PIM2: a revised version of the Paediatric Index of Mortality

A nomogram for predicting postoperative delirium in pediatric patients following cardiopulmonary bypass: A prospective observational study

OBJECTIVES

To create a nomogram for early delirium detection in pediatric patients following cardiopulmonary bypass.

RESEARCH METHODOLOGY/DESIGN

This prospective, observational study was conducted in the Cardiac Intensive Care Unit at a Children's Hospital, enrolling 501 pediatric patients from February 2022 to January 2023. Perioperative data were systematically collected through the hospital information system. Postoperative delirium was assessed using the Cornell Assessment of Pediatric Delirium (CAPD). For model development, Least Absolute Shrinkage and Selection Operator (LASSO) regression was employed to identify the most relevant predictors. These selected predictors were then incorporated into a multivariable logistic regression model to construct the predictive nomogram. The performance of the model was evaluated by Harrell's concordance index, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. External validity of the model was confirmed through the C-index and calibration plots.

RESULTS

Five independent predictors were identified: age, SpO2 levels, lymphocyte count, diuretic use, and midazolam administration, integrated into a predictive nomogram. This nomogram demonstrated strong predictive capacity (AUC 0.816, concordance index 0.815) with good model fit (Hosmer-Lemeshow test p = 0.826) and high accuracy. Decision curve analysis showed a significant net benefit, and external validation confirmed the nomogram's reliability.

CONCLUSIONS

The study successfully developed a precise and effective nomogram for identifying pediatric patients at high risk of post-cardiopulmonary bypass delirium, incorporating age, SpO2 levels, lymphocyte counts, diuretic use, and midazolam medication.

IMPLICATIONS FOR CLINICAL PRACTICE

This nomogram aids early delirium detection and prevention in critically ill children, improving clinical decisions and treatment optimization. It enables precise monitoring and tailored medication strategies, significantly contributes to reducing the incidence of delirium, thereby enhancing the overall quality of patient care.

Caregiver Satisfaction with Medical Providers' Communication: Comparison Between Spanish-Speaking Caregivers with Limited English Proficiency (LEP) and Caregivers Who Are English-Proficient (EP)

OBJECTIVES

Barriers to communication have been observed with patients and families who prefer a language other than English for medical conversations, referred to as individuals with limited English proficiency (LEP). We used the pediatric Family Satisfaction with ICU 24R (FS-ICU) survey to assess communication satisfaction for English-proficient (EP) and Spanish-speaking LEP caregivers. We added additional questions related to attendance at morning rounds, frequency of provider updates, interpreter use, and general satisfaction with communication.

METHODS

This was a single-center, prospective, observational cohort study in the pediatric intensive care unit (PICU) and cardiothoracic intensive care unit (CICU) of a tertiary, academic, free-standing children's hospital. Caregivers of children < 18 years old admitted for at least 48 h to the PICU or CICU between June and September 2022 were eligible for enrollment.

MEASUREMENTS AND MAIN RESULTS

24 LEP and 74 EP caregivers completed the survey questions. The LEP group had lower household income and education levels and higher incidence of public insurance. FS-ICU scores for both LEP and EP caregivers suggested high satisfaction, without significant difference between the groups. However, qualitative analysis revealed dissatisfaction for LEP caregivers related to information, inclusion, and language barriers. EP caregivers had more positive references to information and emotional connection but indicated dissatisfaction around consistency and responsiveness. 18% of LEP caregivers reported regularly attending rounds, versus 67% of the EP group (p value < .001). 39% of LEP versus 52% of EP caregivers reported multiple daily updates, although the difference was not statistically significant. 29% of LEP respondents reported nonfluent MD/NPs using an interpreter never, rarely, or some of the time.

CONCLUSIONS

There was no difference in satisfaction scores between LEP and EP caregivers. LEP caregivers had lower socioeconomic status based on public insurance and reported income and education level. Qualitative data allowed more nuanced understanding of communication satisfaction, which correlated with LEP caregivers' reported lower attendance at morning rounds, inconsistent interpreter use, and a trend toward less frequent provider updates.

Machine learning models to evaluate mortality in pediatric patients with pneumonia in the intensive care unit

OBJECTIVES

This study aimed to predict mortality in children with pneumonia who were admitted to the intensive care unit (ICU) to aid decision-making.

STUDY DESIGN

Retrospective cohort study conducted at a single tertiary hospital.

PATIENTS

This study included children who were admitted to the pediatric ICU at the National Taiwan University Hospital between 2010 and 2019 due to pneumonia.

METHODOLOGY

Two prediction models were developed using tree-structured machine learning algorithms. The primary outcomes were ICU mortality and 24-h ICU mortality. A total of 33 features, including demographics, underlying diseases, vital signs, and laboratory data, were collected from the electronic health records. The machine learning models were constructed using the development data set, and performance matrices were computed using the holdout test data set.

RESULTS

A total of 1231 ICU admissions of children with pneumonia were included in the final cohort. The area under the receiver operating characteristic curves (AUROCs) of the ICU mortality model and 24-h ICU mortality models was 0.80 (95% confidence interval [CI], 0.69-0.91) and 0.92 (95% CI, 0.86-0.92), respectively. Based on feature importance, the model developed in this study tended to predict increased mortality for the subsequent 24 h if a reduction in the blood pressure, peripheral capillary oxygen saturation (SpO2), or higher partial pressure of carbon dioxide (PCO2) were observed.

CONCLUSIONS

This study demonstrated that the machine learning models for predicting ICU mortality and 24-h ICU mortality in children with pneumonia have the potential to support decision-making, especially in resource-limited settings.

Bacterial discrimination by Fourier transform infrared spectroscopy, MALDI-mass spectrometry and whole-genome sequencing

Aim: Proof-of-concept study, highlighting the clinical diagnostic ability of FT-IR compared with MALDI-TOF MS, combined with WGS. Materials & methods: 104 pathogenic isolates of Neisseria meningitidis, Streptococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus were analyzed. Results: Overall prediction accuracy was 99.6% in FT-IR and 95.8% in MALDI-TOF-MS. Analysis of N. meningitidis serogroups was superior in FT-IR compared with MALDI-TOF-MS. Phylogenetic relationship of S. pyogenes was similar by FT-IR and WGS, but not S. aureus or S. pneumoniae. Clinical severity was associated with the zinc ABC transporter and DNA repair genes in S. pneumoniae and cell wall proteins (biofilm formation, antibiotic and complement permeability) in S. aureus via WGS. Conclusion: FT-IR warrants further clinical evaluation as a promising diagnostic tool.

First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure

OBJECTIVES

To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV.

DESIGN

Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019.

SETTING

One hundred thirteen North American PICUs participating in VPS.

PATIENTS

Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia.

CONCLUSIONS

For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.

Institutional Variability in Respiratory Support Use for Pediatric Critical Asthma: A Multicenter Retrospective Study

Rationale: Over 20,000 children are hospitalized in the United States for asthma every year. Although initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the optimal respiratory support devices for these patients.Objectives: The objective of this study was to evaluate institutional and temporal variability in the use of respiratory support modalities for pediatric critical asthma.Methods: We conducted a retrospective cohort study using data from the Virtual Pediatrics Systems database. Our study population included children older than 2 years old admitted to a VPS contributing pediatric intensive care unit from January 2012 to December 2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using a high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive bilevel positive pressure ventilation (NIV), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on the volume of patients. We created logistic regression models to determine the influence of institutional volume and year of admission on respiratory support modality use. We also conducted time-series analyses using Kendall's tau.Results: Our population included 77,115 patient encounters from 163 separate institutions. Institutional use of respiratory modalities had significant variation in HFNC (28.3%, interquartile range [IQR], 11.0-49.0%; P < 0.01), CPAP (1.4%; IQR, 0.3-4.3%; P < 0.01), NIV (8.6%; IQR, 3.5-16.1%; P < 0.01), and IMV (5.1%; IQR, 3.1-8.2%; P < 0.01). Increased institutional patient volume was associated with significantly increased use of NIV (odds ratio [OR], 1.33; 1.29-1.36; P < 0.01) and CPAP (OR, 1.20; 1.15-1.25; P < 0.01), and significantly decreased use of HFNC (OR, 0.80; 0.79-0.81; P < 0.01) and IMV (OR, 0.82; 0.79-0.86; P < 0.01). Time was also associated with a significant increase in the use of HFNC (11.0-52.3%; P < 0.01), CPAP (1.6-5.4%; P < 0.01), and NIV (3.7-21.2%; P < 0.01), whereas there was no significant change in IMV use (6.1-4.0%; P = 0.11).Conclusions: Higher-volume centers are using noninvasive positive pressure ventilation more frequently for pediatric critical asthma and lower frequencies of HFNC and IMV. Treatment with HFNC, CPAP, and NIV for this population is increasing in the last decade.

Infant Intensive Care Unit: Is it Time to Change?

OBJECTIVES

To assess the effect of the Infant intensive care unit (InICU), a specialized unit for critically ill infants established in 2016 in authors' hospital, on infant mortality and compare the outcome with the current Pediatric intensive care units (PICU).

METHODS

In this retrospective cross-sectional study, two groups were defined; the first included expired patients aged 1 mo to 2 y admitted to PICU before the establishment of the InICU (the PICU group). The second included age-matched expired patients admitted to the InICU (the InICU group). Data were recorded using a questionnaire.

RESULTS

The authors found that the age, sex, underlying diseases, the leading cause of admission to the ICU, time of death, hospital and ICU length of stay, and the pediatric index of mortality 2 (PIM 2) score were same between the two groups. The incidence of mortality in the PICU group was 10.66 in 1000 person-month. This value was 6.37 for the InICU group (P-value <0.001). The relative risk of mortality of patients admitted to the PICU group compared to the InICU group was 1.67 (P-value <0.001).

CONCLUSIONS

Establishment of age specific InICU for infants may be beneficial in reducing infant mortality.

Challenges of Families of Patients Hospitalized in the PICU: A Preplanned Secondary Analysis From the Navigate Dataset

OBJECTIVES

To describe challenges experienced by parents of children hospitalized in the PICU during PICU admission as reported by family navigators.

DESIGN

A preplanned secondary analysis of open-response data coded via inductive qualitative approach from the Navigate randomized controlled trial (RCT) dataset (ID NCT02333396).

SETTING

Two university-affiliated PICUs in the Midwestern United States as part of an RCT.

PATIENTS

Two hundred twenty-four parents of 190 PICU patients.

INTERVENTIONS

In 2015-2017, trained family navigators assessed and addressed parent needs, offered weekly family meetings, and provided post-PICU discharge parent check-ins as part of a study investigating the effectiveness of a communication support intervention ("PICU Supports").

MEASUREMENTS AND MAIN RESULTS

We analyzed qualitative data recorded by family navigators weekly across 338 encounters. Navigators described families' "biggest challenge," "communication challenges," and ways the team could better support the family. We used an inductive qualitative coding approach and a modified member-checking exercise. The most common difficulties included home life , hospitalization , and diagnosis distress (45.2%, 29.0%, and 17.2% of families, respectively). Navigators often identified that parents had co-occurring challenges. Communication was identified as a "biggest challenge" for 8% of families. Communication challenges included lack of information, team communication , and communication quality (7.0%, 4.8%, and 4.8% of families, respectively). Suggestions for improving care included better medical communication, listening, rapport, and resources.

CONCLUSIONS

This study describes families' experiences and challenges assessed throughout the PICU stay. Family navigators reported families frequently experience stressors both internal and external to the hospital environment, and communication challenges between families and providers may be additional sources of distress. Further research should develop and assess interventions aimed at improving provider-family communication and reducing stressors outside the hospitalization itself, such as home life difficulties.

Impact of missing values on the ability of the acute physiology and chronic health evaluation III and Japan risk of death models to predict mortality

PURPOSE

This study assessed model performance of the Acute Physiology and Chronic Health Evaluation (APACHE) III and Japan Risk of Death (JROD) when degraded by the number and category of missing variables. We also examined the impact of missing data on predicted mortality for facilities with missing physiological variables.

METHODS

We obtained data from the Japanese Intensive care PAtient Database (JIPAD). We calculated observed and predicted mortality rates using the APACHE III and JROD and the standardized mortality ratio (SMR) by the number and category of missing variables. Smoothed spline curves were calculated for the SMR to the missing proportion of the facility.

RESULTS

A total of 61,357 patients from 57 ICUs were included between April 2015 and March 2019. The APACHE III and JROD SMRs increased as the number of missing values increased. The SMR in the APACHE III model was elevated in facilities with a larger proportion of missing in each of the APS categories, arterial blood gas, albumin, glucose, and bilirubin. Facilities with a high proportion of missing albumin data preserved their SMRs in only the JROD model.

CONCLUSION

An increased number of missing physiological variables resulted in falsely low predicted mortality rates and high SMRs.

ROX index as a predictor of failure of high-flow nasal cannula in infants with bronchiolitis

High-flow nasal cannula (HFNC) is a relatively recent therapy that has been used to treat respiratory failure. Until now, the criterion for failure requiring escalation to other forms of ventilatory support has remained unclear. This study evaluated how the ROX index predicts the success or failure of HFNC in infants with bronchiolitis. A prospective, observational, multicenter study was conducted in 2 pediatric ICUs. The data were collected at 7 moments. Patients were categorized into failure and success groups according to HFNC. A total of 102 infants were included, 18(17.6%) of whom failed HFNC therapy. For the ROX index, significant differences were observed between the failure 5.8(95%CI 4.7-7.1) and success 7.7(95%CI 7.2-8.2) groups (p = 0.005) at the 12 h evaluation. According to the analysis of the performance of the ROX index, the AUC at 12 h was 0.716(95%CI 0.591-0.842; p = 0.016). The best cutoff range for the ROX index at 12 h was 6.50-7.18, with a sensitivity of 42% and a specificity of 66% at the cutoff of 6.50, and a sensitivity of 92% and a specificity of 54% at the cutoff of 7.18. We concluded that the ROX index could be effective at predicting the failure of HFNC therapy in infants with bronchiolitis beginning at 12 h after installation.

Predicting long-term neurocognitive outcome after pediatric intensive care unit admission for bronchiolitis-preliminary exploration of the potential of machine learning

PURPOSE

For successful prevention and intervention, it is important to unravel the complex constellation of factors that affect neurocognitive functioning after pediatric intensive care unit (PICU) admission. This study aims (1) to elucidate the potential relevance of patient and PICU-related characteristics for long-term adverse neurocognitive outcome after PICU admission for bronchiolitis, and (2) to perform a preliminary exploration of the potential of machine learning as compared to linear regression to improve neurocognitive outcome prediction in a relatively small sample of children after PICU admission.

METHODS

This cross-sectional observational study investigated 65 children aged 6-12 years with previous PICU admission for bronchiolitis (age ≤ 1 year). They were compared to demographically comparable healthy peers (n = 76) on neurocognitive functioning. Patient and PICU-related characteristics used for the prediction models were as follows: demographic characteristics, perinatal and disease parameters, laboratory results, and intervention characteristics, including hourly validated mechanical ventilation parameters. Neurocognitive outcome was measured by intelligence and computerized neurocognitive testing. Prediction models were developed for each of the neurocognitive outcomes using Regression Trees, k-Nearest Neighbors, and conventional linear regression analysis.

RESULTS

The patient group had lower intelligence than the control group (p < .001, d = -0.59) and poorer performance in neurocognitive functions, i.e., speed and attention (p = .03, d = -0.41) and verbal memory (p < .001, d = -0.60). Lower intelligence was predicted by lower birth weight and lower socioeconomic status (R2 = 25.9%). Poorer performance on the speed and attention domain was predicted by younger age at follow-up (R2 = 53.5%). Poorer verbal memory was predicted by lower birth weight, younger age at follow-up, and greater exposure to acidotic events (R2 = 50.6%). The machine learning models did not reveal added value in terms of model performance as compared to linear regression.

CONCLUSION

The findings of this study suggest that in children with previous PICU admission for bronchiolitis, (1) lower birth weight, younger age at follow-up, and lower socioeconomic status are associated with poorer neurocognitive outcome; and (2) greater exposure to acidotic events during PICU admission is associated with poorer verbal memory outcome. The findings of this study provide no evidence for the added value of machine learning models as compared to linear regression analysis in the prediction of long-term neurocognitive outcome in a relatively small sample of children.

WHAT IS KNOWN

• Adverse neurocognitive outcomes are described in PICU survivors, which are known to interfere with development in other major domains of functioning, such as mental health, academic achievement, and socioeconomic success, highlighting neurocognition as an important outcome after PICU admission. • Machine learning is a rapidly growing field of artificial intelligence that is increasingly applied in health care settings, with great potential to capture the complexity of outcome prediction.

WHAT IS NEW

• This study shows that lower birth weight, lower socioeconomic status, and greater exposure to acidotic events during PICU admission for bronchiolitis are associated with poorer long-term neurocognitive outcome after PICU admission. Results provide no evidence for the added value of machine learning models in a relatively small sample of children. • As bronchiolitis seldom manifests neurologically, the relation between acidotic events and neurocognitive outcome may reflect either potentially harmful effects of acidosis itself or related processes such as hypercapnia or hypoxic and/or ischemic events during PICU admission. This study further highlights the importance of structured follow-up to monitor long-term outcome of children after PICU admission.

Withholding life support for children with severe neurological impairment: Prevalence and predictive factors prior to admission in the PICU

BACKGROUND

Our study aimed to evaluate the prevalence and predictive factors of withholding life support for children suffering from severe neurological impairment before admission to the pediatric intensive care unit (PICU).

METHOD

Children under 18 years of age with severe neurological impairment, who were hospitalized between January 2006 and December 2016, were included in this retrospective study. They were allocated to a withholding group or a control group, depending on whether life support was withheld or not, before admission to the PICU.

RESULTS

Overall, 119 patients were included. At admission to the PICU, the rate of withholding life support was 10 % (n = 12). Predictive factors were: (1) a previous stay in the PICU (n = 11; 92 %, p<0.01, odds ratio [OR]: 14 [2-635], p = 0.001); (2) the need for respiratory support (n = 5; 42 %, p = 0.01, OR: 6 [1-27], p = 0.01); (3) the need for feeding support (n = 10; 83 %, p = 0.01, OR: 10 [2-100], p = 0.001); and (4) a higher functional status score (FSS: 16 [12.5-19] vs. 10 [8-13], p<0.01).

CONCLUSION

The withholding of life support for children suffering from severe neurological impairment appeared limited in our pediatric department. The main predictor was at least one admission to the PICU, which raised the question of the pediatrician's role in the decision to withhold life support.

Antibiotic treatment duration for culture-negative sepsis in the pediatric intensive care unit

Objective

Sepsis remains a leading cause of morbidity and mortality in children. There is very limited guidance for sepsis treatment when cultures remain negative. This study sought to determine the effectiveness of short versus long course of antibiotics when treating culture-negative sepsis and assess for subsequent multidrug-resistant organism (MDRO) acquisition.

Design

Retrospective cohort study.

Setting

Quaternary academic children's hospital.

Patients

Pediatric intensive care unit (ICU) patients with culture-negative sepsis receiving a minimum of 72 hours of antibiotics.

Methods

Patients found to have culture-negative sepsis from January 2017 to May 2020 were divided into two groups: short and long course of antibiotics. Various demographic and laboratory results were collected for each subject as available. Primary outcomes included mortality and lengths of stay. The secondary outcome was subsequent acquisition of a new MDRO.

Results

Eighty-six patients were treated for culture-negative sepsis with 43 patients in both the short- (< or = 7 days) and long-course (>7 days) treatment cohorts. Patients who received a short course of antibiotics had a lower overall mortality than those who received a long course (9.3% vs 25.6% p = 0.047), but there was no difference in 30-day mortality (p > 0.99). Patients in the short-course group had a shorter hospital length of stay (22 vs 30 days p = 0.018). New MDROs were found in 10% of all patients.

Conclusions

Treatment of culture-negative sepsis with short-course antibiotics was not associated with worse outcomes in ICU patients. These findings warrant further investigation with a larger, prospective, multi-center study.

Potential benefits of prenatal diagnosis of TGA in Australia may be outweighed by the adverse effects of earlier delivery: likely causation and potential solutions

OBJECTIVE

Prenatal diagnosis of transposition of great arteries (TGA) is expected to improve postoperative outcomes after neonatal arterial switch operation (ASO); however, published reports give conflicting results. We aimed to determine the association between prenatal diagnosis and early postoperative outcomes after neonatal ASO.

METHODS

Cohort study involving 243 newborns who underwent ASO (70% prenatally diagnosed) between 2010 and 2019. Multivariable regression was used to determine the association between prenatal diagnosis and (a) birth characteristics and (b) postoperative outcomes.

RESULTS

Gestational age and birthweight centile were lower and small-for-gestational-age more common (11.8% vs 1.4%) in those diagnosed prenatally. Among births which followed labour induction or prelabour caesarean, prenatal diagnosis was associated with earlier gestation at birth (mean (SD), 38.5 (1.6) vs 39.2 (1.4), p=0.01). Among births which followed spontaneous labour, prenatal diagnosis was associated with earlier gestation at labour onset (38.2 (1.8) vs 39.2 (1.4), p=0.01). Prenatal diagnosis was associated with longer postoperative mechanical ventilation (incidence rate ratio 1.74, 95% CI 1.37 to 2.21), intensive care (1.70, 1.31 to 2.21) and hospital length of stay (1.37, 1.14 to 1.66) after ASO. Gestational age mediated up to 60% of the effect of prenatal diagnosis on postoperative outcomes.

CONCLUSION

Among newborns undergoing ASO for TGA, prenatal diagnosis is associated with poorer early postoperative outcomes. In addition to minimising iatrogenic factors (such as planned births) resulting in earlier births, evaluation of other dynamics following a prenatal diagnosis which may result in poor fetal growth and earlier onset of spontaneous labour is important.

Safety and feasibility of adjunct autologous cord blood stem cell therapy during the Norwood heart operation

BACKGROUND

We conducted this phase I, open-label safety and feasibility trial of autologous cord blood (CB) stem cell (CBSC) therapy via a novel blood cardioplegia-based intracoronary infusion technique during the Norwood procedure in neonates with an antenatal diagnosis of hypoplastic left heart syndrome (HLHS). CBSC therapy may support early cardiac remodeling with enhancement of right ventricle (RV) function during the critical interstage period.

METHODS

Clinical grade CB mononucleated cells (CBMNCs) were processed to NetCord-FACT International Standards. To maximize yield, CBSCs were not isolated from CBMNCs. CBMNCs were stored at 4 °C (no cryopreservation) for use within 3 days and delivered after each cardioplegia dose (4 × 15 mL).

RESULTS

Of 16 patients with antenatal diagnosis, 13 were recruited; of these 13 patients, 3 were not treated due to placental abruption (n = 1) or conditions delaying the Norwood for >4 days (n = 2) and 10 received 644.9 ± 134 × 106 CBMNCs, representing 1.5 ± 1.1 × 106 (CD34+) CBSCs. Interstage mortality was 30% (n = 3; on days 7, 25, and 62). None of the 36 serious adverse events (53% linked to 3 deaths) were related to CBMNC therapy. Cardiac magnetic resonance imaging before stage 2 (n = 5) found an RV mass index comparable to that in an exact-matched historical cohort (n = 22), with a mean RV ejection fraction of 66.2 ± 4.5% and mean indexed stroke volume of 47.4 ± 6.2 mL/m2 versus 53.5 ± 11.6% and 37.2 ± 10.3 mL/m2, respectively. All 7 survivors completed stage 2 and are alive with normal RV function (6 with ≤mild and 1 with moderate tricuspid regurgitation).

CONCLUSIONS

This trial demonstrated that autologous CBMNCs delivered in large numbers without prior cryopreservation via a novel intracoronary infusion technique at cardioplegic arrest during Norwood palliation on days 2 to 3 of life is feasible and safe.

Association Between Race/Ethnicity and Severity of Illness in Pediatric Cardiomyopathy and Myocarditis

INTRODUCTION

Previous reports demonstrate racial/ethnic differences in survival for children hospitalized with cardiomyopathy and myocarditis. The impact of illness severity, a potential mechanism for disparities, has not been explored.

METHODS

Using the Virtual Pediatric Systems (VPS, LLC), we identified patients ≤ 18 years old admitted to the intensive care unit (ICU) for cardiomyopathy/myocarditis. Multivariate regression models were used to evaluate the association between race/ethnicity and Pediatric Risk of Mortality (PRISM 3). Multivariate logistic and competing risk regression was used to examine the relationship between race/ethnicity and mortality, CPR, and ECMO.

RESULTS

Black patients had higher PRISM 3 scores on first admission (𝛽 = 2.02, 95% CI: 0.15, 3.90). There was no difference in survival across race/ethnicity over multiple hospitalizations. Black patients were less likely to receive a heart transplant (SHR = 0.65, 95% CI: 0.45-0.92). Black and unreported race/ethnicity had higher odds of CPR on first admission (OR = 1.64, 95% CI: 1.01-2.45; OR = 2.12, 95% CI: 1.11-4.08, respectively).

CONCLUSION

Black patients have higher severity of illness on first admission to the ICU, which may reflect differences in access to care. Black patients are less likely to receive a heart transplant. Additionally, Black patients and those with unreported race/ethnicity had higher odds of CPR, which was not mediated by severity of illness, suggesting variations in care may persist after admission.

Nutritional and clinical factors associated with acute kidney injury development in critically ill children

BACKGROUND

Acute kidney injury (AKI) is common in the pediatric intensive care unit (ICU) and is associated with poorer clinical outcomes. There is scarce data to support an association between nutritional status and nutrient delivery in critically ill pediatric patients. Therefore, the present study aimed to identify the nutritional and clinical factors associated with the development of AKI during pediatric ICU stay.

METHODS

This prospective study included critically ill pediatric patients aged < 15 years who were admitted to the medical and surgical pediatric ICU. Clinical, laboratory, nutritional status, nutritional therapy parameters, and AKI data were recorded. Adjusted logistic regression was applied and expressed as odds ratio (OR) and 95% confidence interval (95%CI). P-value < 0.05 was considered significant.

RESULTS

We enrolled 108 patients with a median age of 9 months (interquartile range/IQR 2.4-62.5), and 43.5% developed AKI. Sepsis/septic shock (OR 8.00; 95% CI 2.06-32.51, p = 0.003), higher severity of illness (OR 1.89; 95% CI 1.24-2.90, p = 0.003), hypoalbuminemia (OR 4.11; 95% CI 1.61-10.46, p = 0.006), edema (OR 3.42, 95% CI 1.10-10.67, p = 0.034), fluid overload (OR 3.52, 95% CI 1.56-7.96, p = 0.003), need for mechanical ventilation (OR 3.62, 95% CI 1.45-9.04, p = 0.006) and adequate protein intake (OR 0.79, 95% CI 0.63-1.00, p = 0.048) were associated with development of AKI.

CONCLUSIONS

Hypoalbuminemia, need for mechanical ventilation, fluid overload, severity of illness, sepsis/septic shock, and edema were risk factors for AKI in pediatric ICU. Furthermore, adequate protein intake is associated with AKI during pediatric ICU stay, making it important to implement nutritional assessment and nutritional therapy protocols for critically ill pediatric patients.

Variation in Early Pediatric Intensive Care Management Strategies and Duration of Invasive Mechanical Ventilation for Acute Viral Bronchiolitis in the United Kingdom: A Retrospective Multicenter Cohort Study

OBJECTIVES

Management of mechanically ventilated patients with bronchiolitis is not standardized and duration of mechanical ventilation has been shown to vary widely between centers. The aim of this study was to examine practice in a large number of U.K. PICUs with a view to identify if early management choices relating to fluid prescription, sedative agent use, and endotracheal tube (ETT) placement were associated with differences in duration of invasive mechanical ventilation (IMV).

DESIGN

Retrospective multicenter cohort study. Primary outcome was duration of IMV. A hierarchical gamma generalized linear model was used to test for associations between practice variables (sedative and neuromuscular blocking agents, route of endotracheal intubation at 24 hr and fluid balance at 48 hr) and duration of IMV after adjustment for known confounders.

SETTING

Thirteen U.K. PICUs. Duration of 2 months between November and December 2019.

PATIENTS

Three hundred fifty infants receiving IMV for bronchiolitis. Excluded were patients receiving long-term ventilation, extracorporeal life support, or who died before separation from IMV.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After adjustment for confounders, several variables were associated with an increase in the geometric mean duration of IMV (expressed as a percentage) including: nasal ETT use, 16% (95% CI, 1-32%); neuromuscular blockade use, 39% (95% CI, 21-61%); and fluid balance at 48 hr, 13% per 100 mL/kg positive fluid balance (95% CI, -1% to 28%). The association of sedative use varied with class of agent. The use of an alpha-2 agonist alone was associated with a reduction in duration of IMV by 19% in relation to no sedative agent (95% CI, -31 to -5%), whereas benzodiazepine uses alone or with alpha-2 agonist in combination were similar to using neither agent.

CONCLUSIONS

Early management strategies for bronchiolitis were associated with the duration of IMV across U.K. centers after adjustment for confounders. Future work should prospectively assess the impact of fluid restriction, route of endotracheal intubation, and alpha-2 agonist use on duration of IMV in infants with bronchiolitis, with the aim of reducing seasonal bed pressure.

The potential role of serum lipoprotein in children with sepsis

To determine whether serum lipoprotein is correlated with sepsis on the day of admission and help with early warning, identification, and intervention for sepsis. This retrospective study involved all children admitted to our pediatric intensive care unit from January 2021 to June 2023. Clinical data of involved patients were collected via inquiring databases of our hospital. The Pediatric Risk of Mortality and Pediatric Index of Mortality II scores were calculated, multivariate analysis was conducted to evaluate the independence of the association between serum lipoprotein and the risk of sepsis on the day of admission. This study involved 88 children (48 with sepsis, 40 non-sepsis). The sepsis group had a lower level of high-density lipoprotein (HDL), total cholesterol, and low-density lipoprotein (LDL). The CRP, white blood cell, and procalcitonin (PCT) were considerably higher than the non-sepsis group. After adjusting for covariates, logistic regression analysis suggested that the CRP, PCT, HDL, Pediatric Risk of Mortality score, Pediatric Index of Mortality II score and LDL were independent risk factors for sepsis. Moreover, the AUC of CRP, PCT, HDL, and LDL were 0.58, 0.76, 0.82, and 0.86, respectively. Our results may indicate that serum lipoprotein is correlated with sepsis on the day of admission and may help with early warning, identification, and intervention for sepsis.

Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit

OBJECTIVES

To describe the characteristics of patients admitted to Pediatric Intermediate Care Units (PImCU) and to assess their illness severity trajectories.

METHODS

This prospective, observational, multicentre cohort study was conducted in seven French PImCUs between September 2012 and January 2014. All consecutive patients aged under 18 were included. The severity of illness was evaluated through the Paediatric Advanced Warning Score (PAWS), measured every 8 h for each patient. A latent class mixed model was used to identify severity trajectory classes.

RESULTS

A total of 2868 patients were included. The median [interquartile range] age was 29 [5-103] mo and the median length of stay was 1 [1-3] d. The primary indication for admission was respiratory (44%). Almost 3% of the patients were subsequently transferred to a pediatric intensive care unit. Three severity trajectory classes were identified. In one class, comprising the largest proportion of patients, the PAWS was low on admission and did not change markedly over time. In this class, patients were older and had a shorter length of stay. The other two classes were characterized by a higher PAWS on admission and rapid or slow improvement. These patients were more severely ill, mostly due to respiratory failure.

CONCLUSIONS

A large proportion of patients had a stable profile and no signs of severity which suggests that the stay in PImCU was not indicated but a part of these patients have remained stable perhaps because of the advanced monitoring and intensive nursing in these units.

CLINICAL TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov Protocol, Identifier: NCT02304341, ClinicalTrials.gov .

Artificial intelligence in early detection and prediction of pediatric/neonatal acute kidney injury: current status and future directions

Acute kidney injury (AKI) has a significant impact on the short-term and long-term clinical outcomes of pediatric and neonatal patients, and it is imperative in these populations to mitigate the pathways leading to AKI and be prepared for early diagnosis and treatment intervention of established AKI. Recently, artificial intelligence (AI) has provided more advent predictive models for early detection/prediction of AKI utilizing machine learning (ML). By providing strong detail and evidence from risk scores and electronic alerts, this review outlines a comprehensive and holistic insight into the current state of AI in AKI in pediatric/neonatal patients. In the pediatric population, AI models including XGBoost, logistic regression, support vector machines, decision trees, naïve Bayes, and risk stratification scores (Renal Angina Index (RAI), Nephrotoxic Injury Negated by Just-in-time Action (NINJA)) have shown success in predicting AKI using variables like serum creatinine, urine output, and electronic health record (EHR) alerts. Similarly, in the neonatal population, using the "Baby NINJA" model showed a decrease in nephrotoxic medication exposure by 42%, the rate of AKI by 78%, and the number of days with AKI by 68%. Furthermore, the "STARZ" risk stratification AI model showed a predictive ability of AKI within 7 days of NICU admission of AUC 0.93 and AUC of 0.96 in the validation and derivation cohorts, respectively. Many studies have reported the superiority of using biomarkers to predict AKI in pediatric patients and neonates as well. Future directions include the application of AI along with biomarkers (NGAL, CysC, OPN, IL-18, B2M, etc.) in a Labelbox configuration to create a more robust and accurate model for predicting and detecting pediatric/neonatal AKI.

Effect of Phytonadione on Correction of Coagulopathy in Pediatric Patients With Septic Shock

OBJECTIVES

The purpose of this study was to evaluate phytonadione in children with septic shock with disseminated intravascular coagulopathy (DIC). The primary objective was to identify the number of patients with an international normalized ratio (INR), defined as ≤1.2, following phytonadione. Secondary objectives were to compare patients who achieved a normalized INR versus those with INR >1.2 and to determine factors associated with a normalized INR.

METHODS

A retrospective study of children <18 years of age receiving phytonadione from October 1, 2013, to August 31, 2020, with a diagnosis of septic shock, were included. Data collection included demographics, phytonadione regimen, INR values, Pediatric Index of Mortality 2 (PIM2) and Pediatric Risk of Mortality III (PRISM III) scores, fresh frozen plasma (FFP) and cryoprecipitate use. A logistic regression model and generalized linear model were used to explore factors associated with a normalized INR and evaluate phytonadione dosing.

RESULTS

Data for initial phytonadione course for 156 patients were evaluated. Sixty-six (42.3%) patients had a normalized INR. Most patients (n = 145; 92.9%) received ≤3 phytonadione doses, with the largest reduction in INR occurring after the second dose. In the logistic regression model, baseline INR, FFP, cryoprecipitate, vasopressors, PIM2, PRISM III, or cumulative phytonadione dose were not associated with achieving a normalized INR.

CONCLUSIONS

Less than half of patients achieved a normalized INR. The median cumulative dose of phytonadione and receipt of FFP or cryoprecipitate was not associated with an increased odds of a normalized INR. Future studies are needed to further explore phytonadione use in children with sepsis-induced coagulopathy.

Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome

The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality.   Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.

Trends in Childhood Oncology Admissions to ICUs in Australia and New Zealand

OBJECTIVES

There are few robust, national-level reports of contemporary trends in pediatric oncology admissions, resource use, and mortality. We aimed to describe national-level data on trends in intensive care admissions, interventions, and survival for children with cancer.

DESIGN

Cohort study using a binational pediatric intensive care registry.

SETTING

Australia and New Zealand.

PATIENTS

Patients younger than 16 years, admitted to an ICU in Australia or New Zealand with an oncology diagnosis between January 1, 2003, and December 31, 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We examined trends in oncology admissions, ICU interventions, and both crude and risk-adjusted patient-level mortality. Eight thousand four hundred ninety admissions were identified for 5,747 patients, accounting for 5.8% of PICU admissions. Absolute and population-indexed oncology admissions increased from 2003 to 2018, and median length of stay increased from 23.2 hours (interquartile range [IQR], 16.8-62 hr) to 38.8 hours (IQR, 20.9-81.1 hr) ( p < 0.001). Three hundred fifty-seven of 5,747 patients died (6.2%). There was a 45% reduction in risk-adjusted ICU mortality, which reduced from 3.3% (95% CI, 2.1-4.4) in 2003-2004 to 1.8% (95% CI, 1.1-2.5%) in 2017-2018 ( p trend = 0.02). The greatest reduction in mortality seen in hematological cancers and in nonelective admissions. Mechanical ventilation rates were unchanged from 2003 to 2018, while the use of high-flow nasal prong oxygen increased (incidence rate ratio, 2.43; 95% CI, 1.61-3.67 per 2 yr).

CONCLUSIONS

In Australian and New Zealand PICUs, pediatric oncology admissions are increasing steadily and such admissions are staying longer, representing a considerable proportion of ICU activity. The mortality of children with cancer who are admitted to ICU is low and falling.

Clinical Decision Support System to Detect the Occurrence of Ventilator-Associated Pneumonia in Pediatric Intensive Care

OBJECTIVES

Ventilator-associated pneumonia (VAP) is a severe care-related disease. The Centers for Disease Control defined the diagnosis criteria; however, the pediatric criteria are mainly subjective and retrospective. Clinical decision support systems have recently been developed in healthcare to help the physician to be more accurate for the early detection of severe pathology. We aimed at developing a predictive model to provide early diagnosis of VAP at the bedside in a pediatric intensive care unit (PICU).

METHODS

We performed a retrospective single-center study at a tertiary-care pediatric teaching hospital. All patients treated by invasive mechanical ventilation between September 2013 and October 2019 were included. Data were collected in the PICU electronic medical record and high-resolution research database. Development of the clinical decision support was then performed using open-access R software (Version 3.6.1®).

MEASUREMENTS AND MAIN RESULTS

In total, 2077 children were mechanically ventilated. We identified 827 episodes with almost 48 h of mechanical invasive ventilation and 77 patients who suffered from at least one VAP event. We split our database at the patient level in a training set of 461 patients free of VAP and 45 patients with VAP and in a testing set of 199 patients free of VAP and 20 patients with VAP. The Imbalanced Random Forest model was considered as the best fit with an area under the ROC curve from fitting the Imbalanced Random Forest model on the testing set being 0.82 (95% CI: (0.71, 0.93)). An optimal threshold of 0.41 gave a sensitivity of 79.7% and a specificity of 72.7%, with a positive predictive value (PPV) of 9% and a negative predictive value of 99%, and with an accuracy of 79.5% (95% CI: (0.77, 0.82)).

CONCLUSIONS

Using machine learning, we developed a clinical predictive algorithm based on clinical data stored prospectively in a database. The next step will be to implement the algorithm in PICUs to provide early, automatic detection of ventilator-associated pneumonia.

Development and validation of a clinical score for early diagnosis of constipation in critically ill children

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children

INTRODUCTION AND OBJECTIVES

No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350 + E) for constipation in critically ill children.

METHODS

We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72 h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350 + E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances).

RESULTS

The sample included 56 patients with a mean age of 48.2 ± 11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350 + E and 12 (21.4%) with rectal enemas. The proportion of patients that responded well to treatment was greater in the PEG 3350 + E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P = .151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350 + E was more effective in children aged less than 2 years (100%) compared to older children (100% vs 65.4%; P < .01), with no significant differences in the development of adverse events.

CONCLUSIONS

The PEG 3350 + E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years.

Troponin I as an Independent Biomarker of Outcome in Children with Systemic Inflammatory Response

Cardiac troponin-I (cTnI) is a biomarker of myocardial injury with implications for clinical outcomes. May other contributing factors that could affect outcomes have not been uniformly considered in pediatric studies. We hypothesized that there is an association between admission serum cTnI and outcomes in critically ill children taking into account the magnitude of the acute systemic inflammatory response syndrome (SIRS), serum lactate concentrations, and nutritional status. Second, we tested for potential factors associated with elevated serum cTnI. This was a prospective cohort study in 104 children (median age: 21.3 months) consecutively admitted to a pediatric intensive care unit (PICU) of a teaching hospital with SIRS and without previous chronic diseases. Primary outcome variables were PICU-free days, ventilator-free days, and 30-day mortality. Exposure variables were serum cTnI concentration on admission, revised pediatric index of mortality (PIM2), pediatric logistic organ dysfunction (PELOD-2), hypotensive shock, C-reactive protein, procalcitonin, and serum lactate on admission, and malnutrition. Elevated cTnI (>0.01 μg/L) was observed in 24% of patients, which was associated with the reduction of ventilator-free days (β coefficient = - 4.97; 95% confidence interval [CI]: -8.03; -1.91) and PICU-free days (β coefficient = - 5.76; 95% CI: -8.97; -2.55). All patients who died had elevated serum cTnI. The increase of 0.1 μg/L in cTnI concentration resulted in an elevation of 2 points in the oxygenation index (β coefficient = 2.0; 95% CI: 1.22; 2.78, p  < 0.001). The PIM2 score, hypotensive shock in the first 24 hours, and serum lactate were independently associated with elevated cTnI on admission. We conclude that elevated serum cTnI on admission is independently associated with adverse outcomes in children with SIRS and without associated chronic diseases.

Effect of paediatric early warning systems (PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a prospective, multicentre cohort study

BACKGROUND

Paediatric early warning systems (PEWS) aid in the early identification of clinical deterioration events in children admitted to hospital. We aimed to investigate the effect of PEWS implementation on mortality due to clinical deterioration in children with cancer in 32 resource-limited hospitals across Latin America.

METHODS

Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement PEWS in hospitals providing childhood cancer care. In this prospective, multicentre cohort study, centres joining Proyecto EVAT and completing PEWS implementation between April 1, 2017, and May 31, 2021, prospectively tracked clinical deterioration events and monthly inpatient-days in children admitted to hospital with cancer. De-identified registry data reported between April 17, 2017, and Nov 30, 2021, from all hospitals were included in analyses; children with limitations on escalation of care were excluded. The primary outcome was clinical deterioration event mortality. Incidence rate ratios (IRRs) were used to compare clinical deterioration event mortality before and after PEWS implementation; multivariable analyses assessed the correlation between clinical deterioration event mortality and centre characteristics.

FINDINGS

Between April 1, 2017, and May 31, 2021, 32 paediatric oncology centres from 11 countries in Latin America successfully implemented PEWS through Proyecto EVAT; these centres documented 2020 clinical deterioration events in 1651 patients over 556 400 inpatient-days. Overall clinical deterioration event mortality was 32·9% (664 of 2020 events). The median age of patients with clinical deterioration events was 8·5 years (IQR 3·9-13·2), and 1095 (54·2%) of 2020 clinical deterioration events were reported in male patients; data on race or ethnicity were not collected. Data were reported per centre for a median of 12 months (IQR 10-13) before PEWS implementation and 18 months (16-18) after PEWS implementation. The mortality rate due to a clinical deterioration event was 1·33 events per 1000 patient-days before PEWS implementation and 1·09 events per 1000 patient-days after PEWS implementation (IRR 0·82 [95% CI 0·69-0·97]; p=0·021). In the multivariable analysis of centre characteristics, higher clinical deterioration event mortality rates before PEWS implementation (IRR 1·32 [95% CI 1·22-1·43]; p<0·0001), being a teaching hospital (1·18 [1·09-1·27]; p<0·0001), not having a separate paediatric haematology-oncology unit (1·38 [1·21-1·57]; p<0·0001), and having fewer PEWS omissions (0·95 [0·92-0·99]; p=0·0091) were associated with a greater reduction in clinical deterioration event mortality after PEWS implementation; no association was found with country income level (IRR 0·86 [95% CI 0·68-1·09]; p=0·22) or clinical deterioration event rates before PEWS implementation (1·04 [0·97-1·12]; p=0·29).

INTERPRETATION

PEWS implementation was associated with reduced clinical deterioration event mortality in paediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of PEWS as an effective evidence-based intervention to reduce disparities in global survival for children with cancer.

FUNDING

American Lebanese Syrian Associated Charities, US National Institutes of Health, and Conquer Cancer Foundation.

TRANSLATIONS

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Safety and efficacy of continuous renal replacement therapy for children less than 10 kg using standard adult machines

Continuous Renal Replacement Therapy (CRRT) machines are used off-label in patients less than 20 kg. Infant and neonates-dedicated CRRT machines are making their way into current practice, but these machines are available only in select centres. This study assesses the safety and efficacy of CRRT using adult CRRT machines in children ≤ 10 kg and to determines the factors affecting the circuit life in these children.

DESIGN

Retrospective cohort study of children ≤ 10 kg who received CRRT (January 2010-January 2018) at a PICU in a tertiary care centre in London, UK. Primary diagnosis, markers for illness severity, CRRT characteristics, length of PICU admission and survival to PICU discharge were collected. Descriptive analysis compared survivors and non-survivors. A subgroup analysis compared children ≤ 5 kg to children 5-10 kg. Fifty-one patients ≤ 10 kg received 10,328 h of CRRT, with median weight of 5 kg. 52.94% survived to hospital discharge. Median circuit life was 44 h (IQR 24-68). Bleeding episodes occurred with 6.7% of sessions and hypotension for 11.9%. Analysis of efficacy showed a reduction in fluid overload at 48 h (P = 0.0002) and serum creatinine at 24 and 48 h (P = 0.001). Blood priming was deemed to be safe as serum potassium decreased at 4 h (P = 0.005); there was no significant change in serum calcium. Survivors had a lower PIM2 score at PICU admission (P < 0.001) and had longer PICU length of stay (P < 0.001).    Conclusion: Pending neonatal and infant dedicated CRRT machines, CRRT can be safely and effectively applied to children weighing ≤ 10 kg using adult-sized CRRT machines.

WHAT IS KNOWN

• Continuous Renal Replacement Therapy can be used for a variety of renal and non-renal indications to improve outcomes for children in the paediatric intensive care unit. These include, persistent oliguria, fluid overload, hyperkalaemia, metabolic acidosis, hyperlactatemia, hyperammonaemia, and hepatic encephalopathy. • Young children ≤ 10 kg are most often treated using standard adult machines, off-label. This potentially places them at risk of side effects due to high extracorporeal circuit volumes, relatively higher blood flows, and difficulty in achieving vascular access.

WHAT IS NEW

• This study found that standard adult machines were effective in reducing fluid overload and creatinine in children ≤ 10 kg. This study also assessed safety of blood priming in this group and found no evidence of an acute fall in haemoglobin or calcium, and a fall in serum potassium by a median of 0.3 mmol/L. The frequency of bleeding episodes was 6.7%, and hypotension requiring vasopressors or fluid resuscitation occurred with 11.9% of treatment sessions. • These findings suggest that adult CRRT machines are sufficiently safe and efficacious for routine use in PICU for children ≤ 10 kg and suggest that further research is undertaken, regarding the routine rollout of dedicated machines.

Peri-Intubation Adverse Events in the Critically Ill Child After Hematopoietic Cell Transplant

OBJECTIVES

Mechanically ventilated children post-hematopoietic cell transplant (HCT) have increased morbidity and mortality compared with other mechanically ventilated critically ill children. Tracheal intubation-associated adverse events (TIAEs) and peri-intubation hypoxemia universally portend worse outcomes. We investigated whether adverse peri-intubation associated events occur at increased frequency in patients with HCT compared with non-HCT oncologic or other PICU patients and therefore might contribute to increased mortality.

DESIGN

Retrospective cohort between 2014 and 2019.

SETTING

Single-center academic noncardiac PICU.

PATIENTS

Critically ill children who underwent tracheal intubation (TI).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from the local airway management quality improvement databases and Virtual Pediatric Systems were merged. These data were supplemented with a retrospective chart review for HCT-related data, including HCT indication, transplant-related comorbidity status, and patient condition at the time of TI procedure. The primary outcome was defined as the composite of hemodynamic TIAE (hypo/hypertension, arrhythmia, cardiac arrest) and/or peri-intubation hypoxemia (oxygen saturation < 80%) events. One thousand nine hundred thirty-one encounters underwent TI, of which 92 (4.8%) were post-HCT, while 319 (16.5%) had history of malignancy without HCT, and 1,520 (78.7%) had neither HCT nor malignancy. Children post-HCT were older more often had respiratory failure as an indication for intubation, use of catecholamine infusions peri-intubation, and use of noninvasive ventilation prior to intubation. Hemodynamic TIAE or peri-intubation hypoxemia were not different across three groups (HCT 16%, non-HCT with malignancy 10%, other 15). After adjusting for age, difficult airway feature, provider type, device, apneic oxygenation use, and indication for intubation, we did not identify an association between HCT status and the adverse TI outcome (odds ratio, 1.32 for HCT status vs other; 95% CI, 0.72-2.41; p = 0.37).

CONCLUSIONS

In this single-center study, we did not identify an association between HCT status and hemodynamic TIAE or peri-intubation hypoxemia during TI.

Undernutrition and 60-day mortality in critically ill children with respiratory failure: a prospective cohort study

BACKGROUND

To determine whether undernutrition affects 60-day mortality in pediatric acute respiratory failure.

METHODS

Subjects with acute respiratory failure aged between two months and 13 years were included in the study. The Z-scores were calculated on admission and children were categorized into two groups of undernutrition and normal nutrition. The nutritional intake of the children was measured daily. The outcome was 60-day mortality.

RESULTS

A total of 126 patients met the inclusion criteria; 41% were undernourished based on the Z-score of BMI and weight for height, 50% based on the Z-score of height and length for age and 45% based on the Z-score of weight for age. Overall, the 60-day mortality rate was 27.8%. The Cox regression analysis adjusted with PIM2, age and gender, showed that undernutrition has a significant relationship with 60-day mortality based on the weight for age Z-score (HR = 2.33; CI: 1.175-4.638). In addition, undernutrition has a significant relationship with 60-day mortality based on the BMI for age (HR = 3.04; CI:1.070-8.639) and weight for height (HR = 2.62; CI: 1.605-6.658) Z-scores. The mean calorie and protein intake of 72% of the children was less than 80% of their calorie needs. The time to start feeding in 63% of the children was more than 48 h. There was no relationship between the time of starting nutrition and nutritional intake during PICU admission and mortality.

CONCLUSION

Undernutrition is prevalent in mechanically ventilated children in the PICU and may be associated with 60-day mortality.

Postpyloric vs gastric enteral nutrition in critically ill children: A single-center retrospective cohort study

BACKGROUND

We aimed to describe enteral nutrition (EN) delivery in patients receiving postpyloric EN (PPEN) vs gastric EN (GEN).

METHODS

Single-center retrospective study including patients aged <21 years admitted to an intensive care unit in a pediatric quaternary care hospital for ≧48 h who received PPEN or GEN as a first approach, as guided by a nutrition algorithm. PPEN patients were 1:1 propensity score matched to GEN patients on demographics, clinical characteristics, and disease severity. Days to EN initiation from admission, percentage of EN adequacy (delivered EN volume/prescribed EN volume) on days 1-3 and 7 after EN initiation, and time to achieving 60% of prescribed EN volume were compared between the two groups using Wilcoxon Mann-Whitney tests and a Cox proportional hazards model. Data are presented as median (IQR1, IQR3).

RESULTS

Forty-six PPEN and 46 GEN patients were matched. Median time to EN initiation was 3.25 (2, 6.8) days for PPEN and 4.15 (1.5, 7.1) days for GEN (P = 0.6). Percentage of EN adequacy was greater for PPEN than GEN patients (day 1 PPEN 59.4% [18.8, 87.5] vs GEN 21.1% [7.8, 62.8], day 2 PPEN 54.3% [16.7, 95.8] vs GEN 24% [5.4, 56.7], day 3 PPEN 65.4% [14.7, 100] vs GEN 16% [0, 64.6], day 7 PPEN 77.8% [11.1, 100] vs GEN 13.8% [0, 74.5]; P < 0.05). PPEN patients had greater likelihood of achieving 60% of their prescribed EN volume than GEN patients (hazard ratio 1.84, 95% CI 1.07-3.15; P = 0.028).

CONCLUSION

PPEN was associated with greater EN delivery compared with GEN.

Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative

OBJECTIVES

Assess clinical outcomes following PICU Liberation ABCDEF Bundle utilization.

DESIGN

Prospective, multicenter, cohort study.

SETTING

Eight academic PICUs.

PATIENTS

Children greater than 2 months with expected PICU stay greater than 2 days and need for mechanical ventilation (MV).

INTERVENTIONS

ABCDEF Bundle implementation.

MEASUREMENT AND MAIN RESULTS

Over an 11-month period (3-mo baseline, 8-mo implementation), Bundle utilization was measured for 622 patients totaling 5,017 PICU days. Risk of mortality was quantified for 532 patients (4,275 PICU days) for correlation between Bundle utilization and MV duration, PICU length of stay (LOS), delirium incidence, and mortality. Utilization was analyzed as subject-specific (entire PICU stay) and day-specific (single PICU day). Median overall subject-specific utilization increased from 50% during the 3-month baseline to 63.9% during the last four implementation months (p < 0.001). Subject-specific utilization for elements A and C did not change; utilization improved for B (0-12.5%; p = 0.007), D (22.2-61.1%; p < 0.001), E (17.7-50%; p = 0.003), and F (50-79.2%; p = 0.001). We observed no association between Bundle utilization and MV duration, PICU LOS, or delirium incidence. In contrast, on adjusted analysis, every 10% increase in subject-specific utilization correlated with mortality odds ratio (OR) reduction of 34%, p < 0.001; every 10% increase in day-specific utilization correlated with a mortality OR reduction of 1.4% (p = 0.006).

CONCLUSIONS

ABCDEF Bundle is applicable to children. Although enhanced Bundle utilization correlated with decreased mortality, increased utilization did not correlate with duration of MV, PICU LOS, or delirium incidence. Additional research in the domains of comparative effectiveness, implementation science, and human factors engineering is required to understand this clinical inconsistency and optimize PICU Liberation concept integration into clinical practice.

Factors linked to Staphylococcus aureus healthcare-associated infections among pediatric intensive care unit colonized patients

BACKGROUND

Staphylococcus aureus (SA) is one of the main pathogens responsible for healthcare-associated infection (HCAI) in pediatrics. The aim of this study was to describe the prevalence of SA-HCAI among colonized patients and the factors associated with it in the pediatric intensive care unit (PICU).

METHODS

We designed a 6-year retrospective cohort study of a PICU in a French university children's hospital including all children admitted to the PICU from January 1, 2011, to December 31, 2016, who had SA colonization on PICU admission. For each patient, the past medical history and the hospitalization data were collected. HCAIs related to SA were verified according to the criteria of the United States Centers for Disease Control and Prevention.

RESULTS

Among all patients colonized with SA (n = 1381, 26%), 105 (8%) had methicillin-resistant SA carriage and 41 (3%) developed an HCAI caused by SA. The main HCAIs were ventilator-associated pneumonia (51%) and central line-associated bloodstream infections (27%). Patients developing HCAI caused by SA had a significantly longer length of hospital stay and a higher mortality rate than the rest of the population. Using a multivariate logistic regression model, the presence of mechanical ventilation, the implementation of a surgical procedure during the PICU stay, and the onset of at least one episode of anemia during the PICU stay were significantly associated with the occurrence of HCAI due to SA.

CONCLUSION

HCAIs linked to SA carriage are rare but severe. Mechanical ventilation, surgery during the PICU stay, and anemia are factors associated with SA-HCAI.

Fluid Removal in Children on Continuous Renal Replacement Therapy Improves Organ Dysfunction Score

The objective is to assess impact of fluid removal on improvement in organ function in children who received continuous renal replacement therapy (CRRT) for management of acute kidney injury and/or fluid overload (FO). A retrospective review of eligible patients admitted to a tertiary level intensive care unit over a 3-year period was performed. Improvement in nonrenal organ function, the primary outcome, was defined as decrease in nonrenal component of Pediatric Logistic Organ Dysfunction (PELOD) score on day 3 of CRRT. The cohort was categorized into Group 1 (improvement) and Group 2 (no improvement or worsening) in nonrenal PELOD score. Multivariable logistic regression analysis was performed to identify independent predictors. A higher PELOD score at CRRT initiation (odds ratio [OR]: 1.11, 95% confidence interval [CI]: 1.05, 1.18, p < 0.001), belonging to infant-age group (OR: 4.53, 95% CI: 4.40, 5.13, p = 0.02) and greater fluid removal during initial 3 days of CRRT (OR: 1.05, 95% CI: 1.01, 1.10, p = 0.01) were associated with an improvement in nonrenal PELOD score at day 3 of CRRT. FO at CRRT initiation (OR: 0.66, 95% CI: 0.46, 0.93, p = 0.02) and having an underlying oncologic diagnosis (OR: 0.28, 95% CI: 0.09, 0.85, p = 0.03) were associated with worsening of nonrenal PELOD score at day 3 of CRRT. Careful consideration of certain modifiable patient and/or fluid removal kinetic factors may have an impact on outcomes.

Comparative Analysis of Intensive Care Prognosis Scoring Systems and Acute Kidney Injury Scores (AKIN and pRIFLE) in Critically Ill Children

The development of AKI (acute kidney injury) in critically ill patients in pediatric intensive care units (PICUs) is one of the most important factors affecting mortality. There are scoring modalities used to predict mortality in PICUs. We compared the AKIN (Acute Kidney Injury Network) and pRIFLE (pediatric risk, injury, failure, loss, and end stage) AKI classifications and PICU scoring modalities in this study. Methods: A total of 716 children, whose serum creatinine levels were within the normal limits at the time of admission to the PICU between January 2018 and December 2020, were included. Along with the demographic and clinical variables, AKIN and pRIFLE classifications were recorded at the most advanced stage of AKI. Along with the PIM-2, PRISM III, and PELOD-2 scores, the highest value of the pSOFA score was recorded. Results: According to the pRIFLE and AKIN classifications, 62 (8.7%) patients developed kidney injury, which had a statistically significant effect on mortality. The occurrence of renal injury was found to be statistically strongly and significantly correlated with high PRISM III, PELOD-2, and pSOFA scores. When the stages of kidney injury according to the AKIN criteria were compared with the PRISM III, PELOD 2, and pSOFA scores, a significant difference was found between the patients who did not develop AKI and those who developed stage 1, stage 2, and stage 3 kidney injury. For the PRISM III, PELOD 2, and pSOFA scores, there were no significant differences between the stages according to the AKIN criteria. A substantial difference was discovered between the patients who did not develop AKI and those who were in the risk, injury, and failure plus loss stages according to the pRIFLE criteria. According to the PIM-2 ratio and pRIFLE criteria, there was a statistically significant difference between patients in the injury and failure plus loss stages and those who did not develop AKI. Conclusions: Our study is the first pediatric study to show a substantial correlation between the variables associated with the PICU scoring modalities in critically ill children with AKI. Identifying the risk factors for the development of AKI and planning antimicrobial regimens for patients with favorable prognoses at the time of PICU admission could lower mortality rates.

Thirty years of ANZICS CORE: A clinical quality success story

In 2023, the Australian and New Zealand Intensive Care Society (ANZICS) Registry run by the Centre for Outcomes and Resources Evaluation (CORE) turns 30 years old. It began with the Adult Patient Database, the Australian and New Zealand Paediatric Intensive Care Registry, and the Critical Care Resources Registry, and it now includes Central Line Associated Bloodstream Infections Registry, the Extra-Corporeal Membrane Oxygenation Database, and the Critical Health Resources Information System. The ANZICS Registry provides comparative case-mix reports, risk-adjusted clinical outcomes, process measures, and quality of care indicators to over 200 intensive care units describing more than 200 000 adult and paediatric admissions annually. The ANZICS CORE outlier management program has been a major contributor to the improved patient outcomes and provided significant cost savings to the healthcare sector. Over 200 peer-reviewed papers have been published using ANZICS Registry data. The ANZICS Registry was a vital source of information during the COVID-19 pandemic. Upcoming developments include reporting of long-term survival and patient-reported outcome and experience measures.

Pediatric sepsis diagnostic and prognostic biomarkers: pancreatic stone protein, copeptin, and apolipoprotein A-V

BACKGROUND

We assessed serum concentrations of pancreatic stone protein (PSP), copeptin, and apolipoprotein A-V (APOA5) biomarkers for the diagnosis and prognosis of pediatric sepsis, a condition associated with high mortality.

METHODS

This prospective study included 180 children admitted to the Pediatric Intensive Care Unit and 100 healthy controls at Menoufia University Hospital. Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality-2 (PIM2), and Pediatric Sequential Organ Failure Assessment (pSOFA) scores were calculated. Serum PSP, copeptin and APOA5 were measured once within 24 h of admission.

RESULTS

PSP, copeptin, and APOA5 were significantly higher in the patients than in the controls (p < 0.001). PSP and copeptin were increased among children who required mechanical ventilation (MV), had multiple organ dysfunctions, and were non-survivors, but APOA5 was decreased in those children. Logistic regression analyses showed that high pSOFA, high PSP and copeptin, low APOA5, and use of MV were associated with mortality. The receiver operating characteristic revealed that the area under the curve (AUC) for APOA5, copeptin, and PSP (0.965, 0.960, and 0.868, respectively) demonstrated high sensitivity (96%, 94%, and 80%) for sepsis diagnosis. The AUC values for PSP, copeptin, and APOA5 were 0.709, 0.705, and 0.571, respectively, with sensitivities of 74%, 58%, and 58% for mortality prediction.

CONCLUSIONS

PSP, copeptin, and APOA5 are promising diagnostic biomarkers for pediatric sepsis but inadequate predictors of mortality.

IMPACT

Apolipoprotein A-V (APOA5), copeptin, and pancreatic stone protein (PSP) are acute-phase proteins with diagnostic value in evaluating critically ill pediatric patients with sepsis and detecting sepsis severity. PSP and copeptin had the power to discriminate non-survivors from survivors. APOA5 was less powerful than the other biomarkers in discriminating between survivors and non-survivors.

Group A streptococcal disease in paediatric inpatients: a European perspective

Group A streptococcal (GAS) disease shows increasing incidence worldwide. We characterised children admitted with GAS infection to European hospitals and studied risk factors for severity and disability. This is a prospective, multicentre, cohort study (embedded in EUCLIDS and the Swiss Pediatric Sepsis Study) including 320 children, aged 1 month to 18 years, admitted with GAS infection to 41 hospitals in 6 European countries from 2012 to 2016. Demographic, clinical, microbiological and outcome data were collected. A total of 195 (61%) patients had sepsis. Two hundred thirty-six (74%) patients had GAS detected from a normally sterile site. The most common infection sites were the lower respiratory tract (LRTI) (22%), skin and soft tissue (SSTI) (23%) and bone and joint (19%). Compared to patients not admitted to PICU, patients admitted to PICU more commonly had LRTI (39 vs 8%), infection without a focus (22 vs 8%) and intracranial infection (9 vs 3%); less commonly had SSTI and bone and joint infections (p < 0.001); and were younger (median 40 (IQR 21-83) vs 56 (IQR 36-85) months, p = 0.01). Six PICU patients (2%) died. Sequelae at discharge from hospital were largely limited to patients admitted to PICU (29 vs 3%, p < 0.001; 12% overall) and included neurodisability, amputation, skin grafts, hearing loss and need for surgery. More patients were recruited in winter and spring (p < 0.001).

CONCLUSION

In an era of observed marked reduction in vaccine-preventable infections, GAS infection requiring hospital admission is still associated with significant severe disease in younger children, and short- and long-term morbidity. Further advances are required in the prevention and early recognition of GAS disease.

WHAT IS KNOWN

• Despite temporal and geographical variability, there is an increase of incidence of infection with group A streptococci. However, data on the epidemiology of group A streptococcal infections in European children is limited.

WHAT IS NEW

• In a large, prospective cohort of children with community-acquired bacterial infection requiring hospitalisation in Europe, GAS was the most frequent pathogen, with 12% disability at discharge, and 2% mortality in patients with GAS infection. • In children with GAS sepsis, IVIG was used in only 4.6% of patients and clindamycin in 29% of patients.

Net Promoter Score (NPS) as a tool to assess parental satisfaction in pediatric intensive care units

OBJECTIVE

To verify the performance of the Net Promoter Score (NPS) as a tool to assess parental satisfaction in pediatric intensive care units (PICUs).

METHODS

The authors conducted an observational cross-sectional multicenter study in the PICUs of 5 hospitals in Brazil. Eligible participants were all parents or legal guardians of PICU-admitted children, aged 18 years or over. The NPS was administered together with the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30), used as the gold standard, and a sociodemographic questionnaire. For analysis, the results were dichotomized into values greater than or equal to the median of the tests. The associations between the 2 tools were evaluated and the distribution of their results was compared.

RESULTS

The parents or legal guardians of 78 PICU-admitted children were interviewed. Of the respondents, 85% were women and 62% were in a private hospital. The median NPS was 10 (IQR, 10-10), and the median EMPATHIC-30 score was 5.7 (IQR, 5.4-5.9). Compared with the gold standard, the NPS had a sensitivity of 100% at all cutoff points, except at cutoff 10, where the sensitivity was slightly lower (97.5%). As for specificity, NPS performance was poorer, with values ranging from 0% (NPS ≥ 5) to 47.4% (NPS = 10).

CONCLUSIONS

NPS proved to be a sensitive tool to assess parental satisfaction, but with poor ability to identify dissatisfied users in the sample.

Health-related quality of life 6 months after pediatric intensive care unit admission for bronchiolitis: a prospective single-center cohort study

Health-Related Quality of Life (HRQoL) after Pediatric Intensive Care Unit (PICU) admission is considered a valuable outcome measure. Yet, data on HRQoL after PICU admission are scarce and often collected in heterogeneous patient groups. The current study aimed to evaluate HRQoL in children with bronchiolitis 6 months after PICU admission, which represents a homogenous patient group. This study was conducted at the Radboud University Medical Centre in the Netherlands. Children admitted to the PICU between November 2019 and April 2020 were eligible. HRQoL was assessed with the "TNO-AZL Preschool children Quality of Life" (TAPQOL) questionnaire and compared to Dutch normative data. Lower scores represent worse HRQoL. HRQoL was assessed in 34 children (response rate 81%), mean age at assessment was 7.6 months (SD 2.5 months), and median length of stay was 5 days (range 1-17). Parents reported significant lower scores on stomach problems (p < 0.001; d = 0.8) and lung problems (p < 0.001; d = 1.2) and significant higher scores on appetite (p < 0.001; d = 0.6) and problem behavior (p < 0.001; d = 0.5) compared to normative data. Effect sizes were moderate to large.

CONCLUSION

Significant differences in several HRQoL domains were found after PICU admission for bronchiolitis compared to normative data. Whereas the domains lung and stomach problems showed significantly impaired scores, most domains revealed HRQoL levels comparable with healthy peers. This study may contribute to the optimization of HRQoL PICU outcomes by highlighting specific HRQoL domains to focus on at admission and during follow-up.

WHAT IS KNOWN

• With the decline in PICU mortality, HRQoL became an important outcome measure. Yet, the currently limited number of studies on HRQoL outcomes often involve heterogeneous patient groups. • Bronchiolitis is one of the most frequent reasons for PICU admission, and although a significant part of children admitted for bronchiolitis has a medical history, compared with other reasons for PICU admission, this patient group is relatively homogeneous in terms of age, disease course, and treatment.

WHAT IS NEW

• In the present study, six months after PICU admission for bronchiolitis, children scored differently on multiple HRQoL domains compared to healthy peers. • Significantly impaired HRQoL scores were reported on lung and stomach problems in comparison to normative data.

Adverse Events in Pediatric Critical Care Nonsurvivors With a Low Predicted Mortality Risk: A Multicenter Case Control Study

OBJECTIVES

Some patients with a low predicted mortality risk in the PICU die. The contribution of adverse events to mortality in this group is unknown. The aim of this study was to estimate the occurrence of adverse events in low-risk nonsurvivors (LN), compared with low-risk survivors (LS) and high-risk PICU survivors and nonsurvivors, and the contribution of adverse events to mortality.

DESIGN

Case control study. Admissions were selected from the national Dutch PICU registry, containing 53,789 PICU admissions between 2006 and 2017, in seven PICUs. PICU admissions were stratified into four groups, based on mortality risk (low/high) and outcome (death/survival). Random samples were selected from the four groups. Cases were "LN." Control groups were as follows: "LS," "high-risk nonsurvivors" (HN), and "high-risk survivors" (HS). Adverse events were identified using the validated trigger tool method.

SETTING

Patient chart review study.

PATIENTS

Children admitted to the PICU with either a low predicted mortality risk (< 1%) or high predicted mortality risk (≥ 30%).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In total, 419 patients were included (102 LN, 107 LS, 104 HN, and 106 HS). LN had more complex chronic conditions (93.1%) than LS (72.9%; p < 0.01), HN (49.0%; p < 0.001), and HS (48.1%; p < 0.001). The occurrence of adverse events in LN (76.5%) was higher than in LS (13.1%) and HN (47.1%) ( p < 0.001). The most frequent adverse events in LN were hospital-acquired infections and drug/fluid-related adverse events. LN suffered from more severe adverse events compared with LS and HS ( p < 0.001). In 30.4% of LN, an adverse event contributed to death. In 8.8%, this adverse event was considered preventable.

CONCLUSIONS

Significant and preventable adverse events were found in low-risk PICU nonsurvivors. 76.5% of LN had one or more adverse events. In 30.4% of LN, an adverse event contributed to mortality.

Unplanned Admissions, Emergency Department Visits, and Epilepsy After Critical Neurological Illness Requiring Prolonged Mechanical Ventilation in Children

Background and Purpose

Long-term outcomes after pediatric neurocritical illness are poorly characterized. This study aims to characterize the frequency and risk factors for post-discharge unplanned health resource use in a pediatric neurocritical care population using insurance claims data.

Methods

Retrospective cohort study evaluating children who survived a hospitalization for an acute neurologic illness or injury requiring mechanical ventilation for >72 hours and had insurance eligibility in Colorado's All Payers Claims database. Insurance claims identified unplanned readmissions and emergency department [ED] visits during the post-discharge year. For patients without pre-existing epilepsy/seizures, we evaluated for post-ICU epilepsy identified by claim(s) for a maintenance anti-seizure medication during months 6-12 post-discharge. Multivariable logistic regression identified factors associated with each outcome.

Results

101 children, median age 3.7 years (interquartile range (IQR) .4-11.9), admitted for trauma (57%), hypoxic-ischemic injury (17%) and seizures (15%). During the post-discharge year, 4 (4%) patients died, 26 (26%) were readmitted, and 48 (48%) had an ED visit. Having a pre-existing complex chronic condition was independently associated with readmission and emergency department visit. Admission for trauma was protective against readmission. Of those without pre-existing seizures (n = 86), 25 (29%) developed post-ICU epilepsy. Acute seizures during admission and prolonged ICU stays were independently associated with post-ICU epilepsy.

Conclusions

Survivors of pediatric neurocritical illness are at risk of unplanned healthcare use and post-ICU epilepsy. Critical illness risk factors including prolonged ICU stay and acute seizures may identify cohorts for targeted follow up or interventions to prevent unplanned healthcare use and post-ICU epilepsy.

Glomerular filtration rate in critically ill neonates and children: creatinine-based estimations versus iohexol-based measurements

BACKGROUND

Acute kidney injury (AKI) and augmented renal clearance (ARC), both alterations of the glomerular filtration rate (GFR), are prevalent in critically ill children and neonates. AKI and ARC prevalence estimates are based on estimation of GFR (eGFR) using serum creatinine (SCr), which is known to be inaccurate. We aimed to test our hypothesis that AKI prevalence will be higher and ARC prevalence will be lower in critically ill children when using iohexol-based measured GFR (mGFR), rather than using eGFR. Additionally, we aimed to investigate the performance of different SCr-based eGFR methods.

METHODS

In this single-center prospective study, critically ill term-born neonates and children were included. mGFR was calculated using a plasma disappearance curve after parenteral administration of iohexol. AKI diagnosis was based on the KDIGO criteria, SCr-based eGFR, and creatinine clearance (CrCL). Differences between eGFR and mGFR were determined using Wilcoxon signed-rank tests and by calculating bias and accuracy (percentage of eGFR values within 30% of mGFR values).

RESULTS

One hundred five children, including 43 neonates, were included. AKI prevalence was higher based on mGFR (48%), than with KDIGO or eGFR (11-40%). ARC prevalence was lower with mGFR (24%) compared to eGFR (38-51%). eGFR equations significantly overestimated mGFR (60-71 versus 41 ml/min/1.73 m², p < 0.001-0.002). Accuracy was highest with eGFR equations based on age- and sex-dependent equations (up to 59%).

CONCLUSION

Iohexol-based AKI prevalence was higher and ARC prevalence lower compared to standard SCr-based eGFR methods. Age- and sex-dependent equations for eGFR (eGFR-Smeets for neonates and eGFR-Pierce for children) best approached measured GFR and should preferably be used to optimize diagnosis of AKI and ARC in this population. A higher resolution version of the Graphical abstract is available as Supplementary information.

Performance of the PRISM I, PIM2, PELOD-2 and PRISM IV scoring systems in western China: a multicenter prospective study

BACKGROUND

The aim of this study was to evaluate the performance of the four scoring tools in predicting mortality in pediatric intensive care units (PICUs) in western China.

METHODS

This was a multicenter, prospective, cohort study conducted in six PICUs in western China. The performances of the scoring systems were evaluated based on both discrimination and calibration. Discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUC) for each model. Calibration was measured across defined groups based on mortality risk using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

A total of 2034 patients were included in this study, of whom 127 (6.2%) died. For the entire cohort, AUCs for Pediatric Risk of Mortality Score (PRISM) I, Pediatric Index of Mortality 2 (PIM2), Pediatric Logistic Organ Dysfunction Score-2 (PELOD-2) and PRISM IV were 0.88 [95% confidence interval (CI) 0.85-0.92], 0.84 (95% CI 0.80-0.88), 0.80 (95% CI 0.75-0.85), and 0.91 (95% CI 0.88-0.94), respectively. The Hosmer-Lemeshow goodness-of-fit Chi-square value was 12.71 (P = 0.12) for PRISM I, 4.70 (P = 0.79) for PIM2, 205.98 (P < 0.001) for PELOD-2, and 7.50 (P = 0.48) for PRISM IV [degree of freedom (df) = 8]. The standardized mortality ratios obtained with the PRISM I, PIM2, PELOD-2, and PRISM IV models were 0.87 (95% CI, 0.75-1.01), 0.97 (95% CI, 0.85-1.12), 1.74 (95% CI, 1.58-1.92), and 1.05 (95% CI, 0.92-1.21), respectively.

CONCLUSIONS

PRISM IV performed best and can be used as a prediction tool in PICUs in Western China. However, PRISM IV needs to be further validated in NICUs.

Hemostasis Proteins in Invasive Meningococcal and Nonmeningococcal Infections: A Prospective Multicenter Study

OBJECTIVES

We aimed to describe the variation of hemostasis proteins in children with bacterial infections due to different pathogens ( Neisseria meningitidis, Streptococcus pneumoniae, Staphylococcus aureus , and group A streptococcus [GAS]) and to study hemostasis proteins in relation to mortality.

DESIGN

Preplanned analysis in prospective cohort study.

SETTING

Hospitals in five European countries (Austria, The Netherlands, Spain, Switzerland, and the United Kingdom).

PATIENTS

Admitted children (2012-2016) with community-acquired infections due to meningococci ( n = 83), pneumococci ( n = 64), S. aureus (n = 50), and GAS ( n = 44) with available serum samples collected less than 48 hours after admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fibronectin, plasminogen activator inhibitor type 1 (PAI-1), thrombomodulin, and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) were measured in serum in 2019-2020. Additionally, von Willebrand factor, protein C, protein S, and factor IX were measured in citrate plasma available from a subset of patients. Outcome measures included in-hospital mortality and disease severity (need for ventilation/inotropes, Pediatric Index of Mortality score).Of 241 children, 21 (8.7%) died and 177 (73.5%) were admitted to PICU. Mortality rate was similar for the pathogen groups. Levels of fibronectin and thrombomodulin differed for the different pathogens ( p < 0.05). Fibronectin levels were lower in GAS infections than in S. pneumoniae and S. aureus infections but did not differ from meningococcal infections. Thrombomodulin levels in meningococcal infections were higher than in S. aureus and pneumococcal infections. Overall, the area under the curve for mortality was 0.81 (95% CI, 0.70-0.92) for thrombomodulin and 0.78 (95% CI, 0.69-0.88) for ADAMTS-13. The association of each hemostasis protein did not vary across pathogens for any of the outcome measures.

CONCLUSIONS

Hemostatic disturbances in childhood bacterial infections are not limited to meningococcal sepsis but occur with a comparable severity across nonmeningococcal infections. High thrombomodulin and high ADAMTS-13 had good discriminative ability for mortality. Our results emphasize the importance of hemostatic disturbances in meningococcal and nonmeningococcal pediatric bacterial infections.

Association of nutritional status with clinical outcomes of critically ill pediatric patients with complex chronic conditions

BACKGROUND & AIMS

There is a high prevalence of children with complex chronic conditions (CCCs) in pediatric intensive care units (PICUs). However, information on the nutritional status (NS) of this specific population is limited. This study aimed to evaluate the NS of critically ill pediatric patients with CCCs and to relate it to clinical outcomes.

METHODS

A retrospective cohort study of children admitted to a PICU over a 4-year period. We classified NS according to body mass index-for-age (BMI/A) and height-for-age (H/A) z-scores, using the World Health Organization (WHO) growth curves as a reference. We recorded the presence of CCC according to the definition proposed by Feudtner et al. Severity on admission was measured using the Pediatric Index of Mortality 2 (PIM2). We assessed the following outcomes: mortality, multiple organ dysfunction syndrome during PICU stay, and PICU length of stay (LOS).

RESULTS

We included 1753 children in the study. Presence of CCC accounted for 49.8% (873) of the sample. Among children with CCCs, 61.7% (539) had appropriate weight, 19.8% (173) were underweight, and 18.4% (161) were overweight. H/A was considered inadequate in 32.2% (281) of patients with CCCs, a higher rate than in those without CCCs (25.3%; 132) (p < 0.001). Regarding outcomes, underweight children had more organ dysfunctions and prolonged LOS. The association only remained for prolonged LOS when adjusting for confounders. Although underweight children had a higher PIM2-predicted risk of mortality, there was no significant difference in actual mortality between the three NS groups (p = 0.200).

CONCLUSIONS

The rates of nutritional inadequacies in patients with CCCs were high. Underweight was independently associated with prolonged LOS in children with CCC.

New-onset refractory status epilepticus (NORSE) in paediatric patients: causes, characteristics and outcomes

Background

New-onset refractory status epilepticus (NORSE) refers to patients without a previous history of seizures who have refractory status epilepticus for at least 72 hours without an identified aetiology. Despite the severe neurological sequelae of NORSE, little is known about this condition in paediatric patients.

Objective

To describe the profile of paediatric patients with NORSE, the profile of seizures, possible causes attributed to this condition, treatments offered to patients and the outcomes at discharge from the paediatric intensive care unit (PICU).

Methods

This retrospective, multicentre, descriptive study (case series) was conducted in the PICUs of three tertiary hospitals. We reviewed the medical records of all patients aged 0–16 years admitted to the participating PICUs between December 2013 and December 2017 with refractory status epilepticus, without a previous history of seizures or neurological disease.

Results

Fifteen patients (2.4%) had NORSE. The median age of patients was 62.3 (IQR 26.2–75.4) months. All patients experienced prodromes before progressing to refractory status epilepticus. Twelve patients (80%) had fever up to 24 hours before seizures. NORSE was classified as cryptogenic in 66% of patients. Twelve patients were treated with complementary therapies, in addition to anticonvulsants. There was no standardisation in the treatment of patients. The overall mortality rate was 20%.

Conclusions

NORSE is associated with high morbidity and mortality, without an identified aetiology in most cases and with a wide range of proposed therapies.

Erythrocyte and plasma selenium in children with acute inflammatory response

OBJECTIVES

Plasma selenium may not reflect selenium status in critically ill patients because it transiently decreases inversely with the magnitude of the systemic inflammatory response. The decision to supplement selenium should ideally be based on laboratory measurements that reliably reflect selenium status. We hypothesized that erythrocyte selenium, unlike plasma selenium, is not affected by the systemic inflammatory response in critically ill children.

METHODS

In a prospective study of 109 critically ill children, plasma and erythrocyte selenium concentrations were evaluated on admission, and plasma selenoprotein P was evaluated on days 1, 2, and 3 of the ICU stay. The main outcome was the effect of systemic inflammation on the erythrocyte and plasma selenium concentrations. The magnitude of the systemic inflammatory response was measured using serum C-reactive protein (CRP) and procalcitonin levels. The covariates were age, sex, anthropometric nutritional status, diagnosis of severe sepsis/septic shock, and clinical severity on admission. Multiple linear regression and generalized estimating equations were used for statistical analysis.

RESULTS

Erythrocyte selenium levels were not influenced by the magnitude of the inflammatory response or by the patient's clinical severity. Procalcitonin (β coefficient=-0.99; 95%CI: -1.64; -0.34, p = 0.003) and clinical severity (β coefficient= -11.13; 95%CI: -21.6; -0.63), p = 0.038) on admission were associated with decreased plasma selenium concentrations. Erythrocyte selenium was associated with selenoprotein P in the first three days of ICU stay (β coefficient=0.32; 95%CI: 0.20; 0.44, p < 0.001).

CONCLUSION

Unlike plasma selenium, erythrocyte selenium does not change in children with an acute systemic inflammatory response and is associated with selenoprotein P concentrations. Erythrocyte selenium is probably a more reliable marker than plasma selenium for evaluating the selenium status in critically ill children.