Hospital Pediatric Intensive Care Unit Research Articles

Prevalence and risk factors of hyponatremia in hospitalized critically ill children: an observational study.

Critically ill children frequently encounter the most common and potentially life-threatening electrolyte disturbances, i.e., hyponatremia. It is an independent risk factor for prolonged hospitalization in the intensive care unit and increased in-hospital mortality. Hyponatremia occurs in up to 20%-30% of admissions in the pediatric intensive care unit (PICU). This observational study was conducted in the PICU of a tertiary care hospital in a developing country from September 2018 to September 2019. Admission criteria in our PICU are the need for mechanical ventilation, fulminant hepatic failure, vasopressor support, respiratory failure and poorly controlled seizure. We studied 256 children, aged 1 month to 18 years, with normal serum sodium at admission. In our study, 72 (28.1%) children developed hyponatremia, and about two third (n=48, 66.7%) of them developed within 72 hours of admission in PICU. The majority of children (n = 46, 63.9%) in the hyponatremic group were below 5 years. Wasted children (n = 68, 26.6%) in the hyponatremic and isonatremic groups were 20 (27.8%) and 48 (26%), respectively. The most common etiology of hyponatremia was cerebral salt wasting syndrome (n = 20, 27.8%) followed by drug-induced cases (n = 19, 26.4%). The drugs responsible were diuretics and anti-epileptics. In our study, multiorgan failure (OR = 5.05, 95%CI = 1.90-13.43; p = 0.0001), shock (OR = 7.38, 95%CI = 3.56-12.28; p = 0.0001), vasopressor use (OR = 6.74, 95%CI = 3.45-13.17; p = 0.0001) and coagulopathy (OR = 6.74, 95%CI = 3.45-13.17; p = 0.0001) were the risk factors for the development of hyponatremia. Mortality among the hyponatremic group (44.4%) was significantly higher than in the isonatremic group (21.7%). Hyponatremia is a common electrolyte disturbance found in critically ill patients and is associated with prolonged hospitalization and increased mortality.

Challenges of the Implementation of a Delirium Rate Scale in a Pediatric Intensive Care Unit: A Qualitative Approach.

Delirium in the pediatric population admitted to intensive care is a worrying reality due to its potential complications and the increase in associated costs. This study aims to explore the experiences of nursing staff of a Pediatric Intensive Care Unit after 15 months of starting a program to fight against childhood delirium in their unit. A qualitative study was conducted through semi-structured interviews with Pediatric Intensive Care Unit (PICU) Key Informants. The Standards for Reporting Qualitative Research (SRQR) and the consolidated criteria for Reporting Qualitative Research (COREQ) were followed as quality measures for the study. Seven nurses (33% of the eligible population) from the PICU of a referral hospital were interviewed. Text transcripts were analyzed using the Interpretative Description and Qualitative Content Analysis method. The interviewees indicated not identifying delirium as an important reality; with great deficiencies observed in what is related to the identification of delirium; identifying CAPD as an unreliable tool in their unit; and not sharing therapeutic objectives in this respect with the medical staff. The nursing staff presented a series of negative attitudes towards the phenomena of delirium in their unit, with gaps in training and in clinical management, and the diagnostic tool used, and did not see it as a priority objective of the unit, partly due to a resistance to change and a latent interprofessional communication conflict. A change at the formative, attitudinal, and relational levels is urgently needed for the success of the program and the well-being of the children in the unit.

PICU Admission of Children for Status Epilepticus: Is There a Different Approach Between Referral and Second-Level Hospitals in an Italian Region?

Appropriate status epilepticus (SE) management is key to minimize admission to the pediatric intensive care unit (PICU). We retrospectively describe 115 children admitted to the PICU of the tertiary-care referral hospital of Padova for seizures, SE, and SE-related complications (59% from second-level hospitals, 41% from the referral hospital) and compare SE management among hospitals. Compared with the referral center, in second-level hospitals, anesthetics were more often administered as first/second drug (P < .001), and intubation was more frequent (P < .001). Intubation was significantly associated with SE onset at home (P = .045) and benzodiazepine-associated respiratory depression (P = .044). There was no association between intubation and SE duration, etiology, PICU length of stay, and morbidity at discharge. In conclusion, adherence to treatment protocols on SE management after the first-line drug differs between referral center and second-level hospitals. Lack of association with SE characteristics and patient's outcome suggests PICU admission could be due to inappropriate invasive management.

Substandard feeding in children undergoing mechanical ventilation in pediatric intensive care unit: A retrospective cohort study in China.

Enteral nutrition is a common yet vital practice in the pediatric intensive care unit (PICU). However, the status of substandard feeding of enteral nutrition in PICU children undergoing mechanical ventilation remains unclear and can be detrimental to the children's prognosis. This study aimed to evaluate the incidence, nursing care status, and influencing factors of substandard feeding in children undergoing mechanical ventilation in the PICU. This study employed a retrospective cohort design. Children undergoing mechanical ventilation and enteral nutrition in the PICU of a public hospital in China from 1 June 2021 to 31 December 2022 were selected using convenience sampling, and their characteristics were collected and evaluated. Pearson correlation analysis and multivariate logistic regression analysis were conducted to assess the influencing factors of substandard feeding in PICU children with mechanical ventilation. A total of 156 PICU children undergoing mechanical ventilation were included for analysis in this study. The rate of substandard feeding in PICU children was 65.38%. Statistically significant differences were observed in diarrhea, vomiting, the use of sedatives, and average infusion speed between the substandard feeding group and the standard group (p <0.05). Pearson correlation results indicated that diarrhea (r = 0.595), vomiting (r = 0.602), and average infusion speed (r = 0.562) were correlated with substandard feeding and characteristics of included ICU children undergoing mechanical ventilation (p <0.05). Logistic regression results found that diarrhea (OR = 2.183, 95%CI: 1.855~2.742), vomiting (OR = 3.021, 95%CI: 2.256~4.294), and average infusion speed ≤40 mL/h (OR = 2.605, 95%CI: 1.921~3.357) were independent risk factors for substandard feeding in mechanically ventilated children in the ICU (p <0.05). The rate of substandard feeding in children with mechanical ventilation in the PICU was high. Diarrhea, vomiting, and slow infusion speed are important influencing factors for substandard feeding. It is suggested that nurses and other healthcare professionals take targeted measures, including the prevention and care of diarrhea and vomiting, as well as monitoring and adjusting the infusion speed of enteral nutrition, to reduce the occurrence of substandard feeding.

Description and outcomes of Afro-Caribbean children treated for multisystem inflammatory syndrome in the French West Indies

IntroductionSeveral studies have reported a higher frequency and greater morbidity and mortality of multisystem inflammatory syndrome in children (MIS-C) of black African descent. ObjectivesWe aimed to describe the clinical, laboratory and echocardiographic characteristics as well as outcomes of children with MIS-C requiring admission to a pediatric intensive care unit (PICU) in the French West Indies (FWI), where the majority of the population is Afro-Caribbean. MethodsAmbidirectional observational cohort study between April 1, 2020 and August 31, 2022. Children (age ≤18 years) with MIS-C and organ failure were included. Every patient was monitored and treated following the same protocol, with repeated biological tests, echocardiography, intravenous steroids and polyvalent immunoglobulins. The primary outcomes were clinical, laboratory and echocardiography characteristics. ResultsForty children (median age 7 years, range: 5–11) were included. The majority (77 %) were included prospectively. Thirty-five (87 %) had gastrointestinal symptoms, 30 (75 %) presented initial heart failure (with persisting diastolic dysfunction at day 7) and 18 (45 %) had pericarditis. Sixteen (40 %) were in cardiogenic shock and required inotropic support. Median duration of inotropic support and hospitalization in PICU were respectively 4 and 5 days. The evolution curves of the inflammatory variables matched after treatment. The clinical outcomes were favorable. The Delta variant was associated with the highest incidence of MIS-C. ConclusionThis is the first description of MIS-C course among children of Afro-Caribbean descent. The outcomes were good, without any death or cardiac sequelae. Our work does not support an ethnic susceptibility for severity of MIS-C in Afro-Caribbean population.

Etiology composition and prognosis of pediatric chronic critical illness in a pediatric intensive care unit

To explore the etiology composition and outcomes of pediatric chronic critical illness (PCCI) in the pediatric intensive care unit (PICU). The children who were hospitalized in the PICU of Dongguan Children's Hospital Affiliated to Guangdong Medical University and met the diagnostic criteria for PCCI from January 2017 to December 2022 were included in the study. The etiology of the children was classified based on their medical records and discharge diagnoses. Relevant clinical data during hospitalization were collected and analyzed. Among the 3 955 hospitalized children in the PICU from January 2017 to December 2022, 321 cases (8.12%) met the diagnostic criteria for PCCI. Among the 321 cases, the most common etiology was infection (71.3%, 229 cases), followed by unintentional injury (12.8%, 41 cases), postoperation (5.9%, 19 cases), tumors/immune system diseases (5.0%, 16 cases), and genetic and chromosomal diseases (5.0%, 16 cases). Among the 321 cases, 249 cases (77.6%) were discharged after improvement, 37 cases (11.5%) were discharged at the request of the family, and 35 cases (10.9%) died in the hospital. Among the deaths, infection accounted for 74% (26/35), unintentional injury accounted for 17% (6/35), tumors/immune system diseases accounted for 6% (2/35), and genetic and chromosomal diseases accounted for 3% (1/35). From 2017 to 2022, the proportion of PCCI in PICU diseases showed an increasing trend year by year (P<0.05). Among the 321 children with PCCI, there were 148 infants and young children (46.1%), 57 preschool children (17.8%), 54 school-aged children (16.8%), and 62 adolescents (19.3%), with the highest proportion in the infant and young children group (P<0.05). The in-hospital mortality rates of the four age groups were 14.9% (22/148), 8.8% (5/57), 5.6% (3/54), and 8.1% (5/62), respectively. The infant and young children group had the highest mortality rate, but there was no statistically significant difference among the four groups (P>0.05). The proportion of PCCI in PICU diseases is increasing, and the main causes are infection and unintentional injury. The most common cause of death in children with PCCI is infection. The PCCI patient population is mainly infants and young children, and the in-hospital mortality rate of infant and young children with PCCI is relatively high.

Study of incidence, microbiological profile of nosocomial infections in pediatric intensive care unit of tertiary care center

Background: Prevalence of nosocomial infections in pediatric intensive care unit (PICU) ranges between from 6-26%. Increased use of broad-spectrum antibiotics, urinary and central venous catheterization and endotracheal intubation put patients at an increased risk of affecting with nosocomial infections in pediatric patients. Methods: A hospital based prospective study was carried out on 725 patients aged between 1 month and 12 years admitted in PICU of Al-Ameen medical college hospital, Bijapur, Karnataka, India and institute of child health and hospital for children, Madras medical college, Chennai, Tamil Nadu, India from 15-09-2020 to 15-08-2022. All patients who were admitted with fever or developed fever in first 48 hours of life were excluded from the study. The data obtained in the course of study was analyzed by appropriate statistical methods. Results: Out of 725 pediatric admissions, the incidence of nosocomial infection in the present was found to be 108 (14.8%). Concerning the type of infection, the commonest reported types were central-line associated bloodstream infection (CABI) 59 (54.6%) and ventilator-associated infection (VAI) 52 (48.1%), followed by bloodstream infection 45 (41.6%), catheter associated urinary tract infection (CA-UTI) 38 (35.1%) and urinary tract infection (UTI) 30 (27.7%) respectively. Conclusions: The incidence of nosocomial infection was 14.8%. The central line associated blood stream infection was the predominant cause of nosocomial infection. This information can help decision makers establish preventive strategies and implement effective and reliable plans.

The effect of Telehealth Antimicrobial Stewardship Program (Tele-ASP) on antimicrobial use in a pediatric intensive care unit: Pre- and post-implementation single center study

BackgroundOveruse or misuse of antimicrobials is common in pediatric intensive care units (PICU) and may be associated with poor clinical outcomes. Although an antimicrobial stewardship program (ASP) has been found to improve this practice, the required expertise in infectious diseases may be limited in some centers. We aimed to evaluate the effect of telehealth ASP on the rate of PICU antimicrobial use in a center without a local Infectious Diseases consultation service. MethodsA retrospective cohort study was performed between October 1st, 2018, and October 31st, 2020, in Farwaniya Hospital PICU, a 20-bed unit. All pediatric patients who were admitted to PICU and received systemic antimicrobials during the study period were included and followed until hospital discharge. The ASP team provided weekly prospective audit and feedback on antimicrobial use starting October 8th, 2019. A pediatric infectious diseases specialist joined the ASP rounds remotely. Descriptive analyses and a pre-post intervention comparison of days of therapy (DOT) were used to assess the effectiveness of the ASP intervention. ResultsThere were 272 and 156 PICU admissions received systemic antimicrobial before and after the initiation of ASP, respectively. Bronchiolitis and pneumonia were the most common admission diagnoses, together compromising 60.7% and 61.2% of cases pre- and post-ASP. The requirement for respiratory support was higher post-ASP (76.5% vs. 91.5%, p < 0.001). Average monthly antimicrobial use decreased from 922 (95%CI 745–1000) to 485 DOT/1000 patient-days (95%CI 246–722, P < 0.05). A decline in DOT was observed across most antibiotic classes, except for ceftriaxone. No effect on the length of PICU stay, length of hospitalization, or mortality was observed. Most (89.7%) ASP recommendations were followed either fully or partially. ConclusionIn settings where Infectious Diseases consultation services are unavailable, PICU telehealth ASP can be effectively implemented and associated with significantly reducing antimicrobial use.

Financial outcomes after pediatric critical illness among commercially insured families

Critical illness results in subjective financial distress for families, but little is known about objective caregiver finances after a child’s pediatric intensive care unit (PICU) hospitalization. Using statewide commercial insurance claims linked to cross-sectional commercial credit data, we identified caregivers of children with PICU hospitalizations in January–June 2020 and January–June 2021. Credit data included delinquent debt, debt in collections (medical and non-medical), low credit score (< 660), and a composite of any debt or poor credit and were measured in January 2021 for all caregivers. For the 2020 cohort (“post-PICU”), credit outcomes in January 2021 were measured at least 6 months following PICU hospitalization and reflect financial status after the hospitalization. For the 2021 cohort (comparison), financial outcomes were measured prior to their child’s PICU hospitalization and therefore reflect pre-hospitalization financial status. We identified 2032 caregivers, 1017 post-PICU caregivers and 1015 comparison cohort caregivers, of which 1016 and 1014 were matched to credit data, respectively. Post-PICU caregivers had higher adjusted odds of having any delinquent debt [aOR 1.25; 95%CI 1.02–1.53; p = 0.03] and having a low credit score [aOR 1.29; 95%CI 1.06–1.58; p = 0.01]. However, there was no difference in the amount of delinquent debt or debt in collections among those with nonzero debt. Overall, 39.5% and 36.5% of post-PICU and comparator caregivers, respectively, had delinquent debt, debt in collections or poor credit. Many caregivers of critically ill children have financial debt or poor credit during hospitalization and post-discharge. However, caregivers may be at higher risk for poor financial status following their child’s critical illness.

Prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit.

To analyze the prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit (PICU) and to compare the efficacy of different scoring systems for predicting the outcome of children. Patients with an acute leukemia diagnosis admitted to a tertiary care university hospital PICU due to sepsis during chemotherapy between May 2015 and August 2022 were retrospectively analyzed through an electronic medical record system. During this period, 693 children with acute leukemia initially diagnosed were admitted to the center, and 155 (22.3%) of them were transferred to PICU due to deterioration of the disease during treatment. Total 109 (70.3%) patients were transferred to PICU due to sepsis. Here, 17 patients was excluded (prior treatment from another hospital; referring from other hospitals; discontinued treatment; incomplete medical record). Of the 92 patients studied, the mortality rate was 35.9%. Multivariate analysis revealed that remission status, lactate level, invasive mechanical ventilation (IMV), and inotropic support within 48hours after PICU transfer were independent risk factors for PICU mortality. The pediatric sequential organ failure assessment (PSOFA) score had the greatest predictive validity for hospital mortality (area under the receiver operating characteristic curve [AUROC]: 0.83, 95% confidence intervals [CI]: 0.74-0.92), followed by the pediatric early warning score (PEWS) (0.82, 0.73-0.91) and pediatric critical illness score (PCIS) (0.79, 0.69-0.88). The mortality rate among children with acute leukemia complicated with sepsis is high after being transferred to the PICU. Various scoring systems can be used to monitor the clinical status of patients, identify sepsis early, detect critical illness, and determine the optimal time for transfer to the PICU for supportive treatment, thereby improving the prognosis of these patients.

Hematological Alterations and their Prognostic Significance in Critically ill Children Admitted to the PICU

ABSTRACT Objective: Hematological parameters such as complete blood count, including red cell distribution width and prothrombin time, activated partial thromboplastin time, and international normalized ratio (INR) are the earliest markers of critical illness. This study was undertaken to evaluate their significance in prognosticating critically ill children admitted to the pediatric intensive care unit (PICU). Methodology: This was a cross-sectional and observational study on 125 critically ill children aged 1 month to 12 years and admitted to the PICU of a tertiary care hospital, conducted from February 2019 to July 2020. Hematological alterations along with clinical profile, Pediatric Risk of Mortality III (PRISM III), and Pediatric Sequential Organ Failure Assessment (pSOFA) scores were analyzed, and prognosis was defined by invasive ventilation requirement, duration of PICU stay, and death. Result: Among the 125 critically ill children, 35.2% were infants. The most common cause of PICU admission was infections (29.6%) followed by the central nervous system (20.8%) and respiratory system (20.8%). Around one-third of the patients required invasive ventilation and about half of the patients required inotropic support in our cohort. Sixty-four percent of critically ill children were found to be anemic at the time of PICU admission. Approximately 50% had leukocytosis and only 6% presented with leukopenia. Thrombocytopenia was present in 24.8%, and 20.8% had thrombocytosis on admission. Fourteen point four percent had deranged INR values. Conclusion: Critically ill children with low hemoglobin (Hb) levels, low white blood cell (WBC) count, high red cell distribution width (RDW) values, and deranged INR required invasive ventilation during PICU stay. Both leukocytosis and leukopenia along with low Hb were associated with prolonged PICU stay and death. No such association was found with either thrombocytopenia or thrombocytosis.

BNT162b2 immunization-related myocarditis in adolescents and consequent hospitalization: Report from a medical center

To investigate Pfizer-BioNTech 162b2 mRNA COVID-19 vaccine (BNT162b2) immunization-related myocarditis and describe the risk factors for consequent hospitalization in the pediatric intensive care unit (PICU) in children between 12 and 18 years. Children and adolescents 12 years of age and older who presented with discomfort after BNT162b2 immunization (BNTI) and visited pediatric emergency room (PER) at Chang Gung Memorial Hospital from September 22, 2021 to March 21, 2022, were included for analysis. 681 children presented with discomfort after BNTI and visited our PER. The mean age was 15.1±1.7 years. Three hundred and ninety-four (57.9%) and 287 (42.1%) events were after 1st and 2nd dose, respectively. 58.4% (n=398) were male. The most common complaints were chest pain (46.7%) and chest tightness (27.0%). The median (interquartile range [IQR]) interval of discomfort after BNTI was 3.0 (1.0-12.0) days. BNTI-related pericarditis, myocarditis and myopericarditis were diagnosed in 15 (2.2%), 12 (1.8%) and 2 (0.3%) patients, respectively. Eleven (1.6%) needed hospitalization in PICU. The median (IQR) hospital stay was 4.0 (3.0-6.0) days. There was no mortality. More patients were diagnosed myocarditis (p=0.004) after 2nd dose BNTI. PICU admission occurred more commonly after 2nd dose BNTI (p=0.007). Risk factors associated with hospitalization in PICU were abnormal EKG findings (p=0.047) and abnormal serum troponin levels (p=0.003) at PER. Myocarditis in children aged 12-18 years occurred more commonly following 2nd dose BNTI. Most cases were of mild or intermediate severity without death. Factors predicting BNTI-related myocarditis and consequent hospitalization in PICU were abnormal EKG findings and abnormal serum troponin levels at PER in this study.

Active surveillance for carbapenem resistant enterobacteriaceae (CRE) using stool cultures as a method to decrease CRE infections in the pediatric intensive care unit (PICU)

BackgroundThe incidence of Carbapenem Resistant Enterobacteriaceae (CRE) infections is increasing worldwide. Due to dearth of alternative antibiotics, prevention of infection transmission is a part of CRE infection management strategy. Early detection of CRE by active surveillance coupled with contact isolation is much more appropriate compared to contact isolation upon receipt of routine cultures dictated by the patient's clinical condition. ObjectivesTo determine whether active CRE surveillance will decrease CRE infection rates in the Pediatric Intensive Care Unit (PICU). MethodsRetrospective observational study done in the 10-bed PICU of a tertiary care teaching children's hospital from July 2013 to June 2015. Rectal swabs for CRE were sent from all PICU patients except stable post-operative patients. Contact isolation precautions were followed for rectal swab positive patients. CRE colonization and infection rates were calculated and compared. ResultsTotal of 1262 rectal swabs were sent from 1022 patients. CRE colonization rate was 19.5%. Post intervention, ICU acquired CRE colonization decreased by 36% and ICU acquired CRE infection rates decreased by 100%, both showed significant decrease (p ​< ​0.0001). ConclusionActive CRE surveillance and institution of contact isolation in appropriate situations is helpful in decreasing CRE colonization and infection rates in the PICU.

Pediatric Outpatient, Urgent-care Emergency and Disaster Planning

Introduction:Children are frequently victims of disasters; however important gaps remain in pediatric disaster planning. This includes a lack of resources for pediatric preparedness planning for patients in outpatient/urgent-care facilities. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response.After creating planning resources in Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Neonatal Intensive Care Units, and Obstetric/Newborn Services within NYC hospitals, the NYCPDC partnered with leaders and experts from outpatient/urgent-care facilities caring for pediatric patients and created the Pediatric Outpatient Disaster Planning Committee (PODPC). PODPC’s goal was to create guidelines and templates for use in disaster planning for pediatric patients at outpatient/urgent-care facilities.Method:The PODPC includes physicians, nurses, administrators and emergency planning experts who have experience working with outpatient facilities. There were 21 committee members from eight organizations (the NYCPDC, DOHMH, Community Healthcare Association of NY State, NY State DOH, NYC Health and Hospitals, Maimonides Medical Center and Presbyterian/Columbia University Medical Center). The committee met six times over a four-month period and shared information to create disaster planning tools that meet the specific pediatric challenges in the outpatient setting.Results:Utilizing an iterative process including literature review, participant presentations, discussions review and improvement of working documents, the final guidelines and templates for surge and evacuation of pediatric patients in outpatient/urgent care facilities were created in 2018. Subsequently model plans were completed and implemented at five NYC Outpatient/Urgent-care facilities.Conclusion:An expert committee utilizing an iterative process successfully created disaster guidelines and templates for pediatric outpatient/urgent care facilities. They addressed the importance of matching the special needs of children to available space, staff and equipment needs and created model plans for site-specific use.

Cluster analysis of plasma cytokines identifies two unique endotypes of children with asthma in the pediatric intensive care unit

Children with life-threatening asthma exacerbations who are admitted to a pediatric intensive care unit (PICU) are a heterogeneous group with poorly studied inflammatory features. We hypothesized that distinct clusters of children with asthma in a PICU would be identified based on differences in plasma cytokine levels and that these clusters would have differing underlying inflammation and asthma outcomes within 1 year. Plasma cytokines and differential gene expression were measured in neutrophils isolated from children admitted to a PICU for asthma. Participants were clustered by differential plasma cytokine abundance. Gene expression differences were compared by cluster and pathway over-representation analysis was performed. We identified two clusters in 69 children with no clinical differences. Cluster 1 (n = 41) had higher cytokines compared to Cluster 2 (n = 28). Cluster 2 had a hazard ratio of 2.71 (95% CI 1.11–6.64) compared to Cluster 1 for time to subsequent exacerbation. Gene expression pathways that differed by cluster included interleukin-10 signaling; nucleotide-binding domain, leucine rich repeat containing receptor (NLR signaling); and toll-like receptor (TLR) signaling. These observations suggest that a subset of children may have a unique pattern of inflammation during PICU hospitalization that might require alternative treatment approaches.

Flexible bronchoscopy in pediatric patients with Down syndrome: A case-control study of the indications, findings, and complications.

Children with Down syndrome (DS) often undergo flexible bronchoscopies (FB) due to common respiratory symptoms. To examine the indications, findings, and complications of FB in pediatric DS patients. A retrospective case-control study on FB performed in DS pediatric patients between 2004 and 2021 in a tertiary center. DS patients were matched to controls (1:3) based on age, gender, and ethnicity. Data collected included demographics, comorbidities, indications, findings, and complications. Fifty DS patients (median age 1.36 years, 56% males) and 150 controls (median age 1.27 years, 56% males), were included. Evaluation for obstructive sleep apnea and oxygen dependence were more common indications among DS (38% vs. 8%, 22% vs. 4%, p < 0.01, respectively). Normal bronchoscopy was less frequent in DS compared with controls (8% vs. 28%, p = 0.01). Soft palate incompetence and tracheal bronchus were more frequent in DS (12% vs. 3.3%, p = 0.024, 8% vs. 0.7%, p = 0.02, respectively). Complications were more frequent in DS (22% vs. 9.3%, incidence rate ratio [IRR] 2.36, p = 0.028). In DS, cardiac anomalies (IRR 3.96, p < 0.01), pulmonary hypertension (IRR 3.76, p = 0.006), and pediatric intensive care unit (PICU) hospitalization before the procedure (IRR 4.2, p < 0.001) were associated with higher complication rates. In a multivariate regression model, history of cardiac disease and PICU hospitalization before the procedure, but not DS, were independent risk factors for complications with an IRR of 4 and 3.1, respectively (p = 0.006, p = 0.05). DS pediatric patients undergoing FB are a unique population with specific indications and findings. DS pediatric patients with cardiac anomalies and pulmonary hypertension are at the highest risk for complications.

Risk factors for hospitalization at the pediatric intensive care unit among infants and children younger than 5 years of age diagnosed with infectious diseases.

Children hospitalized with infectious diseases may develop severe, life-threatening conditions, often requiring admission to pediatric intensive care unit (PICU). The objectives of this study were to identify independent risk factors for PICU hospitalization with an infectious disease in children <5 years of age. In southern Israel, two populations live side by side: the middle-high income Jewish population and the low-income Bedouin population, both receiving equal and free medical care at the only tertiary medical center in the area. The study population included all children born in southern Israel and hospitalized at PICU with an infectious disease during 1991-2012. Risk factors for PICU hospitalizations were retrospectively studied by Kaplan-Meier and Cox proportional hazard survival analyses. 9951 Jewish children and 18,002 Bedouin children were enrolled; overall, 1135 episodes of PICU hospitalizations with an infectious disease were recorded (879, 77.4% Bedouin and 256, 22.6% Jewish patients). Bedouin children had a higher risk for PICU hospitalization with an infectious disease compared with Jewish children (adjusted Hazard Ratio [adj. HR] 1.7, 95% CI 1.5-2.0); maternal multiparity and low-birth weight (<2500g) were additional risk factors for PICU hospitalization with an infectious disease compared to firstborns (adj. HR=1.2, 95% CI 1.0-1.5) or to children with a birth weight ≥2500g (adj. HR=1.5, 95% 1.2-1.9). Older age was a protective factor for PICU hospitalization (adj. HR=0.98, 95% CI 0.97-0.99). Children hospitalized with a central nervous system infection had the highest risk of PICU hospitalization (adj. HR 6.8, 95% CI 5.5-8.4), followed by those with urinary tract infections (UTI, adj. HR 3.1, 95% CI 2.5-3.8) and those with lower respiratory tract infections (LRTI, adj. HR 2.9, 95% CI 2.4-3.4). Bedouin ethnicity, low birth weight, maternal multiparity and younger age were significant risk factors for PICU hospitalizations with an infectious disease. Among the infectious diseases analyzed, CNS infection had the highest risk for PICU hospitalization, followed by UTI and LRTI.

Clinical Pearls

Extubating patients as soon as possible is recommended to prevent adverse physical and cognitive outcomes. Hemodynamic stability is often listed as a criterion for extubation; however, the evidence is conflicting regarding the safety of extubation while the patient is receiving vasopressor medications. In addition, little is known about actual bedside practice in such situations.Costa and colleagues surveyed clinicians to examine their reported practice of extubation with patients receiving vasopressor therapy. They found One-third of respondents stated that they would extubate a patient receiving a continuous infusion of vasopressors.About one-quarter reported that it would depend on the type of medication being used.Almost 58% stated that their unit did not have a protocol or that they did not know if there was a protocol for this practice.Clinicians working in a surgical intensive care unit (ICU) and those who provide direct patient care at least 50% of the time more often said they would extubate patients receiving vasopressors.Extubation of patients receiving a vasopressor varied significantly by unit type and provider role. The authors recommend further research to explore the safety of this practice and examine existing protocols in ICUs.See Article, pp 127-130Parents with children in the pediatric intensive care unit (PICU) rely on the health care team to discuss their child’s possible morbidities and risk of mortality. These are called prognostic conversations. However, very little research has addressed the impact of prognostic conversations on post–intensive care syndrome in families in the PICU.Rissman and colleagues surveyed parents and health care providers at discharge from the PICU. They found Findings support the need for prognostic conversations to occur multiple times and using multiple formats throughout the PICU hospitalization, in order to appropriately prepare families for possible post-PICU morbidities.See Article, pp 118-126Although a necessary therapy, mechanical ventilation can cause significant stress and anxiety in patients. Management of these responses continues to be via medications such as antipsychotics, analgesics, and sedatives. However, these may produce adverse effects that could increase length of stay and cost of care and could contribute to long-term adverse outcomes.Golino and colleagues evaluated the impact of live music therapy as a nonpharmacologic intervention to reduce anxiety, pain, and agitation in adult patients receiving mechanical ventilation. They found Findings show music therapy reduces pain and agitation in adults receiving mechanical ventilation. Further research is needed, but nonpharmacologic interventions such as music therapy may reduce the need for pain and anxiety medications.See Article, pp 109-115The implementation of checklists during intensive care unit (ICU) rounds helps facilitate evidence-based practice and improve patient outcomes. However, checklists are sometimes not used as intended, and customization of the checklist may affect reliability and quality of care.King and colleagues created a paper-based assessment tool that one critical care nurse could use to reliably assess ABCDEF bundle care checklist items during rounds. They evaluated the tool with 2 independent nurses during rounds on 53 patients and found that Although tool item improvements are needed, findings support having one critical care nurse serve as checklist prompter to reliably assess ABCDEF bundle care during ICU rounds.See Article, pp 92-99

The Effect of Serum Electrolyte Levels and Infusion Treatments on the Development of Femoral Central Venous Catheter-Associated Deep Vein Thrombosis in Pediatric Intensive Care Unit.

In this study, we aimed to determine the frequency of symptomatic central venous catheters-associated deep vein thrombosis (CVC-a DVT) among critically ill children with femoral vein implantation in our pediatric intensive care unit (PICU), and to compare the demographic factors, serum electrolyte levels, and types of the infusion treatments performed. A total of 215 patients aged 1 month to 18 years who had femoral CVC implanted between 2019 and 2021 were included in this study. The cases that were clinically symptomatic and had thrombosis diagnosed ultrasonography were accepted as CVC-a DVT (+), and the other cases were considered as CVC-a DVT (-). Of the total 215 cases, 57.2% (n = 123) were female and 42.8% (n = 92) were male. Catheters-associated deep vein thrombosis diagnosis were made in 9.8% of the cases (n = 21). The mean time to diagnose thrombosis in CVC-a DVT (+) cases was 8.33 ± 5.65 days. With regard to gender, age, blood type, intubation status, length of stay on mechanical ventilator, presence of extra hemodialysis catheter, acute and chronic disease status, number of days of PICU hospitalization, and Pediatric Risk of Mortality-3 scoring, no significant differences between CVC-a DVT (-) and CVC-a DVT (+) cases were observed (P > .05). The incidence of thrombosis in refugee cases was found to be significantly higher than in Turkish cases (P = .047; P < .05). There was no statistically significant difference between the groups in baseline, mean, and peak glucose, sodium, and magnesium values and who received magnesium, blood product, inotrope, and 3% hypertonic saline (HTS) infusion (P > .05). No effect of serum glucose, sodium, and magnesium levels on the development of CVC-a DVT was found. Magnesium, blood product, inotrope, and 3% HTS infusion treatments have not been shown to have an effect on the development of CVC-a DVT.

Performance of the Mean, Highest, and Admission Day Pediatric Sequential Organ Failure Assessment Scores As Outcome Predictors in a Pediatric Intensive Care Unit: A Prospective Observational Study

AbstractThe pediatric sequential organ failure assessment (pSOFA) score has been recently validated from its adult version having included the six clinical and biochemical parameters of organ dysfunction (respiratory, coagulation, cardiovascular, neurological, hepatic, and renal) and adapting age-adjusted cutoffs. Our goal was to find out which among the pSOFA scores (recorded on admission, highest score, and the mean score i.e., pSOFA1, pSOFAh, and pSOFAm respectively) performed better to predict mortality among the patients admitted in our pediatric intensive care unit (PICU). This prospective observational study was conducted on 104 patients (1 month to 12 years of age) admitted in the eight bedded PICU of a tertiary care hospital in India who met the inclusion criteria. The highest values of serial pSOFA scores were recorded on every alternate day starting from the day of admission up to day 9. The mean and median values of the pSOFA1, pSOFAm, and pSOFAh were higher in the nonsurvivor group than in the survivors. The mean pSOFA (with a diagnostic accuracy of 92.3% at a mean cut-off value of 12.8) has outperformed the other two pSOFA scores. In this exploratory analysis, the pSOFAm is the best tool in predicting the mortality outcome of any critically ill child. The use of the pSOFA score at admission and the mean values helps the clinician to quantify the organ dysfunction, and it may be helpful for the clinicians to take steps for further management. It may be useful to communicate to the parents of the sick child for prognostication too. The pSOFA1 also reflects well on the early prognostication when multiple pSOFA scores are unavailable. In the resource constraint settings, one may rely on the pSOFA1 and the approximate pSOFAm value may be predicted from the pSOFA1 as pSOFAm=[(1.03 XpSOFA1) – 0.9] within limitations.