Pediatric Cerebral Performance Category Research Articles

Outcomes in Children Treated with Pentobarbital Infusion for Refractory and Super-Refractory Status Epilepticus.

Functional neurologic outcome for children with refractory and super-refractory status epilepticus has not been well defined. Retrospective chart review including children age 0-17years who received pentobarbital infusion from 2003 to 2016 for status epilepticus. Outcomes were defined in terms of mortality, need for new medical technology assistance at hospital discharge and functional neurologic outcome determined by pediatric cerebral performance category score (PCPC). Potential patient characteristics associated with functional neurologic outcome including age, sex, ethnicity, etiology of the status epilepticus, and duration of pentobarbital infusion were evaluated. Forty children met inclusion criteria. In-hospital mortality was 30% (12/40). Of survivors, 21% (6/28) returned to baseline PCPC while half (14/28) declined in function≥2 PCPC categories at hospital discharge. 25% (7/28) of survivors required tracheostomy and 27% (7/26) required new gastrostomy. Seizures persisted at discharge for most patients with new onset status epilepticus while the majority of patients with known epilepsy returned to baseline seizure frequency. Etiology (p=0.015), PCPC at admission (p=0.0006), new tracheostomy (p=0.012), and new gastrostomy tube (p=0.012) were associated with increase in PCPC score≥2 categories in univariable analysis. Duration of pentobarbital infusion (p=0.005) and length of hospital stay (p=0.056) were longer in patients who demonstrated significant decline in neurologic function. None of these variables maintained statistical significance when multiple logistic regression model adjusting for PCPC score at admission was applied. At long-term follow-up, 36% (8/22) of children demonstrated improvement in PCPC compared to discharge and 23% (5/22) showed deterioration including three additional deaths. Mortality in this population was high. The majority of children experienced some degree of disability at discharge. Despite prolonged pentobarbital infusion, there were cases of survival with good neurologic outcome.

Functional outcomes in children with severe sepsis – A prospective observational study

Objective: To evaluate functional outcomes in children with severe sepsis and septic shock admitted to the PICU using Pediatric Overall Performance Category Scale (POPC) and Pediatric Cerebral Performance Category (PCPC) scales at discharge/death as compared to baseline scores. Methods: We conducted this prospective observational study from October 2017 to June 2018. Children aged 2 months to 17 years admitted to PICU with severe sepsis and septic shock were enrolled. Data collection included demographic and clinical details and POPC and PCPC scores. Data was analyzed using stata 11. Results: A total of 96 children were enrolled. Sixty nine % had septic shock and 31% had severe sepsis. Twenty four (25%) died. The Median (IQR) POPC and PCPC scores at admission were – 3 (1 to 4). The POPC and PCPC scores at discharge/death were 2 (1 to 5) and 2 ( 1 to 6) respectively. At admission 49% had a baseline POPC and PCPC score of ≥ ≥ 2 and at discharge/death 59 (61%) had a POPC and PCPC score of ≥ ≥2. Conclusion: The functional outcomes of children admitted to the PICU with severe sepsis and septic shock were poor with more than half having mild to severe disability or death.

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients.

To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness. Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach. Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database. Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015). None. A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90. This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival.

On the basis of laboratory cardiopulmonary resuscitation (CPR) investigations and limited adult data demonstrating that survival depends on attaining adequate arterial diastolic blood pressure (DBP) during CPR, the American Heart Association recommends using blood pressure to guide pediatric CPR. However, evidence-based blood pressure targets during pediatric CPR remain an important knowledge gap for CPR guidelines. All children ≥37 weeks' gestation and <19 years old in Collaborative Pediatric Critical Care Research Network intensive care units with chest compressions for ≥1 minute and invasive arterial blood pressure monitoring before and during CPR between July 1, 2013, and June 31, 2016, were included. Mean DBP during CPR and Utstein-style standardized cardiac arrest data were collected. The hypothesis was that DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old would be associated with survival. Primary outcome was survival to hospital discharge. Secondary outcome was survival to hospital discharge with favorable neurological outcome, defined as Pediatric Cerebral Performance Categories 1 to 3 or no worse than prearrest baseline. Multivariable Poisson regression models with robust error estimates were used to estimate the relative risk of outcomes. Blinded investigators analyzed blood pressure waveforms during CPR from 164 children, including 60% <1 year old, 60% with congenital heart disease, and 54% after cardiac surgery. The immediate cause of arrest was hypotension in 67%, respiratory decompensation in 44%, and arrhythmia in 19%. Median duration of CPR was 8 minutes (quartiles, 3 and 27 minutes). Ninety percent survived the event, 68% with return of spontaneous circulation and 22% by extracorporeal life support. Forty-seven percent survived to hospital discharge, and 43% survived to discharge with favorable neurological outcome. Maintaining mean DBP ≥25 mm Hg in infants and ≥30 mm Hg in children ≥1 year old occurred in 101 of 164 children (62%) and was associated with survival (adjusted relative risk, 1.7; 95% confidence interval, 1.2-2.6; P=0.007) and survival with favorable neurological outcome (adjusted relative risk, 1.6; 95% confidence interval, 1.1-2.5; P=0.02). These data demonstrate that mean DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old was associated with greater likelihood of survival to hospital discharge and survival with favorable neurological outcome.

Intensive care treatments associated with favorable discharge outcomes in Argentine children with severe traumatic brain injury: For the South American Guideline Adherence Group.

ObjectiveLittle is known about the critical care management of children with traumatic brain injury (TBI) in low middle income countries. We aimed to identify indicators of intensive care unit (ICU) treatments associated with favorable outcomes in Argentine children with severe TBI.MethodsWe conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with severe TBI who were admitted to an ICU in one of the seven study centers. Severe TBI was defined by head AIS ≥ 3, head CT with traumatic lesion, and admission GCS < 9. Seven indicators of best practice TBI care were examined. The primary outcome was discharge Pediatric Cerebral Performance Category Scale [PCPC] and Pediatric Overall Performance category Scale [POPC]. We also examined variation in ICU care and in-patient mortality.ResultsOf the 117 children, 67% were male and 7.5 (4.3) years on average, 92% had isolated TBI. Hypotension (54%) was more common than hypoxia (28%) and clinical or radiographic signs of high intracranial pressure (ICP) were observed in 92%. Yet, ICP monitoring occurred in 60% and hyperosmolar therapy was used in only 36%. Adherence to indicators of best TBI practice ranged from 55.6% to 83.7% across the seven centers and adherence was associated with favorable discharge PCPC (aRR 0.98; 95% CI [0.96, 0.99]), and POPC (aRR 0.98; 95% CI [0.96, 0.99]). Compared to patients whose adherence rates were below 65%, patients whose adherence rates were higher between 75%-100% had better discharge PCPC (aRR 0.28; 95% CI [0.10, 0.83]) and POPC (aRR 0.32; 95% CI [0.15, 0.73]. Two indicators were associated with favorable discharge PCPC: Avoidance of hypoxia (aRR 0.46; 95% CI [0.23, 0.93]), and Nutrition started in 72 hours (aRR 0.45; 95% CI [0.21, 0.99]). Avoiding hypoxia was also associated with favorable discharge POPC (aRR 0.47; 95% CI [0.22, 0.99]).ConclusionThere is variation in Argentine ICU practice in the care of children with severe TBI. Second insults are common and hyperosmolar therapy use is uncommon. Adherence to best practice TBI care by avoiding hypoxia and providing timely nutrition were associated with significantly favorable discharge outcomes. Implementing strategies that prevent hypoxia and facilitate early nutrition in the ICUs are urgently needed to improve pediatric TBI outcomes.

Patología neurológica en una unidad de cuidados intensivos pediátricos de tercer nivel. Evolución funcional. Nuestra experiencia

IntroductionNeurological diseases explain a considerable proportion of admissions to paediatric intensive care units (PICU), and are a significant cause of morbidity and mortality. This study aims to analyse the functional progression of children with critical neurological conditions. Material and methodsRetrospective descriptive study of children admitted to PICU with neurological diseases over a period of 3 years (2012-2014), assessing vital and functional prognosis at PICU discharge and at one year according to the Pediatric Cerebral and Overall Performance Category scales (PCPC-POPC) and the Functional Status Scale (FSS). The results are compared with our previous data (1990-1999), and those of the international multicentre PANGEA study. ResultsA total of 266 children were studied. The mortality rate was 3%; the PRISM-III and PIM2 models did not show predictive ability. Clinically significant worsening was observed in functional health at discharge in 30% of the sample, according to POPC, 15% according to PCPC, and 5% according to FSS. After one year, functional performance improved according to PCPC-POPC, but not according to FSS. Children with no underlying neurological disease had a higher degree of functional impairment; this was prolonged over time. We observed a decrease in overall and neurocritical mortality compared with our previous data (5.60 vs. 2.1%, P=.0003, and 8.44 vs. 2.63%, P=.0014, respectively). Compared with the PANGEA study, both mortality and cerebral functional impairment in neurocritical children were lower in our study (1.05 vs. 13.32%, P<.0001, and 10.47% vs. 23.79%, P<.0001, respectively). ConclusionsNearly one-third of critically ill children have neurological diseases. A significant percentage, mainly children without underlying neurological diseases, had a clinically significant functional impact at PICU discharge and after a year. Neuromonitoring and neuroprotection measures and the evaluation of functional progression are necessary to improve critical child care.

Valoración funcional tras tratamiento neurointensivo pediátrico. Nueva escala de estado funcional (FSS)

IntroductionFunctional health, a reliable parameter of the impact of disease, should be used systematically to assess prognosis in paediatric intensive care units (PICU). Developing scales for the assessment of functional health is therefore essential. The Paediatric Overall and Cerebral Performance Category (POPC, PCPC) scales have traditionally been used in paediatric studies. The new Functional Status Scale (FSS) was designed to provide more objective results. This study aims to confirm the validity of the FSS compared to the classic POPC and PCPC scales, and to evaluate whether it may also be superior to the latter in assessing of neurological function. Patients and methodWe conducted a retrospective descriptive study of 266 children with neurological diseases admitted to intensive care between 2012 and 2014. Functional health at discharge and at one year after discharge was evaluated using the PCPC and POPC scales and the new FSS. ResultsGlobal FSS scores were found to be well correlated with all POPC scores (P<.001), except in category 5 (coma/vegetative state). Global FSS score dispersion increases with POPC category. The neurological versions of both scales show a similar correlation. DiscussionComparison with classic POPC and PCPC categories suggests that the new FSS scale is a useful method for evaluating functional health in our setting. The dispersion of FSS values underlines the poor accuracy of POPC-PCPC compared to the new FSS scale, which is more disaggregated and objective.

Clinical prediction rule for neurological sequelae due to acute encephalopathy: a medical community-based validation study in Harima, Japan

ObjectivesThis study aimed to verify the screening performance of our clinical prediction rule for neurological sequelae due to acute encephalopathy (NSAE-CPR), which previously identified the following three variables as predictive...

Prognostic value of serum biomarkers of cerebral injury in classifying neurological outcome after paediatric resuscitation

AimTo investigate if the serum biomarkers of cerebral injury, neuron-specific enolase and S100b protein, may classify unfavourable neurological outcome after paediatric cardiac arrest. MethodsWe performed a retrospective study of neuron-specific enolase and S100b measurements from 95 children treated in our paediatric cardiac intensive care unit after cardiac arrest. Neurological outcome at discharge was evaluated using the paediatric cerebral performance category scale, with unfavourable outcome defined as a change of >1 compared to pre-arrest status or death. ResultsFifty-eight patients (61.1%) survived to discharge with 48 (50.5%) having a favourable neurological outcome. We observed significantly higher levels of both biomarkers in the unfavourable outcome group at designated time points (neuron-specific enolase at 24, 48, and 72h and S100b at 12, 24, and 48h after cardiac arrest, p<0.05). Receiver operating characteristic areas under the curve for neuron-specific enolase were 0.83, 0.80, and 0.73 at time points 24, 48, and 72h and 0.87, 0.81, and 0.82 for S100b at 12, 24, and 48h after cardiac arrest, respectively. Neuron-specific enolase measurement at 24h after cardiac arrest was an independent predictor of unfavourable outcome in a multivariable analysis. ConclusionsNeuron-specific enolase and S100b classify unfavourable neurological outcome in this large paediatric cardiac arrest cohort. Further multi-institutional prospective studies to comprehensively evaluate the diagnostic accuracy of these biomarkers under various clinical conditions and to determine reliable cut-off values in children are warranted.

Brain-Specific Serum Biomarkers Predict Neurological Morbidity in Diagnostically Diverse Pediatric Intensive Care Unit Patients.

Unexpected neurological morbidity in Pediatric Intensive Care Units (PICUs) remains high and is difficult to detect proactively. Brain-specific biomarkers represent a novel approach for early detection of neurological injury. We sought to determine whether serum concentrations of neuron-specific enolase (NSE), myelin basic protein (MBP), and S100B, specific for neurons, oligodendrocytes, and glia, respectively, were predictive of neurological morbidity in critically ill children. Serum was prospectively collected on days 1-7 from diagnostically diverse PICU patients (n=103). Unfavorable neurological outcome at hospital discharge was defined as Pediatric Cerebral Performance Category (PCPC) score of 3-6 with a deterioration from baseline. NSE, MBP, and S100B concentrations were measured by enzyme-linked immunosorbent assay. Peak biomarker levels were greater in patients with unfavorable versus favorable neurological outcome [NSE 39.4±44.1 vs. 12.2±22.9ng/ml (P=0.005), MBP 9.1±11.5 vs. 0.6±1.3ng/ml (P=0.003), S100B 130±232 vs. 34±70pg/ml (P=0.04), respectively; mean±SD]. Peak levels were each independently associated with unfavorable neurological outcome when controlling for presence of primary neurologic admission diagnosis and poor baseline PCPC using logistic regression analysis (NSE, P=0.04; MBP, P=0.004; S100B, P=0.04), and had the following receiver operating characteristics: NSE 0.75 (0.58, 0.92), MBP 0.81 (0.66, 0.94), and S100B 0.80 (0.67, 0.93) (area under the curve [95% confidence intervals]). Prospectively collected brain-specific serum biomarkers predict unfavorable neurological outcome in critically ill children. Serum biomarkers used in conjunction with clinical data could be used to generate models predicting early detection of neurological injury, allowing for more timely diagnostic and therapeutic interventions, potentially reducing neurological morbidity in the PICU.

Transcranial Doppler Identification of Neurologic Injury during Pediatric Extracorporeal Membrane Oxygenation Therapy

We used transcranial Doppler to examine changes in cerebral blood flow velocity in children treated with extracorporeal membrane oxygenation. We examined the association between those changes and radiologic, electroencephalographic, and clinical evidence of neurologic injury. This was a retrospective review and prospective observational study of patients 18 years old and younger at a single university children's hospital. Transcranial Doppler studies were obtained every other day during the first 7 days of extracorporeal membrane oxygenation, and 1 additional study following decannulation, in conjunction with serial neurologic examinations, brain imaging, and 6- to 12-month follow-up. The study included 27 patients, the majority (26) receiving veno-arterial extracorporeal membrane oxygenation. Transcranial Doppler velocities during extracorporeal membrane oxygenation were significantly lower than published values for age-matched healthy and critically ill children across different cerebral arteries. Neonates younger than 10 days had higher velocities than expected. Blood flow velocity increased after extracorporeal membrane oxygenation decannulation and was comparable with age-matched critically ill children. There was no significant association between velocity measurements of individual arteries and acute neurologic injury as defined by either abnormal neurologic examination, seizures during admission, or poor pediatric cerebral performance category. However, case analysis identified several patients with regional and global increases in velocities that corresponded to neurologic injury including stroke and seizures. Cerebral blood flow velocities during extracorporeal membrane oxygenation deviate from age-specific normal values in all major cerebral vessels and across different age groups. Global or regional elevations and asymmetries in flow velocity may suggest impending neurologic injury.

AGITATION IN THE SETTING OF PEDIATRIC TRAUMATIC BRAIN INJURY

BACKGROUND: Agitation following traumatic brain injury (TBI) commonly occurs during the acute phase of recovery and has been shown to hinder rehabilitation. OBJECTIVES: The current study investigated the relationships between acute agitation, injury severity, gender, disability, and functional outcomes in pediatric patients with TBI.This was done using the Agitation Behaviour Scale (ABS), which is being validated for use in children as part of this study. DESIGN/METHODS: 26 children (ages 5-17) with TBI participated in the study as part of the Attention and Outcome Following TBI study. The ABS was completed 3 times daily for 4 days and total mean agitation was calculated for analysis. Injury severity was measured by PRISM III, MRI score, Glasgow Coma Scale, Pediatric Trauma score, and length of intubation. Functional outcomes at baseline and 12 months post-TBI were measured by the Pediatric Injury Functional Outcome Scale. Relationships between injury severity, functional outcomes and agitation were analyzed with Spearman’s rank correlation coefficients. Intellectual and physical disability was measured at baseline and 12 months after TBI using the Pediatric Cerebral Performance Category and patients were categorized according to disability severity. Mean agitation was compared between gender and disability groups with one-way ANOVAs. RESULTS: There was a significant positive association between agitation and duration of ventilation, (= 0.752, P< 0.001). Higher levels of agitation were also displayed by children who had a higher risk of mortality due to their injury, (= 0.465, P= 0.017). There was a trend towards significance between agitation and trauma severity, where children that suffered more traumatic injury showed increased agitation (= -0.382, P= 0.054). In addition, a trend between agitation and long-term functional outcome was found, where more agitated children had increased functional deficits 12 months post-TBI (= 0.445, P=0.084). There were no significant differences in agitation between genders or disability groups at baseline and 12 months post-TBI. CONCLUSION: The ABS is a useful tool in the investigation of potential predictors and outcomes of agitation during TBI recovery in the pediatric population, which may facilitate development of improved management strategies in the future.

Serum Neuronal Biomarkers in Neonates With Congenital Heart Disease Undergoing Cardiac Surgery

BackgroundNewborns with congenital heart disease have associated brain damage that affects short-and long-term neurodevelopment. Several neuronal biomarkers exist that could predict brain damage. We investigated the pattern of neuron-specific enolase (NSE) and s100B levels after cardiopulmonary bypass surgery in neonates with congenital heart disease. MethodsWe completed a prospective observational study of neonates with congenital heart disease who were undergoing cardiopulmonary bypass surgery. NSE and s100B levels were measured from serum samples obtained preoperatively, immediately postoperatively, and once daily on postoperative days one to seven. Cranial ultrasounds were obtained preoperatively and postoperatively and findings were scored using an internally developed scoring system. ResultsEighteen neonates were included. Immediate postoperative and peak levels of both NSE (58.0 [21.6] and 68.1 [55.7] μg/L) and s100B (0.14 [0.3] and 0.14 [0.3] μg/L) were significantly increased when compared with preoperative levels (34.0 [21.6] μg/L; P < 0.01 and 0.08 [0.1] μg/L; P < 0.02). By postoperative day seven, NSE and s100B levels were lower than preoperative levels: NSE (18 [5.7]; P = 0.09) and s100B (0.03 [0.05]; P < 0.01). Postoperative s100B levels were negatively correlated with age at surgery and positively correlated with circulatory arrest time. Although there was no significant correlation between either NSE or s100B levels and intensive care unit length of stay, hospital length of stay, and pediatric cerebral performance category score, there was a negative correlation between postoperative levels of NSE and ventriculomegaly. ConclusionsNSE and s100B levels increase after bypass surgery and return below preoperative baseline levels by postoperative day seven. The levels of s100B were positively correlated with circulatory arrest time and negatively correlated with age at time of surgery. This finding may be supportive of pre-existing prenatal brain injury that could be enhanced by longer surgical times but also of some brain protection effect associated with longer wait until surgery.

International Survey of Critically Ill Children With Acute Neurologic Insults: The Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment Study.

The international scope of critical neurologic insults in children is unknown. Our objective was to assess the prevalence and outcomes of children admitted to PICUs with acute neurologic insults. Prospective study. Multicenter (n = 107 PICUs) and multinational (23 countries, 79% in North America and Europe). Children 7 days to 17 years old admitted to the ICU with new traumatic brain injury, stroke, cardiac arrest, CNS infection or inflammation, status epilepticus, spinal cord injury, hydrocephalus, or brain mass. None. We evaluated the prevalence and outcomes of children with predetermined acute neurologic insults. Child and center characteristics were recorded. Unfavorable outcome was defined as change in pre-post insult Pediatric Cerebral Performance Category score greater than or equal to 2 or death at hospital discharge or 3 months, whichever came first. Screening data yielded overall prevalence of 16.2%. Of 924 children with acute neurologic insults, cardiac arrest (23%) and traumatic brain injury (19%) were the most common. All-cause mortality at hospital discharge was 12%. Cardiac arrest subjects had highest mortality (24%), and traumatic brain injury subjects had the most unfavorable outcomes (49%). The most common neurologic insult was infection/inflammation in South America, Asia, and the single African site but cardiac arrest in the remaining regions. Neurologic insults are a significant pediatric international health issue. They are frequent and contribute substantial morbidity and mortality. These data suggest a need for an increased focus on acute critical neurologic diseases in infants and children including additional research, enhanced availability of clinical resources, and the development of new therapies.

Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest

BackgroundRespiratory care may be important in pediatric out-of-hospital cardiac arrest (OHCA) due to the asphyxial nature of the majority of events. However, evidence of the effect of prehospital advanced airway management (AAM) for pediatric OHCA is scarce. MethodsThis was a nationwide population-based study of pediatric OHCA in Japan from 2011 to 2012 based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients aged between 1 and 17 years old. The primary outcome was one-month neurologically favorable survival defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1–2 (corresponding to a Pediatric CPC score of 1–3). ResultsA total of 2157 patients were included in the final cohort; 365 received AAM and 1792 received bag-valve-mask (BVM) ventilation only. Among the 2157 patients, 213 (9.9%) survived with favorable neurological outcomes (CPC of 1–2) one month after OHCA. There were no significant differences in neurologically favorable survival between the AAM and BVM groups after adjusting for potential confounders, although there was a tendency favoring BVM ventilation: propensity score matching, OR 0.74 (95%CI 0.35–1.59), and multivariable logistic regression modeling, ORadjusted 0.55 (95%CI 0.24–1.14). Subgroup analyses demonstrated that there were no subgroups in which AAM was associated with neurologically favorable survival, including the non-cardiac (primarily asphyxial) etiology group. ConclusionsIn pediatric OHCA, prehospital AAM was not associated with an increased chance of neurologically favorable survival compared with BVM-only ventilation. However, careful consideration is required to interpret the findings, as there may be unmeasured residual confounders and selection bias.

Benchmarking Prehospital and Emergency Department Care for Argentine Children with Traumatic Brain Injury: For the South American Guideline Adherence Group.

ObjectiveThere is little information on the type of early care provided to children with traumatic brain injury (TBI) in low middle income countries. We benchmarked early prehospital [PH] and emergency department [ED] pediatric TBI care in Argentina.MethodsWe conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with TBI. Eligible participants were patients 0–18 years, and had diagnosis of TBI (admission Glasgow Coma scale score [GCS] < 13 or with GCS 14–15 and abnormal head CT scan within 48 hours of admission, and head AIS > 0). Outcomes were transport type, transport time, PH and ED adherence to best practice, and discharge Pediatric Cerebral Performance Category Scale (PCPC) and Pediatric Overall Performance category Scale (POPC).ResultsOf the 366 children, mean age was 8.7 (5.0) years, 58% were male, 90% had isolated TBI and 45.4% were transported by private vehicle. 50 (34.7%) of the 144 children with severe TBI (39.3% of all TBI patients) were transported by private vehicle. Most (267; 73%) patients received initial TBI care at an index hospital prior to study center admission, including children with severe (81.9%) TBI. Transport times were shorter for those patients who were directly transported by ambulance to study center than for the whole cohort (1.4 vs.5.5 hours). Ambulance blood pressure data were recorded in 30.9%. ED guideline adherence rate was higher than PH guideline adherence rate (84.8% vs. 26.4%). For patients directly transferred from scene to study trauma centers, longer transport time was associated with worse discharge outcome (PCPC aOR 1.10 [1.04, 1.18] and (POPC aOR 1.10 [1.04, 1.18]). There was no relationship between PH or ED TBI guideline adherence rate and discharge POPC and PCPC.ConclusionThis study benchmarks early pediatric TBI care in Argentina and shows that many critically injured children with TBI do not receive timely or best practice PH care, that PH guideline adherence rate is low and that longer transport time was associated with poor discharge outcomes for patients with direct transfer status. There is an urgent need to improve the early care of children with TBI in Argentina, especially timely transportation to a hospital.

Vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) levels in the cerebrospinal fluid of children with influenza-associated encephalopathy

To search for an index of neurologic prognosis of children with influenza-associated encephalopathy (IAE), involvement of angiogenesis-related growth factors in the pathology was investigated. The subjects were 11 IAE patients, 6 patients with bacterial meningitis (BM), and 24 patients with non-central nervous system infection as a control group admitted to our hospital. The correlation between the vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF) levels in cerebrospinal fluid and the relationship with an index of inflammatory marker, interleukin (IL)-6, were investigated. Using the Pediatric Cerebral Performance Categories (PCPC) score as a prognostic indicator, we evaluated the association between the biomarkers and neurologic prognosis. PDGF significantly increased in the IAE group compared with that in the BM group. Cerebrospinal fluid VEGF and PDGF increased in all IAE and BM patients compared with that in the control group, and VEGF and PDGF were positively correlated in the 2 groups. No correlation was found between the cerebrospinal fluid VEGF and PDGF levels and IL-6 level in the IAE group, whereas a correlation was found in the BM group. All these factors increased in patients with poor neurologic prognosis. It is possible that the disease state of IAE can be evaluated based on vascular endothelial disorder-related markers.

Abstract 12808: Public Access Defibrillation Has Great Impact on Outcomes After Pediatric Out-of-hospital Cardiac Arrest

Introduction: Use of automated external defibrillators (AEDs) has been recommended for pediatric out-of-hospital cardiac arrest (OHCA). Studies in adults suggest that public-access defibrillation (PAD) improves the outcomes after OHCA, but there have been no conclusive studies in children. Hypothesis: We assessed the hypothesis that PAD is associated with an increased chance of favorable outcomes after pediatric OHCA. Methods: This was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from January 1, 2011, to December 31, 2012, based on data from the All-Japan Utstein Registry. We included pediatric patients who experienced OHCA and received bystander CPR. The primary outcome was a favorable neurological state one month after OHCA defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2 (corresponding to a Pediatric CPC score of 1-3). The secondary outcomes included a neurologically favorable survival with a CPC score of 1 (corresponding to a Pediatric CPC score of 1), one-month survival, and prehospital return of spontaneous circulation (ROSC). Results: A total of 1,193 patients were included in the final cohort; 57 received PAD and 1,136 did not. Among 1,193 patients, 188 (15.8%) survived with a favorable neurological status one month after OHCA. The odds of neurologically favorable survival were significantly higher for patients receiving PAD after adjusting for potential confounders: propensity score matching, OR 3.17 (95%CI 1.40-7.17), and multivariable logistic regression modeling, OR 5.10 (95% CI 2.01-13.70). Similar findings were observed for the secondary outcomes. In subgroup analyses, there were no significant differences in neurologically favorable survival between PAD group and no PAD group in unwitnessed cohort (OR 7.76 [0.75-81.90]) and non-cardiac etiology cohort (OR6.65 [0.64-66.24]). Conclusions: In conclusion, PAD was associated with an increased chance of neurologically favorable survival after pediatric OHCA, except for unwitnessed cases and non-cardiac etiology cases.

Abstract 12806: Advanced Airway Management May Not be Effective Compared to Basic Airway Management After Pediatric Out-of-hospital Cardiac Arrest

Introduction: Respiratory care for pediatric out-of-hospital cardiac arrest (OHCA) may play an important role due to the asphyxial nature of the majority of pediatric OHCA events. Hypothesis: We assessed the hypothesis that prehospital advanced airway management (endotracheal intubation or supraglottic airway device) is associated with an increased chance of favorable outcomes compared with basic airway management (bag-valve-mask ventilation) after pediatric OHCA. Methods: This was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from January 1, 2011, to December 31, 2012, based on data from the All-Japan Utstein Registry. We included pediatric patients aged &lt; 18 years. Infants (≤ 1 year old) were excluded. The primary outcome was a favorable neurological state one month after OHCA defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2 (corresponding to a Pediatric CPC score of 1-3). The secondary outcomes included a neurologically favorable survival with a CPC score of 1 (corresponding to a Pediatric CPC score of 1), one-month survival, and prehospital return of spontaneous circulation (ROSC). Results: A total of 2,157 patients were included in the final cohort; 365 received advanced airway management and 1,792 received basic airway management. Among 2,157 patients, 213 (9.9%) survived with a favorable neurological status one month after OHCA. There were no significant differences in neurologically favorable survival between the advanced airway management group and the basic airway management group after adjusting for potential confounders: propensity score matching, OR 0.74 (95%CI 0.35-1.59), and multivariable logistic regression modeling, OR 0.55 (95% CI 0.24-1.14). Similar findings were observed for the secondary outcomes. In subgroup analyses (including the non-cardiac [mainly asphyxial] etiology group), there were no subgroups in which advanced airway management was associated with neurologically favorable survival. Conclusions: In conclusion, advanced airway management was not associated with an increased chance of neurologically favorable survival, one-month survival, or prehospital ROSC compared to basic airway management after pediatric OHCA.

Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival

Tracheal intubation is common during pediatric in-hospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown. To determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes. Observational study of data from United States hospitals in the Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with index in-hospital cardiac arrest between January 2000 and December 2014 were included. Patients who were receiving assisted ventilation, had an invasive airway in place, or both at the time chest compressions were initiated were excluded. Tracheal intubation during cardiac arrest . The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and neurologic outcome. A favorable neurologic outcome was defined as a score of 1 to 2 on the pediatric cerebral performance category score. Patients being intubated at any given minute were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics. The study included 2294 patients; 1308 (57%) were male, and all age groups were represented (median age, 7 months [25th-75th percentiles, 21 days, 4 years]). Of the 2294 included patients, 1555 (68%) were intubated during the cardiac arrest. In the propensity score-matched cohort (n = 2270), survival was lower in those intubated compared with those not intubated (411/1135 [36%] vs 460/1135 [41%]; risk ratio [RR], 0.89 [95% CI, 0.81-0.99]; P = .03). There was no significant difference in return of spontaneous circulation (770/1135 [68%] vs 771/1135 [68%]; RR, 1.00 [95% CI, 0.95-1.06]; P = .96) or favorable neurologic outcome (185/987 [19%] vs 211/983 [21%]; RR, 0.87 [95% CI, 0.75-1.02]; P = .08) between those intubated and not intubated. The association between intubation and decreased survival was observed in the majority of the sensitivity and subgroup analyses, including when accounting for missing data and in a subgroup of patients with a pulse at the beginning of the event. Among pediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiac arrest compared with no intubation was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding, these findings do not support the current emphasis on early tracheal intubation for pediatric in-hospital cardiac arrest.