Pediatric Intensive Care Unit Setting Research Articles

Influence of implementing a protocol for an intravenously administered ammonia scavenger on the management of acute hyperammonemia in a pediatric intensive care unit.

The purpose of the study was to evaluate the influence of establishing a protocol for the use of combined sodium benzoate and sodium phenylacetate (SBSP) (Ammonul®) to treat acute hyperammonemia. This was a retrospective, single-center study in a 24-bed medical and surgical pediatric intensive care unit (PICU) in a tertiary care teaching maternal-child hospital in Canada. Inclusion criteria were age < 18 years, PICU admission between 1 January 2000 and 30 June 2016, and SBSP treatment. An SBSP delivery protocol was implemented in our hospital on 30 August 2008 in order to improve management of acute hyperammonemia. Patients were assigned to one of the two groups, without or with protocol, depending on date of admission. SBSP was ordered 34 times during the study period, and 23 orders were considered for analysis (14 with and 9 without protocol). Patient characteristics were similar between groups. The median time from diagnosis to prescription was significantly shorter in the protocol group [40 min (21-82) vs 100 min (70-150), p = 0.03)] but the median time from diagnosis to administration of the treatment was equivalent [144 min (90-220) vs 195 (143-274), (p = 0.2)]. Other clinical outcomes did not differ. This study is the first to compare two SBSP delivery strategies in the treatment of acute hyperammonemia in this PICU setting. Implementation of a delivery protocol shortened the time from diagnosis of hyperammonemia to prescription of SBSP and helped us identify other parameters that can be improved to optimize treatment delivery.

Implementing Neurodevelopmental Care Strategies in the Paediatric Intensive Care Unit

Introduction: Neurodevelopmental care is an important part of the overall management for pre-term and at-risk babies within the critical care setting. While this model of care is well recognised in Neonatal Intensive Care Units (NICU), it is not always maintained in the Paediatric Intensive Care Unit (PICU) setting. Integration of developmental rounds in PICU was seen as a way to promote ongoing neurodevelopmental care beyond the NICU.

Propofol-Associated Priapism in a Prepubescent Pediatric Patient.

Introduction. Propofol is a commonly used sedative medication for procedural sedation with a limited side effect profile. Although well tolerated with minimal adverse reactions, uncommon side effects have been reported. Methods. Case report of priapism in a 9-year-old male following the use of propofol for sedation in the pediatric intensive care unit (PICU) setting. The patient was admitted to the PICU for postoperative management following laryngotracheal reconstruction. On postoperative day 2, our patient was initiated on continuous infusion of propofol and he developed priapism. Propofol was then immediately discontinued, and the priapism quickly resolved without any medical or surgical interventions. Results. Priapism is a low-flow state and is considered a urological emergency requiring prompt recognition, withdrawal of suspected offending agents, and possible need for urologic consultation to alleviate complications. Although rare, priapism with propofol has been reported but never in a prepubescent male. The mechanism of propofol-associated priapism is not well understood, but it is thought that it may result from an autonomic system imbalance, leading to an increase in parasympathetic activity. In addition, propofol has been shown to affect nitric oxide–mediated smooth muscle relaxation. In our patient, we suspected propofol to be contributing factor to his priapism based on the temporal relationship between the initiation of the medication and symptoms and resolution of symptoms after propofol discontinuation. Discussion. Given the expansive use of propofol in pediatrics for sedation and anesthesia, pediatric clinicians should be cognizant of this rare adverse effect in pediatric patients with potentially disastrous complications.

Feasibility of Online Mental Wellness Self-assessment and Feedback for Pediatric and Neonatal Critical Care Nurses

PurposeThe primary goal of this study was to test the feasibility of an educational online self-assessment of burnout, resilience, trauma, depression, anxiety, and common workplace stressors among nurses working in a pediatric intensive care unit or neonatal intensive care unit setting. The secondary, exploratory objectives were to estimate the prevalence of psychiatric symptoms in this sample and to identify those variables that most strongly predict burnout. Design and MethodsData from optional and anonymous online measures were analyzed for 115 nurses (67.9% aged 25–44; 61.7% Caucasian) working in an urban children's hospital pediatric or neonatal ICU. Multiple linear regressions identified demographic variables and workplace stressors that significantly predicted each of three components of burnout. ResultsMost respondents found the educational assessment and feedback to be helpful. Choosing nursing as a second career was associated with better resilience. Having worked in ICU settings longer and being older were both linked to lower levels of anxiety. Predictors of burnout varied across the three burnout subscales. ConclusionsImplementation of an online self-assessment with immediate educational feedback is feasible in critical care settings. The variability of predictors across the three burnout subscales indicates the need for tailored interventions for those at risk. Future research may include follow-up of nurses to examine changes in scores over time and expansion of the tool for other medical personnel. Practice ImplicationsAn educational online self-assessment can be a helpful tool for pediatric critical care nurses experiencing varying degrees of burnout and distress.

The outcomes of children with tracheostomy in a tertiary care pediatric intensive care unit in Turkey.

We aimed to describe which clinical characteristics were associated with the outcome of tracheostomy in our tertiary care pediatric intensive care unit. This was a retrospective review of medical records of pediatric patients who underwent tracheostomy in our Pediatric Intensive Care unit from 2008 to 2014 in Turkey. Sixty-three patients were included the study. The median age of patients was 11 (range, 1-195) months. Twenty-five (39.7%) patients were female. The tracheostomy rate was 8.5% over a six-year period. Forty-nine (77.7%) patients were able to be discharged and sent home. The decannulation rate was 12.6% (n=8). The indications for tracheostomy were upper airway obstruction (n=9) and prolonged mechanical ventilation (n=54). The median intubation period before tracheostomy was 32 (range, 1-122) days and the median duration of pediatric intensive care unit stay after tracheostomy was 37 days. A total of 21 (52.5%) patients were weaned off mechanical ventilation. The rate of successful weaning from mechanical ventilation was higher in patients with upper airway obstruction than in those in the prolonged mechanical ventilation group (p=0.021). The complication rate was 25.3% in the pediatric intensive care unit and 11.1% at home. Tracheostomy seems safe and improves pediatric patients' outcomes. The most important factor that affects the prognosis of children who underwent tracheostomy is the indication for tracheostomy. The outcomes are always better if the tracheostomy has been performed because of upper airway obstruction. Performing tracheostomy helps weaning from and off ventilator support and finally the discharge of patients with prolonged mechanical ventilation from the pediatric intensive care unit setting.

Unlicensed and Off-Label Medication Use in Pediatric and Neonatal Intensive Care Units: No Change Over a Decade

Many of the medications prescribed to children are off-label and/or unlicensed because pharmacologic evaluations have not been performed in this age group. All drugs prescribed to patients admitted to the neonatal intensive care units (NICU) (n = 134) and pediatric intensive care units (PICU) (n = 56) during a 2-month observation period were recorded and classified according to patient age, drug license status, indicated use, and typical dosing, frequency and way of administration. Results were compared with prior data collected in 2002, from the same units. In the NICU, among the 1064 prescriptions for 49 medications, 312 (29.2%) were licensed and 63 (5.9%) unlicensed, and 693 (64.8%) were off-label use. For the neonates, 23.9% and 96.3% received at least one unlicensed medication and one off-label medication, respectively. While the difference in off-label use between the two time periods was not statistically significant, unlicensed medications were less frequently prescribed in 2016 (5.9 versus 16.6%, p = 0.001). Regarding the PICU, among the 388 prescriptions for 75 medications, 205 (52%) were licensed and 13 (3.4%) unlicensed, and 170 (43.8%) were off-label. In contrast, in 2002, none of the medications prescribed were unlicensed (p = 0.001). The number of off-label medications (41%) and number of PICU patients receiving at least one unlicensed/off-label medication in these two time periods (88.7% versus 90.5% for 2016 and 2002, respectively) were similar. The current study confirms the high prevalence of unlicensed and off-label drug use in a PICU and NICU setting. Compared with a similar study conducted in the same PICU in 2002, despite regulatory efforts conducted in this area, the prevalence of unlicensed medications was surprisingly higher.

Biobanking in the Pediatric Critical Care Setting: Adolescent/Young Adult Perspectives.

Biorepository research in children raises numerous ethical questions that are heightened in the pediatric intensive care unit (PICU) setting. We conducted a cross-sectional, interview-based study of 20 adolescent/young adult (A/YA) PICU patients and 75 parents of PICU patients to elucidate perspectives on biorepository research. A/YAs had a positive attitude toward biobanking. In young adults, comprehension was higher for knowledge of a choice to withdraw and participate in the research and lower for purpose, procedures, risks, and benefits of participation. All but one A/YA wanted to have a say in whether their samples would be used. Parent views on child assent were mixed; 55% of parents favored child involvement in decisions. Efforts should be made to improve comprehension by A/YAs and involvement of A/YAs in decisions.

Influence of implementing a protocol for an intravenously administered ammonia scavenger on the management of acute hyperammonemia in a pediatric intensive care unit

The purpose of the study was to evaluate the influence of establishing a protocol for the use of combined sodium benzoate and sodium phenylacetate (SBSP) (Ammonul®) to treat acute hyperammonemia. This was a retrospective, single-center study in a 24-bed medical and surgical pediatric intensive care unit (PICU) in a tertiary care teaching maternal–child hospital in Canada. Inclusion criteria were age < 18 years, PICU admission between 1 January 2000 and 30 June 2016, and SBSP treatment. An SBSP delivery protocol was implemented in our hospital on 30 August 2008 in order to improve management of acute hyperammonemia. Patients were assigned to one of the two groups, without or with protocol, depending on date of admission. SBSP was ordered 34 times during the study period, and 23 orders were considered for analysis (14 with and 9 without protocol). Patient characteristics were similar between groups. The median time from diagnosis to prescription was significantly shorter in the protocol group [40 min (21–82) vs 100 min (70–150), p = 0.03)] but the median time from diagnosis to administration of the treatment was equivalent [144 min (90–220) vs 195 (143–274), (p = 0.2)]. Other clinical outcomes did not differ. This study is the first to compare two SBSP delivery strategies in the treatment of acute hyperammonemia in this PICU setting. Implementation of a delivery protocol shortened the time from diagnosis of hyperammonemia to prescription of SBSP and helped us identify other parameters that can be improved to optimize treatment delivery.

Abstract P-221: CLINICAL PROFILE OF CHILDREN WITH DENGUE HAEMORRHAGIC FEVER AT A PAEDIATRIC INTENSIVE CARE UNIT IN A TERTIARY CARE HOSPITAL, SRI LANKA

Aims & Objectives: Introduction Dengue, being a major cause of mortality and having several outbreaks in the recent past in Sri Lanka, raises the need of studying its clinical profile. Objectives To study the clinical profile of children with dengue haemorrhagic fever (DHF) admitted to intensive care unit. Methods This retrospective, descriptive study was conducted in Lady Ridgeway hospital for children. It included 112 children with DHF, admitted to the paediatric intensive care unit (PICU) during an outbreak of dengue, over a period of 11 months from January 2017. Results Out of 10119 dengue admissions, 112 were admitted with DHF to the PICU and 41.9% (n=47) were serologically confirmed. Of them 61% (n=68) were females and the mean age was 6.5 years (SD=4.3). The mean weight was 22.3kg (SD=15.1) and 18.7% (n=21) were overweight. Main presenting features were fever (100%), abdominal pain (20.5%) and diarrhoea (17.9%). Mostly, the indication for PICU admission was shock (46.4%,n=52). All had elevated liver enzymes and 21% (n=24) had liver failure. Hyponatremia was observed among 64.2% (n=72). Sepsis, acute kidney injury, multi organ failure and encephalopathy were evident in 17%, 11%, 9.8% and 8.9% respectively. Haemophagocytic Lymphohistiocytosis (HLH) developed as a complication in 9% (n=10). The mean ICU stay was 3.6 days. Dextran, blood, FFP and platelets were required in 46.4%, 46.5%, 20.5% and 11.6% respectively. The mortality rate was 13.4% (n=15). Conclusions This highlights the disease burden of DHF at PICU setting and it emphasizes the important complication of HLH secondary to dengue with the current epidemic.

Abstract PCCLB-38: SUPPORTING NEURODEVELOPMENTAL OUTCOMES FOR NEONATES IN THE PAEDIATRIC INTENSIVE CARE SETTING

Aims & Objectives: Neurological sequelae in infants with congenital heart disease (CHD) emulate those in premature infants. Developmentally supportive practices are seen as a strategy to mitigate some of the effects of the critical care environment on the vulnerable brain. Aims: To establish a framework of developmentally supportive care beyond the Neonatal Intensive Care Unit (NICU) in the Paediatric Intensive Care Unit (PICU) setting. Methods Based on the success of established neurodevelopmental care initiates in the NICU, we constituted a governance committee and conducted a feasibility survey on PICU staff knowledge and attitudes towards the concept. Targeted multidisciplinary education sessions were undertaken to capture the majority of PICU staff. With a clinical developmental round to support practice and provide practical ongoing education for staff implemented. We plan to conduct a subsequent post-implementation survey in the next six months to gain feedback for evaluation and comparison. Results Twenty four percent of 150 PICU staff completed the survey. 90% of respondents indicated they understood the benefits of neurodevelopmental care while 64% felt confident in implementing developmentally supportive strategies. 45% identified there was adequate resources to support this initiative in the PICU. Conclusions Developmentally supportive practices for young infants are well recognised in the NICU setting. Research indicates this approach may also be helpful in high risk infants and those with CHD, both in pre and postoperative periods in the PICU. The governance committee have formulated a proactive strategy for ongoing staff education, evaluation, and implementation of neuro-protective practice in the PICU designed to support neurodevelopmental outcomes.

Subcutaneous dexmedetomidine infusions to treat or prevent drug withdrawal in infants and children

This retrospective study reports a cohort of pediatric patients in whom subcutaneous dexmedetomidine was used to treat or prevent drug withdrawal following prolonged sedation in the Pediatric Intensive Care Unit setting. There were seven patients ranging in age from 6 months to 3.75 years and in weight from 4.8 to 17.7 kg. The dexmedetomidine infusion before switching to subcutaneous administration varied from 0.8 to 1.4 microg/kg/h. Four of the patients had received dexmedetomidine in conjunction with an opioid as part of a sedation regimen during mechanical ventilation. In these four patients, the duration of the intravenous dexmedetomidine infusion varied from 4 to 10 days. In the three other patients, an intravenous dexmedetomidine infusion was used to treat withdrawal following the prolonged use of an opioid and/or a benzodiazepine. In these three patients, the duration of the intravenous dexmedetomidine varied from 3 to 5 days. Following the switch to subcutaneous dexmedetomidine, the infusion was gradually decreased by 0.1 microg/kg/h every 12 h. Subcutaneous access was maintained, and subcutaneous dexmedetomidine was administered for 4 to 7 days. No problems with the subcutaneous access were noted during treatment. No patient exhibited behavior suggestive of withdrawal during the use of subcutaneous dexmedetomidine. The maximum modified Finnegan score in the seven patients varied from 3 to 7. Our preliminary experience suggests that dexmedetomidine can be administered by subcutaneous infusion without difficulty or alteration of its efficacy. This approach allows the administration of dexmedetomidine when peripheral venous access becomes problematic and may facilitate the removal of central venous catheters in patients recovering from critical illnesses. It also offers the possibility of using dexmedetomidine in settings where peripheral venous access is not available such as home palliative care.

A first contribution to the validation of the Italian version of the Behavioral Pain Scale in sedated, intubated, and mechanically ventilated paediatric patients.

Background and aim of the work: Numerous negative outcomes of inadequate pain management among children have been cited in the literature. Inadequate pain management may be particularly detrimental to children and adolescents facing life-threatening injury or illness on a Paediatric Intensive Care Unit (PICU). It is therefore absolutely necessary that professionals utilize effective and efficient tools in order to evaluate a person’s sensations of pain in the most objective way possible. The COMFORT-B scale is recognised as the gold standard in such patients. However, the use of this instrument in the clinical PICU setting is disputed. It requires long periods of observation to ensure an adequate utilization. Boerlage et al. noted that nurses are often impatient and do not always observe the patient for the recommended 2 minutes period. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. This observational pain scale requires shorter observation time compared to the COMFORT-B. Moreover, BPS three subscales are included in other observational pain scales for paediatric patients. Therefore, the objective of this study was to assess the applicability of the BPS for use with paediatric patients. Methods: Firstly, a questionnaire was administered to physicians and nursing staff that work in the units where the study was conducted in order to investigate the actual use of observational pain scales in their units. A second questionnaire was administered to a group of experts regarding the BPS, to assess both face validity and content validity, and to gain opinions on the relative appropriateness of each item. A descriptive, comparative design was used. A convenience sample of non-verbal, sedated and mechanically ventilated critical care paediatric patients was included. 39 observations were collected from 9 patients, all in their first year of age. Patient pain was assessed concurrently with the three observational scales, before, during and after routine procedures that are considered painful and non-painful. Results: The data collected through questionnaires for professionals gave a useful insight into pain assessment in the investigated units: only 46% of respondents stated that they assessed patients’ pain levels, with an average of 2.8 times per shift; 60% of respondents declared to be unhappy with the observational scales that they utilise. Regarding the observations, internal consistency was α = .865. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the test. T test and ROC curves demonstrated a good discriminant validity as well. Conclusions: Although the current study is based on a small sample of participants, these first results encourage us to continue working in the validation of the BPS in paediatric patients.

Study protocol for a phase II dose evaluation randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study)

BackgroundClinical research has recently demonstrated that vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (PICU) and associated with worse clinical course. Multiple adult ICU trials have suggested that optimization of vitamin D status through high-dose supplementation may reduce mortality and improve other clinically relevant outcomes; however, there have been no trials of rapid normalization in the PICU setting. The objective of this study is to evaluate the safety and efficacy of an enteral weight-based cholecalciferol loading dose regimen in critically ill children with VDD.Methods/designThe VITdAL-PICU pilot study is designed as a multicenter placebo-controlled phase II dose evaluation pilot randomized controlled trial. We aim to randomize 67 VDD critically ill children using a 2:1 randomization schema to receive loading dose enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or a placebo solution. Participants, caregivers and outcome assessors will be blinded to allocation. Eligibility criteria include ICU patient, aged 37 weeks to 18 years, expected ICU length of stay more than 48 h, anticipated access to bloodwork at 7 days, and VDD (blood total 25 hydroxyvitamin D < 50 nmol/L). The primary objective is to determine whether the dosing protocol normalizes vitamin D status, defined as a blood total 25(OH)D concentration above 75 nmol/L. Secondary objectives include an examination of the safety of the dosing regimen (e.g. hypercalcemia, hypercalciuria, nephrocalcinosis), measures of vitamin D axis function (e.g. calcitriol levels, immune function), and protocol feasibility (eligibility criteria, protocol deviations, blinding).DiscussionDespite significant observational literature suggesting VDD to be a modifiable risk factor in the PICU setting, there is no robust clinical trial evidence evaluating the benefits of rapid normalization. This phase II clinical trial will evaluate an innovative weight-based dosing regimen intended to rapidly and safely normalize vitamin D levels in critically ill children. Study findings will be used to inform the design of a multicenter phase III trial evaluating the clinical and economic benefits to rapid normalization. Recruitment for this trial was initiated in January 2016 and is expected to continue until November 30, 2017.Trial registrationClinicaltrials.gov NCT02452762

Vitamin D deficiency in critically ill children: a systematic review and meta-analysis

BackgroundVitamin D deficiency (VDD) has been hypothesized not only to be common but also to represent a potentially modifiable risk factor for greater illness severity and clinical outcome during critical illness. The objective of this systematic review was to determine the frequency of VDD in pediatric critical illness and its association with clinical outcomes.MethodsMEDLINE, Embase, and CENTRAL were searched through December 12, 2016, with no date or language restrictions. The primary objective was to estimate the prevalence of VDD in the pediatric intensive care unit (PICU) and compare vitamin D status with healthy control populations. Secondary objectives were to evaluate whether VDD is associated with mortality, increased illness severity, PICU interventions, and patient clinical course. Random effects meta-analysis was used to calculate pooled VDD event rate, compare levels with those of control subjects, and evaluate for associations between VDD and clinical outcome.ResultsAmong 2700 citations, 17 studies meeting study eligibility were identified. The studies reported a total of 2783 critically ill children and had a median sample size of 120 (range 12–511). The majority of studies used a 25-hydroxyvitamin D [25(OH)D] level less than 50 nmol/L to define VDD, and the pooled VDD prevalence was 54.8 (95% CI 45.4–63.9). Average 25(OH)D levels were significantly lower in PICU patients than in healthy control subjects (pooled difference −17.3 nmol/L, 95% CI −14.0 to −20.6). In a meta-analysis calculation, we found that VDD was associated with increased mortality (OR 1.62, 95% CI 1.11–2.36), illness severity, and need for PICU interventions.ConclusionsApproximately 50% of critically ill children have VDD at the time of PICU admission, defined as a blood total 25(OH)D concentration under 50 nmol/L. VDD was further determined to be associated with greater illness severity, multiple organ dysfunction, and mortality in the PICU setting. Clinical trials are required to determine if optimization of vitamin D status improves patient outcome.Trial registrationPROSPERO, CRD42016026617. Registered on 11 January 2016.

Coming full circle: thirty years of paediatric fluid resuscitation.

Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.

Procedural moderate sedation with ketamine in pediatric critical care unit.

Objective:To evaluate the safety and efficacy of moderate sedation in the Pediatric Intensive Care Unit (PICU) settings according to moderate sedation protocol using ketamine and midazolam and to determine areas for the improvement in our clinical practice.Settings and Design:A retrospective study was conducted in the PICU.Materials and Methods:Retrospective chart review was performed for patients who had received moderate sedation between January and the end of December 2011 and who are eligible to inclusion criteria.Results:In this study, 246 moderate sedation sessions were included. 5.3% were in infant age, while 94.7% were children (1–14 years). Their gender distributed as 59.8% males and 40.2% females. The majority of them had hematology-oncology disease nature, i.e., 80.89% (n = 199). Lumbar puncture accounted for 65.3% (n = 160) of the producers; the rests were bone marrow aspiration 32.7%, endoscopy 8.2%, and colonoscopy 2.9%. Two doses of ketamine (1–1.5 mg/kg) to achieve moderate sedation during the procedure were given to 44.1% (n = 108) of the patients. One dose of midazolam was given to 77.2% (n = 190), while 1.22% (n = 3) of sessions of moderate sedation was done without any dose of midazolam. Adverse events including apnea, laryngeal spasm, hypotension, and recovery agitation were observed during moderate sedation sessions, and it has been noticed in four sessions, i.e., 1.6%, which were mild to moderate and managed conservatively.Conclusion:Moderate sedation in the PICU using ketamine and midazolam is generally safe with minimal side effects as moderate sedation sessions were conducted by pediatric intensivist in highly monitored and equipped environment.

Position Statement on Heparin Safety Concerns.

Position Statement on Heparin Safety Concerns.

Sedation with a remifentanil infusion to facilitate rapid awakening and tracheal extubation in an infant with a potentially compromised airway

Sedation is generally required during endotracheal intubation and mechanical ventilation in infants and children. While there are many options for the provision of sedation, the most commonly used agents such as midazolam and fentanyl demonstrate a context-sensitive half-life, which may result in a prolonged effect when these agents are discontinued following a continuous infusion. We present a 20-month-old infant who required endotracheal intubation due to respiratory failure following seizures. At the referring hospital, multiple laryngoscopies were performed with the potential for airway trauma. To maximize rapid awakening and optimize respiratory function surrounding tracheal extubation, sedation was transitioned from fentanyl and midazolam to remifentanil for 18–24 hours prior to tracheal extubation. The unique pharmacokinetics of remifentanil are presented in this study, its use in this clinical scenario is discussed, and its potential applications in the pediatric intensive care unit setting are reviewed.

Comparison of Severity Scoring Systems in a Pediatric Intensive Care Unit in India: A Single-Center Prospective, Observational Cohort Study.

Objective The aim of this study is to validate Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) scoring systems in a pediatric intensive care unit (PICU) in India. Design This is a single-center prospective cohort study. Setting This study was conducted at an eight-bed PICU. Methods PRISM- and PIM-based predicted mortality rates were calculated and compared in 120 pediatric patients. Results Estimated mortality using PRISM (5.68%) and PIM (8.84%) was lower than observed (21.7%) mortality. PIM had slightly better power of calibration than PRISM. The discriminatory performance of both models was comparable. Conclusion Both models can be validated with suitable changes according to PICU settings of India.

Nutritional support for critically ill children.

Nutritional support in the critically ill child has not been well investigated and is a controversial topic within paediatric intensive care. There are no clear guidelines as to the best form or timing of nutrition in critically ill infants and children. This is an update of a review that was originally published in 2009. . The objective of this review was to assess the impact of enteral and parenteral nutrition given in the first week of illness on clinically important outcomes in critically ill children. There were two primary hypotheses:1. the mortality rate of critically ill children fed enterally or parenterally is different to that of children who are given no nutrition;2. the mortality rate of critically ill children fed enterally is different to that of children fed parenterally.We planned to conduct subgroup analyses, pending available data, to examine whether the treatment effect was altered by:a. age (infants less than one year versus children greater than or equal to one year old);b. type of patient (medical, where purpose of admission to intensive care unit (ICU) is for medical illness (without surgical intervention immediately prior to admission), versus surgical, where purpose of admission to ICU is for postoperative care or care after trauma).We also proposed the following secondary hypotheses (a priori), pending other clinical trials becoming available, to examine nutrition more distinctly:3. the mortality rate is different in children who are given enteral nutrition alone versus enteral and parenteral combined;4. the mortality rate is different in children who are given both enteral feeds and parenteral nutrition versus no nutrition. In this updated review we searched: the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2); Ovid MEDLINE (1966 to February 2016); Ovid EMBASE (1988 to February 2016); OVID Evidence-Based Medicine Reviews; ISI Web of Science - Science Citation Index Expanded (1965 to February 2016); WebSPIRS Biological Abstracts (1969 to February 2016); and WebSPIRS CAB Abstracts (1972 to February 2016). We also searched trial registries, reviewed reference lists of all potentially relevant studies, handsearched relevant conference proceedings, and contacted experts in the area and manufacturers of enteral and parenteral nutrition products. We did not limit the search by language or publication status. We included studies if they were randomized controlled trials; involved paediatric patients, aged one day to 18 years of age, who were cared for in a paediatric intensive care unit setting (PICU) and had received nutrition within the first seven days of admission; and reported data for at least one of the pre-specified outcomes (30-day or PICU mortality; length of stay in PICU or hospital; number of ventilator days; and morbid complications, such as nosocomial infections). We excluded studies if they only reported nutritional outcomes, quality of life assessments, or economic implications. Furthermore, we did not address other areas of paediatric nutrition, such as immunonutrition and different routes of delivering enteral nutrition, in this review. Two authors independently screened the searches, applied the inclusion criteria, and performed 'Risk of bias' assessments. We resolved discrepancies through discussion and consensus. One author extracted data and a second checked data for accuracy and completeness. We graded the evidence based on the following domains: study limitations, consistency of effect, imprecision, indirectness, and publication bias. We identified only one trial as relevant. Seventy-seven children in intensive care with burns involving more than 25% of the total body surface area were randomized to either enteral nutrition within 24 hours or after at least 48 hours. No statistically significant differences were observed for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels. We assessed the trial as having unclear risk of bias. We consider the quality of the evidence to be very low due to there being only one small trial. In the most recent search update we identified a protocol for a relevant randomized controlled trial examining the impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients; no results have been published. There was only one randomized trial relevant to the review question. Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.