The Science Journal of the American Association for Respiratory Care

2001 OPEN FORUM Abstracts

ASTHMAMANAGEMENT IN THE PEDIATRIC INTENSIVE CARE UNIT: CASE COMPARISONS.

TheresaRyan Schultz BA, RRT, RN, Shawn Colborn, AS, RRT, Roberta Hales BS, RRT,Richard Lin MD, Andrew T. Costarino MD. The Children?s Hospital of Philadelphia.Philadelphia, PA.

Introduction:Asthma continues to be a leading cause of admission to the pediatric inpatientsetting. In an effort to standardize the approach to care, a clinical pathwaydeveloped and implemented by a multidisciplinary team at our institution resultedin a decreased length of stay with no increase in the re-admission rate1.This in-patient protocol includes the care of mild, moderate and severe asthmaticsin our Asthma Care Unit. Because our experience indicates that approximately10% of the patients admitted for asthma will require admission to the IntensiveCare Unit (ICU), we extended the asthma protocol to include management of thecritically ill patient. This pathway guides us in the management of terbutaline,heliox, mechanical ventilation and Isoflurane.

Methods: A retrospectivereview of admitted ICU patients requiring mechanical ventilation over a two-yearperiod was done. Compliance with established protocol, determined category as?pathway? or ?non-pathway? patient. Vital signs, Pediatric Risk of Mortality(PRISM III), FiO2, maximum dose of continuous ventolin, steroidsand terbutaline, mechanical ventilation, heliox and Isoflurane hours were evaluatedas well as ICU and hospital length of stay (LOS).

Results: 10 patientswere reviewed, 5 male and 5 female, average age 6.6 years (range 35 mos. to14 yrs.). Of these patients, 70% were managed in compliance with the criticalcare pathway.

PathwayNon-Pathway
PrismIII 12/247/84/4
LOS (ICU days)42
LOS (hospitaldays)5.64
CV max. dose (mg/kg/hr.)1.20.7
Steroid maxdose (mg/kg)1.31
Terbutalinemax. dose (mcg/kg/min.)2.20
Heliox hours1.40
Mechanicalventilation hours32.112.25
Isofluranehours19.250
FiO2> 0.60 (hours)9.11

mean values presented(n=10)

Conclusion:Although the subjective evaluation of this pathway was positive, our retrospectivereview of the data indicates that a positive difference in outcome, LOS (ICUor hospital), between pathway and non-pathway critical care asthma patientswas not realized.

Discussion: Thedifference in Prism III and care requirements; FiO2 > 0.60, terbutalinemaximum dose, heliox, mechanical ventilation and Isoflurane hours suggest adisparity regarding severity of illness between groups. In addition, the possibilityexists that contamination of the non-treatment group occurred, since this reviewincludes patients within the same period of time. Further evaluation of thisprotocol would benefit from a prospective randomized approach to implementation,as well as a disease specific indicator concerning severity of illness.

Welsh KM, Napoli L.,and Magnusson M. Asthma Clinical Pathway: An Interdisciplinary Approach to Implementationin the Inpatient Setting. Pediatric Nursing 1999: 25: 79-87.

 

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