Short-Acting Sedative-Analgesic Drugs Protect Against Development of Ventilator-Associated Events in Children: Secondary Analysis of the EUVAE Study

Abstract

BACKGROUND: The U.S. Centers for Disease Control and Prevention proposed a shift in its surveillance paradigm from ventilator-associated pneumonia to ventilator-associated events (VAE) to broaden the focus of prevention and achieve a greater impact on outcomes. The main objective of the present study was to identify factors associated with pediatric VAEs in children undergoing mechanical ventilation 6 48 h. METHODS: This was a secondary analysis of a pediatric cohort of a multicenter prospective study. Children who underwent mechanical ventilation 6 48 h were included. Exclusion criteria were previous ventilation, extracorporeal life support, and right-to-left shunt or pulmonary hypertension. In the subjects with multiple episodes of mechanical ventilation, only the first episode was considered. Remifentanil and propofol are classified as shortacting sedative and analgesic agents. Pediatric VAE is defined as an "increase in PEEP 6 2 cm of H 2 O, an increase in F IO 2 of 0.20, or an increase in F IO 2 of 0.15 plus an increase in PEEP 6 1 cm of H 2 O sustained for 61 d. Associations with pediatric VAE were estimated through multivariate Cox proportional hazards analysis. Hazard ratios and 95% CI were computed. RESULTS: In a cohort of 90 children, 24 pediatric VAEs were documented in 906 ventilator-days. Pediatric VAEs developed after a median of 4.5 (interquartile range, 4-7.25) d. Surgical admissions, spontaneous breathing trials, early mobility, vasopressors, red blood cell units transfusion, type of sedation (continuous vs intermittent), benzodiazepine use for >3 d, and pharmacologic paralysis were not associated with pediatric VAE, whereas the use of continuous short-acting sedative-analgesic agents was identified as a strong protective factor against pediatric VAE (hazard ratio 0.06 [95% CI 0.007-0.5]). CONCLUSIONS: Treatment with short-acting sedative-analgesic agents should be preferred for sedation of mechanically ventilated children in intensive care.

Epidemiology and outcomes of ventilator-associated events in critically ill children: Evaluation of three different definitions

“…Although this VAE definition might be useful for neonates undergoing high-frequency oscillatory ventilation, it may be suboptimal in pediatric patients who use higher tidal volumes and PEEP, which is the standard ventilation method in this population. 25 It seems that the US Ped VAE definition selects the most severe cases, 7 which makes its utility in clinical diagnosis controversial. Therefore, a more sensitive definition should be addressed.…”

“…Using these different thresholds for changes and duration of changes of FiO 2 and PEEP, the EU Ped VAE definition presented increased sensitivity and greater predictive accuracy regarding clinical outcomes in ventilated critically ill children. 10,25 The advantage of the EU Ped VAE definition is that it has been validated prospectively in children, 10 which highlights the need for more prospective studies of pediatric VAEs. In our study, patients who met only the EU Ped VAE criteria (and not the other VAE definitions) had longer duration of mechanical ventilation and lengths of stay than patients without any VAE (using all definitions).…”

“…We were not able to distinguish whether children experiencing a VAC had suffered a complication of mechanical ventilation or were just displaying progressive respiratory manifestations of the severe illness that necessitated intubation in the first place. Further research is needed to determine whether the currently reported risk factors (eg, surgical admission, inotrope prescription, red blood cell unit transfusion, spontaneous breath trials, type of sedationcontinuous vs intermittent-and type of sedative drugs used, early mobility, positive fluid balance) 25 are strongly associated with pediatric VAE and their adverse outcomes.…”

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

“…Neuromuscular blockade, sedative type, blood transfusions, positive fluid balance, and acute kidney injury have been associated with PedVAE. 63 , 69 , 238 , 239 In general, most VAP prevention interventions recommended for adults are presumed to be applicable to older infants and children. Some interventions recommended for adults, however, are not available for infants and small children.…”

“…Neuromuscular blockade, sedative type, blood transfusions, positive fluid balance, and acute kidney injury have been associated with PedVAE. 63 , 69 , 238 , 239 …”