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Ventilator-Associated Events in Neonates and Children--A New Paradigm
Noelle M Cocoros1, Ken Kleinman, Gregory P Priebe
11Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.2Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA.3Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA.4Department of Pediatrics, Section of Pediatric Infectious Diseases, Rush University Medical Center, Chicago, IL.5Department of Pediatrics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT.6Department of Pediatrics, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania and Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, PA.7Division of Pediatric Critical Care, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH.8Department of Information Services, Rush University Medical Center, Chicago, IL.9Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.10Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA.11Divisions of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.12Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA.
Insights
Pediatric patients with ventilator-associated conditions face higher mortality and morbidity risks. The study suggests using specific oxygen and pressure thresholds to identify these conditions in children.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Healthcare Outcomes Research
Background:
- Ventilator-associated conditions (VACs) are complications in mechanically ventilated patients.
- Defining pediatric VACs is crucial for accurate risk assessment and management.
- Existing definitions may not adequately capture adverse outcomes in neonates and children.
Purpose of the Study:
- To evaluate potential definitions for pediatric ventilator-associated conditions.
- To determine if proposed VAC definitions correlate with worse patient outcomes.
- To establish a reliable method for identifying VACs in pediatric intensive care units (ICUs).
Main Methods:
- Retrospective cohort study and matched cohort analysis in five U.S. hospitals.
- Inclusion of children aged 18 years or younger requiring mechanical ventilation for at least one day.
- Evaluation of oxygenation and airway pressure thresholds to define VACs, analyzed using Cox proportional hazard models.
Main Results:
- All tested VAC definitions were significantly associated with increased hospital mortality.
- VAC identification correlated with prolonged hospital stays, ICU duration, and ventilation duration.
- A definition using fraction of inspired oxygen increase of 0.25 and mean airway pressure increase of 4 cm H2O was proposed.
Conclusions:
- Pediatric patients with VACs exhibit substantially higher risks of mortality and morbidity.
- The chosen VAC definition thresholds are applicable across different ICU types.
- Future research should focus on risk factors, causes, and prevention strategies for pediatric VACs.
Objectives:
To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes.
Design:
Retrospective cohort study and a matched cohort analysis.
Setting:
Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals.
Patients:
Children 18 years old or younger ventilated for at least 1 day.
Interventions:
None.
Measurements And Main Results:
We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1-1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs.
Conclusions:
Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.
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