Days Of Pediatric Intensive Care Unit Admission Research Articles

Pediatric intensive care unit treatment alters the diversity and composition of the gut microbiota and antimicrobial resistance gene expression in critically ill children.

Common critical illnesses are a growing economic burden on healthcare worldwide. However, therapies targeting the gut microbiota for critical illnesses have not been developed on a large scale. This study aimed to investigate the changes in the characteristics of the gut microbiota in critically ill children after short-term pediatric intensive care unit (PICU) treatments. Anal swab samples were prospectively collected from March 2021 to March 2022 from children admitted to the PICU of Xinhua Hospital who received broad-spectrum antibiotics on days 1 (the D1 group) and 7 (the D7 group) of the PICU treatment. The structural and functional characteristics of the gut microbiota of critically ill children were explored using metagenomic next-generation sequencing (mNGS) technology, and a comparative analysis of samples from D1 and D7 was conducted. After 7 days of PICU admission, a significant decrease was noted in the richness of the gut microbiota in critically ill children, while the bacterial diversity and the community structure between groups remained stable to some extent. The relative abundance of Bacilli and Lactobacillales was significantly higher, and that of Campylobacter hominis was significantly lower in the D7 group than in the D1 group. The random forest model revealed that Prevotella coporis and Enterobacter cloacae were bacterial biomarkers between groups. LEfSe revealed that two Gene Ontology entries, GO:0071555 (cell wall organization) and GO:005508 (transmembrane transport), changed significantly after the short-term treatment in the PICU. In addition, 30 KEGG pathways were mainly related to the activity of enzymes and proteins during the processes of metabolism, DNA catabolism and repair, and substance transport. Finally, 31 antimicrobial resistance genes had significantly different levels between the D7 and D1 groups. The top 10 up-regulated genes were Erm(A), ErmX, LptD, eptB, SAT-4, tetO, adeJ, adeF, APH(3')-IIIa, and tetM. The composition, gene function, and resistance genes of gut microbiota of critically ill children can change significantly after short PICU treatments. Our findings provide a substantial basis for a better understanding of the structure and function of gut microbiota and their role in critical illnesses.

Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial.

The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial. To identify the optimal timing of PN initiation in critically ill children. This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes. Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018). Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.

Descriptive and Clinical Characteristics of Nonsurvivors in a Tertiary Pediatric Intensive Care Unit in Turkey: 6 Years of Experience

AbstractThe objective of this study was to identify the characteristics of nonsurvivors in a pediatric intensive care unit (PICU) in Turkey. This is a retrospective analysis of patients who died in a tertiary PICU over a 6-year period from 2016 to 2021. Data were drawn from electronic medical records and resuscitation notes. Mode of death was categorized as failed cardiopulmonary resuscitation (F-CPR) or brain death. Among the 161 deaths, 136 nonsurvivors were included and 30.1% were younger than 1 year. Severe pneumonia, respiratory failure, and acute respiratory distress syndrome (ARDS) (31.6%) were the most common primary diagnoses. The most common mode of death was F-CPR (86.8%). More than half of the subjects had been admitted from pediatric emergency departments (58.1%), and more than half (53.7%) had died within 7 days in the PICU. Patients admitted from pediatric emergency departments had the lowest frequency of comorbidities (p &lt; 0.001). Severe pneumonia, respiratory failure, and ARDS diagnoses were significantly more frequent in those who died after 7 days (p &lt; 0.001), whereas septicemia, shock, and multiple organ dysfunction were more common among those who died within the first day of PICU admission (p &lt; 0.001). It may be important to note that patients referred from wards are highly likely to have comorbidities, while those referred from pediatric emergency departments may be relatively younger. Additionally, patients with septicemia, shock, or multiple organ dysfunction were more likely to die earlier (within 7 days), especially compared with those with severe pneumonia, respiratory failure, or ARDS.

2146. Impact of MRSA colonization pressure on MRSA acquisition and MRSA infection in pediatric intensive care unit

Abstract Background Methicillin-resistant Staphylococcus aureus (MRSA) colonization pressure (CP) is a useful indicator for measuring the extent of MRSA reservoir in healthcare settings. The purpose of this study is to determine the MRSA colonization rate and invasive MRSA infection rate in severely ill pediatric patients requiring pediatric intensive care unit (PICU) stay, and to evaluate the association between MRSA CP and MRSA acquisition/invasive infection. Methods From January 2016 to December 2020, pediatric patients admitted to 2 PICUs with a total of 25 beds were retrospectively analyzed. Routine nasal and/or endotracheal cultures were performed on MRSA at the time of PCIU admission and thereafter, every week. MRSA CP was defined as the ratio of the monthly MRSA positive number of patients to 100 patient days. Among MRSA colonizers, MRSA obtained after 2 days of PICU admission was defined as an acquired colonizer, and imported colonizer was defined when it was confirmed as an MRSA colonizer at the time or within 2 days of entry. When MRSA was cultured in a normally sterile body fluids, it was defined as an invasive MRSA infection. Results Of the total 6,907 patients admitted to the PICUs during this study period, 8.4% (487/6,907) were MRSA colonizers; 30% (139/487) were acquired colonizers, and invasive MRSA infections occurred in 3.3% (16/487). During the stay in the PICUs, the MRSA acquisition rate was 4.1%. A total of 22 invasive MRSA infections occurred during this study period, with an incidence rate of 3.1/1,000 patient days, of which 72.7% (n=16) occurred to the patients with MRSA colonization. Invasive MRSA infection occurred in 2.4% (8/348) of imported colonizers, and 5.2% (8/139) of acquired colonizers (p=0.108). The median duration from the time of colonization to invasive infection was 24 days(IQR; 2.25-49.75). Although MRSA CP was not correlated with the incidence of invasive MRSA infection (p=0.101), MRSA CP itself affected MRSA acquisition in PICU (p&amp;lt; 0.001). Conclusion MRSA CP influenced the new acquisition of MRSA during PICU stay, and newly acquired colonizers are more likely to experience invasive MRSA infection. Continuous multi-faceted efforts to minimize MRSA CP can provide opportunities for reducing MRSA colonization and infections rates in PICU settings. Disclosures All Authors: No reported disclosures.

Parental Views of Social Worker and Chaplain Involvement in Care and Decision Making for Critically Ill Children with Cancer.

Background: Social workers (SWs) and chaplains are trained to support families facing challenges associated with critical illness and potential end-of-life issues. Little is known about how parents view SW/chaplain involvement in care for critically ill children with cancer. Methods: We studied parent perceptions of SW/chaplain involvement in care for pediatric intensive care unit (PICU) patients with cancer or who had a hematopoietic cell transplant. English- and Spanish-speaking parents completed surveys within 7 days of PICU admission and at discharge. Some parents participated in an optional interview. Results: Twenty-four parents of 18 patients completed both surveys, and six parents were interviewed. Of the survey respondents, 66.7% and 75% interacted with SWs or chaplains, respectively. Most parents described SW/chaplain interactions as helpful (81.3% and 72.2%, respectively), but few reported their help with decision making (18.8% and 12.4%, respectively). Parents described SW/chaplain roles related to emotional, spiritual, instrumental, and holistic support. Few parents expressed awareness about SW/chaplain interactions with other healthcare team members. Conclusions: Future work is needed to determine SWs’/chaplains’ contributions to and impact on parental decision making, improve parent awareness about SW/chaplain roles and engagement with the healthcare team, and understand why some PICU parents do not interact with SWs/chaplains.

Epidemiology of Diseases and Mortality in a Pediatric Intensive Care Unit in Qazvin, Iran

Background: Depending on the level of care and the availability of pediatric intensive care unit (PICU) facilities, the mortality rate of acutely ill children varies in PICUs. Referral of patients from other medical centers, admission during working or off-work hours, and nosocomial infections are the most important risk factors for the high mortality rates in PICUs. Objectives: The present study aimed to investigate the characteristics and factors related to the risk of mortality in pediatric patients admitted to the PICU of a pediatric hospital in Qazvin, Iran. Methods: This cross-sectional study was performed on children admitted to the PICU of a pediatric hospital in Qazvin, Iran, between June 2017 and June 2020. During this period, a total of 1504 children, aged one month to 13 years, were admitted to the PICU, and 106 cases expired. The patients’ clinical data (ie, demographic characteristics, underlying disease, cause of death, and length of hospital stay) was extracted from their medical records. A prolonged length of stay was defined as more than 28 days of PICU admission. Results: A total of 106 children, with a mean age of 3.89 ± 3.23 years, expired during the study, with 41 (38.7%) cases being male. Among the investigated cases, 61 (57%) were &lt; 2 years, 18 (17%) were 2 - 5 years old, and 27 (26%) were ≥ 6 years. In these patients, sepsis (13/82, 15.85%) and pneumonia (10/82, 12.19%) were the main causes of death. Other mortalities (14/106) were due to infectious diseases (gastroenteritis, influenza, and coronavirus disease) and non-infectious diseases (aspiration, anaphylaxis, and electrocution). The majority of children with a prolonged length of stay were &lt; 2 years (17/23, 74%). The length of PICU stay was shorter in children with a lower weight percentile (P = 0.016). Conclusions: Following infectious diseases, congenital abnormalities and genetic disorders were the most common causes of pediatric mortality. Chronically ill children were more likely to be underweight and develop nutritional disorders, leading to the deterioration of their condition.

Impact of subspecialty consultations on diagnosis in the pediatric intensive care unit.

Intensivists and subspecialists often collaborate in diagnosing patients in the pediatric intensive care unit (PICU). Our objectives were to characterize critically ill children for whom subspecialty consultations were requested, describe consultation characteristics, and determine consultations' impact on PICU diagnosis. We performed a retrospective study using chart review in a single tertiary referral PICU including children admitted for acute illness. We collected data on patients with and without subspecialty consultations within the first three days of PICU admission and determined changes in PICU clinicians' diagnostic evaluation or treatment after consultations. PICU clinicians requested 152 subspecialty consultations for 87 of 101 (86%) patients. Consultations were requested equally for assistance in diagnosis (65%) and treatment (66%). Eighteen of 87 (21%) patients with consultations had a change in diagnosis from PICU admission to discharge, 11 (61%) attributed to subspecialty input. Thirty-nine (45%) patients with consultations had additional imaging and/or laboratory testing and 48 (55%) hadmedication changes and/or a procedure performed immediately after consultation. Subspecialty consultations were requested during a majority of PICU admissions. Consultations can influence the diagnosis and treatment of critically ill children. Future research should investigate PICU interdisciplinary collaborations, which are essential for teamwork in diagnosis.

Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients.

Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.

Association Between Culture-Negative Versus Culture-Positive Sepsis and Outcomes of Patients Admitted to the Pediatric Intensive Care Unit

BackgroundSepsis remains a major cause of death, with high mortality and morbidity rates in children. The cause of mortality may be associated with several factors, including differences in cultures and the type of organism. This study was aimed at evaluating the characteristics and outcomes of negative bacterial blood culture compared to those of positive bacterial blood culture in children with severe sepsis/septic shock.MethodsA retrospective cohort study was conducted at a pediatric intensive care unit (PICU) of a tertiary care medical center. All pediatric patients, from newborn to 14 years of age, admitted between April 2015 and January 2018 were included in the study if they fulfilled the criteria for severe sepsis/septic shock.ResultsOf the 209 patients, 30 (14.3%) had a positive bacterial blood culture whereas 179 (86.6%) had a negative bacterial blood culture. Mortality was more in positive bacterial blood culture 13 (43%) vs 35 (20%) in negative bacterial blood culture (P = 0.004). Respiratory tract infections were extremely common, present in 108 of 179 (60%) patients, and tended to result in a negative culture. The rate of organ dysfunction was higher in the positive bacterial blood culture group at admission (P = 0.01). However, the results did not reveal a significant finding related to multiorgan dysfunction syndrome (MODS) progression over three days of PICU admission (P = 0.06).ConclusionThe negative bacterial blood culture constitutes a substantial proportion of pediatric patients with severe sepsis/septic shock. Furthermore, these pediatric patients have a lower mortality rate compared to positive bacterial blood cultures. The culture-negative sepsis group also had less organ dysfunction.

Platelet Profile as Prognostic Factor in Critically ill Children

BACKGROUND: Previous studies showed that platelet profile may reflect the platelet function better than the platelet count itself, but the study on its use as a prognostic indicator in critically ill children is still limited.&#x0D; AIM: We analyzed the association between platelet profile such as platelet count, plateletcrit (PCT), mean platelet volume (MPV), and platelet distribution width (PDW) and mortality, also its correlation with pediatric logistic organ dysfunction-2 (PELOD-2) score in critically ill children admitted to the pediatric intensive care unit (PICU).&#x0D; METHODS: A prospective cohort study was conducted in PICU Haji Adam Malik General Hospital, Medan. Assessment of platelet profile (platelet count, PCT, MPV, and PDW) and PELOD score on the 1st and 3rd day of PICU admission were performed.&#x0D; RESULTS: Eighty-three subjects were recruited in this study, 44 were boy with a median age of 6 (1–17) years old. The septic patient was 43 subjects (51.8%). Platelet count on the 1st day (p = 0.024) and PDW on the 3rd day (p = 0.018) of PICU admission was significantly associated with mortality. There was no correlation between platelet profile and PELOD-2 score on day 1 and 3. However, the difference between MPV on days 1 and 3 (ΔMPV) significantly correlated with the change of PELOD-2 score (r = 0,647, p &lt; 0.0001).&#x0D; CONCLUSION: Platelet count on 1st day and PDW on the 3rd day had a significant association with mortality but no correlation between platelet profile and PELOD-2 score.

Burden of respiratory support differs between critically ill children with severe bacterial and viral pneumonia

Background: We hypothesized that children with viral pneumonia have higher severity of illness and higher mechanical ventilation (MV) requirement than children with bacterial pneumonia. We aim to compare respiratory support requirements of severe viral and bacterial pneumonia cases admitted to the pediatric intensive care unit (PICU). Methods: This is a retrospective review of patients with microbiologically proven severe viral and bacterial pneumonia admitted to PICU in KK Women’s and Children’s Hospital, Singapore, from 2010 to 2014. Demographic, clinical and ventilatory data up to 14 days of PICU admission were extracted and analyzed. Results: Forty-nine and 68 patients had sole viral and bacterial pathogens, respectively. Patients with viral pneumonia were more likely to be vs . 27.9%, P=0.011), to have underlying comorbidities (59.2% vs . 35.3%, P=0.010) and had higher pediatric index of mortality 2 (PIM2) score [3.0 (1.1, 8.0) vs . 1.6 (0.8, 3.0), P vs . 24.5%, P=0.008) and required longer duration of MV [7.0 (4.0, 10.0) vs . 4.0 (1.0, 10.8) days, P=0.031]. Oxygenation index (OI) of children with viral pneumonia was higher on day 1 [OI: 11.7 (6.6, 19.3) vs . 5.7 (3.7, 10.8), P=0.006] and 3 [OI: 8.0 (6.0, 20.0) vs . 5.0 (3.0, 8.0), P vs . 0%, P Conclusions: Children with viral pneumonia were more likely to require alternative modes of MV and longer duration of MV.

Association of vitamin D deficiency with clinical outcomes in critically ill Korean children.

BACKGROUND/OBJECTIVESVitamin D is a pleiotropic hormone that affects various body organ systems. We evaluated the prevalence of a vitamin D deficiency (VDD) and its potential role in the clinical condition of critically ill Korean children.SUBJECTS/METHODSPatients under 18 years old with a 25(OH) vitamin D measurement on the first day of PICU admission were included from among the children admitted to the pediatric intensive care unit (PICU) of our tertiary children's hospital between October 2017 and January 2019.RESULTSA total of 172 pediatric patients were enrolled. The mean 25(OH) vitamin D level was 17.5 ± 12.8 ng/mL. There was a 65.1% prevalence of VDD (25(OH) vitamin D level < 20 ng/mL). VDD was associated with age at PICU admission, gastrointestinal/hepatobiliary disorders, International Society of Thrombosis and Hemostasis disseminated intravascular coagulation (ISTH DIC) score, pediatric multiple organ dysfunction syndrome (pMODS) score and with several laboratory test findings including hemoglobin, platelet, C-reactive protein, serum albumin, total bilirubin, prothrombin time, and anti-thrombin III levels. Most of these parameters also showed significant linear correlations with the 25(OH) vitamin D level (P < 0.05). However, no statistically meaningful association was found between VDD and other clinical conditions such as the need for a mechanical ventilator, requirement for vasoactive drugs, duration of the PICU and hospital stays, or PICU mortality.CONCLUSIONThere is a high prevalence of VDD in critically ill Korean children. There were significant associations between the 25(OH) vitamin D level and gastrointestinal/hepatobiliary disorders, the pMODS score and with coagulation related factors. Further large-scale studies with more specific subgroup analyses are required to more precisely assess the clinical implications of VDD in critically ill pediatric patients.

Pathogen screening and prognostic factors in children with severe ARDS of pulmonary origin.

BackgroundAcute respiratory distress syndrome (ARDS) is one of the most lethal diseases encountered in the pediatric intensive care unit (PICU). The etiological pathogens and prognostic factors of severe ARDS of pulmonary origin in children with respiratory virus infections were prospectively investigated.MethodsEnrolled children fulfilled the following criteria: (1) PICU admission; (2) age of 1 month to 16 years; (3) diagnosis of infectious pneumonia and respiratory virus infection; and (4) development of severe ARDS within 72 h after PICU admission. Pathogens were detected in the blood and tracheal lavage fluid using molecular techniques and a conventional culture system. The serum levels of inflammatory mediators on the day of PICU admission were examined.ResultsFifty‐seven patients (32 boys; median age, 9 months) were enrolled. Multiple virus infections, co‐infection with bacteria/fungus, and bacteremia/fungemia were observed in 60%, 49%, and 32% of children, respectively. Adenovirus‐B, measles virus, and cytomegalovirus were detected predominantly in tracheal lavage fluid. There were no statistically significant differences between non‐survivors and survivors regarding the types of pathogen, incidence of multiple virus infection, gender, age, clinical features, and treatment. The serum levels of interferon (IFN)‐γ and the IFN‐γ/interleukin (IL)‐10 ratio were higher in non‐survivors.ConclusionsIFN‐γ upregulation as detected on the day of PICU admission was found to be one of the possible prognostic factors affecting a fatal outcome. These results suggest that modulation of inflammatory responses is critical for the clinical management of children with ARDS.

Delta Neutrophil Index as a Prognostic Marker in the Pediatric Intensive Care Unit

Background: The delta neutrophil index (DNI) is a useful marker for diagnosing and predicting the prognosis of sepsis. The purpose of this study was to investigate the usefulness of DNI as a prognostic marker in patients within the pediatric intensive care unit (PICU), as well as its association with other prognostic factors. Methods: A total of 516 children admitted to Severance Children`s Hospital PICU from December 2009 to February 2015 were ana- lyzed. DNI was measured on the day of PICU admission. Mortality was defined as death within 28 days following PICU admission. Results: The median value of DNI was 1.2% (interquartile range [IQR] 0-4.3%) in the survivor group and 9.5% (IQR 2.3-20.8%) in the non-survivor group, and the difference was statistically significant (p < 0.001). DNI was significantly positively correlated with ICU scores such as Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III, as well as with C-reactive protein and lactate levels. The area under the receiver operating characteristic curve of DNI for mortality was 0.748 (95% CI: 0.687-0.808) and the cut-off value was 4.95%. Conclusions: The initial DNI level can be considered a useful indicator for predicting prognosis in PICU patients.

Atypical presentation of human bocavirus: Severe respiratory tract infection complicated with encephalopathy.

Human bocavirus (HBOV) has been reported as a worldwide distributed respiratory pathogen. It has also been associated with encephalitis recently by detection of the virus in cerebrospinal fluid (CSF) of patients presented with encephalitis. This retrospective study aimed to present clinical features of HBOV infections in children with respiratory symptoms and describe unexplained encephalopathy in a subgroup of these patients. Results of 1,143 pediatric nasal samples from mid‐December 2013 to July 2014 were reviewed for detection of HBOV. A multiplex real time polymerase chain reaction assay was used for viral detection. Medical records of the patients were retrospectively analyzed. HBOV was detected in 30 patients (2.6%). Median age was 14 months (5–80). Clinical diagnoses were upper respiratory tract infection (n = 10), bronchopneumonia (n = 9), acute bronchiolitis (n = 5), pneumonia (n = 4), acute bronchitis (n = 1), and asthma execarbation (n = 1). Hospitalization was required in 16 (53.3%) patients and 10 (62.5%) of them admitted to pediatric intensive care unit (PICU). Noninvasive mechanical ventilation modalities was applied to four patients and mechanical ventilation to four patients. Intractable seizures developed in four patients while mechanically ventilated on the 2nd–3rd days of PICU admission. No specific reason for encephalopathy was found after a thorough investigation. No mortality was observed, but two patients were discharged with neurological sequela. HBOV may lead to respiratory infections in a wide spectrum of severity. This report indicates its potential to cause severe respiratory infections requiring PICU admission and highlights possible clinical association of HBOV and encephalopathy, which developed during severe respiratory infection. J. Med. Virol. 87:1831–1838, 2015. © 2015 Wiley Periodicals, Inc.

Red Blood Cell Distribution Width as a Pragmatic Marker for Outcome in Pediatric Critical Illness.

BackgroundRed cell distribution width (RDW) is a routine laboratory measure associated with poor outcomes in adult critical illness.ObjectiveWe determined the utility of RDW as an early pragmatic biomarker for outcome in pediatric critical illness.MethodsWe used multivariable logistic regression to test the association of RDW on the first day of pediatric intensive care unit (PICU) admission with prolonged PICU length of stay (LOS) >48 hours and mortality. The area under the receiver operating characteristic curve (AUROC) for RDW was compared to the Pediatric Index of Mortality (PIM)-2 score.ResultsOver a 13-month period, 596 unique patients had RDW measured on the first day of PICU admission. Sepsis was an effect modifier for LOS >48 hours but not mortality. In sepsis, RDW was not associated with LOS >48 hours. For patients without sepsis, each 1% increase in RDW was associated with 1.17 (95% CI 1.06, 1.30) increased odds of LOS >48 hours. In all patients, RDW was independently associated with PICU mortality (OR 1.25, 95% CI 1.09, 1.43). The AUROC for RDW to predict LOS >48 hours and mortality was 0.61 (95% CI 0.56, 0.66) and 0.65 (95% CI 0.55, 0.75), respectively. Although the AUROC for mortality was comparable to PIM-2 (0.75, 95% CI 0.66, 0.83; p = 0.18), RDW did not increase the discriminative utility when added to PIM-2. Despite the moderate AUROC, RDW <13.4% (upper limit of lower quartile) had 53% risk of LOS >48 hours and 3.3% risk of mortality compared to patients with an RDW >15.7% (lower limit of upper quartile) who had 78% risk of LOS >48 hours and 12.9% risk of mortality (p<0.001 for both outcomes).ConclusionsElevated RDW was associated with outcome in pediatric critical illness and provided similar prognostic information as the more complex PIM-2 severity of illness score. Distinct RDW thresholds best discriminate low- versus high-risk patients.

Effects of enteral nutrition on clinical outcomes among mechanically ventilated and sedated patients in the pediatric intensive care unit

Objective. To analyze the effects of enteral nutrition on outcomes and complications of critically ill children in the pediatric in-tensive care unit (PICU).Design. Retrospective cohort study. Setting. PICU in a tertiary care academic medical center.Patients. Patients up to age 17 years who were admitted to the PICU between Janu-ary 1, 2011, and December 31, 2013. Interventions. Intubation for more than 48 hours and requiring any sedative medica-tions. Patients with surgical contraindica-tions to feeding were excluded. Measures and Main Results. A total of 165 patients met inclusion criteria. Both manual review of the electronic health re-cord and automated data capture (when-ever technically feasible) were conducted. Data were collected in REDCap software and analyzed using a statistical discovery program. The mean (SD) calorie intake within the first 10 days of PICU admission was 40% (31.9%) of the prescribed calo-ries. Only 67% of the patients had feeding initiated within 48 hours of admission. No significant difference in hospital or PICU length of stay or ventilator-free days was observed in patients who met one-third of their nutritional goals (50.3%) compared with patients who did not (49.7%). Mor-tality was nonsignificantly higher among patients who did not meet nutritional goals (P=.07). No association was found between higher doses of opioids or benzo-diazepines and nutrition tolerance or gas-trointestinal complications. Conclusions. Early adequate enteral nutri-tion had no statistically significant impact on the short-term clinical outcomes of PICU patients.

Registered Dietitians Making a Difference: Early Medical Record Documentation of Estimated Energy Requirement in Critically Ill Children Is Associated with Higher Daily Energy Intake and with Use of the Enteral Route

BackgroundEstablishing a caloric requirement or energy target is a recommended part of any nutrition care plan. ObjectiveOur objective was to describe early documentation of a caloric requirement in critically ill children, and to determine if this would have any effect on daily energy intake and route of nutrition. DesignWe used a descriptive chart review of a subgroup of patients included as part of a larger, retrospective multicenter study. Variables of interest included nutritional intake information, as well as presence/absence and amount of a documented caloric requirement within 48 hours of admission. ParticipantsFive of the original 12 study centers collected the required supplementary data. Enrolled patients were those who were admitted to our pediatric intensive care unit (PICU) from January 1, 2007, through December 31, 2008; were between ages 30 days and 18 years; and had a length of stay in the PICU ≥96 hours. Statistical analysisEnergy intake among patients with and without a documented caloric requirement was analyzed using Mann-Whitney U tests. The difference of receiving enteral nutrition among patients with and without a caloric requirement was analyzed using a χ2 test. ResultsWe studied 1,349 patients, of whom 644 (47.7%) had a caloric requirement documented (95.6% of caloric requirements were entered by a registered dietitian) in the medical record; these patients had higher total daily energy intake and were more likely to be fed enterally during the first 4 days of PICU admission than those without a documented caloric requirement (P<0.001 for all comparisons). ConclusionsLess than half of critically ill children studied had a caloric requirement documented in the medical record; when a caloric requirement was documented in the medical record of a critically ill child, a registered dietitian had likely made the note. Having a caloric requirement documented in the medical record is associated with a higher energy intake and the use of the enteral route.

Hyperglycemia and Outcome in the Pediatric Intensive Care Unit

To identify the frequency of hyperglycemia in children who are nondiabetic and critically ill and assess the independent effect of hyperglycemia on outcome. Consecutive admissions to the pediatric intensive care unit (PICU) were reviewed. The Pediatric Risk of Mortality III score (PRISM) measured patient acuity. Because maximum glucose level in the first day of PICU admission (GLFD) >200mg/dL contributes to PRISM, 200 mg/dL was used to differentiate high glucose (HG) from normal glucose. Of 1550 patients, 221 (14.3%) had HG. GLFD correlated with PRISM (r = 0.39, P < .001). Without controlling for PRISM, the HG group had more mechanical ventilation days (MVD; P < .001), longer PICU length of stay (PLOS; P < .001) and lower percent survival (P < .001) than the normal glucose group. Controlling for PRISM in survivors, GLFD was not associated with PLOS (P = .75) or with MVD (P = .06). GLFD was not significantly associated with survival (P = .76). In nonsurvivors, GLFD was not associated with PLOS (P = .19) or MVD (P = .31). When controlling for disease severity, hyperglycemia within 24 hours of PICU admission was not independently associated with increased mechanical ventilation time, length of stay, or mortality. Prospective evaluation of glycemic control in critically ill children is needed to elucidate its effects on outcome.

Rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit patients.

The objective of this study was to determine the rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit (PICU) patients. Prospective cohort study. This study was performed at St Louis Children's Hospital, a 235-bed academic tertiary care center with a combined 22-bed medical and surgical PICU. Subjects for this study were patients admitted to the PICU between September 1, 1999, and May 31, 2000. None. Patients were monitored for the development of nosocomial bloodstream infections from the day of PICU admission until 48 hours after PICU discharge. Of 911 patients, 526 (58%) were male and 674 (74%) were white. Congenital heart disease (29%), lung disease (25%), and genetic syndrome (18%) were common. There were 65 episodes of primary bloodstream infection in 57 patients; 5 were polymicrobial and 7 patients had multiple bloodstream infections. Coagulase-negative Staphylococcus was the leading cause of bloodstream infection (n = 28), followed by Enterobacter cloacae (n = 8). The rate of bloodstream infection was 13.8 per 1000 central venous catheter days. In multiple logistic regression analysis, patients with bloodstream infection were more likely to have multiple central venous catheters (adjusted odds ratio [aOR]: 5.7; 95% confidence interval [CI]: 2.9-10.9), arterial catheters (aOR: 5.5; 95% CI: 1.8-16.3), invasive procedures performed in the PICU (aOR: 4.0; 95%CI: 2.0-7.8), and be transported out of the PICU (aOR: 3.4; 95% CI: 1.8-6.7) to the radiology or operating room suites. Severity of illness as measured by admission Pediatric Risk of Mortality score, underlying illnesses, and medications were not associated with increased risk of nosocomial bloodstream infection. Conclusions This study identified a high rate of bloodstream infection among St Louis Children's Hospital PICU patients. Risk factors for bloodstream infection were related more to process of care than to severity of illness. Additional research is needed to develop interventions to reduce nosocomial bloodstream infections in children.