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A Pediatric Approach to Ventilator-Associated Events Surveillance

  • Noelle M. Cocoros (a1), Gregory P. Priebe (a2), Latania K. Logan (a3), Susan Coffin (a4), Gitte Larsen (a5), Philip Toltzis (a6), Thomas J. Sandora (a7), Marvin Harper (a7), Julia S. Sammons (a4), James E. Gray (a8), Donald Goldmann (a7) (a9), Kelly Horan (a1), Michael Burton (a1), Paul A. Checchia (a10), Matthew Lakoma (a1), Shannon Sims (a3), Michael Klompas (a1) (a11) and Grace M. Lee (a1) (a7)...

Abstract

OBJECTIVE

Adult ventilator-associated event (VAE) definitions include ventilator-associated conditions (VAC) and subcategories for infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP). We explored these definitions for children.

DESIGN

Retrospective cohort

SETTING

Pediatric, cardiac, or neonatal intensive care units (ICUs) in 6 US hospitals

PATIENTS

Patients ≤18 years old ventilated for ≥1 day

METHODS

We identified patients with pediatric VAC based on previously proposed criteria. We applied adult temperature, white blood cell count, antibiotic, and culture criteria for IVAC and PVAP to these patients. We matched pediatric VAC patients with controls and evaluated associations with adverse outcomes using Cox proportional hazards models.

RESULTS

In total, 233 pediatric VACs (12,167 ventilation episodes) were identified. In the cardiac ICU (CICU), 62.5% of VACs met adult IVAC criteria; in the pediatric ICU (PICU), 54.2% of VACs met adult IVAC criteria; and in the neonatal ICU (NICU), 20.2% of VACs met adult IVAC criteria. Most patients had abnormal white blood cell counts and temperatures; we therefore recommend simplifying surveillance by focusing on “pediatric VAC with antimicrobial use” (pediatric AVAC). Pediatric AVAC with a positive respiratory diagnostic test (“pediatric PVAP”) occurred in 8.9% of VACs in the CICU, 13.3% of VACs in the PICU, and 4.3% of VACs in the NICU. Hospital mortality was increased, and hospital and ICU length of stay and duration of ventilation were prolonged among all pediatric VAE subsets compared with controls.

CONCLUSIONS

We propose pediatric AVAC for surveillance related to antimicrobial use, with pediatric PVAP as a subset of AVAC. Studies on generalizability and responsiveness of these metrics to quality improvement initiatives are needed, as are studies to determine whether lower pediatric VAE rates are associated with improvements in other outcomes.

Infect Control Hosp Epidemiol 2017;38:327–333

Copyright

Corresponding author

Address correspondence to Noelle M. Cocoros, DSc, MPH, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Park Drive, Suite 401, Boston, MA 02215 (Noelle_Cocoros@harvardpilgrim.org).

References

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1. Ventilator-associated event (VAE) protocol. Centers for Disease Control and Prevention website http://www.cdc.gov/nhsn/acute-care-hospital/vae/. Published 2016. Accessed March 15, 2016.
2. Cocoros, NM, Kleinman, K, Priebe, GP, et al. Ventilator associated events in neonates and children—a new paradigm. Crit Care Med 2016;44:1422.
3. Pneumonia (ventilator-associated [VAP] and non-ventilator-associated pneumonia [PNEU]) event. Centers for Disease Control and Prevention website. http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf. Accessed February 21, 2016.
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7. Bouadma, L, Sonneville, R, Garrouste-Orgeas, M, et al. Ventilator-associated events: prevalence, outcome, and relationship with ventilator-associated pneumonia. Crit Care Med 2015;43:17981806.
8. Stevens, JP, Silva, G, Gillis, J, et al. Automated surveillance for ventilator-associated events. Chest 2014;146:16121618.
9. Cirulis, MM, Hamele, MT, Stockmann, CR, et al. Comparison of the new adult ventilator-associated event criteria to the Centers for Disease Control and prevention pediatric ventilator-associated pneumonia definition (PNU2) in a population of pediatric traumatic brain injury patients. Pediatr Crit Care Med 2016;17:157164.
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