Pediatric Cerebral Performance Category Score Research Articles

Outcomes of Day 1 Multiple Organ Dysfunction Syndrome in the PICU.

We sought to describe current outcomes of Multiple Organ Dysfunction Syndrome present on day 1 of PICU admission. Retrospective observational cohort study. Virtual Pediatric Systems, LLC, database admissions, January 2014 and December 2015. We analyzed 194,017 consecutive PICU admissions, (age 1 mo to 18 yr) from the 2014-2015 Virtual Pediatric Systems database. We identified day 1 Multiple Organ Dysfunction Syndrome by International Pediatric Sepsis Consensus Conference criteria with day 1 laboratory and vital sign values. Functional status was evaluated by Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores from PICU admission and discharge. Overall, PICU mortality was 2.1%. We identified day 1 Multiple Organ Dysfunction Syndrome in 14.4% of admissions. Patients with Multiple Organ Dysfunction Syndrome had higher mortality than those without Multiple Organ Dysfunction Syndrome (10.3% vs 0.7%; p < 0.0001), and a higher percentage of survivors had greater than or equal to 2 category worsening in Pediatric Cerebral Performance Category score (3.6% vs 0.5%; p < 0.0001) or Pediatric Overall Performance Category score (6.0% vs 1.8%; p < 0.0001). The odds of death with day 1 Multiple Organ Dysfunction Syndrome was 14.3 (95% CI, 13-15.7), while the odds of death or discharge with Pediatric Overall Performance Category/Pediatric Cerebral Performance Category score greater than or equal to 3 (poor functional outcome) was 6.7 (95% CI, 6-7.4). In a subset of 148,188 patients from hospitals where limitation of support decisions were recorded, 5.8% patients with Multiple Organ Dysfunction Syndrome had limitation of support decisions in place, compared with 0.8% of patients without Multiple Organ Dysfunction Syndrome (p < 0.0001). Of day 1 Multiple Organ Dysfunction Syndrome patients who died, 43.1% had limitation of support decisions in place, and 41.6% had withdrawal of life-sustaining therapies (p < 0.0001). Multiple Organ Dysfunction Syndrome present on day 1 of admission continues to be a major source of morbidity and mortality in the PICU, but risk of poor neurologic outcome may be improved. Further research is needed to understand decisions regarding limitation of support and withdrawal of life-sustaining therapy decisions in patients admitted with day 1 Multiple Organ Dysfunction Syndrome.

The Base Deficit, International Normalized Ratio, and Glasgow Coma Scale (BIG) Score, and Functional Outcome at Hospital Discharge in Children With Traumatic Brain Injury.

To examine the association of the base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score on emergency department arrival with functional dependence at hospital discharge (Pediatric Cerebral Performance Category ≥ 4) in pediatric multiple trauma patients with traumatic brain injury. A retrospective cohort study of a pediatric trauma database from 2001 to 2018. Level 1 trauma program at a university-affiliated pediatric institution. Two to 17 years old children sustaining major blunt trauma including a traumatic brain injury and meeting trauma team activation criteria. None. Two investigators, blinded to the BIG score, determined discharge Pediatric Cerebral Performance Category scores. The BIG score was measured on emergency department arrival. The 609 study patients were 9.7 ± 4.4 years old with a median Injury Severity Score 22 (interquartile range, 12). One-hundred seventy-one of 609 (28%) had Pediatric Cerebral Performance Category greater than or equal to 4 (primary outcome). The BIG constituted a multivariable predictor of Pediatric Cerebral Performance Category greater than or equal to 4 (odds ratio, 2.39; 95% CI, 1.81-3.15) after adjustment for neurosurgery requirement (odds ratio, 2.83; 95% CI, 1.69-4.74), pupils fixed and dilated (odds ratio, 3.1; 95% CI, 1.49-6.38), and intubation at the scene or referral hospital (odds ratio, 2.82; 95% CI, 1.35-5.87) and other postulated predictors of poor outcome. The area under the BIG receiver operating characteristic curve was 0.87 (0.84-0.90). Using an optimal BIG cutoff less than or equal to 8, sensitivity and negative predictive value for functional dependence at discharge were 93% and 96%, respectively, compared with a sensitivity of 79% and negative predictive value of 91% with Glasgow Coma Scale less than or equal to 8. In children with Glasgow Coma Scale 3, the BIG score was associated with brain death (odds ratio, 2.13; 95% CI, 1.58-2.36). The BIG also predicted disposition to inpatient rehabilitation (odds ratio, 2.26; 95% CI, 2.17-2.35). The BIG score is a simple, rapidly obtainable severity of illness score that constitutes an independent predictor of functional dependence at hospital discharge in pediatric trauma patients with traumatic brain injury. The BIG score may benefit Trauma and Neurocritical care programs in identifying ideal candidates for traumatic brain injury trials within the therapeutic window of treatment.

Early EEG Features for Outcome Prediction After Cardiac Arrest in Children.

We aimed to determine which early EEG features and feature combinations most accurately predicted short-term neurobehavioral outcomes and survival in children resuscitated after cardiac arrest. This was a prospective, single-center observational study of infants and children resuscitated from cardiac arrest who underwent conventional EEG monitoring with standardized EEG scoring. Logistic regression evaluated the marginal effect of each EEG variable or EEG variable combinations on the outcome. The primary outcome was neurobehavioral outcome (Pediatric Cerebral Performance Category score), and the secondary outcome was mortality. The authors identified the models with the highest areas under the receiver operating characteristic curve (AUC), evaluated the optimal models using a 5-fold cross-validation approach, and calculated test characteristics maximizing specificity. Eighty-nine infants and children were evaluated. Unfavorable neurologic outcome (Pediatric Cerebral Performance Category score 4-6) occurred in 44 subjects (49%), including mortality in 30 subjects (34%). A model incorporating a four-level EEG Background Category (normal, slow-disorganized, discontinuous or burst-suppression, or attenuated-flat), stage 2 Sleep Transients (present or absent), and Reactivity-Variability (present or absent) had the highest AUC. Five-fold cross-validation for the optimal model predicting neurologic outcome indicated a mean AUC of 0.75 (range, 0.70-0.81) and for the optimal model predicting mortality indicated a mean AUC of 0.84 (range, 0.76-0.97). The specificity for unfavorable neurologic outcome and mortality were 95% and 97%, respectively. The positive predictive value for unfavorable neurologic outcome and mortality were both 86%. The specificity of the optimal model using a combination of early EEG features was high for unfavorable neurologic outcome and mortality in critically ill children after cardiac arrest. However, the positive predictive value was only 86% for both outcomes. Therefore, EEG data must be considered in overall clinical context when used for neuroprognostication early after cardiac arrest.

Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score

BackgroundThe length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission.MethodsWe performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017.ResultsOverall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%).ConclusionsPediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission.

Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale.

Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU. Prospective observation study. Large academic PICU. All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate. None. PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss' Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05). A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.

Five-year survival, performance, and neurodevelopmental outcome following cardiopulmonary resuscitation after pediatric cardiac surgery, preliminary investigation in a single-center experience

Background and aimChildren who suffer cardiopulmonary arrest (CPA) after cardiac surgery frequently survive with return of spontaneous circulation. However, their neurodevelopmental outcomes and performance are still unclear. The aim of this study is to evaluate the midterm neurodevelopmental outcome and overall performance of children who survived CPA following cardiac surgery. Materials and methodsIn this cohort study, we followed-up children who received cardiopulmonary resuscitation (CPR) post cardiac surgery during 2012–2013. We assessed their 5-year survival, functional, and neurodevelopmental outcomes using two performance scales: Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Both scales ranged from 1 for normal to 6 for brain death/death. We compared CPR group with a matching group (1:1) that had similar characteristics and conditions but no CPR. ResultsOut of 758 postoperative cardiac children, 15 (2%) children had 19 episodes of CPA. Their median age was 10 months (0.5–168). Survival rates were 12/15 (80%) on hospital discharge and 10/15 (66%) after 5 years. Among 12 survivors, two patients (17%) scored 6, one (8%) scored 4, five (42%) scored 2, and four (33%) scored 1 on both PCPC and POPC. The median PCPC and POPC scores were [2, (interquartile range: 1–6) and 1, (interquartile range: 1–3, p = 0.018] for CPR and matching group, respectively. Regression analysis identifies duration of CPR, number of CPR session, and late-occurring CPA as risk factors for poor outcome. ConclusionTwo-thirds of children requiring CPR post cardiac surgery survived after 5 years. Their neurodevelopmental and functional evaluation demonstrated worse outcome in comparison with their matching cases. CPR duration, number of CPA events, and late CPA were risk factors for poor outcome. Rehabilitation and special education programs might be needed for these groups of children with special needs.

Combination of Early EEG, Brain CT, and Ammonia Level Is Useful to Predict Neurologic Outcome in Children Resuscitated From Cardiac Arrest.

Purpose: Predicting neurologic prognosis in pediatric patients recovered after cardiac arrest is more difficult than in adults. This study hypothesized that a combination model of early electroencephalography, brain computed tomography (CT), and laboratory findings improve prediction performance of neurologic outcome in pediatric patients after cardiac arrest.Methods: We retrospectively analyzed the medical records of pediatric patients resuscitated after non-traumatic cardiac arrest. Clinical features, electroencephalography, gray matter to white matter attenuation ratio on brain CT, and laboratory findings were analyzed. The primary outcome was neurologic prognosis based on the Pediatric Cerebral Performance Category score.Results: Of 21 patients, seven (33.3%) were classified as a good neurologic outcome group and 14 (66.7%) were classified as a poor neurologic outcome group. The good outcome group was associated with a slow and disorganized electroencephalographic background pattern (P = 0.006), reactivity (P = 0.006), and electrographic seizures (P = 0.03). The frequency of a suppressed electroencephalographic background pattern was significantly higher in the poor outcome group (P = 0.006). The poor outcome group was also associated with a low level of gray matter to white matter attenuation ratio (P = 0.03) and hyperammonemia (P = 0.003). The area under curve of the combined model, consisting of electroencephalographic background, gray matter to white matter attenuation ratio, and ammonia was the highest at 0.959 (0.772–0.999) with a specificity of 100%.Conclusion: Unfavorable electroencephalographic background, low gray matter to white matter attenuation ratio on brain CT, and hyperammonemia are associated with poor neurologic outcome in children after cardiac arrest.

Hyponatremia in Children With Bacterial Meningitis.

Background: Hyponatremia has frequently been described as a common complication associated with bacterial meningitis, though its frequency and clinical course in children with bacterial meningitis are unclear. The present study aimed to investigate the frequency, clinical characteristics, and prognosis associated with pediatric hyponatremia due to bacterial meningitis.Methods: We performed a retrospective review of children with bacterial meningitis provided with standard care. One hundred seventy-five children were included. We documented all participants' symptoms and signs, laboratory and microbiological data, radiological findings, and complications that occurred during their hospital admission. Disease severity was determined using the maximum Pediatric Cerebral Performance Category (PCPC) and minimum Glasgow Coma Scale (GCS). Residual deficits were assessed using PCPC at discharge.Results: Hyponatremia (<135 mmol/L) was seen in 116 (66.4%) of the patients assessed and was classified as mild (130–135 mmol/L) in 77, moderate (125–129 mmol/L) in 26, and severe (<125 mmol/L) in 13. Hyponatremia was associated with a shorter duration of symptoms before admission, higher CSF white cell counts, and a longer duration of hospitalization. Moderate and severe hyponatremia were associated with an increase in convulsions, impaired consciousness, altered CSF protein levels, higher maximum PCPC scores, and lower minimum GCS scores. Severe hyponatremia was further associated with the development of systemic complications including shock, multiple organ dysfunction syndrome, respiratory failure requiring mechanical ventilation, and an increase in poor outcome (PCPC ≥ 2). Hyponatremia was not associated with the development of neurologic complications. Logistic regression analyses revealed that convulsions (OR 12.09, 95% CI 2.63–56.84) and blood glucose levels > 6.1 mmol/L (OR 8.28, 95% CI 1.65–41.60) predicted severe hyponatremia.Conclusion: Hyponatremia occurred in 66.4% of the assessed pediatric bacterial meningitis patients. Moderate and severe hyponatremia affected the severity of pediatric bacterial meningitis. Only severe hyponatremia affected the short-term prognosis of patients with pediatric bacterial meningitis. We recommend that patients with pediatric bacterial meningitis who exhibit convulsions and increased blood glucose levels should be checked for severe hyponatremia. Further studies are needed to evaluate the effectiveness of treatment of hyponatremia.

Factors Associated With Poor Outcome in Pediatric Near-Hanging Injuries.

Hanging injury is the most common method of suicide among children 5 to 11years of age and near-hangings commonly occur. Adult studies in near-hanging injury have shown that need for cardiopulmonary resuscitation, initial blood gas, and poor mental status are associated with poor prognosis. The literature for similar factors in children is lacking. This retrospective, single-center study was performed to identify the clinical factors associated with neurologic outcome in children after near-hanging. Inclusion criteria included <18years of age and a diagnosis of near-hanging or strangulation. All physician documentation was reviewed, and incidences of respiratory complications, seizure, and multiorgan failure were noted. Pediatric cerebral performance category score was based on information at discharge and was defined as favorable (score of 1-4) or unfavorable (score of 5-6). Comparisons were made between outcome groups and suspected clinical factors. The median age was 11.5years with a median initial Glasgow Coma Scale (GCS) score of 10. Of all patients, 25% had a prehospital cardiac arrest, and 51% were admitted to the intensive care unit. Patients with unfavorable outcomes had a lower initial pH (6.9 vs. 7.3) and initial GCS score (3T vs. 14). Patients with an unfavorable outcome had significantly higher rates of intensive care unit admission, respiratory complications, anoxic brain injury, and multiorgan failure. No patient who presented with an initial GCS score of 3T and prehospital cardiac arrest had a favorable neurologic outcome. This is the largest single-center study of children with near-hanging injury. An initial GCS score of 3T and prehospital cardiac arrest was uniformly associated with poor neurologic outcome.

Quantitative EEG predicts outcomes in children after cardiac arrest.

To determine whether quantitative EEG (QEEG) features predict neurologic outcomes in children after cardiac arrest. We performed a single-center prospective observational study of 87 consecutive children resuscitated and admitted to the pediatric intensive care unit after cardiac arrest. Full-array conventional EEG data were obtained as part of clinical management. We computed 8 QEEG features from 5-minute epochs every hour after return of circulation. We developed predictive models utilizing random forest classifiers trained on patient age and 8 QEEG features to predict outcome. The features included SD of each EEG channel, normalized band power in alpha, beta, theta, delta, and gamma wave frequencies, line length, and regularity function scores. We measured outcomes using Pediatric Cerebral Performance Category (PCPC) scores. We evaluated the models using 5-fold cross-validation and 1,000 bootstrap samples. The best performing model had a 5-fold cross-validation accuracy of 0.8 (0.88 area under the receiver operating characteristic curve). It had a positive predictive value of 0.79 and a sensitivity of 0.84 in predicting patients with favorable outcomes (PCPC score of 1-3). It had a negative predictive value of 0.8 and a specificity of 0.75 in predicting patients with unfavorable outcomes (PCPC score of 4-6). The model also identified the relative importance of each feature. Analyses using only frontal electrodes did not differ in prediction performance compared to analyses using all electrodes. QEEG features can standardize EEG interpretation and predict neurologic outcomes in children after cardiac arrest.

Readmissions to the ICU Among Children With Tracheostomies Placed After Cardiac Arrest.

Describe clinical outcomes and risk factors for ICU readmissions in a cohort of children who underwent tracheostomy placement after cardiac arrest. A retrospective, multicenter cohort analysis of children <18 years old admitted to a Virtual Pediatric Systems, LLC-participating PICU from January 2009 to December 2016 and underwent tracheostomy after cardiac arrest. Among 394 index admissions, the median age was 16.8 months (interquartile range [IQR] 5.3-89.3), and Pediatric Risk of Mortality 3 scores (median 9 [IQR 4.75-16]) indicated severe illness. Baseline neurologic function was generally age appropriate (Pediatric Cerebral Performance Category score: median 2 [IQR 1-3]). The most common primary diagnosis categories were respiratory (31.0%), cardiac (21.6%), and injury and/or poisoning (18.3%). Post-tracheostomy mortality during the index admission was 9.3%. Among the 358 patients who survived to discharge, 334 had >180 days of available follow-up data. Two hundred and five (61.4%) patients were readmitted at least once for a total of 643 readmissions (range 0-30; median 1 [IQR 0-2]). We observed 0.54 readmissions per patient-year. The median time to first readmission was 50.3 days (IQR 12.8-173.7). Significant risk factors for readmission included a pre-existing diagnosis of chronic lung disease, congenital heart disease and/or heart failure, prematurity, and new seizures during the index admission. The most common indication for readmission was respiratory illness (46.2%). Mortality (3.3%) and procedural burden during readmission were consistent with general PICU care. ICU readmission among children who undergo postarrest tracheostomy is common, usually due to respiratory causes, and involves outcomes and resource use similar to other ICU admissions. Risk factors for readmission are largely nonmodifiable.

Clinical characteristics and prognosis of pediatric intracranial hemorrhage in pediatric intensive care unit: a prospective and single-center study

Objective To describe the etiology, clinical characteristics and prognosis in children with intracranial hemorrhage who were admitted to pediatric intensive care unit (PICU) and to analyze factors associated with poor prognosis, in order to provide evidence for prevention and early prognosis evaluation. Methods This was a prospective, single-center study including the children with intracranial hemorrhage who were admitted to PICU of Beijing Children′s Hospital from October 1, 2014 to January 31, 2017.Children′s basic information and survival on the 28th day after hospital discharge were collected.Prognosis was evaluated by means of pediatric cerebral performance category score (PCPC) or pediatric overall performance category score (POPC). The related factors with poor prognosis were analyzed. Results Ninety-five children(58 boys and 37 girls) were included; mortality at hospital and on the 28th day after discharge were 7.4% and 22.1%, respectively.Trauma(68.4%) was the most common cause for intracranial hemorrhage(ICH). The most common cause of spontaneous intracranial hemorrhage in infants was vitamin K deficiency (4/16 cases, 0.25), but hematological diseases in school-aged children (7/11 cases, 63.6%). Univariate analysis showed intraparenchymal, intraventricular, extradural hemorrhage.Multiple sites hemorrhage, trauma, hematological system diseases, surgery, and low Glasgow coma scale(GCS) at PICU discharge were associated with poor prognosis(χ2=9.653, 10.658, 7.237, 5.657, 10.966, 4.471, 7.429, 31.308, all P<0.05). Multivariate analysis showed that intraventricular hemorrhage and low GCS at PICU discharge were independent risk factors for poor prognosis(all P<0.001). ICH caused by trauma had a relatively better prognosis(P=0.015). Conclusions The majority of patients with ICH admitted to PICU are infants.The most common cause is trauma.The most common cause of spontaneous ICH in infants is vitamin K deficiency, but hematological diseases in school-aged children.ICH and low GCS at PICU discharge are independent risk factors for poor prognosis.ICH caused by trauma has a relatively better prognosis.Reducing accidental injury is the key to prevent ICH in children. Key words: Intracranial hemorrhage; Child; Trauma; Prognosis

The prognostic value of quantitative diffusion-weighted MRI after pediatric cardiopulmonary arrest

ObjectivesThe prognostic value of quantitative diffusion-weighted magnetic resonance imaging (DWI MRI) in predicting neurologic outcomes after pediatric cardiopulmonary arrest (CPA) has not been determined. The aim of this study was to identify a DWI MRI threshold for brain volume percent that correlates with neurologic outcome in children who remain comatose or display significant neurologic deficits immediately after resuscitation from CPA. MethodsThis single-center retrospective study analyzed DWI MRIs of pediatric patients who remained neurologically impaired after CPA. Any MRI obtained within 2 weeks after CPA was analyzed. The apparent diffusion coefficient (ADC) value of each voxel within the brain was determined. Percentage brain volume with voxels below each ADC threshold between 300 and 1200 × 10−6 mm2/s with a step of 50 were calculated. Area under the receiver operating characteristics curve (AUC) was used to identify optimal DWI MRI thresholds for brain volume percent most predictive of poor neurologic outcome. The primary outcome measure was neurologic outcome 6-months after CPA based on Pediatric Cerebral Performance Category (PCPC) score. Poor neurologic outcome was defined as PCPC score of 3–6, or a worsening from baseline score ≥1 if baseline PCPC score was ≥3. ResultsTwenty-six patients were included in this study. The median age was 8.5 years (2.2–14) and median time from CPA to MRI was 4 days (2–7). Two ADC thresholds for brain volume percent had the largest AUC for predicting poor neurologic outcome. An ADC threshold of <600 × 10−6 mm2/s in ≥7% of brain volume; and <650 × 10−6 mm2/s in ≥11% of brain volume both demonstrated a specificity of 1.0 (0.76–1.0, 95% CI) and a sensitivity of 0.8 (0.44–0.96, 95% CI) for poor outcome. ConclusionsIn pediatric patients who remain comatose or have significant neurologic deficits after CPA, quantitative DWI MRI correlates with neurologic outcome. Both an ADC threshold of <600 × 10−6 mm2/s in ≥7% of brain volume and <650 × 10−6 mm2/s in ≥11% of brain volume are highly specific for predicting poor neurologic outcome. A prospective trial to validate these thresholds is needed.

Nonconvulsive Seizure Detection by Reduced-Lead Electroencephalography in Children with Altered Mental Status in the Emergency Department

To evaluate the proportion of children presenting to the emergency department (ED) with altered mental status who demonstrate nonconvulsive seizures on reduced-lead electroencephalography (EEG), and to further investigate the characteristics, treatment, and outcomes in these patients compared with patients without nonconvulsive seizures. In this retrospective cohort study, we reviewed the database and medical records of pediatric patients (aged <18 years) in a single ED between May 1, 2016, and April 30, 2018. We first determined the proportion of nonconvulsive seizures among patients with altered mental status (Glasgow Coma Scale <15). We then compared the clinical presentation, demographic data, clinical diagnosis, EEG results, treatment, and outcomes of patients with altered mental status with nonconvulsive seizures and those without nonconvulsive seizures. In total, 16.9% of the patients with altered mental status (41 of 242; 95% CI, 12.2%-21.6%) evaluated by EEG had detectable nonconvulsive seizure, equivalent to 4.4% (41 of 932) of all patients with altered mental status presenting at our hospital. More than 80% of patients monitored for nonconvulsive seizures had a previous history of seizures, often febrile. Patients with nonconvulsive seizures were older (median, 68.5 vs 36.1 months) and had a higher Pediatric Cerebral Performance Category score at presentation (median, 2.0 vs 1.0). In addition, the proportion of patients admitted to the intensive care unit was significantly higher in the patients with nonconvulsive seizures (30.3% vs 15.0%). However, total duration of hospitalization, neurologic sequelae, and 30-day mortality rate did not differ between the 2 groups. A relatively high percentage of pediatric patients with altered mental status in the ED experience nonconvulsive seizures. The use of reduced-lead EEG monitoring in the ED might facilitate the recognition and treatment of nonconvulsive seizures, especially among patients with a history of seizures.

Healthcare Utilization Following Pediatric Out-of-Hospital Cardiac Arrest

Background: Understanding long term health care utilization after survival of a pediatric OHCA (out-of-hospital cardiac arrest) may allow more fully integrated and cost-conscious health care. Objective: To evaluate frequency and type of re-hospitalizations, procedures and hospital charges for pediatric OHCA survivors. Methods: Retrospective cohort study from 1/1/1976 to 12/31/2007 of persons Results: Patients were female (49.4%) and ≤ 5 years (43.2%). 53% were readmitted in 189 readmission events, most commonly respiratory (30%) and cardiac (21%) related. Those with unfavorable Pediatric Cerebral Performance Category (PCPC) scores at initial discharge were at higher risk for ≥ 3 hospital readmissions compared to those with favorable PCPC scores (RR 5.94 (95% CI 1.50, 23.61)). Unwitnessed compared to witnessed events were associated with an increased risk of ≥ 3 hospital readmissions (RR 2.59 [95% CI 1.26, 5.31]). Upon readmission, half of patients required procedures of which acute, unplanned procedures including intubation, central and arterial line placement were most common. Adjusted to 2017 consumer price index, average charges/hospitalization were $67,005. Over long-term follow-up, the median adjusted total hospital charges/survivor were $123,190 ($11,091-$822,677). Conclusions: This demonstrates that many children who survive OHCA will develop new chronic health conditions requiring hospital readmission and additional procedures. This data should help parents, primary care providers and subspecialists anticipate and address subsequent needs prior to discharge after the arrest. Early coordinated interventions and establishment of effective outpatient services may reduce hospital readmissions and cost.

Overcoming Barriers to Delirium Screening in the Pediatric Intensive Care Unit.

Delirium is associated with poor outcomes in adults but is less extensively studied in children. To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion. A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case-control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed. Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and "busy patient." Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9-12] vs 12 [10-13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001). Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.

Intensive care resources required to care for critically ill children with focal intracranial infections.

The authors reviewed cases in which children with a focal infection inside the head (ex: a brain abscess) were cared for in their pediatric ICU to describe the frequency of complications and quantify the ICU resources needed (ex: breathing tube, blood pressure medications, and/or an intracranial pressure monitor). This information helps clarify illness severity and has identified complications that we should further investigate to improve care for these children.

Traumatic Brain Injury and Infectious Encephalopathy in Children From Four Resource-Limited Settings in Africa.

To assess the frequency, interventions, and outcomes of children presenting with traumatic brain injury or infectious encephalopathy in low-resource settings. Prospective study. Four hospitals in Sub-Saharan Africa. Children age 1 day to 17 years old evaluated at the hospital with traumatic brain injury or infectious encephalopathy. None. We evaluated the frequency and outcomes of children presenting consecutively over 4 weeks to any hospital department with traumatic brain injury or infectious encephalopathy. Pediatric Cerebral Performance Category score was assessed pre morbidity and at hospital discharge. Overall, 130 children were studied (58 [45%] had traumatic brain injury) from hospitals in Ethiopia (n = 51), Kenya (n = 50), Rwanda (n = 20), and Ghana (n = 7). Forty-six percent had no prehospital care, and 64% required interhospital transport over 18 km (1-521 km). On comparing traumatic brain injury with infectious encephalopathy, there was no difference in presentation with altered mental state (80% vs 82%), but a greater proportion of traumatic brain injury cases had loss of consciousness (80% vs 53%; p = 0.004). Traumatic brain injury patients were older (median [range], 120 mo [6-204 mo] vs 13 mo [0.3-204 mo]), p value of less than 0.001, and more likely male (73% vs 51%), p value of less than 0.01. In 78% of infectious encephalopathy cases, cause was unknown. More infectious encephalopathy cases had a seizure (69% vs 12%; p < 0.001). In regard to outcome, infectious encephalopathy versus traumatic brain injury: hospital lengths of stay were longer for infectious encephalopathy (8 d [2-30 d] vs 4 d [1-36 d]; p = 0.003), discharge rate to home, or for inpatient rehabilitation, or death differed between infectious encephalopathy (85%, 1%, and 13%) and traumatic brain injury (79%, 12%, and 1%), respectively, p value equals to 0.044. There was no difference in the proportion of children surviving with normal or mild disability (73% traumatic brain injury vs 79% infectious encephalopathy; p = 0.526). The epidemiology and outcomes of pediatric traumatic brain injury and infectious encephalopathy varied by center and disease. To improve outcomes of these conditions in low-resource setting, focus should be on neurocritical care protocols for pre-hospital, hospital, and rehabilitative care.

Abstract O-22: SEDATION MANAGEMENT FOR CRITICALLY ILL CHILDREN WITH PRE-EXISTING COGNITIVE IMPAIRMENTS: IS IT DIFFERENT?

Aims & Objectives: While analgesia and sedation are essential for critically-ill children with pre-existing cognitive impairment (CI), the effectiveness of current strategies in this population remains unexplored. Here we compare current analgesia and sedation management practices between patients with CI and neurotypical (NT) children in the PICU. Methods Secondary analysis of existing data from the RESTORE trial of children admitted to the PICU for acute respiratory failure. We defined CI as baseline Pediatric Cerebral Performance Category (PCPC) score ≥3. Analyses adjusted for age and PRISM III-12 score. Results Of 2449 RESTORE subjects, 412 (17%) had CI. Compared to NT subjects, CI subjects were older (p<0.001) with more severe PARDS (40% vs. 33%; p=0.009), received lower cumulative doses of opioids (median, mg/kg, 14.2 vs. 16.2; p<0.001) and benzodiazepines (10.6 vs. 14.4; p<0.001), and fewer classes of sedative medications (% receiving ≥3 classes, 57% vs. 60%; p<0.001). Three non-verbal intubated subjects with CI received no analgesic or sedative medications. Subjects with CI spent more study days awake and calm (median [IQR], 80% [60–100] vs. 80% [56–100]; p=0.003) and experienced fewer days with an episode of pain (33% [13–56] vs. 38% [14–60]; p=0.005). Conclusions Subjects with CI in this study received lower doses of opioids and benzodiazepines while hospitalized in the PICU, including some who received no analgesia or sedation. These data suggest that while comfort for subjects with CI may have been achieved with less medication, the rationale for this observation is unclear. Further prospective study that includes alternative assessment strategies is warranted.

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

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