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As survival after pediatric intensive care unit (PICU) admission has improved over recent years, a key focus now is the reduction of morbidities and optimization of quality of life for survivors. Neurologic disorders and direct brain injuries are the reason for 11-16% of admissions to PICU. In addition, many critically ill children are at heightened risk of brain injury and neurodevelopmental difficulties affecting later life, e.g., complex heart disease and premature birth. Hence, assessment, monitoring and protection of the brain, using fundamental principles of neurocritical care, are crucial to the practice of pediatric intensive care medicine. The assessment of brain function, necessary to direct appropriate care, is uniquely challenging amongst children admitted to the PICU. Challenges in assessment arise in children who are unstable, or pharmacologically sedated and muscle relaxed, or who have premorbid abnormality in development. Moreover, the heterogeneity of diseases and ages in PICU patients, means that high caliber evidence is harder to accrue than in adult practice, nonetheless, great progress has been made over recent years. In this 'state of the art' paper about critically ill children, we discuss (1) patient types at risk of brain injury, (2) new standardized clinical assessment tools for age-appropriate, clinical evaluation of brain function, (3) latest evidence related to cranial imaging, non-invasive and invasive monitoring of the brain, (4) the concept of childhood 'post intensive are syndrome' and approaches for neurodevelopmental follow-up. Better understanding of these concepts is vital for taking PICU survivorship to the next level., Author(s): Kate L. Brown [sup.1] [sup.2], Shruti Agrawal [sup.3], Matthew P. Kirschen [sup.4] [sup.5], Chani Traube [sup.6], Alexis Topjian [sup.4] [sup.5], Ronit Pressler [sup.1] [sup.7] [sup.8], Cecil D. Hahn [sup.9] [...]

Objective To determine how hypotension in the first 48 h of sepsis management impacts acute kidney injury (AKI) development and persistence. Study design Retrospective study of patients > 1 month to < 20 years old with sepsis in a pediatric ICU between November 2012 and January 2015 (n = 217). All systolic blood pressure (SBP) data documented within 48 h after sepsis recognition were collected and converted to percentiles for age, sex, and height. Time below SBP percentiles and below pediatric advanced life support (PALS) targets was calculated by summing elapsed time under SBP thresholds during the first 48 h. The primary outcome was new or persistent AKI, defined as stage 2 or 3 AKI present between sepsis day 3-7 using Kidney Disease: Improving Global Outcomes creatinine definitions. Secondary outcomes included AKI-free days (days alive and free of AKI) and time to kidney recovery. Results Fifty of 217 sepsis patients (23%) had new or persistent AKI. Patients with AKI spent a median of 35 min under the first SBP percentile, versus 4 min in those without AKI. After adjustment for potential confounders, the odds of AKI increased by 9% with each doubling of minutes spent under this threshold (p = 0.03). Time under the first SBP percentile was also associated with fewer AKI-free days (p = 0.02). Time spent under PALS targets was not associated with AKI. Conclusions The duration of severe systolic hypotension in the first 48 h of pediatric sepsis management is associated with AKI incidence and duration when defined by age, sex, and height norms, but not by PALS definitions., Author(s): Julie C. Fitzgerald [sup.1] [sup.2] , Michelle E. Ross [sup.3] , Neal J. Thomas [sup.4] , Scott L. Weiss [sup.1] [sup.2] , Fran Balamuth [sup.5] [sup.6] , Marianne Chilutti [...]

Background Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place. Methods Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting. Results We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms. Conclusions These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference., Author(s): Randall Chesnut [sup.1] [sup.2], Sergio Aguilera [sup.3] [sup.4], Andras Buki [sup.5] [sup.6], Eileen Bulger [sup.7], Giuseppe Citerio [sup.8] [sup.9], D. Jamie Cooper [sup.10] [sup.11], Ramon Diaz Arrastia [sup.12], Michael [...]

Author(s): Scott L. Weiss [sup.1], Mark J. Peters [sup.2] Author Affiliations: (1) 0000 0004 1936 8972, grid.25879.31, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of [...]

Author(s): Massimo Antonelli [sup.1], Elie Azoulay [sup.2], Marc Bonten [sup.3], Jean Chastre [sup.4], Giuseppe Citerio [sup.5], Giorgio Conti [sup.1], Daniel De Backer [sup.6], Herwig Gerlach [sup.7], Goran Hedenstierna [sup.8], Michael [...]