Potentially Hazardous Drugs in the Paediatric ICU: A Narrative Review on the Exemplary Cases of Propofol, Chloramphenicol, and Acetylsalicylic Acid.

IntroductionChildren admitted to paediatric and neonatal intensive care units may be at high risk from medication errors and preventable adverse drug events.ObjectiveThe objective of this systematic review was to review empirical studies examining the prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care units.Data SourcesSeven electronic databases were searched between January 2000 and March 2019.Study SelectionQuantitative studies that examined medication errors/preventable adverse drug events using direct observation, medication chart review, or a mixture of methods in children ≤ 18 years of age admitted to paediatric or neonatal intensive care units were included.Data ExtractionData on study design, detection method used, rates and types of medication errors/preventable adverse drug events, and medication classes involved were extracted.ResultsThirty-five unique studies were identified for inclusion. In paediatric intensive care units, the median rate of medication errors was 14.6 per 100 medication orders (interquartile range 5.7–48.8%, n = 3) and between 6.4 and 9.1 per 1000 patient-days (n = 2). In neonatal intensive care units, medication error rates ranged from 4 to 35.1 per 1000 patient-days (n = 2) and from 5.5 to 77.9 per 100 medication orders (n = 2). In both settings, prescribing and medication administration errors were found to be the most common medication errors, with dosing errors the most frequently reported error subtype. Preventable adverse drug event rates were reported in three paediatric intensive care unit studies as 2.3 per 100 patients (n = 1) and 21–29 per 1000 patient-days (n = 2). In neonatal intensive care units, preventable adverse drug event rates from three studies were 0.86 per 1000 doses (n = 1) and 0.47–14.38 per 1000 patient-days (n = 2). Anti-infective agents were commonly involved with medication errors/preventable adverse drug events in both settings.ConclusionsMedication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.Electronic supplementary materialThe online version of this article (10.1007/s40264-019-00856-9) contains supplementary material, which is available to authorized users.

A point well taken

In São Paulo, we found an uneven distribution of pediatric and neonatal intensive care units among the health districts. There was also an uneven distribution between public and private units, and neonatal and pediatric ones. The current report is the first step in the effort to improve the quality of medical assistance in pediatric and neonatal intensive care units in São Paulo.

Our study aimed to assess differences in the susceptibility to severe acute illness in children with and without chronic health conditions treated in a pediatric intensive care unit (PICU). Data on age, gender, need for ventilator support, length of stay, as well as other parameters for the Paediatric Index of Mortality (PIM2) score were collected. Data were analyzed and compared across three patient groups: those with a neurodevelopmental disability, those with a chronic condition other than a neurodevelopmental disability, and those with no chronic condition. Reasons for admission of patients were classified according to the Australia and New Zealand Paediatric Intensive Care Registry (ANZPIC Registry) diagnostic codes. In the multidisciplinary, seven-bed, level I PICU of the Split University Hospital, the admission data were collected prospectively for 591 consecutively admitted patients aged<or=18 years. Patients with a neurodevelopmental disability had a significantly higher rate of respiratory-related admissions compared to patients with other chronic health conditions and those with no chronic condition (chi2=33.72, P<0.001). There was a significant difference in the age at admission (f=6.04, P=0.003), median length of stay (f=7.94, P<0.001), need for ventilation during the first hour of admission (chi2=14.74, P<0.001) and PICU mortality (chi2=9.91, P=0.007) of patients with neurodevelopmental disabilities, compared to the other two groups of patients. Children with neurodevelopmental disabilities are more susceptible to acute illness compared to children with other chronic health conditions and those with no chronic condition.

To the Editors: Pulmonary arterial pseudoaneurysm (PAP), also called Rasmussen aneurysm, is a rare but sometimes fatal complication of pulmonary diseases. PAP is well reported in chronic tuberculosis, but it can complicate other lung infections. Embolization or surgical resection following episodes of hemoptysis is the usual treatment, but resolution with medical treatment is also possible.1 We report a rare case of multiple PAPs in a child with effective conservative management. A 14-year-old boy was referred to our pediatric intensive care unit, for fever and coma. A computed tomography (CT) scan showed pan-sinusitis with multiple areas of septic venous sinus thrombosis. The diagnosis of a Lemierre’s syndrome was made. The course was complicated by necrotizing pneumonia with septic shock and an acute respiratory distress syndrome. Multiple septic emboli caused renal, cutaneous, laryngeal and pulmonary abscesses. A methicillin-susceptible Staphylococcus aureus secreting the Panton-Valentin leucocidin was identified and treated by clindamycin and linezolid. Heparin treatment was also initiated. On the 25th day after admission, while he was spontaneously breathing through a tracheotomy cannulae, the child had a moderate hemoptysis. Chest CT angiography revealed 5 large PAP (Fig. 1A). Protamine was given and anticoagulant therapy was stopped. The medical staff including intensivists, surgeons and radiologists decided not to embolize these aneurysms and to monitor the child in pediatric intensive care unit. There was no recurrence of hemoptysis. A progressive spontaneous regression of pneumonia and PAPs was shown in 3 CT scans. The child was discharged after 6 months. The aneurysms had almost totally regressed after 10 months (Fig. 1B).FIGURE 1: Follow-up by successive chest CT scans with iodine contrast IV. Chest CT scan at day 30 showed multiple aneurysms. The size of the main aneurysm was 20 mm (A, white arrowhead). The last chest CT done at month 10 showed normal parenchyma (B) and regression of the remaining aneurism measured at 7 mm (B, white arrowhead).Rasmussen pulmonary aneurysms were first described in 1868.2 They classically grow near a tuberculous cavity. They are also a reported complication of endocarditis, pulmonary abscess or catheter infections. The most feared complication of PAP is the erosion of the thin wall of the artery leading to massive pulmonary hemorrhage. Treatment of this complication consists of embolization by steel coil or ethylene vinyl alcohol copolymer3 or in some cases surgical treatment with partial lung resection.4 In our case, we choose not to intervene immediately for 3 reasons. Firstly, hemoptysis was moderate and embolization is mainly indicated in case of massive hemorrhage. Secondly, there were 5 large lesions suggesting difficult and prolonged intervention would have an uncertain result. Finally, anticoagulant treatment was possibly an aggravating factor. Retrospectively, not to embolize these aneurysms was good decision. Regression of Rasmussen aneurysms has been reported after 9 months of antituberculous treatment.5 In this case, antibiotic treatment resolved the infectious episode and inflammation and PAP slowly and spontaneously regressed. This case confirms that little or moderate hemoptysis does not require aggressive treatment of PAP. However, the wait and see attitude requires close monitoring in the intensive care unit, and radiologists must be available at any time to manage a possible acute severe hemorrhage. Pulmonary CT angiography allows easy detection of PAP and its following evolution. Meryl Horwitz, MD Pediatric and Neonatal Intensive Care Unit North Hospital Marseille, France Aix Marseille Université Marseille, France Kathia Chaumoître, PhD Department of Medical Imaging North Hospital Marseille, France Aix Marseille Université Marseille, France Céline Grimaldi, MD Pediatric and Neonatal Intensive Care Unit North Hospital Marseille, France Aix Marseille Université Marseille, France Karine Retornaz, MD Pediatric Medical Unit North Hospital Marseille, France Claire Nicaise, MD Laurent Thomachot, MD Pediatric and Neonatal Intensive Care Unit North Hospital Marseille, France Claude Martin, MD Fabrice Michel, MD Pediatric and Neonatal Intensive Care Unit North Hospital Marseille, France Aix Marseille Université Marseille, France

BackgroundConsensus Guidelines for Pediatric Intensive Care Units (PICUs) were published in Indian Pediatrics in 2002.ObjectiveThe current document represents a recent update in the Indian context, regarding unit design, equipment, organization, staffing as well as admission and discharge criteria for different levels of Pediatric Intensive Care and teaching units with PICU training programs, as well as nonteaching units.ProcessThe Pediatric Intensive Care College Council (PICC), an academic wing of the Indian Academy of Pediatrics (IAP) Intensive Care Chapter took the initiative to update the guidelines with members of the PICU guidelines Committee writing group. After a great deal of discussion at conferences and through mailing and feedback with listed members, as well as with the guidance and feedback of senior PICU guidelines advisory committee members, The consensus is now updated. These guidelines are intended to serve as a reference for health Care institutions wishing to establish a new PICU or to modify an existing PICU. As a resource, experience of those members who have worked extensively in western PICUs was also taken into consideration, in addition to published guidelines in the medical literature. PICUs with teaching programs run by the IAP Intensive Care Chapter must follow these criteria for unit accreditation and teaching curricula as applicable.RecommendationsUnit design, equipment, organization, staffing as well as admission and discharge criteria for different levels of pediatric intensive care are updated.

Should paediatric intensive care be centralised?

To describe the health care service provided in pediatric intensive care units in the city of São Paulo, by identifying and describing the units and analyzing their geographic distribution. A descriptive cross-sectional study was carried out during a two-year period (August 2000 to July 2002). Data were collected through questionnaires answered by medical directors of each pediatric and neonatal intensive care unit. São Paulo is served by 107 pediatric and neonatal intensive care units, of which 85 (79.4%) completed and returned the questionnaire. We found a very unequal distribution of units as there were more units in places with the least pediatric population. Regarding to pediatric intensive care units specialization, 7% were pediatric, 41.2% were neonatal and 51.7% were mixed (pediatric and neonatal). Regarding hospital funds, 15.3% were associated with philanthropic institutions, 37.6% were private and 47% were public. A total of 1,067 beds were identified, of which 969 were active. The ratio bed/patient aged 0-14 was 1/2,728, varying from 1/604 at health districts-I to 1/6,812 at health districts-III. The units reported an average of 11.7 beds (2 to 60). The neonatal intensive care unit had a median of 16.9 beds per unit and pediatric intensive care units a median of 8.5 beds/unit. In São Paulo, we found an uneven distribution of pediatric and neonatal intensive care units among the health districts. There was also an uneven distribution between public and private units, and neonatal and pediatric ones. The current report is the first step in the effort to improve the quality of medical assistance in pediatric and neonatal intensive care units in São Paulo.

ObjectiveTo identify the neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil that use cuffed tracheal tubes in clinical practice and to describe the characteristics related to the use of protocols and monitoring.MethodsTo identify the intensive care units in Brazil, the Ministry of Health’s National Registry of Health Facilities was accessed, and information was collected on 693 registered intensive care units. This was an analytical cross-sectional survey conducted through electronic questionnaires sent to 298 neonatal, pediatric and mixed intensive care units in Brazil.ResultsThis study analyzed 146 questionnaires (49.3% from neonatal intensive care units, 35.6% from pediatric intensive care units and 15.1% from mixed pediatric intensive care units). Most of the participating units (78/146) used cuffed tracheal tubes, with a predominance of use in pediatric intensive care units (52/78). Most of the units that used cuffed tracheal tubes applied a cuff pressure monitoring protocol (45/78). The use of cuff monitoring protocols was observed in intensive care units with a physical therapy service exclusive to the unit (38/61) and in those with a physical therapist present 24 hours/day (25/45). The most frequent cause of extubation failure related to the use of cuffed tracheal tubes in pediatric intensive care units was upper airway obstruction.ConclusionIn this survey, the use of cuffed tracheal tubes and the application of a cuff pressure monitoring protocol was predominant in pediatric intensive care units. The use of a monitoring protocol was more common in intensive care units that had a physical therapist who was exclusive to the unit and was present 24 hours/day.

Objective: Identifying antibiotic use in pediatric and neonatal intensive care units with a point prevalence study in Adana, Turkey’s sixth largest city. Material and Methods: In this point prevalence study, demographic information and antibiotic treatment data were taken on the same day from patients in pediatric and neonatal intensive care units of 6 hospitals located in Adana’s city center. Results: Four pediatric intensive care units (two university, one research and training hospital, and one public hospital) and six neonatal intensive care units (two university, one research and training hospital, one public hospital, and two private hospital) were included in the study; 220 patients were at the intensive care units at the time of the study, 44 (20%) of the patients were in the pediatric intensive care units, and 176 (80%) of them were at the neonatal intensive care units. Also, 146 (66.4%) of the patients were using antibiotics. The frequency of antibiotic use was 72.7% in the pediatric intensive care units and 64.8% in neonatal intensive care units. There was a pediatric infectious disease physician at the university and research and training hospital. Antibiotic usage was lower (p=0.002) in clinics where pediatric infectious disease physician consultations could be done. Double antibiotic combination was applied most frequently. Mostly, ampicillin was preferred at neonatal intensive care units. Clarithromycin was used as a second choice because of seasonal lower respiratory tract infections. Vancomycin was the most preferred antibiotic in pediatric intensive care units, and meropenem and linezolid were the second and third choices. At both intensive care units, use of empiric antibiotic treatment was more frequent. Empiric treatment was applied in 22 (68.7%) patients in the pediatric intensive care units and 95 (83.3%) in neonatal intensive care units. Antibiotics were given to 14.3% of the patients in line with the resulting cultures. Conclusion: Intensive care units are services where antibiotics are used most frequently both in Turkey and in the world. In our opinion, protocols need to be established in clinics, national and international guides should be followed; and pediatric infectious disease physician consultations should be increased in order to reduce the frequency of antibiotic use, inappropriate indications, and inappropriate doses. (J Pediatr Inf 2014; 8: 56-63)

To survey the current monitoring and treatment policies for patients with severe traumatic brain injury (STBI) in Israel, and to compare the management of pediatric and adult intensive care units (ICUs). Questionnaires were sent to the medical directors of all ICUs managing STBI patients. All 21 ICUs responded to the questionnaire. All of the units were within tertiary hospitals. An intracranial pressure (ICP) monitoring device was used in over 75% of the patients in 6 out of7 (86%) of the pediatric intensive care units (PICUs), compared with 11 out of 14 (79%) of the adults ICUs. Mannitol was used in all of the units for documented elevated ICP. Mild hyperventilation (4-4.6 kPa) was applied in 52% of the units. Mild hypothermia was routinely used in 4 out of 7 (57%) and hypertonic solutions (NaCI 3%) in 3 out of 7 (43%) of the PICUs, compared with only 2 out of 14 (14%) and none (0%) of the adults ICUs respectively. PICUs aimed for a lower ICP (< or =15 mm Hg) and cerebral perfusion pressure (> or =50 mm Hg) than adult ICUs (< or =20 mm Hg and > or =60 mmHg respectively). Barbiturates were used only in patients with refractory intracranial hypertension. This survey reveals a relatively high degree of homogeneity in the treatment of STBI patients in Israel. Most patients are treated in accordance with recently published literature. We attribute this uniformity to the fact that all patients are being treated within tertiary care, university-affiliated centers. PICUs are faster at implementing new modalities of treatment and tend to adopt more aggressive treatment strategies.

Our objective was to assess the psychometric performance of the Health Utilities Index 2 and 3 in a pediatric population following admission to a pediatric intensive care unit. As part of a larger study of pediatric intensive care outcomes, children were followed up at 6 and 12 months post admission from pediatric intensive care using the Health Utilities Index 2 and 3. We evaluated and compared the psychometric performance of the Health Utilities Index 2 and 3 in this population by assessing their practicality, reliability, and limited information regarding validity. Twenty-two pediatric intensive care units in the United Kingdom. A total of 685 children aged 5 yrs and over. The Health Utilities Index 2 and 3, which are both generic preference-based measures of health-related quality of life, were completed by proxy and children over 11 yrs of age were invited to self-complete. Both Health Utilities Index 2 and 3 demonstrated good practicality, with excellent completion rates (>97%) and a mean time to complete of around 8 mins. Both Health Utilities Index 2 and 3 demonstrated very good inter-rater reliability and evidence of sensitivity to change. At 6 months after admission, mean scores of the Health Utilities Index 2 and 3 were different in some groups of children with different degrees of in-hospital severity of illness, but those differences were not found at 12 months of follow-up. The Health Utilities Index 2 and 3 both perform well in a pediatric intensive care setting whether by self-complete or proxy complete. Evidence of good inter-rater reliability gives confidence that the measures can be reliably used with a proxy completer, such as parent or caregiver. Additional research is important to investigate their construct validity further in this population, ideally using baseline data collected at the time of hospital stay in pediatric intensive care and other measures of health status at the times of follow-up.

careful selection of the appropriate mode of feeding and monitoring the success of the feeding strategy. The use of specific nutrients, which possess a drug-like effect on the immune or inflammatory state during critical illness, continues to be an exciting area of investigation. The lack of systematic research and clinical trials on various aspects of nutrition support in the PICU is striking and makes it challenging to compile evidence based practice guidelines. There is an urgent need to conduct well-designed, multicenter trials in this area of clinical practice. The extrapolation of data from adult critical care literature is not desirable and many of the interventions proposed in adults will have to undergo systematic examination and careful study in critically ill children prior to their application in this population. In the following sections, we will discuss some of the key aspects of nutrition support therapy in the PICU; examine the literature and provide best practice guidelines based on evidence from PICU patients, where available. While some PICU popu lations include neonates, A.S.P.E.N. Clinical Guidelines for neonates will be published as a separate series.

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.

Background: Having a child admitted to the intensive care unit (ICU) is an extremely distressing experience for parents. This heightened stress can negatively affect their mental health and their capacity to support their child's recovery process. To address this, a range of interventions aimed at empowering parents has been developed. Nonetheless, a comprehensive evaluation of the effectiveness of these interventions in alleviating parental stress is still lacking. Purpose: To evaluate different parent empowerment strategies used in pediatric critical care settings and examine their effects on reducing stress among parents. Method: A systematic review was carried out, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for selecting relevant studies. The review began with formulating clinical questions and defining PICOS criteria—P (Population): parents of children in the pediatric intensive care unit (PICU); I (Intervention): empowerment strategies for parents; C (Comparison): routine care without empowerment or parent groups not receiving targeted interventions; O (Outcome): parental stress levels during ICU hospitalization; S (Study design): randomized controlled trials. The literature search used specific keywords, including: “Parent Empowerment,” “Family Centered Care,” “Pediatric Intensive Care,” “PICU,” “NICU,” and “Parental Stress.” Results: Interventions involving educational support, parental empowerment, and family engagement contribute to better mental health outcomes for parents, particularly enhancing their ability to care for critically ill or premature infants in the NICU. Conclusion: Empowerment strategies in pediatric intensive care settings are effective in lowering stress among parents. This review underscores the importance of educational initiatives, family involvement, supportive empowerment techniques, and digital tools such as telenursing in promoting parents' psychological resilience and participation in infant care.