Hospital Pediatric Intensive Care Unit Research Articles

Palliative care for hospitalized children: perception of the nursing team

Objective: to understand the perception of the nursing team of an intensive care unit and pediatric hospitalization about palliative care for hospitalized children. Methods: a descriptive, qualitative study was conducted with a large hospital pediatric intensive care and hospitalization unit's nursing team. Fourteen nursing professionals participated in the study, including nurses, technicians, and nursing assistants. Data were collected through semi-structured interviews and treated under content analysis. Results: The interpretative analysis of the interviews allowed the construction of three categories:"The knowledge of the nursing team about palliative care in pediatrics", "The challenges of the nursing team in performing palliative care in pediatrics", and "The benefits of palliative care in pediatric care from the perspective of the nursing team". Conclusions: The lack of knowledge and training of nursing professionals on palliative care are factors that can hamper their implementation and consolidation process in units that care for children with no possibility of cure, in addition to favoring decisions to be under the responsibility of the medical category, compromising the role of the multidisciplinary team and depriving patients of the benefits of palliative care.

The Caregiver Burden of Mothers of Patients Who Received Tracheostomy in a University Hospital Pediatric Intensive Care Unit

The Caregiver Burden of Mothers of Patients Who Received Tracheostomy in a University Hospital Pediatric Intensive Care Unit

Variability in Clinician Awareness of Intravenous Fluid Administration in Critical Illness: A Prospective Cohort Study

AbstractIntravenous (IV) fluids are commonly administered to critically ill children, but clinicians lack effective guidance for the correct dose and duration of therapy resulting in variation of prescribing habits which harm children. It is unknown if clinicians recognize the amount of IV fluid that patients receive. We aimed to determine clinician's accuracy in the identification of the volume of IV fluids patients will receive over the next 24 hours. Prospective cohort study enrolled all patients admitted to the pediatric intensive care unit (PICU) from May to August 2021 at the University of Michigan's C.S. Mott Children's Hospital PICU. For each patient, clinicians estimated the volume of IV fluid that patients will receive in the next 24 hours. The primary outcome was accuracy of the estimation defined as predicted volume of IV fluids versus actual volume administered within 10 mL/kg or 500 mL depending on patient's weight. We tested for differences in accuracy by clinician type using chi-square tests. There were 259 patients for whom 2,295 surveys were completed by 177 clinicians. Clinicians' estimates were accurate 48.8% of the time with a median difference of 10 (1–26) mL/kg. We found that accuracy varied between clinician type: bedside nurses were most accurate at 64.3%, and attendings were least accurate at 30.5%. PICU clinicians have poor recognition of the amount of IV fluids their patients will receive in the subsequent 24-hour period. Estimate accuracy varied by clinician's role and improved over time, which may suggest opportunities for improvement.

Asthma as a comorbidity in COVID-19 pediatric ICU admissions in a large metropolitan children's hospital.

Children contribute to 5% ofcoronavirus disease of 2019 (COVID-19)-related hospitalizations in the United States. There is mounting evidence suggesting childhood asthma is a risk factor for severe disease. We hypothesized that asthma is associated with longer length of stay (LOS) and need for respiratory support among children admitted to pediatric intensive care unit (PICU) with COVID-19. We reviewed 150 charts of children and young adults with a positivesevere acute respiratory syndrome coronavirus 2polymerase chain reaction test admitted to the PICU at Children's National Hospital, Washington, DC between 2020 and 2021. We recorded demographics, anthropometrics, past medical history, clinical course, laboratory findings, imaging, medication usage, respiratory support, and outcomes. Functional Status Scale (FSS), which measures an Intensive Care Unitpatient's physical function, was used to characterize children with multiple comorbidities; FSS and obesity were included as covariates in multivariate analysis. Statistical analysis was performed using SPSS v25.0. Sixty-Eight patients ages 0-21 years met inclusion criteria. Median age was 14.9 years, 55.9% were female, median Body Mass Index percentile was 62, and 42.6% were African American. Compared with those without asthma, patients with asthma averaged longer LOS (20.7 vs. 10.2 days, p = 0.02), with longer PICU stay (15.9 vs. 7.6 days, p = 0.033) and prolonged maximum respiratory support (8.3 vs. 3.3 days, p = 0.016). Adjusted for obesity and poor physical function (FSS > 6), asthma remained a significant predictor of hospital LOS, PICU LOS, and days on maximum respiratory support. Asthma can cause severe disease with prolonged need for maximum respiratory support among children with COVID-19.

Communication on analgesia and sedation: parents’ opinions in six pediatric ICU in northern Italy

Abstract Introduction Communication between healthcare professionals and parents regarding analgesic and sedative treatments for seriously ill children is challenging. Although appropriate information may help parents during admission to the pediatric intensive care unit (PICU), some areas of communication may be missed. Objectives To explore and describe the opinions of parents of children admitted to PICU about analgosedation, information received about it and its potential adverse effects, and suggestions for improving the comfort of hospitalized children. Methods Parents’ opinions were collected in six PICUs in northern Italy. Parents of children who were hospitalized for more than 48 hours and required analgesia and sedation were asked to provide opinions on the quality of information with respect to the treatments used, possible short- and long-term sequelae, satisfaction with efficacy, environmental factors perceived as disturbing, and suggestions for improving children’s comfort. Results Forty-eight parents participated. Information about analgosedation was rated, as was its effectiveness. Parents pointed out some interesting suggestions to improve their children’s comfort during their hospitalization in PICU. On the other hand, it was found that information about possible complications, withdrawal syndrome, delirium, or difficulties in obtaining the desired level of sedation was often provided poorly or inadequately. In addition, wide differences were found between centres, particularly with regard to analgosedation side effects and withdrawal syndrome. Conclusions Parents should receive early explanations of these potential complications. Even considering the limited number of participating PICUs, distributed exclusively in northern Italy, and the small number of participants, this is the first data collection focused on communication between health professionals and parents of children undergoing analgosedation treatment in pediatric intensive care units. Key messages • This is the first data collection focused on communication between health professionals and parents of children undergoing analgosedation treatment in pediatric intensive care units. • Information about possible complications, withdrawal syndrome, delirium, or difficulties in obtaining the desired level of sedation was often provided poorly or inadequately.

Severe viral respiratory infections in the pre-COVID era: A 5-year experience in two pediatric intensive care units in Italy.

Viral respiratory infections are one of the main causes of hospitalization in children. Even if mortality rate is low, 2% to 3% of the hospitalized children need mechanical ventilation. Risk factors for admission to the pediatric intensive care unit (PICU) are well known, while few studies have described risk factors for invasive ventilator support and prolonged hospitalization. A retrospective study including all patients aged between 2 and 18 months with a confirmed viral respiratory infection, requiring admission to PICU from September to March between 2015 and 2019, was conducted at Bambino Gesù Children's Hospital in Rome, Italy. One hundred ninety patients were enrolled, with a median age of 2.7months; 32.1% had at least one comorbidity, mainly prematurity. The most frequent isolated viruses were RSV-B, rhinovirus, and RSV-A; 38.4% needed mechanical ventilation. This subgroup of patients had lower median birth weight compared with patients not requiring mechanical ventilation (2800 g vs. 3180 g, p = 0.02); moreover, comorbidities were present in 43.8% of intubated patients and in 24.8% of patients treated with non-invasive ventilation (p = 0.006). Viral coinfection did not result to be a risk factor for mechanical support, while virus-bacteria coinfection was significantly associated with mechanical ventilation (p < 0.001). Similar risk factors were identified for prolonged hospitalization. Early identification of patients who could have a sudden respiratory deterioration and need of mechanical ventilation is crucial to reduce complications due to orotracheal intubation and prolonged hospitalization in PICU. Further studies are needed to define high-risk group of patients and to design targeted interventions.

Retrospective evaluation of pediatric trauma patients: a single-center experience of a tertiary pediatric intensive care unit

Aim: Due to the rapid development in pediatric critical care medicine, some past studies suggested that pediatric trauma patients have better outcomes such as lower mortality and lower length of hospital stay in the pediatric intensive care unit (PICU). In this study, we aim to describe the demographic, clinical features, mechanisms of injury, and outcomes of children hospitalized in our pediatric intensive care unit due to trauma. &#x0D; Material and Method: We performed a retrospective evaluation of 60 pediatric trauma patients (between 0 and16 years of age) admitted to the PICU at University of Health Science, Sancaktepe Sehit Prof. Dr. İlhan Varank Training and Research Hospital from August 2020 to February 2022.&#x0D; Results: A total of 60 pediatric trauma patients were followed up in our PICU. The median age of patients was 17 (0-724) months with a preponderance of male cases (n:38, 63.3%). The median duration of hospitalization in PICU was 6 (1-46) days. According to the trauma type, the majority of the injuries were falling from a height (n:37, 61.7%).&#x0D; Conclusion: We would like to draw attention to the fact that head traumas due to falling were so common and also affect mortality. The lactate and the lactate/albumin ratio ​​of patients who developed mortality were significantly higher. Although there are studies on the association of lactate/albumin ratio with mortality in critically ill pediatric patients, we could not find any data on this issue in pediatric trauma patients in the literature. Our study will contribute to the literature on the relationship between lactate/albumin ratio and mortality in pediatric trauma patients. We suggest that the relationship between lactate/albumin ratio and mortality should be investigated in pediatric trauma patients with larger case numbers.

The impact of the coronavirus disease 2019 epidemic and national public restrictions on Pediatric Intensive Care Units in Taiwan

Background/purposeCoronavirus disease 2019 (COVID-19) pandemic challenges pediatric health globally by limited medical accessibility. In response to COVID-19 epidemic in Taiwan, public restrictions were applied and the Level 3 alert was announced from May to July in 2021 for local outbreak. This study aims to analyze patients’ clinical features and outcomes in the pediatric intensive care unit (PICU) during the COVID-19 epidemic with the Level 3 alert in Taiwan.MethodsMedical records were retrospectively collected in patients admitted to the PICU of National Taiwan University Children's Hospital from May to July 2021 (Level 3 alert) and May to July 2019 and 2020 (control periods). Clinical characteristics and outcomes were compared between patients in the period with the Level 3 alert and control periods.ResultsDuring the study period, PICU monthly admissions significantly decreased in the Level 3 alert period and were negatively correlated with monthly newly confirmed COVID-19 cases. Patients admitted during the Level 3 alert were older, had higher disease severity, lower proportion of cardiovascular disease, and higher proportion of hematology-oncology diseases than those in the control group. After adjusting for the above factors, admission during Level 3 alert was an independent factor for higher mortality rate and prolonged length of stay (>14 days) in the PICU.ConclusionDuring the COVID-19 epidemic with strict public restrictions, critically ill patients admitted to the PICU decreased but had increased disease severity, prolonged length of stay in the PICU, and higher mortality, reflecting the impact of quarantine and limited medical access.

Clinical characteristics of children with MIS-C fulfilling classification criteria for macrophage activation syndrome.

BackgroundMacrophage activation syndrome (MAS) is a potentially life-threatening complication of various inflammatory disorders, including multisystem inflammatory syndrome in children (MIS-C). MIS-C refractory to treatment should raise suspicion of MAS, which can be fatal if a definitive diagnosis is delayed. Unfortunately, there is a lack of data on MAS in children with MIS-C.ObjectiveOur study aims to analyze the risk factors for the development of MAS in MIS-C, its clinical course and response to treatment, and identify predictive factors for pediatric intensive care.Material and methodsWe analyzed data from the Polish MIS-C registry of the MultiOrgan Inflammatory Syndromes COVID-19 Related Study. Patients were diagnosed according to the WHO MIS-C definition and treated according to national guidelines (Polish Pediatric Society) based on international consensus. MAS definition was based on 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis.ResultsTwo-hundred and seventy four children met the study inclusion criteria. Fifty-nine patients fulfilled MAS classification criteria, nine of which required admission to the pediatric intensive care unit (PICU). MIS-C patients with MAS were significantly older than patients without MAS (median 11.2 vs. 8.1 years). Multivariable analysis showed that age, symptoms characteristic of atypical Kawasaki disease, and skin erosions were significant factors associated with MAS in MIS-C patients. Analysis of laboratory parameters showed that on admission, MIS-C patients with MAS had significantly lower median lymphocyte and platelet counts, albumin and sodium levels, and higher median levels of C-reactive protein, procalcitonin, ferritin, D-dimers, triglycerides, serum creatinine, urea, and γ-glutamyl transpeptidase, and neutrophil count. Multivariate analysis showed that higher procalcitonin, ferritin, and fibrinogen levels at admission were predictive of MAS. Only elevated troponin level was a factor indicating a requirement of PICU hospitalization for children with MAS. MIS-C patients fulfilling MAS criteria were treated more often with intravenous immunoglobulins and steroids than children without MAS. Children with MAS more often required mechanical ventilation. None of the patients required biological agents.ConclusionsThe clinical course of MAS in MIS-C seems milder, treatment less aggressive, and the prognosis better than expected based on the current knowledge on MAS complicating other rheumatological diseases.

Association of intensive care unit or paediatric intensive care unit admissions with the method of transporting patients: a multicentre retrospective study

BackgroundReports regarding transportation methods of severely critical patients admitted to an intensive care unit (ICU) or paediatric ICU (PICU) are limited. In an attempt to address this research gap, this study aimed to test the hypothesis that prognosis is worse in patients transported by family members.MethodsThis multicentre study collected data from the Japanese Registry of Paediatric Acute Care database. Data concerning patients aged ≤16 years admitted to a participating hospital ICU or PICU and their transportation method to the hospital were extracted and divided into two groups: transported by family and transported by emergency medical services (EMS).ResultsOf the 2963 patients who met the criteria, 871 (29.4%) were transported by family and 2092 (70.6%) were transported by EMS. Significantly more patients with chronic conditions (551 patients, 63.3% vs. 845 patients, 40.4%; p < 0.01) or respiratory failure (414 patients, 47.5% vs. 455 patients, 21.7%; p < 0.01) were admitted to the ICU or PICU in the family transport group. There was no significant difference in survival rate between EMS and family transport group, matched by PIM2, chronic condition status and transport distance (OR:1.17, 95%CI:0.39–3.47, p = 0.78).ConclusionThe results of this study show that the transportation method does not affect the survival rate of paediatric patients. The proportion of patients with chronic conditions or those admitted because of respiratory failure was higher in the family transport group than in the EMS group. Therefore, as these patients are more likely to be admitted to the ICU or PICU, it is important to provide prompt respiratory care and medical interventions to achieve the best outcomes.

Short- and long-term outcome of allogeneic stem cell transplantation in infants: A single-center experience over 20 years.

IntroductionAllogeneic hematopoietic stem cell transplantation (allo-HSCT) is a treatment method for a wide range of malignant and non-malignant diseases. Infants constitute a distinct patient group, especially due to their organ immaturity and differences in drug metabolism. The present paper aims to analyse the short- and long-term outcomes after allo-HSCT in infants.Material and methodsIn the study period, 67 patients under 12 months of age underwent allo-HSCT. This study is a retrospective analysis of patient medical records, in the form of paper and electronic documentation.ResultsThe probability of 5-year OS was 69% and 72% in patients with malignant and non-malignant diseases, respectively. The allo-HSCT from a matched donor was associated with improved OS in comparison to haploidentical donor (0.8 vs. 0.58%, p = 0.0425). The overall incidence of acute graft-vs.-host disease (aGVHD) was 59.3%, and grade III–IV aGVHD was diagnosed in 23% of patients. The 100-day non-relapse mortality (NRM) in the study cohort was 17.9%, while the 5-year NRM was 26.9%. Among the causes of NRM, infections occurred in 83.3% of patients, and aGVHD in 16.3% of individuals. Twenty-two children (32.8%) required hospitalization in the pediatric intensive care unit (PICU). The median length of PICU hospitalization was 6 days (range 1 to 12 days). Late sequelae diagnosed during post-transplant surveillance included ocular disorders in 26.8% of patients, cardiac complications in 4.4%, as well as endocrinopathy with short stature (<3rd percentile) in 37.2% and overt hypothyroidism in 35.4%. In the long-term perspective, 83.3% of survivors were able to attend a regular school.ConclusionsImprovements in unrelated donor availability, and better supportive care resulted in better outcomes. Management of infant allo-HSCT recipients requires the formation of multi-disciplinary specialist teams. In addition, the role of parental empowerment must be acknowledged; for example, in speech therapy and rehabilitation.

Lean Design of the Pediatric Intensive Care Unit Patient Room for Efficient and Safe Care Delivery.

The pediatric intensive care unit (PICU) is an environment where seriously ill children receive complex care, delivered mostly by specialty-trained nurses (registered nurses [RNs]) who must perform multiple high-level tasks. With stressors on healthcare systems at an all-time high, design that optimizes RN workflow has taken on a renewed imperative. To employ a multimodal approach (1) to identify environmental factors in the PICU patient room that contribute to caregiver workflow inefficiencies, (2) to optimize safety by identifying high-touch surfaces that cause hospital-acquired infections, (3) to develop human-centered design recommendations. This mixed-method case study was conducted in a 23-bed urban hospital PICU. The activities, movements, and workflows of 13 RNs were recorded using spatial movement mapping, behavioral mapping, and clinical activity mapping. Frequency of RN contact with surfaces was documented to assess relative infection transmission risk. Face-to-face interviews were conducted with RNs to elicit their views on care delivery and their physical work environment. Direct patient care occupied 50% of RNs' time. Of the direct patient care workflow activities recorded, 26% were to prepare for care around the bedside, while 27% were for random travel between clean and soiled areas. The surfaces most frequently touched were (1) patient bedrails, (2) intravenous pumps and poles, (3) tubing and medical equipment, and (4) vital sign monitors. Value-added tasks account for only about 20% of nurses' work. Combining technology and strategic interior design to streamline workflow and enhance infection prevention optimizes efficiency and empowers frontline providers to maximize their time at the bedside performing value-added tasks.

Detection of Vancomycin-Resistant Enterococci and Vancomycin Resistance Genes in Patients Hospitalized in the Pediatric Intensive Care Unit

Objective: Vancomycin-resistant enterococci (VRE) infection and colonization are seen increasingly frequently, especially among intensive care unit (ICU) patients. In this study, the aim was to detect VRE in swab samples taken from patients hospitalized in the Pediatric ICU (PICU), colonization, and to investigate the clonal relationship between isolates.&#x0D; Materials and Methods: In the present study, swab samples were taken from the external auditory canal (EAC), umbilical region, and rectal region from 82 patients hospitalized in the Çukurova University Balcalı Hospital PICU. The 246 swab samples from patients were inoculated on Kanamycin-Esculin-Azide agar. Isolates were identified with the help of the BBL Crystal Gram-Positive identification system. The susceptibility of the isolates to vancomycin (30 µg) was investigated by Kirby-Bauer disk diffusion method according to CLSI criteria. VanA-VanB genes in phenotypically defined vancomycin-resistant enterococci were investigated by Polymerase Chain Reaction (PCR) method. The clonal relationship between vancomycin-susceptible (VSE) and -resistant enterococci was determined by the SmaI-PFGE method.&#x0D; Results: A total of 49 (20.3%) enterococcal strains were isolated from 246 swab samples from the patients, of which 14 (28.5%) were VRE. Of the enterococci isolates, 27 (55.10%) were E. faecium and 13 (26.53%) were E. feacalis. While VanA type resistance was detected in 11 of the vancomycin-resistant E. faecium and E. feacalis isolates, VanB type resistance was not detected in any sample. There was no significant clonal relationship between the isolates.&#x0D; Conclusion: Although the prevalence of VRE in the PICU was high throughout the study, no enterococcal infection was observed.

Mortality of Hemato-Oncologic Patients Admitted to a Pediatric Intensive Care Unit: A Single-Center Experience.

IntroductionMortality in children with hemato-oncologic disease admitted to a pediatric intensive care unit (PICU) is higher compared to the general population. The reasons for this fact remain unexplored. The aim of this study was to assess outcomes and trends in hemato-oncologic patients admitted to a PICU, with analytical emphasis on emergency admissions.MethodsPatients with a hemato-oncologic diagnosis admitted to a tertiary care university hospital PICU between 1 January 2009 and 31 December 2019 were retrospectively analyzed. Additionally, patient mortality 6 months after PICU admission and follow-up mortality until 31 December 2020 were recorded.Measurements and Main ResultsWe reviewed a total of 701 PICU admissions of 338 children with hemato-oncologic disease, of which 28.5% were emergency admissions with 200 admissions of 122 patients. Of these, 22 patients died, representing a patient mortality of 18.0% and an admission mortality of 11.0% in this group. Follow-up patient mortality was 25.4% in emergency-admitted children. Multivariable analysis revealed severe neutropenia at admission and invasive mechanical ventilation (IMV) as independent risk factors for PICU death (p = 0.029 and p = 0.002). The total number of PICU admissions of hemato-oncologic patients rose notably over time, from 44 in 2009 to 125 in 2019.ConclusionAlthough a high proportion of emergency PICU admissions of hemato-oncologic patients required intensive organ support, mortality seemed to be lower than previously reported. Moreover, in this study, total PICU admissions of the respective children rose notably over time.

Downregulation of thrombomodulin-thrombin-activated protein C pathway as a mechanism for SARS-CoV-2 induced endotheliopathy and microvascular thrombosis

There is emerging evidence of microvascular thrombosis and thrombotic microangiopathy (TMA) induced by COVID-19, presumably from endothelial injury. Thrombomodulin (TM) is an endothelial glycoprotein that plays a dual role in maintaining healthy endothelium-as a natural anticoagulant by binding thrombin to activate protein C (APC) and a negative regulator of the alternate complement pathway (AP). TM is shed into the plasma as soluble TM (sTM) during endothelial injury.We hypothesize that SARS-CoV-2 spike proteins cause direct microvascular endothelial injury, leading to TM shedding, decreased activation of PC, and consequently, microvascular thrombosis in COVID-19. We conducted this study twofold: 1) in vivo, we assessed endothelial injury (by measuring sTM) and AP activation by quantifying Ba (cleavage product of AP component Factor B) in a cohort of critically ill COVID-19 pediatric patients and the implications on clinical outcomes; and 2)in vitro, we investigated endothelial injury (TM shedding) by SARS-COV-2 spike proteins and the subsequent functional consequence in activated PC (APC) levels and Ba levels.sTM and Ba in plasma samples from SARS-CoV-2 positive patients admitted to Texas Children's Hospital Pediatric Intensive Care Unit (n = 33) and from healthy controls (n = 38) were measured by ELISA. In vitro, confluent glomerular microvascular endothelial cells (GMVECs) were incubated for 48 h in the presence or absence (control) of purified SARS-CoV-2 spike proteins, S1 and S2. TM from the cell lysates while Ba and APC from the cell supernatants were measured by ELISA. sTM and Ba levels were significantly higher in the COVID-19 pediatric patients compared to healthy controls (p < 0.01 and p < 0.001, respectively). Among the COVID-19 patients, elevated sTM was associated with increased vasopressor use (p = 0.01) and elevated Ba was associated with increased duration of mechanical ventilation (p = 0.04). In vitro, surface bound TM and soluble APC were significantly lower in GMVECs after addition of spike proteins (p < 0.05), while Ba was undetectable in both control and spike proteins exposed GMVECs.In conclusion, we provide evidence of endothelial injury in COVID-19 pediatric patients and demonstrate a potential pathway of SARS-CoV-2 induced thrombosis. Decreased surface-bound TM results in lower amount of thrombin-TM complex, hence lesser activation of PC, likely leading to a pro-thrombotic state. These findings in GMVECs could explain the vulnerability of kidneys to COVID-19-induced TMA.

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children:A 10-Year Single-Centre Experience from North India.

ObjectiveTo describe the clinical and laboratory profile, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India.MethodsThis retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011–December 2020) including children < 12 y with TSS (n = 63).ResultsThe median (interquartile range, IQR) age was 5 (2–9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12–17). The primary focus of infection was identified in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n = 11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fluid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n = 17). The duration of PICU and hopsital stay was 5 (4–10) and 7 (4–11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive–inotropic score.ConclusionTSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

Role of Serum Ferritin and PRISM-III in Predicting Mortality in Children with Acute Encephalitis Syndrome in Northern India

AbstractThe aim of this study was to evaluate the role of serum ferritin (SF) and PRISM-III (Pediatric Risk of Mortality) score in predicting mortality in critically ill children aged 6 months to 15 years diagnosed with acute encephalitis syndrome (AES) admitted to the pediatric intensive care unit (PICU). This prospective observational study was conducted in the PICU of a tertiary teaching hospital in Northern India between July 2018 and June 2019. The primary outcome was to determine the association of admission SF levels with mortality. Secondary outcomes included estimating the prevalence of hyperferritinemia and comparing SF with PRISM-III scores in predicting mortality. Etiology could be established in 85.5% (n = 219) of the 256 children enrolled. Scrub typhus accounted for nearly two-thirds of the cases (60.5%), while dengue and Japanese encephalitis were the next common diagnoses. The median [interquartile range] SF at admission was significantly higher among the nonsurvivors than survivors: 514 [260–1,857] and 318 [189–699] µg/L, respectively (p = 0.029). SF and PRISM-III independently predicted mortality in AES. However, both had poor discriminatory power with area under receiver operating curve (95% confidence interval) of 0.61 (0.51–0.72) and 0.67 (0.56–0.77), respectively. Elevated SF and higher PRISM-III scores independently predicted mortality in children admitted to PICU with AES.

Clinical Application Value of Pharmacokinetic Parameters of Vancomycin in Children Treated in the Pediatric Intensive Care Unit.

ObjectiveTo explore the efficacy and safety of vancomycin as measured by pharmacokinetic/pharmacodynamic parameters in children with severe infection in the Pediatric Intensive Care Unit (PICU) and to determine the appropriate threshold for avoiding nephrotoxicity.MethodsThe medical records of hospitalized children with severe infection treated with vancomycin in the PICU of a tertiary pediatric hospital from September 2018 to January 2021 were retrospectively collected. Univariate analysis was used to assess the correlation between vancomycin pharmacokinetic/pharmacodynamic parameters and therapeutic efficacy or vancomycin-related nephrotoxicity. Binary logistic regression was used to analyze the risk factors for vancomycin-related nephrotoxicity. The vancomycin area under the concentration-time curve over 24 h (AUC0–24) threshold was determined by receiver operating characteristic (ROC) curve analysis.ResultsOne hundred and 10 patients were included in this study. Seventy-six patients (69.1%) exhibited clinically effective response, while the rest exhibited clinically ineffective response. There were no significant differences in APACHE II score, steady-state trough concentration, peak concentration or AUC0–24 of vancomycin between the effective and ineffective groups. Among the 110 patients, vancomycin-related nephrotoxicity occurred in 15 patients (13.6%). Multivariate analysis showed that vancomycin treatment duration, trough concentration, and AUC0–24 were risk factors for vancomycin-related nephrotoxicity. The ROC curve indicated that AUC0–24 < 537.18 mg.h/L was a suitable cutoff point for predicting vancomycin-related nephrotoxicity.ConclusionNo significant correlations were found between the trough concentration or AUC0–24 of vancomycin and therapeutic efficacy when the daily dose of vancomycin was approximately 40 mg/kg d, while the trough concentration and AUC0–24 were both closely related to vancomycin-related nephrotoxicity. The combination of AUC0–24 and trough concentration for therapeutic drug monitoring may reduce the risk of nephrotoxicity.

Serum Cystatin C Level Monitoring for Intervention Opportunity of CBP in Children with Severe Sepsis.

Objective The aim of this study is to investigate the instruction value of the serum cystatin C (Cys C) level monitoring for intervention opportunity of continuous blood purification technology (CBP) in children with severe sepsis. Methods 67 children with severe sepsis in the pediatric intensive care unit (PICU) with CBP treatment were retrospectively selected from May 2016 to April 2020. According to the time intervals between the time point of serum Cys C level began to increase (>15 mg/L) and the time point of CBP began, all children were divided into group A (<24 h, 29 cases), group B (24–48 h, 22 cases), and group C (>48 h, 16 cases). The children's general characteristics, vital signs, biochemical parameters, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were evaluated. The influence factors of prognosis of children with severe sepsis were analyzed by multivariate regression analysis. Results The intervals between the time point of PICU hospitalization and the time point of CBP began and the times of CBP in group A were significantly more than those in group B and C (P < 0.05). There was no statistically significant duration of CBP among three groups (P > 0.05). After follow-up of 28 d, there was no significant difference on the occurrence of coagulation disorders and hypovolemic shock induced by CBP among three groups (P > 0.05). However, the mortality of children in group A was lower than that in group C (P < 0.05). Children in group A had lower APACHE II scores, SOFA scores, serum K+, blood urea nitrogen (BUN), serum creatine (SCr), partial pressure of carbon dioxide (PCO2), and higher partial pressure of oxygen (PO2) than those of children in group C after CBP. (P < 0.05). SOFA scores ≥5 after CBP treatment and the time intervals between the time point of serum Cys C level began to increase (>15 mg/L) and the time point of CBP began ≥24 h were the independent influence factors on the prognosis by multivariate regression analysis. Conclusion There are significant evidences that continuous blood purification technology within 24 h of serum Cys C level may better control the condition of children with severe sepsis.

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.