were the major complications. The mortality rate of present study population was 40% as opposed to the overall mortality of 10%.   Conclusions: Present study highlights that critically ill children can be managed with mechanical ventilation even in limited resource settings. The child should be assessed clinically regarding the tolerance to extubation every day, to minimise the complications associated with prolonged ventilator support.

scholarly journals Point of Care Ultrasound First: An Opportunity to Improve Efficiency for Uncomplicated Pregnancy in the Emergency Department

POCUS Journal ◽  
2021 ◽  
Vol 6 (1) ◽  
pp. 42-44
Author(s):  
Sara Urquhart ◽  
Kendall Stevens ◽  
Mariah Barnes ◽  
Matthew Flannigan
Keyword(s):  
Emergency Department ◽  
Random Sample ◽  
Medical Center ◽  
Point Of Care ◽  
Tertiary Care ◽  
Radiology Department ◽  
Point Of Care Ultrasound ◽  
Tertiary Care Medical Center ◽  
Time To Diagnosis ◽  
Emergency Department Patients

Introduction: Research suggests emergency providers using point-of-care ultrasound (POCUS) to confirm an uncomplicated intrauterine pregnancy (IUP) can decrease emergency department (ED) length of stay (LOS) compared to a radiology department ultrasound (RADUS). The objective of this study was to compare the time to diagnosis and LOS between POCUS and RADUS patients. Methods: This was a retrospective study at one urban medical center. A standardized tool was used to abstract data from a random sample of pregnant patients diagnosed with uncomplicated IUP between January 2016 and December 2017 at a single tertiary care medical center. Microsoft Excel 2010 software was used to measure time intervals, prepare descriptive statistics, and perform Mann-Whitney U tests to compare differences. Results: A random sample of 836 (36%) of the 2,346 emergency department patients diagnosed with an IUP between 8-20 weeks’ gestation during the study period was evaluated for inclusion. Three hundred sixty-six met inclusion criteria and were included in the final analysis. Patients were divided into 2 groups based on which type of ultrasound scan they received first: POCUS (n=165) and RADUS (n=201). Patients who received POCUS were found to have an IUP identified in an average of 48 minutes (95% CI, 43 to 53), while the RADUS group’s mean time to diagnosis was 120 minutes (95% CI 113 to 127) with a difference of 72 minutes (95% CI, 63 to 80; p<0.001). The mean LOS for patients who received POCUS was 132 minutes (95% CI, 122 to 142), while that of the RADUS group was 177 minutes (95% CI 170 to 184) with a difference of 45 minutes (95% CI 32 to 56; p<0.001). The study is limited by its single-center, retrospective design and by lack of blinding of data abstractors. Conclusion: Pregnant emergency department patients diagnosed with an uncomplicated IUP between 8-weeks and 20-weeks’ gestation had statistically significant reduction in time to diagnosis and disposition from the ED if assessed with POCUS as compared to RADUS.

scholarly journals P013: A new efficient and accurate scanning protocol for traumatic pneumothorax

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S67
Author(s):  
A. Bignucolo ◽  
C. Acton ◽  
R. Ohle ◽  
S. Socransky
Keyword(s):  
Ct Scan ◽  
Point Of Care ◽  
Data Extraction ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Point Of Care Ultrasound ◽  
Evidence Based ◽  
Left Hemithorax ◽  
Scanning Protocol ◽  
Scanning Area

Introduction: According to the International Evidence-Based Recommendations for Point-of-Care Lung Ultrasound published in 2012, the sonographic technique for evaluating a patient for a pneumothorax (PTX) “consists of exploration of the least gravitationally dependent areas progressing more laterally” in the supine patient. However, there is a wide variety of scanning protocols in the literature with varying accuracy and complexity. We sought to derive an efficient and accurate scanning protocol for diagnosing pneumothorax using point of care ultrasound in trauma. Methods: We performed a retrospective chart review of a tertiary care trauma registry from Nov 2006 to Aug 2016. We included patients with a PTX diagnosed on computed tomography (CT). Patients were excluded if they did not have an identifiable PTX on the CT scan or if they underwent a tube thoracostomy prior to the CT scan. Penetrating and blunt trauma were eligible. Data were extracted with a standardized data collection tool and 20% of charts reviewed by two reviewers. Pre defined zones were used to map area of PTXs on CT. Sensitivity, specificity and 95% CI are reported for presence of PTXs in each individual or combination of lung zones as identified on CT scan. Results: Data were collection yielded 170 traumatic PTX on chest CT with an average age of 44.2 and 77.8% male. The kappa for data extraction was 0.88. 19.4% of patients had bilateral PTX leading to a total sample size of 203. The average ISS score was 20.7 and 93% of patients survived to discharge. The length of ICU stay and hospital stay was 3.7 and 11.2 days respectively. The most accurate and efficient protocol would involve scanning the inferior border of the clavicle at the para-sternal border and again at the mid-clavicular line down to the cardiac (left hemithorax) and liver lung points (right hemithorax). The sensitivity of this scanning area in the detection of PTXs was 91.6% (95% CI 86.9-95%,). Limiting the area to the most anterior point of the chest wall increased the risk of missing a PTX (Sensitivity 89.7% (95%CI 84.6-93.5)). Conclusion: We have derived an evidence-based standardized accurate and efficient scanning protocol to rule out a pneumothorax on point of care ultrasound.

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