Pediatric Intensive Care Unit Research Articles

Development and Validation of a High-Performance Liquid Chromatography With Ultraviolet Detection Method to Facilitate Therapeutic Monitoring of Teicoplanin Using Dried Blood Spots.

In neonatal and pediatric intensive care units, Gram -positive infections are a significant cause of morbidity and mortality. The increase in infections caused by methicillin-resistant Staphylococcus aureus and methicillin-resistant coagulase-negative Staphylococci have led to the increased use of glycopeptides, which treat invasive infections caused by Gram -positive organisms, particularly those resistant to beta-lactam antibiotics. Teicoplanin has bacteriostatic activity against Gram -positive bacteria, but its pharmacokinetics in children is highly variable, with most children failing to reach target levels at the recommended dose. This study aimed to develop a cost-effective method for determining concentrations using dried blood spot (DBS). A method to determine the concentrations of teicoplanin in 20 µL blood or plasma using the Whatman 903 Protein Saver filter was evaluated. High-performance liquid chromatography with ultraviolet detection high-performance liquid chromatography with ultraviolet/vis was used, with internal standard ketoconazole. In addition, a method to quantify teicoplanin using 50 µL of liquid plasma was established to compare the results with the values obtained by DBS and dried plasma methods. The method was successfully developed and validated for 20 µL DBS. Furthermore, 50 µL of plasma was used to quantify teicoplanin with a lower limit of quantification of 10 mg/L. Precision and accuracy ranged from 2.3% to 10.7% and 95%-114.2%, respectively. A consistent factor (1.15) was used to calculate teicoplanin plasma concentrations from whole blood, indicating the reliability of the DBS method for therapeutic drug monitoring of teicoplanin. A simple, reliable, and cost-effective method using high-performance liquid chromatography with ultraviolet/vis was established to determine pediatric teicoplanin concentrations in both small plasma sample volumes and whole blood using DBS, and an accurate correlation factor for estimating teicoplanin plasma concentrations from DBS was identified. This method is suitable for the use in pediatrics.

OTHR-11. TITLE: ELECTROGRAPHIC SEIZURES AND EEG BACKGROUND FEATURES IN PEDIATRIC NEURO-ONCOLOGY PATIENTS ADMITTED TO THE PEDIATRIC INTENSIVE CARE UNIT

Abstract BACKGROUND Electrographic seizures (ES) are common in critically ill children with the incidence of ES ranging from 10-50%. Continuous EEG (cEEG) is frequently obtained in children with brain tumors due to encephalopathy or concern for seizures. Despite this, little is known about the incidence of ES, EEG background features, or the impact of EEG on clinical management in this population. METHODS This is a prospective single center study of critically ill children with brain tumors admitted to the pediatric intensive care unit (PICU) from July 2021 to July 2023. Patients with new or known primary brain tumors and cEEG completed during their admission were included. We excluded patients with planned admissions for EEG. Clinical variables included age, sex, oncologic diagnosis, tumor grade and location, indication for EEG, EEG features, and changes in management. RESULTS Thirty-six patients were identified who met the inclusion criteria. 21 patients were female. The median age was 11.0 years (IQR 6.6– 15.4 years). The most common indication for EEG was encephalopathy in 42% followed by clinical seizure in 31%. ES were captured in 19% (7/36) with the majority being subclinical; in patients with acute encephalopathy, ES were captured in 20% (3/15). The EEG background was abnormal in 97% of cases. The most common EEG background was slow disorganized with background asymmetry seen in in 74%. EEG background features met criteria for the ictal-interictal continuum in 14%. A higher rate of ES was seen in patients with disseminated tumors (p=0.03) and severe encephalopathy on EEG (p=0.006). EEG led to a change in management in 31% of patients. CONCLUSIONS ES are common in critically ill children with brain tumors and would go undetected without cEEG. EEG findings often led to a change in clinical management and is a vital tool for the evaluation of this population.

Invasive Mechanical Ventilation and Risk of Hospital-Acquired Venous Thromboembolism.

This study sought to estimate the overall cumulative incidence and odds of Hospital-acquired venous thromboembolism (VTE) among critically ill children with and without exposure to invasive ventilation. In doing so, we also aimed to describe the temporal relationship between invasive ventilation and hospital-acquired VTE development. We performed a retrospective cohort study using Virtual Pediatric Systems (VPS) data from 142 North American pediatric ICUs among children < 18 y of age from January 1, 2016-December 31, 2022. After exclusion criteria were applied, cohorts were identified by presence of invasive ventilation exposure. The primary outcome was cumulative incidence of hospital-acquired VTE, defined as limb/neck deep venous thrombosis or pulmonary embolism. Multivariate logistic regression was used to determine whether invasive ventilation was an independent risk factor for hospital-acquired VTE development. Of 691,118 children studied, 86,922 (12.4%) underwent invasive ventilation. The cumulative incidence of hospital-acquired VTE for those who received invasive ventilation was 1.9% and 0.12% for those who did not (P < .001). The median time to hospital-acquired VTE after endotracheal intubation was 6 (interquartile range 3-14) d. In multivariate models, invasive ventilation exposure and duration were each independently associated with development of hospital-acquired VTE (adjusted odds ratio 1.64 [95% CI 1.42-1.86], P < .001; and adjusted odds ratio 1.03 [95% CI 1.02-1.03], P < .001, respectively). In this multi-center retrospective review from the VPS registry, invasive ventilation exposure and duration were independent risk factors for hospital-acquired VTE among critically ill children. Children undergoing invasive ventilation represent an important target population for risk-stratified thromboprophylaxis trials.

Virtual Reality in non-pharmacological pain management in the Pediatric Intensive Care Unit

Virtual Reality in non-pharmacological pain management in the Pediatric Intensive Care Unit

Feelings and emotions in the Pediatric ICU: The impact of using Virtual Reality

Feelings and emotions in the Pediatric ICU: The impact of using Virtual Reality

Palliative Care in the Pediatric Intensive Care Unit.

The purposes of this review are to describe differences between palliative care for adult patients and palliative care for pediatric patients, both generally and in the intensive care unit; to highlight ethical considerations for pediatric intensive care unit patients by using illustrative cases; and to examine the impact of these ethical considerations on decision-making for children and their families.

Admission Pattern and Treatment Outcome in Pediatric Intensive Care Unit in Al Zahraa Teaching Hospital, Iraq, Najaf

Admission Pattern and Treatment Outcome in Pediatric Intensive Care Unit in Al Zahraa Teaching Hospital, Iraq, Najaf

Implementation of Nurse Integrated Rounds Improves Interdisciplinary Communication in the Pediatric Intensive Care Unit

Implementation of Nurse Integrated Rounds Improves Interdisciplinary Communication in the Pediatric Intensive Care Unit

The Association of PELOD-2 Score and Nutritional Status of Children Treated in the Pediatric Intensive Care Unit at Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar, 2020-2022

Background: The Pediatric Logistic Organ Dysfunction (PELOD-2) is used to measure the severity of vital organ dysfunction due to disease or other medical conditions in pediatric patients admitted to the Pediatric Intensive Care Unit (PICU). Nutritional status is a crucial factor affecting the body's ability to fight disease and the risk of complications. The aim was to evaluate the association between PELOD-2 scores and nutritional status in children treated in the PICU of Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar. Methods: This study employed a retrospective cross-sectional design using medical record data of children aged 1 month to 18 years treated in the PICU of Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar from January 2020 to December 2022. Data were collected from 428 subjects meeting the inclusion and exclusion criteria. Data analysis was performed using Chi-Square tests and logistic regression. Results: The study results indicated that PELOD-2 scores were significantly associated with poor nutritional status (OR: 1.71; 95% CI: 1.107–2.73), ventilator use (OR: 5.4; 95% CI: 3.336–8.913), and gender, with males being at higher risk (OR: 1.66; 95% CI: 1.042–2.654). Older age was found to be a protective factor against high PELOD-2 scores (ExpB: 0.996; 95% CI: 0.993–1.00). Conclusion: PELOD-2 scores are significantly associated with poor nutritional status, age, ventilator use, and gender in children treated in the PICU.

The Etiologic Organisms, Risk Factors, and Outcomes of Nosocomial Bloodstream Infections in Pediatric Patients

Background Much of the knowledge regarding pediatric healthcare-associated infections is based on studies conducted in adults. Here, we investigated clinical risk factors and etiologic organisms, focusing on antibiotic and antifungal resistance in pediatric patients with nosocomial bloodstream infections (nBSIs) in pediatric intensive care units (PICUs). Methods A retrospective evaluation was conducted on pediatric patients with nBSI in the PICUs of a tertiary referral hospital. Results A total of 69 nBSI episodes in 65 patients were observed during the study period. Of these, a total of 40 (57.97%) were caused by Gram-negative bacteria, 6 (8.7%) by Gram-positive bacteria, and 23 (33.33%) by Candida species. The rankings of Gram-negative bacteria were Klebsiella pneumoniae (37.5%), Acinetobacter baumannii (22.5%), and Serratia marcescens (12.5%). Carbapenem resistance was found to be common among K. pneumoniae (40%) and all Acinetobacter species. Most children (54.41%) had spent &gt;28 days in the PICU at the time of diagnosis of nBSI. The presence of central venous catheters was significantly associated with fungal nBSI (P = 0.047). Conclusions A high rate of antimicrobial resistance was observed among pathogens. A central venous catheter was associated with fungemia in children hospitalized in PICUs. Prolonged hospital stay before the diagnosis of BSI and the use of medical devices were found to be common in fungal infections.

Barriers to Implementing Family-Centered Care in Pediatric and Neonatal Intensive Care Units from the Perspectives of Nurses

Barriers to Implementing Family-Centered Care in Pediatric and Neonatal Intensive Care Units from the Perspectives of Nurses

Pediatric Intermediate Care Units: A Bridge Between Pediatric Ward and ICU Care.

Pediatric Intermediate Care Units: A Bridge Between Pediatric Ward and ICU Care.

Practical quality improvement changes for a low-resourced pediatric unit.

This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative. This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions. 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components. Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Evaluation of the results of the patients who underwent plasmapheresis in the pediatric intensive care unit.

Therapeutic plasma exchange (TPE) is an extracorporeal treatment method that removes large molecular weight substances from plasma. In our study, we aimed to retrospectively examine the indications and procedural methods of the patients who had undergone TPE, and the complications that occurred during the procedure. Forty-one patients who were monitored in thePICU of Gazi Yaşargil Training and Research Hospital and had indications for TPE between 2017 and 2021 were included in the study. Laboratory parameters were checked before and after the TPE procedure. In addition to these, patients' diagnosis, weight, type of procedure and type of device, where the procedure was performed, duration of the procedure, amount of blood and plasma processed, complications, number of procedures, and death during the procedure or independent of the procedure were evaluated. The median age was 93.0 (14.0-167.0) months. Hemolytic uremic syndrome (HUS) was the most common TPE indication with nine patients. The most common complication related to TPE was fever (11 patients), while no complication was observed in 18 patients.When laboratory results were evaluated according to American Society for Apheresis (ASFA) categories, a significant improvement was observed in the values of platelet, AST, ALT, LDH, urea, and creatinine in ASFA1 after TPE. No significant improvement was observed in ASFA2 (p > 0.05). In ASFA3, a significant improvement was observed in INR, AST, ALT, LDH, total bilirubin, creatinine, pH, and lactate values after TPE (p < 0.05). Five patients died from ASFA1, one from ASFA2, and three patients from ASFA3. Since significant adjustments are observed in clinical and laboratory values in sepsis-MOF, which is in the ASFA3 category, we believe that it should be evaluated in the ASFA2 or ASFA1 category in the early treatment of these diseases. In addition, we think that MIS-C cases, which have not been in any category according to ASFA, should be included in the ASFA2 or ASFA3 category, considering our TPE results.

Bio-electrical impedance phase angle and impedance ratio as predictors of disease severity among critically ill children

ObjectiveTo find out the predictive ability of bio-electrical impedance analysis (BIA) phase angle and impedance ratio for disease severity/mortality among critically ill children. MethodsA prospective observational study, among eighty-one children admitted to pediatric intensive care unit (PICU) was undertaken. Using bioelectrical impedance analyzer, phase angle (PA) and impedance ratio (IR) were recorded. Pediatric index mortality score (PIM3) was used to assess disease severity and mortality. Length of hospital stay (LOS), 30-day mortality, demographic and anthropometric measurements were recorded. ResultsMean age of the patients was 4.11 ± 4.60 years, majority were males (54.32 %). Mortality was 6.2 %. IR was significantly lower among survivor group than non-survivor group, while rest of the variables were comparable. The mean PIM3 score was lower (12.71 ± 7.39) among survivors than non-survivors (14.56 ± 5.56). Receiver operator characteristic (ROC) curve analysis showed a cutoff of 3.9° PA predicted the mortality with sensitivity of 93 % and specificity of 86.8 %. At a cutoff of 0.879, IR predicted the mortality with sensitivity and specificity of 93 %. The LOS increased with disease severity, and this difference was statistically significant. Although the mean LOS among survivors was less in comparison to the non-survivors; this difference was not statistically significant. ConclusionsBio-electric impedance PA and IR at the time of PICU admission can be used as an independent predictor of disease severity and 30-day mortality and can be a prognostic marker. Further multicentric studies with large sample size can strengthen our study findings.

Compliance with antibiotic therapy guidelines in french paediatric intensive care units: a multicentre observational study

BackgroundBacterial infections (BIs) are widespread in ICUs. The aims of this study were to assess compliance with antibiotic recommendations and factors associated with non-compliance.MethodsWe conducted an observational study in eight French Paediatric and Neonatal ICUs with an antimicrobial stewardship programme (ASP) organised once a week for the most part. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns < 72 h old, neonates < 37 weeks, age ≥ 18 years and children under surgical antimicrobial prophylaxis were excluded.Results139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% with no BI, 40.3% presumed (i.e., not documented) BI and 35.3% documented BI. Non-compliance with antibiotic recommendations occurred in 51.1%. The main reasons for non-compliance were inappropriate choice of antimicrobials (27.3%), duration of one or more antimicrobials (26.3%) and length of antibiotic therapy (18.0%). In multivariate analyses, the main independent risk factors for non-compliance were prescribing ≥ 2 antibiotics (OR 4.06, 95%CI 1.69–9.74, p = 0.0017), duration of broad-spectrum antibiotic therapy ≥ 4 days (OR 2.59, 95%CI 1.16–5.78, p = 0.0199), neurologic compromise at ICU admission (OR 3.41, 95%CI 1.04–11.20, p = 0.0431), suspected catheter-related bacteraemia (ORs 3.70 and 5.42, 95%CIs 1.32 to 15.07, p < 0.02), a BI site classified as “other” (ORs 3.29 and 15.88, 95%CIs 1.16 to 104.76, p < 0.03), sepsis with ≥ 2 organ dysfunctions (OR 4.21, 95%CI 1.42–12.55, p = 0.0098), late-onset ventilator-associated pneumonia (OR 6.30, 95%CI 1.15–34.44, p = 0.0338) and ≥ 1 risk factor for extended-spectrum β-lactamase-producing Enterobacteriaceae (OR 2.56, 95%CI 1.07–6.14, p = 0.0353). Main independent factors for compliance were using antibiotic therapy protocols (OR 0.42, 95%CI 0.19–0.92, p = 0.0313), respiratory failure at ICU admission (OR 0.36, 95%CI 0.14–0.90, p = 0.0281) and aspiration pneumonia (OR 0.37, 95%CI 0.14–0.99, p = 0.0486).ConclusionsHalf of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should reassess on a day-to-day basis the benefit of using several antimicrobials or any broad-spectrum antibiotics and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using department protocols seem necessary to reduce non-compliance. A daily ASP could also improve compliance in these situations.Trial RegistrationClinicalTrials.gov: number NCT04642560. The date of first trial registration was 24/11/2020.

Comparison of radiologic findings between SARS-CoV-2 and other respiratory tract viruses in critically ill children during the COVID-19 pandemic.

This study was planned because the radiological distinction of COVID-19 and respiratory viral panel (RVP)-positive cases is necessary to prioritize intensive care needs and ensure non-COVID-19 cases are not overlooked. With that purpose, the objective of this study was to compare radiologic findings between SARS-CoV-2 and other respiratory airway viruses in critically ill children with suspected COVID-19 disease. This study was conducted as a multicenter, retrospective, observational, and cohort study in 24 pediatric intensive care units between March 1 and May 31, 2020. SARS-CoV-2- or RVP polymerase chain reaction (PCR)-positive patients' chest X-ray and thoracic computed tomography (CT) findings were evaluated blindly by pediatric radiologists. We enrolled 225 patients in the study, 81 of whom tested positive for Coronovirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The median age of all patients was 24 (7-96) months, while it was 96 (17-156) months for COVID-19-positive patients and 17 (6-48) months for positive for other RVP factor (p < 0.001). Chest X-rays were more frequently evaluated as normal in patients with SARS-CoV-2 positive results (p = 0.020). Unilateral segmental or lobar consolidation was observed more frequently on chest X-rays in rhinovirus cases than in other groups (p = 0.038). CT imaging findings of bilateral peribronchial thickening and/or peribronchial opacity were more frequently observed in RVP-positive patients (p = 0.046). Chest X-ray and CT findings in COVID-19 patients are not specific and can be seen in other respiratory virus infections.

Association of EEG characteristics with outcomes following pediatric ICU cardiac arrest: A secondary analysis of the ICU-RESUScitation trial

Background and ObjectivesThere are limited tools available following cardiac arrest to prognosticate neurologic outcomes. Prior retrospective and single center studies have demonstrated early EEG features are associated with neurologic outcome. This study aimed to evaluate the prognostic value of EEG for pediatric in-hospital cardiac arrest (IHCA) in a prospective, multicenter study. MethodsThis cohort study is a secondary analysis of the ICU-Resuscitation trial, a multicenter randomized interventional trial conducted at 18 pediatric and pediatric cardiac ICUs in the United States. Patients who achieved return of circulation (ROC) and had post-ROC EEG monitoring were eligible for inclusion. Patients < 90 days old and those with pre-arrest Pediatric Cerebral Performance Category (PCPC) scores > 3 were excluded. EEG features of interest included EEG Background Category, and presence of focal abnormalities, sleep spindles, variability, reactivity, periodic and rhythmic patterns, and seizures. The primary outcome was survival to hospital discharge with favorable neurologic outcome. Associations between EEG features and outcomes were assessed with multivariable logistic regression. Prediction models with and without EEG Background Category were developed and receiver operator characteristic curves compared. ResultsOf the 1129 patients with an index cardiac arrest who achieved ROC in the parent study, 261 had EEG within 24 h of ROC, of which 151 were evaluable. The cohort included 57% males with a median age of 1.1 years (IQR 0.4, 6.8). EEG features including EEG Background Category, sleep spindles, variability, and reactivity were associated with survival with favorable outcome and survival, (all p < 0.001). The addition of EEG Background Category to clinical models including age category, illness category, PRISM score, duration of CPR, first documented rhythm, highest early post-arrest arterial lactate improved the prediction accuracy achieving an AUROC of 0.84 (CI 0.77–0.92), compared to AUROC of 0.76 (CI 0.67–0.85) (p = 0.005) without EEG Background Category. ConclusionThis multicenter study demonstrates the value of EEG, in the first 24 h following ROC, for predicting survival with favorable outcome after a pediatric IHCA.

Evaluation of traumatic spinal injuries: a pediatric perspective.

The aim of the present study is to provide information about pediatric patients with spinal trauma. A single-center retrospective chart review was carried out. Children who arrived at the pediatric emergency department due to trauma and those with spinal pathology confirmed by radiological assessment were included. Demographics, mechanisms of trauma, clinical findings, radiological investigations, applied treatments, hospital stay and prognosis were recorded. A total of 105 patients [59 (56.2%) boys; mean age: 12.9 ± 3.8years (mean ± SD)] were included. The most common age group was that of 14-18years (58.1%). The three most common trauma mechanisms were road traffic collisions (RTCs) (60.0%), falls (32.4%), and diving into water (2.9%). A fracture of the spine was detected in 97.1% patients, vertebral dislocation in 10.7%, and spinal cord injury in 16.3%. Of the patients, 36.9% were admitted to the ward and 18.4% to the pediatric intensive care unit; 17.1% were discharged with severe complications and 2.9% cases resulted in death. While 34.3% of the patients had a clinically isolated spine injury, the remaining cases entailed an injury to at least one other body part; the most common associated injuries were to the head (39.8%), abdomen (36.1%), and external areas (28.0%). Spinal trauma was found to have occurred mostly in adolescent males, and the majority of those cases were due to RTCs. Data on the incidence and demographic factors of pediatric spinal trauma are crucial in furthering preventive measures, allowing for the identification of at-risk populations and treatment modalities.

Feasibility of Achieving Nutritional Adequacy in Critically Ill Children with Critical Neurological Illnesses (CNIs)?-A Quaternary Hospital Experience.

The literature on the nutritional needs and outcomes of critically ill children is scarce, especially on those with critical neurological illnesses (CNIs). Current evidence shows a lower mortality in patients who achieve two-thirds of their nutritional needs during the first week of pediatric intensive care unit (PICU) admission. We hypothesized that achieving 60% of the recommended dietary intake during the first week of a PICU stay is not feasible in patients with CNI. We designed an observational retrospective cohort study where we included all index admissions to the PICU in our institution of children (1 month to 18 years) with CNI from January 2018 to June 2021. We collected patient demographics, anthropometric measures, and caloric and protein intake (enteral and parenteral) information during the first week of PICU admission. Goal adequacy for calories and protein was defined as [(intake/recommended) × 100] ≥ 60%. A total of 1112 patients were included in the nutrition assessment, 12% of whom were underweight (weight for age z score < -2). Of this group, 180 met the criteria for nutrition support evaluation. On the third day of admission, 50% of the patients < 2 years achieved caloric and protein goal adequacy, compared to 25% of patients > 2 years, with p-values of 0.0003 and 0.0004, respectively. Among the underweight patients, 60% achieved both caloric and protein goal adequacy by day 3 vs. 30% of non-underweight patients with p-values of 0.0006 and 0.002, respectively. The results show that achieving 60% of the recommended dietary intake by days 5 and 7 of admission was feasible in more than half of the patients in this cohort. Additionally, children who were evaluated by a clinical dietician during the first 48 h of PICU admission reached higher nutrition adequacy.