PICU Prophylaxis

GI stress ulcer prophylaxis

• Prospective studies have demonstrated similar rates of GI hemorrhage in adults and children in the intensive care unit (up to 10%) (Chaibou, Pediatrics 1998)

• Risk factors include respiratory failure, coagulopathy PRISM >10, circulatory shock, multitrauma, or recent prolonged surgery

• Others have demonstrated mechanical ventilation as a risk factor after multivariate analysis

• Sucralfate, H2 receptor antagonists, and PPIs have all shown efficacy in pediatric patients

• Sucralfate was shown to be less effective in adult patients (Cook et al, NEJM 1998)

• Generally, H2 receptor antagonists used as first line agent

  • Potential adverse events incude: thrombocytopenia, drug interactions, and CNS impairment in the presence of renal injury

• PPI's used as a second line agent

  • Potential adverse events include larger association with ventilator associated pneumonia and C difficile. Cost is also a factor

• Bottom line: Patients on mechanical ventilation, with ARDS, ALI, septic shock, coagulopathy, high dose steroids, or critically ill with high PRISM score should probably be placed on stress ulcer prophylaxis, using H2 receptor antagonists (ie famotidine) as a first line with the addition of PPI's if gastric pH <4 or if there are contradindications to H2 blocker use.

VTE Prophlaxis

Guidelines from CHOP, Raffini et al, Pediatrics 2011.

• Catheters (particularly CVL's and PICC lines) are the leading cause of VTE in hospitalized children

• At risk population for non-catheter related VTE are those 14y old or greater

• Major risk factors include impaired mobility, spinal cord injury, major trauma or recent operation to the lower extremities, acute infections, burns, pregnancy, obesity, oral contraceptives, inflammatory bowel disease, nephrotic syndrome, known congenital or acquired thrombophilia, or history of DVT/PE.

• Generally in those 14-21 years of age, if they are immobile or have risk factors, pneumatic compression devices (SCD's) should be used. Strong consideration for prophylactic anticoagulation should be made for those with several risk factors

Figure 1: CHOP Algorithm for Pediatric VTE Prophylaxis

CLABSI

• Daily reconsideration of whether a line is needed (or needs to be placed in the first place)

• Checklists/insertion bundles but more importantly, maintenance bundles/checklists seem to be key in reducing CLABSI rates

• Strong consideration for the use of tPA for lines which will not draw back or have sluggish flow as clot can become a nidus for infection

• See Vascular Access for catheter selection, number of lumens, catheter position, etc

• IDSA Guidelines re: Catheter Related Infections (2009)

CAUTI

• Generally, nosococomial UTI's have been considered less significant than CLABSI and Ventilator Associated Infections (VAI), although studies have shown an associated threefold increase in mortality as well as increased length of stay and costs

• Most common risk factors: duration of catheterization, female sex, catheter insertion outside the operating room, and the quality of catheter care

• Incidence of 4 per 1000 urinary catheter days in the PICU

• No studies comparing various antibiotic regimens

• Most common organisms: E Coli, Klebsilla, Enterobacter, Proteus, Pseudomonas

References

1) M. Chaibou, M. Tucci, M.A. Dugas, et al.: Clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit: a prospective study.Pediatrics. 102 (4 Pt 1):933-938 1998

2) D. Cook, G. Guyatt, J. Marshall: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group, N Engl J Med. 338 (12):791-797 1998

3) Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatrichospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011 May;127(5):e1326-32. doi: 10.1542/peds.2010-3282. Epub 2011 Apr 4. PubMed PMID: 21464186.