Estimating risk of prolonged mechanical ventilation after liver transplantation in children: PROVE-ALT score

BACKGROUND

Children at high risk for prolonged mechanical ventilation (PMV) after liver transplantation (LT) need to be identified early to optimize pulmonary support, allocate resources, and improve surgical outcomes. We aimed to develop and validate a metric that can estimate risk for Prolonged Ventilation After LT (PROVE-ALT).

METHODS

We identified preoperative risk factors for PMV by univariable analysis in a retrospective cohort of pediatric LT recipients between 2011 and 2017 (n = 205; derivation cohort). We created the PROVE-ALT score by mapping multivariable logistic regression coefficients as integers, with cutoff values using the Youden Index. We validated the score by C-statistic in a retrospectively collected separate cohort of pediatric LT recipients between 2018 and 2021 (n = 133, validation cohort).

RESULTS

Among total 338 patients, 21% (n = 72) were infants; 49% (n = 167) had cirrhosis; 8% (n = 27) required continuous renal replacement therapy (CRRT); and 32% (n = 111) required management in hospital (MIH) before LT. Incidence of PMV post-LT was 20% (n = 69) and 3% (n = 12) required tracheostomy. Independent risk factors (OR [95% CI]) for PMV were cirrhosis (3.8 [1-14], p = .04); age <1-year (8.2 [2-30], p = .001); need for preoperative CRRT (6.3 [1.2-32], p = .02); and MIH before LT (12.4 [2.1-71], p = .004). PROVE-ALT score ≥8 [Range = 0-21] accurately predicted PMV in the validation cohort with 73% sensitivity and 80% specificity (AUC: 0.81; 95% CI: 0.71-0.91).

CONCLUSION

PROVE-ALT can predict PMV after pediatric LT with a high degree of sensitivity and specificity. Once externally validated in other centers, PROVE-ALT will empower clinicians to plan patient-specific ventilation strategies, provide parental anticipatory guidance, and optimize hospital resources.

Enhancing family experience in the paediatric intensive care unit through the adoption of the family care journal: A single-center study

BACKGROUND

Multidisciplinary patient care rounds are increasingly seen as a vital complement to patient care management. Family engagement in these rounds, especially in the paediatric population, is important to treatment and outcomes, but there is little information about family experience in the Paediatric Intensive Care Unit (PICU).

AIMS

To develop a process using family care journals (FCJ) to systematically evaluate family experience in the PICU and identify needed supportive resources that will enhance their critical care stay.

METHODS

This is a single-centre quasi-experimental design conducted at a large urban quaternary level freestanding children's hospital. A family care journal (FCJ) was distributed to families upon admission to PICU to serve as a resource tool during their stay. An electronic point of care (POC) questionnaire was used to assess families' experiences in the PICU.

RESULTS

Three hundred sixty-six questionnaires were completed (100% response rate) and analysed. Overall, there was an improvement in all phases post FCJ implementation compared with the baseline. Seventy five percent of families found it a useful tool for communication with the PICU team. Open-ended comments revealed improvement opportunities related to communication, environment, and delay in care. Almost all commented on excellent nursing care.

CONCLUSIONS

Introducing FCJ in a paediatric ICU is a practical approach, providing a cost-effective method to assess family experiences and gain insights for ongoing quality improvement efforts. Collaboration among all care team members, including nursing, medical, and administrative leaders, is crucial for empathetically addressing parental needs during hospitalization.

RELEVANCE TO CLINICAL PRACTICE

Combining the use of journals and questionnaires provides the clinical team with an efficient means of collecting valuable feedback from parents regarding their experience in the PICU and the factors that foster ongoing commitment from families. Nurses play a crucial role in encouraging the adoption of these journals, as they promote greater parent involvement in their children's care.

Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study

OBJECTIVES

To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations.

DESIGN

The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding.

SETTING

Four-one PICUs in 13 LA countries.

PATIENTS

Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively.

CONCLUSIONS

The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.

Macronutrient and Micronutrient Intake in Children with Lung Disease

This review article aims to summarize the literature findings regarding the role of micronutrients in children with lung disease. The nutritional and respiratory statuses of critically ill children are interrelated, and malnutrition is commonly associated with respiratory failure. The most recent nutrition support guidelines for critically ill children have recommended an adequate macronutrient intake in the first week of admission due to its association with good outcomes. In children with lung disease, it is important not to exceed the proportion of carbohydrates in the diet to avoid increased carbon dioxide production and increased work of breathing, which potentially could delay the weaning of the ventilator. Indirect calorimetry can guide the process of estimating adequate caloric intake and adjusting the proportion of carbohydrates in the diet based on the results of the respiratory quotient. Micronutrients, including vitamins, trace elements, and others, have been shown to play a role in the structure and function of the immune system, antioxidant properties, and the production of antimicrobial proteins supporting the defense mechanisms against infections. Sufficient levels of micronutrients and adequate supplementation have been associated with better outcomes in children with lung diseases, including pneumonia, cystic fibrosis, asthma, bronchiolitis, and acute respiratory failure.

Application of organ dysfunction assessment scores following pediatric lung transplantation

OBJECTIVE

Organ dysfunction (OD) after lung transplantation can reflect preoperative organ failure, intraoperative acute organ damage and post-operative complications. We assessed two OD scoring systems, both the PEdiatric Logistic Organ Dysfunction (PELOD) and the pediatric Sequential Organ Failure Assessment (pSOFA) scores, in recognizing risk factors for morbidity as well as recipients with prolonged post-transplant morbidity.

DESIGN

Medical records of recipients from January 2009 to March 2016 were reviewed. PELOD and pSOFA scores were calculated on post-transplant days 1-3. Risk factors assessed included cystic fibrosis (CF), prolonged surgical time and worst primary graft dysfunction (PGD) score amongst others. Patients were classified into three groups based on their initial scores (group A) and subsequent trends either uptrending (group B) or downtrending (group C). Morbidity outcomes were compared between these groups.

RESULTS

Total 98 patients were enrolled aged 0-20 years. Risk factors for higher pSOFA scores ≥ 5 on day 1 included non-CF diagnosis and worst PGD scores (p = .0006 and p = .03, respectively). Kruskal Wallis analysis comparing pSOFA group A versus B versus C scores showed significantly prolonged ventilatory days (median 1 vs. 4 vs. 2, p = .0028) and ICU days (median 4 vs. 10 vs. 6, p = .007). Similarly, PELOD group A versus B versus C scores showed significantly prolonged ventilatory days (1 vs. 5 vs. 2, p = < .0001).

CONCLUSION

Implementing pSOFA scores bedside is a more effective tool compared to PELOD in identifying risk factors for worsened OD post-lung transplant and can be valuable in providing direction on morbidity outcomes in the ICU.

Perioperative Nutritional Status and Organ Dysfunction Following Surgery for Congenital Heart Disease

Children with congenital heart disease (CHD) are at risk of malnutrition; however, there is limited information regarding the impact of nutritional status on organ dysfunction and outcomes after surgery for CHD. The study aim was to assess the association between malnutrition, organ dysfunction, and outcomes after surgery for CHD. Retrospective cohort study of patients aged 30 days to 18 years admitted to the cardiac intensive care unit (CICU) following cardiac surgery. Nutritional status (malnutrition defined as weight for age z-score < - 2) and validated organ dysfunction scores (pSOFA and PELOD-2) on CICU days 1 and 3 were collected. The cohort included 967 patients with a median age of 2.8 years (IQR 0.46, 7.12) and hospital survival of 98.86%. The prevalence of malnutrition was 18.5% (n = 179). By multivariable logistic regression analysis including age, malnutrition, cardiopulmonary bypass time, and duration of mechanical ventilation; High STAT category (OR 7.51 [1.03-54], p = 0.0462) and PSOFA score > 5 day 1 (OR 1.84 [1.25-2.72], p = 0.0021) were associated with mortality; in a similar model including the same variables; High STAT category (OR 9.12 [1.33-62], p = 0.0243) and PELOD-2 score > 5 day 1 (OR 1.75 [1.10-2.77], p = 0.0175) were associated with mortality. Malnutrition was associated with persistent or worsening organ dysfunction by pSOFA (p < 0.05) and PELOD-2 (p < 0.01) on day 3. Malnutrition was present in infants and children undergoing surgery for congenital heart disease. Organ dysfunction and high surgical risk were associated with mortality. Malnutrition was not associated with mortality but was associated with postoperative organ dysfunction.

Post-operative dysnatremia is associated with adverse early outcomes after surgery for congenital heart disease

BACKGROUND

Dysnatremia is a common disorder in critically ill surgical children. The study's aim is to determine the prevalence of dysnatremia and its association with outcomes after surgery for congenital heart disease (CHD).

METHODS

This is a single-center retrospective cohort study of children <18 years of age undergoing surgery for CHD between January 2012 and December 2014. Multivariable logistic regression analysis was used to evaluate the relationship between dysnatremia and outcomes during the perioperative period. A total of 1345 encounters met the inclusion criteria.

RESULTS

The prevalence of pre- and post-operative dysnatremia were 10.2% and 47.1%, respectively. Hyponatremia occurred in 19.1%, hypernatremia in 25.6%. Hypernatremia at 24, 48, and 72 h post-operative was associated with increased hospital mortality (odds ratios (OR) [95% confidence intervals (CI)] 3.08 [1.16-8.17], p = 0.024; 4.35 [1.58-12], p = 0.0045; 4.14 [1.32-12.97], p = 0.0148, respectively. Hypernatremia was associated with adverse neurological events 3.39 [1.12-10.23], p = 0.0302 at 48 h post-operative. Hyponatremia was not associated with any adverse outcome in our secondary analysis.

CONCLUSIONS

Post-operative dysnatremia is a common finding in this heterogeneous cohort of pediatric cardiac-surgical patients. Hypernatremia was more prevalent than hyponatremia and was associated with adverse early post-operative outcomes.

IMPACT

Our study has shown that dysnatremia was highly prevalent in children after congenital heart surgery with hypernatremia associated with adverse outcomes including mortality. It is important to understand fluid and sodium regulation in the post-operative period in children with congenital heart disease to better address fluid overload and associated electrolyte imbalances and acute kidney injury. While clinicians are generally very aware of the importance of hyponatremia in critically ill children, similar attention should be given to hypernatremia in this population.

Intermittent versus continuous enteral nutrition in critically ill children: A pre-planned secondary analysis of an international prospective cohort study

BACKGROUND & AIMS

Intermittent enteral nutrition (EN) may have physiologic benefits over continuous feeding in critical illness. We aimed to compare nutrition and infection outcomes in critically ill children receiving intermittent or continuous EN.

METHODS

International, multi-center prospective observational study of mechanically ventilated children, 1 month to 18 years of age, receiving EN. Percent energy or protein adequacy (energy or protein delivered/prescribed × 100) and acquired infection rates were compared between intermittent and continuous EN groups using adjusted-multivariable and 4:1 propensity-score matched (PSM) analyses. Sensitivity analyses were performed after excluding patients who crossed over between intermittent and continuous EN.

RESULTS

1375 eligible patients from 66 PICUs were included. Patients receiving continuous EN (N = 1093) had a higher prevalence of respiratory illness and obesity, and lower prevalence of neurologic illness and underweight status on admission, compared to those on intermittent EN (N = 282). Percent energy or protein adequacy, proportion of patients who achieved 60% of energy or protein adequacy in the first 7 days of admission, and rates of acquired infection were not different between the 2 groups in adjusted-multivariable and propensity score matching analyses (P > 0.05).

CONCLUSION

Intermittent versus continuous EN strategy is not associated with differences in energy or protein adequacy, or acquired infections, in mechanically ventilated, critically ill children. Until further evidence is available, an individualized feeding strategy rather than a universal approach may be appropriate.

The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children

BACKGROUND

In critically ill children with acute kidney injury (AKI), continuous kidney replacement therapy (CKRT) enables nutrition provision. The magnitude of amino acid loss during continuous venovenous hemodiafiltration (CVVHDF) is unknown and needs accurate quantification. We investigated the mass removal and clearance of amino acids in pediatric CVVHDF.

METHODS

This is a prospective observational cohort study of patients receiving CVVHDF from August 2014 to January 2016 in the pediatric intensive care unit (PICU) of a tertiary children's hospital.

RESULTS

Fifteen patients (40% male, median age 2.0 (IQR 0.7, 8.0) years) were enrolled. Median PICU and hospital lengths of stay were 20 (9, 59) and 36 (22, 132) days, respectively. Overall survival to discharge was 66.7%. Median daily protein prescription was 2.00 (1.25, 2.80) g/kg/day. Median daily amino acid mass removal was 299.0 (174.9, 452.0) mg/kg body weight, and median daily amino acid mass clearance was 18.2 (13.5, 27.9) ml/min/m², resulting in a median 14.6 (8.3, 26.7) % protein loss. The rate of amino acid loss increased with increasing dialysis dose and blood flow rate.

CONCLUSION

CVVHDF prescription and related amino acid loss impact nutrition provision, with 14.6% of the prescribed protein removed. Current recommendations for protein provision for children requiring CVVHDF should be adjusted to compensate for circuit-related loss. A higher resolution version of the Graphical abstract is available as Supplementary information.

Pulmonary specialist involvement in critical asthma in the pediatric intensive care unit: A retrospective review

INTRODUCTION

Asthma is one of the most common chronic diseases of childhood. There is a scarcity of published literature on critical asthma, considered acute asthma requiring pediatric intensive care unit (PICU) admission. The goal of this study was to describe the clinical care of children with critical asthma admitted to a single center PICU and to determine whether pulmonary medicine consultation during admission impacted outcomes.

METHODS

Retrospective chart review of known asthma patients aged 4-18 years admitted to a quaternary PICU between 01/2013 and 07/2019 for management of critical asthma.

RESULTS

A total of 179 patients were enrolled with median age of 8 years. Median hospital length of stay (LOS) was 3.2 days and PICU LOS was 1.5 days. A total of 80 (44.7%) patients had a pulmonary medicine consultation. In the pulmonary medicine consultation group versus the no-pulmonary medicine consultation group, there was a significant difference in hospital LOS (4.16 vs. 2.86 days, p value <.0001) and PICU LOS (2.00 vs. 1.00, p value <.0001), escalation of controller medication (66% vs. 21%, p value <.0001), scheduled outpatient pulmonology follow-up (87.5% vs. 45.4%, p value <.0001), and receiving ≥3 courses of systemic steroids in the 12 months after discharge (32.2% vs. 14.7%). There was no difference in attendance of scheduled follow up appointments or in having ≥3 emergency room visits or admissions in the 12 months after discharge.

CONCLUSION

Pulmonary medicine consultation during hospital admission may impact management of critical asthma by increasing escalation of controller medication and scheduled outpatient follow up.

Effects of COVID-19 Pandemic on Nutritional Status, Feeding Practices, and Access to Food Among Infants and Children in Lower and Middle-Income Countries: a Narrative Review

Purpose of Review

The COVID-19 pandemic has affected children across the planet and the consequences on their health, nutritional status, and social structure have been more pronounced in low- and middle-income countries (LMICs). This review will focus on the effects of the COVID-19 pandemic on infant growth and feeding practices and access to food and obesity prevalence among children in LMICs. An electronic search was performed on MEDLINE and Embase to identify relevant articles in the English language.

Recent Findings

A higher prevalence of infections by the SARS-CoV-2 virus and a lower mortality rate were found in children in LMICs compared to western countries. In 2020, 22% and 52% of the wasting and deaths in children under 5 years of age in LMICS came from the sub-Saharan Africa region, respectively. Despite the decrease in stunting from 40% in 1990 to 24.2% in 2019, the prevalence remains above 30% in LMICs. Regarding breastfeeding practices in LMICs, many organizations recommend breastfeeding for infants and children born to infected mothers with SARS-CoV-2. This pandemic has resulted in higher food insecurity and disruption to access to health care and nutrition-related programs from schools; this situation has been more detrimental for younger children from LMICs.

Summary

Given the devastating effects of the COVID-19 pandemic on the nutritional status, higher food insecurity, and lack of access to health care for infants and children in LMICs, efforts from government, world organizations, and non-for-profit institutions should be implemented to ameliorate the effects of this pandemic.

A methodological and clinical approach to measured energy expenditure in the critically ill pediatric patient

The metabolic response to injury and stress is characterized initially by a decreased energy expenditure (Ebb phase) followed by an increased metabolic expenditure (Flow phase). Indirect calorimetry is a methodology utilized to measure energy expenditure and substrate utilization by measuring gas exchange in exhaled air and urinary nitrogen. The use of indirect calorimetry in critically ill patients requires precise equipment to obtain accurate measurements. The most recent guidelines suggested that measured energy expenditure by indirect calorimetry be used to determine energy requirements. This article reviews the methodological and clinical use of indirect calorimetry in critically ill pediatric patients.

Characteristics and Outcomes of Pediatric Rapid Response With a Respiratory Trigger

BACKGROUND AND OBJECTIVES

Authors of adult rapid response (RRT) studies have established that RRT triggers play an important role in outcomes, but this association is not studied in pediatrics. In this study, we explore the characteristics and outcomes of pediatric rapid response with a respiratory trigger (Resp-RRT). We hypothesize that outcomes differ on the basis of patients' primary diagnoses at the time of Resp-RRT.

METHODS

We conducted a 2-year retrospective observational study at an academic tertiary care pediatric hospital.

RESULTS

Among the 1287 Resp-RRTs in 1060 patients, those with a respiratory diagnosis (N = 686) were younger, less likely to have complex chronic conditions, and less likely to have concurrent triggers (P < .01) than those with a nonrespiratory diagnosis (N = 601). Patients with a respiratory diagnosis were more likely to receive noninvasive ventilation, less likely to receive vasoactive support, and had lower 30-day mortality (P < .01). Among those with a respiratory diagnosis, the 541 patients with acute illness were younger, less likely to have complex chronic conditions, and less likely to receive vasoactive support than those with acute on chronic illness (N = 100) (P < .01).

CONCLUSIONS

Among pediatric respiratory-triggered RRT events, patients with a respiratory diagnosis were more likely to receive acute respiratory support in ICU but have better long-term outcomes. Presence of complex chronic conditions increases risk of acute respiratory support and mortality. The interplay of primary diagnosis with RRT trigger can potentially inform resource needs and outcomes for pediatric Resp-RRTs.

Influence of early extubation on post-operative outcomes after pediatric lung transplantation

Lung transplantation has become an accepted therapeutic option for a select group of children with end-stage lung disease. We evaluated the impact of early extubation in a pediatric lung transplant population and its post-operative outcomes. Single-center retrospective study. PICU within a tertiary academic pediatric hospital. Patients <22 years after pulmonary transplant between January 2011 and December 2016. A total of 74 patients underwent lung transplantation. The primary pretransplantation diagnoses included cystic fibrosis (58%), pulmonary fibrosis (9%), and surfactant dysfunction disorders (10%). Of 60 patients, 36 (60%) were extubated within 24 hours and 24 patients after 24 hours (40%). A total of seven patients (11.6%) required reintubation within 24 hours. Median length of stay for the early extubation group was shorter at 3 days ([(IQR) 2.2-4.7]) compared to 5 days (IQR, 3-7) (P = .02) in the late extubation group. Median costs were lower for the early extubation group with 13,833 US dollars (IQR, 9980-22,822) vs 23 671 US dollars (IQR, 16 673-39 267) (P = .043). Fourteen patients were in the PICU prior to their transplantation; this did not affect their early extubation success. Neither did the fact of requiring invasive or non-invasive mechanical ventilation before transplantation. Early extubation appears to be safe in a pediatric population after lung transplantation and is associated with a shorter LOS and decreased hospital costs. It may prevent known complications associated with mechanical ventilation.

Evaluation of Intravenous Ranitidine on Gastric pH in Critically Ill Pediatric Patients

OBJECTIVE

To determine the dosing regimen of intravenous ranitidine (IVR) most likely to achieve a gastric pH of ≥4 in critically ill pediatric patients.

METHODS

A retrospective cohort study was designed and included patients younger than 19 years with gastric pH samples taken from a nasogastric tube within 24 hours after a dose of IVR in an intensive care unit. Data collection included patient demographics, clinical variables, IVR dosing, and gastric pH samples. Descriptive statistical analysis and multivariable logistic regression analysis with clustering of patients was performed to determine variables associated with odds of obtaining a pH of ≥4.

RESULTS

A total of 628 patients (1356 nasogastric samples) met study criteria (median age 1.3 years [IQR, 0.33, 5.7 years]; 53% male). The IVR dose was 0.90 ± 0.30 mg/kg per dose every 8.1 ± 2.9 hours, and 60.9% of patients (n = 383) had a pH ≥4. Patients with a pH value ≥4 had gastric pH samples taken earlier after a dose of IVR (6.7 ± 5.0 vs. 5.9 ± 4.7 hours, p < 0.001) but had no difference in IVR dose per kilogram (0.88 ± 0.31 vs. 0.88 ± 0.26, p = 0.86) or frequency of dosing (7.9 ± 3.2 vs. 7.9 ± 3.2 hours, p = 0.89). A multivariable logistic regression model identified increasing age, decreased kidney function, and decreased time to pH sample after an IVR dose with significantly greater odds of pH ≥4.

CONCLUSIONS

The IVR dosing to maintain a gastric pH ≥4 in critically ill pediatric patients should occur more frequently than every 8 hours. Gastric pH evaluation may be necessary to assess IVR efficacy.

Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.

Fluid Overload and Kidney Injury Score as a Predictor for Ventilator-Associated Events

Objective: The Pediatric and Neonatal Working group developed new ventilator associated events (VAE) definitions for children and neonates. VAE includes ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and ventilator-associated pneumonia (VAP). Acute kidney injury (AKI) and fluid overload (FO) have been associated with worse clinical outcomes of ventilated children. Fluid Overload and Kidney Injury Score (FOKIS) is an automatically calculated score that combines AKI and FO in one numeric quantifiable metric. This study analyzed the association between FOKIS and VAE. Design: Retrospective matched case control study. Setting: A freestanding children's hospital. Patients: A total of 168 who were ventilated > 2 days. Interventions: None. Measurements and Main Results: We identified 42 VAC cases (18 IVAC and 24 non-infection-related VAC cases). Controls were matched to cases for age, immunocompromised status and ventilator days prior to VAC. VAC cases had longer ICU days, median (IQR), 28.5 (15, 47) vs. controls 11 (6, 16), p < 0.001; longer ventilation days, 19.5 (13, 32) vs. 9 (4,13), p < 0.001; and higher hospital mortality, 45.2 vs. 18%, p < 0.001. VACs had a higher incidence of AKI, 85.7 vs. 47.3%, p < 0.001; higher peak daily FO% within 3 days preceding VAC, mean (SD), 8.1(7.8) vs. 4.1 (3.4), p < 0.005; and higher peak FOKIS, 6.4(3.8) vs. 3.7(2.8), (p < 0.001). Multivariate regression model adjusted for severity of illness identified peak FOKIS (odds ratio [OR] 1.29, 95%CI: 1.14-1.48, p < 0.001) and peak inspiratory pressure (OR 1.08, 95%CI: 1.02-1.15, p = 0.007) as risk factors for VAC. Conclusions: The FOKIS and its clinical variables were associated risk factors for ventilator-associated events. Further studies will determine the utility of FOKIS as a predictor for VAEs.

Variation in Protein Origin and Utilization: Research and Clinical Application

Muscle health can be rapidly compromised in clinical environments. Modifiable strategies to preserve metabolic homeostasis in adult patient populations include physical activity and pharmacologic support; however, optimizing dietary practices, or more specifically protein intake, is a necessary prerequisite for any other treatment strategy to be fully effective. Simply increasing protein intake is a well-intentioned but often unfocused strategy to protect muscle health in an intensive care setting. Protein quality is a frequently overlooked factor with the potential to differentially influence health outcomes. Quality can be assessed by a variety of techniques, with digestible indispensable amino acid score being the current and most comprehensive technique endorsed by the Food and Agriculture Organization. In practical terms, animal-based proteins are consistently scored higher in quality compared with incomplete proteins, regardless of the assessment method. Consequently, choosing parenteral and/or enteral feeding options that contain high-quality proteins, rich in the branched-chain amino acid leucine, may help establish a dietary framework with the potential to support clinical practice and improve health outcomes in critically ill patients.

Protein Requirements of the Critically Ill Pediatric Patient

This article includes a review of protein needs in children during health and illness, as well as a detailed discussion of protein metabolism, including nitrogen balance during critical illness, and assessment and prescription/delivery of protein to critically ill children. The determination of protein requirements in children has been difficult and challenging. The protein needs in healthy children should be based on the amount needed to ensure adequate growth during infancy and childhood. Compared with adults, children require a continuous supply of nutrients to maintain growth. The protein requirement is expressed in average requirements and dietary reference intake, which represents values that cover the needs of 97.5% of the population. Critically ill children have an increased protein turnover due to an increase in whole-body protein synthesis and breakdown with protein degradation leading to loss of lean body mass (LBM) and development of growth failure, malnutrition, and worse clinical outcomes. The results of protein balance studies in critically ill children indicate higher protein needs, with infants and younger children requiring higher intakes per body weight compared with older children. Monitoring the side effects of increased protein intake should be performed. Recent studies found a survival benefit in critically ill children who received a higher percentage of prescribed energy and protein goal by the enteral route. Future randomized studies should evaluate the effect of protein dosing in different age groups on patient outcomes, including LBM, muscle structure and function, duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality.

Implementation of Nutrition Support Guidelines May Affect Energy and Protein Intake in the Pediatric Intensive Care Unit

BACKGROUND

Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality.

OBJECTIVE

The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU).

DESIGN

This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively.

PARTICIPANTS/SETTING

Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation).

INTERVENTION

Implementation of NS Guidelines.

MAIN OUTCOME MEASURES

Changes in actual energy and protein intake in the post- compared with the pre-Implementation period.

STATISTICAL ANALYSIS PERFORMED

Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score.

RESULTS

After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (P<0.05). For the 8-day period, statistically or clinically significant improvements occurred in the cumulative protein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively.

CONCLUSIONS

The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a positive effect on improving NS in critically ill children.

Protein Feeding in Pediatric Acute Kidney Injury Is Not Associated With a Delay in Renal Recovery

OBJECTIVE

Critically ill children with acute kidney injury (AKI) are at high risk of underfeeding. Newer guidelines for nutrition support recommend higher protein intake. Therefore, the study evaluated the effects of protein feeding on the resolution of AKI and compared energy and protein intake in patients with and without AKI after implementation of Nutrition Support guidelines.

DESIGN

Retrospective study.

SUBJECTS

Five hundred twenty critically ill children from October 2012 to June 2013 and October to December 2013.

MAIN OUTCOME MEASURE

Energy and protein intake in patients with no AKI, resolved, or persistent AKI. Energy and protein intake was documented for days 1-8 of Pediatric Intensive Care Unit stay and in the postimplementation versus preimplementation period of nutrition support guidelines. AKI was defined by modified pRIFLE. Persistent AKI was defined as patients who did not resolve their AKI during the study period.

RESULTS

A higher percentage of patients with resolved and persistent AKI met ≥ 80% of protein needs versus no AKI. After adjustment for Pediatric Risk of Mortality Score, the odds ratio for protein intake of ≥ 80% compared to <80% of estimated protein needs was not significant, which suggests that higher protein intake was not associated with nonresolution of AKI. There were significant improvements in the cumulative protein gap in patients with no AKI in the postimplementation (-1.0 [-1.7 to -0.6] g/kg/day) compared to preimplementation period (-1.3 [-1.7 to -0.9] g/kg/day, P = .001) and persistent AKI in the postimplementation (-0.8 [-1.4 to -0.1] g/kg/day) compared to preimplementation (-1.3 [-1.7 to -0.9] g/kg/day, P = .03).

CONCLUSIONS

Higher protein intake was not associated with a delay in renal recovery in patients with AKI after adjustment for severity of illness. Protein intake was improved in critically ill children with no AKI, resolved, and persistent AKI after implementation of Nutrition Support Guidelines, but underfeeding persisted in these patients.

Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema

OBJECTIVE

To compare outcomes of diabetic ketoacidosis (DKA) 6 yrs before and 6 yrs after changing rehydration fluids from ½ normal saline to Lactated Ringer's and decreasing the total intended fluid volume administered in the first 24 hrs from 3500 mL/m(2) /d to ≤ 2500 mL/m(2) /d at Texas Children's Hospital (TCH) in response to recommendations by the ESPE, LWPES, and ISPAD in 2004.

SUBJECTS/METHODS

A retrospective cohort study was conducted in which 1868 admissions for DKA were identified and reviewed. The cohort was divided into two groups: Group A, 1998-2004, and Group B, 2004-2010. Subjects with suspected clinical cerebral edema and adverse outcomes were identified.

RESULTS

Although not statistically significant, there was an equal number (n = 3) of adverse outcomes (death or neurological damage) in each group despite more than double the admissions in Group B (1264) compared with those in Group A (604). Overall, the incidence of suspected clinical cerebral edema was more than double for those admissions in which fluid resuscitation was initiated at an outside hospital (OSH) vs. at TCH (13.6 vs. 5.3%, p < 0.001).

CONCLUSIONS

Decreasing the intended fluid rate during the initial 24 hrs to 2500 mL/m(2) /d and increasing the IV fluid sodium content did not significantly decrease the incidence of adverse outcomes in children with DKA. However, children transferred from an OSH had a higher incidence of suspected clinical cerebral edema. Thus, we need to more readily share our management protocols with the emergency rooms of local referring hospitals to potentially decrease the incidence of suspected clinical cerebral edema and adverse outcomes in children transferred with DKA.

Growth failure and nutrition considerations in chronic childhood wasting diseases

Growth failure is a common problem in many children with chronic diseases. This article is an overview of the most common causes of growth failure/growth retardation that affect children with a number of chronic diseases. We also briefly review the nutrition considerations and treatment goals. Growth failure is multifactorial in children with chronic conditions, including patients with cystic fibrosis, chronic kidney disease, chronic liver disease, congenital heart disease, human immunodeficiency virus, inflammatory bowel disease, short bowel syndrome, and muscular dystrophies. Important contributory factors to growth failure include increased energy needs, increased energy loss, malabsorption, decreased energy intake, anorexia, pain, vomiting, intestinal obstruction, and inflammatory cytokines. Various metabolic and pathologic abnormalities that are characteristic of chronic diseases further lead to significant malnutrition and growth failure. In addition to treating disease-specific abnormalities, treatment should address the energy and protein deficits, including vitamin and mineral supplements to correct deficiencies, correct metabolic and endocrinologic abnormalities, and include long-term monitoring of weight and growth. Individualized, age-appropriate nutrition intervention will minimize the malnutrition and growth failure seen in children with chronic diseases.

Changes in body composition after lung transplantation in children

BACKGROUND

The evaluation of nutritional status, including body composition measurements, in pediatric patients before and after lung transplant (LTx) can aid in adapting nutrition support and physical rehabilitation programs to meet individual patient needs. The purpose of this retrospective study was to determine the changes in weight, lean body mass (LBM), and body fat (BF) before and after LTx and their association with lung function in pediatric patients.

METHODS

Included were 41 LTx patients, aged 3 months to 20.7 years, who had at least 2 body composition measurements determined by dual-energy X-ray absorptiometry (GE Lunar Prodigy, Waukesha, WI) in the first 2 years after LTx were measured pre-LTX and at 12 or 24 months post-LTX, for weight, LBM, and BF.

RESULTS

Pre-LTx, 29% of patients had moderate and 12% had severe chronic malnutrition (growth stunting). This compares with 21% of patients being moderately LBM-depleted and 23% being BF-depleted. The weight change at 12 and 24 months was +9.3% (interquartile range, 5.6%-23%) and +4.7% (0.9%-11.6%), respectively; whereas the LBM change at 12 and 24 months was +15.2% (6.8%-17.1%) and +4.2% (-0.6% to 7.7%), respectively. LBM percentiles correlated with pulmonary function tests ( % predicted forced vital capacity [ρ = 0.36, p = 0.001] and forced expiratory volume in 1 second [ρ = 0.265, p = 0.015).

CONCLUSIONS

Maximum weight and LBM gain occur at 12 months after LTx, with smaller gains noted at 24 months. Clinicians must look beyond height and weight and evaluate LBM and fat mass in pediatric patients after LTx.

Vitamin D: effects on childhood health and disease

Vitamin D is a key nutrient for both healthy children and those with chronic illnesses. Understanding its roles in health and disease has become one of the most important issues in the nutritional management of children. Formal guidelines related to nutrient requirements for vitamin D in healthy children, recommending dietary intakes of 400 IU per day for infants and 600 IU per day for children over 1 year of age, were released by the Institute of Medicine in November 2010. However, application of these guidelines to children with acute and chronic illnesses is less clear. In this Review, we consider major illness categories and specific examples of conditions in children that might be affected by vitamin D. This information can be used in developing both model systems of investigation and clinical trials of vitamin D in children with acute and chronic illnesses.

Nutrition support among critically ill children with AKI

BACKGROUND

Critically ill children are at high risk of underfeeding and AKI, which may lead to further nutritional deficiencies. This study aimed to determine the adequacy of nutrition support during the first 5 days of intensive care unit (ICU) stay.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A chart review of pediatric patients admitted to the pediatric ICU for >72 hours between August 2007 and March 2008 was conducted. Patients were classified as having no AKI versus AKI by modified pediatric RIFLE criteria. All nutrition was analyzed. Basal metabolic rate (BMR) was estimated by the Schofield equation and protein needs by American Society for Parenteral and Enteral Nutrition guidelines.

RESULTS

Of the 167 patients, 102 were male and 65 were female (median age 1.4 years). Using the RIFLE criteria, 102 (61%) patients had no AKI, whereas 44 (26%) were classified as category R (risk), 12 (7%) as category I (injury), and 9 (5%) as category F (failure). The median 5-day energy intake was lower relative to estimated BMR. Overall protein provision (19%) was lower than energy provision (55%) compared with estimated needs (P<0.001). I/F patients were more likely to be fasted versus receiving enteral/parenteral nutrition (n=813 patient days) and to receive <90% of BMR (n=832 patient days) than No AKI/R patients.

CONCLUSIONS

Underfeeding, common in critically ill children, was accentuated in AKI. Protein underfeeding was greater than energy underfeeding in the first 5 days of PICU stay. Efforts should be made to provide adequate nutrition in ICU patients with AKI.

Nutrition support in critically ill children: underdelivery of energy and protein compared with current recommendations

Critically ill children are at high risk for developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. This study's aims were to examine current nutrition practices and the adequacy of nutrition support in the pediatric intensive care unit (PICU). This retrospective chart review included 240 PICU patients admitted to PICU for longer than 48 hours and documented all intravenous (IV), parenteral, and enteral energy and protein for the first 8 days. Basal metabolic rate and protein requirements were estimated by Schofield equation and the American Society for Parenteral and Enteral Nutrition Clinical Guidelines, respectively. Moderate/severe acute malnutrition was defined as weight for age greater than -2 z scores, and moderate/severe chronic malnutrition (growth stunting) was defined as height for age greater than -2 z scores, using 2000 Centers for Disease Control and Prevention growth charts. During the first 8 days of PICU stay, the actual energy intake for all patient-days was an average of 75.7% ± 56.7% of basal metabolic rate and was significantly lower than basal metabolic rate (P<0.001); the actual protein intake for all patient-days met an average of 40.4% ± 44.2% of protein requirements and was significantly lower than the American Society for Parenteral and Enteral Nutrition guidelines (P<0.001). Delivery of energy and protein were inadequate on 60% and 85% of patient-days, respectively. Only 75% of estimated energy and 40% of protein requirements were met in the first 8 days of PICU stay. These data demonstrate a high prevalence of critically ill children who are not meeting their recommended levels of protein and energy. In order to avoid undernutrition of these children, providers must conduct ongoing assessment of protein and energy intake compared with protein and energy requirements.

Is indirect calorimetry a necessity or a luxury in the pediatric intensive care unit?

BACKGROUND

Critically ill children differ in their energy needs from healthy children in terms of underlying metabolic derangement, comorbidities, energy reserve, and response to illness. This study determined how many pediatric intensive care unit (PICU) patients were candidates for indirect calorimetry (IC), per American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommendations.

METHODS

Admission diagnosis, demographics, type/amount of nutrition support, length of intensive care unit/hospital stay were collected. Patients were classified as candidates for IC per A.S.P.E.N. guidelines.

RESULTS

Mean (SD) age of patients (n = 150) was 6.7 (5.6) years, with PICU length of stay of 3.9 (5.3) days. IC was indicated in 72.0% (108/150) of patients during PICU days 1-7. Patients with miscellaneous (50%), neurological (73%), respiratory (81%), sepsis (83%), and oncology (100%) diagnoses were candidates for IC. Underweight/overweight/obese (32.4%), hypermetabolism (26.4%), and not meeting nutrition goals (13.7%) were the most frequent indications for IC (χ(2), P < .001). Patients (31%) met ≥2 indications for IC. Patients with neurological disease (relative risk [RR], 4.8; 95% confidence interval [CI], 1.7-14.6), oncology patients (4.2; 1.1-15.9), respiratory patients (5.5; 2.0-16.9), and children with sepsis/septic shock/infection (5.6; 1.9-18.1) were more likely to have ≥2 indications for IC compared to those with other diagnoses.

CONCLUSIONS

Three of 4 patients were candidates for IC per A.S.P.E.N. guidelines. PICUs might have to prioritize performing IC in patients who are <2 years of age, malnourished (underweight/overweight) on admission, or PICU stay of >5 days. Future studies should determine the cost-benefit ratios of performing IC in PICU patients.

Contribution of galactose and fructose to glucose homeostasis

To determine the contributions of galactose and fructose to glucose formation, 6 subjects (26 +/- 2 years old; body mass index, 22.4 +/- 0.2 kg/m(2)) (mean +/- SE) were studied during fasting conditions. Three subjects received a primed constant intravenous infusion of [6,6-(2)H(2)]glucose for 3 hours followed by oral bolus ingestion of galactose labeled to 2% with [U-(13)C]galactose (0.72 g/kg); the other 3 subjects received a primed constant intravenous infusion of [6,6-(2)H(2)]glucose followed by either a bolus ingestion of fructose alone (0.72 g/kg) (labeled to 2% with [U-(13)C]fructose) or coingestion of fructose (labeled with [U-(13)C]fructose) (0.72 g/kg) and unlabeled glucose (0.72 g/kg). Four hours after ingestion, subjects received 1 mg of glucagon intravenously to stimulate glycogenolysis. When galactose was ingested alone, the area under the curve (AUC) of [(13)C(6)]glucose and [(13)C(3)]glucose was 7.28 +/- 0.39 and 3.52 +/- 0.05 mmol/L per 4 hours, respectively. When [U-(13)C]fructose was ingested with unlabeled fructose or unlabeled fructose plus glucose, no [(13)C(6)]glucose was detected in plasma. The AUC of [(13)C(3)]glucose after fructose and fructose plus glucose ingestion was 20.21 +/- 2.41 and 6.25 +/- 0.34 mmol/L per 4 hours, respectively. Comparing the AUC for the (13)C(3) vs (13)C(6) enrichments, 67% of oral galactose enters the systemic circulation via a direct route and 33% via an indirect route. In contrast, fructose only enters the systemic circulation via the indirect route. Finally, when ingested alone, fructose and galactose contribute little to glycogen synthesis. After the coingestion of fructose and glucose with the resultant insulin response from the glucose, fructose is a significant contributor to glycogen synthesis.

Dead space ventilation in critically ill children with lung injury

STUDY OBJECTIVE

In children with acute lung injury, there is an increase in minute ventilation (E) and inefficient gas exchange due to a high level of physiologic dead space ventilation (VD/VT). Mechanical ventilation with positive end-expiratory pressure, when used in critically ill patients to correct hypoxemia, may contribute to increased VD/VT. The purpose of this study was to measure metabolic parameters and VD/VT in critically ill children.

DESIGN

A cross-sectional study.

SETTING

Pediatric ICU of a university hospital.

PATIENTS

A total of 45 mechanically intubated children (mean age, 5.5 years).

INTERVENTIONS

Indirect calorimetry was used to measure metabolic parameters. VD/VT parameters were calculated using the modified Bohr-Enghoff equation. ARDS was defined based on criteria by The American-European Consensus Conference.

MEASUREMENTS AND RESULTS

The group mean (+/- SD) ventilatory equivalent for oxygen (VeqO(2)) and ventilatory equivalent for carbon dioxide (VeqCO(2)) were 2.9 +/- 1 and 3.3 +/- 1 L per 100 mL, respectively. The group mean VD/VT was 0.48 +/- 0.2. When compared to non-ARDS patients (33 patients), the patients with ARDS (12 patients) had a significantly higher VeqO(2) (3.3 +/- 1 vs 2.8 +/- 1 L per 100 mL, respectively; p < 0.05), a significantly higher VeqCO(2) (3.7 +/- 1 L/100 vs 3.1 +/- 1 L per 100 mL, respectively; p < 0.05), and a significantly higher VD/VT (0.62 +/- 0.14 vs 0.43 +/- 0.15, respectively; p < 0.0005).

CONCLUSIONS

Critically ill children with ARDS have increased VD/VT. Increased VD/VT was the main cause of the excess of E demand in these patients. Increased metabolic demands, as shown by the VeqO(2), VeqCO(2), and ventilatory support, are the major determinants of E requirements in children with ARDS.

Energy metabolism, nitrogen balance, and substrate utilization in critically ill children

BACKGROUND

Critically ill patients are characterized by a hypermetabolic state, a catabolic response, higher nutritional needs, and a decreased capacity for utilization of parenteral substrate.

OBJECTIVE

We sought to analyze the relation between a patient's metabolic state and their nutritional intake, substrate utilization, and nitrogen balance (NB) in mechanically ventilated, critically ill children receiving parenteral nutrition.

DESIGN

This was a cross-sectional study in which resting energy expenditure (REE) and NB were measured and substrate utilization and the metabolic index (MI) ratio (REE/expected energy requirements) were calculated.

RESULTS

Thirty-three children (mean age: 5 y) participated. Their average REE was 0.23 +/- 0.10 MJ x kg(-1) x d(-1) and their average MI was 1.2 +/- 0.5. Mean energy intake, protein intake, and NB were 0.25 +/- 0.14 MJ x kg(-1) x d(-1), 2.1 +/- 1 g x kg(-1) x d(-1), and -89 +/- 166 mg x kg(-1) x d(-1), respectively. Patients with an MI >1.1 (n = 19) had a higher fat oxidation than did patients with an MI <1.1 (n = 14; P < 0.05). Patients with lipogenesis (n = 13) had a higher carbohydrate intake than did patients without lipogenesis (n = 20; P < 0.05). Patients with a positive NB (n = 12) had a higher protein intake than did patients with a negative NB (n = 21; P < 0.001) and lower protein oxidation (P < 0.01).

CONCLUSIONS

Critically ill children are hypermetabolic and in negative NB. In this population, fat is used preferentially for oxidation and carbohydrate is utilized poorly. A high carbohydrate intake was associated with lipogenesis and less fat oxidation, a negative NB was associated with high oxidation rates for protein, and a high protein intake was associated with a positive NB.

Respiratory system mechanics in patients receiving aerosolized ribavirin during mechanical ventilation for suspected respiratory syncytial viral infection

Respiratory syncytial virus (RSV) is an important respiratory pathogen for infants. Aerosolized ribavirin (AR) has been used in mechanically ventilated (MV) patients with RSV bronchiolitis. The purpose of this study was to measure respiratory system mechanics (RSM) in pediatric patients requiring MV and receiving AR for suspected RSV. Patients were prospectively randomized to receive AR, either at a regular dose (RD) (6 g/300 mL over 18 hr/day) or a high dose (HD) (6 g/100 mL over 2 hr, three times a day). To measure changes in RSM, a passive exhalation technique was used before and after each dose of AR; time constant (tc) in s, resistance (Rrs) in cmH(2)O/mL/kg/s, and quasistatic compliance (Crs) in mL/cmH(2)O/kg were measured. Airway pressure and flow signals were obtained and analyzed using a pneumotachograph, a differential pressure transducer, and a computer interface. Statistical analysis was done by Mann-Whitney and Wilcoxon rank tests. Thirteen patients were enrolled: 5 patients in the HD group (mean age of 52 months), and 8 patients in the RD group (mean age of 10 months). Four and 5 patients were positive for RSV by ELISA in the HD and RD groups, respectively. The RSM in the HD group were: tc, 0.58 +/- 0.15 s and 0.55 +/- 0.20 s before and after AR, respectively; Rrs, 0.03 +/- 0. 03 cmH(2)0/mL/kg/s and 0.02 +/- 0.02 cmH(2)0/mL/kg/s, respectively; and Crs, 0.63 +/- 0.21 mL/cmH(2)O/kg and 0.70 +/- 0.13 mL/cmH(2)O/kg, respectively. In the RD group, the RSM were: tc, 0.37 +/- 0.12 s and 0.31 +/- 0.10 s before and after AR, respectively; Rrs, 0.03 +/- 0.02 cmH(2)0/mL/kg/s and 0.02 +/- 0.01 cmH(2)0/mL/kg/s, respectively (P < 0.05); and Crs, 0.46 +/- 0.20 mL/cmH(2)O/kg and 0.46 +/- 0.19 mL/cmH(2)O/kg, respectively. We conclude that the use of AR for bronchiolitis in infants and young children during mechanical ventilation does not worsen RSM.

Evaluation of a real-time blood glucose monitor in children with diabetic ketoacidosis

Use of a real-time bedside glucose monitor was analyzed during the course of management of diabetic ketoacidosis (DKA) in children. Simultaneous determinations of blood glucose were obtained, using three methods: bedside glucose meter (One Touch II), laboratory glucose analyzer (YSI 2300 STAT), and a real-time bedside glucose monitor (VIA 1-01G Blood Chemistry monitor). Study patients included seventeen patients < 18 years of age admitted to a Pediatric Intensive Care Unit, with blood samples obtained during treatment of DKA by continuous insulin infusion. Four patients did not complete the study. Three experienced temporary technical problems with the monitor, and four required repeat IV placement. Duration of monitor use ranged between 6 and 47 h (mean 24 +/- 4 h). Blood glucose values ranged between 2.6 and 22.5 mmol/l. Overall correlation of blood glucose values were as follows: 0.965, 0.965, 0.973, VIA 1-01G vs. One Touch II, VIA 1-01G vs. YSI 2300 STAT, and One Touch II vs. YSI 2300 STAT, respectively (all P-values < 0.0001). This real-time bedside glucose monitor is accurate at glucose values < 13.8 mmol/l, and reliable for rapid, repetitive analyses. Results indicate that blood glucose values obtained using this real-time monitor are comparable to those using standard methods of measurement, and that this device is clinically applicable for use in management of children with DKA.

Resting energy expenditure and nitrogen balance in critically ill pediatric patients on mechanical ventilation

Nutritional support is important in critically ill patients, with variable energy and nitrogen requirements (e.g., sepsis, trauma, postsurgical state) in this population. This study investigates how age, severity of illness, and mechanical ventilation are related to resting energy expenditure (REE) and nitrogen balance. Nineteen critically ill children (mean age, 8 +/- 6 [SD] y and range 0.4-17.0 y) receiving total parenteral nutrition (TPN) were enrolled. We used indirect calorimetry to measure REE. Expected energy requirements (EER) were obtained from Talbot tables. Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) score were calculated. Total urinary nitrogen was measured using the Kjeldahl method. PRISM and TISS scores were 9 +/- 5 and 31 +/- 6 points, respectively. REE was 62 +/- 25 kcal.kg-1.d-1, EER was 42 +/- 11 kcal.kg-1. d-1, and caloric intake was 49 +/- 22 kcal.kg-1.d-1. Nitrogen intake was 279 +/- 125 mg.kg-1.d-1, total urinary nitrogen was 324 +/- 133 mg.kg-1.d-1, and nitrogen balance was -120 +/- 153 mg.kg-1.d-1. The protein requirement in this population was approximately 2.8 g.kg-1.d-1. These critically ill children were hypermetabolic, with REE 48% higher (20 kcal.kg-1.d-1) than expected. Nitrogen balance significantly correlated with caloric and protein intake, urinary nitrogen, and age, but not with severity of illness scores or ventilatory parameters.

Resting energy expenditure in children in a pediatric intensive care unit: comparison of Harris-Benedict and Talbot predictions with indirect calorimetry values

The use of prediction equations has been recommended for calculating energy expenditure. We evaluated two equations that predict energy expenditure, each of which were corrected for two different stress factors, and compared the values obtained with those calculated by indirect calorimetry. The subjects were 55 critically ill children on mechanical ventilation. Basal metabolic rates were calculated with the Harris-Benedict and Talbot methods. Measured resting energy expenditure was 4.72 +/- 2.53 MJ/d. The average difference between measured resting energy expenditure and the Harris-Benedict prediction with a stress factor of 1.5 was -0.98 MJ/d, with an SD delta of 1.56 MJ/d and limits of agreement from -4.12 to 2.15; for a stress factor of 1.3 the average difference was -0.22 MJ/d, with an SD delta of 1.57 MJ/d and limits of agreement from -3.37 to 2.93. The average difference between measured resting energy expenditure and the Talbot prediction with a stress factor of 1.5 was -0.23 MJ/d, with an SD delta of 1.36 MJ/d and limits of agreement from -2.95 to 2.48; for a stress factor of 1.3, it was 0.42 MJ/d, with an SD delta of 1.24 MJ/d and limits of agreement from -2.04 to 2.92. These limits of agreement indicate large differences in energy expenditure between the measured value and the prediction estimated for some patients. Therefore, neither the Harris-Benedict nor the Talbot method will predict resting energy expenditure with acceptable precision for clinical use. Indirect calorimetry appears to be the only useful way of determining resting energy expenditure in these patients.

Hemoptysis: a 10-year retrospective study

BACKGROUND

Hemoptysis is uncommon in pediatric practice. We reviewed 10 years of experience with hemoptysis in a tertiary pediatric hospital to identify patient characteristics and predictors of mortality.

METHODS

Patients were divided into four age groups (0 to 5, 6 to 10, 11 to 20, and >20 years). Hemoptysis was defined as mild (<150 mL/day), large (150 to 400 mL/day), or massive (>400 mL/day). Fever was defined as >/=38.5 degrees C.

RESULTS

A total of 228 patients (115 males and 113 females) with 246 episodes of hemoptysis were identified and grouped according to primary diagnosis. There were 149 patients in the cystic fibrosis (CF) group, 37 in the congenital heart disease (CHD) group, and 42 in the Other group. Age was significantly higher in the CF group compared with the CHD and Other groups. Length of stay was significantly prolonged in the CF group compared with the Other group. The overall mortality was 13%. After initial analysis, mortality predictors were age, amount of hemoptysis, receipt of blood products, and fever. After stratification, we found: 1) in the >20-year age group, there was a difference in mortality when comparing CF patients with CHD patients; 2) for patients who received blood products, there were differences in mortality in patients with CF, CHD, and Other diagnoses; 3) for patients who received blood, there were differences in mortality only for the 0- to 5-year age group; and 4) the amount of hemoptysis was predictive for mortality only in CHD patients.

CONCLUSIONS

Hemoptysis presented in young adult CF patients and in adolescent CHD patients. Young adult CF patients with hemoptysis had a higher risk of mortality compared with young adult CHD patients. The amount of hemoptysis predicted mortality only for CHD patients. Receiving blood products was predictive of mortality for all patients.

Nutrition requirements in patients with toxic epidermal necrolysis

Patients with toxic epidermal necrolysis, a severe, exfoliative skin disorder, have clinical features similar to those of partial-thickness burn patients. The literature suggests that they also have similar nutritional requirements. We report two patients diagnosed with toxic epidermal necrolysis on mechanical ventilation, in whom resting energy expenditure and respiratory quotient were measured by indirect calorimetry. The patients were treated using standard burn protocols. Nitrogen balance was calculated by measuring total urinary nitrogen in urine samples obtained over 24 hours. These measurements were done while the patients were on mechanical ventilation and receiving total parenteral nutrition. As in burn patients, early in their course the two patients had resting energy expenditure values twice that predicted. After 12 days of hospitalization, nitrogen balance was negative in patient 1 and positive in patient 2. Energy and protein requirements appear to have been related to the amount of body surface affected.