Pediatric Intensive Care Unit Discharge Research Articles

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Use of Continuous EEG Monitoring and Short-Term Outcomes in Critically Ill Children

AbstractThis study aimed to compare short-term outcomes at pediatric intensive care unit (PICU) discharge in critically ill children with and without continuous electroencephalography (cEEG) monitoring. We retrospectively compared 234 patients who underwent cEEG with 2294 patients without cEEG. Propensity score matching was used to compare patients with seizures and status epilepticus between cEEG and historical cohorts. The EEG cohort had higher in-hospital mortality, worse Pediatric Cerebral Performance Category (PCPC) scores, and greater PCPC decline at discharge. In patients with status epilepticus, the PCPC decline was higher in the cEEG cohort. PCPC decline at PICU discharge was associated with cEEG monitoring in patients with status epilepticus.

#19 Viral DNAemia and Viral Seropositivity are Associated with Mortality in Pediatric Patients with Severe Sepsis

Abstract Background Sepsis remains the leading cause of pediatric mortality worldwide. While sepsis recognition campaigns have improved early mortality, current contributors to mortality are unclear. Little attention has been paid to the incidence of latent viral infection in septic pediatric patients, but resultant immune remodeling may affect future host response to acute illness. We report a large multi-center study of viral DNAemia and viral seropositivity in pediatric patients with severe sepsis. Method 401 patients from 9 Pediatric Intensive Care Units (PICUs) in the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Collaborative Pediatric Critical Care Research Network were enrolled. Enrollment criteria included severe sepsis, indwelling central venous or arterial catheter, and age between 44 weeks gestation and 18 years. Blood samples were collected twice per week up to 28 days of admission or until death or PICU discharge. Viral DNAemia was defined by qPCR detection of EBV, CMV, HSV, adenovirus, TTV, HHV6, and/or parvovirus B19. CMV, EBV, HSV and HHV6 serologies (IgG) were performed on one sample from each subject. Infection status was defined as uninfected (serologically negative without detectable DNAemia), acute infection (serologically negative with DNAemia), reactivated infection (serologically positive with DNAemia), or latent infection (serologically positive without DNAemia). Results Of 401 pediatric patients with severe sepsis, 55% were male, 39% previously healthy, and 27% immunocompromised. 44 subjects (11%) died in the PICU. 56% of subjects had documented infection(s) on enrollment (63% bacterial, 50% viral, and 2% fungal). Viral DNAemia, excluding TTV, was detected in 57% of immunocompromised patients and 44% of non-immunocompromised patients. Among patients with viral DNAemia, detection was due to reactivation in 91% of subjects with EBV DNAemia, 63% of those with CMV, and 100% of subjects with HSV and HHV-6. After adjusting for age, PRISM, previously healthy and immunosuppressed status, higher mortality was observed in patients with viral DNAemia due to CMV (OR 3.29 [1.46,7.21], p=0.005), adenovirus (3.55 [1.45,8.38] p=0.006), and HHV-6 (2.29 [1.11,4.63] p=0.025). DNAemia with multiple viruses, excluding TTV, during ICU admission was also independently associated with increased mortality in both immunocompromised (OR 5.51 [1.61,22.6] p=0.001) and non-immunocompromised subjects (OR 3.93 [1.36,11.5] p=0.015). Seropositivity was common (HSV 33%, CMV 42%, EBV 61%, HHV6 98%). Mortality was significantly higher in subjects who were seropositive for EBV (OR 11.5 [2.24, 211.2], p<0.001) and HSV (OR 2.65, [1.03, 7.21], p=0.004). Mortality was increased if more than one virus antibody was detected (OR 6.89 [1.98, 43.5], p<0.001) and highest when all four virus antibodies were detected. With HHV6, DNAemia increased mortality associated with seropositivity (18% vs. 7%, p=0.024). Conclusion In this study, viral DNAemia was common in pediatric patients with severe sepsis and was associated with mortality. Detection of multiple viruses during ICU admission increased risk of mortality, even in patients without preexisting immunosuppression. CMV and adenovirus reactivation were most strongly associated with mortality. Viral seropositivity was also strongly associated with ICU mortality independent of the presence of viral DNAemia. Future analyses will investigate mechanisms by which viral DNAemia and seropositivity contribute to pediatric sepsis mortality.

Prevalence, Characteristics, and Determinants of Suboptimal Care in the Initial Management of Community-Onset Severe Bacterial Infections in Children

Assessment of the quality of initial care is necessary to target priority actions that can reduce the still high morbidity and mortality due to community-onset severe bacterial infections (COSBIs) among children. To study the prevalence, characteristics, and determinants of suboptimal care in the initial management of COSBIs. This prospective, population-based, cohort study and confidential enquiry was conducted between August 2009 and January 2014 in western France, a region accounting for 15% of the French pediatric population (1 968 474 children aged 1 month to 16 years) and including 6 pediatric intensive care units (PICUs) and 35 emergency departments. Participants included all children aged 1 month to 16 years who died before PICU admission or were admitted to a PICU with a COSBI (ie, bacterial sepsis, including meningitis, purpura fulminans, and pulmonary, osteoarticular, intra-abdominal, cardiac, and soft-tissue severe infections). Data were analyzed from March to June 2020. Suboptimal care determined according to evaluation of 8 types of care: (1) the delay in seeking care by family, (2) the physician's evaluation of severity, (3) the patient's referral at the first consultation with signs of severity, (4) the timing and (5) dosage of antibiotic treatment, (6) the timing and (7) volume of fluid bolus administration, and (8) the clinical reassessment after fluid bolus. Two experts assessed the quality of care before death or PICU admission as optimal, possibly suboptimal, or certainly suboptimal. The consequences and determinants of certainly suboptimal care were identified with multinomial logistic regression and generalized linear mixed models. Of the 259 children included (median [IQR] age, 24 [6-66] months; 143 boys [55.2%]), 27 (10.4%) died, and 25 (9.6%) had severe sequelae at PICU discharge. The quality of care was certainly suboptimal in 89 cases (34.4%). Suboptimal care was more frequent in children with sequelae (adjusted odds ratio [aOR], 5.61; 95% CI, 1.19-26.36) and less frequent in children who died (aOR, 0.16; 95% CI, 0.04-0.65) vs those surviving without sequelae. Factors independently associated with suboptimal care were age younger than 5 years (aOR, 3.15; 95% CI, 1.25-7.90), diagnosis of sepsis with no source (aOR, 5.77; 95% CI, 1.64-20.30) or meningitis (aOR, 3.39; 95% CI, 1.15-9.96) vs other severe infections, and care by a primary care physician (aOR, 3.22; 95% CI, 1.17-8.88) vs a pediatric hospital service. This study found that suboptimal care is frequent in the initial management of COSBI and is associated with severe sequelae. The paradoxical association with reduced risk of death may be explained by an insufficient adjustment on bacterial or host intrinsic factors. Management could be optimized by improving the quality of primary care, especially for young children.

Incidence of venous thromboembolic events not related to vascular catheters in a prospective cohort of critically ill children

The risk for venous thromboembolism (VTE) is considered to be low in the general paediatric intensive care unit (PICU) population, and pharmacological thromboprophylaxis is not routinely used. PICU patients considered at high-risk of VTE could possibly benefit from pharmacological thromboprophylaxis, but the incidence of VTE in this group of patients is unclear. This was an observational, prospective study at a tertiary multi-disciplinary paediatric hospital. We used comprehensive ultrasonography screening for VTE in critically ill children with multiple risk factors for VTE. Patients admitted to PICU ≥ 72 h and with ≥ two risk factors for VTE were included. Patients receiving pharmacological thromboprophylaxis during their entire PICU stay were excluded. The primary outcome of the study was VTEs not related to the use of a CVC. Ultrasonography screening of the great veins was performed at PICU discharge. Seventy patients with median (interquartile range) 3 (2–4) risk factors for VTE were evaluated. Median age was 0.3 years (0.03–4.3) and median PICU length of stay 9 days (5–17). Regarding the primary outcome, no symptomatic VTEs occurred and no asymptomatic VTEs were found on ultrasonography screening, resulting in an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0–5.1%).Conclusion: Our results indicate that VTEs not related to a vascular catheter are a rare event even in a selected group of severely ill small children considered to be at high risk of VTE.What is Known:• Children in the PICU often have several risk factors for venous thromboembolism (VTE).• The incidence of VTE in PICU patients is highly uncertain, and there are no evidence-based guidelines regarding VTE prophylaxis.What is New:• This study found an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0–5.1%).• This indicates that such VTE events are rare even in PICU patients with multiple risk factors for VTE.

Neuromuscular diseases in the pediatric intensive care unit: 11 years of experience from a tertiary children’s hospital

Background & Objective: We present 11-year data of patients with neuromuscular disease (NMD) that were treated in the pediatric intensive care unit of a tertiary children’s hospital. Methods: The data of all cases followed-up in the pediatric intensive care unit (PICU) were retrospectively analyzed. Patients were evaluated in terms of age, gender, diagnosis, PRISM, neuroanatomical localization, hospitalization time-age, cause of admission to pediatric intensive care unit, clinical course, complications and clinical discharge status. Results: A NMD was detected in 43 of the 1,411 patients admitted within the study period and accounted for approximately 3% of pediatric intensive care unit admissions. NMD consisted of genetic (n= 35, 74.8%), acquired (n=6, 13.8%) and metabolic (n=2, 4.6%) causes. The diagnoses included spinal muscular atrophy type 1 (n=12, 27.9%), Duchenne and Becker muscular dystrophy (n=7, 16.2%), congenital myopathy (n=6, 13.9%), congenital muscular dystrophy (n=5, 11.6%), Guillain-Barre syndrome and its variants (n=2, 4.6%), spinal muscular atrophy associated with respiratory distress type 1 (n=2, 2.3%), critical illness neuropathy (n=2, 4.6%), acute flaccid myelitis (n=2, 4.6%), congenital myasthenic syndrome (n=1, 2.3%), peripheral neuropathy associated with disorder of riboflavin transporter (n=1, 2.3%), juvenile amyotrophic lateral sclerosis (n=1, 2.3%), stress-induced childhood-onset neurodegeneration with ataxia and variable seizures (n=1, 2.3%), and metabolic myopathy (n=1, 2.3%). Respiratory complications (n=31, 72%) were the most common reasons of admission to the pediatric intensive care unit. Seven (16.2%) patients have the NMD diagnosis confirmed during their first admission in PICU. These included both genetic cause of NMDs (n=4) and acquired NMDs (n=3). Mortality rate was 6.9% (n=3). Forty-three patients diagnosed with NMD had 75 times PICU admissions. The disease with the highest rate of re-admission to the PICU was SMA type 1, and the most common reason for re-admission was respiratory reasons. Conclusion: Accurate diagnosis of NMD and knowledge of causes of admission to PICU is crucial for increasing awareness, sensitivity and effectiveness when treating these diseases.

Risk Factors of Readmission to Pediatric Intensive Care Unit Within 1 Year: A Case-Control Study.

BackgroundResearch on pediatric intensive care unit (PICU) readmission is lacking in China. This study was conducted to describe the risk factors associated with PICU readmission within 1 year after PICU discharge.MethodsThis retrospective case-control study included patients aged from 1 month to 16 years who were discharged between January 2018 and May 2020. The case group included readmitted patients with two or more PICU admissions within 1 year during the study period. The control group included survivors with only one PICU admission during the same study period, and the controls were matched on age and sex. Demographic and clinical variables were collected from the electronic administrative database. Risk factors were analyzed by univariate and multivariate analyses.ResultsFrom January 2018 to May 2020, 2,529 patients were discharged from the PICU, and 103 (4.07%) were readmitted within 1 year. In the univariate analysis, PICU readmission within 1 year was associated with lower weight, the presence of chronic conditions, a higher StrongKids score on admission, length of PICU stay of more than 2 weeks, the presence of dysfunction at discharge, sedation medications use, vasopressor use, and invasive mechanical ventilation in the first PICU stay. Patients had a higher StrongKids score as a surrogate for increased risk of malnutrition. In the multivariate analysis, the factors most significantly associated with PICU readmission within 1 year were the presence of chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks in the first PICU stay. In the subgroup analysis, compared with the control group, the factors most significantly associated with readmission within 48 h of discharge were the presence of chronic conditions, a higher StrongKids score on admission, and vasopressor use during the first PICU stay. The mortality rate was 8.74% (9/103) in patients with PICU readmission. The overall PICU mortality rate was 7.39% (201/2,721) during the study period.ConclusionsPatients with chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks were at much higher risk for PICU readmission within 1 year. Patients with vasopressor use during the first PICU hospitalization were more likely to be readmitted within 48 h of discharge.

Clinical Characteristics and Outcomes of Acute Childhood Encephalopathy in a Tertiary Pediatric Intensive Care Unit.

Childhood encephalopathy comprises a wide range of etiologies with distinctive distribution in different age groups. We reviewed the pattern of encephalopathy admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital. We reviewed the medical records and reported the etiologies, clinical features, and outcomes of children with encephalopathy. Twenty-four admissions to the PICU between April 2019 and May 2020 were reviewed. The median (interquartile range) age was 10.0 (14.7) years and 62.5% were boys. Confusion (66.7%) was the most common presentation. Adverse effects related to medications (33.3%) and metabolic disease (20.8%) were predominant causes of encephalopathies in our study cohort. Methotrexate was responsible for most of the medication-associated encephalopathy (37.5%), whereas Leigh syndrome, pyruvate dehydrogenase deficiency and Wernicke's encephalopathy accounted for those with metabolic disease. The median Glasgow Coma Scale (GCS) on admission was 12.5 (9.0). Antimicrobials (95.8%) and antiepileptic drugs (60.9%) were the most frequently given treatment. Children aged 2 years or younger were all boys (P = 0.022) and had a higher proportion of primary metabolic disease (P = 0.04). Intoxication or drug reaction only occurred in older children. The mortality was 8.3%, and over half of the survivors had residual neurological disability upon PICU discharge. Primary metabolic disease (P = 0.002), mechanical ventilation (P = 0.019), failure to regain GCS back to baseline level (P = 0.009), and abnormal cognitive function on admission (P = 0.03) were associated with cerebral function impairment on PICU discharge. Primary metabolic encephalopathy was prevalent in younger children, whereas drug-induced toxic encephalopathy was common among older oncology patients. Survivors have significant neurologic morbidity. Failure to regain baseline GCS was a poor prognostic factor for neurological outcomes.

Association of Acute Respiratory Failure in Early Childhood With Long-term Neurocognitive Outcomes

Approximately 23 700 US children undergo invasive mechanical ventilation for acute respiratory failure annually, with unknown long-term effects on neurocognitive function. To evaluate neurocognitive outcomes of children who survive pediatric intensive care unit (PICU) hospitalization for acute respiratory failure compared with their biological siblings. Prospective sibling-matched cohort study conducted at 31 US PICUs and associated neuropsychology testing centers. Patients were 8 years or younger with a Pediatric Cerebral Performance Category score of 1 (normal) before PICU admission and less than or equal to 3 (no worse than moderate neurocognitive dysfunction) at PICU discharge, excluding patients with a history of neurocognitive deficits or who were readmitted and underwent mechanical ventilation. Biological siblings were aged 4 to 16 years at testing, with Pediatric Cerebral Performance Category score of 1 and no history of mechanical ventilation or general anesthesia. A total of 121 sibling pairs were enrolled from September 2, 2014, to December 13, 2017, and underwent neurocognitive testing starting March 14, 2015. The date of the final follow-up was November 6, 2018. Critical illness and PICU treatment for acute respiratory failure. The primary outcome was IQ, estimated by the age-appropriate Vocabulary and Block Design subtests of the Wechsler Intelligence Scale. Secondary outcomes included measures of attention, processing speed, learning and memory, visuospatial skills, motor skills, language, and executive function. Evaluations occurred 3 to 8 years after hospital discharge. Patients (n = 121; 55 [45%] female patients) underwent PICU care at a median (IQR) age of 1.0 (0.2-3.2) years, received a median (IQR) of 5.5 (3.1-7.7) days of invasive mechanical ventilation, and were tested at a median (IQR) age of 6.6 (5.4-9.1) years. Matched siblings (n = 121; 72 [60%] female siblings) were tested at a median (IQR) age of 8.4 (7.0-10.2) years. Patients had a lower mean estimated IQ than matched siblings (101.5 vs 104.3; mean difference, -2.8 [95% CI, -5.4 to -0.2]). Among secondary outcomes, patients had significantly lower scores than matched siblings on nonverbal memory (mean difference, -0.9 [95% CI, -1.6 to -0.3]), visuospatial skills (mean difference, -0.9 [95% CI, -1.8 to -0.1]), and fine motor control (mean difference, -3.1 [95% CI, -4.9 to -1.4]) and significantly higher scores on processing speed (mean difference, 4.4 [95% CI, 0.2-8.5]). There were no significant differences in the remaining secondary outcomes, including attention, verbal memory, expressive language, and executive function. Among children, survival of PICU hospitalization for respiratory failure and discharge without severe cognitive dysfunction was associated with significantly lower subsequent IQ scores compared with matched siblings. However, the magnitude of the difference was small and of uncertain clinical importance.

Characteristics and Outcome of Children with Wilms Tumor Requiring Intensive Care Admission in First Line Therapy.

Simple SummarySurvival of children with Wilms tumor is excellent. However, treatment-related complications may occur, requiring treatment at the pediatric intensive care unit (PICU). The aim of our retrospective study was to assess the frequency, clinical characteristics, and outcome of 175 children with Wilms tumor requiring treatment at the PICU in the Netherlands. Thirty-three patients (almost 20%) required unplanned PICU admission during their disease course. Younger age at diagnosis, intensive chemotherapy regimens, and bilateral tumor surgery were risk factors for these unplanned PICU admissions. Three children required renal replacement therapy, two of which continued dialysis after PICU discharge. Two children died during their PICU stay. During follow up, hypertension and renal dysfunction were frequently observed, which justifies special attention for kidney function and blood pressure monitoring during and after treatment of these children.Survival rates are excellent for children with Wilms tumor (WT), yet tumor and treatment-related complications may require pediatric intensive care unit (PICU) admission. We assessed the frequency, clinical characteristics, and outcome of children with WT requiring PICU admissions in a multicenter, retrospective study in the Netherlands. Admission reasons of unplanned PICU admissions were described in relation to treatment phase. Unplanned PICU admissions were compared to a control group of no or planned PICU admissions, with regard to patient characteristics and short and long term outcomes. In a multicenter cohort of 175 children with an underlying WT, 50 unplanned PICU admissions were registered in 33 patients. Reasons for admission were diverse and varied per treatment phase. Younger age at diagnosis, intensive chemotherapy regimens, and bilateral tumor surgery were observed in children with unplanned PICU admission versus the other WT patients. Three children required renal replacement therapy, two of which continued dialysis after PICU discharge (both with bilateral disease). Two children died during their PICU stay. During follow-up, hypertension and chronic kidney disease (18.2 vs. 4.2% and 15.2 vs. 0.7%) were more frequently observed in unplanned PICU admitted patients compared to the other patients. No significant differences in cardiac morbidity, relapse, or progression were observed. Almost 20% of children with WT required unplanned PICU admission, with young age and treatment intensity as potential risk factors. Hypertension and renal impairment were frequently observed in these patients, warranting special attention at presentation and during treatment and follow-up.

Feasibility of bioimpedance spectroscopy and long-term functional assessment in critically ill children.

Lean body mass loss due to critical illness in childhood could be detrimental to long term outcomes, including functional status and quality of life. We describe the feasibility of body composition assessment by bioimpedance spectroscopy (BIS) in the pediatric intensive care unit (PICU), and functional status and quality of life assessments up to 6 months following admission in a cohort of mechanically ventilated, critically ill children. We conducted a prospective, observational pilot study in a multidisciplinary PICU. Children aged 1 month to 18 years who required mechanical ventilation, with expected stay in the PICU of at least 5 days were included. We examined the feasibility of consenting, enrolling, and completing baseline and 6-month assessments of BIS variables, Functional Status Scale (FSS), and Pediatric Quality of Life (Peds QL), in eligible patients. Of 32 patients approached, 23 (72%) completed baseline assessments [median (IQR) age 3.4 (1.0, 7.8) years, 14 (61%) male]; 6-month assessments were completed in 15 (65%) enrolled patients. Mean (SD) phase angle at study enrollment was 2.95 (0.93) and the impedance ratio was 0.90 (0.03). Phase angle (rs=-0.58, p=0.03) and impedance ratio (rs=0.61, p=0.02) by BIS were significantly correlated with total FSS at PICU discharge. Median total FSS and FSS tech (feeding and respiratory domains of FSS) scores improved from enrollment [16 (13, 26) and 8 (7, 10)] to 6 months [6 (6, 9) and 2 (2, 4), respectively, p<0.001]. Median Peds QL total, physical summary and psychosocial summary scores were not significantly different between PICU discharge and 6 months after PICU admission. Correlations between the total 6-month FSS and a) phase angle (-0.45, p=0.197) and b) impedance ratio (0.56, p=0.096) at PICU discharge were not significant. We have demonstrated the feasibility of obtaining bedside BIS measurements in the PICU, and functional and quality of life assessments remotely following PICU discharge. Body composition and long-term assessment of functional outcomes and quality of life must be incorporated in nutrition trials in critically ill children.

Paediatric Acute Respiratory Distress\xa0Syndrome Neuromuscular Blockade study (PAN-study): a phase IV randomised controlled trial of early neuromuscular blockade in moderate-to-severe paediatric acute respiratory distress syndrome

BackgroundPaediatric acute respiratory distress syndrome (PARDS) is a manifestation of severe, life-threatening lung injury necessitating mechanical ventilation with mortality rates ranging up to 40–50%. Neuromuscular blockade agents (NMBAs) may be considered to prevent patient self-inflicted lung injury in PARDS patients, but two trials in adults with severe ARDS yielded conflicting results. To date, randomised controlled trials (RCT) examining the effectiveness and efficacy of NMBAs for PARDS are lacking. We hypothesise that using NMBAs for 48 h in paediatric patients younger than 5 years of age with early moderate-to-severe PARDS will lead to at least a 20% reduction in cumulative respiratory morbidity score 12 months after discharge from the paediatric intensive care unit (PICU).MethodsThis is a phase IV, multicentre, randomised, double-blind, placebo-controlled trial performed in level-3 PICUs in the Netherlands. Eligible for inclusion are children younger than 5 years of age requiring invasive mechanical ventilation with positive end-expiratory pressure (PEEP) ≥ 5 cm H2O for moderate-to-severe PARDS occurring within the first 96 h of PICU admission. Patients are randomised to continuous infusion of rocuronium bromide or placebo for 48 h. The primary endpoint is the cumulative respiratory morbidity score 12 months after PICU discharge, adjusted for confounding by age, gestational age, family history of asthma and/or allergy, season in which questionnaire was filled out, day-care and parental smoking. Secondary outcomes include respiratory mechanics, oxygenation and ventilation metrics, pulmonary and systemic inflammation markers, prevalence of critical illness polyneuropathy and myopathy and metrics for patient outcome including ventilator free days at day 28, length of PICU and hospital stay, and mortalityDiscussionThis is the first paediatric trial evaluating the effects of muscular paralysis in moderate-to-severe PARDS. The proposed study addresses a huge research gap identified by the Paediatric Acute Lung Injury Consensus Collaborative by evaluating practical needs regarding the treatment of PARDS. Paediatric critical care practitioners are inclined to use interventions such as NMBAs in the most critically ill. This liberal use must be weighed against potential side effects. The proposed study will provide much needed scientific support in the decision-making to start NMBAs in moderate-to-severe PARDS.Trial registrationClinicalTrials.govNCT02902055. Registered on September 15, 2016.

Reducing Avoidable Transfer Delays in the Pediatric Intensive Care Unit for Status Asthmaticus Patients.

Introduction:Status asthmaticus (acute severe asthma) is one of the most common reasons for Pediatric Intensive Care Unit (PICU) admission. Accordingly, ensuring optimal throughput for patients admitted with status asthmaticus is essential for optimizing PICU capacity. Few studies specifically address effective methods to reduce delays related to PICU discharge. This project aimed to identify and reduce avoidable delays in PICU discharge for status asthmaticus patients.Methods:This quality improvement project focused on reducing transfer delays for status asthmaticus patients admitted to the PICU at a freestanding academic children’s hospital. We standardized the transfer criteria, identified barriers to an efficient transfer, and implemented multidisciplinary interventions. The primary aim was to decrease the average duration from fulfilling the transfer criteria to PICU discharge by 15% from the baseline within 8 months of implementation. The balancing measure was readmissions to the PICU for asthma exacerbations within 24 hours from PICU discharge.Results:The analysis included 623 patients. Following interventions, the time from fulfilling transfer criteria to PICU discharge decreased from 9.8 hours to 6.8 hours, a 30.6% reduction from baseline. Improvements were sustained for 6 months. In the preintervention group, three patients were readmitted to the PICU within 24 hours of transferring out of the PICU, but no patient was readmitted during the postintervention period.Conclusions:Standardizing transfer criteria and implementing multidisciplinary strategies can reduce avoidable PICU discharge delays for patients with status asthmaticus. The application of a similar approach could potentially reduce avoidable delays for other conditions in the PICU.

BIG score is a strong predictor of mortality and morbidity for high-energy traumas in pediatric intensive care unit.

Severe traumatic injuries not only constitute an important population of pediatric intensive care unit (PICU) but they also play a major role in mortality and morbidity. Mortality risk assessment of traumatic injuries in the PICU is a delicate issue as it influences the treatment decisions. BIG score (Base Deficit +[2.5 × INR] + [15-GCS]) and the Pediatric Trauma Score (PTS) are utilized in pediatric trauma centers for the assessment of trauma severity. In this research, we aimed to elucidate the predictivity of trauma severity scores, the PRISM-3 (pediatric risk of mortality), and admission laboratory parameters in pediatric patients with high-energy traumas. Children who had been exposed to high-energy polytraumas between 2018 and 2020 and treated in a tertiary care PICU were included in this retrospective analysis. Newly developed mental or motor disabilities, post-traumatic acquired epilepsy, requirement for tracheostomy, and/or extremity loss at PICU discharge were defined as morbidity. The PTS, the BIG score, PRISM-3 score, and admission laboratory parameters were utilized for mortality and morbidity prediction. A total of 155 patients were included in the study. The median age of the participants were 66 months (25-134). The origin of trauma was fall from height in 45.2% (n=70) of the subjects and traffic accident 54.8% (n=85) of the cases. New morbidities had occurred in 8.7% (n=13) and 3.2% (n=5) of the patients deceased in the ICU. The results of logistic regression analysis indicated that BIG score (p=0.01), PTS (p=0.003), PRISM-3 (p=0.02), admission D-dimer (p=0.01), and albumin levels (p=0.001) were significantly associated with mortality. The receiver operating characteristics curve analysis denoted that BIG score (cutoff >21.5, area under the curve [AUC]: 0.984 95% CI: 0.943-0.988), PRISM-3 score (cutoff >18, AUC: 0.997 95% CI: 0.970-1), the PTS (cutoff ≤3, AUC: 0.969 95% CI: 0.928-0.990), admission albumin level (cutoff ≤3 g/dL, AUC: 0.987 95% CI: 0.953-0.998), and D-dimer level (cutoff >13,100 mcg/L, AUC: 0.776 95% CI: 0.689-0.849) all had high predictive values for mortality. Regarding the results of this research, one can conclude that BIG score is a strong predictor of mortality and morbidity in high-energy pediatric traumas. Although PRISM-3 score has a similar predictive capability, the earlier and easier calculation as-sets of BIG score positions itself as a more useful and powerful predictor for mortality and morbidity in pediatric high-energy traumas.

Protein supplementation versus standard feeds in underweight critically ill children: a pilot dual-centre randomised controlled trial protocol

IntroductionProtein–energy malnutrition, increased catabolism and inadequate nutritional support leads to loss of lean body mass with muscle wasting and delayed recovery in critical illness. However, there remains clinical equipoise regarding...

School and Work Absences After Critical Care Hospitalization for Pediatric Acute Respiratory Failure

Patients who survive pediatric critical illness and their caregivers commonly experience physical, emotional, and cognitive sequelae. However, the rate and duration of school absence among patients and work absence among their caregivers are unknown. To determine the rates and duration of school absence among children who survived hospitalization with acute respiratory failure and work absence among their caregivers. The Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) cluster randomized trial included 2449 children from 31 sites to protocolized sedation (intervention) vs usual care (control) from June 6, 2009, to December 2, 2013. In total, 1360 children survived hospitalization and were selected for follow-up at 6 months after pediatric intensive care unit (PICU) discharge, which was completed from January 12, 2010, to April 13, 2015. This secondary analysis was conducted from July 1, 2020, to September 30, 2021. PICU hospitalization for acute respiratory failure, including invasive mechanical ventilation. Postdischarge assessments with caregivers of eligible participants at 6 months after PICU discharge, including questions about school and work absence. Risk factors associated with longer absence from school and work were identified. Postdischarge assessments were completed for 960 children who survived treatment for acute respiratory failure, of whom 443 (46.1%) were girls and 517 (53.9%) were boys; 509 of 957 (53.2%) were non-Hispanic White. Median age was 1.8 years (IQR, 0.4-7.9 years). In total, 399 children (41.6%) were enrolled in school, of whom 279 (69.9%) missed school after discharge. Median duration of postdischarge absence was 9.1 days (IQR, 0-27.9 days) among all children enrolled in school and 16.9 days (IQR, 7.9-43.9 days) among the 279 children with postdischarge absence. Among 960 primary caregivers, 506 (52.7%) were employed outside the home, of whom 277 (54.7%) missed work. Median duration of postdischarge work absence was 2 days (IQR, 0-10 days) among all employed primary caregivers, and 8 days (IQR, 4-20 days) among the 277 caregivers who missed work after discharge. The odds of postdischarge school absence and greater duration of absence increased for children 5 years or older (compared with 0-4 years, odds ratios [ORs] for 5-8 years, 3.20 [95% CI, 1.69-6.05] and 2.09 [95% CI, 1.30-3.37], respectively; ORs for 9-12 years, 2.49 [95% CI, 1.17-5.27] and 2.32 [95% CI, 1.30-4.14], respectively; and ORs for 13-18 years, 2.37 [95% CI, 1.20-4.66] and 1.89 [95% CI, 1.11-3.24], respectively) and those with a preexisting comorbidity (ORs, 1.90 [95% CI, 1.10-3.29] and 1.76 [95% CI, 1.14-2.69], respectively). In this secondary analysis of a cluster randomized trial, 2 in 3 children hospitalized for acute respiratory failure missed school after discharge, for a median duration of nearly 2 weeks. In addition, more than half of primary caregivers missed work after discharge. The magnitude of school absenteeism suggests that children may be at increased risk for lower educational achievement, economic hardship, and poor health outcomes in adulthood.

Drowning Accidents in a Spanish Pediatric Intensive Care Unit: An Observational Study for 29 Years.

Drowning is one of the most frequent accidents in children. We aimed to describe demographic and epidemiological characteristics of drowned children who required admission to a pediatric intensive care unit (PICU) to identify risk factors to guide possible preventive measures to avoid severe drowning. We conducted an observational study for 29 years (retrospective between 1991 and 2004; prospective between 2005 and 2019) that included all children (0-15 years old) requiring PICU admission after drowning. Data regarding patient characteristics, accident circumstances, and neurological outcomes at PICU discharge were analyzed. A total of 160 patients were included, with no significant decrease over the study period. There was a predominance of males (75%), young age (60%; 1-5 years), summer months (91.1%; May-September), tourists (14.12 [95% confidence interval, 9.2-21.7] times higher risk of drowning than residents), swimming pool accidents (88.8%), and inadequate supervision (77.9%). The mortality was 18.7%, and 7.5% of admitted children had severe neurological sequelae. The initial resuscitation maneuvers by accident witnesses were incorrect in nearly half of the patients in whom these could be analyzed. Emphasis should be placed on implementing preventive measures, focused on the described risk groups, and insisting on adequate supervision, swimming training programs, and training of the general population in safe rescue and cardiopulmonary resuscitation.

Sepsis-Related Brain MRI Abnormalities Are Associated With Mortality and Poor Neurological Outcome in Pediatric Sepsis

BackgroundIt is not known whether brain magnetic resonance imaging (MRI) abnormalities in pediatric sepsis are associated with clinical outcomes. Study objectives were to (1) determine the prevalence and type of sepsis-related neuroimaging abnormalities evident on clinically indicated brain MRI in children with sepsis and (2) test the association of these abnormalities with mortality, new disability, length of stay (LOS), and MRI indication. MethodsRetrospective cohort study of 140 pediatric patients with sepsis and a clinically indicated brain MRI obtained within 60 days of sepsis onset at a single, large academic pediatric intensive care unit (PICU). Two radiologists systematically reviewed the first post-sepsis brain MRI and determined which abnormalities were sepsis-related. Outcomes compared in patients with versus without sepsis-related MRI abnormalities. ResultsPICU mortality was 7%. Thirty patients had one or more sepsis-related MRI abnormality, yielding a prevalence of 21% (95% confidence interval 15%, 28%). Among those, 53% (16 of 30) had sepsis-related white matter signal abnormalities; 53% (16 of 30) sepsis-related ischemia, infarction, or thrombosis; and 27% (eight of 30) sepsis-related posterior reversible encephalopathy. Patients with one or more sepsis-related MRI abnormality had increased mortality (17% vs 5%; P = 0.04), new neurological disability at PICU discharge (32% vs 11%; P = 0.03), and longer PICU LOS (median 18 vs 11 days; P = 0.04) compared with patients without. ConclusionsIn children with sepsis and a clinically indicated brain MRI, 21% had a sepsis-related MRI abnormality. Sepsis-related MRI abnormalities were associated with increased mortality, new neurological disability, and longer PICU LOS.

Fluid overload in children with pediatric acute respiratory distress syndrome: A retrospective cohort study.

To assess the association of cumulative fluid overload (FO) up to 14 days from the diagnosis of pediatric acute respiratory syndrome (PARDS) with pediatric intensive care unit (PICU) mortality, 28-day mechanical ventilation free days (VFD), and 28-day intensive care unit free days (IFD). We hypothesized that fluid overload, even beyond the acute period, would be associated with increased morbidity and mortality. We conducted a retrospective cohort study of PARDS patients admitted to PICU from 2009 to 2015. For repeated admissions, we considered the admission with the highest oxygenation index (OI). Daily FO (%) was calculated as (intake - output)/weight at PICU admission × 100. Peak cumulative FO (CFO) was the highest CFO from the diagnosis of PARDS to Day 14 or to PICU discharge or mortality, whichever was earliest. Rate to peak CFO was the peak CFO divided by the number of days to reach that highest CFO. The association of FO with mortality, VFD and IFD were analyzed with logistic and linear regression models, with the following covariates: Pediatric Index of Mortality 2 score, PARDS severity, and the presence of acute kidney injury (AKI). There were 165 patients included in this study, with a mortality rate of 45.5% (75/165), median age 3.2 years (interquartile range [IQR] 0.7-9.9) and OI 15.8 (IQR 9.5-27.9). Seventy-three (44.2%) patients had severe PARDS and 64 (38.8%) had AKI. AKI (aOR [adjusted odds ratio] 3.19, 95% CI [confidence interval] 1.43-7.09, p = 0.004) and rate to peak cumulative FO (aOR 1.23, 95% CI 1.07-1.42, p = 0.004) were associated with mortality. AKI and peak cumulative FO were associated with decreased VFD and IFD. The rate to peak CFO over the first 14 days of PARDS was associated with mortality and peak CFO was associated with decreased VFD and IFD.

Sedation protocols in the pediatric intensive care unit: fact or fiction?

Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient’s clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.