Tertiary-care Pediatric Intensive Care Unit Research Articles

Impact of a tracheal aspirate culture diagnostic test stewardship intervention in a tertiary care PICU.

To assess the impact of a diagnostic test stewardship intervention focused on tracheal aspirate cultures. Quality improvement intervention. Tertiary care pediatric intensive care unit (PICU). Mechanically ventilated children admitted between 9/2018 and 8/2022. We developed and implemented a consensus guideline for obtaining tracheal aspirate cultures through a series of Plan-Do-Study-Act cycles. Change in culture rates and broad-spectrum antibiotic days of therapy (DOT) per 100 ventilator days were analyzed using statistical process control charts. A secondary analysis comparing the preintervention baseline (9/2018-8/2020) to the postintervention period (9/2020-8/2021) was performed using Poisson regression. The monthly tracheal aspirate culture rate prior to the COVID-19 pandemic (9/2018-3/2020) was 4.6 per 100 ventilator days. A centerline shift to 3.1 cultures per 100 ventilator days occurred in 4/2020, followed by a second shift to 2.0 cultures per 100 ventilator days in 12/2020 after guideline implementation. In our secondary analysis, the monthly tracheal aspirate culture rate decreased from 4.3 cultures preintervention (9/2018-8/2020) to 2.3 cultures per 100 ventilator days postintervention (9/2020-8/2021) (IRR 0.52, 95% CI 0.47-0.59, P < 0.01). Decreases in tracheal aspirate culture use were driven by decreases in inappropriate cultures. Treatment of ventilator-associated infections decreased from 1.0 to 0.7 antibiotic courses per 100 ventilator days (P = 0.03). There was no increase in mortality, length of stay, readmissions, or ventilator-associated pneumonia postintervention. A diagnostic test stewardship intervention was both safe and effective in reducing the rate of tracheal aspirate cultures and treatment of ventilator-associated infections in a tertiary PICU.

Comparison of pSOFA with PRISM III and PIM 2 as Predictors of Outcome in a Tertiary Care Pediatric ICU: A Prospective Cross-sectional Study.

Severity scores are used to predict the outcome of children admitted to the intensive care unit. A descriptive score such as the pediatric sequential organ failure assessment (pSOFA) may be useful for prediction of outcome. This study was planned to compare the pSOFA score with these well-studied scores for prediction of mortality. This prospective cross-sectional study was conducted at the pediatric intensive care units (PICU) of a tertiary care hospital. Children aged from 1 month to 12 years were enrolled sequentially. The pediatric index of mortality (PIM 2) score was calculated within 1 hour, and pediatric risk of mortality (PRISM) III and pSOFA scores were calculated within 24 hours of PICU admission. The pediatric sequential organ failure assessment score was recalculated after 72 hours. The primary outcome variable was hospital mortality, and secondary outcome variables were duration of PICU stay, need for mechanical ventilation, and occurrence of acute kidney injury (AKI). Appropriate statistical tests were used. About 151 children with median (IQR) age of 36 (6, 84) months were enrolled. Mechanical ventilation was required in 87 (57.6%) children. Mortality was 21.2% at 28 days. The median (IQR) predicted mortality using PRISM III and PIM 2 score were 3.4 (1.5%, 11%) and 8.2 (3.1%, 16.6%) respectively. Area under ROC for prediction of mortality was highest for pSOFA 72 with a cut-off of 6.5 having sensitivity of 83.3% and specificity of 76.9%. The pSOFA score calculated at admission and at 72 hours had a better predictive ability for the PICU mortality compared to PRISM III and PIM 2 score. Agrwal S, Saxena R, Jha M, Jhamb U, Pallavi. Comparison of pSOFA with PRISM III and PIM 2 as Predictors of Outcome in a Tertiary Care Pediatric ICU: A Prospective Cross-sectional Study. Indian J Crit Care Med 2024;28(8):796-801.

Comparison of efficacy of dopamine versus epinephrine infusion in fluid refractory septic shock in a tertiary care pediatric ICU.

Objective: To compare the effectiveness of dopamine versus epinephrine as 1st line vasoactive therapy among children aged 6 months to 12 years and presenting with fluid-refractory septic shock in pediatric intensive care unit (PICU). Study Design: Randomized Controlled Trial. Setting: Department of Medicine, The Children’s Hospital, Multan, Pakistan. Period: August 2022 to January 2023. Material &amp; Methods: A total of 156 children aged between 6 months to 12 year presenting to PICU with fluid refractory shock. Children were randomized to either Group-A (epinephrine) or Group-B (dopamine) till end points of resolution of shock was achieved. When the maximum recommended dose of the study drugs was reached, open-label vasoactive was initiated. Frequency of resolution of shock within 1st hour of resuscitation was noted. Results: In a total of 156 children, there were 85 (54.5%) children between 7 to 12 years of age. There were 90 (57.7%) males and 66 (42.3%) females. The efficacy was observed in 41 (52.6%) children in Group-A (epinephrine) versus 18 (23.1%) in Group-B (dopamine), p=0.0001. Conclusion: The epinephrine was more effective than dopamine as first-line vasoactive therapy in fluid-refractory septic shock in children aged 6 months to 12 years presenting in PICU.

Etiology of acute respiratory infections using multiplex polymerase chain reaction in children admitted to pediatric intensive care unit: A single-centered retrospective observational study from Western India

Background: Acute respiratory infections (ARIs) are an important cause of pediatric mortality–morbidity worldwide, the most common etiology being viral. This study aims to identify causative organisms for ARIs admitted in pediatric intensive care unit (PICU), when multiplex polymerase chain reaction (PCR) testing of respiratory secretions was sent; any seasonal trends detect microbiological correlation when co-infections. Subjects and Methods: This was a retrospective observational study, from July 2021 to December 2022, of children aged 1 month–18 years, whose multiplex PCR tests (nasopharyngeal, endotracheal [ET] secretion or bronchoscopic alveolar lavage [BAL]) were sent when admitted for ARI to tertiary care PICU. Results: In the study period, 372 of 1492 medical PICU admissions were ARI. Multiplex PCR of 81 respiratory secretions was sent, of which 69 (85%) were positive. Multiplex pcr sample positivity : 83% for nasopharyngeal aspirate, 78% for ET secretions, 100% for BAL samples. Forty-one percent of samples detected &gt;1 organism. Respiratory syncytial virus (RSV)-A was the most common virus (18); other organisms included adenovirus (n = 5), influenza (n = 9), parainfluenza (n = 5), rhinovirus: 13, Pneumocystis Jerovecci (PCP): 4, Streptococcus pneumoniae: 17, pertussis: 1, and Haemophilus influenzae B: 9. ARIs were seen throughout the year with peaks in monsoon season and a peak in cases of ARI due to RSV from July to October. Of co-infections with bacteria in ET secretions and BAL samples via multiplex PCR, bacterial culture reports were sterile. Conclusions: Multiplex PCR detected organisms in 85% of ARI patients tested. Most of the ARIs getting admitted to PICU were viral in origin. RSV was the most common virus isolated showing peak from July to October, local monsoon season. With extended viral and bacterial PCR being available, mixed infections/colonization with uncertain significance are being detected.

Supporting Clinical Decisions with Rapid Molecular Diagnostic Pneumonia Panel in Pediatric Intensive Care Unit: Single Center Experience in Turkiye.

Lower respiratory tract infections are the leading cause of morbidity and mortality in children worldwide. It is crucial to promptly conduct diagnostic investigations in order to determine the microbiological cause of pneumonia, since this is necessary to ensure the appropriate delivery of antibiotic therapy to each individual patient. We evaluated the results of a rapid molecular diagnostic pneumonia panel in children with LRTI in a pediatric intensive care unit (PICU). Rapid molecular diagnostic pneumonia panel (BioFire®, FilmArray Pneumonia Panel plus; FA-PP) findings (71 results from 46 children) in a tertiary care PICU between 2019 and 2023 were retrospectively reviewed. At least one bacterial pathogen was detected in 57 cases. A total of 77% of children had underlying conditions. A total of 70.4% of children needed invasive mechanical ventilation and 54.4% had ventilator-associated pneumonia. Pseudomonas aeruginosa (50.8%), Acinetobacter calcoaceticus baumannii complex (42%), and Klebsiella pneumoniae (38.6%) were the most common pathogens detected with the FA-PP. Of the 33 cases diagnosed with VAP, more than one pathogen was identified in 65.9% of cases, with the most commonly identified bacteria being K. pneumoniae (43.1%), P. aeruginosa (38.6%), and Acinetobacter calcoaceticus baumannii complex (31.8%). According to the FA-PP results, the same antibiotic therapy was continued in 39.4% of cases, escalated in 54.5%, and de-escalated in 6.1%. The utilization of the FA-PP has some beneficial effects, including more prompt delivery of findings compared to conventional approaches. Additionally, this approach enables the identification of resistance profiles in children diagnosed with pneumonia in the PICU. Consequently, these test results facilitate the organization of antibiotic treatment strategies, including escalation and de-escalation approaches. The detection of resistance patterns was exclusively determined via the implementation of molecular testing, prompting a reevaluation of the isolation technique in accordance with the obtained data.

Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit.

Introduction: Patients admitted to the pediatric intensive care unit (PICU) typically transfer to an acute care floor prior to discharge (ACD). Various circumstances, including rapid clinical improvement, technology dependence, or capacity constraints, may lead to discharge directly to home from a PICU (DDH). This practice has been studied in adult intensive care units, but research is lacking for PICU patients. Methods: We aimed to describe characteristics and outcomes of patients requiring PICU admission who experienced DDH versus ACD. We conducted a retrospective cohort study of patients ≤18 years old admitted to our academic, tertiary care PICU between 1/1/15 and 12/31/20. Patients who died or were transferred to another facility were excluded. Baseline characteristics (including home ventilator dependence) and markers of illness severity, specifically the need for vasoactive infusion or new mechanical ventilation, were compared between groups. Admission diagnoses were categorized using the Pediatric Clinical Classification System (PECCS). Our primary outcome was hospital readmission within 30 days. Results: Of 4042 PICU admissions during the study period, 768 (19%) were DDH. Baseline demographic characteristics were similar, although DDH patients were more likely to have a tracheostomy (30% vs 5%, P < .01) and require a home ventilator at discharge (24% vs 1%, P < .01). DDH was associated with being less likely to have required a vasoactive infusion (7% vs 11%, P < .01), shorter median length of stay (LOS) (2.1 days vs 5.9 days, P < .01) and increased rate of readmission within 30 days of discharge (17% vs 14%, P < .05). However, repeat analysis after removing ventilator-dependent patients at discharge (n = 202) showed no difference in rates of readmission (14% vs 14%, P = .88). Conclusions: Direct discharge home from the PICU is a common practice. DDH and ACD groups had similar 30-day readmission rate when patient admissions with home ventilator dependence were excluded.

Supporting families during pediatric critical illness: Opportunities identified in a multicenter, qualitative study.

Critical illness resulting in a pediatric intensive care unit (PICU) admission is a profoundly stressful experience for a child and their family. Increasing evidence for emotional and behavioral sequelae post-PICU emphasizes a need to provide better support for families throughout this period of care and recovery. The aim of this qualitative investigation was to identify salient and modifiable aspects of a critical care experience that can be addressed to better support families of critically ill children. Individual semi-structured interviews were conducted with 26 caregivers of children who survived a PICU admission. Interviews were audio-recorded and transcribed verbatim; themes were identified via thematic analysis. Caregivers were enrolled using convenience sampling from seven tertiary care PICUs in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Themes from caregiver interviews were identified within two overarching categories containing three themes each. Advice for future PICU families: (1) Be intentional about caring for your own well-being, (2) speak up, ask questions, and challenge decisions you're not comfortable with, and (3) continue to engage with your child. Characteristics of a satisfactory PICU experience: (1) A caregiver-provider relationship of mutual trust established through clear communication and respectful collaboration, (2) hospital environments that provide physical and social supports to maintain humanity in healthcare, and (3) preparing families for care transitions. Targeted, interdisciplinary approaches to partner with families during critical care may improve their PICU experience and contribute to improved long-term outcomes for PICU survivors.

Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention.

To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. Mixed-methods study. Tertiary-care pediatric intensive care unit (PICU). Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.

609: NEPHROTOXIC MEDICATIONS AND THEIR ASSOCIATION WITH ACUTE KIDNEY INJURY IN CRITICALLY ILL CHILDREN

Introduction: The incidence of developing acute kidney injury (AKI) in the pediatric intensive care unit (PICU) is estimated to be 26% (Kaddourah, 2017). Nephrotoxic medications are a modifiable risk factor associated with AKI in non-critically ill children & neonates (Moffett, 2011 & Stoops, 2019). The primary objective of this study is to evaluate the association between the number of nephrotoxic medications and the risk of developing AKI in critically ill children. Methods: This is a single center retrospective cohort study of critically ill children admitted to a tertiary care PICU. Inclusion criteria was patients age 0-21 years admitted for >24 hours. Exclusion criteria was history of chronic kidney disease or if expired within 24 hours of admission. We considered the same list of medications used in previous studies to be nephrotoxic, NSAIDs, certain antibiotics, and chemotherapy agents. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria including serum creatinine increase by ≥0.3, >1.5 times baseline, or urine output < 0.5 mL/kg/hr for ≥12 hours. Severe AKI was defined as Stage 2 & 3 AKI. Exposure to the number of nephrotoxic medications and development of AKI was analyzed. Results: 60 patients were analyzed. Median age was 6.55 (1.12-12.71) years and mostly male (55%). Median LOS was 3 (2-5) days. Majority had a respiratory illness as primary diagnosis (31%). Median PELOD2 score was 3.5 (2-7). Incidence of AKI was 40%. 46% of patients who developed AKI did not have any nephrotoxic medications administered. 42% of patients with AKI were administered 1 nephrotoxic medication. 12% of patients with AKI had exposure to ≥2 medications. Amongst all patients with AKI, 88% had severe AKI. The most common medications administered were ibuprofen (22%) and vancomycin (17%). Exposure to the number of nephrotoxic medications and development of AKI was assessed with Fisher’s Exact test. There was no statistical significance with the number of nephrotoxic medications and the development of AKI (p=0.962). Correlation analysis revealed an increased rate of AKI with PICU LOS ≥5 days (p=0.029). Conclusions: There was no statistically significant association between the number of nephrotoxic medications and the development of AKI. Patients with longer LOS had a higher risk of developing AKI.

Parent post-traumatic growth after a child's critical illness.

ObjectivePost-traumatic growth is the experience of a positive change after a traumatic event. Our objective is to characterize the factors associated with post-traumatic growth in parents after a child's pediatric intensive care unit (PICU) admission.Study designA cross-sectional survey study examining post-traumatic growth and select independent variables in parents 1 year after a child's ≥72 h PICU admission for an acute illness or injury. The study was completed in parents of children discharge alive from a tertiary care PICU from January 1, 2017 to December 31, 2017. A mixed-effects linear regression model was built to evaluate the association of post-traumatic stress, anxiety, depression, resiliency, family function, and child function with post-traumatic growth.ResultsEighty-two parents of 52 children discharged alive in 2017 completed the survey. Fifty-two percent were ≥35 years and 64.3% were mothers. Median age of their children was 2.8 years (IQR 0.5–11.3) with a median hospital stay of 12 Days (IQR 6–20). Moderate-to-high levels of post-traumatic growth occurred in 67.1% of parents. Increased hospital length of stay (β Coeff 0.85; p = 0.004, 95% CI 0.27, 1.43) and parent post-traumatic stress symptoms (β Coeff 1.04; p = 0.006, 95% CI 0.29, 1.78) were associated with increased post-traumatic growth, and increased parent depression symptoms (β Coeff −1.96; p = 0.015; 95% CI −3.54, −0.38) with decreased post-traumatic growth.ConclusionLonger child hospital stays and increased parent post-traumatic stress symptoms were associated with increased post-traumatic growth, while increased depression was associated with less post-traumatic growth. The impact of future PICU parent psychosocial interventions on parents may be best assessed using a dual outcome focused on both reducing negative mental health symptoms while concurrently promoting skills to facilitate parent adaptation and post-traumatic growth.

Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children.

The Venous Excess Ultrasound (VExUS) score has been described as a useful tool to estimate the degree of venous congestion in adult patients. The present study aimed to analyze the feasibility and usefulness of the VExUS score to detect and grade central venous pressure (CVP) elevation in critically ill children. A cross-sectional pilot study was conducted in a tertiary-care pediatric intensive care unit between November 2020 and June 2021. All children in whom CVP was monitored, were enrolled. At the time of central venous catheter placement, CVP and VExUS score grade were determined, analyzing the inferior vena cava (IVC) diameter and the hepatic (HVD), portal (PVD), and intrarenal (IRVD) venous Doppler waveforms. A total of 33 children were studied (median age 12.2 [interquartile range (IQR) 4.1-100.6] months old; median weight 8.5 [IQR 5.6-35] kg; 20 [60.6%] males). The VExUS score was successfully obtained in 100% of the patients and its severity was strongly associated with the CVP levels (P< .001). Analyzing the VExUS score components separately, IVC dilation (P< .001) and severe HVD (P= .026), mild IRVD (P= .005), and severe IRVD (P= .025) patterns were associated with elevated CVP. After adjustment for confounding factors, IRVD pattern remained the only independent variable associated with elevated CVP. The VExUS score appears to be a feasible and potentially useful bedside noninvasive monitoring tool for the detection and grading of CVP elevation in critically ill children. Among all its components, IRVD assessment seems most associated with high CVP in this population.

Performance and analysis of four pediatric mortality prediction scores among critically ill children: A multicenter prospective observational study in four PICUs

ObjectiveWe aimed to evaluate and compare the prognostic performance of common pediatric mortality scoring systems (the Pediatric Index of Mortality 2 [PIM2], PIM3, Pediatric Risk of Mortality [PRISM], and PRISM4 scores) to determine which is the most applicable score in our pediatric study cohort. MethodsThis prospective observational multicenter cohort study was conducted in four tertiary-care pediatric intensive care units (PICUs) in Turkey. All children, between 1 month and 16 years old, admitted to the participating PICUs between October 1, 2019, and March 31, 2020, were included in the study. Discrimination between death and survival was assessed by area under the receiver operating characteristic plot (AUC) for each model. The Hosmer–Lemeshow goodness-of-fit (GOF) test was used to assess the calibration of the models, ResultsA total of 570 patients (median age 35 months) were enrolled in the study. The observed mortality rate was 8.2% (47/570). The standardized mortality ratio (SMR) of PIM2, PIM3, PRISM, and PRISM4 with 95% confidence interval (CI) were 0.94 (0.68–1.23), 1.27 (0.93–1.68), 0.86 (0.63–1.13), and 1.5 (1.10–1.97), respectively. The AUC with 95% CI was 0.934 (0.91–0.96) for PIM2, 0.934 (0.91–0.96) for PIM3, 0.917 (0.88–0.95) for PRISM, and 0.926 (0.88–0.97) for PRISM4 models. The Hosmer–Lemeshow test showed that the difference between observed and predicted mortality by PIM3 (p = 0.003) and PRISM4 (p = 0.008) was statistically significant whereas PIM2 (p = 0.28) and PRISM (p = 0.62) showed good calibration. ConclusionThe overall performance of (both discrimination and calibration) PRISM and PIM2 scoring systems in Turkish pediatric patients aged 1 month to 16 years was accurate and had the best fit for risk groups according to our study. Although PIM3 and PRISM4 have good discriminatory power, their calibration was very poor in our study cohort.

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.

Performance of PRISM III, PELOD-2, and P-MODS Scores in Two Pediatric Intensive Care Units in China.

Objective: The performances of the pediatric risk of mortality score III (PRISM III), pediatric logistic organ dysfunction score-2 (PELOD-2), and pediatric multiple organ dysfunction score (P-MODS) in Chinese patients are unclear. This study aimed to assess the performances of these scores in predicting mortality in critically ill pediatric patients.Methods: This retrospective observational study was conducted at two tertiary-care PICUs of teaching hospitals in China. A total of 1,253 critically ill pediatric patients admitted to the two Pediatric Intensive Care Units (PICUs) of the First Affiliated Hospital, Sun Yat-Sen University from August 2014 to December 2019 and Shen-Zhen Children's Hospital from January 2019 to December 2019 were analyzed. The indexes of discrimination and calibration were applied to evaluate score performance for the three models (PRISM III, PELOD-2, and P-MODS scores). The receiver operating characteristic (ROC) curve was plotted, and the efficiency of PRISM III, PELOD-2, and P-MODS in predicting death were evaluated by the area under ROC curve (AUC). Hosmer–Lemeshow goodness-of-fit test was used to evaluate the degree of fitting between the mortality predictions of each scoring system and the actual mortality.Results: A total of 1,253 pediatric patients were eventually enrolled in this study (median age, 38 months; overall mortality rate, 8.9%; median length of PICU stay, 8 days). Compared to the survival group, the non-survival group showed significantly higher PRISM III, PELOD-2, and P-MODS scores [PRISM III: 18 (12, 23) vs. 11 (0, 16); PELOD-2, 8 (4, 10) vs. 4 (0, 6); and P-MODS: 5 (4, 9) vs. 3 (0, 4), all P < 0.001]. ROC curve analysis showed that the AUCs of PRISM III, PELOD-2, and P-MODS for predicting the death of critically ill children were 0.858, 0.721, and 0.596, respectively. Furthermore, in the Hosmer–Lemeshow goodness-of-fit test, PRISM III and PELOD-2 showed the better calibration between predicted mortality and observed mortality (PRISM III: χ2 = 5.667, P = 0.368; PELOD-2: χ2 = 9.582, P = 0.276; P-MODS: χ2 = 12.449, P = 0.015).Conclusions: PRISM III and PELOD-2 can discriminate well between survivors and non-survivors. PRISM III and PELOD-2 showed the better calibration between predicted and observed mortality, while P-MODS showed poor calibration.

The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial.

Rudeness exposure has been shown to inhibit diagnostic performance. The effects of rudeness on challenging a handed-off diagnostic error has not been studied. This was a randomized controlled study of attending, fellow, and resident physicians in a tertiary care pediatric ICU. Participants underwent a standardized simulation that started with the wrong diagnosis in hand-off. The hand-off was randomized to neutral vs. rude. Participants were not informed of the randomization nor diagnostic error prior to the simulation. Perspective taking questionnaires were administrated for each participant. Primary outcome was challenging diagnostic error post-simulation. Secondary outcomes included rate and frequency of diagnostic error challenge during simulation. Among 41 simulations (16 residents, 14 fellows, and 11 attendings), the neutral group challenged the diagnostic error more than the rude group (neutral: 71%, rude: 55%, p=0.28). The magnitude of this trend was larger among resident physicians only, although not statistically significant (neutral: 50%, rude: 12.5%, p=0.11). Experience was associated with a higher percentage of challenging diagnostic error (residents: 31%, fellows: 86%, attendings: 82%, p=0.003). Experienced physicians were faster to challenge diagnostic error (p<0.0003), and experience was associated with a greater frequency of diagnostic error challenges (p<0.0001). High perspective taking scores were also associated with 1.63 times more diagnostic error challenges (p=0.007). Experience was strongly associated with likelihood to challenge diagnostic error. Rudeness may disproportionally hinder diagnostic performance among less experienced physicians. Perspective taking merits further research in possibly reducing diagnostic error momentum.

Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study

BackgroundInappropriate antibiotic utilization is associated with the emergence of antimicrobial resistance (AMR) and a decline in antibiotic susceptibility in many pathogenic organisms isolated in intensive care units. Antibiotic stewardship programs (ASPs) have been recommended as a strategy to reduce and delay the impact of AMR. A crucial step in ASPs is understanding antibiotic utilization practices and quantifying the problem of inappropriate antibiotic use to support a targeted solution. We aim to characterize antibiotic utilization and determine the appropriateness of antibiotic prescription in a tertiary care pediatric intensive care unit.MethodsA retrospective cohort study was conducted at King Abdullah Specialized Children’s Hospital, Riyadh, Saudi Arabia, over a 6-month period. Days of therapy (DOT) and DOT per 1000 patient-days were used as measures of antibiotic consumption. The appropriateness of antibiotic use was assessed by two independent pediatric infectious disease physicians based on the Centers for Disease Control and Prevention 12-step Campaign to prevent antimicrobial resistance among hospitalized children.ResultsDuring the study period, 497 patients were admitted to the PICU, accounting for 3009 patient-days. A total of 274 antibiotic courses were administered over 2553 antibiotic days. Forty-eight percent of antibiotic courses were found to be nonadherent to at least 1 CDC step. The top reasons were inappropriate antibiotic choice (empirical or definitive) and inappropriate prophylaxis durations. Cefazolin and vancomycin contributed to the highest percentage of inappropriate DOTs.ConclusionsAntibiotic consumption was high with significant inappropriate utilization. These data could inform decision-making in antimicrobial stewardship programs and strategies. The CDC steps provide a more objective tool and limit biases when assessing antibiotic appropriateness

Opioid use is Associated with ICU Delirium in Mechanically Ventilated Children.

IntroductionPediatric delirium is a significant problem when encounterd in an intensive care unit (ICU). The pathophysiology of pediatric delirium is complex and the etiology is typically multifactorial. Even though various risk factors associated with pediatric delirium in a pediatric ICU have been identified, there is still a paucity of literature associated with the condition, especially in extremely critically ill children, sedated and mechanically ventilated.Aim of the studyTo identify factors associated with delirium in mechanically ventilated children in an ICU.Material and MethodsThis is a single-center study conducted at a tertiary care pediatric ICU. Patients admitted to the pediatric ICU requiring sedation and mechanical ventilation for >48 hours were included. Cornell Assessment of Pediatric Delirium scale was used to screen patients with delirium. Baseline demographic and clinical factors as well as daily and cumulative doses of medications were compared between patients with and without delirium. Firth’s penalized maximum likelihood logistic regression was used on a priori set of variables to examine the association of potential factors with delirium. Two regression models were created to assess the effect of daily medication doses (Model 1) as well as cumulative medication doses (Model 2) of opioids and benzodiazepines.Results95 patient visits met the inclusion criteria. 19 patients (20%) were diagnosed with delirium. Older patients (>12 years) had higher odds of developing delirium. Every 1mg/kg/day increase in daily doses of opioids was associated with an increased risk of delirium (OR=1.977, p=0.017). Likewise, 1 mg/kg increase in the cumulative opioid dose was associated with a higher odds of developing delirium (OR=1.035, p=0.022). Duration of mechanical ventilation was associated with the development of delirium in Model 1 (p=0.007).ConclusionsAge, daily and cumulative opioid dosage and the duration of mechanical ventilation are associated with the development of delirium in mechanically ventilated children.

Five years study of mortality and morbidity patterns of Tetanus cases in a Tertiary Care PICU (Pediatric Intensive Care Unit), Multan Pakistan.

Objectives: Tetanus is an avoidable disease. Significant reduction in the incidence of tetanus is observed around the globe but in Pakistan, its incidence is still high. The objective of current study was to determine the demographic, clinical features, outcome and complications of tetanus patients admitted in Pediatric Intensive Care Unit (PICU). Study Design: This Descriptive-observational study. Setting: At PICU of The Children Hospital &amp; ICH Multan Pakistan. Periods: 1st January 2013 to 31st December 2017. Material and Methods: A total of 77 tetanus cases admit through the study period in PICU. Clinical features, complications, duration of stay and outcome of 77 tetanus cases during study period were noted. Results: Amongst a total of 77 cases, 62 were male (80.6%) and 15(19.4%) female. Most (57.1%) were between 2 to 7 years. Twenty five (32.4%) were unvaccinated, 52 (67.6%) partially vaccinated. According to the grade of severity (Ablett classification), majority (40) were of grade-III. Regarding the outcome, 15 (19.5%) expired. Conclusion: Tetanus is a fatal disease with high mortality rate. Vaccination and right management of the disease are the best options to minimize the load of tetanus in our country.

Study of use of intravenous immunoglobulin in pediatric intensive care unit in a tertiary care center: An audit and review of evidence

Introduction: The label and off-label use of intravenous immunoglobulin (IVIG) in pediatric intensive care unit (PICU) is done as a replacement therapy also for immunomodulation. As there are no standard guidelines for the use of IVIG in PICU; hence, the need to study the pattern of indications for which IVIG has been used in critically ill children and review the quality of evidence as per the available data. Materials and Methods: The retrospective chart review of indications for IVIG therapy in children over a period of 4 years in a tertiary care PICU from January 2015 to December 2018. Collection of data included demographic profile, indication of transfusion of IVIG, dose of IVIG received, and outcome of the patients. Results: The IVIG therapy was given to 301 children under the following groups, 120 children for neuroimmunologic disorders, 73 children for cardiology-related indications, 65 children for infection and infection-related causes, 31 children for autoimmune diseases, seven and five children each for primary immunodeficiency and dermatological causes, respectively. The indications, for which IVIG therapy given included, approved by the Food and Drug Administration in 56 children, under evidence category Level Ia in 50 children and with strength of recommendation Grade A in 51 children. Conclusion: There is a rise in off-label use of IVIG as the quality of evidence is variable for different indications hence there is a need for better quality of evidence and more multicentric randomized control trials to define the precise impact of IVIG on various conditions.

7 Is the New 8: Improving Adherence to Restrictive PRBC Transfusions in the Pediatric ICU.

Up to 30%-40% of children admitted to the pediatric intensive care unit (PICU) have anemia, and approximately 15% receive packed red blood cell (pRBC) transfusions. Current literature supports a pRBC transfusion threshold of hemoglobin less than or equal to seven for most PICU patients. Our objective was to determine pRBC transfusion rates, assess compliance with transfusion guidelines, understand patient-level variables that affect transfusion practices, and use cross-industry innovation to implement a practice strategy. This was a pre-post study of pediatric patients admitted to our PICU. We collected baseline data on pRBC transfusion practices. Next, we organized an innovation platform, which generated multi-industry ideas and produced an awareness campaign to effect pRBC ordering behavior. Innovative educational interventions were implemented, and postintervention transfusion practices were monitored. Statistical analysis was performed using linear mixed models. A p value < .05 was considered statistically significant. At baseline, 41% of pRBC transfusions met restrictive transfusion guidelines with a pretransfusion hemoglobin less than or equal to 7 g/dl. In the postintervention period, 53% of transfusions met restrictive transfusion guidelines (odds ratio 1.66, 95% confidence interval 1.21-2.28). Implementation of a behavioral campaign using multi-industry innovation led to improved adherence to pRBC transfusion guidelines in a tertiary care PICU.