Bilateral cerebral peduncle infarct in a paediatric intensive care unit patient.

Intubation is a risk factor for nosocomial sinusitis in adult intensive care patients. Sinusitis in intubated adults can be an occult cause of fever. In children, nasal intubation may increase the risk of sinusitis. No pediatric study has determined the frequency of nosocomial sinusitis in the pediatric intensive care unit setting. We hypothesized that within a subset of patients who had head computed tomography imaging 1) the incidental frequency of sinusitis in pediatric intensive care unit patients exceeds the frequency in non-pediatric intensive care unit patients, 2) the frequency of sinusitis is greater in pediatric intensive care unit patients with a tube (nasotracheal, nasogastric, orotracheal, or orogastric) compared to those without a tube, and 3) nasal tubes confer an increased risk for sinusitis over oral tubes. Retrospective chart review. Independent not-for-profit pediatric healthcare system. Pediatric intensive care unit and non-pediatric intensive care unit (inpatients hospitalized on medical-surgical wards) patients referred for head computed tomography. None. Computed tomography images were scored using the Lund-MacKay staging system. Sinusitis was defined as a Lund-MacKay score ≥5. A total of 596 patients were studied, 395 (66.3%) in the pediatric intensive care unit. A total of 154 (44.3%) pediatric intensive care unit vs. 54 (26.9%) non-pediatric intensive care unit patients had sinusitis (p < .001). A total of 102 of 147 (69.4%) pediatric intensive care unit patients with a tube present had sinusitis vs. 73 of 248 (29.4%) patients without a tube present (p < .001). There was no difference in sinusitis based on tube location (p = .472). Of patients with sinusitis, 51.3% (81 of 158) compared to 39.4% (89 of 226) were febrile within 48 hrs of imaging (p = .021). A younger age or the presence of a tube increased the probability of sinusitis (p < .001). A total of 44.3% of our pediatric intensive care unit patients imaged for reasons other than evaluation for sinus disease had evidence of sinusitis, and 51.3% of these had fever. These findings raise the concern that sinusitis in pediatric intensive care unit patients is common and should be considered in the differential diagnosis of fever in pediatric intensive care unit patients.

As part of the overall quality assurance program for the Department of Pediatrics, we determined whether there were differences in the rates of unexpected autopsy findings between pediatric intensive care unit (ICU), emergency department, and ward patients. Prospective, descriptive study. Tertiary care children's hospital. Pediatric deaths (n = 212). None. Autopsies were obtained more frequently in emergency department patients (27/29 [93%]) compared with pediatric ICU (88/121 [73%] and ward (42/62 [68%]) patients (p = .03). The medical examiner's cases were more frequently from emergency department patients (22/27 [81%]) compared with pediatric ICU (39/88 [44%]) or ward (11/42 [26%]) patients (p < .001). We found unexpected autopsy findings in 19 (12%) of 157 patients. There were no unexpected findings from the medical examiner's cases. The most common unexpected findings were unidentified infections (n = 7 [three fungal, three viral, and one nonspecific]) and unrecognized cardiac malformations (n = 4). Unexpected findings occurred more frequently in pediatric ICU patients (16/88 [18%]) vs. emergency department (2/27 [7%]) or ward (1/42 [2%]) patients (p = .03). The occurrence rates of major unexpected findings (Class I and II) in pediatric ICU (7/79 [9%]), emergency department (2/27 [7%]), and ward (1/42 [2%]) patients were similar (p = .4). There were two Goldman's Class I unexpected findings in the pediatric ICU and emergency department patients, and one Goldman's Class I unexpected finding in the ward patients. Autopsies were performed more frequently in emergency department patients. Class I through IV unexpected findings occurred more frequently in pediatric ICU patients compared with emergency department or ward patients. Autopsy examinations are an especially valuable diagnostic tool for pediatric ICU patients and physicians.

A point well taken

Background: Korean children are often treated in Intensive Care Units (ICUs) rather than in Pediatric Intensive Care Units (PICUs). However, pediatric critical care (PCC) in ICUs, other than in PICUs, may have effects on patient’s outcome. Objectives: To compare the PCC outcomes of pediatric patients in the PICU with the outcomes of pediatric patients in other ICUs. Methods: This is a retrospective study of pediatric patients treated in ICUs. The participants of this study were children aged < 18 years who were admitted to the ICUs from the Pediatric Department of Seoul St. Mary’s Hospital from April 2009 to June 2017. Patients with hemato-oncologic diseases or those needing postoperative care were excluded. Results: Among the 429 ICU cases, 306 were PICU and 123 were ICU patients. The age (18 months vs. 26 months; P = 0.104) and male sex ratio (57% vs. 54%; P = 0.587) were not significantly different between PICU and other ICU patients. PICU patients (73%) were commonly admitted from another hospital compared with ICU patients (63%, P = 0.043). The pediatric index of mortality -3 score was not significantly different between the PICU and ICU patients (-4.3 vs -4.1; P = 0.128); the ICU and hospital length of stay were 5 days vs 5 days (P = 0.357) and 11 days vs 11 days (P = 0.317); and the mortality rate was 4% vs 11% (P = 0.008), respectively. Respiratory and neurologic complications were 5% vs 11% (P = 0.021) and 4% vs 2% (P = 0.282), respectively. The risk of mortality was higher for ICUs patients (odds ratio = 2.56; 95% CI = 1.11 - 5.87), adjusted for source of ICU admission, and type of ICU. Conclusions: Pediatric patients treated in a PICU had a lower mortality compared to those treated in other ICUs.

Invasive fungal infections are responsible for significant morbidity and mortality. Safety and effectiveness of antifungal agents is a particular concern in pediatric populations, where data are often limited. Micafungin is an echinocandin with demonstrated antifungal activity against a wide spectrum of Candida spp.; this subanalysis of data from the MYRIADE study describes the use of micafungin and its therapeutic outcomes in pediatric patients, in normal clinical practice. MYRIADE was an observational, multicenter, national, prospective, longitudinal study conducted from January 2010 to December 2012, in patients treated with micafungin using a prophylactic or curative strategy, across 17 sites [oncohematology (n = 8), neonatal intensive care units (ICUs) (n = 5) and pediatric ICUs (n = 4)]. The treatment regimen, the achievement of the therapeutic objective and the tolerance were reported. The study population consisted of 110 pediatric patients (31 neonates, 24 children <2 years old and 55 children ≥2 to <16 years old). The therapeutic objective was achieved in 49/64 (76.6%) oncohematology patients, 28/29 (96.6%) neonatal ICU patients and 12/14 (85.7%) pediatric ICU patients. Twenty-four (21.8%) children developed an adverse event (AE); more AEs were observed in oncohematology patients compared with ICU patients [17 (26.1%) vs. 7 (15.6%)]. Only one serious AE, reported in an oncohematology patient, was considered related to micafungin. In the first large observational study of micafungin treatment or prophylaxis conducted under real-world conditions in France, micafungin was effective and well tolerated for prophylaxis of invasive fungal infections in pediatric oncohematology patients and for curative purposes in pediatric and neonatal ICU patients.

Background and importanceVancomycin, a glycopeptide antibiotic, is used for the treatment of serious infections by gram positive microorganisms, especially methicillin resistant Staphylococcus aureus (MRSA). However, the attributable mortality of paediatric...

Introduction: Korean children are often treated in intensive care units (ICUs) other than the pediatric intensive care unit (PICU). However, pediatric critical care (PCC) in ICUs other than PICU may have an effect on the outcomes. Aims and Objectives: This study aimed to compare the PCC outcomes of pediatric patients in the PICU and other ICUs. Methods: The participants of this study were children aged Results: Among the 429 ICU cases, 306 were PICU and 123 were other ICU patients. The age (18mo vs. 26mo; p=0.104) and sex ratio (57% vs. 54%; p=0.587) were not statistically different between PICU and other ICU patients. PICU patients (73%) were commonly admitted from another hospital compared with other ICU patients (63%, p=0.043). The PIM-3 was not statistically different between the PICU and other ICU patients (-4.3 vs. -4.1, respectively; p=0.128); the ICU and hospital length of stay were 5 vs. 5 days (p=0.357) and 11 vs. 11 days (p=0.317); and ICU mortality was 4% vs. 11% (p=0.008), respectively. Respiratory and neurologic complications were 5% vs. 11% (p=0.021) and 4% vs. 2% (p=0.282), respectively. The odds of mortality was higher for other ICUs than for PICUs (odds ratio, 2.56; 95% CI, 1.11–5.87), adjusted source of ICU admission, and type of ICU. Conclusions: Pediatric patients treated at PICUs show lower mortality.

The systemic inflammatory response syndrome (SIRS) is typified by the presence of fever, hemodynamic changes, and end organ dysfunction. Endothelial cell activation leads to overproduction of nitric oxide, which results in sustained vasodilation and hypotension. This study was undertaken to determine the sensitivity, specificity, and positive and negative predictive values of plasma nitrite/nitrate measurements in identifying patients with clinical characteristics of SIRS, as defined by criteria based on physician diagnosis. Prospective cohort study with consecutive sampling of patients. Tertiary, multidisciplinary, pediatric intensive care unit (ICU) at Children's Hospital of Wisconsin. Patients were divided into five groups. There were 16 pediatric controls undergoing elective surgery and 177 pediatric ICU patients without and 46 pediatric ICU patients with physician-diagnosed sepsis, septic shock, SIRS, or sepsis syndrome documented in the medical record (all considered physician-diagnosed sepsis). The 223 pediatric ICU patients included 195 pediatric ICU patients not meeting and 28 pediatric ICU patients meeting predetermined physiologic criteria for SIRS (considered criteria-based sepsis). Blood samples were obtained for quantitative nitrite/nitrate analysis at the time of admission to the pediatric ICU and daily until discharge. Mean plasma nitrite/nitrate concentrations in the controls were 34.5 +/- 12 microM (95th percentile 54 microM). In pediatric ICU patients without and with physician-diagnosed sepsis, mean plasma nitrite/nitrate concentrations were 39 +/- 24 microM (p > .05 compared with controls) and 127 +/- 91 microM (p < .0001 compared with both controls and patients without physician-diagnosed sepsis), respectively. In pediatric ICU patients without and with criteria-based sepsis, the mean total plasma nitrite/nitrate concentrations were 56 +/- 59 microM (p = .008 compared with controls) and 80 +/- 64 microM (p = .003 compared with patients without criteria-based sepsis), respectively. The ability of plasma nitrite/nitrate > 54 microM to identify patients with physician-diagnosed sepsis is characterized as follows: 87% sensitivity, 77% specificity, 50% positive predictive value, and 96% negative predictive value. The ability of plasma nitrite/nitrate > 54 microM to identify patients with criteria-based sepsis is characterized as follows: 61% sensitivity, 68% specificity, 21% positive predictive value, and 92% negative predictive value. Clinical diagnosis of SIRS is strongly associated with increased total plasma nitrite/nitrate concentrations in pediatric patients in the pediatric ICU. Many patients with increased nitrite/nitrate concentrations have inflammation without having a clinical diagnosis of SIRS. Our data suggest that increased plasma nitrite/nitrate concentrations are the standard for identifying patients with inflammation in the pediatric ICU.

Children admitted to pediatric intensive care units (PICUs) often receive sedatives to facilitate mechanical ventilation. However, despite their widespread use, data supporting appropriate dosing, safety, and optimal regimens for sedation during mechanical ventilation are lacking. Therefore, we conducted a systematic review of published data regarding efficacy of sedation to facilitate mechanical ventilation in PICU patients. Our primary objective was to identify and evaluate the quality of evidence supporting sedatives used in PICUs for this purpose. We searched MEDLINE, EMBASE, and The Cochrane Registry of Clinical Trials from 1966 to June 2008 to identify published articles evaluating sedation regimens to facilitate mechanical ventilation in PICU patients. We included only those studies of intubated PICU or pediatric cardiac intensive care unit patients receiving pharmacologic agents to facilitate mechanical ventilation that reported quality of sedation as an outcome. We analyzed studies separately for study type and by agents being studied. Studies were appraised using criteria of particular importance for reviews evaluating sedatives. Our search strategy yielded 39 studies, including 3 randomized trials, 15 cohort studies, and 21 cases series or reports. The 39 studies evaluated a total of 39 different sedation regimens, with 21 different scoring systems, in a total of 901 PICU/cardiac intensive care unit patients ranging in age from 3 days to 19 years old. Most of the studies were small (<30 patients), and only four studies compared one or more agents to another. Few studies thoroughly evaluated drug safety, and only one study met all quality criteria. Despite the widespread use of sedatives to facilitate mechanical ventilation in the PICU, we found that high-quality evidence to guide clinical practice is still limited. Pediatric randomized, controlled trials with reproducible methods and assessment of drug safety are needed.

Implementing Standardized Post-Intensive Care Syndrome Education by an Advanced Practice Registered Nurse in the Pediatric Intensive Care Unit

OBJECTIVE: To compare resource utilization and outcomes between cohorts of pediatric and adult intensive care unit (ICU) patients from a single institution. DESIGN: Prospective, observational cohort study. SETTING: A large, urban, tertiary care medical center. PATIENTS: A total of 780 patients consecutively admitted to the pediatric ICU, adult medical ICU, and adult surgical ICU. MEASUREMENTS AND MAIN RESULTS: ICU, hospital and 6-month survivals and hospital costs from index ICU admission. Predicted mortality by Pediatric Risk of Mortality III and Acute Physiology and Chronic Health Evaluation II. Health status at 6 months from index ICU admission. Pediatric patients had lower ICU (7.8% vs. 13.7%; p =.01), hospital (10.1% vs. 16.9%; p =.009), and 6-month (16.2% vs. 29.2%; p <.001) mortalities compared with adult patients. Adult patients had significantly lower probability of survival for 6 months from initial ICU admission compared with pediatric patients. The difference in survival was primarily accounted for by adult and pediatric medical patients. No differences could be observed between pediatric and adult ICU patients for mean hospital costs ($33,316 +/- $48,467 vs. $32,877 +/- $46,411; p =.92). Pediatric and adult patients incurred increasing costs with increasing risks of mortality. More than 50% of pediatric patients had a risk of mortality <0.5% compared with 1.2% of adult patients, but there was no difference in the mean use of ICU-specific interventions. CONCLUSIONS: Pediatric critical care patients have better short-term and longer-term survival compared with adult patients. The difference in survival is accounted for by the lower survival of adult medical patients. Despite the survival differences, pediatric and adult ICU patients incur similar hospital costs, and the proportions of patients who receive active ICU interventions are similar.

There is limited information available regarding clinical outcome and rate of mortality in relation to invasive methicillin-resistant Staphylococcus aureus (MRSA) infection in pediatric intensive care unit (PICU) patients treated with vancomycin in this tertiary hospital in northern Thailand. Therapeutic drug monitoring (TDM) is recommended vancomycin prescription; however, it is important to investigate the outcome of this monitoring in PICU patients. This study aims to evaluate the mortality and factors related to these in PICU patients treated with vancomycin. A retrospective study was conducted in PICU patients given vancomycin from April 2018 to April 2019. The following variables were included: age, sex, underlying disease, diagnosis, length of stay (LOS) in PICU, Pediatric Index of Mortality 2 (PIM 2) score, mechanical ventilator use, renal replacement therapy (RRT), laboratory data, vancomycin dose, trough serum vancomycin concentration (Ctrough) and mortality rate. One hundred and sixty pediatric patients were enrolled into the study (median age 12 months, range 2-180 months, 69.4% male). Ctrough of vancomycin (10–20 mg/L) was recorded in 32.5% (n = 52) of cases. Septic shock was the most common diagnosis (49.3%) and the mortality rate was 39.4%. Results indicated that children who had a vancomycin Ctrough outside the therapeutic range, mechanical ventilator use and RRT use were statistically significantly associated with higher mortality rate (adjusted OR 3.29, 95% CI, 1.41-7.69; P &lt;0.05), (adjusted OR 6.22, 95% CI, 1.67-23.16; P &lt; 0.05) and (adjusted OR 10.41, 95% CI, 2.62-41.37; P &lt; 0.05). These factors were related to mortality and further studies are needed to determine if this outcome can be improved. Keywords: Vancomycin, Vancomycin trough concentration, Pediatric patients, Intensive care, Mortality, Factors related to mortality

Pediatric Critical Care Medicine: March 2004 - Volume 5 - Issue 2 - p 193-194 doi: 10.1097/01.PCC.0000115621.73210.B9

AIMTo synthesize the available evidence focusing on morbidities in pediatric survivors of critical illness that fall within the defined construct of postintensive care syndrome (PICS) in adults, including physical, neurocognitive and psychological morbidities.METHODSA comprehensive search was conducted in MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and CINAHL using controlled vocabulary and key word terms to identify studies reporting characteristics of PICS in pediatric intensive care unit (PICU) patients. Two reviewers independently screened all titles and abstracts and performed data extraction. From the 3176 articles identified in the search, 252 abstracts were identified for full text review and nineteen were identified for inclusion in the review. All studies reporting characteristics of PICS in PICU patients were included in the final synthesis.RESULTSNineteen studies meeting inclusion criteria published between 1995 and 2016 were identified and categorized into studies reporting morbidities in each of three categories-physical, neurocognitive and psychological. The majority of included articles reported prospective cohort studies, and there was significant variability in the outcome measures utilized. A synthesis of the studies indicate that morbidities encompassing PICS are well-described in children who have survived critical illness, often resolving over time. Risk factors for development of these morbidities include younger age, lower socioeconomic status, increased number of invasive procedures or interventions, type of illness, and increased benzodiazepine and narcotic administration.CONCLUSIONPICS-related morbidities impact a significant proportion of children discharged from PICUs. In order to further define PICS in children, more research is needed using standardized tools to better understand the scope and natural history of morbidities after hospital discharge. Improving our understanding of physical, neurocognitive, and psychological morbidities after critical illness in the pediatric population is imperative for designing interventions to improve long-term outcomes in PICU patients.

The few studies of associations between fever and outcomes in pediatric intensive care unit (PICU) patients have conflicting findings. Associations between hypothermia and patient outcomes have not been studied. To investigate the incidence and characteristics of fever and hypothermia and their associations with adverse outcomes among PICU patients. Patients consecutively admitted to 2 PICUs in a 2-year period were prospectively studied. Core temperature was mainly measured by rectal or axillary thermometry. Fever and hypothermia were defined as core temperatures of greater than 38.0 °C and less than 36.0 °C, respectively. Prolonged mechanical ventilation, prolonged PICU stay, and PICU mortality were the adverse patient outcomes studied. Associations between patient outcomes and core temperature disorders were evaluated with univariate comparisons and multivariate analyses. Of 545 patients enrolled, fever occurred in 299 (54.9%) and hypothermia occurred in 161 (29.5%). Both temperature disorders were independently associated with prolonged mechanical ventilation and prolonged PICU stay (P < .001) but not with PICU mortality. Late onset of fever (P < .001) and hypothermia (P = .009) were independently associated with prolonged mechanical ventilation, fever magnitude and duration (both P < .001) were independently associated with prolonged PICU stay, and fever magnitude (P < .001) and infectious cause of hypothermia (P= .01) were independently associated with higher PICU mortality. These findings provide evidence that the manifestation and characteristics of fever and hypothermia are independent predictors of adverse outcomes in PICU patients.