Pediatric Intensive Care Services Research Articles

The impact of rural status on pediatric chronic kidney disease.

Children and adolescents in rural areas with chronic kidney disease (CKD) face unique challenges related to accessing pediatric nephrology care. Challenges to obtaining care begin with living increased distances from pediatric health care centers. Recent trendsof increasing centralization of pediatric care mean fewer locations have pediatric nephrology, inpatient, and intensive care services. In addition, access to care for rural populations expands beyond distance and encompasses domains of approachability, acceptability, availability and accommodation, affordability, and appropriateness. Furthermore, the current literature identifies additional barriers to care for rural patients that include limited resources, including finances, education, and community/neighborhood social resources. Rural pediatric kidney failure patients have barriers to kidney replacement therapy options that may be even more limited for rural pediatric kidney failure patients when compared to rural adults with kidney failure. This educational review identifies possible strategies to improve health systems for rural CKD patients and their families: (1) increasing rural patient and hospital/clinic representation and focus in research, (2) understanding and mediating gaps in the geographic distribution of the pediatric nephrology workforce, (3) introducing regionalization models for delivering pediatric nephrology care to geographic areas, and (4) employing telehealth to expand the geographic reach of services and reduce family time and travel burden.

A Comprehensive Coalition-Based Regional Approach to Pediatric Disaster Planning

Introduction:Children, who comprise 25% of the US population, are frequently victims of disasters and have special needs during these events. To prepare NYC for a large-scale Pediatric Disaster, NYCPDC has worked with an increasing number of providers that initially included only a small number of hospitals and agencies. Through a cooperative team approach, stakeholders now include local public health, emergency management and emergency medical services, 28 hospitals, community-based providers, and the Medical Reserve Corps.Method:The NYCPDC utilized an inclusive iterative process model whereby a desired plan was achieved by stakeholders reviewing the literature and current practice through repeated discussion and consensus building. NYCPDC used this model in developing a comprehensive regional pediatric disaster plan.Results:The plan included disaster scene triage (adapted for pediatric use) to transport (with prioritization) to surge and evacuation. Additionally, site-specific plans utilizing guidelines and templates now include Pediatric Long-Term Care Facilities, Hospital Pediatric Departments including Pediatric and Neonatal Intensive Care Services and Outpatient/Urgent Care Centers. A force multiplier course in critical care for non-intensivists has been provided. An extensive Pediatric Exercise program has been used to develop, operationalize and revise plans based on lessons learned. This initially included pediatric tabletop, functional and full-scale exercises at individual hospitals leading to citywide exercises at 13 and subsequently all 28 hospitals caring for children.Conclusion:The NYCPDC has comprehensively planned for the special needs of children during disasters utilizing a pediatric coalition based regional approach that matches pediatric resources to needs to provide best outcomes.The NYCPDC has responded to real time events (H1N1, Haiti Earthquake, Superstorm Sandy, Ebola), and participated in local (NYC boroughs and executive leadership) and nationwide coalitions (including the National Pediatric Disaster Coalition). The NYCPDC has had the opportunity to present their Pediatric Disaster Planning and Response efforts at local, national and International conferences.

Abstract 1122‐000017: Giant Brain Aneurysm: A Case Report in a Pediatric Patient

Introduction : The incidence of intracranial aneurysms in the pediatric population ranges from 1 to 3 per million inhabitants. Within this population, aneurysms are even rarer in lactating patients. Unlike the adult population, the male gender is predominant, and the incidence is more significant in the posterior circulation, with a higher percentage in the middle cerebral artery. Microsurgical and endovascular treatment has been described as feasible treatment in these cases. Methods : Methodology: Description of a case report of a patient admitted to the Pediatric Intensive Care service of the Hospital Materno Infantil in Tegucigalpa, Honduras. We took informed consent from parents for the patient’s treatment and subsequent academic dissemination of the clinical and neuroimaging data. Results : Case report: A two‐year‐old male patient presented to the pediatric emergency department with a 24‐hour evolution of sudden headache of severe intensity, accompanied by nausea and multiple episodes of vomiting. At hospital arrival, the patient presented an episode of generalized epileptic seizures. At the initial clinical neurological evaluation with altered consciousness somnolent. Motor examination revealed a right facial and body hemiparesis and Hunt and Hess of 1. Noncontrast cerebral tomography (NCCT) showed Fisher IV subarachnoid haemorrhage, left frontal lobar intraparenchymal hematoma and acute hydrocephalus (Fig 1A). Consequently, we placed an external ventricular shunt, for which the patient was admitted to the pediatric intensive care unit. The computed tomography angiography (CTA) showed a giant aneurysm in the anterior communicating artery (Fig. 1B). The patient underwent an endovascular procedure with the placement of coils with a successful result (Fig. 1C and Fig. 1D). Conclusions : Giant aneurysms are sporadic in children. They are commonly associated with the posterior circulation and, to a lesser extent, the middle cerebral artery is more commonly affected with the anterior circulation. Aneurysms in children tend to be more extensive compared to their adult counterparts. Clinically, they present with subarachnoid haemorrhage and seizures, as in our case. This case is a pediatric patient with a giant brain aneurysm at a less common age and rare localization. Endovascular management was successful, adding information to the therapeutic spectrum in these cases. It is essential to perform a detailed angiographic investigation. Surgery is the treatment of choice; however, clinical trials are needed to clarify endovascular versus microsurgical management.

Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings.

Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.

High-flow oxygen nasal cannula for treating acute bronchiolitis in infants: A systematic review and meta-analysis.

Oxygen therapy through a high-flow nasal cannula is thought to improve the work of breathing and the comfort of patients with acute bronchiolitis. It is widely used in hospital wards and critical care of pediatric patients. However, there is uncertainty on the magnitude of the effect on critical and important outcomes in these patients. The objective of this review is to evaluate the available evidence on the use of oxygen administered through high-flow cannula versus low-flow oxygen for the treatment of acute bronchiolitis in children under two years of age. We carried out a systematic review and a meta-analysis following the PRISMA standards for reporting. The search was carried out in electronic databases by two researchers independently. The evidence was summarized using the GRADE methodology. Six randomized and non-randomized clinical trials were included, including 1867 individuals younger than 24 months of age with acute bronchiolitis in pediatric emergency, hospitalization, and intensive care services. Mortality was not reported in the included studies. Treatment failure occurred in 108/933 in the high flow group and 233/934 in the low flow group (relative risk: 0.46; 95% confidence interval: 0.35 to 0.62), which shows 11.7% less treatment failure (95% confidence interval between 7.9% and 14.5% less) in the high flow group with a number needed to treat of 7.5 (95% confidence interval 6 to 10) with moderate certainty in the evidence. The use of humidified and heated oxygen with high flow compared to oxygen at low flow is probably associated with decreased treatment failure in children younger than two years with acute bronchiolitis. There is uncertainty about the effect on hospitalization days and clinical progression.

O uso de narrativas biográficas em investigação

Este artigo tem como objetivo refletir sobre as três dimensões – ética e deontológica, heterobiográfica e de engajamento social – inscritas na abordagem da pesquisa biográfica em educação. Para tanto, tomará como base um estudo desenvolvido junto a profissionais de saúde de um serviço de reanimação pediátrica e cuidados intensivos pediátricos de um hospital de referência aos cuidados de crianças, situados na cidade de Paris/França. Tal estudo teve como objetivo compreender a construção da trajetória biográfica dos profissionais de saúde que trabalham em reanimação e cuidados intensivos, assim como os aprendizados adquiridos no curso das experiências vividas pelos mesmos. No escopo do presente artigo colocou-se em relevo a postura adotada pelo pesquisador, as escolhas metodológicas, a maneira de conduzir o trabalho de campo e o processo de interpretação e análise a fim de tecer os laços entre investigação, saúde e educação com vistas a enfatizar a relevância social da abordagem biográfica em educação e seu carácter interdisciplinar. Como resultados, a investigação contribuiu para erigir uma compreensão sobre como os sujeitos participantes se constroem e aprendem a partir das experiências de vida, usando-as como motores de suas formas de agir no quotidiano de trabalho. Essa compreensão social e eticamente construída não teria sido possível sem a adopção de valores e posturas que valorizem a construção partilhada do conhecimento.

Pediatric Cardiac Intensive Care Distribution, Service Delivery, and Staffing in the United States in 2018.

To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States. Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders. Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease. Cardiac ICU or mixed ICU physician medical directors or designees. One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001). Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.

Performance of the Pediatric Index of Mortality 3 Score in PICUs in Argentina: A Prospective, National Multicenter Study.

To assess the performance of the Pediatric Index of Mortality 3 score in a population of children admitted to PICUs in Argentina. Prospective, national, multicenter study. Forty-nine PICUs located in Argentina belonging to public and private institutions. All children between 1 month and 16 years old admitted to the participating PICUs between May 15, 2016, and February 15, 2017. None. A total of 6,602 patients were enrolled in the study. The observed mortality was 8% (531/6,602), whereas mortality predicted by Pediatric Index of Mortality 3 was 6.16% (407 deaths). The standardized mortality rate was 1.3 (95% CI, 1.20-1.42). The area under the receiver operating characteristic curve was 0.83 (95% CI, 0.82-0.85). The Hosmer-Lemeshow test showed that the difference between the mortality observed and the mortality predicted by Pediatric Index of Mortality 3 was statistically significant (χ, 135.63; p < 0.001). The Pediatric Index of Mortality 3 score adequately discriminated patients who died from those who survived in our population. However, the observed mortality was higher than predicted by the score. The use of an updated instrument such as Pediatric Index of Mortality 3 will allow an actual comparison between pediatric intensive care provided in the country and care provided internationally. This might also allow future planning of pediatric intensive care services in Argentina.

Processos de confronto dos enfermeiros face à morte inesperada de crianças e adolescentes

Objetivo: compreender as estratégias de confronto utilizadas pelos enfermeiros para lidar com a morte inesperada em pediatria. Métodos: pesquisa qualitativa com seis profissionais de enfermagem que trabalham em serviços de urgência e cuidados intensivos pediátricos. Procedeu-se a analise de conteúdo. Resultados: dos dados emergiram dois grupos: Estratégias centradas na avaliação da situação em que os profissionais tentam, através de processos racionais, compreender e aceitar a morte inesperada; estratégias centradas na gestão emocional, em que é reconhecido o sofrimento resultante do confronto com a morte inesperada, procurando estratégias de melhor gestão desse confronto. Conclusão: os profissionais sofrem e procuram mecanismos de confronto para gerir o processo de luto com a morte inesperada de criança/adolescente.

Paediatric critical care needs assessment in a tertiary facility in a developing country

Introduction and Aim: There is a great burden of critically ill children in developing countries where paediatric critical care is still in its early stages. The actual burden of critically ill children is necessary for healthcare planning however, in Nigeria the magnitude is unknown. In order to provide the basic paediatric intensive care services which will likely reduce mortality and improve patient outcomes, the specific burden and need for various aspects of paediatric critical care services must be quantified. This study set out to determine the volume, specific critical care needs and outcomes of critically ill paediatric emergencies in the UCH.Methods: It was a prospective study of all consecutive patients admitted into the children’s emergency ward over a three-month period. Data on clinical state on admission and the need or otherwise for critical care using the paediatric assessment triangle (PAT) were documented.Results: There were 391 admissions during the study period, of which 130 were critically ill. They had one or more of the following; respiratory distress 93(28.3%), respiratory failure 35 (19.0%), shock 65(50%), central nervous system/metabolic derangements 64 (49.2%). Eighty-nine (68.5%) of the critically ill were under-5s. The diagnoses commonly associated with critical illness were malaria, 59 (45.4%), septicaemia, 18, (13.8%) and meningitis 17 (13. 1%). Four of the critically ill children (2.8%) were admitted into the general ICU and 33 (25.4%) died within 48hours of presentation.Conclusion: There is a huge burden of critical care needs among children presenting to the children’s emergency ward, which remains largely unmet. There is an urgent need to address paediatric critical care services in order to improve child survival.

Clinical Evaluation of Invasive Home Mechanical Ventilation Dependent Pediatric Patients

Objectives: With the advancements in neonatal and pediatric intensive care services and technology, the number of children requiring long term mechanical ventilation support is increasing. Home mechanical ventilators enable discharge of patients with chronic respiratory failure from hospital and allows children to grow in natural environment. The objective of this study was to define clinical characteristics and follow up results of pediatric patients who are dependent on invasive home mechanical ventilation support. Methods: This retrospective study included a total of 61 patients discharged from pediatric intensive care unit while on mechanical ventilation (HMV). Results: The median age of patients was 8.5 (2 - 196) months with 60% of them being younger than 12 months. The decision for HMV was made after median 38 ± 37.2 days of mechanical ventilation in hospital. The most common reason of dependency on invasive HMV was found as central nervous system and neuromuscular diseases by 94%. The median duration of follow up was 11 months (4 days-7.5 years). HMV was no longer necessary in 12% of patients ventilated for neurological reasons and 50% for chronic pulmonary diseases. Anthropometric measures were observed to be improved in 69% of the patients. Mortality rate attributed to complications of tracheostomy was 15% and overall mortality was found as 46.7%. Conclusions: HMV enables ventilator dependent patients to be discharged and allows patients to develop and grow in their natural environment which helps them to catch up their growth potentials. The survival and quality of life (QoL) of these patients can be improved by family education and with the support by nutrition and care rehabilitation programs.

The mobile paediatric circulatory support unit

A mobile paediatric circulatory support unit has been set up within the paediatric and neonatal intensive care service at the Armand-Trousseau Hospital in Paris (AP-HP, 75). It is in place for situations of refractory respiratory and/or circulatory failure and can intervene in a radius of several hundred kilometres, in order to establish long-term extracorporeal circulation. In this delicate context, transporting children requires specific skills, coordination between all intervening parties and faultless organisation.

Paediatric mobile emergency and intensive care services, objectives and missions

The paediatric mobile emergency and intensive care service care teams have expertise in taking care of children in life-threatening circumstances. At the Robert-Debré Hospital in Paris, the paediatric Smur is multi-skilled, specialising particularly in transporting neonates and infants with severe cardiac or respiratory difficulties. The pathologies handled are very varied and include both neonatal pathologies and trauma pathologies in older children.

Teamwork in a paediatric mobile emergency and intensive care service

A paediatric mobile emergency and intensive care service team comprises several professionals with complementary skills. The cohesion of a team, as well as the listening and communication skills of each of its members, allow it to respond in the best possible way to emergency situations. Feedback sessions on practice and simulation exercises enhance teamwork.

Referral and transfer of the critically ill child

### Key points Centralization of paediatric intensive care over the last 20 yr, to lead centres serving a network of referring hospitals, has led to an increase in the numbers of critically ill children being transferred between healthcare institutions in the UK. The majority of these transfers are undertaken by specialist teams, with only 7% conducted by an ad hoc non-specialist team.1 Evidence of fewer critical incidents and improved outcomes after specialist transfer supports this balance of provision.2 However, current capacity and the need for time-critical transfer mean that non-specialists should be prepared to resuscitate, stabilize, refer, and, on occasions, transfer the critically ill child. In recent years, there have been significant changes to the systems in place to refer, transfer, and care for critically ill children. This evolution of paediatric intensive care units (PICU) in the UK dates back to 1996 when the Department of Health, in the face of evidence that centralization of services at larger centres improves patient outcome, set up a national coordinating group. The aim was to outline a strategy to develop and unify the services caring for critically ill children. They initially found an ad hoc service with a lack of structure, training, and staff. There were few specialist transport services and those that did exist were unit-based, bed-dependent, and often not staffed 24/7. Paediatric intensive care services in …

Transporting the paediatric intensive care patient: an insight into CATS

The Children's Acute Transport Service (CATS) is a specialist paediatric intensive care service operating in the North Thames and East Anglian areas of the UK. Alan Weir provides an overview of the service and the care it provides.

A Novel Method to Identify the Start and End of the Winter Surge in Demand for Pediatric Intensive Care in Real Time.

Implementation of winter surge management in intensive care is hampered by the annual variability in the start and duration of the winter surge. We aimed to develop a real-time monitoring system that could identify the start promptly and accurately predict the end of the winter surge in a pediatric intensive care setting. We adapted a method from the stock market called "Bollinger bands" to compare current levels of demand for pediatric intensive care services to thresholds based on medium-term average demand. Algorithms to identify the start and end of the surge were developed using Bollinger bands and pragmatic considerations. The method was applied to a specific pediatric intensive care service: the North Thames Children's Acute Transport Service using eight winters of data (2005-2012) to tune the algorithms and one winter to test the final method (2013/2014). A regional specialized pediatric retrieval service based in London, United Kingdom. The optimal Bollinger band thresholds were 1.2 and 1 SDs above and below a 41-day moving average of demand, respectively. A simple linear model was found to predict the end of the surge and overall surge demand volume as soon as the start had been identified. Applying the method to the validation winter of 2013/2014 showed excellent performance, with the surge identified from November 18, 2013, to January 4, 2014. We have developed and tested a novel method to identify the start and predict the end of the winter surge in emergency demand for pediatric intensive care.

Evaluation report of pediatric intensive care units in Turkey.

To collect data from throughout Turkey in order to facilitate the organization of pediatric intensive care units (PICUs), and to develop short-term immediate action plans and draft long-term strategic plans. A total of 35 specialists including 17 pediatric critical care (PCC) specialists, 9 PCC fellows in training, and 9 pediatricians working in PICUs evaluated PICUs and their infrastructures, mortality rates, appropriateness of indications for PICU admissions, PICU bed numbers, and utilization of those PICU beds. PICU bed numbers, PCC specialist numbers, and PICU nurse numbers are insufficient in Turkey. The high percentage of inappropriate and inefficient use of current PICU beds is also another problem. In the light of this report, it is obvious that pediatric intensive care services are successful and efficient only in the presence of PCC specialists in PICUs. Studies for improving the infrastructure of PICUs and the training of PCC specialists and other health personnel should be started immediately.

Stabilisation and Transport of the Critically Ill Child

Since the Department of Health Report ‘Paediatric Intensive Care: A framework for the future’ in 1997, paediatric intensive care services have been centralised and 24-hour retrieval services developed. However, all hospitals admitting critically ill children must be able to resuscitate and stabilise prior to retrieval, and occasionally undertake the ‘time-critical’ transfers themselves. This article reviews the clinical and organisational skills involved in the retrieval process, and also suggests ways in which knowledge and skills can be maintained.

Demographic and geographical characteristics of pediatric trauma in Scotland

BackgroundTrauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland. MethodsRetrospective analysis of incidents involving children aged 1–14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories. ResultsOf 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service. ConclusionsThe majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.