Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children

Variability in the Physiologic Response to Fluid Bolus in Pediatric Patients Following Cardiac Surgery

BACKGROUND

Fluid boluses aiming to improve the cardiac output and oxygen delivery are commonly administered in children with shock. An increased mean arterial pressure in addition to resolution of tachycardia and improved peripheral perfusion are often monitored as clinical surrogates for improvement in cardiac output. The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance.

OBJECTIVE

The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance.

DESIGN, SETTING, PATIENTS, AND INTERVENTIONS

We prospectively analyzed hemodynamic data from children in the cardiac ICU who received fluid bolus (10mL/kg of Ringers-Lactate over 30 min) for management of shock and/or hypoperfusion within 12h of cardiac surgery. Cardiac index responders and mean arterial pressure-responders were defined as CI ≥10% and mean arterial pressure ≥10%, respectively. We evaluated the gradient for venous-return (mean systemic filling pressure-central venous pressure), arterial load properties (systemic vascular resistance index and elastance index) and changes in vasopressor support after fluid bolus.

MEASUREMENTS AND MAIN RESULTS

Fifty-seven children between 1 month and 16 years (median Risk adjustment after congenital heart surgery Model for Outcome Surveillance in Australia and New Zealand score of 3.8 (interquartile range 3.7-4.6) received fluid bolus. Cardiac index-responsiveness and mean arterial pressure-responsiveness rates were 33% and 56%, respectively. No significant correlation was observed between changes in mean arterial pressure and cardiac index (r = 0.035, p = 0.79). Although the mean systemic filling pressure - central venous pressure and the number of cardiac index-responders after fluid bolus were similar, the arterial load parameters did not change in mean arterial pressure-nonresponders. Forty-three patients (75%) had a change in Vasoactive-Inotrope Score after the fluid bolus, of whom 60% received higher level of vasoactive support.

CONCLUSIONS

The mean arterial pressure response to fluid bolus in cardiac ICU patients was unpredictable with a poor relationship between cardiac index-responsiveness and mean arterial pressure-responsiveness. Because arterial hypotension is frequently a trigger for administering fluids and changes in blood pressure are commonly used for tracking changes in cardiac output, we suggest a cautious and individualized approach to repeat fluid bolus based solely on lack of mean arterial pressure response to the initial fluid, since the implications include decreased arterial tone even if the cardiac index increases.

Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation

OBJECTIVES

Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation.

DESIGN

Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry.

SETTING

Thirteen PICUs (in 12 institutions) in the United States and Canada.

PATIENTS

All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events.

CONCLUSIONS

Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.

Propofol, Ketamine, and Etomidate as Induction Agents for Intubation and Outcomes in Critically Ill Patients: A Retrospective Cohort Study

Propofol, ketamine, and etomidate are common anesthetic agents for induction of anesthesia in the ICU. The choice between these agents is complex and may not depend solely upon severity of illness.

OBJECTIVES

To evaluate the association between the administration of propofol, ketamine, and etomidate and ICU, hospital mortality, and length of stay.

DESIGN SETTING AND PARTICIPANTS

Retrospective single-center cohort study. ICUs in a tertiary medical center, between January 01, 2012, and December 31, 2017. Critically ill adult patients given a single IV anesthetic for intubation.

MAIN OUTCOME AND MEASURES

Primary outcomes were ICU and hospital mortality. Secondary outcomes were ICU- and hospital-free days through 28 days. An inverse probability of treatment weighed approach was used. The propensity score was estimated using a generalized logit model as a function of patient characteristics, admission source, ICU type, readmission status, length of ICU stays prior to intubation, and acute physiology score. Mortality outcomes were assessed with weighted logistic regression and -free days assessed by weighted linear regression with Bonferroni correction for pairwise comparisons.

RESULTS

Of 2,673 patients, 36% received propofol, 30% ketamine and 34% etomidate. Overall ICU and hospital mortality were 19% and 29%, respectively. Patients given ketamine had higher odds of ICU mortality (1.45; [95% CI, 1.07-1.94]; p = 0.015) and patients given etomidate had higher odds of ICU mortality (1.87; 1.40-2.49; p < 0.001), hospital mortality (1.43; 1.09-1.86; p = 0.009), and less ICU-free days (-2.10; -3.21 to -1.00; p < 0.001) than those given propofol. Patients given ketamine and etomidate had similar odds of hospital mortality (1.06; 0.80-1.42; p = 0.761) and similar hospital-free days (0.30; -0.81 to 1.40; p = 0.600).

CONCLUSIONS AND RELEVANCE

Compared with ketamine and etomidate, propofol was associated with better outcome in critically ill patients undergoing anesthesia for intubation. Even after adjusting for severity of illness prior to intubation, residual confounders cannot be excluded.

Hyperchloremia on Admission to Pediatric Intensive Care in Mechanically Ventilated Children is Associated with Impaired Renal Function

Objective  There is recent interest in the association between hyperchloremic metabolic acidosis and adverse outcomes. In vitro, hyperchloremia causes renal vasoconstriction and fall in glomerular filtration rate (GFR). The objective of this retrospective, observational study is to examine associations between chloride level at admission to pediatric intensive care (PICU) and worst GFR and requirement for renal replacement therapy. Materials and Methods  All admissions to PICU between 2009 and 2019 who received invasive mechanical ventilation and had blood gas analysis performed were included. Data analyzed included patient characteristics (age, gender, diagnosis, pediatric index of mortality [PIM]-2 score); results of initial blood gas; and maximum serum creatinine (then used to calculate minimum GFR). Primary outcome measure was worst GFR during PICU stay. Secondary outcome measures were requirement for renal replacement therapy and PICU mortality. Multivariable regression analysis was used to assess if admission chloride level was independently predictive of minimum GFR during PICU stay and to examine associations between hyperchloremia (>110 mEq/L) at admission and requirement for renal replacement therapy after adjustment for confounders. Results  Data were available for 2,217 patients. Median age was 16.4 months and 39% of patients were hyperchloremic at admission to PICU. Admission chloride level was independently predictive of worst GFR during PICU stay after adjustment for known confounders. Patients with hyperchloremia were not more likely to require renal replacement therapy or die than patients with normochloremia. Conclusion  Prospective studies are necessary to determine if high chloride, specifically chloride containing resuscitation fluids, have a causal relationship with poor outcomes.

Pediatric Coronavirus Disease 2019: Clinical Features and Management

There is a lack of clarity regarding management of COVID-19 infection in children. This review aims to summarize the key clinical presentations and management of Pediatric COVID-19. The Medline database was searched for seminal articles and guidelines on COVID-19 presentation and management in children less than 18 years of age. COVID-19 has a lower incidence (1-5% of reported cases worldwide), causes milder disease with lower need for intensive care admission and lower mortality rate (0-0.7%) in children compared with adults. Multisystem inflammatory syndrome is a rare but severe complication in children. Majority of patients require supportive care including adequate hydration, nutrition and antipyretics. Supplemental oxygen therapy should be given in moderate to severe cases with all precautions to prevent air-borne COVID-19 spread. Steroids may be helpful in severe cases. Anticoagulation is indicated in moderate to severe cases with risk factors. More data on the efficacy and safety of antivirals and immunomodulators in children is needed.

Diagnostic biomarkers to differentiate sepsis from cytokine release syndrome in critically ill children

Chimeric antigen receptor (CAR) T-cells directed against CD19 have drastically altered outcomes for children with relapsed and refractory acute lymphoblastic leukemia (r/r ALL). Pediatric patients with r/r ALL treated with CAR-T are at increased risk of both cytokine release syndrome (CRS) and sepsis. We sought to investigate the biologic differences between CRS and sepsis and to develop predictive models which could accurately differentiate CRS from sepsis at the time of critical illness. We identified 23 different cytokines that were significantly different between patients with sepsis and CRS. Using elastic net prediction modeling and tree classification, we identified cytokines that were able to classify subjects as having CRS or sepsis accurately. A markedly elevated interferon γ (IFNγ) or a mildly elevated IFNγ in combination with a low IL1β were associated with CRS. A normal to mildly elevated IFNγ in combination with an elevated IL1β was associated with sepsis. This combination of IFNγ and IL1β was able to categorize subjects as having CRS or sepsis with 97% accuracy. As CAR-T therapies become more common, these data provide important novel information to better manage potential associated toxicities.

Repeated Emergency Department Visits Among Children with Invasive Bacterial Infections

We carried out a retrospective cohort study of 271 previously healthy children younger than 14 years old diagnosed with invasive bacterial infection in an emergency department. Of them, 72 (26.6%) had previous visits to the emergency department. Not identifying children with an invasive bacterial infection and not administering antibiotics on the first visit was associated with a severe outcome.

A trend skill that makes pediatric intensivists stand out: Critical care echocardiography

Recently, the use of point-of-care ultrasonography (POCUS) by pediatricians especially in emergency and intensive care departments has become increasingly popular. Critical care echocardiography (CCE) quickly and accurately identifies cardiac function, allowing intensivists to manage critically ill pediatric patients by manipulating vasoactive-inotrope-fluid treatment based on the echocardiographic results. Training courses for POCUS are increasingly available and more intensivists are learning how to use CCE. In this review, we focus on the importance and utility of CCE in pediatric intensive units and how it assists in the management of hemodynamically unstable pediatric patients. We highlight the common measurements carried out by intensive care specialists and emphasize the role of the CCE methods in PICUs.

Evaluation of a Sepsis Alert in the Pediatric Acute Care Setting

BACKGROUND

Severe sepsis can cause significant morbidity and mortality in pediatric patients. Early recognition and treatment are vital to improving patient outcomes.

OBJECTIVE

The study aimed to evaluate the impact of a best practice alert in improving recognition of sepsis and timely treatment to improve mortality in the pediatric acute care setting.

METHODS

A multidisciplinary team adapted a sepsis alert from the emergency room setting to facilitate identification of sepsis in acute care pediatric inpatient areas. The sepsis alert included clinical decision support to aid in timely treatment, prompting the use of intravenous fluid boluses, and antibiotic administration. We compared sepsis-attributable mortality, time to fluid and antibiotic administration, proportion of patients who required transfer to a higher level of care, and antibiotic days for the year prior to the sepsis alert (2017) to the postimplementation phase (2019).

RESULTS

We had 79 cases of severe sepsis in 2017 and 154 cases in 2019. Of these, we found an absolute reduction in both 3-day sepsis-attributable mortality (2.53 vs. 0%) and 30-day mortality (3.8 vs. 1.3%) when comparing the pre- and postintervention groups. Though our analysis was underpowered due to small sample size, we also identified reductions in median time to fluid and antibiotic administration, proportion of patients who were transferred to the intensive care unit, and no observable increase in antibiotic days.

CONCLUSION

Electronic sepsis alerts may assist in improving recognition of sepsis and support timely antibiotic and fluid administration in pediatric acute care settings.

Metric Development for the Multicenter Improving Pediatric Sepsis Outcomes (IPSO) Collaborative

BACKGROUND

A 56 US hospital collaborative, Improving Pediatric Sepsis Outcomes, has developed variables, metrics and a data analysis plan to track quality improvement (QI)-based patient outcomes over time. Improving Pediatric Sepsis Outcomes expands on previous pediatric sepsis QI efforts by improving electronic data capture and uniformity across sites.

METHODS

An expert panel developed metrics and corresponding variables to assess improvements across the care delivery spectrum, including the emergency department, acute care units, hematology and oncology, and the ICU. Outcome, process, and balancing measures were represented. Variables and statistical process control charts were mapped to each metric, elucidating progress over time and informing plan-do-study-act cycles. Electronic health record (EHR) abstraction feasibility was prioritized. Time 0 was defined as time of earliest sepsis recognition (determined electronically), or as a clinically derived time 0 (manually abstracted), identifying earliest physiologic onset of sepsis.

RESULTS

Twenty-four evidence-based metrics reflected timely and appropriate interventions for a uniformly defined sepsis cohort. Metrics mapped to statistical process control charts with 44 final variables; 40 could be abstracted automatically from multiple EHRs. Variables, including high-risk conditions and bedside huddle time, were challenging to abstract (reported in <80% of encounters). Size or type of hospital, method of data abstraction, and previous QI collaboration participation did not influence hospitals' abilities to contribute data. To date, 90% of data have been submitted, representing 200 007 sepsis episodes.

CONCLUSIONS

A comprehensive data dictionary was developed for the largest pediatric sepsis QI collaborative, optimizing automation and ensuring sustainable reporting. These approaches can be used in other large-scale sepsis QI projects in which researchers seek to leverage EHR data abstraction.

Importance of Reviewing Antibiotic Courses by 48 Hours: Risk Factors for Third-Generation Cephalosporin Resistance Among AmpC Harboring Organisms in Urine and Respiratory Cultures

BACKGROUND

Citrobacter, Enterobacter, Morganella, and Serratia (AmpC organisms) species can exhibit third-generation cephalosporin (TGC) resistance after TGC exposure. We aimed to assess if institutional TGC utilization correlated with institutional AmpC organism susceptibility and if prior TGC exposure ≤48 hours were associated with TGC resistance in the first culture of a future infection episode caused by an AmpC organism.

METHODS

A 5-year retrospective cohort study was performed, including AmpC organisms isolated from pediatric urinary and respiratory tract cultures at an institution with TGC courses reviewed by the antimicrobial stewardship program at 48 hours. Correlations were assessed by Pearson's correlation. Multivariable logistic regression identified factors independently associated with TGC resistance in a subcohort of infection episodes.

RESULTS

Among 654 cultures, AmpC organism TGC susceptibility increased from 74% in 2013 to 89.3% in 2017, and this correlated with a 26.1% decrease in TGC utilization (R = -0.906; P = 0.034). Among 275 AmpC organism infections, 21.1% were resistant. Resistance occurred in 13.6%, 17.4%, and 56.5% of infections with no exposure, ≤48 hours, and >48 hours of TGC exposure in the past 30 days, respectively. TGC exposure ≤48 hours was not associated with resistance (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.32-4.94; P = 0.74), whereas, TGC exposure >48 hours was (OR, 8.7; 95% CI, 3.67-20.6; P  < 0.001). Infections in 2017 were less likely to be resistant (OR, 0.25; 95% CI, 0.08-0.8; P = 0.019).

CONCLUSIONS

Decreased TGC utilization, likely related to antimicrobial stewardship, correlated with increased AmpC organism susceptibility. Limiting TGC exposure to ≤48 hours when possible may reduce AmpC organism resistance in future infections.

Pediatric Coronavirus Disease 2019: Clinical Features and Management

There is a lack of clarity regarding management of COVID-19 infection in children. This review aims to summarize the key clinical presentations and management of Pediatric COVID-19. The Medline database was searched for seminal articles and guidelines on COVID-19 presentation and management in children less than 18 years of age. COVID-19 has a lower incidence (15% of reported cases worldwide), causes milder disease with lower need for intensive care admission and lower mortality rate (00.7%) in children compared with adults. Multisystem inflammatory syndrome is a rare but severe complication in children. Majority of patients require supportive care including adequate hydration, nutrition and antipyretics. Supplemental oxygen therapy should be given in moderate to severe cases with all precautions to prevent air-borne COVID-19 spread. Steroids may be helpful in severe cases. Anticoagulation is indicated in moderate to severe cases with risk factors. More data on the efficacy and safety of antivirals and immunomodulators in children is needed.

Association Between Unbalanced Solutions and Acute Kidney Injury During Fluid Resuscitation in Children With Sepsis

OBJECTIVE

To evaluate the outcomes of patients with sepsis-associated organ dysfunction and septic shock who receive fluid resuscitation with balanced and unbalanced solutions in a middle-income country.

DESIGN

An observational, analytical cohort study with propensity score matching (PSM) in children admitted to a pediatric intensive care unit (PICU). Patients from one month to 17 years old who required fluid boluses due to hemodynamic instability were included. The primary outcome was the presence of acute kidney injury and the secondary outcomes were the need to begin continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay and mortality.

MEASUREMENTS AND MAIN RESULTS

Out of the 1,074 admissions to the PICU during the study period, 99 patients had sepsis-associated organ dysfunction and septic shock. Propensity score matching was performed including each patient´s baseline characteristics. The median age was 9.9 months (IQR 4.9-22.2) with 55.5% of the patients being male. Acute kidney injury was seen less frequently in children who received a balanced solution than in those who received an unbalanced solution (20.3% vs 25.7% P = 0.006 ORa, 0.75; 95% CI, 0.65-0.87), adjusted for disease severity. In addition, the group that received balanced solutions had less need for CRRT (3.3 % vs 6.5%; P = 0.02 ORa 0.48; 95% CI, 0.36-0.64) and a shorter PICU stay (6 days IQR 4.4-20.2 vs 10.2 days IQR 4.7-26; P < 0.001) than the group with unbalanced solutions. We found no difference in the frequency of metabolic acidosis (P = 0.37), hyperchloremia (P = 0.11) and mortality (P = 0.25) between the 2 groups.

CONCLUSION

In children with sepsis-associated organ dysfunction and septic shock, the use of unbalanced solutions for fluid resuscitation is associated with a higher frequency of acute kidney injury, a greater need for continuous renal support and a longer PICU stay compared to the use of balanced solutions, in a middle-income country.

Unsatisfactory Short-Term Neurodevelopmental Outcomes of Preterm Infants Who Received Polymyxin B-Immobilized Fiber Column-Direct Hemoperfusion for Septic Shock

Sepsis and septic shock are associated with high mortality and neurodevelopmental impairment in preterm infants. Recently, endotoxin and mediator removal using a polymyxin B-immobilized fiber column for direct hemoperfusion (PMX-DHP) has been used for the management of septic shock even in neonates. Although early withdrawal from shock with PMX-DHP contributes to survival, its effect on neurodevelopment after discharge is unclear. This study aimed to examine short-term neurodevelopmental impairment in preterm infants with septic shock who were treated with PMX-DHP. We retrospectively assessed five infants who received treatment with PMX-DHP (median 25.5 [interquartile range: 24.8-28.3] weeks and 817 [interquartile range: 667-954] g). Neurodevelopmental outcomes were assessed with the Kyoto Scale of Psychological Development 2001 at a median 34.5 (interquartile range: 29.5-44.5) months of corrected age after discharge. The short-term neurodevelopmental prognosis of preterm infants treated with PMX-DHP for septic shock was delayed (overall developmental quotient < 70) with an average quotient of 57.3. Furthermore, four (80%) of five patients presented with intraventricular hemorrhage and another four (80%) with periventricular leukomalacia. In conclusion, preterm infants with septic shock treated with PMX-DHP had unsatisfactory short-term neurodevelopmental outcomes. Hence, the effect of PMX-DHP in improving neurodevelopmental prognosis even in preterm infants with septic shock should be further evaluated.

Identification and Management of Pediatric Sepsis: A Medical Student Curricular Supplement for PICU and NICU Rotations

INTRODUCTION

Medical students frequently report lack of confidence and skill in managing ill pediatric patients. We aimed to implement targeted learning interventions to address these knowledge gaps, specifically focusing on pediatric sepsis. Our objective was to create a curriculum to advance knowledge and confidence in identifying and managing pediatric sepsis.

METHODS

We designed this curriculum to augment medical student pediatric ICU (PICU) and neonatal ICU (NICU) rotations. We first emailed students a pretest and upon completion, we emailed students a series of brief educational videos. Students then participated in a simulation experience designed to assess their ability to diagnose and manage severe sepsis. We provided immediate debriefing after each session. Upon completion of the simulation experience, we emailed students a posttest (identical to the pretest). The pre-/posttest included multiple-choice questions to assess the students' ability to recognize and manage pediatric sepsis and septic shock, as well as Likert-scale questions assessing confidence levels in diagnosis and management of pediatric sepsis. We performed paired Student t tests comparing knowledge-based question scores and Likert-scale results.

RESULTS

Of students, 40 enrolled in and 30 completed the curriculum between 2015 and 2020. When comparing pre- and posttest results, we found a significant improvement in knowledge scores (33% mean increase, 95% CI [22%-45%], p < .001) and confidence levels (mean increase in Likert scale score of 1.5, 95% CI [1.2-1.7], p < .001).

DISCUSSION

Results suggested that the curriculum advanced students' knowledge scores and improved self-reported confidence in managing theoretical pediatric patients with sepsis.

Comparison of children receiving emergent sepsis care by mode of arrival

OBJECTIVE

To determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport).

METHODS

Retrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported.

RESULTS

Of the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days).

CONCLUSIONS

Children with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.

COVID-19 Management in the Pediatric Age: Consensus Document of the COVID-19 Working Group in Paediatrics of the Emilia-Romagna Region (RE-CO-Ped), Italy

Since December 2019, coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread, becoming the first pandemic of the 21st century by number of deaths (over 2,000,000 worldwide). Many aspects of SARS-CoV-2 infection in children and adolescents remain unclear, and optimal treatment has not yet been defined. Therefore, our goal was to develop a consensus document, practically synthesizing the accumulated data and clinical experience of our expert group. Literature research was carried out using the keywords "COVID-19" or "SARS-CoV-2" and "children" or "pediatrics" and "prevention" or "diagnosis" or "MIS-C" or "treatment" in electronic databases (MEDLINE, PUBMED), existing guidelines and gray literature. The fact that the majority of the problems posed by SARS-CoV-2 infection in pediatric age do not need hospital care and that, therefore, infected children and adolescents can be managed at home highlights the need for a strengthening of territorial pediatric structures. The sharing of hospitalization and therapeutic management criteria for severe cases between professionals is essential to ensure a fair approach based on the best available knowledge. Moreover, the activity of social and health professionals must also include the description, management and limitation of psychophysical-relational damage resulting from the SARS-CoV-2 pandemic on the health of children and adolescents, whether or not affected by COVID-19. Due to the characteristics of COVID-19 pathology in pediatric age, the importance of strengthening the network between hospital and territorial pediatrics, school, educational, social and family personnel both for strictly clinical management and for the reduction in discomfort, with priority in children of more frail families, represents a priority.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

A literature review of 2019 novel coronavirus (SARS-CoV2) infection in neonates and children

At the time of writing, there are already millions of documented infections worldwide by the novel coronavirus 2019 (2019-nCoV or severe acute respiratory syndrome coronavirus 2 (SARS-CoV2)), with hundreds of thousands of deaths. The great majority of fatal events have been recorded in adults older than 70 years; of them, a large proportion had comorbidities. Since data regarding the epidemiologic and clinical characteristics in neonates and children developing coronavirus disease 2019 (COVID-19) are scarce and originate mainly from one country (China), we reviewed all the current literature from 1 December 2019 to 7 May 2020 to provide useful information about SARS-CoV2 viral biology, epidemiology, diagnosis, clinical features, treatment, prevention, and hospital organization for clinicians dealing with this selected population. IMPACT: Children usually develop a mild form of COVID-19, rarely requiring high-intensity medical treatment in pediatric intensive care unit. Vertical transmission is unlikely, but not completely excluded. Children with confirmed or suspected COVID-19 must be isolated and healthcare workers should wear appropriate protective equipment. Some clinical features (higher incidence of fever, vomiting and diarrhea, and a longer incubation period) are more common in children than in adults, as well as some radiologic aspects (more patchy shadow opacities on CT scan images than ground-glass opacities). Supportive and symptomatic treatments (oxygen therapy and antibiotics for preventing/treating bacterial coinfections) are recommended in these patients.

Optimizing Aminoglycoside Dosing Regimens for Critically Ill Pediatric Patients with Augmented Renal Clearance: a Convergence of Parametric and Nonparametric Population Approaches

Augmented renal clearance (ARC) can occur in critically ill pediatric patients receiving aminoglycosides such as gentamicin and tobramycin, yet optimal dosing strategies for ARC are undefined. We evaluated the probability of achieving efficacious or toxic exposures in pediatrics. Parallel population modeling of concentration strategies were pursued using Pmetrics v1.5.2 (nonparametric) and Monolix v2019R2 (parametric). Bayesian exposures were used to classify ARC based on total clearance (CL). The effects of serum creatinine (SCR), creatinine clearance (CRCL), total body weight (TBW), postnatal age (PNA), and ARC were explored as covariates. The probabilities of target attainment (PTA) (i.e., maximum concentration [C _max]/MIC, area under the concentration-time curve [AUC]/MIC) and of toxic exposure (PTE) (i.e., minimum concentration [C _min] > 2 μg/ml) were calculated according to PNA and ARC. A total of 123 patients (1 to 21 years old, 56% female) contributed 304 concentrations. A two-compartment model was superior to a one-compartment model in both approaches. Bayesian posterior predicted concentrations from the nonparametric base model fit the data well (R ² = 0.96) and classified 34 patients as having ARC (28%). Both the nonparametric and parametric approaches resulted in allometrically scaling of TBW on volume (V) and clearance (CL). ARC modified CL and central V. CRCL and a maturation function modified CL. ARC was associated with a 1.49- versus 1.66-fold increase in CL and a 1.56- versus 1.66-fold increase in the central V (nonparametric versus parametric). A high dose of 12 mg/kg of body weight/day was required to achieve adequate PTA when MICs were 1 to 2 μg/ml; ARC lowered achievable MICs. When PNA was <2 years, PTE was increased. Aminoglycoside monotherapy should be avoided in critically ill pediatric patients with ARC when MICs exceed 1 μg/ml, as optimal exposures are unachievable with standard dosing.

Central venoarterial extracorporeal life support in pediatric refractory septic shock: a single center experience

OBJECTIVE

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution.

DESIGN

Retrospective case series.

SETTING

Pediatric and cardiac intensive care units in an academic pediatric hospital.

PATIENTS

All patients 0-18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS

Demographics, relevant clinical variables, ECMO run details, and outcomes were collected.

RESULTS

Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9-178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5-185.7) versus non survivors 114.7 hours (IQR: 63.7-163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5-42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4-188.1) versus the peripheral with 133.5% (98.1-149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03).

CONCLUSION

A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.

Multisystem Inflammatory Syndrome in Children Associated With Coronavirus Disease 2019 in a Children's Hospital in New York City: Patient Characteristics and an Institutional Protocol for Evaluation, Management, and Follow-Up

OBJECTIVES

The disease caused by severe acute respiratory syndrome coronavirus 2, known as coronavirus disease 2019, has resulted in a global pandemic. Reports are emerging of a new severe hyperinflammatory syndrome related to coronavirus disease 2019 in children and adolescents. The Centers for Disease Control and Prevention has designated this disease multisystem inflammatory syndrome in children. Our objective was to develop a clinical inpatient protocol for the evaluation, management, and follow-up of patients with this syndrome.

DATA SOURCES

The protocol was developed by a multidisciplinary team based on relevant literature related to coronavirus disease 2019, multisystem inflammatory syndrome in children, and related inflammatory syndromes, as well as our experience caring for children with multisystem inflammatory syndrome in children. Data were obtained on patients with multisystem inflammatory syndrome in children at our institution from the pre-protocol and post-protocol periods.

DATA SYNTHESIS

Our protocol was developed in order to identify cases of multisystem inflammatory syndrome in children with high sensitivity, stratify risk to guide treatment, recognize co-infectious or co-inflammatory processes, mitigate coronary artery abnormalities, and manage hyperinflammatory shock. Key elements of evaluation include case identification using broad clinical characteristics and comprehensive laboratory and imaging investigations. Treatment centers around glucocorticoids and IV immunoglobulin with biologic immunomodulators as adjuncts. Multidisciplinary follow-up after discharge is indicated to manage continued outpatient therapy and evaluate for disease sequelae. In nearly 2 months, we admitted 54 patients with multisystem inflammatory syndrome in children, all of whom survived without the need for invasive ventilatory or mechanical circulatory support. After institution of this protocol, patients received earlier treatment and had shorter lengths of hospital stay.

CONCLUSIONS

This report provides guidance to clinicians on evaluation, management, and follow-up of patients with a novel hyperinflammatory syndrome related to coronavirus disease 2019 known as multisystem inflammatory syndrome in children. It is based on the relevant literature and our experience. Instituting such a protocol during a global pandemic is feasible and is associated with patients receiving treatment and returning home more quickly.

Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment

OBJECTIVES

To assess focused cardiac ultrasound impact on clinician hemodynamic characterization of patients with suspected septic shock as well as expert-generated focused cardiac ultrasound algorithm performance.

DESIGN

Retrospective, observational study.

SETTING

Single-center, noncardiac PICU.

PATIENTS

Less than 18 years old receiving focused cardiac ultrasound study within 72 hours of sepsis pathway initiation from January 2014 to December 2016.

INTERVENTIONS

Hemodynamics of patients with suspected septic shock were characterized as fluid responsive, myocardial dysfunction, obstructive physiology, and/or reduced systemic vascular resistance by a bedside clinician before and immediately following focused cardiac ultrasound performance. The clinician's post-focused cardiac ultrasound hemodynamic assessments were compared with an expert-derived focused cardiac ultrasound algorithmic hemodynamic interpretation. Subsequent clinical management was assessed for alignment with focused cardiac ultrasound characterization and association with patient outcomes.

MEASUREMENTS AND MAIN RESULTS

Seventy-one patients with suspected septic shock (median, 4.7 yr; interquartile range, 1.6-8.1) received clinician performed focused cardiac ultrasound study within 72 hours of sepsis pathway initiation (median, 2.1 hr; interquartile range, -1.5 to 11.8 hr). Two patients did not have pre-focused cardiac ultrasound and 23 patients did not have post-focused cardiac ultrasound hemodynamic characterization by clinicians resulting in exclusion from related analyses. Post-focused cardiac ultrasound clinician hemodynamic characterization differed from pre-focused cardiac ultrasound characterization in 67% of patients (31/46). There was substantial concordance between clinician's post-focused cardiac ultrasound and algorithm hemodynamic characterization (33/48; κ = 0.66; CI, 0.51-0.80). Fluid responsive (κ = 0.62; CI, 0.40-0.84), obstructive physiology (к = 0.87; CI, 0.64-1.00), and myocardial dysfunction (1.00; CI, 1.00-1.00) demonstrated substantial to perfect concordance. Management within 4 hours of focused cardiac ultrasound aligned with algorithm characterization in 53 of 71 patients (75%). Patients with aligned management were less likely to have a complicated course (14/52, 27%) compared with misaligned management (8/19, 42%; p = 0.25).

CONCLUSIONS

Incorporation of focused cardiac ultrasound in the evaluation of patients with suspected septic shock frequently changed a clinician's characterization of hemodynamics. An expert-developed algorithm had substantial concordance with a clinician's post-focused cardiac ultrasound hemodynamic characterization. Management aligned with algorithm characterization may improve outcomes in children with suspected septic shock.

Echocardiographic Parameters and Mortality in Pediatric Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to investigate the prognostic value of echocardiographic parameters in pediatric septic patients.

DATA SOURCES

MEDLINE, PubMed, and EMBASE (last update April 5, 2020).

STUDY SELECTION

Observational studies of pediatric sepsis providing echocardiographic parameters in relation to mortality.

DATA EXTRACTION

Echocardiography data were categorized as those describing left ventricular systolic or diastolic function, right ventricular function, and strain echocardiography parameters. Data from neonates and children were considered separately. Analysis is reported as standardized mean difference and 95% CI.

DATA SYNTHESIS

We included data from 14 articles (n = 5 neonates, n = 9 children). The fractional shortening was the most commonly reported variable (11 studies, n = 555 patients) and we did not identify an association with mortality (standardized mean difference 0.22, 95% CI [-0.02 to 0.47]; p = 0.07, I2 = 28%). In addition, we did not find any association with mortality also for left ventricular ejection fraction (nine studies, n = 417; standardized mean difference 0.06, 95% CI [-0.27 to 0.40]; p = 0.72, I2 = 51%), peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave (four studies, n = 178; standardized mean difference -0.01, 95% CI [-0.34 to 0.33]; p = 0.97, I2 = 0%), and myocardial performance index (five studies, n = 219; standardized mean difference -0.51, 95% CI [-1.10 to 0.08]; p = 0.09, I2 = 63%). However, in regard to left ventricular diastolic function, there was an association with mortality for higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging ratio (four studies, n = 189, standardized mean difference -0.45, 95% CI [-0.80 to -0.10]; p = 0.01, I2 = 0%) or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging wave (three studies, n = 159; standardized mean difference 0.49, 95% CI [0.13-0.85]; p = 0.008, I2 = 0%). We did not find any association with mortality for early wave of transmitral flow/late (atrial) wave of trans-mitral flow ratio (six studies, n = 273; standardized mean difference 0.28, 95% CI [-0.42 to 0.99]; p = 0.43, I2 = 81%) and peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave measured at the tricuspid annulus (three studies, n = 148; standardized mean difference -0.18, 95% CI [-0.53 to 0.17]; p = 0.32, I2 = 0%). Only a few studies were conducted with strain echocardiography.

CONCLUSIONS

This meta-analysis of echocardiography parameters in pediatric sepsis failed to find any association between the measures of left ventricular systolic or right ventricular function and mortality. However, mortality was associated with higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging, indicating possible importance of left ventricular diastolic dysfunction. These are preliminary findings because of high clinical heterogeneity in the studies to date.

Left Ventricular Diastolic Dysfunction in Pediatric Sepsis: Outcomes in a Single-Center Retrospective Cohort Study

OBJECTIVES

Left ventricular diastolic dysfunction is associated with difficulty in ventilator weaning and increased mortality in septic adults. We evaluated the association of left ventricular diastolic dysfunction with outcomes in a cohort of children with severe sepsis and septic shock.

DESIGN

Retrospective cohort study.

SETTING

Single-center noncardiac PICU.

PATIENTS

Age greater than 1 month to less than 18 years old with severe sepsis or septic shock from January 2011 to June 2017 with echocardiogram within 48 hours of sepsis onset.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Echocardiograms were retrospectively assessed for mitral inflow E (early) and A (atrial) velocity and e' (early mitral annular motion) septal and lateral velocity. Left ventricular diastolic dysfunction was defined as E/e' greater than 10, E/A less than 0.8, or E/A greater than 1.5. Left ventricular diastolic dysfunction was present in 109 of 204 patients (53%). The data did not demonstrate an association between the presence of left ventricular diastolic dysfunction and the proportion of children requiring invasive mechanical ventilation at the time of echocardiogram (difference in proportion, +5% [72% vs 67%; 95% CI, -8% to 17%]; p = 0.52). The duration of mechanical ventilation was median 192.9 hours (interquartile range, 65.0-378.4 hr) in the left ventricular diastolic dysfunction group versus 151.0 hours (interquartile range, 45.7-244.3 hr) in the group without left ventricular diastolic dysfunction. The presence of left ventricular diastolic dysfunction was not significantly associated with ICU length of stay or mortality. Exploratory analyses revealed that an alternative definition of left ventricular diastolic dysfunction, solely defined by E/e' greater than 10, was found to have an association with mechanical ventilation requirement at the time of echocardiogram (difference in proportion, +15%; 95% CI, 3-28%; p = 0.02) and duration of mechanical ventilation (median, 207.3 vs 146.9 hr).

CONCLUSIONS

The data failed to show an association between the presence of left ventricular diastolic dysfunction defined by both E/e' and E/A and the primary and secondary outcomes. When an alternative definition of left ventricular diastolic dysfunction with E/e' alone was used, there was a significant association with respiratory outcomes.

Epidemiology of Sepsis Among Children and Neonates in Germany: Results From an Observational Study Based on Nationwide Diagnosis-Related Groups Data Between 2010 and 2016

OBJECTIVES

Worldwide, more than half of all sepsis cases occur in pediatric and adolescent patients, particularly in neonates. Previous population-based studies in these age groups often were limited to either neonatal or pediatric patients admitted to ICUs. We aimed to investigate the overall and age-specific incidence and case fatality of sepsis in children in Germany, a high-income country with a total population of 82 million.

DESIGN

Retrospective observational study based on the German Diagnosis-related Groups statistics of the years 2010-2016.

SETTING

All acute care hospitals in Germany except for prison and psychiatric hospitals.

PATIENTS

Pediatric patients less than or equal to 19 years with International Classification of Diseases, 10th Revision-coded sepsis, neonates with International Classification of Diseases, 10th Revision-coded neonatal sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed pediatric sepsis incidence in patients aged birth to less than or equal to 19 years old, case fatality, and underlying comorbidities, and neonatal sepsis incidence and case fatality within the neonatal period. We identified 14,635 pediatric sepsis cases among 15.4 million pediatric hospitalizations between 2010 and 2016 (= 0.1% of pediatric hospitalizations). The incidence of pediatric sepsis was 14 cases per 100,000 children between 0 and 19 years. Case fatality was 16.6% and decreased from 17.8% (2010) to 15.0% (2016). A total of 11.5% of hospital deaths in the age group 0-19 years were associated with pediatric sepsis. Sepsis incidence and case fatality were highest in children less than 1 year old and declined in older children and adolescents. Admissions with pediatric sepsis were more common in children with preexisting comorbidities compared with those without (0.52% vs 0.03% of pediatric admissions). In neonates, the incidence of neonatal sepsis was 1,006 cases per 100,000 live births. Case fatality was 3.9%. While 17.7% of very low birth weight infants had neonatal sepsis, only 2.1% of low birth weight and 0.6% of normal birth weight neonates were affected, respectively.

CONCLUSIONS

Sepsis is also in Germany a common and frequently fatal condition in pediatric patients, particularly among neonates and children with comorbidities.

Association of early hypotension in pediatric sepsis with development of new or persistent acute kidney injury

OBJECTIVE

To determine how hypotension in the first 48 h of sepsis management impacts acute kidney injury (AKI) development and persistence.

STUDY DESIGN

Retrospective study of patients > 1 month to < 20 years old with sepsis in a pediatric ICU between November 2012 and January 2015 (n = 217). All systolic blood pressure (SBP) data documented within 48 h after sepsis recognition were collected and converted to percentiles for age, sex, and height. Time below SBP percentiles and below pediatric advanced life support (PALS) targets was calculated by summing elapsed time under SBP thresholds during the first 48 h. The primary outcome was new or persistent AKI, defined as stage 2 or 3 AKI present between sepsis day 3-7 using Kidney Disease: Improving Global Outcomes creatinine definitions. Secondary outcomes included AKI-free days (days alive and free of AKI) and time to kidney recovery.

RESULTS

Fifty of 217 sepsis patients (23%) had new or persistent AKI. Patients with AKI spent a median of 35 min under the first SBP percentile, versus 4 min in those without AKI. After adjustment for potential confounders, the odds of AKI increased by 9% with each doubling of minutes spent under this threshold (p = 0.03). Time under the first SBP percentile was also associated with fewer AKI-free days (p = 0.02). Time spent under PALS targets was not associated with AKI.

CONCLUSIONS

The duration of severe systolic hypotension in the first 48 h of pediatric sepsis management is associated with AKI incidence and duration when defined by age, sex, and height norms, but not by PALS definitions. Graphical abstract.

Comparison of Manual and Automated Sepsis Screening Tools in a Pediatric Emergency Department

OBJECTIVES

To compare the performance and test characteristics of an automated sepsis screening tool with that of a manual sepsis screen in patients presenting to a pediatric emergency department (ED).

METHODS

We conducted a retrospective cohort study of encounters in a pediatric ED over a 2-year period. The automated sepsis screening algorithm replaced the manual sepsis screen 1 year into the study. A positive case was defined as development of severe sepsis or septic shock within 24 hours of disposition from the ED. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios with 95% confidence intervals (CIs) for each.

RESULTS

There were 122 221 ED encounters during the study period and 273 cases of severe sepsis. During year 1 of the study, the manual screen was performed in 8910 of 61 026 (14.6%) encounters, resulting in the following test characteristics: sensitivity of 64.6% (95% CI 54.2%-74.1%), specificity of 91.1% (95% CI 90.5%-91.7%), PPV of 7.3% (95% CI 6.3%-8.5%), and NPV of 99.6% (95% CI 99.5%-99.7%). During year 2 of the study, the automated screen was performed in 100% of 61 195 encounters, resulting in the following test characteristics: sensitivity of 84.6% (95% CI 77.4%-90.2%), specificity of 95.1% (95% CI 94.9%-95.2%), PPV of 3.7% (95% CI 3.4%-4%), and NPV of 99.9% (95% CI 99.9%-100%).

CONCLUSIONS

An automated sepsis screening algorithm had higher sensitivity and specificity than a widely used manual sepsis screen and was performed on 100% of patients in the ED, ensuring continuous sepsis surveillance throughout the ED stay.

[Spanish consensus document on diagnosis, stabilisation and treatment of pediatric multisystem inflammatory syndrome related to SARS-CoV-2 (SIM-PedS)]

A new paediatric multisystem inflammatory syndrome, linked to SARS-CoV-2, has been described. The clinical picture is variable and is associated with an active or recent infection due to SARS-CoV-2. A review of the existing literature by a multidisciplinary group of paediatric specialists is presented in this document. Later, they make recommendations on the stabilisation, diagnosis, and treatment of this syndrome.

Sepsis in the urgent care setting

Sepsis, in particular severe sepsis, is a major cause of morbidity and mortality in pediatrics. It is most likely to affect very young children and children with significant medical comorbidities. The definition of sepsis in pediatrics is currently rapidly evolving but the best treatment for children with severe sepsis remains early goal directed therapy with intravenous fluids and antibiotics. It is therefore important for any pediatric urgent care providers to be able to recognize and treat patients with severe sepsis. It is also important for pediatric urgent care providers to be aware of certain groups of patients who have an increased risk of mortality when they develop sepsis. This article summarizes the current understanding of pediatric sepsis and then focuses on the management of these patients in the pediatric urgent care setting, with special attention paid to groups at higher risks of negative outcomes.

Thiamine Status in Children with Septic Shock from a Developing Country: A Prospective Case-Control Study

OBJECTIVE

Mitochondrial dysfunction is central to sepsis-induced multi-organ dysfunction. Thiamine deficiency may contribute to mitochondrial dysfunction and thus high mortality. Study was planned to assess thiamine status in children with septic shock in comparison to healthy controls from a developing country and to study the effect of thiamine levels on its outcome.

METHODS

A prospective case-control study (April 2017 to May 2018) enrolling consecutive children with septic shock as 'cases' (n = 76), their healthy siblings (n = 51) and apparently healthy children from immunization clinic (n = 35) as 'controls'. Whole blood total thiamine (WBTT) level was measured on days 1, 10 and 1-month post-discharge. Outcome parameters were acute care area free days on days 14 and 28, and mortality.

RESULTS

WBTT [nMol/l; median (interquartile range, IQR)] was significantly lower on day 1 in cases compared with sibling controls [23.1 (21.8-26.3) vs. 36.9 (33.6-40.5); p < 0.001]. It fell further on day 10 [20.8 (18.1-21.1); p < 0.02]. Levels rose significantly 1-month post-discharge [35.5 (31.2-36.6)] and became comparable to sibling controls (p = 0.4). Immunization clinic controls also had lower WBTT [42.3 (40.1-45.9)], but was significantly higher than sibling controls and cases at 1-month post-discharge (p < 0.001). Survivors and non-survivors of septic shock were similar. WBTT levels did not correlate with any of the severity indicators of septic shock or its outcomes.

CONCLUSIONS

WBTT was significantly low in all children, and fell further during septic shock. Observed severe deficiency might have precluded any further association of thiamine levels with severity of septic shock and its outcome. Data obtained may inform trials on metabolic resuscitation in paediatric septic shock in developing countries. Lay summaryThiamine deficiency may contribute to high mortality in paediatric septic shock as thiamine is an essential factor for functioning of mitochondria, the powerhouse of the cells. This prospective case-control study was conducted to assess thiamine status in children with septic shock in comparison with healthy controls in a developing country. Consecutive children with fluid-refractory septic shock were enrolled as 'cases'. Their apparently healthy siblings, and apparently healthy children from immunization clinic, were enrolled as 'controls'. The whole blood total thiamine (WBTT) level was measured on days 1, 10 and 1 month after hospital discharge. Seventy-six children were enrolled as cases, 51 children as sibling controls and 35 children as immunization clinic controls. WBTT was significantly lower on day 1 in cases as compared with their sibling controls. It fell further on day 10. The level rose significantly after a month of discharge and became comparable to sibling controls. Immunization clinic controls also had lower WBTT but was significantly higher compared with sibling controls and cases at 1-month post-discharge. Survivors and non-survivors of septic shock had similar WBTT levels. Observed severe deficiency might have precluded any further association of thiamine levels with septic shock outcome.

Intravenous and Oral Fluid Therapy in Neonatal Calves With Diarrhea or Sepsis and in Adult Cattle

Optimal fluid therapy protocols in neonatal calves and adult cattle are based on consideration of signalment, history, and physical examination findings, and individually tailored whenever laboratory analysis is available. Measurement of the magnitude of eye recession, duration of skin tenting in the lateral neck region, and urine specific gravity by refractometry provide the best estimates of hydration status in calves and cattle. Intravenous and oral electrolyte solutions (OES) are frequently administered to critically ill calves and adult cattle. Application of physicochemical principles indicates that 0.9% NaCl, Ringer's solution, and 5% dextrose are equally acidifying, lactated Ringer's and acetated Ringer's solution are neutral to mildly acidifying, and 1.3-1.4% sodium bicarbonate solutions are strongly alkalinizing in cattle. Four different crystalloid solutions are recommended for intravenous fluid therapy in dehydrated or septic calves and dehydrated adult cattle: (1) lactated Ringer's solution and acetated Ringer's solution for dehydrated calves, although neither solution is optimized for administration to neonatal calves or adult cattle; (2) isotonic (1.3%) or hypertonic (5.0 or 8.4%) solutions of sodium bicarbonate for the treatment of calves with diarrhea and severe strong ion (metabolic) acidosis and hyponatremia, and adult cattle with acute ruminal acidosis; (3) Ringer's solution for the treatment of metabolic alkalosis in dehydrated adult cattle, particularly lactating dairy cattle; and (4) hypertonic NaCl solutions (7.2%) and an oral electrolyte solution or water load for the rapid resuscitation of dehydrated neonatal calves and adult cattle. Much progress has been made since the 1970's in identifying important attributes of an OES for diarrheic calves. Important components of an OES for neonatal calves are osmolality, sodium concentration, the effective SID that reflects the concentration of alkalinizing agents, and the energy content. The last three factors are intimately tied to the OES osmolality and the abomasal emptying rate, and therefore the rate of sodium delivery to the small intestine and ultimately the rate of resuscitation. An important need in fluid and electrolyte therapy for adult ruminants is formulation of a practical, effective, and inexpensive OES.

Treatment of suspected sepsis and septic shock in children with chronic disease seen in the pediatric emergency department

BACKGROUND

Research demonstrates that timely recognition and treatment of sepsis can significantly improve pediatric patient outcomes, especially regarding time to intravenous fluid (IVF) and antibiotic administration. Further research suggests that underlying chronic disease in a septic pediatric patient puts them at higher risk for poor outcomes.

OBJECTIVE

To compare treatment time for suspected sepsis and septic shock in pediatric patients with chronic disease versus those without chronic disease seen in the Pediatric Emergency Department (PED).

METHODS

We reviewed patient data from a pediatric sepsis outcomes dataset collected at two tertiary care pediatric hospital sites from January 2017-December 2018. Patients were stratified into two groups: those with and without chronic disease, defined as any patient with at least one of eight chronic health conditions.

INCLUSION CRITERIA

patients seen in the PED ultimately diagnosed with sepsis or septic shock, patient age 0 to 20 years and time zero for identification of sepsis in the PED.

EXCLUSION CRITERIA

time zero unavailable, inability to determine time of first IVF or antibiotic administration or patient death within the PED. Primary analysis included comparison of time zero to first IVF and antibiotic administration between each group.

RESULTS

312 patients met inclusion criteria. 169 individuals had chronic disease and 143 did not. Median time to antibiotics in those with chronic disease was 41.9 min versus 43.0 min in patients without chronic disease (p = 0.181). Time to first IVF in those with chronic disease was 22.0 min versus 12.0 min in those without (p = 0.010). Those with an indwelling line/catheter (n = 40) received IVF slower than those without (n = 272), with no significant difference in time to antibiotic administration by indwelling catheter status (p = 0.063). There were no significant differences in the mode of identification of suspected sepsis or septic shock between those with versus without chronic disease (p = 0.27).

CONCLUSIONS

Study findings suggest pediatric patients with chronic disease with suspected sepsis or septic shock in the PED have a slower time to IVF administration but equivocal use of sepsis recognition tools compared to patients without chronic disease.

Outcomes of Pediatric Patients With Sepsis Related to Staphylococcus aureus and Methicillin-Resistant Staphylococcus aureus Infections Requiring Extracorporeal Life Support: An ELSO Database Study

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly utilized for pediatric sepsis unresponsive to steroids and inotropic support. Outcomes of children with sepsis are influenced by the type of pathogen causing their illness. Objective: To determine if the outcomes of children with Staphylococcus aureus sepsis receiving ECMO differed according to microbial sensitivity (Methicillin-resistant Staphylococcus aureus [MRSA] vs. Methicillin-sensitive Staphylococcus aureus [MSSA]). Methods: Retrospective case-matched cohort study of children (0-<18 years) with Staphylococcus aureus sepsis reported to the ELSO registry from more than 995 centers. Inclusion criteria were age 0-18 years, laboratory diagnosis of Staphylococcal infection, clinical diagnosis of sepsis, and ECMO deployment. Exclusion criteria were no laboratory diagnosis of Staphylococcal infection. We compared patient demographics, pre-ECMO management and outcomes of those with MRSA vs. MSSA using Chi-Square test, with independent samples t-test used to test to compare continuous variables. Results: In our study cohort of 308 patients, 160 (52%) had MSSA and 148 (48%) MRSA with an overall survival rate of 41.5%. There were no differences in the age group (p = 0.76), gender distribution (p = 0.1) or racial distribution (p = 0.58) between the two groups. P value for racial distribution should be 0.058. There were 91 (56.8%) deaths in the MSSA group and 89 (60.1%) deaths (p = 0.56) in the MRSA group. Duration on ECMO (p = 0.085) and the time from intubation to ECMO (p = 0.37) were also similar in the two groups. Survival with MSSA sepsis and MRSA sepsis did not improve significantly over the 20 years evaluated despite an increase in ECMO utilization. Conclusion: In this multi-center retrospective study, there were no differences in outcomes for children receiving ECMO support with Staphylococcus aureus sepsis according to microbial methicillin sensitivity. There was no significant increase in survival among patients with MRSA and MSSA infections receiving ECMO in the last 20 years.

Safety and Feasibility of Antibiotic De-escalation in Critically Ill Children With Sepsis - A Prospective Analytical Study From a Pediatric ICU

Introduction: De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis. Materials and Methods: Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48-72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured. Results: Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39-11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children. Conclusion: Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.

Role of Hemoperfusion With CytoSorb Associated With Continuous Kidney Replacement Therapy on Renal Outcome in Critically III Children With Septic Shock

Introduction: Sepsis-associated acute kidney injury (SA-AKI) represents a relevant cause of mortality and morbidity in critically ill children. Since with the "inflammatory theory" the authors have been witnessed an important role of inflammatory mediators in the pathophysiology and in the prognosis of SA-AKI, making the need of adjunctive therapies in association with kidney replacement therapies mandatory. Hemoperfusion with CytoSorb is a safe and well-tolerated therapy in septic shock: the very high surface area of the absorber means it is able to efficiently remove cytokines and other medium size molecules involved in cytokine storm, thus playing a synergistic effect with Continuous Kidney Replacement Therapy (CKRT). Materials and Methods: We retrospectively analyzed data from a cohort of eight critically ill children treated from January 2018 to March 2020 describing the impact of CKRT plus hemoperfusion with CytoSorb on renal outcome in critically ill children with septic shock. Results: We evidenced a significant reduction in interleukin (IL)-6 an IL-10 after hemoperfusion with CytoSorb in our pediatric population. Furthermore, we were able to show a significant improvement of creatinine and blood urea nitrogen (BUN) after blood purification and at pediatric intensive care units (PICU) discharge. We have observed a median of 2.5 CKRT days after stop of hemoperfusion (Q₁ 0.25; Q₃ 18.75). None of our patients required CKRT 30 days after PICU discharge (PICU-D). None of them developed CKD. Conclusion: Hemoperfusion with CytoSorb is a valuable therapeutic option in combination with CKRT in SA-AKI. More studies are warranted to confirm our results and in particular to define the role of this adjuvant therapy as a preemptive strategy to protect renal function in pediatric septic shock.

Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes

Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.

Development and Validation of a Model to Predict Pediatric Septic Shock Using Data Known 2 Hours After Hospital Arrival

Objective:

To use Electronic Health Record (EHR) data from the first two hours of care to derive and validate a model to predict hypotensive septic shock in children with infection.

Design:

Derivation-validation study using an existing registry

Setting:

Six emergency care sites within a regional pediatric healthcare system. Three datasets of unique visits were designated:

Patients:

Patients in whom clinicians were concerned about serious infection from 60 days-17 years were included; those with septic shock in the first two hours were excluded. There were 2318 included visits; 197 developed septic shock (8.5%).

Interventions:

Lasso with tenfold cross-validation was used for variable selection; logistic regression was then used to construct a model from those variables in the training set. Variables were derived from EHR data known in the first two hours, including vital signs, medical history, demographics, laboratory information. Test characteristics at two thresholds were evaluated: 1) optimizing sensitivity and specificity, 2) set to 90% sensitivity.

Measurements and Main Results:

Septic shock was defined as systolic hypotension and vasoactive use or ≥30 ml/kg isotonic crystalloid administration in the first 24 hours. A model was created using twenty predictors, with an area under the receiver operating curve in the training set of 0.85 (0.82-0.88); 0.83 [0.78-0.89] in the temporal test set; 0.83 [0.60-1.00] in the geographic test set. Sensitivity and specificity varied based on cutpoint; when sensitivity in the training set was set to 90% (83%, 94%), specificity was 62% (60%, 65%).

Conclusions:

This model predicted risk of septic shock in children with suspected infection 2 hours after arrival, a critical timepoint for emergent treatment and transfer decisions. Varied cutpoints could be used to customize sensitivity to clinical context.

Dynamic Transitions of Pediatric Sepsis: A Markov Chain Analysis

Pediatric sepsis is a heterogeneous disease with varying physiological dynamics associated with recovery, disability, and mortality. Using risk scores generated from a sepsis prediction model to define illness states, we used Markov chain modeling to describe disease dynamics over time by describing how children transition among illness states. We analyzed 18,666 illness state transitions over 157 pediatric intensive care unit admissions in the 3 days following blood cultures for suspected sepsis. We used Shannon entropy to quantify the differences in transition matrices stratified by clinical characteristics. The population-based transition matrix based on the sepsis illness severity scores in the days following a sepsis diagnosis can describe a sepsis illness trajectory. Using the entropy based on Markov chain transition matrices, we found a different structure of dynamic transitions based on ventilator use but not age group. Stochastic modeling of transitions in sepsis illness severity scores can be useful in describing the variation in transitions made by patient and clinical characteristics.

Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols

The implementation of managed protocols contributes to a systematized approach to the patient and continuous evaluation of results, focusing on improving clinical practice, early diagnosis, treatment, and outcomes. Advantages to the adoption of a pediatric sepsis recognition and treatment protocol include: a reduction in time to start fluid and antibiotic administration, decreased kidney dysfunction and organ dysfunction, reduction in length of stay, and even a decrease on mortality. Barriers are: absence of a written protocol, parental knowledge, early diagnosis by healthcare professionals, venous access, availability of antimicrobials and vasoactive drugs, conditions of work, engagement of healthcare professionals. There are challenges in low-middle-income countries (LMIC). The causes of sepsis and resources differ from high-income countries. Viral agent such as dengue, malaria are common in LMIC and initial approach differ from bacterial infections. Some authors found increased or no impact in mortality or increased length of stay associated with the implementation of the SCC sepsis bundle which reinforces the importance of adapting it to most frequent diseases, disposable resources, and characteristics of healthcare professionals. Conclusions: (1) be simple; (2) be precise; (3) education; (5) improve communication; (5) work as a team; (6) share and celebrate results.

Evolution of a Bidirectional Pediatric Critical Care Educational Partnership in a Resource-Limited Setting

Introduction: Children in resource-limited settings are disproportionately affected by common childhood illnesses, resulting in high rates of mortality. A major barrier to improving child health in such regions is limited pediatric-specific training, particularly in the care of children with critical illness. While global health rotations for trainees from North America and Europe have become commonplace, residency and fellowship programs struggle to ensure that these rotations are mutually beneficial and do not place an undue burden on host countries. We created a bidirectional, multimodal educational program between trainees in Manila, Philippines, and Baltimore, Maryland, United States, to improve the longitudinal educational experience for all participants. Program Components: Based on stakeholder input and a needs assessment, we established a global health training program in which pediatricians from the Philippines traveled to the United States for observerships, and pediatric residents from a tertiary care center in Baltimore traveled to Manila. Additionally, we created and implemented a contextualized simulation-based shock curriculum for pediatric trainees in Manila that can be disseminated locally. This bidirectional program was adapted to include telemedicine and regularly scheduled "virtual rounds" and educational case conferences during the COVID-19 pandemic. Providers from the two institutions have collaborated on educational and clinical research projects, offering opportunities for resource sharing, bidirectional professional development, and institutional improvements. Conclusion: Although creating a mutually beneficial global health partnership requires careful planning and investment over time, establishment of a successful bidirectional educational and professional development program in a limited-resource setting is feasible and benefits learners in both countries.

Advancing pediatric antimicrobial stewardship: Has pharmacodynamic dosing for gram-negative infections taken effect?

Objective:

To characterize pharmacodynamic dosing strategies used at children’s hospitals using a national survey.

Design:

Survey.

Setting:

Children’s hospitals.

Participants:

Volunteer sample of antimicrobial stewardship program (ASP) respondents.

Methods:

A nationwide survey was conducted to gain greater insight into the current adoption of nontraditional dosing methods and monitoring of select β-lactam and fluoroquinolone antibiotics used to treat serious gram-negative infections in pediatric populations. The survey was performed through the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative.

Results:

Of the 75 children’s hospitals that responded, 68% of programs reported adoption of pharmacodynamically optimized dosing using prolonged β-lactam infusions and 35% using continuous β-lactam infusions, although use was infrequent. Factors including routine MIC monitoring and formal postgraduate training and board certification of ASP pharmacists were associated with increased utilization of pharmacodynamic dosing. In addition, 60% of programs reported using pharmacodynamically optimized ciprofloxacin and 14% reported using pharmacodynamically optimized levofloxacin. Only 20% of programs monitored β-lactam levels; they commonly cited lack of published guidance, practitioner experience, and laboratomory support as reasons for lack of utilization. Less physician time dedicated to ASP programs was associated with lower adoption of optimized dosing.

Conclusions:

Use of pharmacodynamic dosing through prolonged and continuous infusions of β-lactams have not yet been routinely adopted at children’s hospitals. Further guidance from trials and literature are needed to continue to guide pediatric pharmacodynamic dosing efforts. Children’s hospitals should utilize these data to compare practices and to prioritize further research and education efforts.