Enhance quality care performance: Determination of the variables for establishing a common database in French paediatric critical care units

Abstract Selected variables for the French Paediatric Intensive Care registry. Rationale, aims, and objectives Providing quality care requires follow-up in regard to clinical and economic activities. Over the past decade, medical databases and patient registries have expanded considerably, particularly in paediatric critical care medicine (eg, the Paediatric Intensive Care Audit Network (PICANet) in the UK, the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry in Australia and New Zealand, and the Virtual Paediatric Intensive Care Unit Performance System (VPS) in the USA). Such a registry is not yet available in France. The aim of this study was to determine variables that ought to be included in a French paediatric critical care registry. Methods Variables, items, and subitems from 3 foreign registries and 2 French local databases were used. Items described each variable, and subitems described items. The Delphi method was used to evaluate and rate 65 variables, 90 items, and 17 subitems taking into account importance or relevance based on input from 28 French physicians affiliated with the French Paediatric Critical Care Group. Two ratings were used between January and May 2013. Results Fifteen files from 10 paediatric intensive care units were included. Out of 65 potential variables, 48 (74%) were considered to be indispensable, 16 (25%) were considered to be optional, and 1 (2%) was considered to be irrelevant. Out of 90 potential items, 62 (69%) were considered to be relevant, 23 (26%) were considered to be of little relevance, and 5 (6%) were considered to be irrelevant. Out of 17 potential subitems, 9 (53%) were considered to be relevant, 6 (35%) were considered to be of little relevance, and 2 (12%) were considered to be irrelevant. Conclusions The necessary variables that ought to be included in a French paediatric critical care registry were identified. The challenge now is to develop the French registry for paediatric intensive care units

Surveillance de la balance hydrique en Réanimation Pédiatrique (le calcul du bilan entrées-sorties est-il un bon outil ?)

Le suivi de la balance hydrique en Unité de Réanimation Pédiatrique (URP) est réalisé par des pesées ou des calculs du bilan entrées-sorties (BES). Principal: Étudier la fiabilité du BES en URP pour estimer les variations de la balance hydrique. Secondaires: Comparer deux formules de calcul du BES avec ou sans la prise en compte des pertes insensibles. Évaluer le coût en temps de travail infirmier et la facilité d'utilisation du BES et de la pesée. Étudier dévolution de la précision du BES sur deux périodes de 24h. Étude prospective monocentrique conduite dans l'URP de l'hôpital Robert Debré du 01 Juin au 16 Août 2011. Analyse de la corrélation entre BES et pesée par régression linéaire. Analyse de la concordance entre BES et pesée par le test de Bland et Altman. Comparaison des temps nécessaires à chaque technique et des évaluations de la facilité d'utilisation de chaque outil par un modèle mixte linéaire. Les variations de la balance hydrique calculées par BES et mesurées par les pesées sont associées de façon significative (r2=0,52, r2=0,55, p<0,001). Le test de Bland et Altman montre une concordance pauvre entre les deux techniques (précision sans et avec les pertes insensibles +-SD): 0,3811 +-0,4501 et 0,3011 +-0,4471. Il n'y a pas de différence significative entre le temps nécessaire au BES et à la pesée ni dans l'évaluation de leur facilité d'utilisation respective. Le BES avec ou sans prise en compte des pertes insensibles n'est pas fiable pour évaluer la balance hydrique en URP malgré un coût en temps de travail infirmier et une facilité d'utilisation comparable.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Contrôle respiratoire néonatal (le phénotype des souris mutantes Mash-1)

A LA NAISSANCE, LE CONTROLE DE LA RESPIRATION EST MARQUE PAR UNE GRANDE INSTABILITE QUI PEUT CONTRIBUER A L'AUGMENTATION DE LA FREQUENCE DES APNEES, AUX MALAISES GRAVES ET A LA MORT SUBITE DU NOURRISSON. LE SYNDROME D'HYPOVENTILATION ALVEOLAIRE CENTRALE CONGENITALE (SHACC) EST LA MIEUX CARACTERISEE DE CES ANOMALIES ET POURRAIT ETRE DU A UN DEFAUT DE DEVELOPPEMENT DE LA CRETE NEURALE. NOTRE HYPOTHESE EST QUE MASH-1, UN FACTEUR DE TRANSCRIPTION PARTICIPANT A LA DETERMINATION NEURONALE DES CELLULES DE LA CRETE NEURALE, EST IMPLIQUE DANS LE CONTROLE RESPIRATOIRE NEONATAL. NOUS AVONS DEVELOPPE DES METHODES D'EXPLORATION NON-INVASIVES DU CONTROLE RESPIRATOIRE PAR PLETHYSMOGRAPHIE CORPS-ENTIER CHEZ LE SOURICEAU NOUVEAU-NE, ET MONTRE D'IMPORTANTES MODIFICATIONS DE CE CONTROLE DURANT LES DEUX PREMIERS JOURS DE VIE. CELLES-CI CONCERNENT LA VENTILATION DE BASE, LA REPONSE HYPERPNEIQUE A L'HYPERCAPNIE, LA REPONSE BIPHASIQUE ET LA REACTION D'EVEIL A L'HYPOXIE. NOUS AVONS APPLIQUE CES METHODES D'EXPLORATION A L'ETUDE DU PHENOTYPE RESPIRATOIRE DU SOURICEAU TRANSGENIQUE MASH-1. LES SOURICEAUX MASH-1-/- PRESENTENT UN FAIBLE SCORE D'ADAPTATION A LA VIE EXTRA-UTERINE, DES ANOMALIES DE LA FREQUENCE RESPIRATOIRE, ET MEURENT RAPIDEMENT. LES MASH-1+/- SURVIVENT MAIS PRESENTENT LES MEMES ANOMALIES RESPIRATOIRES. LA PERTE DE FONCTION DE MASH-1 PERTURBE L'EXPRESSION DU PROTO-ONCOGENE RET DANS DES STRUCTURES NORADRENERGIQUES DU TRONC CEREBRAL QUI MODULENT LA FREQUENCE RESPIRATOIRE (NOYAUX A5 ET A6), AINSI QUE DANS DES CELLULES DE LA PARTIE VENTROLATERALE DU BULBE (HYBRIDATION IN SITU). LE NIVEAU INTERMEDIAIRE D'EXPRESSION DE RET DANS LE TRONC CEREBRAL DES MASH-1+/- (PCR QUANTITATIVE) PEUT EXPLIQUER LEUR PHENOTYPE ATTENUE. CES RESULTATS MONTRENT QUE MASH-1 EST IMPLIQUE DANS LE DEVELOPPEMENT DU CONTROLE RESPIRATOIRE AU TRAVERS DE L'EXPRESSION DE RET DANS LES STRUCTURES NORADRENERGIQUES DU TRONC CEREBRAL. CES DONNEES QUALIFIENT MASH-1 COMME UN DES GENES CANDIDATS DU SHACC.At birth, the control of breathing shows a large instability, which may increase apnea frequency, and provoke life threatening events and sudden infant death. The Central Congenital Hypoventilation Syndrome (CCHS), which is the best characterized of these disorders, is possibly due to a defect 0f neural crest development. We hypothesized that Mash-1, a transcription factor that contributes to the neural crest celis determination, is involved in the control of breathing at birth. We developed methods to explore non-invasively the control of breathing in newbom mice, using whole-body plethysmography. We showed important changes in this control during the first two days of life. These changes concerned in particular the baseline breathing, the hyperpneic response to hypercapnia, and the biphasic and arousal response to hypoxia. We applied these methods,to respiratory phenotype 0f Mash-1 transgenic newborn mice. The Mash-1-/- newborns showed a low adaptation score to extra-uterine life, breathing frequency abnormalities and they died soon after birth. The Mash-1+/- survived, although they showed the same breathing abnormalities. The Ioss-of-function 0f Mash-1 impaired Ret proto-oncogene expression in noradrenergic brainstem structures that modulate respiratory frequency (A5 and A6 nuclei), and in scattered cells 0f ventrolateral medulla (in situ hybridization). The intermediate level 0f Ret expression in Mash-1+/- brainstem (quantitative PCR) may account for their intermediate phenotype. These data showed that Mash-1 is involved in the development of breathing control through Ret expression in brainstem noradrenergic structures. This result designates MASH-1 as a candidate gene for CCHS.PARIS12-CRETEIL BU Multidisc. (940282102) / SudocSudocFranceF

Estimating 'lost heart beats' rather than reductions in heart rate during the intubation of critically-ill children.

PURPOSE: Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication. METHODS: Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats. RESULTS: 333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0-1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15-83]). During intubation the median number of lost beats was 8 [1]-[32] when atropine was not used compared to 0 [0-0] when atropine was used (p50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range

The ECGs of four intubations are shown to demonstrate loss of beats.

<p>Strip ‘A’ shows heart rate variability from a minimum of 135 beats/min to a maximum of 165 beats/min which is similar to that of the one minute pre-intubation strip, no loss of beats is recorded. Strip ‘B’ shows variation form 175 beats/min to a short deceleration of 108 beats/min which results in the loss of one heart beat. Strip ‘C’ shows a longer deceleration from 110 to 67 beats/min which results in the loss of six beats and strip ‘D’ a prolonged deceleration from 142 to 87 beats/min which results in the loss of 25 beats.</p

Flow chart of inclusions, non-inclusions and exclusions with the number of intubations available for analysis according to atropine use.

<p>Flow chart of inclusions, non-inclusions and exclusions with the number of intubations available for analysis according to atropine use.</p

Hyponatremia in children under 100 days old: incidence and etiologies

Hyponatremia is one of the most common electrolyte disorders in hospitalized children. The underlying mechanisms are poorly understood and potentially multifactorial, making management difficult, particularly in neonates. This retrospective study aimed to determine the incidence and etiologies of hyponatremia in hospitalized children under the age of 100 days, in our pediatric tertiary care hospital over a 1-year period. The etiology of hyponatremia was determined by reviewing the data noted in each patient's medical reports. Neonatal hyponatremia had a prevalence of 4.3% (86/2012 patients) and was mostly hospital-acquired (74/86 patients). Fifty-nine patients (68.9%) were preterm neonates. The etiology was iatrogenic in 26 cases (30.2%). In other cases, hyponatremia was due to transient (23 patients, 26.7%) or genetic abnormalities of the renal mineralocorticoid pathway (3 patients, 3.4%), SIADH (12 patients, 14%), digestive disease (3 patients, 3.5%), acute renal failure (3 patients, 3.5%), or heart failure (1 patient, 1.2%).Conclusion: Our findings confirm that hyponatremia is a frequent electrolyte disorder in neonates. Various mechanisms underlie this condition, most of which could be prevented by optimized management. The prevalence of genetic hypoaldosteronism and pseudohypoaldosteronism was higher than expected. We provide a simple diagram to help physicians identify the mechanisms underlying neonatal hyponatremia. What is Known: • In neonates, hyponatremia may be multifactorial, making it difficult to treat. • Newborns display partial resistance to aldosterone, and preterms have a defect in aldosterone secretion. What is New: • Four percent of hospitalized neonates had hyponatremia, 86% hospital-acquired. Hyponatremia was due to a transient or constitutional defect of the mineralocorticoid pathway in 26/86 patients (30%) which is higher than expected. • We propose a tree diagram for improving the management of hyponatremia in neonates