PICU Care Research Articles

Meaning-Making Among Parents of Children With Severe Neurologic Impairment in the PICU.

Parents and family caregivers of children with severe neurologic impairment (SNI) experience many stressors, especially during their child's critical illness. This study aimed to examine parent experiences around the time of their child's PICU care to explore ways parents make meaning in relation to these stressors. This qualitative study of data from a single center in the United States followed Consolidated Criteria for Reporting Qualitative Research guidelines. One to one semistructured interviews queried parents' psychosocial well-being around the time of their child's PICU care. Eligible participants had a child with an SNI condition for >3 months admitted to the PICU for >24 hours with an expected length of stay >1 week. Data were analyzed by a research team with expertise in palliative care, psychology, critical care, and qualitative methods. Fifteen family caregivers of 15 children participated. Children were a median of 8 years old (interquartile range 4-11.5) and 80% (n = 12) had congenital/genetic conditions. Parent/family caregivers were a median age of 39 years old (interquartile range 36-42.5); 20% (n = 3) self-identified as fathers and 47% (n = 7) as having to a minority racial background. Parents discussed ongoing meaning-making that occurred through domains of comprehension and purpose, and themes of understanding of other people and the world around them. Subthemes focused on appreciation/acceptance, adaptability/accountability, valuing all lives, and learning/teaching about their child. Meaning-making may be an opportunity for support in the PICU among parents/family caregivers of children with SNI.

Race, Ethnicity, and Intensive Care Utilization for Common Pediatric Diagnoses: U.S. Pediatric Health Information System 2019 Database Study.

Racial and ethnic disparities in healthcare delivery for acutely ill children are pervasive in the United States; it is unknown whether differential critical care utilization exists. Retrospective study of the Pediatric Health Information System (PHIS) database. Multicenter database of academic children's hospitals in the United States. Children discharged from a PHIS hospital in 2019 with one of the top ten medical conditions where PICU utilization was present in greater than or equal to 5% of hospitalizations. None. Race and ethnicity categories included Asian, Black, Hispanic, White, and other. Primary outcomes of interest were differences in rate of PICU admission, and for children requiring PICU care, total hospital length of stay (LOS). One-quarter ( n = 44,200) of the 178,134 hospital discharges included a PICU admission. In adjusted models, Black children had greater adjusted odds ratio (aOR [95% CI]) of PICU admission in bronchiolitis (aOR, 1.08 [95% CI, 1.02-1.14]; p = 0.01), respiratory failure (aOR, 1.18 [95% CI, 1.10-1.28]; p < 0.001), seizure (aOR, 1.28 [95% CI, 1.08-1.51]; p = 0.004), and diabetic ketoacidosis (DKA) (aOR, 1.18 [95% CI, 1.05-1.32]; p = 0.006). Together, Hispanic, Asian, and other race children had greater aOR of PICU admission in five of the diagnostic categories, compared with White children. The geometric mean (± sd ) hospital LOS ranged from 47.7 hours (± 2.1 hr) in croup to 206.6 hours (± 2.8 hr) in sepsis. After adjusting for demographics and illness severity, children from families of color had longer LOS in respiratory failure, pneumonia, DKA, and sepsis. The need for critical care to treat acute illness in children may be inequitable. Additional studies are needed to understand and eradicate differences in PICU utilization based on race and ethnicity.

Measuring Physical Function in the PICU: Development and Testing of a Children's Version (Age 2-18 yr) of the Chelsea Critical Care Physical Assessment Tool.

To adapt and develop a reliable and easily administered outcome measure of physical and respiratory function in critically ill children in the PICU. Modified Delphi study to adapt the Chelsea Critical Care Physical Assessment (CPAx) tool for use in children 2-18 years old, with subsequent prospective testing in a single-center cohort. Single-center tertiary PICU. Delphi process in 27 panelists (including physiotherapists, occupational therapists, and pediatric intensivists from seven countries from January 2018 to March 2018). Cohort study in 54 patients admitted to PICU for greater than 24 hours over a 3-month period (April 2018 to June 2018), with median age 5.5 years (interquartile range [IQR], 3-12.75 yr), 33 of 54 male, and 38 of 54 invasively ventilated. None. Three Delphi iterations were required to reach greater than or equal to 80% consensus in all the children's CPAx (cCPAx) items. In the subsequent cohort study, six physiotherapists used the cCPAx tool and scored 54 participants, with a total 106 observations. The median cCPAx tool score was 14.50 (IQR, 3-25) out of a possible total of 50. Inter-rater reliability for 30 randomly selected participants was excellent (intraclass correlation coefficient, 0.998). Completion rate of cCPAx in the 54 patients occurred in 78 of 106 occasions (74%). The cCPAx tool content that was developed using Delphi methodology provided a feasible and clinically relevant tool for use in assessing physical morbidity in PICU patients 2-18 years old. Overall, the cCPAx scores were low, demonstrating low levels of physical function and high levels of immobility during PICU care.

Family experiences and perceptions of quality and safety of care in PICU

Family experiences and perceptions of quality and safety of care in PICU

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit.

Optimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU. To assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design-informed tools would either maintain or improve situation awareness. A 15-week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation. Improved and updated communication devices and bedside mitigation plans. Process metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre- and post-transition. When evaluating all patients, shared situation awareness for accurate high-risk status improved from 81% pre-transition to 92% post-transition (p = .006). When assessing individual care team roles, accuracy of patient high-risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.

Pulmonary Hemorrhage in Pediatric Hematopoietic Stem Cell Transplant Recipients: A Single-Center Retrospective Study.

Pulmonary hemorrhage (PH) is a serious complication posthematopoietic stem cell transplant (HSCT). In view of limited available pediatric data, we performed a retrospective study to describe epidemiology, management, and outcomes of PH post-HSCT in children in our national center. Retrospective study. Academic children's hospital (2000-2015). Children (< 18 yr) with PH and requiring PICU care post-HSCT. None. The historical prevalence of PH in our center was 2.7% (31/1,148). Twenty patients had a concomitant infection, 15 had bacterial infection, 8 had viral infection, and 3 patients had a fungal infection. With a median follow-up time of 60 months, 7 of 31 patients were alive. Early PH (< 40 d post-HSCT) was associated with improved survival (6/15 vs 1/16, p = 0.035). Patients who received high-dose pulsed corticosteroid had improved survival when compared with those who did not (7/22 vs 0/9, p = 0.0012); this also applied to the subgroup of patients with a concomitant infection (5/15 vs 0, p = 0.001). None of the patients who survived had measurable respiratory sequelae. PH is a rare but serious complication after HSCT. Corticosteroids were associated with improved survival even in patients with a concomitant infection.

Walking a Tightrope: Balancing Continuity for Long-Stay Patients and Wellness for Clinicians in an Ever-Evolving Landscape.

Walking a Tightrope: Balancing Continuity for Long-Stay Patients and Wellness for Clinicians in an Ever-Evolving Landscape.

Covid-19 Pandemic and Childhood Cancer: Lessons Learnt from a Pediatric Oncology Unit in a Developing Country

Background: COVID-19 pandemic has caused unprecedented challenges to healthcare delivery globally. Children with cancer are a vulnerable group given their immunosuppressed state. There is paucity of data regarding the organisation of pediatric cancer care and outcomes of children with cancer who developed COVID-19 infection. We describe the organisation of care in a Pediatric Oncology unit in a tertiary care hospital in South India and describe the clinical profile and outcomes of children with cancer who were diagnosed with COVID-19 infection. Methods: This was a retrospective chart review of all children admitted to the pediatric oncology unit and diagnosed with COVID-19 infection between March 2020 and October 2020. Descriptive statistics were calculated. Results: A total of 144 children were on active chemotherapy during the study period. Of these, Nine (6.2 %) were diagnosed with COVID-19. Fever and cough were the predominant symptoms. Majority (88%) had mild symptoms. COVID-19 was positive at cancer diagnosis in 22%. PICU care was required for 33%, but for non-covid related concerns. Recovery from Covid-19 was seen in 88%. Chemotherapy administered during or after Covid-19 infection was well tolerated. Co-existent sepsis or CMV infection resulted in severe symptoms leading to mortality and this was not related to severe covid related symptomatology. Conclusions: In our study, majority of children with cancer who developed covid-19 had mild symptoms and recovered uneventfully. Chemotherapy should not be delayed in children with active cancer. The overall outcomes of pediatric oncology care during the pandemic are reassuring.

Asthma Cases Treated With Inhaled Anesthetics or Extracorporeal Membrane Oxygenation: A Virtual Pediatric Systems Database Study of Outcomes.

Extracorporeal membrane oxygenation (ECMO) and/or inhaled anesthetics (IAs) are considered in the management of asthma when refractory to conventional therapy. We aimed to compare the outcomes of these two modalities in asthma PICU care and determine associated survival to hospital discharge among patients in a United States database. Retrospective analysis using the Virtual Pediatric Systems (VPS, LLC) database. PICUs participating in the VPS database. Patients less than 18 years old with diagnosis of asthma treated with IA and/or ECMO from January 2010 to December 2020. None. A total of 221 patients were included; 149 (67%) received ECMO, 62 (28%) received IA, and 10 (5%) received both interventions. We failed to identify any difference between the ECMO and IA groups in demographics, Pediatric Index of Mortality 2 percentage, Pediatric Risk of Mortality 3 score, Pediatric Logistic Organ Dysfunction score, or pre-intervention pH and Pa co2 levels. Use of ECMO versus IA was associated with lower pre-intervention Pa o2 (60 torr [7.99 kPa] vs 78 torr [10.39 kPa]; p < 0.001) and higher utilization of high-frequency oscillatory ventilation. We failed to identify an association between type of intervention (IA vs ECMO) and greater odds of survival (57/62 [92%] vs 128/149 [86%]; odds ratio [OR], 1.87; 95% CI, 0.67-5.21; p = 0.23). However, these data do not exclude the possibility that IA use is associated with more than five-fold greater odds of survival. ECMO use was associated with longer duration of intervention (5 vs 1.3 d; p < 0.001) and PICU length of stay (LOS) (13 vs 7 d; p < 0.001). As expected, ECMO versus IA was also associated with greater odds of undergoing bronchoscopy (34% vs 11%; OR, 3.7; 95% CI, 1.5-9.4; p = 0.004). In the VPS database of asthma management cases, we failed to identify an association between ECMO versus IA use and survival to hospital discharge. However, ECMO was associated with longer duration of intervention and PICU LOS.

Outcome in Children Admitted to the First PICU in Malawi.

Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality. Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models. A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi. Children admitted to PICU between August 1, 2017, and July 31, 2019. None. Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality. In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.

Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU.

Multicenter retrospective cohort study. Pediatric Health Information System (PHIS) database. Children 0-18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of "Complicated TBI" was created based on radiology, pharmacy, and procedure codes. None. Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8-145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0-6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1-16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study. Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.

Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs.

To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived. A cross-sectional survey. U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships. One senior physician and one senior nurse at each institution. None. Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility. Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.

Non-comorbid Respiratory Factor and Work of Breathing in Pediatric COVID-19 Patient: How is Their Synergistic Correlation with the Level of Care?

Background: Work of breathing (WOB) and non-comorbidities factors in the respiratory system are the two probable findings in pediatric COVID-19 patients. However, the association of those factors with level of care was not well reported.Purpose: This study aimed to identify the relation between potential predictors including comorbidity, low nutritional fulfillment, infectious disease, shock, cough, O2 saturation reduction, abnormal blood gas analysis and sore throat with the level of care among pediatric COVID-19 patients. We also analyzed the synergistic correlation of non-comorbidities factors in the respiratory system and work of breathing to predict level of care in pediatric COVID-19 patients.Methods: A cross-sectional study was conducted in the six referral hospitals from July to September 2020 in four provinces in Indonesia. An observation checklist was used to collect data from the medical records of pediatric patients with COVID-19, including medical diagnosis, demographic, and clinical manifestation. This study included 423 participants aged from 0 to 18. The multivariate logistic regression was performed to test the adjusted odds ratios (AORs) with the 95% confidence intervals (CIs) of the association between WOB, non-comorbid respiratory, and level of care. Moreover, dummy variables (2x2) were made to analyze synergistic correlation of non-comorbid respiratory disease and WOB. The AOR with the 95% CIs was applied in the association between the complication of non-comorbid respiratory diseases and high work of breathing with level of care among pediatric patients with COVID-19.Results: Results showed that age, presence of comorbidity, nutritional fulfillment, infectious disease, shock, work of breathing, O2 saturation reduction, abnormal blood gas analysis, sore throat, and convulsive meningeal consciousness were significantly associated with the level of care (p&lt;0.05). Pediatric patients with non-comorbid respiratory and increased work of breathing had a 15.59 times higher risk of requiring PICU care level (p&lt;0.01). Meanwhile, pediatric patients who experienced both non-comorbid respiratory and increased work of breathing had a 5.76 times risk of requiring an intermediate level of care (p&lt;0.05), and 9.32 times higher risk of requiring a PICU level of care (p&lt;.05).Conclusion: It was found that both non-comorbid respiratory and increased WOB had a significant relationship with the level of care for pediatric patients with COVID-19. Nurse should take into account those clinical findings to increase the awareness in monitoring clinical deterioration in pediatric COVID-19 patients.

671: HEAD INJURY DEPTH AND FUNCTIONAL OUTCOMES IN PEDIATRIC TRAUMATIC BRAIN INJURY

Introduction: The centripetal theory of traumatic brain injury (TBI) posits that an inertial mechanism (rotational acceleration and deceleration) injures the brain in an outward-in fashion, where mild injuries affect only the superficial brain and severe injuries affect the deep, subcortical structures of the brain. Neurologic symptoms progressively worsen as depth of injury increases. Depth of brain lesion has been proposed as a potential prediction tool for functional outcome in older children and adolescents, but there is a paucity of data connecting depth of injury and outcome in young children. We hypothesized that functional outcome at hospital discharge will worsen as greatest depth of injury increases in children < 3. Methods: Retrospective chart review including patients < 3 years of age admitted to a tertiary children’s hospital PICU or Intermediate Care Unit between 2015 - 2020 with acute TBI. Patients were divided into 4 cohorts based on greatest depth of injury visible on initial neuroimaging: scalp/skull/epidural vs. subdural/subarachnoid vs. cortical brain vs. subcortical brain injury. Baseline and hospital discharge Functional Status Score (FSS) (score 6-30) and Pediatric Cerebral Performance Category (PCPC) (score 1-5) were assigned. Results: A total of 170 patients were included (scalp/skull/epidural, n=54; subdural/subarachnoid, n=76; cortical brain, n=17; subcortical brain, n=23). Median age was 6 months. Sixty percent of patients were male. Nine patients died, 1 with a cortical injury and 8 with subcortical injuries. Total length of stay (LOS), PICU LOS, and ventilator days all increased as depth of injury increased (p< 0.001). All patients had a normal baseline FSS of 6 and a PCPC of 1. As depth of injury increased from superficial to deepest, patients were more likely to have functional deficits at discharge (FSS: 4% vs. 7% vs. 38% vs. 73%, p< 0.001; PCPC: 2% vs. 8% vs. 44% vs. 73%, p< 0.001). Patients with subcortical injuries had significantly higher median FSS (10, IQR 6.5-13, p< 0.001) and PCPC (2, IQR 1.5-3.5, p< 0.001) at discharge. Conclusions: Functional outcomes at hospital discharge worsen as greatest depth of injury increases in children < 3 with acute TBI, supporting the potential use of depth of brain injury as a prediction tool for functional outcome in this population.

Editor's Choice Articles for December.

Editor's Choice Articles for December.

PP063 [Lung » Airway disease and related issues]: PATIENT CHARACTERISTICS, RESOURCE USE, AND CLINICAL OUTCOMES OF STATUS ASTHMATICUS IN TWO DIFFERENT MODELS OF PICU CARE

PP063 [Lung » Airway disease and related issues]: PATIENT CHARACTERISTICS, RESOURCE USE, AND CLINICAL OUTCOMES OF STATUS ASTHMATICUS IN TWO DIFFERENT MODELS OF PICU CARE

Epidemiology of Pediatric Critical Care Admissions in 43 United States Children’s Hospitals, 2014–2019*

To identify trends in the population of patients in PICUs over time. Cross-sectional, retrospective cohort study using the Pediatric Health Information System database. Forty-three U.S. children's hospitals. All patients admitted to Pediatric Health Information System-participating hospitals from January 2014 to December 2019. Individuals greater than 65 years old and normal newborns were excluded. None. PICU care occurred in 13.8% of all pediatric hospital encounters and increased over the study period from 13.3% to 14.3%. Resource intensity, based on average Hospitalization Resource Intensity Scores for Kids score, increased significantly across epochs (6.5 in 2014-2015 vs 6.9 in 2018-2019; p < 0.001), although this was not consistently manifested as additional procedural exposure. Geometric mean PICU cost per patient encounter was stable. The two most common disease categories in PICU patients were respiratory failure and cardiac and circulatory congenital anomalies. Of all PICU encounters, 35.5% involved mechanical ventilation, and 25.9% involved vasoactive infusions. Hospital-level variation in the percentage of days spent in the PICU ranged from 15.1% to 63.5% across the participating sites. Of the total hospital costs for patients admitted to the PICU, 41.7% of costs were accrued during the patients' PICU stay. The proportional use of PICU beds is increasing over time, although was variable across centers. Case-based resource use and complexity of pediatric patients are also increasing. Despite the higher use of PICU resources, the standardized costs of PICU care per patient encounter have remained stable. These data may help to inform current PICU resource allocation and future PICU capacity planning.

Hospital Charges Associated With Critical Bronchiolitis From 2009 to 2019.

To evaluate the contribution of PICU care to increasing hospital charges for patients with bronchiolitis over a 10-year study period. In this retrospective multicenter study, changes in annual hospital charges (adjusted for inflation) were analyzed using linear regression for subjects admitted to the PICU with invasive mechanical ventilation (PICU + IMV) and without IMV (PICU - IMV), and for children not requiring PICU care. Free-standing children's hospitals contributing to the Pediatric Health Information System (PHIS) database. Children less than 2 years with bronchiolitis discharged from a PHIS hospital between July 2009 and June 2019. Subjects were categorized as high risk if they were born prematurely or had a chronic complex condition. None. PICU patients were 26.5% of the 283,006 included subjects but accrued 66% of the total $14.83 billion in charges. Annual charges increased from $1.01 billion in 2009-2010 to $2.07 billion in 2018-2019, and PICU patients accounted for 83% of this increase. PICU + IMV patients were 22% of all PICU patients and accrued 64% of all PICU charges, but PICU - IMV patients without a high-risk condition had the highest relative increase in annual charges, increasing from $76.7 million in 2009-2010 to $377.9 million in 2018-2019 (374% increase, ptrend < 0.001). In a multicenter cohort study of children hospitalized with bronchiolitis, PICU patients, especially low-risk children without the need for IMV, were the highest driver of increased hospital charges over a 10-year study period.

Mortality and PICU Hospitalization Among Pediatric Gunshot Wound Victims in Chicago.

IMPORTANCE:Firearm injury accounts for significant morbidity with high mortality among children admitted to the PICU. Understanding risk factors for PICU admission is an important step toward developing prevention and intervention strategies to minimize the burden of pediatric gunshot wound (GSW) injury.OBJECTIVES:The primary objective of this study was to characterize outcomes and the likelihood of PICU admission among children with GSWs.DESIGN, SETTING, AND PARTICIPANTS:Retrospective cohort study of GSW patients 0–18 years old evaluated at the University of Chicago Comer Children’s Hospital Pediatric Trauma Center from 2010 to 2017.MAIN OUTCOMES AND MEASURES:Demographic and injury severity measures were acquired from an institutional database. We describe mortality and hospitalization characteristics for the cohort. We used logistic regression models to test the association between PICU admission and patient characteristics.RESULTS:During the 8-year study period, 294 children experienced GSWs. We did not observe trends in overall mortality over time, but mortality for children with GSWs was higher than all-cause PICU mortality. Children 0–6 years old experienced longer hospitalizations compared with children 13–16 years old (5 vs 3 d; p = 0.04) and greater frequency of PICU admission (83.3% vs 52.9%; p = 0.001). Adjusting for severity of illness, children less than 7 years old were four-fold more likely to be admitted to the PICU than children 13–16 years old (aOR range, 3.9–4.6).CONCLUSIONS AND RELEVANCE:Despite declines in pediatric firearm mortality across the United States, mortality did not decrease over time in our cohort and was higher than all-cause PICU mortality. Younger children with GSWs experience longer hospitalizations and require PICU care more often than older children. Our findings suggest that the youngest victims of firearm-related injury may be particularly at-risk of the long-term sequelae of critical illness and injury.

1193. Mucosal Antibody Responses to Respiratory Syncytial Virus (RSV) in Infants and Young Children

Abstract Background The burden associated with RSV infection is substantial. Although RSV initially infects the upper respiratory tract, there is limited information of the mucosal concentrations of antibodies (Abs) directed to RSV specific proteins and whether patient’s age and disease severity influence production of mucosal Abs. Methods From 2017 to2019 we enrolled previously healthy children &amp;lt; 2 years of age hospitalized with RSV infection and obtained acute and convalescent (day; D30) nasopharyngeal (NP) samples to measure preF and postF specific IgG and IgA Abs by ELISA. Demographic and clinical data were collected and analyzed according to Abs responses. Results We enrolled 77 children (median [IQR] age: 2.8 [1.5-5.2] months; 49 % females) within the first 24 hours of hospitalization. Of those 25 (33%) patients required PICU care. A significant increase in convalescent IgG preF Abs titers was detected in 62 (81%) children, while IgA preF titers significantly increased in all but one child on D30. The magnitude of the increase was 56-fold higher for preF IgA versus preF IgG (p&amp;lt; 0.0001). PostF IgG and IgA titers were also increased on D30 but at significant lower levels. Infants &amp;lt; 3 months of age compared with those &amp;gt;3-24 months had significantly higher baseline preF and postF IgG Abs titers (p &amp;lt; 0.001) but not IgA antibodies. D30 preF and post F IgG titers were higher in children &amp;gt; 6 months of age (p &amp;lt; 0.0001) but only preF titers fold change significantly correlated with age (r=0.4, p&amp;lt; 0.0001). These correlations were not identified with IgA preF antibodies. There were no statistical differences in antibody titers at baseline and on D30 according to breastfeeding, and disease severity as defined by the need for PICU care. Conclusion Children hospitalized with RSV infection demonstrated significantly increased titers of mucosal preF and post F IgG and IgA specific Abs in convalescent samples. Baseline IgG Abs where higher in younger infants, which likely reflects maternally acquired antibodies. Age significantly correlated with Abs production, suggesting a more robust immune response in older children. Disclosures Mark E. Peeples, PhD, Janssen (Research Grant or Support)Pfizer (Research Grant or Support) Octavio Ramilo, MD, Adagio (Consultant)Bill &amp; Melinda Gates Foundation (Grant/Research Support)Janssen (Grant/Research Support)Lilly (Consultant)Merck (Consultant, Grant/Research Support)NIH (Grant/Research Support)Pfizer (Consultant)SANOFI (Board Member) Asuncion Mejias, MD, PhD, MsCS, Janssen (Grant/Research Support, Advisor or Review Panel member)Merck (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member)Sanofi (Advisor or Review Panel member)