Biomedical subjects
R Pettignano
Publications and source records attributed to R Pettignano.
Extracorporeal life support in pediatric acute respiratory failure: we can afford it AND need it.
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Evaluation of an opiate-weaning protocol using methadone in pediatric intensive care unit patients.
OBJECTIVE: To evaluate the efficacy of a standardized opiate-weaning protocol using methadone compared with methadone weaning before protocol development. DESIGN: Time series, prospective study with comparison to historical controls. SETTING: Twenty-bed medical-surgical intensive care unit in an academic children's hospital. PATIENTS: Ten children, aged 6 months to 18 yrs, who received methadone for weaning from continuous opiate infusions for >or=7 days compared with ten patients undergoing weaning by standardized protocol. INTERVENTIONS: Institution of standardized opiate-weaning protocol. MEASUREMENTS AND MAIN RESULTS: Patient age, gender, and diagnosis were similar in both nonprotocol (NP) and protocol (P) groups (p = NS). Days of opiate use were also similar between groups. Nine of ten NP and seven of ten P patients were on continuous fentanyl infusions, and the remainder were on continuous morphine infusions. P patients were weaned significantly faster than NP patients (median, 9 days and 20 days, respectively; p <.001). P patients requiring short-term opiate use also weaned significantly faster than short-term NP patients (median, 5 days and 21.5 days, respectively; p <.001). Withdrawal complications were seen in three NP patients with weaning delayed in two. Two P patients had withdrawal complications with no delay in weaning (p = NS). Significant methadone calculation discrepancy occurred in one NP patient but in no P patients. CONCLUSIONS: Pediatric intensive care unit patients requiring prolonged opiate use can be weaned by using methadone with minimal signs of withdrawal. Use of a standardized weaning protocol decreased time for weaning without increasing the frequency rate of withdrawal symptoms.
Is the leak test reproducible?
BACKGROUND: The leak test is an accepted practice for evaluating airway edema and patient readiness for extubation. Reproducibility and interobserver reliability for this test have not been established. We studied the reproducibility and reliability of the leak test in and among health care professionals. METHODS: Thirteen consecutive intubated patients were tested in triplicate and in blinded fashion by three observers to determine the leak around the endotracheal tube before extubation. All patients were pharmacologically paralyzed and sedated before assessment. RESULTS: Neither interobserver or intraobserver variability was statistically significant when a standardized method was used to determine the leak. CONCLUSION: The leak test is reliable by the same or different observers regardless of varied clinical experience when using a standardized approach to measuring the leak.
Intramural anomalous left coronary artery from the right sinus of Valsalva supported with venoarterial extracorporeal membrane oxygenation.
We report the case of a 14-month-old girl with a wide complex dysrhythmia and cardiogenic shock due to abnormal coronary anatomy. She was kept alive for 20 days by full cardiocirculatory support, using venoarterial extracorporeal membrane oxygenation (VA ECMO). While she was on VA ECMO, a diagnosis was made of extensive myocardial infarction and an anomalous left main coronary artery. The patient was listed for heart transplantation and received a donor heart 20 days after beginning VA ECMO. We discuss the unusual presentation and course of the coronary arteries and the use of VA ECMO to support this patient before heart transplantation.
Total enteral nutrition versus total parenteral nutrition during pediatric extracorporeal membrane oxygenation.
OBJECTIVE: To evaluate the adequacy, tolerance, and complications of enteral nutrition, compared with parenteral nutrition, in pediatric patients requiring extracorporeal membrane oxygenation (ECMO). DESIGN: A retrospective chart review of all patients placed on extracorporeal life support from January 1991 through December 1995. SETTING: Medical/surgical pediatric intensive care unit at Egleston Children's Hospital, a tertiary care pediatric center. PATIENTS: Twenty-nine consecutive pediatric patients who required ECMO and were provided nutritional support, either enterally or parenterally. Group A consisted of 14 patients who were provided nutritional support using total parenteral nutrition. Group B consisted of 15 patients. Two patients were excluded from group B because their ECMO run was <36 hrs, leaving insufficient data for analysis. The remaining 13 patients were provided total enteral nutrition during ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Both groups were similar in age, weight, pre-ECMO oxygenation index, alveolar-arterial oxygen difference, type, and duration of ECMO (p = NS). Comparison of percent ideal body weight on admission did not show a statistical difference between groups A and B (p = .883). There was no difference between the two groups in the time needed to achieve caloric goal (p = .536) from the initiation of ECMO. No complications were associated with the utilization of enteral feedings. Savings for the nutritional supplement was estimated to be $170 per day for the enterally fed group. The percentage of patients surviving was higher in the enterally fed patients compared with the parenterally fed group (79% vs. 100%), although this difference was not statistically significant (p = .47). CONCLUSIONS: Enteral nutrition in patients receiving either venoarterial or venovenous ECMO is well tolerated, provides adequate nutrition, is cost effective, and is without complications, as compared with parenteral nutrition. These data suggest that total enteral nutrition can be safely administered for nutritional support in pediatric patients undergoing either venoarterial or venovenous ECMO.
Cost of extracorporeal life support in pediatric patients with acute respiratory failure.
OBJECTIVES: To determine the impact of extracorporeal life support (ECLS) on mortality in pediatric patients with acute hypoxemic respiratory failure (AHRF) at our institution; and to calculate the hospital charges associated with the use of ECLS. DESIGN: Retrospective review of medical records and hospital charges. SETTING: Pediatric intensive care unit (ICU) of a university-affiliated children's hospital. PATIENTS: Twenty patients admitted to the pediatric ICU between 1991 and 1995 for AHRF who received ECLS as a part of their hospital course. INTERVENTIONS: Predicted mortality was calculated using the Pediatric Respiratory Failure score and was compared with survival at the time of hospital discharge. Hospital charges were used as a proxy for resource utilization. Cost-per-life-year-saved calculations were performed based on a normal life expectancy for survivors. MEASUREMENTS AND MAIN RESULTS: Twenty patients were identified. The median age was 4.83 yrs. The median duration of ECLS was 9 days, with 19.5 days in the pediatric ICU and 23.5 days for the entire hospital length of stay. The observed mortality rate for these patients was 20%. Median predicted mortality rate based on the Pediatric Respiratory Failure score calculation was 83%. The hospital charges incurred by these patients was a median of $199,096. Based on a normal life expectancy for survivors, this results in a cost of $4,190/life-year. CONCLUSIONS: ECLS for the pediatric patient with AHRF is done at a considerable cost. However, ECLS affects survival favorably, and compares favorably when considering cost/life-year calculations. The data presented in this study may serve as a benchmark for comparison with newer therapies (i.e., liquid ventilation, nitric oxide). These data also provide a framework for cost-based analyses at other ECLS institutions.
Daily cranial ultrasounds during ECMO: a quality review/cost analysis project.
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The use of cephalad cannulae to monitor jugular venous oxygen content during extracorporeal membrane oxygenation.
BACKGROUND: When used during extracorporeal membrane oxygenation (ECMO), jugular venous bulb catheters, known as cephalad cannulae, increase venous drainage, augment circuit flow and decompress cerebral venous pressure. Optimized cerebral oxygen delivery during ECMO may contribute to a reduction in neurological morbidity. This study describes the use of cephalad cannulae and identifies rudimentary data for jugular venous oxygen saturation (JVO2) and arterial to jugular venous oxygen saturation difference (AVDO2) in this patient population. RESULTS: Patients on venoarterial (VA) ECMO displayed higher JVO2 (P < 0.01) and lower AVDO2 (P = 0.01) than patients on venovenous (VV) ECMO (P < 0.01). During VV ECMO, JVO2 was higher and AVDO2 lower when systemic pH was < 7.35 rather than > 7.4 (P = 0.01). During VA ECMO, similar differences in AVDO2 but not in JVO2 were observed at different pH levels (P = 0.01). CONCLUSIONS: Jugular venous saturation and AVDO2 were influenced by systemic pH, ECMO type and patient age. These data provide the foundation for normative values of JVO2 and AVDO2 in neonates and children treated with ECMO.
Plastic bronchitis: an unusual complication associated with sickle cell disease and the acute chest syndrome.
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Cisapride-induced dysrhythmia in a pediatric patient receiving extracorporeal life support.
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