Ventilator-Associated Events in Neonates and Children--A New Paradigm.

TitleVentilator-Associated Events in Neonates and Children--A New Paradigm.
Publication TypeJournal Article
Year of Publication2016
AuthorsCocoros NM, Kleinman K, Priebe GP, Gray JE, Logan LK, Larsen G, Sammons J, Toltzis P, Miroshnik I, Horan K, Burton M, Sims S, Harper M, Coffin SE, Sandora TJ, Hocevar SN, Checchia PA, Klompas M, Lee GM
Corporate AuthorsPediatric Ventilator-Associated Conditions Study Team
JournalCrit Care Med
Volume44
Issue1
Pagination14-22
Date Published2016 Jan
ISSN1530-0293
KeywordsAdolescent, Child, Child, Preschool, Cohort Studies, Hospital Mortality, Humans, Infant, Infant, Newborn, Retrospective Studies, Ventilators, Mechanical
Abstract

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.

DOI10.1097/CCM.0000000000001372
Alternate JournalCrit. Care Med.
PubMed ID26524075
Grant List1R18HS021636 / HS / AHRQ HHS / United States
5K08AI112506-01 / AI / NIAID NIH HHS / United States