Bernier Meghan L, Romer Lewis H, Bembea Melania M
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Crit Care Explor. 2019 Aug 9;1(8):e0037. doi: 10.1097/CCE.0000000000000037. eCollection 2019 Aug.
Pulmonary hypertension is a growing pediatric problem and children may present with pulmonary hypertensive crisis-a life-threatening emergency requiring acute interventions. The aim of this study was to characterize the broad spectrum of care provided in North American PICUs for children who present with pulmonary hypertensive crisis.
Electronic cross-sectional survey. Survey questions covered the following: demographics of the respondents, institution, and patient population; pulmonary hypertension diagnostic modalities; pulmonary hypertension-specific pharmacotherapies; supportive therapies, including sedation, ventilation, and inotropic support; and components of multidisciplinary teams.
PICUs in the United States and Canada.
Faculty members from surveyed institutions.
None.
The response rate was 50% of 99 identified institutions. Of the respondents, 82.2% were pediatric intensivists from large units, and 73.9% had over a decade of experience beyond training. Respondents provided care for a median of 10 patients/yr with acute pulmonary hypertensive crisis. Formal echocardiography protocols existed at 61.1% of institutions with varying components reported. There were no consistent indications for cardiac catheterization during a pulmonary hypertensive crisis admission. All institutions used inhaled nitric oxide, and enteral phosphodiesterase type 5 inhibitor was the most frequently used additional targeted vasodilator therapy. Milrinone and epinephrine were the most frequently used vasoactive infusions. Results showed no preferred approach to mechanical ventilation. Fentanyl and dexmedetomidine were the preferred sedative infusions. A formal pulmonary hypertension consulting team was reported at 51.1% of institutions, and the three most common personnel were pediatric cardiologist, pediatric pulmonologist, and advanced practice nurse.
The management of critically ill children with acute pulmonary hypertensive crisis is diverse. Findings from this survey may inform formal recommendations - particularly with regard to care team composition and pulmonary vasodilator therapies - as North American guidelines are currently lacking. Additional work is needed to determine best practice, standardization of practice, and resulting impact on outcomes.
肺动脉高压在儿科中日益常见，儿童可能会出现肺动脉高压危象——这是一种危及生命的紧急情况，需要进行紧急干预。本研究的目的是描述北美儿科重症监护病房（PICU）为出现肺动脉高压危象的儿童提供的广泛护理情况。
电子横断面调查。调查问题涵盖以下方面：受访者、机构和患者群体的人口统计学特征；肺动脉高压的诊断方式；肺动脉高压特异性药物治疗；支持性治疗，包括镇静、通气和强心支持；以及多学科团队的组成部分。
美国和加拿大的儿科重症监护病房。
接受调查机构的教职员工。
无。
99家已识别机构的回复率为50%。在受访者中，82.2%是来自大型单位的儿科重症监护医生，73.9%有超过十年的培训后工作经验。受访者每年平均为10例急性肺动脉高压危象患者提供护理。61.1%的机构有正式的超声心动图检查方案，报告的组成部分各不相同。在肺动脉高压危象入院期间，心脏导管插入术没有一致的指征。所有机构都使用吸入一氧化氮，肠内5型磷酸二酯酶抑制剂是最常用的额外靶向血管扩张剂治疗。米力农和肾上腺素是最常用的血管活性输注药物。结果显示，对于机械通气没有首选方法。芬太尼和右美托咪定是首选的镇静输注药物。51.1%的机构报告有正式的肺动脉高压咨询团队，最常见的三名人员是儿科心脏病专家、儿科肺病专家和高级执业护士。
急性肺动脉高压危象重症儿童的管理方式多样。本次调查结果可能为正式建议提供参考——特别是在护理团队组成和肺血管扩张剂治疗方面——因为目前缺乏北美指南。需要进一步开展工作以确定最佳实践、实践标准化以及对结果的影响。
