Tertiary-care Pediatric Intensive Care Unit Research Articles

Performance and Analysis of Pediatric Index of Mortality 3 Score in a Pediatric ICU in Latifa Hospital, Dubai, UAE

Introduction: The pediatric index of mortality (PIM) 3 is one of several severity scoring systems used for predicting the outcome of patients admitted to pediatric intensive care units (PICUs) based on data collected within the first hour of admission. It avoids potential bias from the effects of treatment after admission and offers practical utility in assigning children to clinical trials soon after PICU admission. PIM 3 is an updated version of PIM 2 for predicting mortality in the PICU. It provides an international standard based on a large contemporary dataset for the comparison of risk-adjusted mortality among children admitted to intensive care. Objective: The aim was to evaluate the performance of the PIM 3 score in predicting mortality in a tertiary care PICU. Materials and Methods: This was a cohort observational study conducted at a tertiary care PICU from January 2016 to October 2018. All patients between 1 month and 15 years of age who were admitted in the PICU in Latifa Hospital were included. PIM 3 scoring was done for all the patients. All data were extracted from the computerized ICU registry database. Scores were calculated using the PIM 3 calculator application. Data were entered into Microsoft Excel 2013 and analyzed using SPSS v24.0. We analyzed the association between PIM 3 score and mortality. The performance of PIM 3 score was assessed by calibration and discrimination. Calibration evaluated PIM 3 at different risks of mortality and was assessed by standardized mortality ratio (SMR) and Pearson’s χ² goodness-of-fit test. SMR was calculated to a mean probability of death and the ratio of observed-to-expected death rates. Discrimination evaluated how well PIM distinguished between patients who survived and died and was assessed using the area under the curve (AUC) with a 95% confidence interval (CI) from the receiver-operating characteristics plot. Results: A total of 583 patients were included in the study, 46 of whom (7.9%) died. The overall SMR was 0.53. SMR was 0.33 and 0.72 in the p < 14.3% and p > 14.3% group, respectively. The expected mortality rate based on PIM 3 score was 9.2 and 37.5% in the p < 14.3% and p > 14.3% group, respectively. Conclusion: The PIM 3 was used to predict mortality in PICU patients in Latifa Hospital, Dubai. The overall accumulated expected mortality was 87.081 (5%) compared to the observed mortality of 46 (7.9%) and SMR of 0.53. PIM 3 had acceptable discrimination ability with an AUC of 0.78 (95% CI 0.69–0.87).

Noninvasive Ventilation Is Interrupted Frequently and Mostly Used at Night in the Pediatric Intensive Care Unit

Noninvasive ventilation (NIV) is commonly used to support children with respiratory failure, but detailed patterns of real-world use are lacking. The aim of our study was to describe use patterns of NIV via electronic medical record (EMR) data. We performed a retrospective electronic chart review in a tertiary care pediatric ICU in the United States. Subjects admitted to the pediatric ICU from 2014 to 2017 who were mechanically ventilated were included in the study. The median number of discrete device episodes, defined as a time on support without interruption, was 20 (interquartile range [IQR] 8-49) per subject. The median duration of bi-level positive airway pressure (BPAP) support prior to interruption was 6.3 h (IQR 2.4-10.4); the median duration of CPAP was 6 h (IQR 2.1-10.4). Interruptions to BPAP had a median duration of 6.3 h (IQR 2-15.5); interruptions to CPAP had a median duration of 8.6 h (IQR 2.2-16.8). Use of NIV followed a diurnal pattern, with 44% of BPAP and 42% of CPAP subjects initiating support between 7:00 pm and midnight, and 49% of BPAP and 46% of CPAP subjects stopping support between 5:00 am and 10:00 am. NIV was frequently interrupted, and initiation and discontinuation of NIV follows a diurnal pattern. Use of EMR data collected for routine clinical care allowed the analysis of granular details of typical use patterns. Understanding NIV use patterns may be particularly important to understanding the burden of pediatric ICU bed utilization for nocturnal NIV. To our knowledge, this is the first study to examine in detail the use of pediatric NIV and to define diurnal use and frequent interruptions to support.

Evaluation of Healthcare-Acquired Infection Rates in a Pediatric Intensive Care Unit in Turkey

AbstractHealthcare-acquired infections (HAIs) have become a major concern and a significant cause of morbidity and mortality in pediatric intensive care units (PICUs). The purpose of this study was to evaluate HAI rates as well as the rates of invasive device utilization at a PICU at a large tertiary care pediatric teaching hospital from a developing country over a 4-year period, and to compare findings with those of the National Health Safety Network United States, the International Nosocomial Infection Control Consortium, and Turkey's national HAI rates. An active prospective surveillance was performed at a tertiary care PICU from January 2014 to December 2017. It was especially analyzed for nosocomial infections, related to invasive devices: the central line catheter (CL), mechanical ventilator (MV), and the urinary catheter (UC). During the 4-year period, a total of 2,855 patient admissions and 30,499 patient-days were evaluated. The device-associated (DA)-HAI incidence density was 17.57 per 1,000 patient-days, and the incidence rate was 18.8 per 100 admissions. The most common site of the DA-HAIs was ventilator-associated pneumonia (VAP) with the highest rate (60.9%). The second was the central line-associated bloodstream infection (CLA-BSI) rate (24.8%). Catheter-associated urinary tract infections (CA-UTI) rank third (14.3%). The HAI location was VAP in 187 patients (11.31/1,000 MV-days), CLA-BSI in 76 patients (4.39/1,000 CL-days), and CA-UTI in 44 patients (3.35/1,000 UC-days). The most frequent pathogens, isolated from the overall DA-HAIs as being causative microorganisms were Acinetobacter baumannii (23%), followed by Pseudomonas aeruginosa (14%). Resistance of Acinetobacter baumannii to Carbapenem was 76.47%, and methicillin-resistance Staphylococcus aureus was 50% at the pediatric ICU. This study reported data on incidence rates as well as pathogens of HAIs from a developing country's PICU, which may later supply useful data about other pediatric hospitals.

Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients: A Quality Improvement Project.

To evaluate the effect of implementation of a comfort algorithm on infusion rates of opioids and benzodiazepines in postneonatal postoperative pediatric cardiac surgery patients. A quality improvement project, using statistical process control methodology. Twenty-five-bed tertiary care pediatric cardiac ICU in an urban academic Children's hospital. Postoperative pediatric cardiac surgery patients. Implementation of a guided comfort medication algorithm which consisted of key components; a low dose opioid continuous infusion, judicious use of frequent as needed opioids, initiation of dexmedetomidine infusion postoperatively, and minimal use of benzodiazepines. Among the baseline group admitted over the 18 month period prior to comfort algorithm implementation, 58 of 116 intubated patients (50%) received a continuous opioid infusion, compared with 30 of 41 (73%) for the implementation group over the 9-month period following implementation. Following algorithm implementation, opioid infusion rates were decreased and benzodiazepine infusions were nearly eliminated. Dexmedetomidine use and infusion rates did not change. Although mean duration of sedative drug infusions did not change with implementation, the frequency of high outliers was diminished. Duration of mechanical ventilation, length of ICU stay (outcome measures), and the frequency of unplanned extubation (balancing measure) were not affected by implementation. Implementation of a pediatric comfort algorithm reduced opioid and benzodiazepine dosing, without compromising safety for postoperative pediatric cardiac surgical patients.

Clinical Decision Support Tools and a Standardized Order Set Enhances Early Enteral Nutrition in Critically Ill Children.

Critically ill children in a pediatric intensive care unit (PICU) have unique nutrition needs that are challenging to achieve and thus are at high risk of malnutrition. There is increasing evidence that children who reach caloric goals early have improved outcomes. The purpose of this initiative was to implement an enteral nutrition (EN) algorithm in a tertiary care PICU utilizing clinical decision support tools (CDSTs) and a standardized order set within an electronic health record. A quality improvement initiative was undertaken to implement an EN feeding protocol using electronic CDSTs, including a new standardized order set. In a historical cohort of 376 patients, only 18% met goal EN in the first 48 hours of admission. The EN protocol was implemented in 272 patients who met 88% goal feed volume within 48 hours of intensive care unit admission. Median time to start EN (1.7 vs 1.3 days, P < 0.0001) and time to goal nutrition (2.8 vs 2.2 days, P < 0.001) improved after project implementation. Length of stay in the PICU was significantly reduced following protocol implementation (202 hours pre-implementation vs 156 hours post implementation, P < 0.0001). We used CDSTs and standardized order sets to implement a nutrition algorithm to facilitate and likely improve the nutrition care of critically ill children.

A Descriptive Study of Decision-Making Conversations during Pediatric Intensive Care Unit Family Conferences.

Little is known about how decision-making conversations occur during pediatric intensive care unit (PICU) family conferences (FCs). Describe the decision-making process and implementation of shared decision making (SDM) during PICU FCs. Observational study. University-based tertiary care PICU, including 31 parents and 94 PICU healthcare professionals involved in FCs. We recorded, transcribed, and analyzed 14 PICU FCs involving decision-making discussions. We used a modified grounded theory and content analysis approach to explore the use of traditionally described stages of decision making (DM) (information exchange, deliberation, and determining a plan). We also identified the presence or absence of predefined SDM elements. DM involved the following modified stages: information exchange; information-oriented deliberation; plan-oriented deliberation; and determining a plan. Conversations progressed through stages in a nonlinear manner. For the main decision discussed, all conferences included a presentation of the clinical issues, treatment alternatives, and uncertainty. A minority of FCs included assessing the family's understanding (21%), assessing the family's need for input from others (28%), exploring the family's desired decision-making role (35%), and eliciting the family's opinion (42%). In the FCs studied, we found that DM is a nonlinear process. We also found that several SDM elements that could provide information about parents' perspectives and needs did not always occur, identifying areas for process improvement.

Abstract P-265: ENERGY BALANCE IN CHILDREN WITH SEVERE SEPSIS USING INDIRECT CALORIMETRY – A PROSPECTIVE COHORT STUDY

Aims & Objectives: Nutritional requirements in severe sepsis is dynamic. We planned to study the energy balance using indirect calorimetry (IC) in critically ill children with severe sepsis. Methods Single center, prospective cohort study of children aged 5 -12 years admitted with severe sepsis to tertiary care pediatric ICU from May 2016 to June 2017. Patients with active air leak, ventilator circuit leak >10%, on FiO2>60% or on high frequency oscillatory ventilation were excluded. Demographic, anthropometric and nutritional data were collected. Resting energy expenditure (mREE) was measured once daily with portable metabolic cart (Quark RMR, COSMED®) till 7 days or PICU discharge whichever was earlier. Results A total of 40 patients (24 boys) with median age of 7(5.2,10)years were enrolled. Mean PRISM III score was 19 ± 7. All patients received enteral nutrition with a median time of initiation of feeds of 12 hours. 35 patients(87.5%) received inotropic support. Median ventilation free days was 19 days and 4 children died(10%)(Table1). 176 IC measurements were obtained with an average of 4 per patient. The mean mREE was 1123 ± 310 Kcal (51 ± 17 Kcal/kg) and mean respiratory quotient was 0.77 ± 0.07. There was persistent negative energy and nitrogen balance from day 1 to 7 which showed an improving trend(Table2). There was poor agreement of predicted REE (using Schofield, Harris Benedict equation and FAO/WHO/UNU equations) with mREE(Figure 1). There was no significant correlation of PRISM III score, daily SOFA score and daily Vasoactive Inotropic Score with mREE. Conclusions Persistent negative calorie and nitrogen balance exist during acute illness. Predictive equations have poor agreement with mREE.

Children with severe acute asthma admitted to Dutch PICUs: A changing landscape

The number of children requiring pediatric intensive care unit (PICU) admission for severe acute asthma (SAA) around the world has increased.ObjectivesWe investigated whether this trend in SAA PICU admissions is present in the Netherlands.MethodsA multicenter retrospective cohort study across all tertiary care PICUs in the Netherlands. Inclusion criteria were children (2‐18 years) hospitalized for SAA between 2003 and 2013. Data included demographic data, asthma diagnosis, treatment, and mortality.ResultsIn the 11‐year study period 590 children (660 admissions) were admitted to a PICU with a threefold increase in the number of admissions per year over time. The severity of SAA seemed unchanged, based on the first blood gas, length of stay and mortality rate (0.6%). More children received highflow nasal cannula (P < 0.001) and fewer children needed invasive ventilation (P < 0.001). In 58% of the patients the maximal intravenous (IV) salbutamol infusion rate during PICU admission was 1 mcg/kg/min. However, the number of patients treated with IV salbutamol in the referring hospitals increased significantly over time (P = 0.005). The proportion of steroid‐naïve patients increased from 35% to 54% (P = 0.004), with a significant increase in both age groups (2‐4 years [P = 0.026] and 5‐17 years [P = 0.036]).ConclusionsThe number of children requiring PICU admission for SAA in the Netherlands has increased. We speculate that this threefold increase is explained by an increasing number of steroid‐naïve children, in conjunction with a lowered threshold for PICU admission, possibly caused by earlier use of salbutamol IV in the referring hospitals.

Development and validation of a diagnostic model for early differentiation of sepsis and non-infectious SIRS in critically ill children - a data-driven approach using machine-learning algorithms

BackgroundSince early antimicrobial therapy is mandatory in septic patients, immediate diagnosis and distinction from non-infectious SIRS is essential but hampered by the similarity of symptoms between both entities. We aimed to develop a diagnostic model for differentiation of sepsis and non-infectious SIRS in critically ill children based on routinely available parameters (baseline characteristics, clinical/laboratory parameters, technical/medical support).MethodsThis is a secondary analysis of a randomized controlled trial conducted at a German tertiary-care pediatric intensive care unit (PICU). Two hundred thirty-eight cases of non-infectious SIRS and 58 cases of sepsis (as defined by IPSCC criteria) were included. We applied a Random Forest approach to identify the best set of predictors out of 44 variables measured at the day of onset of the disease. The developed diagnostic model was validated in a temporal split-sample approach.ResultsA model including four clinical (length of PICU stay until onset of non-infectious SIRS/sepsis, central line, core temperature, number of non-infectious SIRS/sepsis episodes prior to diagnosis) and four laboratory parameters (interleukin-6, platelet count, procalcitonin, CRP) was identified in the training dataset. Validation in the test dataset revealed an AUC of 0.78 (95% CI: 0.70–0.87). Our model was superior to previously proposed biomarkers such as CRP, interleukin-6, procalcitonin or a combination of CRP and procalcitonin (maximum AUC = 0.63; 95% CI: 0.52–0.74). When aiming at a complete identification of sepsis cases (100%; 95% CI: 87–100%), 28% (95% CI: 20–38%) of non-infectious SIRS cases were assorted correctly.ConclusionsOur approach allows early recognition of sepsis with an accuracy superior to previously described biomarkers, and could potentially reduce antibiotic use by 30% in non-infectious SIRS cases. External validation studies are necessary to confirm the generalizability of our approach across populations and treatment practices.Trial registrationClinicalTrials.gov number: NCT00209768; registration date: September 21, 2005.

Clinical profile and predictors of outcome of hemophagocytic lymphohistiocytosis in critically ill children of a tertiary care pediatric Icu

Background : Hemophagocytic Lymphohistiocytosis (HLH) is a rare multisystem disorder where a diagnosis, underlying etiology and management remains a challenge for intensivists as the distinction between hyperferritinemic conditions in PICU is not clearly understood. HLH can either be genetic (primary) or triggered (secondary) due to infections, malignancy or autoimmune disorders. In this study we describe the clinical characteristics and predictors of mortality in our cohort of critically ill children with HLH of any etiology Methods : Single center, retrospective study of children aged 2 months– 12 years admitted with HLH to tertiary care pediatric ICU of Advanced Pediatric Center, PGIMER, India from January 2012 to August 2017 (5 years).We analyzed the clinical, laboratory characteristics, intensive care need like ventilation, hemodynamic support and the specific treatment from our electronic medical record. Multivariate logistic regression was used to identify the predictors of outcome Results : Total of 26 patients of HLH were observed over a period of 5 years. All but one episode were diagnosed as secondary HLH and did not have risk factors for familial HLH. Nineteen (67.9%) were males with a median age of 6.83 years (IQR 3.47, 9.64) and median PRISM 3 of 16 (IQR 13.5, 23). The underlying etiology was diagnosed in 15 patients (53.57%). Scrub typhus (n=5, 17.9%) was the commonest followed by acute encephalitic syndromes (n=3), dengue (n=2) and juvenile idiopathic arthritis (n=2).Ten patients (37.5%) had sepsis of unknown etiology. Twenty one out of 28 episodes fulfilled HLH 2004 criteria with a median Hemoglobin of 8.55 gm/dl (IQR 6.27, 9.9), total leucocyte count of 7000/uL (IQR 2725,15175), platelets of 45,000 u/L(IQR 22750,98750), triglyceride 362 mg/dL (IQR 278, 597), fibrinogen of 1.4 g/L (IQR 0.94, 1.92). Median serum ferritin in the cohort was 5238 ng/mL (IQR 4084, 44000). Nineteen patients underwent bone marrow examination out of which 16 had an evidence of hemophagocytosis. Fifteen received steroids and 7 received IVIG as treatment of HLH. Seventeen out of 26 patients died (65.3%). On univariate analysis among non-survivors vs survivors, PRISM 3 scores [23 (IQR 15, 28) vs 13 (IQR 8.5, 16); P=0.012], Vasoactive inotropes scores (97 vs 11.67; P=0.001), number of PRBC transfusion episodes [1.37 (IQR 1, 2) vs 0.33 (IQR 1, 2); P=0.008] and need for mechanical ventilation (100% vs 11.11%; P<0.001) were predictive of poor outcome. Organ involvement such as acute respiratory distress syndrome (57.89% vs 11.11%; P=0.039); disseminated intravascular coagulation (63.15% vs 22.22%; P=0.046) and septic shock (94.73% vs 11.11%; P<0.001) were higher among the non-survivors. On multivariate analysis, none of these parameters were predictive of mortality. Conclusion : Secondary HLH due to acute infections in PICU is associated with high incidence of organ failures and mortality. Prospective studies are needed to determine the effect of treatment and predictors of outcome

Clinical profile and predictors of outcome in children with Non-traumatic Coma undergoing decompressive Craniectomy : A tertiary center experience

Background : Raised intracranial pressure (ICP) in non-traumatic coma (NTC) is common in children and requires urgent, protocol based management and multimodal monitoring. Initial tiers of raised ICP management are based on evidence based guidelines. However, treatment for refractory raised ICP is limited to medical measures like barbiturate coma, targeted therapeutic hypothermia or a neurosurgical procedure like decompressive craniectomy (DC). Evidence regarding the role of DC in refractory raised ICP due to NTC in children is lacking. Therefore, we planned to study the clinical profile and outcome of these patients undergoing DC. Methods : All patients aged 1 month to 12 years, admitted to a tertiary care pediatric ICU over a period of 5 years (2012 to 2017) and underwent DC for non-traumatic refractory raised ICP were retrospectively analysed. Clinical profile, course and neurological outcomes were studied. Primary outcome measures were survival to hospital discharge and neurological outcome after 3 months using Glasgow Outcome Scale (GOS). GOS of 1 & 2 were classified as good and 3 to 5 as poor. Statistical analysis was done using SPSS version 21 software. Descriptive data were summarized as mean ± SD or median (IQR). Predictors of good outcome were analysed using Chi Square test and multivariate logistic regression. Results : A total of 30 children with median age of 6.5 months (IQR 2, 50) were included. 26 (86.7%) were males. Common presenting symptoms were seizures (n=25; 83%), altered sensorium (n=19; 63%) and fever (n=12; 40%). Common clinical signs were pallor (n=20; 66.6%), asymmetric pupils (n = 15; 50%), bulging anterior fontanelle (n=12; 40%), focal deficits (n=6; 20%) and skin bleeds (n=4; 13%). Median (IQR) Glasgow Coma Score (GCS) at admission was 9 (6,11). Commonest etiology was intracranial bleed in 24 (80%) and infarct in 6 (20%). Location of bleed was parenchymal in 10 (33.3%), subdural 8 (26.7%), extradural 1 (3.3%) and multi-site in 5 (16.7%). All had a midline shift of >5mm on neuroimaging. Median (IQR) time to DC was 24 (24,72) hours of hospital admission. Twenty-six (86.7%) were ventilated for a median (IQR) duration of 96 (48, 144) hours and one patient required tracheostomy. Two patients died (6.6%) during hospital stay. Median (IQR) length of PICU and hospital stay was 5.5 (3, 10) and 17 (12, 27) days respectively. Twenty-one patients were examined at median (IQR) follow-up duration of 12 (5, 54) months. Six more patients died and one lost to follow-up. Good neurological outcome was seen in 15/29 (51.7%) patients. On univariate analysis, skin bleed (p-0.042), pupillary asymmetry (p-0.002) and focal deficit (p-0.011) at admission were significant predictors of poor outcome. On regression analysis, pupillary asymmetry at admission was predictive of poor neurological outcome [p-0.003]. Conclusion : Evidence on management of refractory raised ICP in NTC is still evolving. Timely DC can be considered as an effective treatment modality with good survival and neurological outcome.

Energy balance in children with severe sepsis using indirect calorimetry : A prospective cohort study

Background : Nutritional requirements in severe sepsis is dynamic varying from hypermetabolic to a hypometabolic state. We planned to study the energy balance using indirect calorimetry (IC) in critically ill children with severe sepsis Methods : Single center, prospective cohort study of children aged 5 -12 years admitted with severe sepsis to tertiary care pediatric ICU of Advanced Pediatric Center, PGIMER, India from May 2016 to June 2017. Patients with active air leak, ventilator circuit leak >10%, on FiO2>60% or on high frequency oscillatory ventilation were excluded. Demographic, anthropometric and nutritional data were collected. Resting energy expenditure (mREE) was measured once daily with portable metabolic cart (Quark RMR, COSMED@) till 7 days or till PICU discharge whichever was earlier. Results : A total of 40 patients (24 boys) with median age of 7 (5.2, 10) years and mean weight of 23 ± 8 kg were included. Tropical infections contributed majority of diagnosis with acute CNS infections in 18 (45%), severe pneumonia in 7 (17.5%), scrub typhus in 5 (12.5%), disseminated staphylococcal sepsis in 4 (10%) and dengue shock syndrome in 3 (7.5%). Mean PRISM III score was 19 ± 7 with calculated risk of mortality of 30%. All patients received enteral nutrition with a median time of initiation of feeds of12 hours. 35 patients (87.5%) received inotropic support with median day 1 vasoactive inotropic score (VIS) of 28. Median ventilation free days was 19 days and 4 children died (10%). Total of 176 IC measurements were obtained with an average of 4 per patient. The mean mREE for the cohort was 1123 ± 310 Kcal (51 ± 17 Kcal/kg) and the mean respiratory quotient was 0.77 ± 0.07. There was persistent negative energy balance from day 1 to 7 and a negative nitrogen balance which improved by day 7 to positive balance. There was poor agreement of predicted REE (using Schofield, Harris Benedict equation and FAO/WHO/UNU equations) with mREE. There was no significant correlation of PRISM III score at 24 hours, daily SOFA score and daily VIS with mean mREE. Conclusion : Consistent negative calorie and protein balance exist during acute phase of illness. There was poor agreement of predicted REE with mREE and no significant correlation with severity of illness scores.

Physical and occupational therapy utilization in a pediatric intensive care unit

PurposeTo characterize the use of physical therapy (PT) and occupational therapy (OT) consultation in our pediatric intensive care unit (PICU). Materials and methodsWe studied children aged 1week–18years admitted to a tertiary care PICU for ≥3days. Patient characteristics, details of PT and OT sessions and adverse events were collected. A multivariable logistic regression was performed to determine factors associated with receipt of PT and OT consultation with propensity analysis followed by a regression for factors associated with outcome. ResultsOf 138 children studied, 40 (29%) received PT and OT consultation. Services were initiated 6.9±10.0 (mean±standard deviation) days after PICU admission. Range of motion (83%) was the most common therapy provided and 28% of patients were ambulated. Sixty-four of 297 (21.5%) sessions were deferred and 7 (2.4%) sessions were terminated early due to physiologic instability with no serious adverse events. Children who received PT and OT were older, more likely to require neuromuscular blocking agents, and had lower pre-PICU POPC scores (all p<0.05). ConclusionsData are needed to inform on the efficacy of rehabilitative therapies initiated in the ICU to improve outcome for critically ill children.

Plasma Biomarker Analysis in Pediatric ARDS: Generating Future Framework from a Pilot Randomized Control Trial of Methylprednisolone: A Framework for Identifying Plasma Biomarkers Related to Clinical Outcomes in Pediatric ARDS.

Lung injury activates multiple pro-inflammatory pathways, including neutrophils, epithelial, and endothelial injury, and coagulation factors leading to acute respiratory distress syndrome (ARDS). Low-dose methylprednisolone therapy (MPT) improved oxygenation and ventilation in early pediatric ARDS without altering duration of mechanical ventilation or mortality. We evaluated the effects of MPT on biomarkers of endothelial [Ang-2 and soluble intercellular adhesion molecule-1 (sICAM-1)] or epithelial [soluble receptor for activated glycation end products (sRAGE)] injury, neutrophil activation [matrix metalloproteinase-8 (MMP-8)], and coagulation (plasminogen activator inhibitor-1). Double-blind, placebo-controlled randomized trial. Tertiary-care pediatric intensive care unit (ICU). Mechanically ventilated children (0-18 years) with early ARDS. Blood samples were collected on days 0 (before MPT), 7, and 14 during low-dose MPT (n = 17) vs. placebo (n = 18) therapy. The MPT group received a 2-mg/kg loading dose followed by 1 mg/kg/day continuous infusions from days 1 to 7, tapered off over 7 days; placebo group received equivalent amounts of 0.9% saline. We analyzed plasma samples using a multiplex assay for five biomarkers of ARDS. Multiple regression models were constructed to predict associations between changes in biomarkers and the clinical outcomes reported earlier, including P/F ratio on days 8 and 9, plateau pressure on days 1 and 2, PaCO2 on days 2 and 3, racemic epinephrine following extubation, and supplemental oxygen at ICU discharge. No differences occurred in biomarker concentrations between the groups on day 0. On day 7, reduction in MMP-8 levels (p = 0.0016) occurred in the MPT group, whereas increases in sICAM-1 levels (p = 0.0005) occurred in the placebo group (no increases in sICAM-1 in the MPT group). sRAGE levels decreased in both MPT and placebo groups (p < 0.0001) from day 0 to day 7. On day 7, sRAGE levels were positively correlated with MPT group PaO2/FiO2 ratios on day 8 (r = 0.93, p = 0.024). O2 requirements at ICU transfer positively correlated with day 7 MMP-8 (r = 0.85, p = 0.016) and Ang-2 levels (r = 0.79, p = 0.036) in the placebo group and inversely correlated with day 7 sICAM-1 levels (r = -0.91, p = 0.005) in the MPT group. Biomarkers selected from endothelial, epithelial, or intravascular factors can be correlated with clinical endpoints in pediatric ARDS. For example, MPT could reduce neutrophil activation (⇓MMP-8), decrease endothelial injury (⇔sICAM-1), and allow epithelial recovery (⇓sRAGE). Large ARDS clinical trials should develop similar frameworks. https://clinicaltrials.gov, NCT01274260.

Hemoglobin Threshold for Blood Transfusion in a Pediatric Intensive Care Unit

Objective: To evaluate the hemoglobin threshold for red cell transfusion in children admitted to a pediatric intensive care unit (PICU). Methods: Retrospective chart review study. Tertiary care PICU. Critically ill pediatric patients requiring blood transfusion. No intervention. Results: We analyzed the charts of all children between 1 month and 21 years of age who received packed red blood cell (PRBC) transfusions during a 2-year period. The target patients were identified from our blood bank database. For analysis, the patients were subdivided into four groups: acute blood loss (postsurgically, trauma, or acute gastrointestinal bleeding from other causes), hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, or sickle cell disease), unstable (FiO₂ > 0.6 and/or on inotropic support), and stable groups. We also compared the pre-transfusion hemoglobin threshold in all unstable patients with that of all stable patients. A total of 571 transfusion episodes in 284 patients were analyzed. 28% (n = 160) of transfusions were administered to patients in the acute blood loss group, 36% (n = 206) to hematologic patients, 17% (n = 99) to unstable patients, and 18% (n = 106) to stable patients. The mean pre-transfusion hemoglobin (± SD) in all children as well as in the acute blood loss, hematologic, unstable and stable groups was 7.3 ± 1.20, 7.83 ± 1.32, 6.97 ± 1.31, 7.96 ± 1.37, 7.31 ± 1.09 g/dl, respectively. The transfusion threshold for acute blood loss and unstable groups was higher compared to hematologic and stable groups (p < 0.001; ANOVA with multiple comparisons). The mean pre-transfusion hemoglobin threshold for stable and unstable patients among all groups was 7.3 ± 1.3 and 7.9 ± 1.3 (p < 0.0001), respectively. The observed mortality rate was higher among children who received transfusion compared to other children admitted to PICU. Conclusion: The hemoglobin threshold for transfusion varied according to clinical conditions. Overall, the hemoglobin threshold for transfusion was 7.3 ± 1.20 g/dl.

Risk Factors Associated with Infections and Need for Permanent Cerebrospinal Fluid Diversion in Pediatric Intensive Care Patients with Externalized Ventricular Drains

Externalized ventricular drains (EVDs) are commonly used in pediatric intensive care units (PICU) but few data are available regarding infection rates, infection risks, or factors associated with conversion to permanent cerebrospinal fluid (CSF) diversion. Retrospective observational study of patients managed with EVDs admitted to a tertiary care PICU from January 2005 to December 2009. Three hundred eighty patients were identified. Neurologic diagnostic groups were externalization of existing shunt in 196 patients (52 %), brain tumor in 122 patients (32 %), intracranial hemorrhage in 23 patients (6 %), traumatic brain injury in 17 patients (5 %), meningitis in 9 patients (2 %), or other in 13 patients (3 %). Six percent of all patients (24/380) had new infections associated with EVD management for an infection rate of 8.6 per 1,000 catheter days. The median time to positive cultures was 7 days (interquartile range 4.75, 9) after EVD placement. Patients with EVD infections had significantly longer EVD duration 6 versus 11.5 days (p = 0.0001), and higher maximum EVD outputs 1.9 versus 1.5 mL/kg/h (p = 0.0017). Need for permanent CSF diversion was associated with higher maximum EVD drainage (1.3 vs. 1.6 mL/kg/h p < 0.0001), longer EVD duration (5 vs. 4 days, p < 0.005), and younger age (4.5 vs. 8 years, p < 0.02) but not intracranial hypertension (72 vs. 82 % of patients, p = 0.4). In our large pediatric cohort, EVD infections were associated with longer EVD duration and higher maximum EVD output. Permanent CSF diversion was more likely in patients with higher maximum EVD drainage, longer EVD duration, and younger age.

588

Introduction: Acuity scoring systems were implemented in the pediatric intensive care unit (PICU) to provide an assessment of severity of illness and outcome. The Pediatric Risk of Mortality (PRISM), Pediatric Incidence of Mortality (PIM), and Pediatric Logistic Organ Dysfunction (PELOD) scoring systems are the most commonly used predictors of mortality. Packed red blood cell (PRBC) transfusions are common practice and associated with adverse outcomes. Although some factors used in the clinical decision to transfuse are also variables in acuity scoring, therapeutic interventions are not included in calculations of acuity. We hypothesize that transfusion in the PICU results in an increase in mortality that is independent of acuity. Methods: We conducted a retrospective review of all patients admitted to a tertiary care PICU between 2008 and 2012. T-test and Chi-square were utilized to compare groups. Multiple regression and logistic regression analysis were used to examine outcome. Results: Of 5,178 PICU admissions, 480 (9.3%) received PRBC transfusions. Utilizing multiple regression analysis, transfusion, age at admission, gender, PRISM, and PIM were all significantly predictive of average PELOD score. Using regression analysis, transfusion, PIM, and age at admission were significantly predictive of length of stay (LOS) with transfusion adding 7.0 days (P<.001), an increase in PIM by 10 adding 7.5 days (P<.001), and a 10 month increase in age decreasing LOS by 0.06 days (P<.001). Assessing transfusion, PRISM, and PIM, only transfusion was a significant predictor of mechanical ventilator days adding 5.9 vent days (P< 0.001). Mortality occurred during 51(10.6%) admissions among transfused and 43 (0.9%) of the 4,698 not transfused (P<.000). Logistic regression analysis showed transfusion, PRISM, and PIM were significantly predictive of mortality with transfusion independently increasing mortality by 2.9 times (95%CI: 1.6-5.5), an increase of 10 in PRISM leading to a 4.9 fold increase in risk of death (95%CI: 3.4-7.2), and an increase in PIM by 5 leading to a 21.9 fold increase in risk of death (95%CI: 8.6-55.4). Conclusions: Transfusion was predictive of higher PELOD score, LOS, and ventilator days. When controlled for severity of illness, transfusion was independently associated with an increase in mortality.

563

Introduction: Inhaled nitric oxide (iNO) is a pulmonary vasodilator that is used as rescue therapy for hypoxemic respiratory failure in the pediatric intensive care unit (PICU) despite lacking evidence for an outcomes benefit. Methods: Due to lack of evidence, high cost of therapy, and wide practice variability, we developed a protocol to standardize iNO management in our 30-bed tertiary care PICU. Our protocol contained guidelines for initiation, continuation, and weaning of iNO as well as expected documentation. After initial education and protocol implementation, we audited practitioner documentation for protocol compliance. We analyzed protocol utilization and compliance as well as patient characteristics and outcomes for 1 year prior to (2011) and 1 year after (2012) protocol implementation using Fisher's exact, Wilcoxon rank-sum, and statistical process control charts as appropriate. Results: 11 pre-protocol patients (15 courses) were compared to 18 post-protocol patients (21 courses). Despite no difference in illness severity [median PRISM3 of 11 (9,17) vs 10 (5,18), p=0.41], we found that protocol patients trended toward shorter iNO course duration [152 hr (89, 389) pre-protocol vs 99 (71, 171) post-protocol; p=0.09]. By May 2012, variation in hours of iNO usage decreased to the point that the control chart centerline was lowered from 330 to 63 hours per patient (p<0.001). Although similar rates of patients met iNO start criteria between groups [67% for both; p=1.0], pre-protocol patients were less likely than post-protocol patients to be weaned in a manner consistent with our local guidelines [40% vs 81%; p=0.02], potentially explaining the difference in iNO treatment duration and variability. Additionally, appropriate documentation improved post-protocol for initiation [13% (pre) vs 67% (post); p=0.002], response [20% (pre) vs 76% (post); p=0.002], and weaning [40% (pre) vs 86% (post); p=0.01]. Interestingly, 18 post-protocol patients had improved oxygenation with iNO (86%) vs 6 pre-protocol patients (53%) [p=0.06]. Unexpectedly, more pre-protocol patients than post-protocol patients died [7 (64%) vs 3 (17%); p=0.02]. Conclusions: Implementation of a PICU iNO utilization protocol improved documentation and iNO weaning, decreased iNO usage, and reduced variability in the management of iNO in critically ill children in the PICU. Research is ongoing to evaluate whether this improved iNO usage can be sustained and if it can translate into improved PICU morbidity and mortality.

The Relationship Between Vitamin D Status and Adrenal Insufficiency in Critically Ill Children

Recent studies in critically ill populations have suggested both adrenal insufficiency (AI) and vitamin D deficiency to be associated with worse clinical outcome. There are multiple mechanisms through which these pleiotropic hormones might synergistically influence critical illness. The aim of the study was to investigate potential relationships between vitamin D status, adrenal status, and cardiovascular dysfunction in critically ill children. We conducted a secondary analysis of data from a prospective cohort study. The study was conducted on 319 children admitted to 6 Canadian tertiary-care pediatric intensive care units. Vitamin D status was determined through total 25-hydroxyvitamin D (25OHD) levels. AI was defined as a cortisol increment under 9 μg/dL after low-dose cosyntropin. Clinically significant cardiovascular dysfunction was defined as catecholamine requirement during pediatric intensive care unit admission. Using 3 different thresholds to define vitamin D deficiency, no association was found between vitamin D status and AI. Furthermore, linear regression failed to identify a relationship between 25OHD and baseline or post-cosyntropin cortisol. However, the association between AI and cardiovascular dysfunction was influenced by vitamin D status; compared to children with 25OHD above 30 nmol/L, AI in the vitamin D-deficient group was associated with significantly higher odds of catecholamine use (odds ratio, 5.29 vs 1.63; P = .046). We did not find evidence of a direct association between vitamin D status and critical illness-related AI. However, our results do suggest that vitamin D deficiency exacerbates the effect of AI on cardiovascular stability in critically ill children.

Pediatric index of mortality 2 score as an outcome predictor in pediatric Intensive Care Unit in India

Background and Aims:Pediatric index of mortality (PIM) 2 score is one of the severity scoring systems being used for predicting outcome of patients admitted to intensive care units (ICUs). The aim of the present study was to evaluate the usefulness of PIM2 score in predicting mortality in a tertiary care pediatric ICU (PICU) and to assess the associated factors in predicting mortality such as presence of shock, need for assisted ventilation and Glasgow coma scale <8.Materials and Methods:This was a prospective observation study done at tertiary care PICU from May 2011 to July 2011. Consecutive 119 patients admitted to PICU (aged 1 month to 12 years) were enrolled in the study. PIM2 scoring was done for all patients. The outcome was recorded as death or discharge. The associated factors for mortality were analyzed with SPSS 17.Results:PIM2 score discriminated between death and survival at a 99.8 cut-off, with area under receiver operating characteristic curve 0.843 with 95% confidence interval (CI) (0.765, 0.903). Most patients were referred late to this hospital, which explains higher death rate (46.2%), lesser length of hospital stay (mean 2.98 days) in the mortality group, and increased rate of mechanical ventilation (68.1%). Presence of shock was independently associated with mortality, as evidenced by binary logistic regression.Conclusion:PIM2 score discriminated well between survivors and death at PICU. Presence of shock was significantly associated with mortality.