title: Ventilator-Associated Events in Neonates and Children--A New Paradigm.
abstract: OBJECTIVE
  To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes.
  
  
  METHODS
  Retrospective cohort study and a matched cohort analysis.
  
  
  METHODS
  Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals.
  
  
  METHODS
  Children 18 years old or younger ventilated for at least 1 day.
  
  
  METHODS
  None.
  
  
  RESULTS
  We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1-1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs.
  
  
  CONCLUSIONS
  Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.
authors.affiliation: 1Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.2Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA.3Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA.4Department of Pediatrics, Section of Pediatric Infectious Diseases, Rush University Medical Center, Chicago, IL.5Department of Pediatrics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT.6Department of Pediatrics, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania and Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, PA.7Division of Pediatric Critical Care, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH.8Department of Information Services, Rush University Medical Center, Chicago, IL.9Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.10Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, GA.11Divisions of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.12Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA.
authors.forename: Noelle M
authors.initials: NM
authors.lastname: Cocoros
authors.forename: Ken
authors.initials: K
authors.lastname: Kleinman
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Priebe
authors.forename: James E
authors.initials: JE
authors.lastname: Gray
authors.forename: Latania K
authors.initials: LK
authors.lastname: Logan
authors.forename: Gitte
authors.initials: G
authors.lastname: Larsen
authors.forename: Julia
authors.initials: J
authors.lastname: Sammons
authors.forename: Philip
authors.initials: P
authors.lastname: Toltzis
authors.forename: Irina
authors.initials: I
authors.lastname: Miroshnik
authors.forename: Kelly
authors.initials: K
authors.lastname: Horan
authors.forename: Michael
authors.initials: M
authors.lastname: Burton
authors.forename: Shannon
authors.initials: S
authors.lastname: Sims
authors.forename: Marvin
authors.initials: M
authors.lastname: Harper
authors.forename: Susan
authors.initials: S
authors.lastname: Coffin
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Sandora
authors.forename: Susan N
authors.initials: SN
authors.lastname: Hocevar
authors.forename: Paul A
authors.initials: PA
authors.lastname: Checchia
authors.forename: Michael
authors.initials: M
authors.lastname: Klompas
authors.forename: Grace M
authors.initials: GM
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D012189:Retrospective Studies; D012122:Ventilators, Mechanical / Q000009:adverse effects*