Pediatric Intensive Care Unit Admission Research Articles

Rehospitalization of preterm infants below 32 weeks of gestational age in the first 2 years post discharge

To describe the frequency and characteristics of readmissions in preterm infants younger than 32 weeks of GA or weighing less than 1500 g (< 32w/< 1500 g) at 2 years post-discharge from neonatology. Retrospective observational study of a cohort of newborns < 32w/< 1500 g discharged from a public health care center (2009-2017). The frequency, time of occurrence, risk factors, causes, and severity of hospital readmissions were analyzed. The respective perinatal characteristics and subsequent readmissions were described. The Ethics Committee approved the data collection protocol. 989 newborns < 32w/< 1500 g were included; 410 (41.5%) were readmitted at least once before the age of 2 years, equivalent to 686 episodes (1.7/child); 129 children (31.4%) were admitted to the Pediatric Intensive Care Unit (PICU), with a mean length of stay of 7.7 days. The greatest risk for hospital readmission was during the first 6 months post-discharge. The main cause was respiratory (70%) and respiratory syncytial virus was the most frequent germ. The risk factors associated with readmission due to respiratory causes were bronchopulmonary dysplasia (BPD) (OR: 1.73; 95%CI: 1.26-2.37) and number of siblings (OR: 1.18; 95%CI: 1.04-1.33). Newborns < 32s/< 1500 g are at high risk of hospital readmission due to respiratory causes and PICU admission in the first months post-discharge; BPD and number of siblings were the main risk factors.

Epidemiologic Trends In Children With Toxicologic Exposures Requiring Intensive Care Before and During the COVID-19 Pandemic.

Pediatric poison exposures are a common reason for pediatric intensive care unit (PICU) -admission. The purpose of this study was to examine the exposure trends and patient outcomes in 2018-2019 compared with 2020-2021 amidst the COVID-19 pandemic. This was a retrospective cohort study of patients 18 years of age or younger with a suspected toxicologic exposure from January 2018 to March 2021. The primary endpoint was rate of PICU admissions between the 2 cohorts. Secondary endpoints included medical outcome stratified by severity, PICU length of stay, and need for mechanical ventilation. Our study included a total of 340 patients with median age 14.5 (IQR, 11.9-16.1) years. There was no significant difference in age, sex, or race between the 2 cohorts. The percentage of patients admitted to the PICU for poison exposures was significantly higher in the COVID-19 cohort compared with the pre-COVID-19 cohort (8.4% vs 3.7%, p < 0.01). Severity of medical outcomes differed between the groups; the COVID-19 cohort had more extreme clinical presentations of no effect or death (p < 0.01). No significant difference was found among the remaining secondary outcomes. Classes of substances ingested were comparable with baseline poison center data. Poisoning-related PICU admissions occurred at more than twice the pre-pandemic rate. This may emphasize the effect of the COVID-19 pandemic on pediatric access and exposure to poisons.

Clinical presentation, diagnosis and management of multisystem inflammatory syndrome in children (MIS-C): a systematic review

BackgroundKnowledge about multisystem inflammatory syndrome in children (MIS-C) is evolving, and evidence-based standardised diagnostic and management protocols are lacking. Our review aims to summarise the clinical and diagnostic features, management...

Recognizing Complications in Youth With Diabetes Admitted With Diabetic Ketoacidosis Versus Hyperglycemic Hyperosmolar State

IntroductionAlthough the numbers of youth with diabetes mellitus (DM) who have diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are increasing, data regarding acute complications are limited. We compare in-hospital complications in youth with isolated DKA to those in youth with hyperosmolarity. MethodsWe reviewed medical records of youth (ages 1-20 years) admitted over a two-year period with DKA (serum bicarbonate ≤16 mEq/L; ketones ≥0.6 mmol/L), HHS (blood glucose ≥33.3 mmol/L [600 mg/dL]; osmolality ≥320 mOsm/kg), and hyperosmolar DKA. We evaluated outcomes including hospital length of stay (LOS), altered mental status (AMS), and acute kidney injury (AKI). ResultsOf 369 admissions, 334 (90.5%) had isolated DKA, 32 (8.7%) had hyperosmolar DKA, and three (0.8%) had isolated HHS. Compared to youth with isolated DKA, hyperosmolar youth had longer LOS (median 37.4 hours [IQR=24.6,63.5] vs 26.5 hours [IQR=20.2,41.3], p=0.002) and larger initial fluid boluses (median 10.28 ml/kg [IQR=10.00,19.75] vs 10.02 ml/kg [9.96,10.55], p=0.013). Hyperosmolar youth also had more frequent pediatric intensive care unit admission (71% vs 28%, p<0.001), AKI (63% vs 15%, p<0.001), and AMS (46% vs 12%, p<0.001). Multivariable logistic regression indicated the odds of AKI were positively associated with serum osmolality (OR 1.11; 95% CI 1.08-1.14; p<0.001) and negatively associated with new-onset DM compared to established DM (OR 0.32; 95% CI, 0.14-0.71; p=0.005). ConclusionIn youth with DM, hyperosmolarity increases acute complications compared to isolated DKA. Larger-scale studies are needed. Our findings can guide interventional studies and identify ways to prevent acute complications in youth experiencing hyperglycemic emergencies.

Plasma exchange is the hope for critically ill children with life-threatening autoimmune hemolytic anemia

BackgroundAutoimmune hemolytic anemia (AIHA) is a rare disease in children, sometimes associated with acute, life-threatening, rapidly progressive course requiring prompt management. The aim of our study is to describe the role and outcome of plasma exchange in the acute management of pediatric patients with AIHA requiring transfusion and refractory to high doses of corticosteroids.MethodsThis was a descriptive retrospective report of all patients admitted to the pediatric intensive care unit (PICU) of Children’s University Hospital who received PE for acute intractable AIHA resistant to management with pulse steroids starting from June 2017 to June 2022. The demographic data, vitals, and laboratory investigations at PICU admission and upon discharge were gathered. The number of PE sessions needed for each patient, volume used for exchange, type of replacement, IV access used, complications, and outcome were reported.ResultsThis series included 19 patients, 10 males, and 9 females, with a median age and weight of 76 months (IQR 18–121), and 20.9 kg. Improvement of the mean hemoglobin was observed from 5.3 ± 1.8 to 9.9 ± 2.6 g/dl at discharge. The average number of PE sessions was 2.4 sessions with no adverse effects encountered. The mean PICU stay was 16.6 days. Mortality occurred in 2 patients (10.5%) due to their primary illness, while 7 patients (36.8%) were in need of further immunotherapy, and 5 patients (28%) showed relapse.ConclusionPE may be used as a safe and successful therapy in children with severe acute life-threatening AIHA not responding to steroids, or if well-matched PRBCs are unavailable for transfusion.

P.130 Endoscopic fenestration of trapped fourth ventricle

Background: Trapped fourth ventricle (TFV) is a rare entity that occurs when the fourth ventricle is obstructed and isolated from the normal cerebrospinal fluid (CSF) circulation. While not always symptomatic, TFV can lead to compression of the cerebellum and brainstem, with potential for serious consequences. Treatment of TFV can be challenging, with options including CSF diversion via shunts versus open or endoscopic fenestrations. In this report, we describe a case of TFV that was managed endoscopically. Methods: A seven-year-old girl with a history of myelomeningocele and hydrocephalus, presented with a change in neurological status. Imaging of the brain and spine showed syringomyelia, markedly dilated ventricles, and a TFV. An endoscopic approach was used to fenestrate the wall of the fourth ventricle. Results: While there was an early favorable outcome, the first fenestration closed over within one month, requiring a repeat endoscopic fenestration. Both procedures were complicated by transient seizures, requiring a pediatric intensive care unit (PICU) admission after the second intervention. Pre- and post-operative clinical and diagnostic imaging findings are reported. Conclusions: Endoscopic fenestration can be an effective treatment option for management of TFV. The patient, family, and treating team should be prepared to deal with acute peri-operative complications that may require PICU management.

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

Risk factors for intensive care admission in pediatric patients with COVID-19 - results of the German na-tionwide inpatient sample

Abstract Funding Acknowledgements None. Background In December 2019 first patient-cases of pneumonia caused by an unknown virus were detected in Wuhan, China. From this day on, SARS-CoV-2 spread throughout the world with an enormous pace causing the deadliest pandemic of the twenty-first century. First infection cases in Germany were reported at the end of January 2020 in Bavaria and sustained transmission of SARS-CoV-2 resulted also in Germany in a strong spread of COVID-19 in the population. Although children and young people aged ≤18 years represent approximately 2%-5% of the SARS-CoV-2 cases globally, research efforts regarding COVID-19 pandemic have mainly focused on disease course of adults. Thus, early identification of children who must be monitored for life-threatening severe COVID-19 course remains difficult. Understanding of risk factors for ICU admission as one important bottleneck of adequate management regarding escalated treatment of COVID-19 pandemic is of outstanding interest to understand determinants, which are both crucial factors for adequate health care planning, decision making and pandemic management. Purpose We aimed to close this gap with identification of associated factors with pediatric ICU admissions in Germany. Methods We used the German nationwide inpatient sample analysing all hospitalised children ≤18 years with confirmed COVID-19 diagnosis in Germany between January 1st and December 31st, 2020 stratified fur ICU admission (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Results Overall, 3,360 cases of hospitalised children ≤18 years with COVID-19 infection were diagnosed in Germany 2020 (median age 7.0 [IQR 0.0-15.0] years, 49.8% of female sex); among them 4.3% had to be admitted on ICU. In-hospital death occurred in five patients with and three without ICU admission (3.5% vs. 0.1%, P&amp;lt;0.001) and ICU admission was independently associated with increased case-fatality (OR 21.573 [95%CI 4.191-111.044], P&amp;lt;0.001). Obesity (OR 3.419 [95%CI 1.300-8.993], P=0.013), diabetes mellitus (OR 6.929 [95%CI 3.327-14.432], P&amp;lt;0.001), pneumonia (OR 7.373 [95%CI 4.823-11.271], P&amp;lt;0.001), ARDS (OR 48.058 [95%CI 11.689-197.588], P&amp;lt;0.001) and multi-segmental Inflammatory syndrome caused by COVID-19 (OR 9.573 [95%CI 3.036-30.191], P&amp;lt;0.001), heart failure (OR 64.509 [95%CI 24.462-170.121], P&amp;lt;0.001), myocarditis (OR 4.682 [95%CI 1.278-17.149], P=0.020), acute and/or chronic kidney failure (OR 7.946 [95%CI 3.606-17.508], P&amp;lt;0.001), cancer (OR 5.220 [95%CI 2.599-10.485], P&amp;lt;0.001) and liver diseases (OR 5.501 [95%CI 2.177-13.899], P&amp;lt;0.001) were associated with ICU admission. Conclusions The proportion of hospitalized paediatric COVID-19 patients admitted on ICU in Germany was low with 4.3% accompanied by 3.5% case-fatality rate. Independent factors for ICU admission comprised cardio-vascular risk factors, comorbidities and complications of COVID-19.

An assessment of severity of acute bronchiolitis using bronchiolitis severity score and its relation to serum sodium level in children attending Alexandria University Hospital

Background Acute viral bronchiolitis is a significant cause of respiratory morbidity globally. Acute bronchiolitis is a clinical diagnosis based on the clinical judgment of the treating physician. Consequently, management strategies for acute bronchiolitis have great variability. Therefore, valid objective, evidence-based assessment tools were needed to help assess the severity of the illness, therefore reducing variation in management plans and standardizing care. Aim The present work aims to assess the validity of the use of bronchiolitis severity score (BSS) and serum sodium level in predicting the severity of acute bronchiolitis and the relation between them in children attending Alexandria University Children’s Hospital. Patients and methods The study was a comparative cross-sectional study of 131 children clinically diagnosed with acute bronchiolitis, from 1 month to 2 years of age, who presented to the Emergency Department of Alexandria University Children’s Hospital. Measurement of each patient’s BSS and serum sodium level was done on presentation in triage. Admitted and nonadmitted patients were followed up. Longer length of hospital stay and Pediatric Intensive Care Unit (PICU) admission were considered indicators of increased severity of the disease and worse outcomes. Results There was a male predominance and the median age of the studied patients was 3 months. On the basis of BSS, acute bronchiolitis was classified as mild in 19 (14.5%) cases, moderate in 79 (60.3%), and severe in 33 (25.2%). Hyponatremia at presentation was present in 20 (15.2%) cases. Increased severity, as determined by BSS, was statistically significantly associated with higher rates of admissions, longer hospital stays, and increased incidence of PICU hospitalization. There was no statistically significant difference between the hyponatremic status and increased hospital stay or the incidence of PICU admission. By univariate analysis, length of hospital stay and incidence of PICU admission was significantly affected by BSS and by hyponatremia. By multivariate analysis, the only parameter that was significant was BSS. In predicting a longer hospital stay in admitted patients, BSS showed a sensitivity (Se)=77.78%, specificity (Sp)=100%, positive predictive value (PPV)=100%, and negative predictive value (NPV)=42.9 while hyponatremia showed a Se=20.83%, Sp=91.67%, PPV=93.75%, and NPV=16.18. In predicting the need for PICU admission in studied cases, BSS showed a Se=69.23%, Sp=94.92%, PPV=60%, and NPV=96.6 and Se=38.46%, while hyponatremia showed Sp=87.29%, PPV=25%, and NPV=92.79. Conclusion BSS could be used as a valuable tool for assessing the severity of acute bronchiolitis. The presence of hyponatremia on initial presentation, although occasionally observed, cannot be used as a predictor of disease severity, but it could be used as a prognostic factor of a more severe disease course.

Predictive value of laboratory indicators for in-hospital death in children with community-onset sepsis: a prospective observational study of 266 patients

Background and objectivesThis study aimed to identify predictors of sepsis-associated in-hospital mortality from readily available laboratory biomarkers at onset of illness that include haematological, coagulation, liver and kidney function, blood...

Postcardiac Arrest Care Delivery in Pediatric Intensive Care Units: A Plan and Call to Action.

Despite national pediatric postcardiac arrest care (PCAC) guidelines to improve neurological outcomes and survival, there are limited studies describing PCAC delivery in pediatric institutions. This study aimed to describe PCAC delivery in centers belonging to a resuscitation quality collaborative. An institutional review board-approved REDCap survey was distributed electronically to the lead resuscitation investigator at each institution in the international Pediatric Resuscitation Quality Improvement Collaborative. Data were summarized using descriptive statistics. A chi-square test was used to compare categorical data. Twenty-four of 47 centers (51%) completed the survey. Most respondents (58%) belonged to large centers (>1,000 annual pediatric intensive care unit admissions). Sixty-seven percent of centers reported no specific process to initiate PCAC with the other third employing order sets, paper forms, or institutional guidelines. Common PCAC targets included temperature (96%), age-based blood pressure (88%), and glucose (75%). Most PCAC included electroencephalogram (75%), but neuroimaging was only included at 46% of centers. Duration of PCAC was either tailored to clinical improvement and neurological examination (54%) or time-based (45%). Only 25% of centers reported having a mechanism for evaluating PCAC adherence. Common barriers to effective PCAC implementation included lack of time and limited training opportunities. There is wide variation in PCAC delivery among surveyed pediatric institutions despite national guidelines to standardize and implement PCAC.

Clinical characteristics of persistent or recurrent pneumonia combined with airway malacia in children.

The aim of this study is to investigate the clinical characteristics and pathogens involved in persistent or recurrent pneumonia combined with airway malacia in children. We retrospectively reviewed the information of children hospitalised with persistent or recurrent pneumonia, including clinical presentations, laboratory examination results and pathogens. A total of 554 patients were admitted, 285 (51.44%) of whom were found to have airway malacia. There were 78 (27.37%), 166 (58.25%) and 41 (14.39%) patients with mild, moderate and severe malacia, respectively. Patients with airway malacia were younger than those without malacia (6.0 vs. 12.0 months, p < 0.01) and were more likely to present with wheezing (75.07%), fever (34.39%), dyspnoea (28.77%), cyanosis (13.68%) and wheezing in the lungs (78.95%). The incidence of preterm delivery, oxygen therapy, paediatric intensive care unit (PICU) admission and mechanical ventilation was higher, and the hospital stay (11.0 vs. 10.0 days, p= 0.04) was longer in these patients than in those without malacia. Patients with severe airway malacia were more likely to undergo oxygen therapy, PICU admission, mechanical ventilation and have multiple malacia than were those with mild or moderate malacia. Mycoplasma pneumoniae (30.18%) was the most common pathogen. Severe airway malacia likely aggravates conditions combined with pneumonia. The proportion of multisite malacia was greater in severe airway malacia patients.

Acute respiratory failure due to pulmonary exacerbation in children with cystic fibrosis admitted in a pediatric intensive care unit: outcomes and factors associated with mortality

BackgroundChildren with advanced pulmonary disease due to cystic fibrosis (CF) are at risk of acute respiratory failure due to pulmonary exacerbations leading to their admission to pediatric intensive care units (PICU). The objectives of this study were to determine short and medium-term outcomes of children with CF admitted to PICU for acute respiratory failure due to pulmonary exacerbation and to identify prognosis factors.MethodsThis retrospective monocentric study included patients less than 18 years old admitted to the PICU of a French university hospital between 2000 and 2020. Cox proportional hazard regression methods were used to determine prognosis factors of mortality or lung transplant.ResultsPrior to PICU admission, the 29 patients included (median age 13.5 years) had a severe lung disease (median Forced Expiratory Volume in 1 s percentage predicted at 29%). Mortality rates were respectively 17%, 31%, 34%, 41% at discharge and at 3, 12 and 36 months post-discharge. Survival rates free of lung transplant were 34%, 32%, 24% and 17% respectively. Risk factors associated with mortality or lung transplant using the univariate analysis were female sex and higher pCO2 and chloride levels at PICU admission, and following pre admission characteristics: home respiratory and nutritional support, registration on lung transplant list and Stenotrophomonas Maltophilia bronchial colonization.ConclusionChildren with CF admitted to PICU for acute respiratory failure secondary to pulmonary exacerbations are at high risk of death, both in the short and medium terms. Lung transplant is their main chance of survival and should be considered early.

Prognostic values of serum lactate-to-bicarbonate ratio and lactate for predicting 28-day in-hospital mortality in children with dengue shock syndrome.

This study aimed to assess the clinical utility of blood lactate-to-bicarbonate (L/B) ratio, as a prognostic factor for 28-day in-hospital mortality in children with dengue shock syndrome (DSS), admitted to the pediatric intensive care unit (PICU). This single-center retrospective study was conducted at a tertiary children hospital in southern Vietnam from 2013 to mid-2022. Prognostic models for DSS mortality were developed, using a predefined set of covariates in the first 24 hours of PICU admission. Area under the curves (AUCs), multivariable logistic and Least Absolute Shrinkage and Selection Operator (LASSO) regressions, bootstrapping and calibration slope were performed. A total of 492 children with DSS and complete clinical and biomarker data were included in the analysis, and 26 (5.3%) patients died. The predictive values for DSS mortality, regarding lactate showing AUC 0.876 (95% CI, 0.807-0.944), and that of L/B ratio 0.867 (95% CI, 0.80-0.934) (P values of both biomarkers < .001). The optimal cutoff point of the L/B ratio was 0.25, while that of lactate was 4.2 mmol/L. The multivariable model showed significant clinical predictors of DSS fatality including severe bleeding, cumulative amount of fluid infused and vasoactive-inotropic score (>30) in the first 24 hours of PICU admission. Combined with the identified clinical predictors, the L/B ratio yielded higher prognostic values (odds ratio [OR] = 8.66, 95% confidence interval [CI], 1.96-38.3; P < .01) than the lactate-based model (OR = 1.35, 95% CI, 1.15-1.58; P < .001). Both the L/B and lactate models showed similarly good performances. Considering that the L/B ratio has a better prognostic value than the lactate model, it may be considered a potential prognostic biomarker in clinical use for predicting 28-day mortality in PICU-admitted children with DSS.

Characteristics and spectrum changes of PICU cases during the COVID-19 pandemic: a retrospective analysis.

This study aims to compare the changes in the disease spectrum of children admitted to the Pediatric Intensive Care Units (PICU) during the COVID-19 pandemic with the three years prior to the pandemic, exploring the impact of the COVID-19 pandemic on the disease spectrum of PICU patients. A retrospective analysis was conducted on critically ill children admitted to the PICU of Hunan Children's Hospital from January 2020 to December 2022, and the results were compared with cases from the same period between January 2017 and December 2019. The cases were divided into pre-pandemic period (January 2017-December 2019) with 8,218 cases, and pandemic period (January 2020-December 2022) with 5,619 cases. General characteristics, age, and gender were compared between the two groups. Compared to the pre-pandemic period, there was a 31.62% decrease in the number of admitted children during the pandemic period, and a 52.78% reduction in the proportion of respiratory system diseases. The overall mortality rate decreased by 87.81%. There were differences in age and gender distribution between the two periods. The length of hospital stay during the pandemic showed no statistical significance, whereas hospitalization costs exhibited statistical significance. The COVID-19 pandemic has exerted a certain influence on the disease spectrum of PICU admissions. Implementing relevant measures during the pandemic can help reduce the occurrence of respiratory system diseases in children. Considering the changes in the disease spectrum of critically ill PICU children, future clinical prevention and treatment in PICUs should continue to prioritize the respiratory, neurological, and hematological oncology systems.

Social Disadvantage and Inequity in Access to Pediatric Critical Care Services for Children Living Remote from a Children's Hospital

AbstractRegionalization of health care has created geographical distance between pediatric specialty services and children, with the potential for disparities in access to care. We investigated the association of state-level area deprivation index (S-ADI), a measure of socioeconomic disadvantage, and characteristics and outcomes in a cohort of children requiring unplanned hospital transfer to a quaternary care pediatric intensive care unit (PICU). We conducted a single-center retrospective cohort study of children requiring unplanned hospital transfer to the PICU at the University of Virginia Children's Hospital from July 1, 2019 to December 31, 2020, excluding planned transfers, transfers from another intensive care unit, and patients whose address could not be associated with an S-ADI. We collected demographic and clinical data as well as the S-ADI, an ordinal variable ranging from 1 to 10 with 10 representing the most disadvantage. We observed no differences in S-ADI based on patient sex, age, history of chronic medical conditions, or need for a medical device (tracheostomy, home ventilator, surgical feeding tube, cerebrospinal fluid shunt). We also did not observe differences in PICU or hospital length of stay based on S-ADI. We did observe for every one-point increase in S-ADI there was an associated increase of 8.6 miles (p &lt; 0.001) in patient travel distance. Among patients from a higher S-ADI area, we observed increased severity of illness on PICU admission (p = 0.02) and case fatality as compared with patients from a lower S-ADI area (11 vs. 1.9%, p = 0.038). Children traveling the farthest for subspeciality pediatric critical care at our hospital had higher measures of socioeconomic disadvantage and severity of illness.

Gram-negative bacteremia, the risk factors, and outcome in children

We aimed to determine the epidemiology and resistance patterns of Gram-negative bacteria, the risk factors and outcome of bloodstream infection (BSI). In all, 412 episodes in children who were hospitalized with the diagnosis of bacteremia were analyzed. The most common microorganisms were Klebsiella spp. (43.9%), Escherichia coli (13.5 %) and Acinetobacter spp. (10.6 %). Among isolates, 41.2 % were multidrug-resistant, 13.5 % were extensively drug-resistant and 0.4 % were pan-drug-resistant. Carbapenem resistance was revealed in 27.6 % of isolates. Carbapenem and colistin resistance increased over the years. The most common risk factors were the presence of a central-venous catheter and pediatric intensive care unit admission. Clinical response and infection-related mortality were significantly different in cases infected with carbapenem-resistant gram-negative (CRGN) vs carbapenem-susceptible gram-negative bacteria. The increase in multi-resistant Klebsiella spp. seems to be the biggest obstacles in fight against nosocomial infections. The increasing number of CRGN infections over the years affects both the clinical response and mortality rate of BSI.

Paediatric sequential organ failure assessment score (p-SOFA) as an outcome predictor in critically ill children admitted to a paediatric intensive care unit in a tertiary care hospital in central India.

Background Pediatric intensive care remains a critical and challenging field, where early recognition of organ dysfunction and timely intervention are essential for improved patient outcomes. The Pediatric Sequential Organ Failure Assessment (P-SOFA) score is a tool designed to assess organ dysfunction in critically ill children. This prospective observational study aims to evaluate the effectiveness of the P-SOFA score in predicting morbidity and mortality in pediatric patients admitted to the Pediatric Intensive Care Unit (PICU). Methods Over two years, we will enrol pediatric patients aged one month to 17 years in the PICU at Jawaharlal Nehru Medical College and AVBRH, Sawangi, Wardha, Central India. Data will be collected on demographic characteristics, clinical assessments, laboratory investigations, SOFA score calculations at admission and 48 hours later, treatments received, and outcomes. Inclusion criteria encompass patients with PICU stays exceeding 24 hours, while exclusion criteria include consent refusal, planned procedures for PICU admission, and PICU stays of less than 24 hours. Expected Results We anticipate that the P-SOFA score will be a valuable predictor of morbidity and mortality in critically ill pediatric patients. The study will also investigate the potential of ΔSOFA (change in SOFA scores) as an outcome indicator and compare the P-SOFA score with the Pediatric Logistic Organ Dysfunction Score 2 (PELOD2) for mortality prediction.

Efficacy and safety of withholding antimicrobial therapy in children with cancer, fever, and neutropenia, with a demonstrated viral respiratory infection: a randomized clinical trial

ObjectivesTo validate the efficacy and safety of withholding antimicrobial therapy in a new cohort of children with cancer and febrile neutropenia (FN) having a demonstrated viral respiratory tract infection. MethodsProspective, multicenter, noninferiority, randomized study, approved by the ethical committee, in children presenting with FN at seven hospitals in Chile, evaluated at admission for diagnosis of bacterial and viral pathogens. Children who were positive for a respiratory virus, negative for a bacterial pathogen, and had a favourable evolution after 48–72 hours of antimicrobial therapy were randomized to either maintain or withhold antimicrobial therapy. The primary endpoint was the percentage of episodes with an uneventful resolution, whereas the secondary endpoints were days of fever, days of hospitalization, requirement of antimicrobial treatment readministration, sepsis, paediatric intensive care unit admission, and death. ResultsA total of 301 of 939 children with FN episodes recruited between March 2021 and December 2023 had a respiratory virus as a unique identified microorganism, of which 139 had a favourable evolution at 48–72 hours and were randomized, 70 to maintain and 69 to withdraw antimicrobial therapy. The median days of antimicrobial therapy was 5 (IQR 3–6) versus 3 (IQR 3–6) days (p < 0.001), with similar frequency of uneventful resolution 66/70 (94%) and 66/69 (96%); relative risk, 1.01; (95% CI, 0.93 to 1.09), absolute risk difference 0.01; (95% CI, −0.05 to 0.08) and similar number of days of fever and days of hospitalization. No cases of sepsis, paediatric intensive care unit admission, or death were reported. DiscussionWe validated the strategy of withdrawal antimicrobial therapy in children with FN and viral respiratory tract infection based on clinical and microbiological/molecular diagnostic criteria. This will enable advances in antimicrobial stewardship strategies with a possible future impact on antimicrobial resistance.

Respiratory outcomes after cleft palate closure in Robin sequence: a retrospective study

ObjectivesThere is a paucity of information about the possible risk factors that could identify patients with Robin sequence (RS) who are more prone to developing obstructive airway complications after palate closure. This study aimed to compare the respiratory complication rates in patients with RS and isolated cleft palate (ICP).Materials and methodsIn this retrospective study, we reviewed the medical records of 243 consecutive patients with RS and ICP who were treated at Amsterdam University Medical Centers over the past 25 years. We collected preoperative data on previous treatment, diagnostic findings, surgical technique, weight, and presence of congenital anomalies.ResultsDuring cleft palate closure, patients with RS were older (11.9 versus 10.1 months; p = 0.001) and had a lower gestational age than those with ICP (37.7 versus 38.5 weeks; p = 0.002). Patients with RS had more respiratory complications (17 versus 5%; p = 0.005), were more often non-electively admitted to the pediatric intensive care unit (PICU) (13 versus 4.1%; p = 0.022), and had a longer hospital stay duration (3.7 versus 2.7 days; p = 0.011) than those with ICP. The identified risk factors for respiratory problems were a history of tongue-lip-adhesion (TLA) (p = 0.007) and a preoperative weight of < 8 kg (p = 0.015). Similar risk factors were identified for PICU admission (p = 0.015 and 0.004, respectively).ConclusionsThe possible risk factors for these outcomes were a low preoperative weight and history of TLA. Closer postoperative surveillance should be considered for patients with these risk factors.Clinical relevanceIdentifying risk factors for respiratory complications could provide clinicians better insight into their patients and allows them to provide optimal care for their patients.