Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.

Glycoprotein (GP) IIb/IIIa inhibitors have been extensively studied in the setting of percutaneous coronary intervention (PCI) and in the management of non-ST-segment elevation acute coronary syndromes. However, the use of GP IIb/IIIa inhibitors is less well established in the setting of acute ST-segment elevation myocardial infarction (MI). Multiple nonrandomized studies suggest that combination therapy with GP IIb/IIIa inhibitors and thrombolytic agents leads to increased rates of TIMI 3 flow. However, two clinical trials involving over 22,000 patients demonstrated that combination therapy is associated with only modest reductions in major adverse cardiac events, does not reduce mortality, and is associated with an increase in bleeding. In the setting of primary PCI, four clinical trials involving over 3,000 patients demonstrated that GP IIb/IIIa inhibition results in a significant decrease in the need for urgent target vessel revascularization but not in reductions of death or recurrent MI. Thus, GP IIb/IIIa inhibition may provide only limited benefits in the setting of acute ST-segment elevation MI.

No abstract

Objective: This global survey aimed to assess the current respiratory support capabilities for children with hypoxemia and respiratory failure in different economic settings. Methods: An online, anonymous survey of medical providers with experience in managing pediatric acute respiratory illness was distributed electronically to members of the World Federation of Pediatric Intensive and Critical Care Society, and other critical care websites for 3 months. Results: The survey was completed by 295 participants from 64 countries, including 28 High-Income (HIC) and 36 Low- and Middle-Income Countries (LMIC). Most respondents (≥84%) worked in urban tertiary care centers. For managing acute respiratory failure, endotracheal intubation with mechanical ventilation was the most commonly reported form of respiratory support (≥94% in LMIC and HIC). Continuous Positive Airway Pressure (CPAP) was the most commonly reported form of non-invasive positive pressure support (≥86% in LMIC and HIC). Bubble-CPAP was used by 36% HIC and 39% LMIC participants. ECMO for acute respiratory failure was reported by 45% of HIC participants, compared to 34% of LMIC. Oxygen, air, gas humidifiers, breathing circuits, patient interfaces, and oxygen saturation monitoring appear widely available. Reported ICU patient to health care provider ratios were higher in LMIC compared to HIC. The frequency of respiratory assessments was hourly in HIC, compared to every 2–4 h in LMIC. Conclusions: This survey indicates many apparent similarities in the presence of respiratory support systems in urban care centers globally, but system quality, quantity, and functionality were not established by this survey. LMIC ICUs appear to have higher patient to medical staff ratios, with decreased patient monitoring frequencies, suggesting patient safety should be a focus during the introduction of new respiratory support devices and practices.