Ventilation In Children Research Articles

Can Providers Use Clinical Skills to Assess the Adequacy of Ventilation in Children During Bag-Valve Mask Ventilation?

Bag-valve mask (BVM) ventilation requires both manual skill and clinical assessment of minute ventilation. Subjective factors can make supplying appropriate ventilation difficult. Capnography is not routinely used when ventilating nonintubated patients. Our objective was to determine if providers were able to maintain normal capnography values with BVM ventilation in pediatric patients based on clinical skills alone. Providers (nurses, residents, and fellows) delivered 2 minutes of BVM respiratory support to healthy children during induction of anesthesia for elective surgery. All patients had standard monitoring including capnography, but providers were blinded to capnography data. Capnography data were video recorded; values between 30 and 50 mmHg were considered indicative of normal ventilation. Any deviation from this range for greater than 10 consecutive seconds was considered an episode of inappropriate ventilation. Twenty-five providers-patient pairs were enrolled. Nineteen providers were anesthesia residents. The median age of patients was 5.3 years (interquartile range, 3.3-8.5 years). Nineteen providers (76%) had at least 1 episode of abnormal ventilation with a median of 2 episodes per provider (interquartile range, 0.5-2.5). Among these providers, total mean duration of abnormal ventilation was 57 seconds (95% confidence interval, 41-72) or 47% (95% confidence interval, 34%-60%) of the 2-minute period. Normal ventilation is difficult to maintain among providers delivering BVM ventilation to pediatric patients without objective feedback. Incorporation of capnography monitoring may improve BVM ventilation in children.

Implementation of a checklist to increase adherence to evidence-based practices in a single pediatric intensive care unit.

The use of checklists to increase adherence to evidence-based practices is not yet widespread in pediatric intensive care units. The objective of this study was to achieve 90% compliance with studied practices using an ad hoc checklist. Time series quasiexperimental study conducted in ventilated children hospitalized in the pediatric intensive care unit. Studied practices included sedation breaks, plateau pressure ≤ 30 cm H 2O, fraction of inspired oxygen ≤ 60%, maintenance of headboard at > 30°, chlorhexidine mouthwash, weekly ventilator circuit changes, preference for enteral feeding, reduction in the threshold for blood transfusions (hemoglobin: 7 g/dL), daily consideration of spontaneous breathing trials and central venous catheter removal. The checklist was used during ward rounds by the staff physicians in charge of the pediatric intensive care unit as part of an intervention to increase adherence and as a tracking tool. Each form completed on a daily basis was considered an observation. Observations were classified as defective in the case of non-compliance with one or more items. Adherence (the rate of nondefective units of observation) is summarized in the control chart. The study period lasted 420 days. A total of 732 patients were hospitalized; 218 underwent mechanical ventilation; 1201 observations were made, and 1191 were included in the study. The control chart with a 14-month time horizon showed increased adherence, a special cause variation pattern in the last 3 months of the study period, and > 90% compliance over the last 2 months. The implementation of a checklist increased adherence to studied practices and achieved more than 90% compliance over the last 2 months of the study period.

Hydrogen Sulfide in Exhaled Gases From Ventilated Septic Neonates and Children: A Preliminary Report.

There is increasing interest in hydrogen sulfide as a marker of pathologic conditions or predictors of outcome. We speculate that as hydrogen sulfide is a diffusible molecule, if there is an increase in plasma hydrogen sulfide in sepsis, it may accumulate in the alveolar space and be detected in exhaled gas. We wished to determine whether we could detect hydrogen sulfide in exhaled gases of ventilated children and neonates and if the levels changed in sepsis. Prospective, observational study. The study was conducted across three intensive care units, pediatric, neonatal and cardiac in a large tertiary children's hospital. We studied ventilated children and neonates with sepsis, defined by having two or more systemic inflammatory response syndrome criteria and one organ failure or suspected infection. A control group of ventilated non-septic patients was also included. A portable gas chromatograph (OralChroma; Envin Scientific, Chester, United Kingdom) was used to measure H2S in parts per billion. A 1-2 mL sample of expired gas was taken from the endotracheal tube and analyzed. A repeat sample was taken after 30 minutes and a further single daily sample up to a maximum of 5 days or until the patient was extubated. WBC and C-reactive protein were measured around the time of gas sampling. Each group contained 20 subjects. Levels of H2S were significantly higher in septic patients (Mann Whitney U-test; p < 0.0001) and trended to control levels over five days. C- reactive protein levels were also significantly raised (p < 0.001) and mirrored the decrease in H2S levels. Hydrogen sulfide can be detected in expired pulmonary gases in very low concentrations of parts per billion. Significantly higher levels are seen in septic patients compared with controls. The pattern of response was similar to that of C-reactive protein.

Critical illness myopathy and polyneuropathy in children admitted to the ICU

Objective The aim of the present study was to detect critical illness polyneuropathy and myopathy in children admitted to the ICU in relation to clinical findings and therapeutic regimen. Background Critical illness polyneuropathy and myopathy is a frequent complication of critical illness, acutely and primarily affecting the motor and sensory axons. This disorder can cause severe limb weakness and prolonged weaning. Patients and methods This study included 75 patients with different diseases admitted to the pediatric ICU at Menoufia University and was conducted for the period of 2 years. The patients were divided into five groups. All patients underwent nerve conduction, and electromyography was carried out on the seventh day of admission to ICU. Results The mean age of the patients was 4.5 ± 2.3 years. Twenty-four (24%) patients developed critical illness neuropathy and myopathy, among whom 21 (28%) patients developed axonal polyneuropathy, one (1.3%) had demyelinating polyneuropathy, and two (2.7%) cases were myopathic. In children with sepsis the prevalence of axonal polyneuropathy was five (33.3%) cases, one case had axonal polyneuropathy and one had myopathy. Among children with chest diseases, four cases of the ventilated ones had axonal polyneuropathy, six (40%) cases of the sepsis ventilated children developed axonal polyneuropathy, and one was myopathic. One child of the ventilated children due to chest disease had demyelinating polyneuropathy, whereas the other five cases had axonal polyneuropathy. Overall, 66.7% of the deaths were of those who developed axonal polyneuropathy, and 85.7, 47.6, and 90.5% of the deaths were of those who were hyperglycemic, ventilated, and acidotic, respectively. Conclusion The incidence of critical illness axonal polyneuropathy was 28%, 1.3% for demyelinating polyneuropathy, and 2.7% for critical illness myopathy.

Postoperative resting energy expenditure in children with congenital heart disease

Objective To determine postoperative resting energy expenditure (REE) in children with congenital heart disease (CHD) requiring open heart surgery, to compare measured resting energy expenditure(MREE) with current predictive equations (PEE), and to investigate the possible influencing factors on the metabolic status of the postoperative CHD children. Methods From February 2015 to June 2015, 150 ventilated children admitted to the cardiac intensive care unit after surgery for congenital heart disease in Shanghai Children's Medical Center were enrolled consecutively. Indirect calorimetry (IC) measurements were performed using metabolic cart 4 hours after surgery. General clinical data were recorded. Results Totally 104 male and 46 female patients were enrolled, with a median age of 14 months (8.3-36.0 months). The non-protein respiratory quotient of patient was 0.79±0.20, MREE was (264.76±61.74)kJ/(kg·d), and PEE using Schofield equations was (278.51±93.42)kJ/(kg·d). Although there was no significant differences (P=0.096) between MREE and PEE, the agreement was poor between them (R2=0.119). Multivariate stepwise regression analysis showed that MREE had significant positive correlation with risk adjustment in congenital heart surgery(RACHS-1) score(P=0.012) and negative correlation with age (P=0.010). Up to 97.33% of children(146/150) had lower energy intake compared with MREE on the 1st postoperative day. Conclusions MREE does not increase after surgery in CHD children; however, the substrate utilization is influenced. Factors influencing the postoperative REE include RACHS-1 score and age. The energy intake at 1st day after surgery is generally lower than REE in these children. Key words: Children; Congenital heart disease; Resting energy expenditure; Indirect calorimetry

Early Fluid Overload Prolongs Mechanical Ventilation in Children With Viral-Lower Respiratory Tract Disease.

Viral-lower respiratory tract disease is common in young children worldwide and is associated with high morbidity. Acute respiratory failure due to viral-lower respiratory tract disease necessitates PICU admission for mechanical ventilation. In critically ill patients in PICU settings, early fluid overload is common and associated with adverse outcomes such as prolonged mechanical ventilation and increased mortality. It is unclear, however, if this also applies to young children with viral-lower respiratory tract disease induced acute respiratory failure. In this study, we aimed to investigate the relation of early fluid overload with adverse outcomes in mechanically ventilated children with viral-lower respiratory tract disease in a retrospective dataset. Retrospective cohort study. Single, tertiary referral PICU. One hundred thirty-five children (< 2 yr old) with viral-lower respiratory tract disease requiring mechanical ventilation admitted to the PICU of the Academic Medical Center, Amsterdam between 2008 and 2014. None. The cumulative fluid balance on day 3 of mechanical ventilation was compared against duration of mechanical ventilation (primary outcome) and daily mean oxygen saturation index (secondary outcome), using uni- and multivariable linear regression. In 132 children, the mean cumulative fluid balance on day 3 was + 97.9 (49.2) mL/kg. Higher cumulative fluid balance on day 3 was associated with a longer duration of mechanical ventilation in multivariable linear regression (β = 0.166; p = 0.048). No association was found between the fluid status and oxygen saturation index during the period of mechanical ventilation. Early fluid overload is an independent predictor of prolonged mechanical ventilation in young children with viral-lower respiratory tract disease. This study suggests that avoiding early fluid overload is a potential target to reduce duration of mechanical ventilation in these children. Prospective testing in a clinical trial is warranted to support this hypothesis.

Outcome of Non Invasive Ventilation in Children with Acute Respiratory Failure

Outcome of Non Invasive Ventilation in Children with Acute Respiratory Failure

Predicting Fluid Responsiveness in Children Undergoing Cardiac Surgery After Cardiopulmonary Bypass.

Dynamic parameters of fluid responsiveness (FR), namely aortic blood flow velocity variation (delta V peak), left ventricular velocity-time integral variation (delta VTI), stroke volume variation, and pulse pressure variation (PPV) have demonstrated good diagnostic performance for the prediction of response to fluid loading in mechanically ventilated critically ill adult patients. We aimed to evaluate these parameters in children undergoing cardiac surgery. A retrospective observational study of mechanically ventilated patients weighing less than 20kg who received a volume expansion (VE) of 10ml/kg after sternal closure was conducted. A 10% cardiac index (CI) increase divided patients into 7 responders (R) and 9 non-responders (NR). Transesophageal echocardiography and Pressure Recording Analytical Method data were retrieved. The percentage CI increase was 18.6 (12)% in R and 2.9 (5.7)% in NR (p = 0.037). Prior to VE, delta V peak, delta VTI, PPV, and SPV differed between R and NR (p = 0.045, 0.043, 0.048, 0,037 and 0.044, respectively). Systolic (p = 0.004), diastolic (p = 0.002), mean blood pressure (p = 0.003), delta V peak (p = 0.03), delta VTI (p = 0.04), CI (p = 0.01), PPV (p = 0.04), SPV (p = 0.04), and dP/dt max (maximal pressure-to-time ratio) (p = 0.02) changed the following VE in R patients. Delta V peak decreased after VE in NR patients (p = 0.004). Delta VTI and PPV showed the highest predictive values, with area under receiver operator characteristic curves of 0.76 (p = 0.049) and 0.76 (p = 0.045), respectively. Delta VTI and PPV were revealed to be potential predictors of FR in ventilated children after cardiac surgery. Their combined evaluation could be useful for fluid management after sternal closure.

Sedation in Critically Ill Children with Respiratory Failure.

This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.

Reply: It Is Too Early to Say No Place for High-Frequency Oscillatory Ventilation in Children with Respiratory Failure.

Reply: It Is Too Early to Say No Place for High-Frequency Oscillatory Ventilation in Children with Respiratory Failure.

It Is Too Early to Say No Place for High-Frequency Oscillatory Ventilation in Children with Respiratory Failure.

It Is Too Early to Say No Place for High-Frequency Oscillatory Ventilation in Children with Respiratory Failure.

Patient-Ventilator Asynchrony During Assisted Ventilation in Children.

To describe the frequency and type of patient-ventilator asynchrony in mechanically ventilated children by analyzing ventilator flow and pressure signals. Prospective observational study. Tertiary PICU in a university hospital. Mechanically ventilated children between 0 and 18 years old and who were able to initiate and maintain spontaneous breathing were eligible for inclusion. Patients with congenital or acquired neuromuscular disorders, those with congenital or acquired central nervous system disorders, and those who were unable to initiate and maintain spontaneous breathing from any other cause were excluded. None. All patients were ventilated in a time-cycled, pressure-limited mode with flow triggering set at 1.0 L/min by using the Evita XL (Dräger, Lubeck, Germany). Patient-ventilator asynchrony was identified by a random 30-minute continuous recording and an offline analysis of the flow and pressure signals. Patient-ventilator asynchrony was categorized and labeled into four different groups: 1) trigger asynchrony (i.e., insensitive trigger, double triggering, autotriggering, or trigger delay), 2) flow asynchrony, 3) termination asynchrony (i.e., delayed or premature termination), and 4) expiratory asynchrony. Flow and pressure signals were recorded in 45 patients for 30 minutes. A total number of 57,651 breaths were analyzed. Patient-ventilator asynchrony occurred in 19,175 breaths (33%), and it was seen in every patient. Ineffective triggering was the most predominant type of asynchrony (68%), followed by delayed termination (19%), double triggering (4%), and premature termination (3%). Patient-ventilator asynchrony significantly increased with lower levels of peak inspiratory pressure, positive end-expiratory pressure, and set frequency. Patient-ventilator asynchrony is extremely common in mechanically ventilated children, and the predominant cause is ineffective triggering.

High Pressures in Non-Invasive Ventilation in Children, Where is the Limit?

Non-invasive positive pressure ventilation (NPPV) refers to the delivery of mechanical respiratory support without the use of endotraqueal intubation. It has been proposed as a valuable alternative to invasive mechanical ventilation (MV) in selected children with acute respiratory failure (ARF). The pressures usually employed in NPPV are lower than those in MV, but in some cases high pressures are needed.

Computerized Decision Support Systems for Mechanical Ventilation in Children.

Mechanical ventilation is an effective treatment in the ICU but can have significant adverse effects. Approaches from adult research have been adopted in pediatric critical care despite known differences in respiratory physiology and ICU processes. There continues to be considerable variation in how ventilators are managed. Computerized decision support systems implement explicit protocols, and are designed to make mechanical ventilation management safer, more consistent, and more lung protective. Variable results and low or unknown compliance with protocols and CDSS tools have been reported. To date, there has been limited research regarding CDSS for mechanical ventilation in children.

Factors Associated with Survival during High-Frequency Oscillatory Ventilation in Children.

Our aim is to determine indicators of survival in children with severe hypoxic respiratory failure (HRF) after transition to high-frequency oscillatory ventilation (HFOV). Single-center retrospective examination of children with HRF transitioned to HFOV. Blood gases and ventilator settings 24 hours prior to and 48 hours after HFOV in survivors and nonsurvivors were evaluated. Sixty-two children with mean age of 7 years and mean weight of 26 kg were included with an observed mortality of 29%. Mean airway pressures (Paw), oxygenation index (OI), arterial oxygen partial pressure (PaO2)/fraction of inspired oxygen (FiO2) (P/F) ratio, pH, bicarbonate, and arterial carbon dioxide partial pressure were similar prior to HFOV in survivors and nonsurvivors. During HFOV, mean OI and P/F ratio improved in both groups with an average Paw increase of ∼10 cm H2O. Survivors had lower OI than nonsurvivors (21 ± 0.9 vs. 26.5 ± 2.2; p < 0.01) beginning 24 hours after HFOV. P/F ratio appears to diverge by 36 hours, with survivors having P/F ratio >200. Survivors had higher pH than nonsurvivors at 36 hours (7.40 ± 0.01 vs. 7.32 ± 0.02; p < 0.05), higher bicarbonate levels (27.1 ± 0.7 vs. 23.9 ± 1.3 mEq/L), and similar arterial carbon dioxide partial pressure with less oscillatory support (i.e., hertz and amplitude). Inhaled nitric oxide was used in 53% of patients with improvements in oxygenation but with no effect on mortality. HFOV improves oxygenation in children with severe HRF. Nonsurvivors can be distinguished from survivors at 24 to 36 hours during HFOV by higher OI, metabolic acidosis, and higher oscillatory support. These data may assist in prognostication or timing of initiating alternative therapies, such as extracorporeal membrane oxygenation.

Bacterial Isolates from Tracheal Aspirates and their Anti-microbial Susceptibility in Mechanically-Ventilated Children with Pneumonia Admitted to an Urban Critical Care Ward

Background and Aims: Data on Bacterial isolates from tracheal aspirates in children with severe pneumonia requiring intubation and mechanical ventilation especially in developing countries are very limited. We examined the microbial spectrum of bacteria isolated from tracheal aspirate of those children. The antibiotic susceptibility profiles of those bacteria were also examined.Methods: We evaluated the data of all mechanically ventilated children aged 0-59 months admitted to Intensive Care Unit (ICU) of “Dhaka Hospital” of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) between August 2009 and July 2013 having their tracheal aspirate culture done. Data were extracted from electronic medical records of the Dhaka Hospital.Results: Among 836 admitted pneumonia children in the ICU, we identified 35 children who fulfilled the inclusion criteria. Among them 34 (97%) had positive bacterial growths: Klebseilla species in 14 (40%), Escherichia coli in 11 (31%), Acinetobacter in 8 (23%) and Streptococcus species in 8 (23%). Additionally, Enterococcus, Staphylococcus aureus, Pseudominas and Proteus species were identified in 6 (17%), 4 (11%), and 2 (6%) of the children respectively. The susceptibility of the gram-negatives, except Klebseilla, to ampicillin, cotrimoxazole, gentamycin, ciprofloxacin, azithromycin, and ceftriaxone ranged from 0- 54%, while that for ceftazidime and amikacin ranged from 12-80%. The sensitivity of Klebseilla to these antibiotics ranged from 0-100%.Conclusions: Our data suggests that gram-negative bacteria, Klebseilla followed by Escherichia coli, and Acenetobacter are the predominant bacteria associated with severe pneumonia in ventilated children. The increased number of infections caused by Gram-negative bacteria is being accompanied by rising rates of multi-drug resistance which underscores the importance of aggressive antimicrobial therapy in the management of such children.Bangladesh Crit Care J September 2014; 2 (2): 60-64

Spontaneous Breathing Trial: A Reliable Method for Weaning in Children

Introduction Mechanical ventilation may be lifesaving intervention,It can be associated with complications,Thus,successful weaning is constitutive.One of the factors which is important in successful weaning is method of weaning. It is shown that weaning is conducted successfully by using Spontaneous Breathing Trial (SBT) through T-piece and pressure support (PS) ventilation.But few studies have not accepted it.In this study,we evaluated the role of SBT in extubation of patients in pediatric intensive care. Materials and Methods In a cross sectional and analytical study, three hundred sixty patients with adequate gas exchange (indicated by PaO2 higher than 60 mm/Hg while FIO2 of 0.40 or less (or PaO2 ∕ FIO2ratio> 300) were enrolled. Patients underwent a 2-hours trial of spontaneous breathing with pressure support ventilation.They were monitored during the test for 2 hours and were classified as failing the test if at any time in the 2-hours period ,there was tachypnea , excessive work of breathing,Tachycardia and SPO2<90%.Extubation failure was defind as needing reintubation within 72 hours of extubation. Results 240 patients(66%) of 360 patients successfully underwent SBT and were immediately extubated.In 120 patients(33%) ,the trial of spontaneous breathing was stopped.(trial failure;33% vs. 66% P=0.04). Of the 240 patients with successful SBT,29 patients were re-intubated (extubation failure) and 211 patients had successful extubation.(12% vs. 88% p=o.oo2).For patients experienced successful extubation ,the mortality rate was 5% While the rate of mortality was 27% in patients with needing re-intubation.(5% vs. 27% p= o.oo3) Conclusion The spontaneous breathing trial with pressure support prior to elective extubation may predict successful extubation in ventilated children.

Long term non-invasive ventilation in children: impact on survival and transition to adult care.

BackgroundThe number of children receiving domiciliary ventilatory support has grown over the last few decades driven largely by the introduction and widening applications of non-invasive ventilation. Ventilatory support may be used with the intention of increasing survival, or to facilitate discharge home and/or to palliate symptoms. However, the outcome of this intervention and the number of children transitioning to adult care as a consequence of longer survival is not yet clear.MethodsIn this retrospective cohort study, we analysed the outcome in children (<17 years) started on home NIV at Royal Brompton Hospital over an 18 year period 1993-2011. The aim was to establish for different diagnostic groups: survival rate, likelihood of early death depending on diagnosis or discontinuation of ventilation, and the proportion transitioning to adult care.Results496 children were commenced on home non invasive ventilation; follow-up data were available in 449 (91%). Fifty six per cent (n=254) had neuromuscular disease. Ventilation was started at a median age (IQR) 10 (3-15) years. Thirteen percent (n=59) were less than 1 year old. Forty percent (n=181) have transitioned to adult care. Twenty four percent (n=109) of patients have died, and nine percent (n=42) were able to discontinue ventilatory support.ConclusionLong term ventilation is associated with an increase in survival in a range of conditions leading to ventilatory failure in children, resulting in increasing numbers surviving to adulthood. This has significant implications for planning transition and adult care facilities.

The characteristics of bacterial biofilm formation in endotracheal tubes in ventilated patients and the relationship between the biofilm and ventilator-associated pneumonia

Objective To observe the formation of the biofilm in endotracheal tubes, the characteristics of etiology, drug resistance and relationship between the biofilm and ventilator-associated pneumonia(VAP). Methods A total of 60 cases of ventilated children patients whose mechanical ventilation time were ≥48 h in the ICU from September 2010 to September 2012, according to the mechanical ventilation time, all cases were divided into 2 to 6 d group, 7 to 14 d group and ≥15 d group.The incidence of VAP, biofilm structure under the electron microscope, etiology culture positive rate of the lower airway secretions and biofilm, etiological characteristics and drug resistance were prospectively studied. Results (1) A total of 19 cases occurred VAP in 60 cases of mechanical ventilation, the incidence of VAP was 31.7%.(2) Observed by electron microscope, biofilm had formed in the endotracheal tube inner wall in early period of mechanical ventilation.With prolonged mechanical ventilation, biofilm structure had improved, as well as VAP incidence rate from 9.1%(2 to 6 d group ) increased to 44.4%(7 to 14 d group) and 88.9%(≥15 d group). (3) A large number of pathogenic bacteria colonized in the biofilm.Gram-negative bacilli were dominate and drug resistance was high.(4) With prolonged mechanical ventilation, the cultured pathogens from the lower airway secretions and biofilm converged. Conclusion Biofilm could form in the endotracheal tube with mechanical ventilation patients, and is associated with the occurrence of VAP and refractory infections. Key words: Endotracheal tube; Biofilm; Ventilator-associated pneumonia; Pathogens; Drug resistance

Impact of Malnutrition on the Outcome of Critically Ill Children.

To assess the impact of nutritional status on outcomes like mortality rate, length of mechanical ventilation and length of Pediatric Intensive Care Unit (PICU) stay, in critically ill children. In this retrospective study conducted at a tertiary care center, records of 332 critically ill children between 1 mo to 15 y of age for whom anthropometric parameters were available were included. Anthropometric parameters for the study subjects were used to assess the nutritional status using the WHO growth charts as the reference. The study subjects were categorized as non-malnourished, moderately, and severely malnourished, defined by Body mass index (BMI) for age 0 to -2 SD, -2 to -3 SD and less than -3 SD of WHO growth charts, respectively. Various outcomes like mortality, duration of PICU stay and duration of mechanical ventilation were assessed in the 3 groups based on the nutritional status. The prevalence of malnutrition in the index study was 51.2 % with an overall mortality of 38.8 %. No difference was found between mortality rates and proportion of ventilated children in the three study groups. However, more children who were severely malnourished had significantly prolonged ICU stay (>7 d) as well as duration of mechanical ventilation (>7 d). When the outcome variables were compared after adjusting for PIM2 scores, there were increasing odds of mortality, ventilation, prolonged PICU stay and duration of mechanical ventilation with increasing severity of malnutrition. After stabilization of the initial critical phase, PICU outcome is influenced by the nutritional status of the children.