PICU Care Research Articles

Epidemiology and Outcomes of Critically Ill Children at Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Interventional trials aimed at pediatric acute respiratory distress syndrome prevention require accurate identification of high-risk patients. In this study, we aimed to characterize the frequency and outcomes of children meeting "at risk for pediatric acute respiratory distress syndrome" criteria as defined by the Pediatric Acute Lung Injury Consensus Conference. Planned substudy of the prospective multicenter, international Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study conducted during 10 nonconsecutive weeks (May 2016-June 2017). Thirty-seven international PICUs. Three-hundred ten critically ill children meeting Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria. None. We evaluated the frequency of children at risk for pediatric acute respiratory distress syndrome and rate of subsequent pediatric acute respiratory distress syndrome diagnosis and used multivariable logistic regression to identify factors associated with subsequent pediatric acute respiratory distress syndrome. Frequency of at risk for pediatric acute respiratory distress syndrome was 3.8% (95% CI, 3.4-5.2%) among the 8,122 critically ill children who were screened and 5.8% (95% CI, 5.2-6.4%) among the 5,334 screened children on positive pressure ventilation or high-flow oxygen. Among the 310 at-risk children, median age was 2.1 years (interquartile range, 0.5-7.3 yr). Sixty-six children (21.3%) were subsequently diagnosed with pediatric acute respiratory distress syndrome, a median of 22.6 hours (interquartile range, 9.8-41.0 hr) later. Subsequent pediatric acute respiratory distress syndrome was associated with increased mortality (21.2% vs 3.3%; p < 0.001) and longer durations of invasive ventilation and PICU care. Subsequent pediatric acute respiratory distress syndrome rate did not differ by respiratory support modality at the time of meeting at risk criteria but was independently associated with lower initial saturation:Fio2 ratio, progressive tachycardia, and early diuretic administration. The Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria identify critically ill children at high risk of pediatric acute respiratory distress syndrome and poor outcomes. Interventional trials aimed at pediatric acute respiratory distress syndrome prevention should target patients early in their illness course and include patients on high-flow oxygen and positive pressure ventilation.

Suicide and Self-Harm in Children and Adolescents Admitted to PICUs in the United States.

To characterize the epidemiology of children and adolescents admitted for deliberate self-harm to PICUs in the United States by examining patient demographics, diagnoses, modes of self-harm, and outcomes. Descriptive analysis of a large, multicenter, quality-controlled database. The 137 PICUs participating in the Virtual Pediatric Systems database during the study period. Children between 6 and 18 years old admitted to a participating PICU from January 1, 2009, to December 31, 2017, with a diagnosis involving deliberate self-harm or a suicide attempt. None. Of 9,197 admissions for self-harm, females accounted for 6,740 (73.3%), whereas males incurred 174 of the 284 deaths (61.3%). Admissions for self-harm doubled over the study period (0.56% in 2009 vs 1.13% in 2017), with an increase observed across every age group. After PICU care, most patients were transferred to a general care floor (51.1%) or to a psychiatric rehabilitation facility (31.8%). Intentional drug ingestion (84%) was the most common mode of self-harm but was associated with less than 1% of the fatalities. Asphyxia/hanging or firearms were a factor in 411 (4.5%) and 106 (1.2%) of the admissions but were associated with 117 (28.5%) and 55 (51.9%) of the deaths, respectively. PICU admissions due to self-harm increased for all age groups during the study period. Females accounted for most of these admissions, whereas males accrued most of the in-hospital deaths. Intentional drug ingestion was the most common mode of self-harm and was rarely fatal, whereas asphyxia and firearms were the mechanisms associated with the highest mortality.

Outcomes of Firearm Injuries Among Children in the PICU

Source: Bagdure D, Foster CB, Garber N, et al. Outcomes of children with firearm injuries admitted to the PICU in the United States [published online ahead of print June 7, 2021]. Pediatr Crit Care Med. doi:10.1097/PCC.0000000000002785Investigators from the University of Maryland, College Park, conducted a retrospective study to assess the morbidity and mortality among children admitted to the PICU with firearm injuries. Data for this study was obtained from 107 PICUs participating in the Virtual Pediatrics Systems (VPS) database, a consortium of PICUs that contribute demographic and clinical data on hospitalized children. VPS data from 2009–2017 were obtained for the current study.Patients with firearm injure in the VPS database using ICD codes. Among identified patients, demographics, cause of firearm injury (assault, suicide attempt, unintentional, or undetermined), site of injury, and discharge scores on validated scales for overall functional morbidity (the Pediatric Overall Performance Category; POPC) and cognitive impairment (Pediatric Cerebral Performance Category; PCPC) were abstracted from VPS. The primary outcome was death in the PICU. Secondary outcomes included discharge scores on the POPC and PCPC among those who survived, with scores categorized as normal, mild, moderate, or severe disability, or coma/vegetative state. The investigators used chi-squared tests to assess the association of demographics and clinical characteristics with outcomes.There were 1,447 identified patients admitted to the PICU for firearm injuries. Of these, 44.60 were Black, 77.50 were male, and 57.30 were 13-18 years old. The most common cause of firearm injury was unintentional (67.70), and the most common site of injury was the head or neck (30.70).Overall, 175 (120) patients died, with a higher proportion of white (41.10) children who died compared to Black (30.90) and Hispanic (6.90) children (P < 0.05). Suicide attempt was the cause of firearm injury with the highest rate of death (52 of 95 patients with suicide attempt by firearm injury died). Overall, among those who survived to discharge, most had mild disability.The investigators conclude that the mortality among children admitted to the PICU for firearm injury is high.Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The SARS-CoV-2 pandemic has intensified economic and social stressors and highlighted the presence of systemic racism in the US. Gun ownership and violent crime as well as mass shootings have increased dramatically during the past year.1 In the current study of PICU gun victims, male, teenaged, and Black children were over-represented. Younger children were more likely to have unintentional injuries compared to older children. Assault was more common among Black children, while self-inflicted injuries were more common in white children, led to head and neck injuries, and were more frequently lethal. To develop and evalu-ate prevention strategies to decrease firearm injuries and death, the investigators need to capture information on all children at risk for firearm injuries and death. Those who die prior to hospital admission and those with less severe injuries not requiring PICU care need to be included as well as those treated in adult hospi-tals. For some pediatric groups (such as Black males 15-18 years old), assault with firearms is the leading cause of death, while drowning and motor vehicle accidents remain more common in white children 1 to 10 years of age.2In order to evaluate populations at risk for firearm injuries, important factors include the relationship of the victim to the shooter, the injury intent, and determination of the impact of alcohol and drugs, gangs, poverty, racism, or access to guns. Other factors include mental illness, robbery, domestic violence, or hate crimes.3 Public support favors strict enforcement of back-ground checks prior to purchasing a gun as well as prohibition of gun sales with high-capacity magazines.3 However, the impact of legislation targeted to decrease mass shootings, or from shooters with a history of mental illness who passed a background check, remains untested.2Firearm injuries are a significant, largely preventable, cause of morbidity and mortality in children admitted to the PICU. These injuries impact males and minority groups at much higher rates.The mortality rate from firearm injuries in the current study is 5 times greater than the all-cause PICU mortality.4 As most of the injuries are unintentional, and most survivors incur neurologic morbidity, is it not time to institute preventive strategies?

A Review of Infections After Hematopoietic Cell Transplantation Requiring PICU Care: Transplant Timeline Is Key.

Despite major advances in antimicrobial prophylaxis and therapy, opportunistic infections remain a major cause of morbidity and mortality after pediatric hematopoietic cell transplant (HCT). Risk factors associated with the development of opportunistic infections include the patient's underlying disease, previous infection history, co-morbidities, source of the donor graft, preparative therapy prior to the graft infusion, immunosuppressive agents, early and late toxicities after transplant, and graft-vs.-host disease (GVHD). Additionally, the risk for and type of infection changes throughout the HCT course and is greatly influenced by the degree and duration of immunosuppression of the HCT recipient. Hematopoietic cell transplant recipients are at high risk for rapid clinical decompensation from infections. The pediatric intensivist must remain abreast of the status of the timeline from HCT to understand the risk for different infections. This review will serve to highlight the infection risks over the year-long course of the HCT process and to provide key clinical considerations for the pediatric intensivist by presenting a series of hypothetical HCT cases.

Hemodynamic Patterns Before Inhospital Cardiac Arrest in Critically Ill Children: An Exploratory Study.

Exploratory retrospective analysis of arterial blood pressure and electrocardiogram waveforms. PICU and cardiac critical care unit in a tertiary-care children's hospital. Twenty-seven children with invasive blood pressure monitoring who suffered a total of 31 inhospital cardiac arrest events between June 2017 and June 2019. None. We assessed changes in cardiac output, systemic vascular resistance, stroke volume, and heart rate derived from arterial blood pressure waveforms using three previously described estimation methods. We observed substantial prearrest drops in cardiac output (population median declines of 65-84% depending on estimation method) in all patients in the 10 minutes preceding inhospital cardiac arrest. Most patients' mean arterial blood pressure also decreased, but this was not universal. We identified three hemodynamic patterns preceding inhospital cardiac arrest: subacute pulseless arrest (n = 18), acute pulseless arrest (n = 7), and bradycardic arrest (n = 6). Acute pulseless arrest events decompensated within seconds, whereas bradycardic and subacute pulseless arrest events deteriorated over several minutes. In the subacute and acute pulseless arrest groups, decreases in cardiac output were primarily due to declines in stroke volume, whereas in the bradycardic group, the decreases were primarily due to declines in heart rate. Critically ill children exhibit distinct physiologic behaviors prior to inhospital cardiac arrest. All events showed substantial declines in cardiac output shortly before inhospital cardiac arrest. We describe three distinct prearrest patterns with varying rates of decline and varying contributions of heart rate and stroke volume changes to the fall in cardiac output. Our findings suggest that monitoring changes in arterial blood pressure waveform-derived heart rate, pulse pressure, cardiac output, and systemic vascular resistance estimates could improve early detection of inhospital cardiac arrest by up to several minutes. Further study is necessary to verify the patterns witnessed in our cohort as a step toward patient rather than provider-centered definitions of inhospital cardiac arrest.

Repurposing a PICU for Adult Care in a State Mandated COVID-19 Only Hospital: Outcome Comparison to the MICU Cohort to Determine Safety and Effectiveness.

Objective: The ongoing coronavirus 2019 (COVID-19) pandemic is disproportionally impacting the adult population. This study describes the experiences after repurposing a PICU and its staff for adult critical care within a state mandated COVID-19 hospital and compares the outcomes to adult patients admitted to the institution's MICU during the same period.Design: A retrospective chart review was performed to analyze outcomes for the adults admitted to the PICU and MICU during the 27-day period the PICU was incorporated into the institution's adult critical care surge plan.Setting: Tertiary care state University hospital.Patients: Critically ill adult patients with proven or suspected COVID-19.Interventions: To select the most ideal adult patients for PICU admission a tiered approach that incorporated older patients with more comorbidities at each stage was implemented.Measurements and Main Results: There were 140 patients admitted to the MICU and 9 patients admitted to the PICU during this period. The mean age of the adult patients admitted to the PICU was lower (49.1 vs. 63.2 p = 0.017). There was no statistically significant difference in the number of comorbidities, intubation rates, days of ventilation, dialysis or LOS. Patients selected for PICU care did not have coronary artery disease, CHF, cerebrovascular disease or COPD. Mean admission Sequential Organ Failure Assessment (SOFA) score was lower in patients admitted to the PICU (4 vs. 6.4, p = 0.017) with similar rates of survival to discharge (66.7 vs. 44.4%, p = 0.64).Conclusion: Outcomes for the adult patients who received care in the PICU did not appear to be worse than those who were admitted to the MICU during this time. While limited by a small sample size, this single center cohort study revealed that careful assessment of critical illness considering age and type of co-morbidities may be a safe and effective approach in determining which critically ill adult patients with known or suspected COVID-19 are the most appropriate for PICU admission in general hospitals with primary management by its physicians and nurses.

"You Have Made All the Loving Choices": Good Parent Praise in Pediatric Critical Care Conferences.

Parents' ideas about what it means to be a "good parent" to their seriously ill child influence parental decision-making. Little is known about when, why, and how clinicians offer good-parent praise or how parents react. Our objective was to describe clinicians' spontaneous use of good-parent praise statements to parents during PICU care conferences and how parents respond. Single-center, cross-sectional review of 72 transcripts of audio-recorded PICU care conferences in a quaternary medical center. Qualitative analysis was conducted to code triggers for clinician good-parent statements and parent responses. Clinicians made at least one statement of good-parent praise in 32% of family conferences. Triggers for clinician statements of good-parent praise were categorized into 6 themes: decision making, gratitude to the clinical team, defense of parenting, parental body language, parental guilt, and intention to close the meeting. Parental responses to clinician statements of good-parent praise fell into 6 themes: acknowledgment, medical talk, deepening of feelings expressed in conversation, focusing on a decision, redirecting on the patient, and gratitude. Clinicians spontaneously praised parents for their role in being a good parent in less than one-third of family conferences. Clinician statements were triggered by verbal and nonverbal parental behaviors, a critical decision-making point in the conversation, and an intention to close the meeting. In response, parents frequently responded positively to the praise and often returned the gratitude or reflected on their feelings about caregiving for their child.

End-of-Life Care in Taiwan: Single-Center Retrospective Study of Modes of Death.

Medical advances and the National Health Insurance coverage in Taiwan mean that mortality in the PICU is low. This study describes change in modes of death and end-of-life care in a single center, 2011-2017. Multidisciplinary PICU in a tertiary referral Children's Hospital in Taiwan. There were 316 deaths in PICU patients. Palliative care consultation in the PICU service occurred after the 2013 "Hospice Palliative Care Act" revision. In the whole cohort, 22 of 316 patients (7%) were determined as "death by neurologic criteria". There were 94 of 316 patients (30%) who had an event needing cardiopulmonary resuscitation within 24 hours of death: 17 of these patients (17/94; 18%) died after failed cardiopulmonary resuscitation without a do-not-resuscitate order, and the other 77 of 94 patients (82%) had a do-not-resuscitate order after cardiopulmonary resuscitation. Overall, there were 200 of 316 patients (63%) who had a do-not-resuscitate order and were entered into the palliative program: 169 of 200 (85%) died after life-sustaining treatment was limited, and the other 31 of 200 (15%) died after life-sustaining treatment was withdrawn. From 2011 to 2017, the time-trend in end-of-life care showed the following associations: 1) a decrease in PICU mortality utilization rate, from 22% to 7% (p < 0.001); 2) a decrease in use of catecholamine infusions after do-not-resuscitate consent, from 87% to 47% (p = 0.001), in patients having limitation in life-sustaining treatment; and 3) an increase in withdrawal of life-sustaining treatment, from 4% to 31% (p < 0.001). In our practice in a single PICU-center in Taiwan, we have seen that the integration of a palliative care consultation service, developed after the revision of a national "Palliative Care Act," was associated with increased willingness to accept withdrawal of life-sustaining treatment and a lowered PICU care intensity at the end-of-life.

P0482 / #1466: POST-INTENSIVE CARE SYNDROME AMONG SURVIVORS OF CRITICAL BRONCHIOLITIS

Aims & Objectives: We previously showed that ~15% of previously healthy PICU patients with bronchiolitis have evidence of post-intensive care syndrome (PICS) in administrative databases. Now, we aimed to evaluate for post-bronchiolitis PICS using detailed, in-person testing. Methods: Critical bronchiolitis patients discharged from our urban, academic PICU 1-3 years ago were invited via mail for in-person testing with Bayley Scales of Infant & Toddler Development (Bayley-III), Ages and Stages Questionnaire, and Pediatric Evaluation of Disability Inventory-Computer Adaptive Test. Children with pre-PICU developmental delay (per the admission medical records or parental recall) were excluded. For each domain (motor, language, etc.) of each test, mild dysfunction (>1SD below the mean) and severe dysfunction (>2SD below) were identified. PICS was defined as severe dysfunction in ≥3 of the 11 total domains or mild dysfunction in ≥5 domains. Data shown as median (IQR). Results: With IRB approval, 20 children (80% without previous hospitalizations) underwent testing at 2.1 (1.8-2.8) years after PICU care. Most had been supported by HFNC (95%) and/or invasive ventilation (20%). PICS was identified in 35% of cases, including 25% with severe dysfunction in ≥3 domains. For the whole group, median scores in each Bayley-III domain were below normal (Cognitive: 25th [16th-37th] percentile; Language: 31st [6th-50th] percentile; Motor: 21st [12th-29th] percentile). Excluding children born prematurely or with cyanotic congenital heart disease, PICS was observed in 5 of 15 subjects. Conclusions: PICS is common after critical bronchiolitis, even among generally healthy children. Future studies should prospectively compare scores measured at and after PICU admission.

P0096 / #565: THE TRAVAILS OF SETTING UP A LIVING DONOR LIVER TRANSPLANT PROGRAM: THE PICU PERSPECTIVES EXPERIENCE FROM TUNISIA

Aims & Objectives: To report our first experience of PICU care of living donor liver transplant (LDLT) in Tunisia, and the challenges encountered. Methods: This was a retrospective, descriptive study, collecting the first 10 pediatric LDLT at the Fattouma Bourguiba Hospital between November 2017 and March 2019. Results: The patients average age was 5 years and 11 months. The most common indication of LDLT was cirrhosis complicating PFIC. The average duration of mechanical ventilation was 1.8 days. One child developed hepatic artery thrombosis, another patient developed supra hepatic vein thrombosis. 2 patients developed acute rejection treated with immunosuppressant. The PICU length of stay ranged from 4 to 10 days and there was no ICU mortality. Challenges: - The Creation of liver transplant unit, - The Shortage of nursing staff was addressed by the participation of nurses from pediatric and adult ICU while awaiting the recruitment of more nurses, - The lack of experience of nurses in post- LT care necessitated to send few of them to Necker enfant malades to gain exposure to various aspects of LDLT, - The lack of Pediatric intensivist with expertise in LT was alleviated by the collaboration of pediatric intensivist from France. A daily staff by tele medicine guarantees the continuity of follow-up by the 2 teams. Conclusions: This study marks the successful development of a pediatric LT program in Tunisia. In the developing countries PICU care faces unique challenges in developing LDLT programs. Acknowledgements: We thank Christophe Chardot for his efforts and support in the inception of our transplant program

P0614 / #1185: GRAM NEGATIVE BACTERIAL INFECTIONS (GNB) IN PEDIATRIC INTESIVE CARE UNIT (PICU): CLINICAL AND MICROBIOLOGICAL CHARACTERISTICS AND OUTCOME

Aims & Objectives: GNB are a major cause of morbidity and mortality in critically ill patients. .To determine the characteristics of GNB acquired in the community (CA) vs associated with health care (IAAS) in PICU. Methods: Retrospective, observational study that included childrens admitted to PICU from 2013 to 2019 with a diagnosis of GNB. Clinical, microbiological and outcome were obtained from patient records, and analyzed Results: During the study period, 70 children with GNB were admited to PICU: 35 with CA and 35 IAAS, with similar mean age (18 and 22 months, respectively) (p=0.33). The majority of the patients required mechanical ventilation, 83 % in CA and 88.6% in IAAS (p=0.73). Shock was presented in 60% in CA and 51.4% in IAAS (p=0.33). E. coli (17% in both groups), P.aeruginosa (17% in CA vs 14% in IAAS), K. pneumoniae (14% in CA vs 20% in IAAS), and E. cloacae were the most frequent organisms isolated. Anemia was significant more frequent in patients with IAAS (n=30, 86%) (p=0.008) and was associated to mortality [p=0.008; RO=0.19 (0.06-0.6)]. The duration of stay in the PICU was more prolonged in IAAS patients (26.4± 28 days vs 14.9 ± 21 days) (p<0.05). The final mortality was higher in patients with CA GNB (n=14, 40%) compared to IAAS infections (n=5, 14%) [p= 0.03, RO=4 (1.24-12.8)]. Conclusions: The study reveals the high mortalitity of gram-negative infections especially in those with community adquisition. We identified anemia as important risk factor for mortality.

P0194 / #1925: AMELIORATING IMPACT OF THE PRESENCE OF AN INTENSIVIST IN PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: To evaluate the effect of first graduate of the PICU fellowship program on process of care and patient outcomes in PICU. Methods: This study is retrospective observational study and conducted in 16-bed PICU of tertiary referral center in Turkey. Two years (2013-2015) period of the PICU without an intensivist and sequential two years (2015-2017) period managed by an intensivist are compared. Results: Number of patients followed in PICU was increased more than 2 fold. Number of mechanically ventilated patients was increased more than 2 folds and presence of intensivist reduced the MV duration 59%. Presence of intensivist reduced mortality 2.18 times. It was showed that management of PICU beds by intensivist yielded increased number of PICU hospitalizations, care of true critical care patients with more intensive therapies and invasive procedures including extracorporeal treatment options, decreased length of stay, decreased number and rate of nosocomial infections and solely decreased mortality. Conclusions: What transforms a unit filled with critical care patients to an intensive care unit is a dedicated intensivist. The current study demonstrates that intensivist is the crucial component of PICUs.

P0049 / #710: EARLY MOBILISATION IN CRITICALLY ILL CHILDREN: DOES ROUTINE PATIENT SCREENING CHANGE PRACTICE?

Aims & Objectives: Aims and Objectives: The survival rate in Australasian PICUs has improved and with this improvement there is increased morbidity following critical illness. This demands a shift in PICU care to consider the long-term outcomes for children post critical illness. This study explored whether the routine use of an “Early Mobilisation(EM) Screening Checklist’ by medical staff would reduce patient time to mobilisation. Methods: Methods: A prospective study with historical controls was undertaken in a PICU of a South Australian public hospital. Data on time to mobilisation and patient characteristics was extracted via an unblinded case note audit of patients admitted over 5-months in 2018 for the baseline group (n=36) and over a corresponding period in 2019 for the intervention group (n=36). Time to mobilisation between groups was compared using Survival analysis. Results: Results: The intervention group were 1.3 times more likely to be mobilised, although this was not significant (p=0.33, 95% CI [0.77-2.17], Cox regression). Patients with motor impairment were 38% less likely to be mobilised (P= p=0.11, 95% CI [0.35, 1.12], Cox regression), while those who were mechanically ventilated were 44% less likely to be mobilised (p=0.03, 95% CI 0.33-0.95). Nil adverse events were reported. Conclusions: Conclusions: The absence of significant change between baseline and intervention groups may be due to the small sample size, or the number of lower acuity subjects diluting the sample. The identification of groups less likely to receive mobilisation interventions warrants further exploration. The absence of any adverse events supports that EM in PICU is safe.

Resources and Costs Associated With Repeated Admissions to PICUs.

To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge. Cross-sectional, retrospective cohort study using Pediatric Health Information System. Fifty-two tertiary children's hospitals. Pediatric patients under 18 years old admitted to the PICU from January 1, 2016, to December 31, 2017. None. Patient characteristics and costs of care were compared between those with readmission requiring PICU care and those with only a single PICU admission per annum. In this 2-year cohort, there were 239,157 index PICU patients of which 36,970 (15.5%) were readmitted and required PICU care during the 12 months following index admission. The total hospital cost for all index admissions and readmissions was $17.3 billion, of which 21.5% ($3.71 billion) were incurred during a readmission stay involving care in the PICU; of the 3,459,079 hospital days, 20.3% (702,200) were readmission days including those where PICU care was required. Of the readmitted patients, 11,703 (30.0%) received only PICU care, accounting for $662 million in costs and 110,215 PICU days. Although 43.6% of all costs were associated with patients who required readmission, these patients only accounted for 15.5% of the index patients and 28% of index hospitalization expenditures. More patients in the readmitted group had chronic complex conditions at index discharge compared with those not readmitted (83.9% vs 54.9%; p < 0.001). Compared with those discharged directly to home without home healthcare, patients discharged to a skilled nursing facility had 18% lower odds of readmission (odds ratio 0.82 [95% CI, 0.75-0.89]; p < 0.001) and those discharged home with home healthcare had 43% higher odds of readmission (odds ratio, 1.43 [95% CI, 1.36-1.51]; p < 0.001). Repeated admissions with PICU care resulted in significant direct medical costs and resource use for U.S. children's hospitals.

LINC-10. SIOP PODC ADAPTED TREATMENT GUIDELINES FOR CRANIOPHARYNGIOMA IN LOW- AND MIDDLE-INCOME SETTINGS

Pediatric craniopharyngioma is a rare tumor with excellent survival but significant long-term morbidities due to the loco-regional tumor growth or secondary to its treatment. Visual impairment, panhypopituitarism, hypothalamic damage and behavioral changes are amongst the main challenges. This tumor should be managed under the care of a multidisciplinary team to determine the optimum treatment within the available resources. This is particularly important for low middle-income countries (LMICs) where resources are variable. We provide a risk-stratified management guideline for children diagnosed with craniopharyngioma in a resource limited setting based on the service levels describing the facilities and personnel required for management as previously specified by the Pediatric Oncology in Developing Countries (PODC) committee of The International Society of Pediatric Oncology (SIOP). A multi-disciplinary group of neurosurgeons, radiation and pediatric oncologists, radiologists, pediatric endocrinologists and an ophthalmologist with experience in managing children with craniopharyngioma in LMIC setting was formed and carried online meetings to form a consensus guideline. The clinical characteristics (including the visual and endocrine presentations), suggestive radiological features as well as potential treatment options including surgery, radiotherapy and intra-cystic therapies were discussed in depth and in relation to available resources. In addition, hormonal management, pre- and post-operative PICU care and expected future complications related to craniopharyngioma and to follow up these children were discussed and documented in the guideline. We believe this guideline is a useful reference for health care providers in LMIC.

Rapid Transition of a PICU Space and Staff to Adult Coronavirus Disease 2019 ICU Care.

We describe the process by which a PICU and a PICU care team were incorporated into a hospital-wide ICU care model during the coronavirus disease 2019 pandemic. A descriptive, retrospective report from a single-center PICU. Twenty-three bed, quaternary PICU, within an 862-bed hospital. Critically ill adults, with coronavirus disease 2019-related disease. ICU care provided by pediatric intensivists with training and support from medical intensivists. Within the context of the institution's comprehensive effort to centralize and systematize care for adults with severe coronavirus disease 2019 disease, the PICU was transitioned to an adult coronavirus disease 2019 critical care unit. Nurses and physicians underwent just-in-time training over 3 days and 2 weeks, respectively. Medical ICU physicians and nurses provided oversight for care and designated hospital-based teams were available for procedures and common adult emergencies. Over a 7-week period, the PICU cared for 60 adults with coronavirus disease 2019-related critical illness. Fifty-three required intubation and mechanical ventilation for a median of 18 days. Eighteen required renal replacement therapy and 17 died. During the current and potentially in future pandemics, where critical care resources are limited, pediatric intensivists and staff can be readily utilized to meaningfully contribute to the care of critically ill adults.

Clinical and Biochemical Characterizations of Pediatric Patients with Urea Cycle Disorders in Upper Egypt: A Case- Control Study

Background: The diagnosis of inborn errors of metabolism is generally challenging. We aimed to explore various types of urea cycle disorders (UCDs), and their clinical presentations and biochemical findings among Egyptian pediatric patients. Materials and Methods: This case-control study was conducted on 86 participants categorized into 43 pediatric patients suspected to have UCDs and 43 age- and sex-matched healthy controls, recruited from the Pediatric Outpatient Clinics, Inpatients Pediatric Departments, PICU and Neonatal Intensive Care Units of Qena, Assiut and Aswan University Hospitals, Egypt. In addition to the clinical assessments and routine laboratory investigations, colorimetric assays of blood lactate and ammonia, and plasma free amino acids assays using high performance liquid chromatography (HPLC), were performed for all included children. For patients with abnormal aminograms, the five enzymes of the urea cycle were measured in their liver tissue homogenates, using chemical methods. Results: The results showed that 25 out of 43 suspected patients were confirmed to have UCDs. The most frequent type of UCDs was Ornithine transcarbamylase (OTC) deficiency (48%), followed by Argininosuccinate synthase (ASS) deficiency (36%) and the least frequent was arginase (ARG) deficiency (16%). The main clinical presentations were poor oral intake (100%), followed by lethargy (96%), hypotonia (68%), vomiting (64%), and hepatomegaly (48%). There were normal glucose and ABG values with significantly higher ammonia; lactate and the measured plasma free amino acids among patients with UCDs vs. the controls (p˂0.05). Conclusion: The most frequent types of UCDs among pediatric patients in Upper Egypt were OTC and ASS deficiencies. In addition to clinical suspicion, assays of lactate, ABG, glucose, ammonia and aminogram may be helpful biochemical tests in diagnosing UCDs.

Pediatric Palliative Care When COVID-19 Positive Adults Are Dying in a Children's Hospital.

* Abbreviations: CHAM — : Children’s Hospital at Montefiore COVID-19 — : coronavirus disease In March 2020, Montefiore Health System in the Bronx, New York, received an influx of adults who were critically ill with coronavirus disease (COVID-19). The Children’s Hospital at Montefiore (CHAM), a 130-bed facility attached to an adult hospital, accommodated adult patients in the PICU, inpatient wards, and post-anesthesia care unit. CHAM pediatric faculty and housestaff were deployed to serve as primary care physicians and subspecialists for these adults (up to 84 years old), anticipating up to 100 patients. Among many challenges faced was the commitment by the pediatric faculty and staff to find a way to continue family-centered and compassionate care in the face of social distancing rules during the pandemic. Our goal was to preserve the patient’s humanity and their relationship to family and friends who were not permitted to visit. There is an ethical imperative to provide palliative care during a crisis when lives will be lost.1 As a result, we chose to rapidly expand our palliative care capabilities by training frontline medical providers and enlarging our pediatric palliative care presence to serve each adult admitted with COVID-19. Through deployment, the palliative care presence was expanded from 1 hospice and palliative care board-certified pediatrician (S.E.N) to a team that included 15 pediatricians, 2 nurse practitioners, and 8 psychologists in 3 days. Our standard … Address correspondence to Sarah E. Norris, MD, MEd, Department of Pediatrics, Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY 10467. E-mail: sanorri{at}montefiore.org

The Impact of Coronavirus Disease 2019 Pandemic on U.S. and Canadian PICUs.

There are limited reports of the impact of the coronavirus disease 2019 pandemic focused on U.S. and Canadian PICUs. This hypothesis-generating report aims to identify the United States and Canadian trends of coronavirus disease 2019 in PICUs. To better understand how the coronavirus disease 2019 pandemic was affecting U.S. and Canadian PICUs, an open voluntary daily data collection process of Canadian and U.S. PICUs was initiated by Virtual Pediatric Systems, LLC (Los Angeles, CA; http://www.myvps.org) in mid-March 2020. Information was made available online to all PICUs wishing to participate. A secondary data collection was performed to follow-up on patients discharged from those PICUs reporting coronavirus disease 2019 positive patients. To date, over 180 PICUs have responded detailing 530 PICU admissions requiring over 3,467 days of PICU care with 30 deaths. The preponderance of cases was in the eastern regions. Twenty-four percent of the patients admitted to the PICUs were over 18 years old. Fourteen percent of admissions were under 2 years old. Nearly 60% of children had comorbidities at admission with the average length of stay increasing by age and by severity of comorbidity. Advanced respiratory support was necessary during 67% of the current days of care, with 69% being conventional mechanical ventilation. PICUs have been significantly impacted by the pandemic. They have provided care not only for children but also adults. Patients with coronavirus disease 2019 have a high frequency of comorbidities, require longer stays, more ventilatory support than usual PICU admissions. These data suggest several avenues for further exploration.

Children's Hospital ICU Resource Allocation in an Adult Pandemic.

* Abbreviation: COVID-19 — : coronavirus disease 2019 Imagine the following situation: A 25-year-old is intubated in the emergency department for coronavirus disease 2019 (COVID-19)–related acute respiratory distress syndrome. The adult ICU is full. The nearby PICU has many available beds and staff. The pediatric intensivist and their administrators must decide how to respond. Do ethical considerations permit, require, or forbid extending PICU care to this adult patient? Two features of the COVID-19 pandemic make situations like this increasingly likely. First, there is significant variation in disease incidence. Adults are at much higher risk of serious COVID-19–related illness requiring ICU care than are children.1,2 Children generally have had fewer infections and milder disease.3,4 Second, there is significant variation in available capacity. According to the Society of Critical Care Medicine, there are only 68 558 adult ICU beds, 5137 PICU beds, 22 901 NICU beds, 25 157 step-down beds, and 1183 burn beds in the United States today.5 In a moderate or severe outbreak, with tens of thousands of adults requiring ICU care,1 the need will quickly outstrip available resources.6 Children’s hospitals, by contrast, likely will have surplus capacity. We are at the end of the typical influenza and respiratory syncytial virus seasons. We have canceled nearly all elective surgery nationwide, easing demand for postoperative care in the PICU. This has left … Address correspondence to Ian D. Wolfe, PhD, RN, CCRN, Children’s Mercy Bioethics Center, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: wolfe370{at}umn.edu