Pediatric Cerebral Performance Category Research Articles

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.

Relationships between three and twelve month outcomes in children enrolled in the therapeutic hypothermia after pediatric cardiac arrest trials

AimTo inform design aspects of future trials by comparing 3 and 12-month neurobehavioural outcomes in children enrolled in Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-Of-Hospital and In-Hospital (THAPCA-OH, THAPCA-IH) trials. MethodsThe THAPCA trials evaluated two targeted temperature management interventions (hypothermia, 32.0–34.0 °C; normothermia, 36.0–37.5 °C). Children, aged 2 days to <18 years, were enrolled from 2009–2015. Three and 12-month post-cardiac arrest (CA) outcomes included the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) (population mean = 100, SD = 15) and the pediatric cerebral performance category (PCPC) scale. Children without significant pre-existing neurodevelopmental deficits were included in primary outcome analyses. Among survivors, favorable 12-month outcome was defined as VABS-II ≥ 70. ResultsVABS-II and PCPC were available at 3 and 12 months in 204 of 222 eligible survivors (THAPCA-OH, n = 82; THAPCA-IH, n = 122). Relative to THAPCA-IH, THAPCA-OH had significantly less pre-CA disability and significantly greater 12-month CA impairment, based on both VABS-II and PCPC. Correlations between 3 and 12-month VABS-II scores were strong for THAPCA-OH (r = 0.95) and THAPCA-IH (r = 0.72), and lower (p ≤ 0.001) in THAPCA-IH. Between time-points correlations were lower, but still significant in children <1 year at CA (p < 0.001). In both cohorts, 3-month VABS-II and PCPC categorical outcomes had high sensitivity (≥70%) for predicting favorable 12-month VABS-II outcomes, but specificity was lower for THAPCA-IH (68–89%) relative to THAPCA-OH (≥95%). Overall, 12-month diagnostic accuracy was ≥80% for both VABS-II and PCPC in both cohorts. ConclusionsIn future paediatric cardiac arrest clinical trials that enroll similar cohorts, integration of 3-month neurobehavioral outcome measures should be considered.

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

Multimodal assessment using early brain CT and blood pH improve prediction of neurologic outcomes after pediatric cardiac arrest

BackgroundEarly prediction of neurologic prognosis in children resuscitated from cardiac arrest is a major challenge. This study aimed to investigate the usefulness of a combined model based on brain computed tomography (CT) and initial blood gas analysis to predict neurologic prognoses in pediatric patients after cardiac arrest. MethodsWe retrospectively analyzed the medical records of patients resuscitated after cardiac arrest from 2000 to 2018. Patients aged one month to 18 years were included. Gray to white matter ratio (GWR), ambient cistern effacement (ACE), and blood gas analysis were studied. The primary outcome was neurological prognosis, which was evaluated using the Pediatric Cerebral Performance Category (PCPC) scale at discharge. ResultsOf 97 resuscitated patients, 64 brain CT images were available. Fourteen patients had a good neurologic outcome (PCPC 1–3) and 50 patients a poor neurologic outcome (PCPC 4–6). The multimodal model (AUC 0.897) containing GWR of basal ganglia (BG), ACE, and blood pH was found to be superior for predicting poor neurologic prognosis than single variable models (AUC of GWR-BG: 0.744, ACE: 0.804, pH: 0.747). Interestingly, we found the GWR-BG cutoff value for specificity 100% differed significantly between patients <4 years (cutoff value: 1.08, p = 0.04) and ≥4 years (cutoff value: 1.18, p = 0.004). ConclusionsThe combination of GWR-BG, ambient cistern effacement, and blood pH was found to usefully predict neurological outcome in children resuscitated from cardiac arrest. In addition, the cutoff value of GWR-BG for the prediction of neurologic outcome was found to increase with age.

Neurologic Outcomes in a Two-Center Cohort of Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation.

Contemporary studies of long-term outcomes in children supported on extracorporeal membrane oxygenation (ECMO) in the United States are limited. We enrolled 99 ECMO patients between July 2010 and June 2015 in a two-center prospective observational study that included neurologic and neuropsychologic evaluation at 6 and 12 months, using standardized outcome measures. Pre-ECMO, 20 (20%) had a pre-existing neurologic diagnosis, 40 (40%) had cardiac arrest, and 10 of 47 (21%) children with neuroimaging had acute abnormal findings. Of 50 children eligible for follow-up at 6 or 12 months, 40 (80%) returned for at least one visit. At the follow-up visit of longest interval from ECMO, the median Vineland Adaptive Behavior Scales-II (VABS-II) score was 91 (interquartile range [IQR], 81-98), the median Pediatric Stroke Outcome Measure (PSOM) score was 1 (IQR, 0-2), and the median Mullen Scales of Early Learning composite score was 85 (IQR, 72-96). Presence of new neuroimaging abnormalities during ECMO or within 6 weeks post-ECMO was associated with VABS-II score <85 or death within 12 months after ECMO. The Pediatric Cerebral Performance Category at hospital discharge showed a strong relationship with unfavorable VABS-II and PSOM scores at 6 or 12 months after ECMO. In this study, we report a higher prevalence of pre-ECMO neurologic conditions than previously described. In survivors to hospital discharge, median scores for adaptive behavior and cognitive, neurologic, and quality of life assessments were all below the general population means, but most deficits would be considered minor within each of the domains tested.

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.

Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment

To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy. This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable. This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P < .001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P = .009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P < .001) and benzodiazepines (10.6 vs 14.4; P < .001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects. Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

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.

Clinical and Electroencephalographic Correlates in Pediatric Cardiac Arrest: Experience at a Tertiary Care Center.

Pediatric cardiac arrest is a significant cause of death and neurologic disability; however, there is a paucity of literature specifically evaluating the utility of prognostic factors in the pediatric population. This retrospective chart review examines clinical, laboratory, and electroencephalographic (EEG) data in children following cardiopulmonary arrest to better characterize findings that may inform prognosis. Pre-arrest clinical characteristics, resuscitation details, and post-arrest hospital course variables were analyzed and neurologic outcome was determined using the Pediatric Cerebral Performance Category scale. Forty-one patients were identified who had cardiac arrest from March, 2011 to January, 2015. Duration of cardiopulmonary resuscitation (p = 0.013), out-of-hospital arrest (p = 0.005), arterial pH (0.014), arterial lactate (0.004), lack of pupil reactivity to light (p < 0.001), absent motor response to noxious stimuli (p < 0.001), and absent brainstem reflexes (p < 0.001) were all predictors of poor neurologic outcome. EEG background suppression (p = 0.005) was associated with poor outcome. Nine patients had electrographically recorded seizures, which began up to 1 week following cardiac arrest. Two patients (4.9%) experienced post-anoxic myoclonic status epilepticus and both had a poor outcome.

Long-term neuropsychological outcome following pediatric anti-NMDAR encephalitis.

ObjectiveTo provide detailed long-term outcome data of children and adolescents following pediatric anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, to identify neuropsychological impairments, and to evaluate the influence of these factors on quality of life (QoL).MethodsAll Dutch children diagnosed with anti-NMDAR encephalitis were identified. Patients currently aged 4 years or older were included in the follow-up study, consisting of a visit to our clinic for a detailed interview and a standardized neuropsychological assessment. The following domains were included: attention, memory, language, executive functioning, QoL, and fatigue. Primary outcome measures were z scores on sustained attention, long-term verbal memory, QoL, fatigue, and working memory.ResultsTwenty-eight patients were included. Median Pediatric Cerebral Performance Category at last visit was 1 (interquartile range 1–2, range 1–4), and 64% (18/28) of patients returned consistently to their previous school level. Twenty-two patients were included in the cross-sectional part of the long-term follow-up study. Median follow-up time was 31 months (interquartile range 15–49, range 5–91). There were problems with sustained attention (z = −2.10, 95% confidence interval = −2.71 to −1.46, p < 0.0001) and fatigue (z = −0.96, 95% confidence interval = −1.64 to −0.28, p = 0.008). Cognitive deficits were not correlated with QoL, while fatigue was strongly correlated with QoL (r = 0.82, p < 0.0001).ConclusionsAlthough follow-up is often reported as “good” following pediatric anti-NMDAR encephalitis, many patients have cognitive problems and fatigue, even up until adolescence, resulting in academic achievement problems and lower QoL. For physicians, it is essential to be aware of these problems, to provide valuable advice to patients and caregivers in the acute and follow-up phase, and to consider early neuropsychological counseling.

Burden of caregiving after a child’s in-hospital cardiac arrest

ObjectiveTo describe caregiver burden among those whose children survive in-hospital cardiac arrest and have high risk of neurologic disability, and explore factors associated with burden during the first year post-arrest. MethodsThe study is a secondary analysis of the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial. 329 children who had an in-hospital cardiac arrest, chest compressions for >2 min, and mechanical ventilation after return of circulation were recruited to THAPCA-IH. Of these, 155 survived to one year, and caregivers of 138 were assessed for burden. Caregiver burden was assessed at baseline, and 3 and 12 months post-arrest using the Infant Toddler Quality of Life Questionnaire for children <5 years old and the Child Health Questionnaire for children >5 years. Child functioning was assessed using the Vineland Adaptive Behaviour Scales Second Edition (VABS-II), the Paediatric Overall Performance Category (POPC) and Paediatric Cerebral Performance Category (PCPC) scales, and caregiver perception of global functioning. ResultsOf 138 children, 77 (55.8%) were male, 77 (55.8%) were white, and 109 (79.0%) were <5 years old at the time of arrest. Caregiver burden was greater than reference norms at all time points. Worse POPC, PCPC and VABS-II scores at 3 months post-arrest were associated with greater caregiver burden at 12 months. Worse global functioning at 3 months was associated with greater burden at 12 months for children <5 years. ConclusionsCaregiver burden is substantial during the first year after paediatric in-hospital cardiac arrest, and associated with the extent of the child’s neurobehavioural dysfunction.

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.