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Pediatrická problematika v intenzivní péči
Doc. MUDr. Michal Fedora, PhD.Klinika dětské anesteziologie a resuscitace LF MU a FN Brno
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62 JIP, 22 057 pts, 1995 - 1998
Gunning K, BMJ 1999; 319: 241 - 244
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PRISM skore
Pollack MM, Crit Care Med 1988; 16: 1110 - 1116
Systolický krevní tlakDiastolický krevní tlakSrdeční frekvencePočet dechůPaO2/FiO2 PaCO2
Glasgow Coma Scale
Reakce zornicPT / PTTCelkový bilirubinKaliumKalciumGlykemieNaHCO3
Predikce mortality během prvních 24 hod i celého pobytu na JIP
Skutečná mortalita, predikovaná mortalita, SMR
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PRISM skore
Srovnání jednotlivých JIP
SMR
∅ délka hospitalisace
∅ délka hospitalisace pro jednotlivou dg.
cena za hospitalisaci
cena za 1 den hospitalisace pro jednotlivou dg.
Srovnání regionů
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Srovnání jednotlivých JIP
Srovnání mortality a péče u dětí s AHRF a KCT za 6 měsíců
JIP III. typu
JIP nižšího typu
mortalita (%)
predikovaná mortalita
Pollack MM, Crit Care Med 1991; 19: 150 - 159
skutečná mortalita
p
23 % 6 % <.00001
29.3
30
p >.4
14
20
<.05
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Paediatric Intensive Care SocietyBritish Paediatric Association
British Paediatric Association. The care of critically ill children. Report of a multidisciplinary working party on intensive care. London: BPA, 1993
rok 1991
29 % standardní oddělení
12 882 dětí, které byly „...identified as having received intensive care“
20 % JIP pro dospělé
51 % PICU
= 2627 dětí: 23 % < 1 rok
5 % < 1 měsíc
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Paediatric Intensive Care SocietyBritish Paediatric Association
Paediatric Intensive Care Society. Standards for paediatric intensive care including standards of practice for the transportation of the critically ill child. Bishop 's Stortford, Herts: Saldatore, 1996
Ashworth W. Inquiry into the care and treatment of Nicholas Geldard. Manchester: North West Regional Health Authority, 1996.
National Coordinating Group on Paediatric Intensive Care. Paediatric intensive care: a framework for the future. London: Department of Health, 1997.
29 PICU
1.2 příjmu na PICU / 1000 dětí / rok
10 PICU < 3 lůžka, 6 PICU > 8 lůžek
1995 zemřel Nicolas Geldard (spontánní intracerebrální krvácení)
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Pearson G, Shann F, Barry P et al:Should paediatric intensive care be centralised? Trent versus Victoria.Lancet 1997; 349: 1213 - 1217
všechny děti přijaté na oddělení intensivní péče věk: 1 měsíc - 16 let
1.4.1994 - 31.3.1995
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Pearson G, Lancet 1997; 349: 1213 - 1217
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Pearson G, Lancet 1997; 349: 1213 - 1217
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Pearson G, Lancet 1997; 349: 1213 - 1217
mortalita:
riziko úmrtí vztažené k závažnosti celkového stavu:
Trent 7.3 % Victoria 5.0 %
Trent vs Victoria 2.09 (95 % CI, 1.37 - 3.19, p < 0.005)
úmrtí „navíc“ v Trentu 31.7 (42.8 %)
Trent: děti < 16 let - 833 000 31.7 úmrtí „navíc“ / rokUK: děti < 16 let - 11 900 000 453 úmrtí „navíc“ / rok
12 PICU pro UK↓ mortality: ET intubace > 12 - 24 hod → PICU
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Ratcliffe J:Provision of intensive care for childrenBMJ 1998; 316: 1547 - 1548
pediatrická intensivní péče bude centralisována
kriteria pro PICU
červenec 1998: dítě, které vyžaduje intensivní péči, nesmí být hospitalisováno na standardním oddělení
2000: kriticky nemocné děti musí být hospitalisovány pouze na PICU
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Pearson G, Barry P, Timmins C et al:Changes in the profile of paediatric intensive care associated with centralisationIntensive Care Med 2001; 27: 1670 - 1673porovnání 2 období 12 měsíců - 1991 a 1999 v Birminghamu a okolí (Trent)
počet pts na PICU 277 vs 5101.3 vs 2.3 příjmu na PICU / 1000 dětí / rok
p < 0.0001
% pts přijatých na PICU 60 % vs 90 % p < 0.0001
délka hospitalisace 103 vs 74 hod p < 0.0001
mortalita ↓ o 34 úmrtí / 100 000 dětí p < 0.0001
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JIRP NsP Most JIP Kliniky popáleninové medicíny FN KV Praha
JIRP DK IPVZ Nemocnice České Budějovice
Dětská JIRP ARK FN Ostrava
JIRP DK FN PlzeňJIRP DK IPVZ Ústí nad Labem JIRP dětské chirurgie FTN Praha
JIRP DK FN Olomouc
JIRP KDDL VFN PrahaARK FN Motol
KDAR FN Brno
JIRP pediatrické kliniky FTN PrahaJIRP DK FN Hradec Králové
JIRP Kliniky dětské chirurgie FN Motol
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1.1.2001 - 1.9.2003 KDAR FN Brno
888 pts
∅ LOS: 5.8 dne
∅ PRISM: 7.3
Zemřelo: 66 pts
Predikovaná mortalita: 8.6 %
Skutečná mortalita: 7.4 %
SMR: 0.87
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% kategorií PRISM
0 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 > 30
53 %
27 %
9 %
4 %3 % 2 % 5 %
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Mortalita v kategoriích PRISM
0 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 > 30
1 pt 0.31
4 pts0.85 3 pts
0.614 pts0.69
10 pts1.15
8 pts1.00
36 pts0.88
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1.1.2001 - 1.9.2003 všechna pracoviště
8014 pts
∅ LOS: 5.2 dne
∅ PRISM: 5.2
Zemřelo: 209 pts
Predikovaná mortalita: 4.2 %
Skutečná mortalita: 2.6 %
SMR: 0.62
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rok 2001 www.simcps.czwww.csarim.cz
2 330 000 dětí v ČR1.6 pt / 1000 dětí / rok
11 900 000 dětí v UK... 12 PICU v UK... 2.3 PICU v ČR
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g r e a te r u s e o f p h y s ic a l e x a m in a t io n t h e r a p e u t ic e n d p o in t s (2 C );d o p a m in e a s th e f i r s t d r u g o f c h o ic e fo r h y p o t e n s io n (2 C ); s t e r o id s o n ly in c h i ld r e n w i t h s u s p e c t e d o r p r o v e n a d r e n a l in s u f f ic ie n c y (2 C ); a n d a r e c o m m e n d a t i o n a g a in s t t h e u s e o f r e c o m b in a n t a c t i v a te d p r o t e in C in c h i ld r e n (1 B ).
g r e a te r u s e o f p h y s ic a l e x a m in a t io n th e r a p e u t ic e n d p o in t s (2 C );d o p a m in e a s th e f i r s t d r u g o f c h o ic e fo r h y p o te n s io n (2 C ); s te r o id s o n ly in c h i ld r e n w i t h s u s p e c te d o r p r o v e n a d r e n a l in s u f f ic ie n c y (2 C ); a n d a r e c o m m e n d a t io n a g a in s t th e u s e o f r e c o m b in a n t a c t iv a te d p r o te in C in c h i ld r e n (1 B ).
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C a r c i l lo J A e t a l, Crit Care Med 2 0 0 2 ; 3 0 : 1 3 6 5 – 1 3 7 8
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Ú v o d n í t e k u t in o v á r e s u s c i t a c e
P o d á n í i.v . k r y s t a lo id (2 0 m l/k g ) b h e m 5 – 1 0 ů ěm in u t
• H R• d iu r e s a• k a p i lá r n í n á v r a t• s t a v v d o m íě
Z a j iš t n í i.v . p í s t u p u u d t í s lo i t jš íě ř ě ž ěÚ v o d n í d á v k a te k u t in 4 0 – 6 0 m l/k gN o rm o te n z e n e n í s p o le h l iv ý m te r a p e u t ic k ý m
c í le m
D e l l in g e r R P e t a l, Crit Care Med 2 0 0 8 ; 3 6 : 2 9 6 – 3 2 7
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Ú v o d n í t e k u t in o v á r e s u s c i t a c e
D e l l in g e r R P e t a l, Crit Care Med 2 0 0 8 ; 3 6 : 2 9 6 – 3 2 7
• n o rm á ln í H R p r o v kě• k a p i lá r n í n á v r a t < 2 s• t e p lé k o n e t in yč• d iu r e s a > 1 m l/k g /h• n o rm á ln í s t a v v d o m íě
T e r a p e u t ic k é c í le :
• n o rm á ln í h o d n o ta la k t á t u• C V P 8 – 1 2 m m H g• S v O 2 (S c v O 2) > 7 0 %
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C a r c i l lo J A , T a s k e r R C , Intensive Care Med 2 0 0 6 ; 3 2 : 9 5 8 – 9 6 1
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C a r c i l lo J A , T a s k e r R C , Intensive Care Med 2 0 0 6 ; 3 2 : 9 5 8 – 9 6 1
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C a r c i l lo J A e t a l, JAMA 1 9 9 1 ; 2 6 6 : 1 2 4 2 – 1 2 4 5
S e p t ic k ý š o k , r e t r o s p e k t iv n í s t u d ie (6 le t), P A C d o 6 h o d d g3 4 p t s , Ø v k 1 3 m sě ě
3 s k u p in y p o d le m n o s t v í t e k u t in b h e m p r v n í h o d in yž ě
1. < 2 0 m l/k g2. 2 0 – 4 0 m l/k g3. > 4 0 m l/k g
p t s
1 41 19
1 . h o d
1 1 ± 63 2 ± 56 9 ± 1 9
6 . h o d
7 1 ± 2 9 1 0 8 ± 5 41 1 7 ± 2 9
m o r t a l i t a
5 7 % 6 3 %1 1 %
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N h a n N T e t a l, CID 2 0 0 1 ; 3 2 : 2 0 4 – 2 1 3
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N h a n N T e t a l, CID 2 0 0 1 ; 3 2 : 2 0 4 – 2 1 3
M o r ta l i t a 0 %
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W il ls B A e t a l , N Engl J Med 2 0 0 5 ; 3 5 3 : 8 7 7 – 8 8 9
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W il ls B A e t a l , N Engl J Med 2 0 0 5 ; 3 5 3 : 8 7 7 – 8 8 9
M o r t a l i t a < 0 .2 %1 / 5 1 2
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Ú v o d n í t e k u t in o v á r e s u s c i t a c e
D e l l in g e r R P e t a l, Crit Care Med 2 0 0 8 ; 3 6 : 2 9 6 – 3 2 7
• n o rm á ln í H R p r o v kě• k a p i lá r n í n á v r a t < 2 s• t e p lé k o n e t in yč• d iu r e s a > 1 m l/k g /h• n o rm á ln í s t a v v d o m íě
T e r a p e u t ic k é c í le :
• n o rm á ln í h o d n o ta la k t á t u• C V P 8 – 1 2 m m H g• S v O 2 (S c v O 2) > 7 0 %
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Ú v o d n í t e k u t in o v á r e s u s c i t a c e
C a r c i l lo J A e t a l, Crit Care Med 2 0 0 2 ; 3 0 : 1 3 6 5 – 1 3 7 8
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C a r c i l lo J A e t a l, Crit Care Med 2 0 0 2 ; 3 0 : 1 3 6 5 – 1 3 7 8
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C e n e v iv a G e t a l, Pediatrics 1 9 9 8 ; 1 0 2 : e 1 9
S e p t ic k ý š o k r e f r a k t e r n í k p o d á n í t e k u t in (> 6 0 m l/k g ),P A C d o 6 h o d d g , 5 0 d t íě
P ts r o z d le n i p o d le h e m o d y n a m ik y a p o u i t í ě žin o t r o p , v a s o p r e s o r a /n e b o v a s o d i la t á t o r s c í le mů ů ů
C I > 3 .3 l/m in /m 2 a S V R I > 8 0 0 d y n /s /c m 5/m 2
1 . C O S V R I↓ ↑ 5 8 % in o t r o p ik a (+ v a s o d i la t a c e )2 . C O S V R I↑ ↓ 2 0 % v a s o p r e s o r3 . C O S V R I↓ ↓ 2 2 % v a s o p r e s o r + in o t r o p ik a
2 8 %1 0 %
9 %
m o r ta l i ta
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N í z k ý C O je s p o je n s v y š š í m o r t a l i t o u u d t í ě(u d o s p lý c h n í z k á S V R )ě
C I > 3 .3 l/m in /m 2
H la v n í d e t e rm in a n t o u V O 2 je D O 2 ,
n ik o l iv O 2e x t ja k o u d o s p lý c h .ě
V O 2 > 2 0 0 m l/m in /m 2
C a r c i l lo J A e t a l, Crit Care Med 2 0 0 2 ; 3 0 : 1 3 6 5 – 1 3 7 8
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d e O l iv e i r a e t a l , Intensive Care Med 2 0 0 8 ; 3 4 : 1 0 6 5 – 1 0 7 5
S e p t ic k ý š o k r e f r a k t e r n í k p o d á n í t e k u t in
1 0 2 p t s
5 1 p t s
S c v O 2 7 0 %≥
5 1 p t s
M o r t a l i t a (2 8 .d e n ) 3 9 .2 % 1 1 .8 % 0 .0 0 2
K r y s ta lo id y (b h e m 6 h ) 5 m l/k gě 2 8 m l/k g < 0 .0 0 0 1
In o t r o p ik a (b h e m 6 h ) 7 .8 % 2 9 .4 %ě 0 .0 1
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C a r c i l lo J A e t a l, Crit Care Med 2 0 0 2 ; 3 0 : 1 3 6 5 – 1 3 7 8
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H a n Y Y e t a l, Pediatrics 2 0 0 3 ; 1 1 2 : 7 9 3 – 7 9 9
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H a n Y Y e t a l, Pediatrics 2 0 0 3 ; 1 1 2 : 7 9 3 – 7 9 9