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Fluid overload is a risk factor for poor outcome in intensive care; thus volume loading should be tailored towards patients who are likely to increase stroke volume. We aimed to evaluate the paediatric predictive ability (stroke volume increase of at least 15 % after fluid bolus) of novel and established volumetric and dynamic haemodynamic variables, and assess the influence of baseline contractility on response.We assessed 142 volume loading episodes (10 ml/kg crystalloid) in 100 critically ill ventilated children, median (interquartile) weight 10 (5.6-15) kg. Eight advanced haemodynamic variables were assessed using two commercially available devices. Systemic ventricular contractility was measured as the maximum rate of systolic arterial pressure rise.Overall, predictive ability was poor, with volumetric variables performing better than dynamic (area under receiver operating characteristic curves ranged from 0.53 to 0.67). The best predictor was total end-diastolic volume index; however, this did not increase in a consistent way with volume loading, with change post volume being weakly related to baseline values (r = -0.19, p = 0.02). A multivariable model quantified the importance of contractility in stroke volume response. Children with high baseline contractility (≥75th centile) typically achieved a positive stroke volume response when end-diastolic volume values changed by 10-15 ml/m(2.6), whereas patients with low contractility (≤25th centile) typically required end-diastolic volume increases of 35-40 ml/m(2.6).Current paediatric predictors of volume response perform poorly; prediction may be improved if baseline contractility is taken into account.

To report on the monitoring of diaphragm electrical activity (Edi) using neurally adjusted ventilator assist (NAVA) technology to investigate the mechanisms of ventilator dependence in children with neuromuscular and respiratory control disorders.Using NAVA technology, electrical activity of the diaphragm (Edi) was monitored at the lowest achievable level of respiratory support in six ventilator-dependent patients with neuromuscular and respiratory control disorders, aged 6 weeks to 12 years, admitted to a tertiary paediatric intensive care unit between 2009 and 2011.Edi monitoring identified markedly abnormal respiratory dynamic patterns that were not always apparent clinically. These were associated with disorders of central respiratory control, muscle weakness and diaphragm pathology.Edi monitoring using NAVA technology is a valuable, minimally invasive, diagnostic adjunct in children with neuromuscular and respiratory control disorders who are ventilator-dependent.

Children with Down syndrome (DS) have several genetic anomalies within chromosome 21 which may influence their response to critical illness. We compared the intensive care course and outcome of children with DS versus those without. Retrospective cohort study in four English paediatric intensive care units (ICUs) (2003–2009, n = 33,485). We examined, via a competing risks model, whether risk (subhazard) for ICU mortality differed for children with DS, after adjusting for important confounders. DS patients exhibited lower disease severity at ICU admission but subsequently required a higher proportion of cardiovascular support, and similar renal support to non-DS patients. Children with DS (n = 1,278) had lower crude mortality than those without (4.2 versus 6.2 %, p = 0.003). This was not significant when expressed as standardized mortality ratio: 0.83 [95 % confidence interval (CI) 0.63–1.09] versus 0.90 (95 % CI 0.86–0.94). However, the competing risks model showed that mortality risk was influenced by length of ICU stay. At admission, DS patients exhibited a subhazard for mortality of 0.63 (95 % CI 0.46–0.85), which increased to 1.00 by day 10 of admission, and continued rising above that of non-DS children thereafter. Children with DS require a higher proportion of organ support than expected by disease severity at ICU admission. In addition, the mortality risk for children with DS is dependent upon length of ICU stay. These findings could reflect differences in case mix, but are also compatible with different response to critical illness in this group.

Pulmonary artery (PA) banding has been established as a palliative surgical technique for congenital heart defects for over 50 years [1]. With the advent of earlier corrective surgery, the indications for PA banding have changed over time [2, 3]. Currently these include: (a) limitation of pulmonary blood flow in the setting of an excessive left-toright shunt; (b) regulation of pulmonary blood flow in the univentricular circulation; and (c) a training procedure for the left ventricle prior to conversion to the systemic pumping chamber (late presentation of D-transposition of the great arteries, or prior to a double-switch procedure with L-transposition).

Unplanned extubation (UE) is an important paediatric intensive care unit (PICU) quality indicator. Studies on UE have been modest in size, with accurate UE rate calculation potentially hampered by ventilation episodes recorded in calendar days. We wished to document UE rates, outcomes, associated factors and quantify error when calendar days rather than exact timings are used. We recorded prospectively all UE episodes and potential associated factors in our 20-bed PICU for 12,533 admissions (2000–2013). Ventilation episodes were recorded to the minute, with non-invasive and tracheostomy ventilation excluded. Analysis utilised multilevel mixed-effects Poisson regression, adjusting for multiple ventilation episodes in the same patient. Overall, 243 UEs occurred within 14,141 ventilation episodes (31,564 intubated days), giving a UE rate of 0.77 (95 % CI 0.67–0.87) episodes per 100 intubated days. If calendar ventilation days were used, the yearly UE rate was underestimated by 27–35 %. UE rates decreased with time, by approximately 0.05/100 intubated days each year. Associations with UE incidence rate included patient age, source of admission, disease severity and diagnostic category, with nasal tubes decreasing the risk. Although UE versus planned extubation was associated with a higher re-intubation rate (43 versus 8 %) and longer median PICU stay (4.6 versus 2.6 days, p

To demonstrate the diagnostic yield, therapeutic role and safety of flexible bronchoscopy via an intensivist-led service in critically ill children. Retrospective chart review. Regional paediatric intensive care unit. One hundred forty-eight flexible bronchoscopies were performed by two intensivists on 134 patients (median age 16.5 months) over a 2.5-year period. Eighty-eight percent of patients required mechanical ventilation, and 22% were receiving inotropes. Case mix included general (n = 77), cardiac surgery (n = 18), cardiology (n = 13), ear-nose-and-throat surgery (n = 17), oncology (n = 8) and renal (n = 1). The indication for bronchoscopy was defined a priori according to one of four categories: suspected upper airway disease (n = 32); lower airway disease (n = 70); investigation of pulmonary disease (n = 25); and extubation failure (n = 21). Bronchoscopy was generally performed soon after PICU admission, at a median time of 1.5 days for the former three categories, and 4 days for extubation failure group. A positive yield from bronchoscopy (diagnosis that explained the clinical condition or influenced patient management) was present in 113 of 148 (76%) procedures, varying within groups from 44% (pulmonary disease) to 90% (extubation failure).Ten percent of patients developed a fall in oxygen saturations > 20% during the procedure and 17% required a bolus of at least 10 ml/kg of 0.9% saline for hypotension. Critically ill patients with respiratory problems may benefit from a PICU-led bronchoscopy service as the yield for positive bronchoscopic finding is high, particularly for upper airway problems or extubation failure.

Dear Editor, The use of clinical information systems (CIS) and electronic prescribing have been shown in single centre studies to improve access to vital data, enhance patient safety and reduce manual documentation time in critical care [1, 2]. There are few large-scale reports of CIS utilisation in paediatric intensive care units (PICU). As part of the Informatics subgroup of the UK Paediatric Intensive Care Society, we conducted a national survey to study the distribution, characteristics and satisfaction with existing electronic systems. Lead intensivists, nurses and/or data managers from the Paediatric Intensive Care Audit Network (PICANet) [3] were invited to complete a self-administered questionnaire survey in September 2007, either online (QuestionPro, http://www. questionpro.com), on an emailed portable document format (PDF) form or on paper. Questions focused on: (a) use of hospital-wide electronic systems; (b) clinical functionality available in PICU systems; (c) data security; (d) research and audit; (e) user satisfaction measured on a Likert scale (1, very satisfied; 5, very dissatisfied); and (f) future plans for CIS implementation. Data were analysed at the unit level, except satisfaction scores, which were analysed at the respondent level. Characteristics of participating units (admission numbers, number of beds and unit type) were obtained from PICANet. Group-wise differences were analysed by using the chi-square test; Wilcoxon sign rank test was used for satisfaction scores. Fifty respondents from 28 out of 32 UK PICUs completed the survey (response rate 88%). Intensivists and nurses comprised the majority of subjects (62%). One-third of the units admitted more than 500 patients/ year, the majority being combined medical-surgical units. More than 80% of the units used hospital-wide systems for patient admission/discharge, radiology and laboratory results. In addition, units used a mixture of small locally developed (16/28) and commercial databases (8/28) with widely varying clinical functionality. Only one unit had gone ‘‘paperless’’ by implementing an integrated CIS with charting, clinical documentation and prescribing functions. In general, larger units were more likely to adopt more functional, commercial systems rather than ‘‘home-grown’’ databases (p \ 0.05). Clinical functionality provided by the various PICU systems is summarised in Table 1. In addition to clinical systems, a number of separate research and audit databases were also used to store data on specific patient groups (e.g. sepsis or extracorporeal membrane oxygenation) resulting in significant duplication of data entry and storage. No significant differences were seen between satisfaction levels of doctors and nurses, although ‘‘home-grown’’, less functional systems scored marginally higher satisfaction levels than commercially procured systems (median 2.5 vs. 2.0). Nevertheless, 5 PICUs reported plans to procure fully functional CIS within a year of the survey. Our study demonstrates poor uptake of CIS in UK PICUs, with larger units more likely to invest in clinical systems and smaller units