High-Flow Nasal Cannula in the Pediatric ICU: Popular or Efficient?

High-flow nasal cannula (HFNC) delivers a heated and humidified gas mixture at a flow greater than patient inspiratory flow demand. Several physiological studies have evaluated HFNC in neonates, infants, children, and adults. These found that HFNC improves gas exchange, applies positive pressure, flushes anatomical dead space, and decreases work of breathing. In adults, the FLORALI trial3 was the first to provide evidence of HFNC superiority over noninvasive ventilation (NIV) and standard oxygenation, which places the HFNC as the primary respiratory support for adults with hypoxemic acute respiratory failure

Evaluation d'un système sentinelle de lutte et de surveillance des infections nosocomiales en réanimation et néonatologie

DIJON-BU Médecine Pharmacie (212312103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Nasal high flow in management of children with status asthmaticus: a retrospective observational study

Abstract Background Asthma is the most common obstructive airway disease in children and adults. Nasal high flow (NHF) is a recent device that is now used as a primary support for respiratory distress. Several studies have reported use of NHF as a respiratory support in status asthmaticus; however, there are no data to recommend such practice. We therefore conducted this preliminary study to evaluate NHF therapy for children with status asthmaticus admitted to our PICU in order to prepare a multicentre randomized controlled study. Results Between November 2009 and January 2014, 73 patients with status asthmaticus were admitted to the PICU, of whom 39 (53%) were treated with NHF and among these 10 (26%) presented severe acidosis at admission (pH < 7.30). Thirty-four less severe children (41%) were treated with standard oxygen. For one child (2.6%) NHF failed and was then switched to non-invasive ventilation. NHF was discontinued in another patient because of the occurrence of pneumothorax after 31 h with NHF; the patient was then switched to standard oxygen therapy. Mean ± SD heart rate (165 ± 21 vs. 141 ± 25/min, p < 0.01) and respiratory rate (40 ± 13 vs. 31 ± 8/min, p < 0.01) decreased significantly, and blood gas improved in the first 24 h. In the subgroup of patients with acidosis, median [IQR] pH increased significantly between hour 0 and 2 (7.25 [7.21–7.26] vs. 7.30 [7.27–7.33], p = 0.009) and median [IQR] pCO2 decreased significantly (7.27 kPa [6.84–7.91 vs. 5.85 kPa [5.56–6.11], p = 0.007). No patient was intubated. Conclusion This retrospective study showed the feasibility and safety of NHF in children with severe asthma. Blood gas and clinical parameters were significantly improved during the first 24 h. NHF failed in only two patients, and none required invasive ventilation

Neurally adjusted ventilator assist (NAVA) reduces asynchrony during non-invasive ventilation for severe bronchiolitis

To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis. Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes. Methods This prospective physiological study was performed in a university hospital's paediatric intensive care unit and included 11 children (aged 35.2?±?23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2?hr in PAC mode followed by 2?hr in NAVA mode. Electrical activity of the diaphragm and pressure curves were recorded for 10?min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analyzed, and the asynchrony index was calculated for each period. Results The asynchrony index was lower during NAVA than during PAC (3?±?3% vs. 38?±?21%, P

Interest of high‑flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) during the initial management of severe bronchiolitis in infants: a multicenter randomized controlled trial

International audienceIntroduction The aim of this study was to evaluate the long-term effects of the implementation of “good laboratory test practices” pro-cedure on blood test prescription, cost cutting laboratory test and patient outcome and red cells transfusion needs. In addition, we looked for factors associated with transfusion.Patients and methods This is a retrospective, single-center study.Considering that prescription of laboratory tests was excessive in our ICU, we developed in 2009 a procedure aiming at limiting assays and blood sampling. All adult patients over 18 years admitted in the ICU from January 1, 2008, to December 31, 2012, were consecutively included. For each patient, the following data were retrospectively obtained from medical records and institutional databases: demo-graphic and severity of illness parameters, the amount and costs of laboratory tests, daily blood volume drawn, number of red cells trans-fusions and ICU and in-hospital outcomes.Results A total of 3568 patients were included between January 1, 2008, and December 31, 2012. Patient’s characteristics were similar during the study with respect to overall severity and vital organ sup-port, except the need for vasoactive drugs which increased across time. After implementation of guidelines, the total number of labora-tory tests decreased from 78,406 in 2008 (18.1 tests/patient/day) to 27,514 in 2012 (6.4 tests/patient/day). 318,000€ were saved in 2012 on the five more expensive tests as compared to 2008. Average daily blood drawn volume decreased from 29.2 ± 13 ml/day in 2008 to 22.4 ± 10.1 ml/day (p < 0.001) in 2012 in the whole population. The decline was larger for transfused patients (33.8 ± 15.6 ml/day in 2008 to 23.6 ± 10.7 ml/day in 2012 p < 0.001). We observed a nonsignifi-cant reduction in PRBC administered after the institution of guidelines. Hemoglobin threshold for blood transfusion remained unchanged over time. There was a significant relationship between daily blood volume loss and blood transfusion [OR 1.012 per ml volume drawn CI (1.009–1.014), p < 0.001], but mechanical ventilation, renal replace-ment, invasive monitoring and use of vasoactive drugs were more potent independent factors for transfusion. ICU and in-hospital mor-tality did not change across time (p= 0.367 and p= 0.361)Conclusion Guidelines of laboratory tests prescription led to a sus-tained reduction in the number of laboratory tests and related costs, the average daily blood volume drawn, without changing the ICU and in-hospital mortality. Although there was a correlation between the amount of blood sampled and the transfusion of PRBC, the number of patients transfused and the amount of red blood cells transfused did not significantly decrease

Malignant pertussis in infants: factors associated with mortality in a multicenter cohort study

International audienceBackground: Malignant pertussis (MP) affects young infants and is characterized by respiratory distress, perpetual tachycardia and hyperleukocytosis up to 50 G/l, leading to multiple organ failure and death in 75% of cases. Leukodepletion may improve prognosis. A therapeutic strategy based on leukodepletion and extracorporeal life support (ECLS) according to different thresholds of leucocytes has been proposed by Rowlands and colleagues. We aimed at identifying factors associated with death and assess whether the respect of the Rowlands' strategy is associated with survival.Methods: We reviewed all MP infants hospitalized in eight French pediatric intensive care units from January 2008 to November 2013. All infants younger than 3 months of age, admitted for respiratory distress with a diagnosis of pertussis and WBC count ≥ 50 G/l were recorded. Evolution of WBC was analyzed and an optimal threshold for WBC growth was obtained using the ROC-curve method. Clinical and biological characteristics of survivors and non-survivors were compared. Therapeutic management (leukodepletion and/or ECLS) was retrospectively assessed for compliance with Rowlands' algorithm (indication and timing of specific treatments).Results: Twenty-three infants were included. Nine of 23 (40%) died: they presented more frequently cardiovascular failure (100% vs 36%, p = 0.003) and pulmonary hypertension (PHT; 100% vs 29%, p = 0.002) than survivors and the median [IQR] WBC growth was significantly faster among them (21.3 [9.7-28] G/l/day vs 5.9 [3.0-6.8] G/l/day, p = 0.007). WBC growth rate > 12 G/l/day and lymphocyte/neutrophil ratio < 1 were significantly associated with death (p = 0.001 and p = 0.003, respectively). Ten infants (43%) underwent leukodepletion, and seven (30%) underwent ECLS. Management following Rowlands' strategy was associated with survival (100% vs 0%; p < 0.001, relative risk of death = 0.18, 95%-CI [0.05-0.64]).Conclusions: A fast leukocyte growth and leukocytosis with neutrophil predominance during acute pertussis infection were associated with death. These findings should prompt clinicians to closely monitor white blood cells in order to early identify infants at risk of fatal outcome during the course of malignant pertussis. Such an early signal in infants at high risk of death would increase feasibility of compliant care to Rowlands' strategy, with the expectation of a better survival

Predictive Value of Optic Nerve Sheath Diameter for Diagnosis of Intracranial Hypertension in Children With Severe Brain Injury

International audienceBackground and Aims Intracranial Hypertension (ICH) is a life-threatening complication of brain injury. The invasive measurement of intracranial pressure (ICP) remains the gold standard to diagnose ICH. Measurement of Optic Nerve Sheath Diameter (ONSD) using ultrasonography is a non-invasive method for detecting ICH. However, data on paediatric brain injury are scarce. The aim of the study was to determine the performance of the initial ONSD measurement to predict ICH occurring in children with severe brain injury and to describe the ONSD values in a control group. Methods In this cross-sectional study, ONSD was measured in children aged 2 months-17 years old with invasive ICP monitoring: before placement of ICP probe and within the 60 min after, and then daily during 3 days. ONSD was also measured in a control group. Results Ninety-nine patients were included, of whom 97 were analysed, with a median (IQR) age of 8.7 [2.3–13.6] years. The median (IQR) PIM 2 score was 6.6 [4.4–9.7] and the median (IQR) PELOD score was 21 [12–22]. Aetiologies of brain injury were trauma ( n = 72), infection ( n = 17) and stroke ( n = 8). ICH occurred in 65 children. The median (IQR) ONSD was 5.58 mm [5.05–5.85]. ONSD performed poorly when it came to predicting ICH occurrence within the first 24 h (area under the curve, 0.58). There was no significant difference between the ONSD of children who presented with ICH within the first 24 h and the other children, with a median (IQR) of 5.6 mm [5.1–5.9] and 5.4 mm [4.9–5.8], respectively. Infants aged less than 2 years had a median (IQR) ONSD of 4.9 mm [4.5–5.2], significantly different from children aged more than 2 years, whose median ONSD was 5.6 mm [5.2–5.9]. Age, aetiology or ICP levels did not change the results. Thirty-one controls were included, with a median age of 3.7 (1.2–8.8) years. The median (IQR) of their ONSD measurement was 4.5 mm [4.1–4.8], significantly lower than the patient group. Conclusion In a paediatric severe brain injury population, ONSD measurement could not predict the 24 h occurrence of ICH. Severity of patients, timing and conditions of measurements may possibly explain these results

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study)

International audiencePURPOSE:Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.METHODS:A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH2O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.RESULTS:From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.CONCLUSION:In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013)

A multicenter randomized controlled trial of a 3-L/kg/min versus 2-L/kg/min high-flow nasal cannula flow rate in young infants with severe viral bronchiolitis (TRAMONTANE 2)

High-flow nasal cannula (HFNC) therapy is increasingly proposed as first-line respiratory support for infants with acute viral bronchiolitis (AVB). Most teams use 2 L/kg/min, but no study compared different flow rates in this setting. We hypothesized that 3 L/kg/min would be more efficient for the initial management of these patients

Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d’Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies

International audienceThe French Emergency Medicine Society, the French Intensive Care Society and the Pediatric Intensive Care and Emergency Medicine French-Speaking Group edited guidelines on severe asthma exacerbation (SAE) in adult and pediatric patients