Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom.
Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, United Kingdom.
Pediatr Crit Care Med. 2021 Mar 1;22(3):231-240. doi: 10.1097/PCC.0000000000002631.
Bronchiolitis is a leading cause of PICU admission and a major contributor to resource utilization during the winter season. Management in mechanically ventilated patients with bronchiolitis is not standardized. We aimed to assess whether variations exist in management between the centers and then to assess if differences in PICU outcomes are found.
Retrospective cohort study.
Three tertiary PICUs (Centers A, B, and C) in London, United Kingdom.
Patients under 1 year of age (n = 462) who received invasive mechanical ventilation for acute viral bronchiolitis from 2012-2016.
None.
Retrospective cohort study.
Data collected include all sedative agents administered, 48 hour cumulative fluid balance and location of endotracheal tube (oral or nasal). Primary outcome was duration of invasive mechanical ventilation. A generalized linear model was used to test for differences in duration of invasive mechanical ventilation between centers after adjustment for confounders: corrected gestational age, oxygen saturation index, bacterial coinfection, prematurity, respiratory syncytial virus status, risk of mortality score and comorbidity. Baseline characteristics were similar, other than a higher risk of mortality score at center A and higher admission oxygen saturation index at center C. Center A was associated with utilization of the most benzodiazepine and opiate sedation, the fewest nasal endotracheal tubes, and the highest mean cumulative fluid balance at 48 hours.Center A had an adjusted mean duration of invasive mechanical ventilation that was 44% longer than center C (95% CI, 25-66%; p < 0.001).The majority of confounders had an association with the duration of invasive mechanical ventilation; all were biologically plausible. Corrected gestational age was negatively associated with the duration of invasive mechanical ventilation for preterm infants less than 32 weeks, but not for term or 32-37 week infants (interaction effect). This meant that at a corrected age of 0 months, a less than 32-week infant had a mean duration that was 55% greater than a term infant: this effect had disappeared by 8 months old.
Between-center variations exist in both practices and outcomes. The relationship between these two findings could be further tested through implementation science with "optimal care bundles."
毛细支气管炎是小儿重症监护病房（PICU）收治的主要原因，也是冬季资源利用的主要原因。机械通气治疗毛细支气管炎患者的管理尚未标准化。我们旨在评估中心之间的管理是否存在差异，然后评估是否存在不同的 PICU 结果。
回顾性队列研究。
英国伦敦的三个三级 PICU（中心 A、B 和 C）。
2012-2016 年期间因急性病毒性毛细支气管炎接受有创机械通气治疗且年龄在 1 岁以下的患者（n=462）。
无。
回顾性队列研究。
收集的数据包括所有给予的镇静剂、48 小时累积液体平衡和气管内导管位置（口腔或鼻腔）。主要结局是有创机械通气的持续时间。使用广义线性模型在调整混杂因素（校正胎龄、氧饱和度指数、细菌合并感染、早产、呼吸道合胞病毒状态、死亡风险评分和合并症）后测试中心之间有创机械通气持续时间的差异。除中心 A 的死亡风险评分较高和中心 C 的入院氧饱和度指数较高外，各中心的基线特征相似。中心 A 与使用最多的苯二氮䓬类和阿片类镇静剂、使用最少的鼻腔气管内导管以及 48 小时内最高平均累积液体平衡有关。中心 A 的有创机械通气持续时间比中心 C 长 44%（95%CI，25-66%；p<0.001）。大多数混杂因素与有创机械通气的持续时间有关；所有因素均具有生物学合理性。校正胎龄与小于 32 周的早产儿的有创机械通气持续时间呈负相关，但与足月或 32-37 周的婴儿无关（交互效应）。这意味着在校正年龄为 0 个月时，小于 32 周的婴儿的平均持续时间比足月婴儿长 55%：这种影响在 8 个月大时已经消失。
中心之间在实践和结果方面存在差异。这两个发现之间的关系可以通过“最佳护理包”的实施科学进一步测试。
