Respiratory support by neurally adjusted ventilatory assist (NAVA) in severe RSV-related bronchiolitis: a case series report

<p>Abstract</p> <p>Background</p> <p>Neurally adjusted ventilatory assist (NAVA) is a new mode of mechanical ventilation controlled by diaphragmatic electrical signals. The electrical signals allow synchronization of ventilation to spontaneous breathing efforts of a child, as well as permitting pressure assistance proportional to the electrical signal. NAVA provides equally fine synchronization of respiratory support and pressure assistance varying with the needs of the child. NAVA has mainly been studied in children who underwent cardiac surgery during the period of weaning from a respirator.</p> <p>Case presentation</p> <p>We report here a series of 3 children (1 month, 3 years, and 28 days old) with severe respiratory distress due to RSV-related bronchiolitis requiring invasive mechanical ventilation with a high level of oxygen (FiO₂≥50%) for whom NAVA facilitated respiratory support. One of these children had diagnosis criteria for acute lung injury, another for acute respiratory distress syndrome.</p> <p>Establishment of NAVA provided synchronization of mechanical ventilatory support with the breathing efforts of the children. Respiratory rate and inspiratory pressure became extremely variable, varying at each cycle, while children were breathing easily and smoothly. All three children demonstrated less oxygen requirements after introducing NAVA (57 ± 6% to 42 ± 18%). This improvement was observed while peak airway pressure decreased (28 ± 3 to 15 ± 5 cm H₂O). In one child, NAVA facilitated the management of acute respiratory distress syndrome with extensive subcutaneous emphysema.</p> <p>Conclusions</p> <p>Our findings highlight the feasibility and benefit of NAVA in children with severe RSV-related bronchiolitis. NAVA provides a less aggressive ventilation requiring lower inspiratory pressures with good results for oxygenation and more comfort for the children.</p

Admission criteria and management of critical care patients in a pandemic context: position of the Ethics Commission of the French Intensive Care Society, update of April 2021.

Intensive care unit professionals have experience in critical care and its proportionality, collegial decision-making, withholding or withdrawal of treatment deemed futile, and communication with patients' relatives. These elements rely on ethical values from which we must not deviate in a pandemic situation. The recommendations made by the Ethics Commission of the French Intensive Care Society reflect an approach of responsibility and solidarity towards our citizens regarding the potential impact of a pandemic on critical care resources in France, with the fundamental requirement of respect for human dignity and equal access to health care for all

Impact de la mise en place d'un protocole de sédation en réanimation pédiatrique sur les complications liées à une sédation prolongée

La sédation regroupe l'ensemble des moyens destinés à assurer le confort physique et psychique des patients. Une sédation inadéquate peut avoir des conséquences néfastes: augmentation de la durée de ventilation, du risque d'infections nosocomiales, troubles hémodynamiques, échecs d'extubation ou extubations accidentelles, syndrome de sevrage et syndrome de stress post-traumatique (SSPT). Différentes études réalisées chez l'adulte ont montré que la mise en place d'un protocole de sédation-analgésie permettait de diminuer l'incidence de ces complications. Nous faisons l'hypothèse que l'introduction d'un tel protocole, géré par l'équipe infirmière, permettra de diminuer la durée de ventilation de 40% en réanimation pédiatrique. Nous allons réaliser une étude prospective de type avant-après, Pediased , dans le service de réanimation pédiatrique du CHU de Nantes. Les enfants âgés d'1 mois à 18 ans, ventilés plus de 24 heures, seront inclus. L étude se réalisera en trois phases : la première durant 15 mois, évaluant les pratiques actuelles de sédation; la deuxième durant 6 mois, avec écriture et mise en place du protocole ; la troisième durant 15 mois, évaluant l'impact de l'introduction de ce protocole. 120 enfants seront inclus dans chaque phase. Adapter la sédation de façon adéquate pourrait permettre de diminuer les complications liées à une sédation prolongée, si notre hypothèse se confirme. Les enfants chez lesquels un SSPT sera diagnostiqué pourront être suivis de façon appropriée. La connaissance des facteurs de risque du SSPT pourrait permettre la diminution de son incidence. Enfin, l'impact de cette étude pourrait également être économique.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Faltering growth in the critically ill child: prevalence, risk factors, and impaired outcome

Low body mass index (BMI) z score is commonly used to define undernutrition, but faltering growth allows for a complementary dynamic assessment of nutritional status. We studied the prevalence of undernutrition and faltering growth at admission in the pediatric intensive care (PICU) setting and their impacts on outcome. All (685) consecutive children (aged 0 to 18 years old) admitted in a single-center PICU over a 1-year period were prospectively enrolled. Nutritional status assessment was based on anthropometric measurements performed at admission and collected from medical files. Undernutrition was considered when z score BMI for age was &#60; ? 2SD. Faltering growth was considered when the weight for age curve presented a deceleration of &#62; ? 1 z score in the previous 3 months. Undernutrition was diagnosed in 13% of children enrolled, and faltering growth in 13.7% mostly in children with a normal BMI. Faltering growth was significantly associated with a history of underlying chronic disease, and independently with extended length of PICU stay in a multivariate analysis. Conclusion: Assessment of nutritional status in critically ill children should include both undernutrition and faltering growth. This study highlights that faltering growth is independently associated with suboptimal outcome in PICU. What is Known: ? Malnutrition, defined according to BMI-for-age z score, is correlated with poor outcome in the critically ill child. ? In this setting, nutritional assessment should consist not only of a static assessment based on BMI-for-age z score but also of a dynamic assessment to identify recent faltering growth. What is New: ? Critically ill children frequently present with faltering growth at admission. ? Faltering growth is a newly identified independent associated factor of suboptimal outcome in this setting (extended length of stay)

Nutritional status deterioration occurs frequently during childrens’ intensive care unit stay

OBJECTIVES: Malnutrition and faltering growth at PICU admission have been related to suboptimal outcomes. However, little is known about nutritional status deterioration during PICU stay, as critical illness is characterized by a profound and complex metabolism shift, which affects energy requirements and protein turnover. We aim to describe faltering growth occurrence during PICU stay. DESIGN: Single-center prospective observational study. SETTING: Twenty-three-bed general PICU, Lyon, France. PATIENTS: All critically ill children 0-18 years old with length of stay longer than 5 days were included (September 2013-December 2015). INTERVENTIONS: Weight and height/length were measured at admission, and weight was monitored during PICU stay, in order to calculate body mass index for age z score. Faltering growth was defined as body mass index z score decline over PICU stay. Children admitted during the first year of the study and who presented with faltering growth were followed after PICU discharge for 3 months. MEASUREMENTS AND MAIN RESULTS: We analyzed 579 admissions. Of them, 10.2% presented a body mass index z score decline greater than 1 SD and 27.8% greater than 0.5. Admission severity risk scores and prolonged PICU stay accounted for 4% of the variability in nutritional status deterioration. Follow-up of post-PICU discharge nutritional status showed recovery within 3 months in most patients. CONCLUSIONS: Nutritional deterioration is frequent and often intense in critically ill children with length of stay greater than 5 days. Future research should focus on how targeted nutritional therapies can minimize PICU faltering growth and improve post-PICU rehabilitation