Critically-ill Children Research Articles

OP035 Topic: AS22–Quality and Safety/Errors/Data Management/Other: EARLY MOBILIZATION IN CRITICALLY ILL CHILDREN: A QUALITY IMPROVEMENT STUDY

OP035 Topic: AS22–Quality and Safety/Errors/Data Management/Other: EARLY MOBILIZATION IN CRITICALLY ILL CHILDREN: A QUALITY IMPROVEMENT STUDY

James Cameron, Critically Ill Children and the Law: Medical Decision-Making and the Best Interests Principle

James Cameron, <i>Critically Ill Children and the Law: Medical Decision-Making and the Best Interests Principle</i>

Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study.

Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries. The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867). The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.

The role of malnutrition on outcomes of multisystem inflammatory syndrome in children (MIS-C) due to COVID-19.

Malnutrition increases the complications and mortality in critically-ill children. We performed a retrospective analysis to define the impact of malnutrition on the outcomes of multisystem inflammatory syndrome in children (MIS-C) due to COVID-19. Patients with MIS-C were evaluated for demographic features, anthropometric parameters, clinical findings and outcomes. Patients with z scores of body mass index (> 5 years) and weight-for-age (< 5 years) < -2 were considered malnourished. Sarcopenia was defined by total psoas muscle area (tPMA), calculated on abdominal computed tomography (CT) at the level of L3 and L4 vertebrae. The z scores <- 2 for tPMA were considered sarcopenia. The results of patients with and without malnutrition were compared. Twenty-seven patients were included. Forty-four percent (n=12) of patients had malnutrition. Malnutrition was classified as mild to moderate (1/3), severe (1/3) and overweight (1/3). Eighty-two % of cases had acute malnutrition. Among MIS-C symptom criteria, rash was significantly higher in children with malnutrition (p<0.05). Laboratory investigations showed higher ferritin levels in patients with malnutrition (p<0.05). The median tPMA and sarcopenia were significantly higher in patients with malnutrition when compared to patients without malnutrition (42% vs 7%, p<0.05). The oral feeding time, complication rates, and length of hospital stay were similar in both groups (p>0.05). Children with MIS-C already had mild to severe malnutrition at admission. Rash and higher ferritin levels were more common in patients with malnutrition. In addition to anthropometric parameters, sarcopenia calculated using tPMA can be used to predict malnutrition in critically-ill children.

Effect of Combined Chest Mobilization with Conventional Chest Physical Therapy on Vital Signs and Respiratory Parameters in Critically-Ill Children

Effect of Combined Chest Mobilization with Conventional Chest Physical Therapy on Vital Signs and Respiratory Parameters in Critically-Ill Children

Citrate anticoagulation and systemic heparin anticoagulation during continuous renal replacement therapy among critically-ill children

BakcgroundThe aim of this study was to evaluate the efficacy and safety of citrate versus heparin anticoagulation for CRRT in critically-ill children.MethodsThis retrospective comparative cohort reviewed the clinical records of critically-ill children undergoing CRRT with either RCA or systemic heparin anticoagulation. The primary outcome measure was hemofilter survival time. Secondary outcomes included the comparison of complications and metabolic disorders.ResultsA total of 131 patients (55 RCA and 76 systemic heparin) were included, in which a cumulative number of 280 hemofilters were used (115 in RCA with 5762 h total CRRT time, and 165 in systemic heparin with 6230 h total CRRT time). Hemofilter survival was significantly longer for RCA (51.0 h; IQR: 24–67 h) compared to systemic heparin (29.5 h; IQR, 17–48 h) (p = 0.002). Clotting-related hemofilter failure occurred in 9.6% of the RCA group compared to 19.6% in the systemic heparin group (p = 0.038). Citrate accumulation occurred in 4 (3.5%) of 115 RCA sessions. Hypocalcemia and metabolic alkalosis episodes were significantly more frequent in RCA recipients (35.7% vs 15.2%, p < 0.0001; 33.0% vs 19.4%, p = 0.009).ConclusionRCA is a safe and effective anticoagulation method for CRRT in critically-ill children and it prolongs hemofilter survival.ImpactRCA is superior to systemic heparin for the prolongation of circuit survival (overall and for clotting-related loss) during CRRT.These data indicate that RCA can be used to maximize the effective delivery of CRRT in critically-ill patients admitted to the PICU.There are potential cost-saving implications from our results owing to benefits such as less circuit downtime and fewer circuit changes.

Impact of malnutrition on the outcome of critically-ill children: A comprehensive narrative review

Malnutrition presents a universal challenge, affecting millions of children and resulting in severe health consequences. Notably, its consequences within the pediatric population, especially those that necessitate admission to the pediatric intensive care unit (PICU), are of concern. This narrative review discusses the nutritional status, particularly malnutrition, and factors associated that impact the outcome during the PICU stay. Furthermore, the interpretation of clinical conditions and physiological aspects and the understanding of potential interventions together help to analyze the outcome associated with malnutrition. By studying these aspects, this review proposes to contribute a proper understanding of how malnutrition closely influences outcomes in the condition of children admitted to PICUs.

Critically-Ill Children and the International Human Rights System: Assessing the Status and Role of the UNCRPD in the Case of Archie Battersbee.

Over the past few years, some parents and clinicians in the UK have argued about decisions on the fate of critically-ill children, with the cases ending in protracted and emotionally-sapping legal disputes. The long-running legal conflicts have played out in the public eye, eliciting conflicting opinions. At the core of the disputes is whether parents or clinicians should determine the appropriate course of action. In the event of the disagreements, the domestic court intervenes guided by the 'best interests' principle. A corpus of scholarship, falling on either side of the debate, has captured the contradictions. Until recently, the discourse had focused on the common recourses to domestic courts and the European Court of Human Rights. However, in the recent case of incapacitated 12-year-old Archie Battersbee, his parents sought redress from the international human rights system through the Committee on the Rights of People with Disabilities to stop termination of his life support. The courts barred the involvement of the Committee on the basis that the UK had not incorporated the treaty which birthed the Committee. The case brought into sharp focus the relationship between international law and domestic law. First, this paper asserts that the weight (not) given to international law by the domestic courts was inconsistent with its treatment of international obligations in other cases. Secondly, the position that unincorporated treaties do not have legal effect in domestic proceedings is ambiguous. Finally, the treaty body appeared ill-suited to handle a case of a critically-ill child in the face of the impatient demands of local justice.

Neurofilament light as a predictor of long- and short-term outcomes in critically ill children

PurposePlasma neurofilament light (NFL) is a marker of neuronal injury, associated with poor neurological outcomes in adults and neonates in a wide range of diseases. We sought to describe the associations between NFL at admission (NFLadm) and outcomes in a heterogenous cohort of critically ill children needing unplanned admission to the pediatric intensive care unit (PICU).Materials and methodsWe analysed prospectively collected biobank samples from critically-ill children with unplanned admissions to PICU. Samples were selected for survivors who had a 12-month follow-up with parent-completed Pediatric Quality of Life Inventory (PedsQL) scores as the primary outcome of interest.ResultsData from 52 children were analysed. The median NFL was 17.0 pg/ml (IQR 5.8–28.1). There were no significant associations between NFLadm levels and PedsQL (NFLadm-adjusted odds ratio 0.99, 95% CI 0.97, 1.02) at 12 months. NFL showed associations with outcomes at PICU discharge, such as change in functional status and need for organ support but interpretation is limited by sample size.ConclusionsAdmission NFL values were not associated with 12-month quality of life outcomes in a heterogenous cohort of children admitted to PICU.

ICVS-Inferring Cardio-Vascular hidden States from physiological signals available at the bedside.

Intensive care medicine is complex and resource-demanding. A critical and common challenge lies in inferring the underlying physiological state of a patient from partially observed data. Specifically for the cardiovascular system, clinicians use observables such as heart rate, arterial and venous blood pressures, as well as findings from the physical examination and ancillary tests to formulate a mental model and estimate hidden variables such as cardiac output, vascular resistance, filling pressures and volumes, and autonomic tone. Then, they use this mental model to derive the causes for instability and choose appropriate interventions. Not only this is a very hard problem due to the nature of the signals, but it also requires expertise and a clinician's ongoing presence at the bedside. Clinical decision support tools based on mechanistic dynamical models offer an appealing solution due to their inherent explainability, corollaries to the clinical mental process, and predictive power. With a translational motivation in mind, we developed iCVS: a simple, with high explanatory power, dynamical mechanistic model to infer hidden cardiovascular states. Full model estimation requires no prior assumptions on physiological parameters except age and weight, and the only inputs are arterial and venous pressure waveforms. iCVS also considers autonomic and non-autonomic modulations. To gain more information without increasing model complexity, both slow and fast timescales of the blood pressure traces are exploited, while the main inference and dynamic evolution are at the longer, clinically relevant, timescale of minutes. iCVS is designed to allow bedside deployment at pediatric and adult intensive care units and for retrospective investigation of cardiovascular mechanisms underlying instability. In this paper, we describe iCVS and inference system in detail, and using a dataset of critically-ill children, we provide initial indications to its ability to identify bleeding, distributive states, and cardiac dysfunction, in isolation and in combination.

Outcomes of acute kidney injury in critically ill children who need renal replacement therapy.

Aim To determine an outcome of acute kidney injury (AKI) in critically ill children (CIC) who needed renal replacement therapy (RRT) and were admitted to the Paediatric and Neonatal Intensive Care Unit (PICU and NICU) at the Paediatric Clinic, University Clinical Centre Sarajevo (UCCS). Methods The research included 81 children with AKI. The Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI was used. Other laboratory findings and imaging tests were made depending on children's primary disease that led to the AKI. Results Among 81 children with AKI, 38 were girls and 43 boys. A total of 39 (48.1%) patients died; the death was due to the nature of the primary disease and multiple organ failure syndromes. Out of the total of 81 patients the highest mortality rate was found in children in the first year of life, 22 (56.4%), while 17 (43.6%) patients died after the first year of life. Conclusion Without an accurate diagnosis at the right time, due to the lack of adequate biomarkers for AKI screening, the heterogeneity of AKI, comorbidities often lead to unfavourable outcomes of the disease, among CIC, especially in infants with low birth weight and extreme immaturity. Some causes of AKI are preventable and can be reduced by a better organization of primary and secondary health care.

A Randomized Controlled Trial to Compare the Efficacy of Single Mega Dose Vitamin D Therapy with Standard Daily Dose Vitamin D Therapy in Vitamin D Deficient Critically Ill Children

Introduction: The prevalence of vitamin D deficiency has been reported to be very high (up to 50%) in criticallyill children admitted in Paediatric ICU, and vitamin D deficiency has been associated with increased mortality,increased length of Paediatric ICU and hospital stay. But the impact of supplementation of vitamin D in thesechildren on the clinical outcome is not very clear.Study Objectives: Primary Objective: To compare the efficacy of single mega dose vitamin D therapy withstandard daily dose vitamin D therapy in vitamin D deficient critically ill children.Secondary Objective: To assess the prevalence of vitamin D deficiency in critically ill children in a tertiary carecentre.Methodology: A study population of 50 children meeting inclusion criteria were enrolled in our study. All thesubjects admitted to our Paediatric ICU were subjected to a detailed history and examination. Vitamin D levelswere sent at admission and children with vitamin D deficiency (&lt; 20ng/dl) were taken as study subjects andrandomized into two groups. One group received single mega dose vitamin D therapy, and the second groupreceived standard daily dose vitamin D therapy. These children were followed up until their Paediatric ICU stayor death. The impact of supplementation was compared among both the groups in terms of length of PaediatricICU stay and mortality.Results: The mean length of Paediatric ICU stay among children receiving a single mega dose vitamin D therapywas 5.04 days compared to 3.56 days among children receiving standard-dose vitamin D therapy (p-value 0.337),suggesting no significant difference in the length of Paediatric ICU stay among the study subjects of both groups.There was no mortality among these study subjects. The prevalence of vitamin D deficiency in the study groupwas 55.6%.Conclusion: Supplementation of a single mega dose of vitamin D compared to the standard dose of vitamin D hasno advantage on the clinical outcome of Vitamin D deficient critically ill children in terms of length of PaediatricICU stay and mortality.

Machine learning to support triage of children at risk for epileptic seizures in the pediatric intensive care unit

Objective. Epileptic seizures are relatively common in critically-ill children admitted to the pediatric intensive care unit (PICU) and thus serve as an important target for identification and treatment. Most of these seizures have no discernible clinical manifestation but still have a significant impact on morbidity and mortality. Children that are deemed at risk for seizures within the PICU are monitored using continuous-electroencephalogram (cEEG). cEEG monitoring cost is considerable and as the number of available machines is always limited, clinicians need to resort to triaging patients according to perceived risk in order to allocate resources. This research aims to develop a computer aided tool to improve seizures risk assessment in critically-ill children, using an ubiquitously recorded signal in the PICU, namely the electrocardiogram (ECG). Approach. A novel data-driven model was developed at a patient-level approach, based on features extracted from the first hour of ECG recording and the clinical data of the patient. Main results. The most predictive features were the age of the patient, the brain injury as coma etiology and the QRS area. For patients without any prior clinical data, using one hour of ECG recording, the classification performance of the random forest classifier reached an area under the receiver operating characteristic curve (AUROC) score of 0.84. When combining ECG features with the patients clinical history, the AUROC reached 0.87. Significance. Taking a real clinical scenario, we estimated that our clinical decision support triage tool can improve the positive predictive value by more than 59% over the clinical standard.

A Systematic Review of Nursing Theories in Pediatrics Settings

Background: The only way to present nursing as a profession, in its own right, is to develop its theories. The pursuit of further clarity may enable pediatric nurses to plan for further studies and use appropriate theories in practice. This needs an inquiry to start with a review of existing literature from various research fields to clarify key knowledge and gaps. Therefore, this study aimed to review studies on nursing theories in pediatric settings. Methods: The study design was a systematic review with a qualitative synthesis approach. The inclusion criteria were articles written in English published from 2000 to 2020, focusing on developing a new theory or using previous nursing theories in pediatric settings, in PubMed, Scopus, Ovid, and EBSCO databases. The exclusion criteria were the articles written in languages other than English, settings other than pediatric, and not finding the full text. The qualitative synthesis was used to integrate the data using MAXQDA10. Results: The results of data analysis showed 24 new theories were developed by the grounded theory approach regarding parenting, nurse-family interaction, and improving nursing care. Moreover, the theories of some nursing scholars, such as Orem and Watson, were mostly used as a framework in studies on cancer (18.96%) and critically-ill children, especially adolescents (21.81%). Conclusion: This study clarified the trend of nursing theories in pediatric settings and highlighted the gaps in the literature, over the last two decades. The study provides implications for future studies regarding nursing theories in pediatric settings and, encourages nurses to strive in the journey of professionalization by utilizing and developing more nursing theories. Future studies can focus on other aspects, such as primary and tertiary prevention in different age groups or the most prevalent diseases in children.

Parental experience of transition from a paediatric intensive care unit to a general ward: A qualitative study.

We aim to explore parental experience in transitioning from a paediatric intensive care unit to a general ward and to investigate parental involvement in caring for their critical illness children. Parents have a major responsibility in caring for seriously ill children, but nursing staff fail to meet the expectations of parents regarding nursing care. Few studies have investigated the challenges and needs of Chinese parents during the transition from paediatric intensive care unit to general ward. Semi-structured interviews were conducted with 24 parents of children with critical illness in a paediatric hospital in Shanghai, mainland China to explore their views. Transcripts were entered into NVivo. Framework analysis was used to analyse the qualitative data. Four themes were identified by data analysis: changes in the child during post paediatric intensive care unit periods; experiencing a wide range of emotions; factors involved in the transition; and suggestions for improving transitional care. Due to the unmet needs of parents, a more flexible visiting policy and social media support were highly desirable. Getting accurate information, establishing family integrated care, and strengthening ward-based critical support services were also listed as important needs of parents caring for critically ill children. A profound understanding of parental experiences during the transitional period can help nursing staff to assess the effects on children and their families, improve ward-based intensive care, support parental participation, and improve visitation policies. Based on these findings, nurse managers can develop reasonable intervention programmes in order to improve nursing quality and patient outcomes.

Frequency of hypophosphatemia in critically ill children: risk factors and outcome

Background: Phosphorus plays a vital role in maintaining metabolism and energy of body. The objective of this study was to determine the frequency, risk factors and outcome of hypophosphatemia (HP) in critically ill children admitted in pediatric intensive care unit.Methods: This retrospective study included all critically-ill children having phosphate levels within 24 hours of admission from July 2019 to December 2020. Demographic, clinical and laboratory variables were collected. HP is defined as serum phosphorus level ≤4 mg/dl in this study. Descriptive statistics along with logistic regression analysis have been reported. Results: Prevalence of HP was 53.7% (94/175). Median age was 2 year (0.5-15) and male were 58.5% (106). Serum magnesium level [2.2 (1.5-12.1) vs. 1.8 (1.2-4.0) mg/dl] and serum calcium level [8.7 (.18-10.7) 8.0 (1.8-14.0) mg/dl] were significantly low in the HP group as compared to the normo-phosphatemic group. There was no significant association of hypo-phosphataemia with admitting diagnosis, ICU therapies, and medications on univariate analysis. Hypo-phosphataemia at admission had no effect on mortality. On multivariate analysis, only male gender demonstrated independent association with HP (OR: 2.2; 95% CI 1.2-4.1; p&lt;0.01).Conclusions: HP is common in critically ill children and is significantly associated with male gender. Prospective, larger sample size studies are needed to study the prevalence and risk factors of HP at pediatric intensive care units.

An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers.

Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Methods: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Results: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusions: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.

Comparing ventilation modes by electrical impedance segmentography in ventilated children

Electrical impedance segmentography offers a new radiation-free possibility of continuous bedside ventilation monitoring. The aim of this study was to evaluate the efficacy and reproducibility of this bedside tool by comparing synchronized intermittent mandatory ventilation (SIMV) with neurally adjusted ventilatory assist (NAVA) in critically-ill children. In this prospective randomized case–control crossover trial in a pediatric intensive care unit of a tertiary center, including eight mechanically-ventilated children, four sequences of two different ventilation modes were consecutively applied. All children were randomized into two groups; starting on NAVA or SIMV. During ventilation, electric impedance segmentography measurements were recorded. The relative difference of vertical impedance between both ventilatory modes was measured (median 0.52, IQR 0–0.87). These differences in left apical lung segments were present during the first (median 0.58, IQR 0–0.89, p = 0.04) and second crossover (median 0.50, IQR 0–0.88, p = 0.05) as well as across total impedance (0.52 IQR 0–0.87; p = 0.002). During NAVA children showed a shift of impedance towards caudal lung segments, compared to SIMV. Electrical impedance segmentography enables dynamic monitoring of transthoracic impedance. The immediate benefit of personalized ventilatory strategies can be seen when using this simple-to-apply bedside tool for measuring lung impedance.

Management of Pediatric Sepsis: Considerations for the Austere Prehospital Setting

Septic children are among the most challenging and resource-intensive patients that clinicians see around the world daily. These patients often require a broad range of therapies and assessment techniques, frequently relying on expertise across multiple specialties such as radiology and laboratory services. In developed nations, these resources are readily available or in close proximity, as transport is often logistically feasible to coordinate transfer to definitive care. In developing nations and areas of conflict, this is not the case. Most of the world's population lives in developing nations, resulting in inadequate access to specialized pediatric intensive care resources. As a result, many clinicians globally face the unique challenge of caring for septic children in resource-deprived and austere settings. Areas recovering from natural disasters, remote villages, and conflict zones are examples of austere environments where children have an increased risk of sepsis while having the fewest medical resources available. This creates a unique challenge that prehospital clinicians are specifically tasked with managing, sometimes lasting for multiple days pending the possibility of a transport option. Clinicians in these environments must be aggressive in identifying and treating critically-ill children in resource limited environments, but also nuanced in their care plan due to the limitations of the environment.

Red blood cell transfusion in critically-ill children and its association with outcome.

To determine the indications and threshold of haemoglobin levels for packed red blood cell transfusion and its association with outcomes in a paediatric intensive care setting. The retrospective study was conducted in the paediatric intensive care unit of the Aga Khan University Hospital, Karachi, and comprised medical records of all inpatients with age between 1 month and 16 years who received packed red blood cell transfusions between January and December 2017. Data was retrieved from the hospital database and was analyzed using SPSS 22. Of the 147 subjects with a mean age of 67.89±65.8 months, 76(51.7%) were males. Mean paediatric risk of mortality score was 11.72±7.86. Major admitting diagnosis included sepsis and multiorgan dysfunction 50(34%), respiratory diseases 26(17.7%) and haematology/oncology diseases 22(15%). The indications for transfusion was low haemoglobin in 90(61.2%) patients, shock 29(19.7%) and hypoxia 28(19%). Acute transfusion reaction was observed in 1(0.7%) patient; 120(82%) required mechanical ventilation; and 94(64%) required inotropic support. Of the total, 88(59.9%) patients survived. Paediatric risk of mortality score, need for inotropic support and mechanical ventilation were associated with mortality (p<0.05). Packed red blood cell transfusion, which is frequently prescribed in intensive care settings, was not found to be associated with favourable outcome.