Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021)

OBJECTIVES

Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients.

DESIGN

Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497).

SETTING

Eighteen ICUs participated in ICU-RESUS.

PATIENTS

There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation.

CONCLUSIONS

We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.

Association of Pediatric Post-Cardiac Arrest Ventilation and Oxygenation with Survival Outcomes

RATIONALE

Adult and pediatric studies provide conflicting data whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia and/or hypocapnia are associated with worse outcomes.

OBJECTIVES

Determine if post-arrest hypoxemia or post-arrest hyperoxemia are associated with lower rates of survival to hospital discharge compared to post-arrest normoxemia, and if post-arrest hypocapnia or hypercapnia are associated with lower rates of survival compared to post-arrest normocapnia.

METHODS

Embedded prospective observational study during a multi-center interventional cardiopulmonary resuscitation trial from 2016-2021. Patients ≤18 years and ≥37 weeks corrected gestational age who received chest compressions for cardiac arrest in one of 18 ICUs were included. Exposures during the first 24 hours post-arrest were hypoxemia, hyperoxemia, or normoxemia defined as lowest PaO2 <60mmHg, highest PaO2 ≥200mmHg, or every PaO2 60-199mmHg, respectively, and hypocapnia, hypercapnia, or normocapnia defined as lowest PaCO2 <30mmHg, highest PaCO2 ≥50mmHg, or every PaCO2 30-49mmHg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates.

MEASUREMENTS AND MAIN RESULTS

The hypoxemia group was less likely to survive to hospital discharge compared with the normoxemia group (aRR 0.71, 0.58-0.87), whereas the hyperoxemia group survival did not differ from the normoxemia group (aRR 1.0, 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge compared with the normocapnia group (aRR 0.74, 0.64-0.84), whereas the hypocapnia group survival did not differ from the normocapnia group (aRR 0.91, 0.74-1.12).

CONCLUSIONS

Post-arrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.

Healthcare Burden and Resource Utilization After Pediatric Acute Respiratory Distress Syndrome: A Secondary Analysis of the Collaborative Pediatric Critical Care Research Network Acute Respiratory Distress Syndrome Study

OBJECTIVES

To describe family healthcare burden and health resource utilization in pediatric survivors of acute respiratory distress syndrome (ARDS) at 3 and 9 months.

DESIGN

Secondary analysis of a prospective multisite cohort study.

SETTING

Eight academic PICUs in the United States (2019-2020).

PATIENTS

Critically ill children with ARDS and follow-up survey data collected at 3 and/or 9 months after the event.

INTERVENTIONS

None.

METHODS AND MEASUREMENT

We evaluated family healthcare burden, a measure of healthcare provided by families at home, and child health resource use including medication use and emergency department (ED) and hospital readmissions during the initial 3- and 9-month post-ARDS using proxy-report. Using multivariable logistic regression, we evaluated patient characteristics associated with family healthcare burden at 3 months.

MAIN RESULTS

Of 109 eligible patients, 74 (68%) and 63 patients (58%) had follow-up at 3- and 9-month post-ARDS. At 3 months, 46 families (62%) reported healthcare burden including (22%) with unmet care coordination needs. At 9 months, 33 families (52%) reported healthcare burden including 10 families (16%) with unmet care coordination needs. At month 3, 61 patients (82%) required prescription medications, 13 patients (18%) had ED visits and 16 patients (22%) required hospital readmission. At month 9, 41 patients (65%) required prescription medications, 19 patients (30%) had ED visits, and 16 (25%) required hospital readmission were reported. Medication use was associated with family healthcare burden at both 3 and 9 months. In a multivariable analysis, preillness functional status and chronic conditions were associated with healthcare burden at month 3 but illness characteristics were not.

CONCLUSIONS

Pediatric ARDS survivors report high rates of healthcare burden and health resource utilization at 3- and 9-month post-ARDS. Future studies should assess the impact of improved care coordination to simplify care (e.g., medication management) and improve family burden.

"I Didn't Realize How Hard It Was Going to Be Just Transitioning Back into Life": A Qualitative Exploration of Outcomes for Survivors of Pediatric Septic Shock

Recovery following pediatric critical illness is multifaceted and complex. While most critically ill children survive, many experience morbidities in physical, emotional, cognitive, and social function. We aimed to deeply explore and describe the multidimensional impact of pediatric septic shock for affected children and their families at the granular level using exploratory qualitative methodology. We performed semistructured telephone interviews of adolescents and caregivers of children admitted with community-acquired septic shock to two tertiary pediatric intensive care units in the United States. Interviews were conducted within two years of hospital admission, and were recorded, transcribed, and analyzed using thematic analysis. Two adolescents and 10 caregivers were interviewed. Participants described meaningful and long-lasting outcomes of septic shock on multiple dimensions of their lives. The adolescents and caregivers described substantial negative consequences on physical health and function which resulted in increased medical complexity and heightened caregiver vigilance. The physical impact led to substantial psychosocial consequences for both the child and family, including social isolation. Most caregivers expressed that septic shock was transformational in their lives, with some caregivers describing posttraumatic growth. This preliminary study provides a novel, granular view of the multidimensional impact of septic shock in pediatric patients and their families. Exploring these experiences through qualitative methodology provides greater insight into important patient and family outcomes. Deeper understanding of these outcomes may support the development of meaningful interventions to improve quality of life for children and their families following critical illness.

Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival

BACKGROUND

Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that "specific values to guide therapy have not been established in children."

METHODS

This prospective observational cohort study was a National Heart, Lung, and Blood Institute-funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate).

RESULTS

Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00-1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups.

CONCLUSIONS

In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.

Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis

AIM

Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes.

METHODS AND RESULTS

Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes.

CONCLUSIONS

Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.

Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease

OBJECTIVES

To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease.

DESIGN

Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021).

SETTING

Eighteen PICUs.

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups.

CONCLUSIONS

In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.

Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection

OBJECTIVES

Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs).

DESIGN

This is an analysis of of a seven-center prospective cohort study.

SETTING

Seven PICUs within academic children's hospitals in the United States.

PATIENTS

Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours.

INTERVENTIONS

We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement.

MEASUREMENTS AND MAIN RESULTS

Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001).

CONCLUSIONS

Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.

Change in Functional Status During Hospital Admission and Long-Term Health-Related Quality of Life Among Pediatric Septic Shock Survivors

OBJECTIVES

To investigate whether change in functional status from pre-hospitalization baseline to hospital discharge is associated with long-term health-related quality of life (HRQL) among children surviving septic shock.

DESIGN

Secondary analysis of Life After Pediatric Sepsis Evaluation (LAPSE), a prospective cohort study of children with community-acquired septic shock, enrolled from January 2014 to June 2017.

SETTING

Twelve U.S. academic PICUs.

PATIENTS

Children, 1 month to 18 years, who survived to hospital discharge and had follow-up data for HRQL at 3 and/or 12 months.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional Status Scale (FSS) was assessed around enrollment to ascertain baseline status (pre-hospitalization) and at 28 days or hospital discharge. Two measures of HRQL were utilized: children with significant development delay were measured with the Functional Status II-R (FSII-R); typically, developing children were measured with the Pediatric Quality of Life Inventory (PedsQL). Each group was analyzed separately with multivariable regression modeling to determine the association between change in FSS from baseline to day 28 and HRQL at 3 and 12 months from PICU admission. Of the original 389 LAPSE participants, 224 (58%) are included. Among children with developmental delay ( n = 88), worsened FSS was associated with lower FSII-R at 3 months from PICU admission (-2.02; 95% CI, -3.34 to -0.0.71; p = 0.003), but not 12 months. Among developmentally typical children ( n = 136), worsened FSS was associated with lower PedsQL at both 3 and 12 months. Developmentally typical children with a neurologic insult during the PICU stay had the largest decrement in PedsQL at 12 months (-14.04 mo; 95% CI, -22.15 to -5.94 mo; p < 0.001). However, worsened FSS remained associated with poor HRQL-PedsQL at 3 and 12 months, after controlling for neurologic events (both p < 0.001).

CONCLUSIONS

Change in FSS during hospitalization for septic shock is associated with long-term reductions in HRQL and could serve as a useful tool for identifying children at risk for this sequela.

Predicting functional and quality-of-life outcomes following pediatric sepsis: performance of PRISM-III and PELOD-2

BACKGROUND

Illness severity scores predict mortality following pediatric critical illness. Given declining PICU mortality, we assessed the ability of the Pediatric Risk of Mortality-III (PRISM) and Pediatric Logistic Organ Dysfunction-2 (PELOD) scores to predict morbidity outcomes.

METHODS

Among 359 survivors <18 years in the Life After Pediatric Sepsis Evaluation multicenter prospective cohort study, we assessed functional morbidity at hospital discharge (Functional Status Scale increase ≥3 points from baseline) and health-related quality of life (HRQL; Pediatric Quality of Life Inventory or Functional Status II-R) deterioration >25% from baseline at 1, 3, 6, and 12 months post-admission. We determined discrimination of admission PRISM and admission, maximum, and cumulative 28-day PELOD with functional and HRQL morbidity at each timepoint.

RESULTS

Cumulative PELOD provided the best discrimination of discharge functional morbidity (area under the receive operating characteristics curve [AUROC] 0.81, 95% CI 0.76-0.87) and 3-month HRQL deterioration (AUROC 0.71, 95% CI 0.61-0.81). Prediction was inferior for admission PRISM and PELOD and for 6- and 12-month HRQL assessments.

CONCLUSIONS

Illness severity scores have a good prediction of early functional morbidity but a more limited ability to predict longer-term HRQL. Identification of factors beyond illness severity that contribute to HRQL outcomes may offer opportunities for intervention to improve outcomes.

IMPACT

Illness severity scores are commonly used for mortality prediction and risk stratification in pediatric critical care research, quality improvement, and resource allocation algorithms. Prediction of morbidity rather than mortality may be beneficial given declining pediatric intensive care unit mortality. The PRISM and PELOD scores have moderate to good ability to predict new functional morbidity at hospital discharge following pediatric septic shock but limited ability to predict health-related quality of life outcomes in the year following PICU admission. Further research is needed to identify additional factors beyond illness severity that may impact post-discharge health-related quality of life.

Parental supporter in pediatric resuscitation: A mixed-method study with Delphi and analytic hierarchy process

INTRODUCTION

Providing support to parents is an evidence-based practice and a crucial part of family-centered nursing care. However, it is not clear who and how to provide the best support to parents during and after their child's resuscitation attempts.

PURPOSE

This study was conducted to explore the characteristics and roles of parental supporters responsible for caring for parents during and after their child's resuscitation.

METHODS

This is a mixed-method study combining the Delphi technique and the Analytic Hierarchy Process. A list of potentially important items describing the characteristics and roles of parental supporters caring for parents during and after pediatric resuscitation was developed through qualitative interviews with parents and members of the resuscitation team, and a thorough literature search. Then, the Delphi round was conducted with key experts. In the final step, the Analytic Hierarchy Process was used for ranking items in the order of their importance.

RESULTS

A list with 69 items describing the characteristics and roles of parental supporters was developed. 15 items (21.74%) were related to the "Characteristics of parental supporter" category; 8 items (11.59%) were related to the "Roles of a parental supporter during resuscitation" category; 13 items (18.84%) were related to the "Roles of a parental supporter after successful resuscitation" category; 23 items (33.34%) were related to the "Roles of a parental supporter after unsuccessful resuscitation" category; and 10 items (14.49%) were related to the "Roles of a parental supporter after unsuccessful resuscitation with help of other staff of the hospital" category.

CONCLUSION

The findings of this study can be used to develop guidelines that include parental supporter characteristics and roles to support parents during and after their child's resuscitation according to family-centered care practices in pediatric settings.

CLINICAL RELEVANCE

Study findings indicate the need for the presence of a parental supporter during and after pediatric resuscitation, whether witnessed by the parents or not. Knowledge regarding the characteristics and roles of parental supporters can be used in practice to uphold family-centered nursing care during critical situations.

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

INTRODUCTION

Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.

METHODS

We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.

RESULTS

Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).

CONCLUSIONS

Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.

Fluid Balance and Its Association With Mortality and Health-Related Quality of Life: A Nonprespecified Secondary Analysis of the Life After Pediatric Sepsis Evaluation

OBJECTIVES

To evaluate the association between fluid balance (FB) and health-related quality of life (HRQL) among children at 1 month following community-acquired septic shock.

DESIGN

Nonprespecified secondary analysis of the Life After Pediatric Sepsis Evaluation. FB was defined as 100 × [(cumulative PICU fluid input - cumulative PICU fluid output)/PICU admission weight]. Three subgroups were identified: low FB (< 5%), medium FB (5%-15%), and high FB (> 15%) based on cumulative FB on days 0-3 of ICU stay. HRQL was measured at ICU admission and 1 month after using Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales or the Stein-Jessop Functional Status Scale. The primary outcome was a composite of mortality or greater than 25% decline in HRQL 1 month after admission compared with baseline.

SETTING

Twelve academic PICUs in the United States.

PATIENTS

Critically ill children between 1 month and 18 years, with community-acquired septic shock who survived to at least day 4.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred ninety-three patients were included of whom 66 (23%) had low FB, 127 (43%) had medium FB, and 100 (34%) had high FB. There was no difference in Pediatric Risk of Mortality Score 3 (median 11 [6, 17]), age (median 5 [1, 12]), or gender (47% female) between FB groups. After adjusting for potential confounders and comparing with medium FB, higher odds of mortality or greater than 25% HRQL decline were seen in both the low FB (odds ratio [OR] 2.79 [1.20, 6.57]) and the high FB (OR 2.16 [1.06, 4.47]), p = 0.027. Compared with medium FB, low FB (OR 4.3 [1.62, 11.84]) and high FB (OR 3.29 [1.42, 8.00]) had higher odds of greater than 25% HRQL decline.

CONCLUSIONS

Over half of the children who survived septic shock had low or high FB, which was associated with a significant decline in HRQL scores. Prospective studies are needed to determine if optimization of FB can improve HRQL outcomes.

Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest

AIM

To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest.

METHODS

This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status.

RESULTS

Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites.

CONCLUSIONS

Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.

Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study

OBJECTIVES

Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure.

DESIGN

Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS).

SETTING

Nine tertiary care PICUs in the United States.

PATIENTS

Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC.

CONCLUSIONS

One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.

Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial

BACKGROUND

Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes.

METHODS

This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR.

RESULTS

Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups.

CONCLUSIONS

In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.

Association of Sex and Age with Mortality and Health-Related Quality of Life in Children with Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation

Introduction: Sepsis is more common in males than females, but whether outcomes differ by sex in various pediatric age groups is unclear. The Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter prospective cohort study that evaluated health-related quality of life (HRQL) in children after community-acquired septic shock. In this secondary analysis, we evaluated whether male children are at increased risk of mortality or long-term decline in HRQL than female children by age group. Methods: Children (1 month-18 years) with community-acquired septic shock were recruited from 12 pediatric intensive care units in the U.S. Data included sex, age group (<1 year, 1-<13 years, 13-18 years), acute illness severity (acute organ dysfunction and inflammation), and longitudinal assessments of HRQL and mortality. Persistent decline in HRQL was defined as a 10% decrease in HRQL comparing baseline to 3 months following admission. Male and female children were stratified by age group and compared to evaluate the difference in the composite outcome of death or persistent decline in HRQL using the Cochran-Mantel-Haenszel test. Results: Of 389 children, 54.2% (n = 211) were male. Overall, 10% (21/211) of males and 12% (22/178) of females died by 3 months (p = 0.454). Among children with follow-up data, 41% (57/138) of males and 44% (48/108) of females died or had persistent decline in HRQL at 3 months (p = 0.636), with no observed difference by sex when stratified by age group. There was no significant difference in acute illness severity between males and females overall or stratified by age group. Conclusions: In this secondary analysis of the LAPSE cohort, HRQL, and mortality were not different between male and female children when stratified by age group. There were no significant differences by sex across multiple measures of illness severity or treatment intensity.

Tobacco smoke exposure, the lower airways microbiome and outcomes of ventilated children

BACKGROUND

Tobacco smoke exposure increases the risk and severity of lower respiratory tract infections in children, yet the mechanisms remain unclear. We hypothesized that tobacco smoke exposure would modify the lower airway microbiome.

METHODS

Secondary analysis of a multicenter cohort of 362 children between ages 31 days and 18 years mechanically ventilated for >72 h. Tracheal aspirates from 298 patients, collected within 24 h of intubation, were evaluated via 16 S ribosomal RNA sequencing. Smoke exposure was determined by creatinine corrected urine cotinine levels ≥30 µg/g.

RESULTS

Patients had a median age of 16 (IQR 568) months. The most common admission diagnosis was lower respiratory tract infection (53%). Seventy-four (20%) patients were smoke exposed and exhibited decreased richness and Shannon diversity. Smoke exposed children had higher relative abundances of Serratia spp., Moraxella spp., Haemophilus spp., and Staphylococcus aureus. Differences were most notable in patients with bacterial and viral respiratory infections. There were no differences in development of acute respiratory distress syndrome, days of mechanical ventilation, ventilator free days at 28 days, length of stay, or mortality.

CONCLUSION

Among critically ill children requiring prolonged mechanical ventilation, tobacco smoke exposure is associated with decreased richness and Shannon diversity and change in microbial communities.

IMPACT

Tobacco smoke exposure is associated with changes in the lower airways microbiome but is not associated with clinical outcomes among critically ill pediatric patients requiring prolonged mechanical ventilation. This study is among the first to evaluate the impact of tobacco smoke exposure on the lower airway microbiome in children. This research helps elucidate the relationship between tobacco smoke exposure and the lower airway microbiome and may provide a possible mechanism by which tobacco smoke exposure increases the risk for poor outcomes in children.

Association Between Mortality and Ventilator Parameters in Children With Respiratory Failure on ECMO

BACKGROUND

In refractory respiratory failure, extracorporeal membrane oxygenation (ECMO) is a rescue therapy to prevent ventilator-induced lung injury. Optimal ventilator parameters during ECMO remain unknown. Our objective was to describe the association between mortality and ventilator parameters during ECMO for neonatal and pediatric respiratory failure.

METHODS

We performed a secondary analysis of the Bleeding and Thrombosis on ECMO dataset. Ventilator parameters included breathing frequency, tidal volume, peak inspiratory pressure, PEEP, dynamic driving pressure, pressure support, mean airway pressure, and FIO2 . Parameters were evaluated before cannulation, on the calendar day of ECMO initiation (ECMO day 1), and the day before ECMO separation.

RESULTS

Of 237 included subjects analyzed, 64% were neonates, of whom 36% had a congenital diaphragmatic hernia. Of all the subjects, 67% were supported on venoarterial ECMO. Overall in-hospital mortality was 35% (n = 83). The median (interquartile range) PEEP on ECMO day 1 was 8 (5.0-10.0) cm H2O for neonates and 10 (8.0-10.0) cm H2O for pediatric subjects. By multivariable analysis, higher PEEP on ECMO day 1 in neonates was associated with lower odds of in-hospital mortality (odds ratio 0.77, 95% CI 0.62-0.92; P = .01), with a further amplified effect in neonates with congenital diaphragmatic hernia (odds ratio 0.59, 95% CI 0.41-0.86; P = .005). No ventilator type or parameter was associated with mortality in pediatric subjects.

CONCLUSIONS

Avoiding low PEEP on ECMO day 1 for neonates on ECMO may be beneficial, particularly those with a congenital diaphragmatic hernia. No additional ventilator parameters were associated with mortality in either neonatal or pediatric subjects. PEEP is a modifiable parameter that may improve neonatal survival during ECMO and requires further investigation.

Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes

AIM

To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit.

METHODS

This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses.

RESULTS

Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency.

CONCLUSIONS

Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.

The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes

BACKGROUND

Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC.

METHODS

This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders."

RESULTS

Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline).

CONCLUSIONS

The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.

Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis

To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.

Intrapulmonary Feeding Tube Placements While Using an Electromagnetic Placement Device: A Review (2019-2021)

BACKGROUND

Intrapulmonary placements of feeding tubes inserted with use of an electromagnetic placement device (EMPD) continue to occur.

OBJECTIVE

To describe circumstances and outcomes associated with intrapulmonary feeding tube placements during use of an EMPD.

METHODS

A retrospective review of reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database of intrapulmonary feeding tube placements during use of an EMPD from 2019 through 2021. Complications, outcomes, operator training, interference from anatomical variations and medical devices, and the use and accuracy of radiographs in identifying pulmonary placements were recorded.

RESULTS

Sixty-two cases of intrapulmonary tube placement were identified; 10 were associated with a fatal outcome. Pneumothorax occurred in 35 cases and feedings were delivered into the lung in 11 cases. User error was cited in 6 cases and was implicit in most others. Little information was provided about operator training. Four intrapulmonary placements were associated with anatomical variations and 1 with a left ventricular assist device. Radiographic follow-up was described in 28 cases and correctly identified 23 of the intrapulmonary placements.

CONCLUSIONS

User error was a significant factor, which highlights the need for empirical data to clarify the amount of training needed to safely credential EMPD operators. Clearer information is needed about anatomical variations that may contraindicate use of an EMPD, as well as medical devices that may interfere with an EMPD. Use of follow-up radiographs, interpreted by qualified personnel, is supported to increase the probability of identifying intrapulmonary tube placements.

Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study

OBJECTIVES

Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort.

DESIGN

Prospective observational study.

SETTING

Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020.

PATIENTS

Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051).

CONCLUSIONS

These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.

Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial

OBJECTIVES

To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA).

DESIGN

Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial.

SETTING

Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497).

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621).

CONCLUSIONS

In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.

The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock

OBJECTIVES

Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes.

DESIGN

Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity.

SETTING

Twelve academic PICUs in the United States.

PATIENTS

Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212).

CONCLUSIONS

This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.

Association of Pathogen Type With Outcomes of Children Encountering Community-Acquired Pediatric Septic Shock

OBJECTIVES

To determine the association of pathogen type with mortality, functional status, and health-related quality of life (HRQL) among children at hospital discharge/1 month following hospitalization for septic shock.

DESIGN

Secondary database analysis of a prospective, descriptive cohort investigation.

SETTING

Twelve academic PICUs in the United States.

PATIENTS

Critically ill children, 1 month to 18 years old, enrolled from 2013 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Association of clinical outcomes with pathogen type was assessed for all patients and separately for surviving patients enrolled in the primary Life After Pediatric Sepsis Evaluation (LAPSE) investigation. For this secondary analysis, we predicted that age would be associated with pathogen type and outcomes, and accordingly, it was incorporated as a confounding variable in primary analyses. Among 389 children enrolled with septic shock, at 1 month/hospital discharge, we observed no statistically significant differences in relation to pathogen types for the composite outcome mortality or substantial new functional morbidity: no causative organism identified (27% [28/103]), pure viral infections (26% [24/91]), pure bacterial/fungal infections (25% [31/125]), and bacterial/fungal+viral coinfections (33% [23/70]). Similarly, we observed no statistically significant differences in relation to pathogen types for the composite outcome, mortality, or persistent serious deterioration of HRQL: no causative organism identified (43% [44/103]), pure viral infections (33% [30/91]), pure bacterial/fungal infections (46% [57/125]), and bacterial/fungal+viral coinfections (43% [30/70]). However, we did identify statistically significant associations between pathogen type and the outcome ventilator-free days ( p = 0.0083) and PICU-free days (0.0238).

CONCLUSIONS

This secondary analysis of the LAPSE database identified no statistically significant association of pathogen type with composite mortality and morbidity outcomes. However, pathogen type may be associated with PICU resources employed to treat sepsis organ dysfunction. Ultimately, pediatric septic shock was frequently associated with adverse patient-centered, clinically meaningful outcomes regardless of infectious disease pathogen type.

Post-discharge rehabilitation and functional recovery after pediatric injury

INTRODUCTION

Variability in rehabilitation disposition has been proposed as a trauma center quality metric. Benchmarking rehabilitation disposition is limited by a lack of objective measures of functional impairment at discharge. The primary aim of this study was to determine the relative contribution of patient characteristics and hospitalization factors associated with inpatient and outpatient rehabilitation after discharge. The secondary aims were to evaluate the sensitivity of the Functional Status Scale (FSS) score for identifying functional impairments at hospital discharge and track post-discharge recovery.

PATIENTS AND METHODS

We report a planned secondary analysis of a prospective observational study of seriously injured children (<15 years old) enrolled at seven pediatric trauma centers. Functional Status Scale (FSS) score was measured for pre-injury, hospital discharge, and 6-month follow-up timepoints. Multinomial logistic regression identified factors associated with three dispositions: home without rehabilitation services, home with outpatient rehabilitation, and inpatient rehabilitation. Relative weight analysis was used to identify the impact of individual factors associated with inpatient or outpatient rehabilitation disposition.

RESULTS

We analyzed 427 children with serious injuries. Functional impairment at discharge was present in 103 (24.1%) children, including 43/337 (12.8%) discharged without services, 12/38 (31.6%) discharged with outpatient rehabilitation, and 44/47 (93.6%) discharged to inpatient rehabilitation. In multivariable modeling, variables most contributing to prediction of inpatient rehabilitation were severe initial Glasgow coma scale (GCS), injured body region, and functional impairment at discharge. Severe initial GCS, private insurance, and extremity injury were independently associated with disposition with outpatient rehabilitation. Patients discharged without services or with outpatient rehabilitation most frequently had motor impairments that improved during the next 6 months. Patients discharged to inpatient rehabilitation had impairments in all domains, with many improving within 6 months. A higher proportion of patients discharged to inpatient rehabilitation had residual impairments at follow-up.

CONCLUSION

Injury characteristics and discharge impairment were associated with discharge to inpatient rehabilitation. The FSS score identified impairments needing inpatient rehabilitation and characterized improvements after discharge. Less severe impairments needing outpatient rehabilitation were not identified by the FSS score.

Assessment of Patient Health-Related Quality of Life and Functional Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

To describe health-related quality of life (HRQL) and functional outcomes in pediatric acute respiratory distress syndrome (ARDS) and to determine risk factors associated with poor outcome defined as death or severe reduction in HRQL at 28 days or ICU discharge.

DESIGN

Prospective multisite cohort-outcome study conducted between 2019 and 2020.

SETTING

Eight academic PICUs in the United States.

PATIENTS

Children with ARDS based on standard criteria.

INTERVENTIONS

Patient characteristics and illness severity were collected during PICU admission. Parent proxy-report measurements were obtained at baseline, day 28/ICU discharge, month 3, and month 9, utilizing Pediatric Quality of Life Inventory and Functional Status Scale (FSS). A composite outcome evaluated using univariate and multivariate analysis was death or severe reduction in HRQL (>25% reduction in the Pediatric Quality of Life Inventory at day 28/ICU discharge.

MEASUREMENTS AND MAIN RESULTS

This study enrolled 122 patients with a median age of 3 years (interquartile range, 1-12 yr). Common etiologies of ARDS included pneumonia ( n = 63; 52%) and sepsis ( n = 27; 22%). At day 28/ICU discharge, half (50/95; 53%) of surviving patients with follow-up data reported a greater than 10% decrease in HRQL from baseline, and approximately one-third of participants ( n = 19/61; 31%) reported a greater than 10% decrease in HRQL at 9 months. Trends in FSS were similar. Of 104 patients with data, 47 patients (45%) died or reported a severe decrease of greater than 25% in HRQL at day 28/ICU discharge. Older age was associated with an increased risk of death or severe reduction in HRQL (odds ratio, 1.08; CI, 1.01-1.16).

CONCLUSIONS

Children with ARDS are at risk for deterioration in HRQL and FSS that persists up to 9 months after ARDS. Almost half of children with ARDS experience a poor outcome including death or severe reduction in HRQL at day 28/ICU discharge.

Research in Pediatric Intensive Care

Many important clinical questions remain unanswered in the practice of pediatric intensive care due to the lack of high-quality evidence. Although challenges exist in conducting research in pediatric intensive care units, identification of research priorities, interdisciplinary collaborations, innovative trial designs, and the use of common datasets and outcome measures helps to bring new knowledge to our field. The topic of "Research in PICUs" is extremely broad; therefore, this review focuses on a few common themes receiving increased attention in the literature, including research agendas, core outcome sets, precision medicine, and novel clinical trial strategies.

Health Resource Use in Survivors of Pediatric Septic Shock in the United States

OBJECTIVES

To evaluate postdischarge health resource use in pediatric survivors of septic shock and determine patient and hospitalization factors associated with health resource use.

DESIGN

Secondary analyses of a multicenter prospective observational cohort study.

SETTING

Twelve academic PICUs.

PATIENTS

Children greater than or equal to 1 month and less than 18 years old hospitalized for community-acquired septic shock who survived to 1 year.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For 308/338 patients (91%) with baseline and greater than or equal to one postdischarge survey, we evaluated readmission, emergency department (ED) visits, new medication class, and new device class use during the year after sepsis. Using negative binomial regression with bidirectional stepwise selection, we identified factors associated with each outcome. Median age was 7 years (interquartile range, 2-13), 157 (51%) had a chronic condition, and nearly all patients had insurance (private [n = 135; 44%] or government [n = 157; 51%]). During the year after sepsis, 128 patients (42%) were readmitted, 145 (47%) had an ED visit, 156 (51%) started a new medication class, and 102 (33%) instituted a new device class. Having a complex chronic condition was independently associated with readmission and ED visit. Documented infection and higher sum of Pediatric Logistic Organ Dysfunction--2 hematologic score were associated with readmission, whereas younger age and having a noncomplex chronic condition were associated with ED visit. Factors associated with new medication class use were private insurance, neurologic insult, and longer PICU stays. Factors associated with new device class use were preadmission chemotherapy or radiotherapy, presepsis Functional Status Scale score, and ventilation duration greater than or equal to 10 days. Of patients who had a new medication or device class, most had a readmission (56% and 61%) or ED visit (62% and 67%).

CONCLUSIONS

Children with septic shock represent a high-risk cohort with high-resource needs after discharge. Interventions and targeted outcomes to mitigate postdischarge resource use may differ based on patients' preexisting conditions.

Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients

OBJECTIVES

Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery.

DESIGN

Observational cohort study.

SETTING

PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals.

PATIENTS

Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days.

CONCLUSIONS

Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.

All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores

PURPOSE

Functional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity.

METHODS

Children with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores.

RESULTS

The study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries.

CONCLUSIONS

AIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment.

LEVEL OF EVIDENCE

1 (Prognostic and Epidemiological).

Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial

IMPORTANCE

Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes.

OBJECTIVE

To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings.

DESIGN, SETTING, AND PARTICIPANTS

A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021).

INTERVENTION

During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge.

RESULTS

Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02837497.

Post-Traumatic Growth in Parents following Their Child's Death in a Pediatric Intensive Care Unit

Background: Although bereaved parents suffer greatly, some may experience positive change referred to as post-traumatic growth. Objective: Explore the extent to which parents perceive post-traumatic growth after their child's death in a pediatric intensive care unit (PICU), and associated factors. Design: Longitudinal parent survey conducted 6 and 13 months after a child's death. Surveys included the Post-traumatic Growth Inventory-Short Form (PTGI-SF), a 10-item measure with range of 0-50 where higher scores indicate more post-traumatic growth. Surveys also included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a single item on perceived overall health, and sociodemographics. Setting/Subjects: One hundred fifty-seven parents of 104 children who died in 1 of 8 PICUs affiliated with the U.S. Collaborative Pediatric Critical Care Research Network. Results: Of participating parents, 62.4% were female, 71.6% White, 82.7% married, and 89.2% had at least a high school education. Mean PTGI-SF scores were 27.5 ± 12.52 (range 5-50) at 6 months and 28.6 ± 11.52 (range 2-49) at 13 months (p = 0.181). On multivariate modeling, higher education (compared with those not completing high school) and higher 6-month ICG scores (reflecting more complicated grief symptoms) were associated with lower 13-month PTGI-SF scores (p = 0.005 and 0.033, respectively). Conclusion: Parents bereaved by their child's PICU death perceive a moderate degree of post-traumatic growth in the first 13 months after the death however variability is wide. Education level and complicated grief symptoms may influence parents' perception of post-traumatic growth.

Trajectory and Risk Factors of Persistent Decline in Health-Related Quality of Life after Septic Shock in Children with Preexisting Neurologic Disability

Preexisting neurologic disability is common among children with septic shock. Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter cohort study that evaluated health-related quality of life (HRQL) in children with community-acquired septic shock. In this secondary analysis of LAPSE, we described the burden, trajectory, and risk factors for reduced HRQL in children with preexisting neurologic disability. Children (1 month–18 years) with community-acquired septic shock were evaluated for HRQL at baseline (reflecting pre-hospitalization status), day 7 and 28, and month 3, 6, and 12 following admission using the Pediatric Quality of Life Inventory or the Stein–Jessop Functional Status Scale. HRQL was expressed as a percentage of baseline scores. Of 365 evaluable children, 133 (36%) had preexisting neurologic disability. Neurologically disabled children had less decline in HRQL at day 7 (median −15% [interquartile range IQR −38, 8] vs. −22% [−51, −3], p = 0.005) and day 28 (4% [−16, 22] vs. −11% [−37, 7], p < 0.001) than those without neurologic disability, and there was no difference in the extent of decline at month 3 (p = 0.241). Using multivariable modeling, higher baseline HRQL (odds ratio [OR] 1.04 [95% confidence interval [CI] 1.00, 1.08], p = 0.027) and acute renal dysfunction (OR 1.08 [1.02, 1.16], p = 0.007) were associated with HRQL less than 90% of baseline at month 3 in neurologically disabled children who survived. Children with preexisting neurologic disability recover to baseline HRQL after septic shock sooner than those without neurologic disability. Higher baseline HRQL and acute renal dysfunction are risk factors for reduced HRQL in neurologically disabled children who survive sepsis.

Parent post-traumatic growth after a child's critical illness

OBJECTIVE

Post-traumatic growth is the experience of a positive change after a traumatic event. Our objective is to characterize the factors associated with post-traumatic growth in parents after a child's pediatric intensive care unit (PICU) admission.

STUDY DESIGN

A cross-sectional survey study examining post-traumatic growth and select independent variables in parents 1 year after a child's ≥72 h PICU admission for an acute illness or injury. The study was completed in parents of children discharge alive from a tertiary care PICU from January 1, 2017 to December 31, 2017. A mixed-effects linear regression model was built to evaluate the association of post-traumatic stress, anxiety, depression, resiliency, family function, and child function with post-traumatic growth.

RESULTS

Eighty-two parents of 52 children discharged alive in 2017 completed the survey. Fifty-two percent were ≥35 years and 64.3% were mothers. Median age of their children was 2.8 years (IQR 0.5-11.3) with a median hospital stay of 12 Days (IQR 6-20). Moderate-to-high levels of post-traumatic growth occurred in 67.1% of parents. Increased hospital length of stay (β Coeff 0.85; p = 0.004, 95% CI 0.27, 1.43) and parent post-traumatic stress symptoms (β Coeff 1.04; p = 0.006, 95% CI 0.29, 1.78) were associated with increased post-traumatic growth, and increased parent depression symptoms (β Coeff -1.96; p = 0.015; 95% CI -3.54, -0.38) with decreased post-traumatic growth.

CONCLUSION

Longer child hospital stays and increased parent post-traumatic stress symptoms were associated with increased post-traumatic growth, while increased depression was associated with less post-traumatic growth. The impact of future PICU parent psychosocial interventions on parents may be best assessed using a dual outcome focused on both reducing negative mental health symptoms while concurrently promoting skills to facilitate parent adaptation and post-traumatic growth.

Outcomes Associated With Early RBC Transfusion in Pediatric Severe Sepsis: A Propensity-Adjusted Multicenter Cohort Study

BACKGROUND

Little is known about the epidemiology of and outcomes related to red blood cell (RBC) transfusion in septic children across multiple centers. We performed propensity-adjusted secondary analyses of the Biomarker Phenotyping of Pediatric Sepsis and Multiple Organ Failure (PHENOMS) study to test the hypothesis that early RBC transfusion is associated with fewer organ failure-free days in pediatric severe sepsis.

METHODS

Four hundred one children were enrolled in the parent study. Children were excluded from these analyses if they received extracorporeal membrane oxygenation (n = 22) or died (n = 1) before sepsis day 2. Propensity-adjusted analyses compared children who received RBC transfusion on or before sepsis day 2 (early RBC transfusion) with those who did not. Logistic regression was used to model the propensity to receive early RBC transfusion. A weighted cohort was constructed using stabilized inverse probability of treatment weights. Variables in the weighted cohort with absolute standardized differences >0.15 were added to final multivariable models.

RESULTS

Fifty percent of children received at least one RBC transfusion. The majority (68%) of first transfusions were on or before sepsis day 2. Early RBC transfusion was not independently associated with organ failure-free (-0.34 [95%CI: -2, 1.3] days) or PICU-free days (-0.63 [-2.3, 1.1]), but was associated with the secondary outcome of higher mortality (aOR 2.9 [1.1, 7.9]).

CONCLUSIONS

RBC transfusion is common in pediatric severe sepsis and may be associated with adverse outcomes. Future studies are needed to clarify these associations, to understand patient-specific transfusion risks, and to develop more precise transfusion strategies.

Prevalence of Pathogenic and Potentially Pathogenic Inborn Error of Immunity Associated Variants in Children with Severe Sepsis

Purpose

Our understanding of inborn errors of immunity is increasing; however, their contribution to pediatric sepsis is unknown.

Methods

We used whole-exome sequencing (WES) to characterize variants in genes related to monogenic immunologic disorders in 330 children admitted to intensive care for severe sepsis. We defined candidate variants as rare variants classified as pathogenic or potentially pathogenic in QIAGEN’s Human Gene Mutation Database or novel null variants in a disease-consistent inheritance pattern. We investigated variant correlation with infection and inflammatory phenotype.

Results

More than one in two children overall and three of four African American children had immunodeficiency-associated variants. Children with variants had increased odds of isolating a blood or urinary pathogen (blood: OR 2.82, 95% CI: 1.12–7.10, p = 0.023, urine: OR: 8.23, 95% CI: 1.06–64.11, p = 0.016) and demonstrating increased inflammation with hyperferritinemia (ferritin \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge 500$$\end{document}≥500 ng/mL, OR: 2.16, 95% CI: 1.28–3.66, p = 0.004), lymphopenia (lymphocyte count < 1000/µL, OR: 1.66, 95% CI: 1.06 – 2.60, p = 0.027), thrombocytopenia (platelet count < 150,000/µL, OR: 1.76, 95% CI: 1.12–2.76, p = 0.013), and CRP greater than 10 mg/dl (OR: 1.71, 95% CI: 1.10–2.68, p = 0.017). They also had increased odds of requiring extracorporeal membrane oxygenation (ECMO, OR: 4.19, 95% CI: 1.21–14.5, p = 0.019).

Conclusion

Herein, we describe the genetic findings in this severe pediatric sepsis cohort and their microbiologic and immunologic significance, providing evidence for the phenotypic effect of these variants and rationale for screening children with life-threatening infections for potential inborn errors of immunity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10875-021-01183-4.

Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism

BACKGROUND

Children with abusive injuries have worse mortality, length-of-stay, complications, and healthcare costs compared to those sustaining an accidental injury. Long-term functional impairment is common in children with abusive head trauma but has not been examined in a cohort with heterogeneous body region injuries.

OBJECTIVE

To assess for an independent association between child physical abuse and functional impairment at discharge and six-month follow-up.

PARTICIPANTS AND SETTING

Seriously injured children (<15 years) treated at seven pediatric trauma centers.

METHODS

Functional status was compared between child physical abuse and accidental injury groups at discharge and six-month follow-up. Functional impairment was defined at discharge ("new domain morbidity") as a change from pre-injury ≥2 points in any of the six domains of the Functional Status Scale (FSS), and impairment at six-month follow-up as an abnormal total FSS score.

RESULTS

Children with abusive injuries accounted for 10.5% (n = 45) of the cohort. New domain morbidity was present in 17.8% (n = 8) of child physical abuse patients at discharge, with 10% (n = 3) of children having an abnormal FSS at six-months. There were no differences in new domain morbidity at hospital discharge between children injured by abuse and or accidental injury. However, children injured by physical abuse were 4.09 (2.15, 7.78) times more likely to have functional impairment at six months.

CONCLUSIONS

Child physical abuse is an independent risk factor for functional impairment at six-month follow-up. Functional status measurement for this high-risk group of children should be routinely measured and incorporated into trauma center quality assessments.

Incentive delivery timing and follow-up survey completion in a prospective cohort study of injured children: a randomized experiment comparing prepaid and postpaid incentives

Background

Retaining participants over time is a frequent challenge in research studies evaluating long-term health outcomes. This study’s objective was to compare the impact of prepaid and postpaid incentives on response to a six-month follow-up survey.

Methods

We conducted an experiment to compare response between participants randomized to receive either prepaid or postpaid cash card incentives within a multisite study of children under 15 years in age who were hospitalized for a serious, severe, or critical injury. Participants were parents or guardians of enrolled children. The primary outcome was survey response. We also examined whether demographic characteristics were associated with response and if incentive timing influenced the relationship between demographic characteristics and response. We evaluated whether incentive timing was associated with the number of calls needed for contact.

Results

The study enrolled 427 children, and parents of 420 children were included in this analysis. Follow-up survey response did not differ according to the assigned treatment arm, with the percentage of parents responding to the survey being 68.1% for the prepaid incentive and 66.7% with the postpaid incentive. Likelihood of response varied by demographics. Spanish-speaking parents and parents with lower income and lower educational attainment were less likely to respond. Parents of Hispanic/Latino children and children with Medicaid insurance were also less likely to respond. We found no relationship between the assigned incentive treatment and the demographics of respondents compared to non-respondents.

Conclusions

Prepaid and postpaid incentives can obtain similar participation in longitudinal pediatric critical care outcomes research. Incentives alone do not ensure retention of all demographic subgroups. Strategies for improving representation of hard-to-reach populations are needed to address health disparities and ensure the generalizability of studies using these results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01421-8.

Inhaled Nitric Oxide Use and Outcomes in Critically Ill Children With a History of Prematurity

BACKGROUND

Inhaled nitric oxide (INO) is used to treat hypoxic respiratory failure without clear evidence of benefit. Future trials to evaluate its use will be designed based on an understanding of the populations in which this therapy is provided and with outcomes based on patient characteristics, for example, a history of premature birth.

METHODS

This was a multi-center prospective observational study that evaluated subjects in the pediatric ICU who were treated with INO for a respiratory indication, excluding those treated in the neonatal ICU or treated for birth-related disease. We used logistic regression to evaluate characteristics associated with mortality and duration of mechanical ventilation. Specifically, we compared subjects born early preterm (<32 weeks post-conceptual age), late preterm (32-37 weeks post-conceptual age), and full term.

RESULTS

A total of 163 children (median age [interquartile range], 1.8 [0.7-6.0] y) were included, 41 (25.2%) had a history of preterm birth (18 born early preterm and 23 born late preterm). INO was initiated for less-severe lung disease in the early preterm versus late preterm versus full-term subjects (median mean airway pressures, 16 vs 19 vs 19 cm H2O; P = .03), although the oxygenation index and oxygenation saturation index did not differ. The early preterm subjects had more ventilator-free days (median, 18.0, 7.0, 4.5 d; P = .02) and lower 28-d mortality (0, 26.1, 32.0%; P = .007). Lower respiratory tract disease, but not a history of prematurity, was independently associated with lower mortality.

CONCLUSIONS

INO was used differently in early preterm subjects. Clinical trials that evaluate INO use should have standardized oxygenation deficit thresholds for initiation of therapy and should consider stratifying by early preterm status.

Factors Associated With Functional Impairment After Pediatric Injury

Importance

Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown.

Objective

To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers.

Design, Setting, and Participants

This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020.

Exposure

At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5).

Main Outcomes and Measures

New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites.

Results

This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge.

Conclusions and Relevance

In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

Structured Chart Review: Assessment of a Structured Chart Review Methodology

BACKGROUND AND OBJECTIVES

Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability.

METHODS

A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability.

RESULTS

The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories.

CONCLUSIONS

A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.

Posthospitalization follow-up recommendations after pediatric critical illness due to respiratory failure

OBJECTIVES

To characterize the recommended posthospitalization follow-up by provider type and location after a pediatric critical illness due to respiratory failure.

WORKING HYPOTHESIS

After pediatric critical illness due to respiratory failure, patients will not have a standard follow-up pattern with regard to provider type or follow-up location.

STUDY DESIGN

A retrospective cohort study.

SUBJECT SELECTION

Children, 18 years or younger, admitted to a quaternary care pediatric intensive care unit with respiratory failure between January 1, 2013 and December 31, 2014.

METHODOLOGY

For eligible patients, recommendations for posthospitalization follow-up including provider type (primary care and specialty care) and location (community care center vs. tertiary care center) were characterized from medical chart review. Recommendations were examined for all patients and two patient subgroups (patients who received extracorporeal membrane oxygenation and patients with tracheostomy).

RESULTS

Of 155 patients alive at hospital discharge, the median age was 2.1 (interquartile range, 0.7-10.6) years. Eighty percent of patients were instructed to follow-up with a primary care provider but only 52.9% with a pulmonologist. We found 10 unique follow-up patterns between provider location (community care center, tertiary care center, or both) and global provider type (primary care versus specialty care). Primary care follow-up was recommended more often at community locations (74.2%), whereas specialty care was more often recommended at tertiary care centers (68.6%).

CONCLUSIONS

Our study findings demonstrate significant variability in the recommendations for follow-up by provider type and location after hospitalization for acute respiratory failure and highlight areas for improvement in follow-up care after pediatric critical illness.

The Association between Therapeutic Alliance and Parental Health Outcomes following a Child's Death in the Pediatric Intensive Care Unit

Therapeutic alliance reflects the strength and quality of the physician-patient/family relationship. We investigated the association between therapeutic alliance and bereaved parents' mental health and perceived overall health following their child's death in a pediatric intensive care unit (PICU). Bereaved parents were surveyed 6 months after their child's death in a PICU affiliated with the Collaborative Pediatric Critical Care Research Network. Parents were evaluated for complicated grief, depression, and post-traumatic stress using the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire (PHQ-8), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), respectively. Overall health was evaluated using a single item. Therapeutic alliance between parents and their deceased child's PICU physicians was assessed using the Human Connection scale (HCS). Two hundred and thirty-five parents of 158 deceased children completed surveys. Mean ICG score was 34.4 ± 14.9 with 142 (60.4%) parents screening positive for complicated grief. Mean PHQ-8 score was 9.1 ± 6.2 with 102 (43.4%) screening positive for at least moderate depression. Mean SPRINT score was 14.6 ± 8.2 with 122 (51.9%) screening positive for post-traumatic stress disorder. Overall health was perceived as fair for 47 (20.0%) parents and poor for 10 (4.3%). Using multivariable modeling, higher HCS score (greater therapeutic alliance) was significantly associated with lower (better) ICG score (-0.23, 95% CI -0.42, -0.04, p  = 0.018). HCS score was not significantly associated with PHQ-8, SPRINT, or overall health scores. We conclude that bereaved parents experience a high level of adverse mental health symptoms including complicated grief, depression, and post-traumatic stress symptoms. Greater therapeutic alliance with PICU physicians may lessen symptoms of complicated grief during bereavement.

Complicated Grief, Depression and Post-Traumatic Stress Symptoms Among Bereaved Parents following their Child's Death in the Pediatric Intensive Care Unit: A Follow-Up Study

BACKGROUND

Parents often suffer reduced mental health after their child's death; however, the trajectory and risk factors are not well described.

OBJECTIVE

Describe the change in complicated grief, depression, and post-traumatic stress symptoms among parents between 6 and 13 months after their child's death in a pediatric intensive care unit (PICU), and factors associated with 13-month symptoms.

METHODS

Parents whose children died in 1 of 8 PICUs affiliated with the Collaborative Pediatric Critical Care Research Network completed surveys 6 and 13 months after their child's death. Surveys included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). Parents provided sociodemographics. Charts were reviewed for child characteristics.

RESULTS

One-hundred and fifty seven parents of 104 deceased children completed surveys at both time points. Mental health symptoms declined over time (mean (SD)): ICG (33.8 (15.4) vs. 30.5 (15.2), p < 0.001), PHQ-8 (9.0 (6.4) vs. 7.3 (5.8), p < 0.001), and SPRINT (14.1 (8.3) vs. 12.0 (8.2), p < 0.001). After controlling for 6-month scores, higher 13-month ICG was independently associated with sudden unexpected death; higher PHQ-8 with Black race, insecure attachment style, and sudden unexpected death; and higher SPRINT with having a high school level of education (compared to college degree or higher).

CONCLUSION

Mental health symptoms improve among parents during the first 13 months after their child's death; however, symptoms persist for many. Black parents and those whose children die suddenly may be high risk for poor adjustment during bereavement.