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Background: Multidisciplinary patient care rounds are increasingly seen as a vital complement to patient care management. Family engagement in these rounds, especially in the paediatric population, is important to treatment and outcomes, but there is little information about family experience in the Paediatric Intensive Care Unit (PICU). Aims: To develop a process using family care journals (FCJ) to systematically evaluate family experience in the PICU and identify needed supportive resources that will enhance their critical care stay. Study Design: This is a single‐centre quasi‐experimental design conducted at a large urban quaternary level freestanding children's hospital. A family care journal (FCJ) was distributed to families upon admission to PICU to serve as a resource tool during their stay. An electronic point of care (POC) questionnaire was used to assess families' experiences in the PICU. Results: Three hundred sixty‐six questionnaires were completed (100% response rate) and analysed. Overall, there was an improvement in all phases post FCJ implementation compared with the baseline. Seventy five percent of families found it a useful tool for communication with the PICU team. Open‐ended comments revealed improvement opportunities related to communication, environment, and delay in care. Almost all commented on excellent nursing care. Conclusions: Introducing FCJ in a paediatric ICU is a practical approach, providing a cost‐effective method to assess family experiences and gain insights for ongoing quality improvement efforts. Collaboration among all care team members, including nursing, medical, and administrative leaders, is crucial for empathetically addressing parental needs during hospitalization. Relevance to Clinical Practice: Combining the use of journals and questionnaires provides the clinical team with an efficient means of collecting valuable feedback from parents regarding their experience in the PICU and the factors that foster ongoing commitment from families. Nurses play a crucial role in encouraging the adoption of these journals, as they promote greater parent involvement in their children's care. [ABSTRACT FROM AUTHOR]

Aims: To explore how parents experienced their child with delirium and how parents viewed our delirium management bundle. Design: We conducted a qualitative exploratory descriptive study using semi‐structured individual or dyad interviews. Methods: Twelve semi‐structured interviews with 16 parents of 12 critically ill children diagnosed with delirium in a paediatric intensive care unit were conducted from October 2022 to January 2023 and analysed through a reflexive thematic analysis. Findings: We generated five themes: (1) knowing that something is very wrong, (2) observing manifest changes in the child, (3) experiencing fear of long‐term consequences, (4) adding insight to the bundle, and (5) family engagement. Conclusion: The parents in our study were able to observe subtle and manifest changes in their child with delirium. This caused fear of lasting impact. The parents regarded most of the interventions in the delirium management bundle as relevant but needed individualization in the application. The parents requested more information regarding delirium and a higher level of parent engagement in the care of their child during delirium. Impact: This paper contributes to understanding how parents might experience delirium in their critically ill child, how our delirium management bundle was received by the parents, and their suggestions for improvement. Our study deals with critically ill children with delirium, their parents, and staff working to prevent and manage paediatric delirium (PD) in the paediatric intensive care unit. Reporting Method: The consolidated criteria for reporting qualitative research guidelines were used to ensure the transparency of our reporting. Patient or Public Contribution: No patient or public contribution to the research design. What does this Paper Contribute to the Wider Global Community?: ‐ It increases awareness of the parent's perspective on PD in critically ill children.‐ It shows how PD might affect parents, causing negative emotions such as distress, frustration, and fear of permanent damage.‐ It shows that the parents in our study, in addition to the care bundle, requested more information on delirium and more involvement in the care of their delirious child. [ABSTRACT FROM AUTHOR]

Objective: Pressure ulcers (PUs) severely impact health outcomes in neonatal intensive care, with up to 28% prevalence and doubled mortality rates. Due to their only partially developed stratum corneum, neonates are highly susceptible to PUs because of a lack of adequate support surfaces. The occipital region of the head and hip are the main risk areas due to immobility and newborn body proportions. The main goal of the study was to investigate the impact of reduction in local pressure in these body areas by two air mattress designs and different filling states. Method: Two innovative air-filled mattress prototypes (prototype 1 and prototype 2), consisting of three different segments (head, trunk and feet regions), were developed to reduce local interface pressures by optimising pressure distribution, and were assessed with three air pressure filling states (0.2kPa, 0.4kPa and 0.6kPa). A baby doll was used to investigate pressure distribution and local pressure impact. It measured 51cm and the weight was modified to be 1.3kg, 2.3kg and 3.3kg, representing premature to term newborn weights, respectively. A specialised foam mattress and an unsupported surface were considered as controls. Results: The interface pressures at the hip region for newborn models could be reduced by up to 41% with mattress prototype 1 and 49% with prototype 2 when filled with 0.2kPa air pressure. It was found that the size and the pressure inside air segments was crucial for interface pressure. Conclusion: Our results demonstrated that air mattresses achieved lower interface pressures compared to conventional support surfaces, and that the benefit of the air mattresses depended on their filling status. The importance of using innovative, segmented designs that were tailored to meet the specific needs of highly vulnerable paediatric patients was demonstrated. [ABSTRACT FROM AUTHOR]

Aims Methods Results Conclusions Population pharmacokinetics (PK) models may be effective in improving antibiotic exposure with individualized dosing. The aim of the study is to assess cefazolin exposure using a population PK model in critically ill children.We conducted a single‐centre observational study including children under 18 years old who had cefazolin plasma monitoring before and after a cefazolin model implementation. The first concentration at steady state of each cefazolin course was analysed. The optimal exposure was defined by concentration values ranging from free concentration over four times the minimal inhibitory concentration (MIC) for 100% of the dosing interval to total trough or plateau concentration under 100 mg. L−1.A total of 58 patients were included, of whom 39 and 19 children received conventional dosing or model‐informed dosing, respectively. Median [range] age was 2.3 [0.1–17] years old, and median weight was 14.2 [2.9–72] kg. There were more continuous infusions (CI) in the model group than in the conventional group (n = 19/19 [100%] vs. n = 23/39 [59%]). Compared to conventional dosing, model‐informed dosing provided more optimal exposure (n = 17/39 [44%] vs. n = 15/19 [79%], P = .01) and less underexposure (n = 18/39 [46%] vs. n = 2/19 [10%], P = .008), without increasing overexposure (n = 4/39 [10%] vs. n = 2/19 [11%], P = 1). Moreover, the time to C‐reactive protein decrease by 50% was significantly shorter in the model group than the conventional group (3 [0.5–13] vs. 4 [1–34]; P = .045).Use of individualized cefazolin model‐informed dosing improves critically ill children's exposure. Further studies are needed to assess the clinical benefit of cefazolin PK model application. [ABSTRACT FROM AUTHOR]

Abstract Background Deaths in paediatric intensive care units (PICUs) are not uncommon. End-of-life care in PICUs is generally considered more challenging than other settings since it is framed within a context where care is focused on curative or life-sustaining treatments for children who are seriously ill. This review aimed to identify and synthesise literature related to the essential elements in the provision of end-of-life care in the PICU from the perspectives of both healthcare professionals (HCPs) and families. Methods A systematic integrative review was conducted by searching EMBASE, CINAHL, MEDLINE, Nursing and Allied Health Database, PsycINFO, Scopus, Web of Science, and Google Scholar databases. Grey literature was searched via Electronic Theses Online Service (EthOS), OpenGrey, Grey literature report. Additionally, hand searches were performed by checking the reference lists of all included papers. Inclusion and exclusion criteria were used to screen retrieved papers by two reviewers independently. The findings were analysed using a constant comparative method. Results Twenty-one studies met the inclusion criteria. Three elements in end-of-life care provision for children in the PICUs were identified: 1) Assessment of entering the end-of-life stage; 2) Discussion with parents and decision making; 3) End of life care processes, including care provided during the dying phase, care provided at the time of death, and care provided after death. Conclusion The focus of end-of-life care in PICUs varies depending on HCPs’ and families’ preferences, at different stages such as during the dying phase, at the time of death, and after the child died. Tailoring end-of-life care to families’ beliefs and rituals was acknowledged as important by PICU HCPs. This review also emphasises the importance of HCPs collaborating to provide the optimum end-of-life care in the PICU and involving a palliative care team in end-of-life care.

Abstract Background Bacterial infections (BIs) are widespread in ICUs. The aims of this study were to assess compliance with antibiotic recommendations and factors associated with non-compliance. Methods We conducted an observational study in eight French Paediatric and Neonatal ICUs with an antimicrobial stewardship programme (ASP) organised once a week for the most part. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns

Background: Deaths in paediatric intensive care units (PICUs) are not uncommon. End-of-life care in PICUs is generally considered more challenging than other settings since it is framed within a context where care is focused on curative or life-sustaining treatments for children who are seriously ill. This review aimed to identify and synthesise literature related to the essential elements in the provision of end-of-life care in the PICU from the perspectives of both healthcare professionals (HCPs) and families. Methods: A systematic integrative review was conducted by searching EMBASE, CINAHL, MEDLINE, Nursing and Allied Health Database, PsycINFO, Scopus, Web of Science, and Google Scholar databases. Grey literature was searched via Electronic Theses Online Service (EthOS), OpenGrey, Grey literature report. Additionally, hand searches were performed by checking the reference lists of all included papers. Inclusion and exclusion criteria were used to screen retrieved papers by two reviewers independently. The findings were analysed using a constant comparative method. Results: Twenty-one studies met the inclusion criteria. Three elements in end-of-life care provision for children in the PICUs were identified: 1) Assessment of entering the end-of-life stage; 2) Discussion with parents and decision making; 3) End of life care processes, including care provided during the dying phase, care provided at the time of death, and care provided after death. Conclusion: The focus of end-of-life care in PICUs varies depending on HCPs' and families' preferences, at different stages such as during the dying phase, at the time of death, and after the child died. Tailoring end-of-life care to families' beliefs and rituals was acknowledged as important by PICU HCPs. This review also emphasises the importance of HCPs collaborating to provide the optimum end-of-life care in the PICU and involving a palliative care team in end-of-life care. [ABSTRACT FROM AUTHOR]

Background: Bacterial infections (BIs) are widespread in ICUs. The aims of this study were to assess compliance with antibiotic recommendations and factors associated with non-compliance. Methods: We conducted an observational study in eight French Paediatric and Neonatal ICUs with an antimicrobial stewardship programme (ASP) organised once a week for the most part. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns < 72 h old, neonates < 37 weeks, age ≥ 18 years and children under surgical antimicrobial prophylaxis were excluded. Results: 139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% with no BI, 40.3% presumed (i.e., not documented) BI and 35.3% documented BI. Non-compliance with antibiotic recommendations occurred in 51.1%. The main reasons for non-compliance were inappropriate choice of antimicrobials (27.3%), duration of one or more antimicrobials (26.3%) and length of antibiotic therapy (18.0%). In multivariate analyses, the main independent risk factors for non-compliance were prescribing ≥ 2 antibiotics (OR 4.06, 95%CI 1.69–9.74, p = 0.0017), duration of broad-spectrum antibiotic therapy ≥ 4 days (OR 2.59, 95%CI 1.16–5.78, p = 0.0199), neurologic compromise at ICU admission (OR 3.41, 95%CI 1.04–11.20, p = 0.0431), suspected catheter-related bacteraemia (ORs 3.70 and 5.42, 95%CIs 1.32 to 15.07, p < 0.02), a BI site classified as "other" (ORs 3.29 and 15.88, 95%CIs 1.16 to 104.76, p < 0.03), sepsis with ≥ 2 organ dysfunctions (OR 4.21, 95%CI 1.42–12.55, p = 0.0098), late-onset ventilator-associated pneumonia (OR 6.30, 95%CI 1.15–34.44, p = 0.0338) and ≥ 1 risk factor for extended-spectrum β-lactamase-producing Enterobacteriaceae (OR 2.56, 95%CI 1.07–6.14, p = 0.0353). Main independent factors for compliance were using antibiotic therapy protocols (OR 0.42, 95%CI 0.19–0.92, p = 0.0313), respiratory failure at ICU admission (OR 0.36, 95%CI 0.14–0.90, p = 0.0281) and aspiration pneumonia (OR 0.37, 95%CI 0.14–0.99, p = 0.0486). Conclusions: Half of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should reassess on a day-to-day basis the benefit of using several antimicrobials or any broad-spectrum antibiotics and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using department protocols seem necessary to reduce non-compliance. A daily ASP could also improve compliance in these situations. Trial Registration: ClinicalTrials.gov: number NCT04642560. The date of first trial registration was 24/11/2020. [ABSTRACT FROM AUTHOR]

Objective To study the association of raised CRP with prolonged ICU stay in children with bronchopneumonia at Ghurki Trust Teaching Hospital, Lahore, Pakistan. Methodology This cross-sectional study was conducted in Paediatric Intensive Care Unit of Ghurki Trust Teaching Hospital, Lahore, Pakistan, for a duration of six months (June 2023 to December 2023). Out of 127 children admitted into ICU, 82 met the inclusion criteria, aged 2-60 months, diagnosed with bronchopneumonia. Upon admission, blood sample was taken for CRP levels and these levels were correlated with ICU stay, TLC count, O2 dependency, and antibiotics duration of the patients. Patients were divided into five groups based on CRP counts. CRP counts less than 0.3 mg/dL were taken as normal. CRP counts from 0.4-0.9 mg/dL were taken as mild, 1-10 mg/dL were considered moderate, 11-49 mg/dL were considered marked, and ≥50 mg/dL were considered severe. Results Out of 82 patients, 45 (54.88%) were males and 37 (45.12%) were females. This study found that raised CRP was present in 73 (89.02%) out of 82 children (p

Death and dying, while uncommon in day-to-day paediatrics practice, are becoming increasingly common occurrences as children with life-limiting illnesses are living longer. We reflect on our experiences with death and dying in our residency training and whether paediatrics, as a specialty, is uncomfortable with death. Paediatric trainees should be included in honest discussions about disease trajectories and participate in providing end-of-life care. Anticipatory guidance helps personalize care and can prevent unnecessary procedures or suffering that patients may experience. While trainees may not be present at the end-of-life for many patients, managing death and dying are important competencies for future paediatricians. Current paediatricians should reflect on their comfort with death and how this may impact their patient care. [ABSTRACT FROM AUTHOR]

Summary: Background: Non-digestible dietary fiber undergoes fermentation by the intestinal microbiota to produce short-chain fatty acids (SCFAs). Intestinal SCFAs control the production of T-helper cells, antibodies and are involved in maintaining homeostasis of the mucosal system. Sepsis is the leading cause of mortality in hospitalised children and is treated with antibiotics which disrupts the normal maturation of the microbiome causing dysbiosis. This study assessed the impact of a high-fibre Food-Based formula on feed tolerance and faecal SCFA concentrations in children admitted to intensive care with sepsis. Methods: An open-label single-subject study was based on repeated observations over 14 days in children admitted to intensive care with sepsis who commenced a high-fiber Food-Based enteral formula Compleat®Paediatric, (Nestle Health Science). Stool samples were collected to measure SCFA concentrations (acetate, butyrate and propionate). A Wilcoxon Signed-Rank test was used to measure change in SCFA concentrations. Other data collection included feed tolerance, anthropometrics, antibiotic administration and inflammatory markers. Results: Twenty children with sepsis were recruited over six months. The mean age was 10.8 years (±5.6 years SD). The most common sepsis-related organ failure was the respiratory tract (50 %). The mean duration of mechanical ventilation was 9 days (±4 SD), 25 % of children were treated with more than two antibiotics during their time in intensive care. Faecal propionate and butyrate concentrations were maintained during the children's time in intensive care. Stool frequency reduced from 2.6 per day (±1.08 SD) at baseline to 1.2 per day (±0.45 SD) after one week in intensive care (p

Introduction: A crucial metric for evaluating the effectiveness of microcirculation in septic shock is serum lactate. Lactate clearance within the first 24 hours of admission has predictive value for death in Paediatric Intensive Care Unit (PICU) admissions. Higher mortality was observed in septic patients who were unable to clear elevated admission lactate. Aim: To determine the admission lactate level and to investigate whether failure to clear elevated lactate in septic patients can prognosticate high PICU mortality. Materials and Methods: This prospective cohort study was conducted from August 2021 to July 2022 at PICU, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. A total of 75 children, aged two months to 18 years, admitted to the PICU for sepsis or septic shock, were enrolled in the study. The authors measured blood lactate at Intensive Care Unit (ICU) admission, at 6, 12, and 24 hours. Lactate clearance was calculated, and its association with mortality after 24 hours of PICU stay was measured using the Chi-square test. Results: Out of the total, 55 survived, comprising 31 males (41.3%) and 44 females (58.7%). When comparing admission blood lactate to lactate clearance >10% at 6, 12, and 24 hours, there was no correlation between the two variables and mortality in PICU patients with sepsis. Conclusion: Lactate clearance in the first 24 hours of PICU stay was recommended as a parameter associated with the mortality rate among septic patients. However, the authors did not find any correlation.

HIV-infected and HIV-exposed but uninfected (HEU) children have unique health risks. Our study looked at how HIV exposure and infection impact presentation and outcomes in PICU in an era of improved ART. A retrospective analysis of children admitted to PICU was performed. The sample was divided into HIV negative, HEU and HIV infected, and presentation and outcomes were compared with a significance level set at α = 0.05. Our study showed that 16% (109/678) of children admitted to PICU were HEU and 5.2% (35/678) were HIV infected. HIV-infected children were admitted at a younger age (median two months) with an increased incidence of lower respiratory infections than HIV-negative children (p < 0.001); they also required longer ventilation and admission (p < 0.001). HIV-infected children had a higher mortality (40%) (p = 0.02) than HIV-negative (22.7%) children; this difference was not significant when comparing only children with a non-surgical diagnosis (p = 0.273). HEU children had no significant difference in duration of ICU stay (p = 0.163), ventilation (p = 0.443) or mortality (p = 0.292) compared to HIV-negative children. In conclusion, HIV-infected children presented with more severe disease requiring longer ventilation and admission. HEU had similar outcomes to HIV-negative children.

HIV-infected and HIV-exposed but uninfected (HEU) children have unique health risks. Our study looked at how HIV exposure and infection impact presentation and outcomes in PICU in an era of improved ART. A retrospective analysis of children admitted to PICU was performed. The sample was divided into HIV negative, HEU and HIV infected, and presentation and outcomes were compared with a significance level set at α = 0.05. Our study showed that 16% (109/678) of children admitted to PICU were HEU and 5.2% (35/678) were HIV infected. HIV-infected children were admitted at a younger age (median two months) with an increased incidence of lower respiratory infections than HIV-negative children (p < 0.001); they also required longer ventilation and admission (p < 0.001). HIV-infected children had a higher mortality (40%) (p = 0.02) than HIV-negative (22.7%) children; this difference was not significant when comparing only children with a non-surgical diagnosis (p = 0.273). HEU children had no significant difference in duration of ICU stay (p = 0.163), ventilation (p = 0.443) or mortality (p = 0.292) compared to HIV-negative children. In conclusion, HIV-infected children presented with more severe disease requiring longer ventilation and admission. HEU had similar outcomes to HIV-negative children. [ABSTRACT FROM AUTHOR]

Background: Paediatric critical care practitioners have become increasingly concerned about venous thromboembolism (VTE). Although a wide range of factors associated with VTE in paediatric intensive care units (PICUs) have been identified, the strength and consistency of effect sizes are uncertain. Study Design: Systematic review and meta‐analysis of case–control and cohort studies. We searched six electronic databases from inception to 20 June 2021. The study population consisted of hospitalized children aged 0–21 years. Our primary outcome was factors associated with VTE in the PICU. We pooled effect sizes as odds ratios (ORs) using random‐effects models for each factor that was examined in at least three distinct samples. We assessed study quality using the Newcastle–Ottawa Scale and examined between‐study heterogeneity. Results: The meta‐analysis showed that age <1 year (OR = 1.80, 95% confidence interval [CI]: 1.08–3.01), sepsis (OR = 3.14, 95% CI: 1.55–6.38), central venous catheterization (CVC; OR = 7.76, 95% CI: 3.63–16.61), and mechanical ventilation (OR = 2.80, 95% CI: 1.90–4.13) was associated with an increased VTE risk. Conclusion: We identified that infancy, sepsis, and the use of CVC and mechanical ventilation therapies are more likely to cause VTE in critically ill children. It is still necessary to identify the association between VTE and important clinical variables (e.g., postpubertal age, postoperative status). Relevance to Clinical Practice: This review provides evidence that supports the factors associated with VTE in specific clinical settings and suggests that nurses should focus on the precise identification of the factors associated with VTE. [ABSTRACT FROM AUTHOR]

Introduction: A crucial metric for evaluating the effectiveness of microcirculation in septic shock is serum lactate. Lactate clearance within the first 24 hours of admission has predictive value for death in Paediatric Intensive Care Unit (PICU) admissions. Higher mortality was observed in septic patients who were unable to clear elevated admission lactate. Aim: To determine the admission lactate level and to investigate whether failure to clear elevated lactate in septic patients can prognosticate high PICU mortality. Materials and Methods: This prospective cohort study was conducted from August 2021 to July 2022 at PICU, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. A total of 75 children, aged two months to 18 years, admitted to the PICU for sepsis or septic shock, were enrolled in the study. The authors measured blood lactate at Intensive Care Unit (ICU) admission, at 6, 12, and 24 hours. Lactate clearance was calculated, and its association with mortality after 24 hours of PICU stay was measured using the Chi-square test. Results: Out of the total, 55 survived, comprising 31 males (41.3%) and 44 females (58.7%). When comparing admission blood lactate to lactate clearance >10% at 6, 12, and 24 hours, there was no correlation between the two variables and mortality in PICU patients with sepsis. Conclusion: Lactate clearance in the first 24 hours of PICU stay was recommended as a parameter associated with the mortality rate among septic patients. However, the authors did not find any correlation. [ABSTRACT FROM AUTHOR]

Background Aim Study Design Findings Conclusions Relevance to Clinical Practice Although a child‐ and family‐centred care (CFCC) philosophy has been emphasized and adopted for decades in paediatric critical care settings in several countries, numerous issues from parents' perspectives regarding the philosophy remain unresolved. To facilitate the full translation of CFCC into clinical practice, health care professionals need an in‐depth understanding of family experiences. Real‐life mothering experiences, including maternal roles and identities, remain largely unknown at paediatric intensive care units (PICUs) in the Republic of Korea, where family visitation, presence, and participation are restricted.To explore mothering experiences at a PICU where family visitation is strictly constrained, and to identify maternal needs and values.We conducted a qualitative descriptive study of eight individual in‐depth interviews with seven mothers of hospitalized children. Qualitative data were analysed using inductive thematic analysis.Five major themes, along with four subthemes, emerged: (1) shifts in maternal roles and responsibilities, (2) shifts in interpersonal relationships, (3) desire for CFCC in the PICU, (4) practising self‐defined mothering roles, and (5) reconstructing maternal identities. The themes revealed the experiences of becoming mothers of a child in a constrained PICU. Ultimately, mothers demanded that the unit improve its physical and cultural environments through, for example, liberalized family visitation and participation in the care of their children.Nursing professionals should lead the charge for humanizing a restrictive PICU in the Republic of Korea by ensuring a safe and open environment and mothering continuity based on child‐ and family‐centred holistic care.Effective interventions must be developed and tested to globally establish and fully implement strong evidence‐based CFCC in PICUs; constant co‐commitment among children, families, health care professionals, and institutions is also necessary. [ABSTRACT FROM AUTHOR]

Aim: To understand the moral distress experienced by health‐care workers (HCWs) in the COVID paediatric intensive care unit (PICU). We also aimed to assess the psychological well‐being and the coping mechanisms used by HCWs. Methods: A prospective observational cross‐sectional study was conducted from July to September 2021, involving all HCWs who worked in the COVID PICU. Moral distress using Moral Distress for Health‐care Professionals (MMD‐HPs) scale, psychological well‐being using Trauma Screening Questionnaire (TSQ) and coping strategies adopted by HCWs using Brief‐COPE (Coping Orientation to Problems Experienced) were measured. Results: One hundred and eighty‐four HCW data were examined. The most common causes of moral distress among HCWs were compromised patient care caused by a lack of resources and caring for more patients than they could safely handle. Moral distress was the same regardless of the HCWs' job profile, marital status, number of children or age. The TSQ revealed psychological stress in 23.3% of HCWs with Post‐traumatic Stress Disorder, significantly higher in HCWs under the age of 30 and without children. Few HCWs turned to substance use, self‐blame or denial as coping mechanisms; instead, acceptance, self‐distraction and emotional support were the most frequently used. Conclusion: The most common reasons for moral and psychological distress perceived by participants were insufficient staff and organisational support. Younger HCWs and those without children experienced higher levels of psychological distress. HCWs' typical coping mechanisms are constructive, such as seeking help and support from others, reframing situations and meditation. Health‐care administrators must develop a framework to assist HCWs in dealing with such serious issues. [ABSTRACT FROM AUTHOR]

Background: Delirium is one of the most common complications in critically ill children. Once delirium occurs, it will cause physical and psychological distress in children and increase the length of their ICU stay and hospitalization costs. Understanding the risk factors for delirium in critically ill children can help develop targeted nursing interventions to reduce the incidence of delirium. Aims: To investigate the incidence and the risk factors of delirium in the paediatric intensive care unit (PICU). Study design: We performed a prospective observational study in critically ill patients in the PICU between February and July 2020. Delirium was diagnosed by the Cornell Assessment of Paediatric Delirium (CAPD) and the Richmond Agitation Sedation Scale and analysed via univariate analysis and multivariate logistic regression to determine the independent risk factors of delirium in critically ill children. Results: The study enrolled 315 patients ranging in age from 1–202 (65.3–54.3) months, with 56.2% (n = 177) being male. The incidence of delirium was 29.2% (n = 92) according to CAPD criteria. Among them, 33 cases (35.9%) were of hyperactive delirium, 16 cases (17.4%) were of hypoactive delirium, and 43 cases (46.7%) were of mixed delirium. By using stepwise logistic regression, the independent risk factors of delirium included mechanical ventilation (odds ratio [OR], 11.470; 95% confidence interval [CI], 4.283–30.721), nervous system disease (OR, 5.596; 95%CI, 2.445 to 12.809), developmental delay (OR, 5.157; 95% CI, 1.990–13.363), benzodiazepine (OR, 3.359; 95% CI 1.278–8.832), number of catheters (OR, 1.918; 95% CI, 1.425 to 2.582), and age (OR, 0.985; 95% confidence interval CI, 0.976–0.993). Conclusions: Delirium is a common complication in the PICU. The independent risk factors include mechanical ventilation, nervous system disease, developmental delay, benzodiazepines, higher number of catheters, and younger age. This study may help develop intervention strategies to reduce the incidence of delirium in critically ill children by targeting modifiable risk factors. Relevance to Clinical Practice: Recommendations for practice include paying attention to high‐risk children in the ICU who are prone to delirium, removing influencing factors as soon as possible, and providing targeted nursing interventions. [ABSTRACT FROM AUTHOR]

Paediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, current evidence-base for interventions and suggest possible areas of improvement. Controversy remains regarding accurate definitions for paediatric sepsis, resuscitation fluid volume and type, choice of vasoactive agents for use in resuscitation and antibiotic choices. Many adjunctive therapies have been suggested with theoretical benefit, although few have proven beneficial. Definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Early diagnosis and aggressive intervention with timely antibiotics, fluid resuscitation and vasoactive medications are the most important interventions in to improve outcomes. The implementation of protocols, resource-adjusted sepsis bundles and advanced technologies will impact on reducing sepsis mortality. [ABSTRACT FROM AUTHOR]

Introduction: Mortality due to sepsis is increasing in the PICUs of India. This study was conducted with the aim to investigate the prognostic value of lactate level at the time of admission and lactate clearance for mortality in sepsis and estimate its cut-off value of predicting mortality. This study also aimed to estimate the correlation between lactate clearance with PRISM III score (Pediatric Risk of Mortality score) and duration of stay. Materials and Methods: This was a prospective study on 150 patients admitted with severe inflammatory response syndrome with a probable infection in the paediatric intensive care unit with an estimation of serial lactate levels in the blood at 0–3 h, 24 h and 48 h of admission. Lactate clearance was calculated, and patients were followed up till discharge/death. Results: Out of 150 patients, there were 94 survivors and 56 non-survivors; the mean lactate clearance at 24 h was 6.16% in non-survivors, which was lower than survivors at 28.41%. The cut-off value of lactate clearance for predicting mortality was estimated to be 17.6%. PRISM III score and lactate clearance were inversely related. The duration of intensive care unit stay was more in non-survivors with low lactate clearance. Conclusion: Lactate clearance can be used as a prognostic measure for mortality in patients with sepsis and can be used as a guide for treatment.

Introduction: Mortality due to sepsis is increasing in the PICUs of India. This study was conducted with the aim to investigate the prognostic value of lactate level at the time of admission and lactate clearance for mortality in sepsis and estimate its cut-off value of predicting mortality. This study also aimed to estimate the correlation between lactate clearance with PRISM III score (Pediatric Risk of Mortality score) and duration of stay. Materials and Methods: This was a prospective study on 150 patients admitted with severe inflammatory response syndrome with a probable infection in the paediatric intensive care unit with an estimation of serial lactate levels in the blood at 0-3 h, 24 h and 48 h of admission. Lactate clearance was calculated, and patients were followed up till discharge/death. Results: Out of 150 patients, there were 94 survivors and 56 non-survivors; the mean lactate clearance at 24 h was 6.16% in non-survivors, which was lower than survivors at 28.41%. The cut-off value of lactate clearance for predicting mortality was estimated to be 17.6%. PRISM III score and lactate clearance were inversely related. The duration of intensive care unit stay was more in non-survivors with low lactate clearance. Conclusion: Lactate clearance can be used as a prognostic measure for mortality in patients with sepsis and can be used as a guide for treatment. [ABSTRACT FROM AUTHOR]

Introduction: Organ donation is the offer of organs and tissues for transplantation to a fellow human being by the donor who has been declared as clinically dead. However, that organ donation rates for paediatric patients remain low, both nationally and globally. Purpose: Identifying, examining and understanding the factors that influence parents' decisions, when faced with the organ donation of their deceased child. Methods: A review of the literature was conducted in PubMed and Science Direct databases from December 2020 to February 2021.Epidemiological studies written in Greek and English language and published from 2006 to 2020, with regards to organ donation, as well as tissue and bodily fluids from paediatric patients, alongside factors contributing to the parents' decision, were included in the review. Results: 544 articles were retrieved and finally 11 of them were studied extensively, based on the inclusion criteria According to the outcome of the studies that have been reviewed showed that interpersonal/personal experiences, society, religion, health professionals, education, traditional values, child death conditions and stages of mourning and grief were the reasons that primarily influence and shape the decision of the parent/proxy. Conclusions: Increase in donation rates to pediatric patients, will be achieved through raising awareness, the education of society and information campaigns, in addition to the contribution received by medical and healthcare professionals. [ABSTRACT FROM AUTHOR]

A child's illness and admission in a hospital are stressful and can negatively affect the child and his/her caregivers. The stress is further exacerbated when a child is critically ill and has been admitted to an intensive care unit (ICU). The effects can be reduced when caregivers of the sick children are present and involved in decision making and actual care of their hospitalized children, a care model called family-centered care. Malawi has adopted family-centered care model in the newly instituted Mercy James Pediatric ICU. Little is known about experiences of caregivers with FCC in Malawi. This qualitative study was therefore conducted to explore experiences of caregivers on their involvement in decision making and care at Mercy James Pediatric ICU in Blantyre, Malawi. This was a descriptive qualitative study with a sample size of fifteen participants, however, data saturation was reached with ten participants. One on one in-depth interviews were conducted among a purposively selected sample of ten caregivers whose children had been discharged from the PICU. Content analysis was deductively and manually undertaken to analyze data with the aid of delve software to organize the data. Findings show that not every caregiver was involved in the decision making of their children's care, and if they did, it was not adequate. Barriers to effective involvement such as using a foreign language had a negative impact on comprehensive involvement of caregivers in decision making for their children's care. All participants were, however, involved in the physical care of their children. It is important that health care workers should continuously encourage caregivers to get involved in the decision making and care of their children. [ABSTRACT FROM AUTHOR]

Introduction: A seizure is a brief change in normal electrical brain activity resulting in alterations in awareness, perception, behaviour, or movement, which affect persons of all ages, but are particularly common in childhood. Seizure is a serious neurological symptom in the Paediatric Intensive Care Unit (PICU), yet data on the clinical spectrum of seizures occurring in the PICU setting in India are scarce. Aim: To determine the aetiology, clinical and radiological features of seizures in critically ill children admitted to PICU at a tertiary care hospital. Materials and Methods: This retrospective study was conducted at Gauhati Medical College and Hospital, Guwahati, Assam, India, from April 2017 to September 2018. A total of 253 children aged between 29 days to 12 years, admitted to PICU with seizures were enrolled in the study. Data regarding demographics, diagnosis, clinical seizures, associated diagnosis, Electroencephalogram (EEG) features, imaging, length of stay in PICU, and in-hospital mortality were collected. Data was presented in frequencies, mean, standard deviation. Results: In present study, male to female ratio was 1.5:1 with mean age of 48.9±44.5 months. The most common causes of seizures in PICU setting were acute symptomatic in 185 (73.1%) and epileptic in 68 (26.9%) patients. Central Nervous System (CNS) infections constituted 15.8% of the PICU admissions following seizures. Most frequent co-existent diagnosis at admission was infectious diseases in 96 (38%) patients, followed by pulmonary diseases in 28 (11%) and cardiologic diseases in 14 (5.5%). Conclusion: CNS infections are the most common cause of acute symptomatic seizure, while non infectious diseases such as metabolic disorders, epilepsy and immune disorders also contribute to seizure occurrence in PICU. Identification of common seizure aetiologies in PICU is important step for a prompt and effective treatment. [ABSTRACT FROM AUTHOR]

Introduction: A seizure is a brief change in normal electrical brain activity resulting in alterations in awareness, perception, behaviour, or movement, which affect persons of all ages, but are particularly common in childhood. Seizure is a serious neurological symptom in the Paediatric Intensive Care Unit (PICU), yet data on the clinical spectrum of seizures occurring in the PICU setting in India are scarce. Aim: To determine the aetiology, clinical and radiological features of seizures in critically ill children admitted to PICU at a tertiary care hospital. Materials and Methods: This retrospective study was conducted at Gauhati Medical College and Hospital, Guwahati, Assam, India, from April 2017 to September 2018. A total of 253 children aged between 29 days to 12 years, admitted to PICU with seizures were enrolled in the study. Data regarding demographics, diagnosis, clinical seizures, associated diagnosis, Electroencephalogram (EEG) features, imaging, length of stay in PICU, and in-hospital mortality were collected. Data was presented in frequencies, mean, standard deviation. Results: In present study, male to female ratio was 1.5:1 with mean age of 48.9±44.5 months. The most common causes of seizures in PICU setting were acute symptomatic in 185 (73.1%) and epileptic in 68 (26.9%) patients. Central Nervous System (CNS) infections constituted 15.8% of the PICU admissions following seizures. Most frequent co-existent diagnosis at admission was infectious diseases in 96 (38%) patients, followed by pulmonary diseases in 28 (11%) and cardiologic diseases in 14 (5.5%). Conclusion: CNS infections are the most common cause of acute symptomatic seizure, while non infectious diseases such as metabolic disorders, epilepsy and immune disorders also contribute to seizure occurrence in PICU. Identification of common seizure aetiologies in PICU is important step for a prompt and effective treatment.

Aims and objectives: The aims of the present study were investigating the feasibility of: (1) using the Danish version of Sophia Observation withdrawal Symptoms‐Paediatric Delirium (SOS‐PD) screening tool in clinical practice and (2) comparing SOS‐PD performance to a child psychiatrist's assessment using the diagnostic criteria as a reference standard. Background: Critically ill children risk developing delirium potentially causing discomfort and suffering. Intensive care delirium has a fluctuating course complicating detection. Systematic screening during and after intensive care is central to manage paediatric delirium. Design and methods: We used a descriptive and comparative design. First aim: Bedside nurses were asked to evaluate their experience of using the SOS‐PD. Second aim: We compared the SOS‐PD performance with the child psychiatrist assessment in 50 children aged 4 weeks to 18 years. Results: Nurses found the Danish version of the SOS‐PD applicable and easy to use. Of the 50 children included, 13 were diagnosed with delirium by the child psychiatrist. Consistency was found between the SOS‐PD score and the child psychiatrist's assessment (88%). We found three false‐negative and three false‐positive SOS‐PD cases. The false‐negative cases could be explained by the differences in time periods for the assessments. SOS‐PD assessments covered the past 4 h, whereas the psychiatric assessments covered the past 24 h. We assume the false‐positive cases represent an acceptable inconsistency between the two assessment methods. Conclusions: The Danish version of the SOS‐PD appeared suitable for identifying paediatric delirium. Our results emphasised the importance of assessment at least once during each nursing shift to ensure delirium detection around the clock due to the fluctuating course of delirium. Relevance to clinical practice: Implementing the Danish SOS‐PD may increase awareness of this critical disorder by improving systematic identification of paediatric delirium in clinical practice paving the way for improved delirium prevention and management. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to describe epidemiological and clinical characteristics of Serratia bacteraemia and to identify factors associated with mortality. Methods: The microbiology database of Schneider Children's Medical Centre of Israel was examined for Serratia marcescens positive blood cultures, between January 2007 and May 2020. Demographic, clinical and microbial characteristics were analysed. Results: Of the 81 patients files that met the inclusion criteria, 64 (80%) were of patients hospitalised in paediatric intensive care units. The median age was 78 days and 54% were male. In‐hospitalisation mortality was 26%, 62% died under 90 days old. Underlying conditions including prematurity, congenital cardiac defects and malignancies were noted in 95% of patients. Prior to the bloodstream infections, 62% of patients underwent procedures, 64% were on ventilatory support and 77% had central lines. Thrombocytopenia and elevated C‐reactive protein levels were found in 60% of the children. Twenty‐eight children received definitive monotherapy as either piperacillin‐tazobactam or a third‐generation cephalosporin; survival rates were similar between the two antibiotic treatment groups. Conclusion: In our cohort, 26% died. Death was more common in young infants. Mortality was associated with hospitalisation in intensive care units and thrombocytopenia. Survival rates following definitive monotherapy were similar for patients treated with piperacillin‐tazobactam and those treated with third‐generation cephalosporin. [ABSTRACT FROM AUTHOR]

Background: Non‐pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU). Aim: To explore expert opinions and generate informed consensus decisions regarding the content of a non‐pharmacologic delirium bundle to manage delirium in PICU patients. Study design: A two‐round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated. Results: We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9‐point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0–2, 3–5, and 6–18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence. Conclusions: Based on expert consensus, we developed an age‐specific non‐pharmacologic delirium bundle of interventions to manage delirium in PICU patients. Relevance to Clinical Practice: An age‐specific Non‐Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium. [ABSTRACT FROM AUTHOR]

Abstract We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.

Background: Critically ill children are vulnerable to acute kidney injury (AKI) and are often exposed to nephrotoxic medications. Objectives: We aimed to investigate the association between nephrotoxic medications and the risk of AKI in critically ill children admitted to our paediatric intensive care unit (PICU). Methods: Patients aged > 1 month to ≤18 years old were prospectively recruited from 6/2020 to 6/2021. The medication records from 14 days prior to PICU admission to PICU discharge were reviewed. Medication-exposure intensity was defined as the number of concomitant nephrotoxic medications. The relative risk (RR) of nephrotoxic medication exposure indices and other potential predictors for AKI development were determined. Results: Altogether 253 episodes of admissions (median [IQR] age of 4.9 [9.6] years) were enrolled. The AKI incidence was 41.9% and 69.2% of the patients were exposed to ≥1 of the 47 nephrotoxic medications. The total nephrotoxic medication dose (RR: 1.01 [1.00, 1.02]) and medication-exposure intensity (RR: 1.381 [1.101, 1.732]) were significantly associated with AKI development. The risk of AKI increased when the medication-exposure intensity was ≥4 (RR: 3.687 (1.320, 10.301)). During their PICU stay, children with AKI received a higher number (P < .01), total dose (P < .01) and medication exposure intensity (P < .01) of nephrotoxic medications. Children with AKI who received nephrotoxic medications were more likely to have a persistently higher peak-to-baseline ratio (P = .046). Conclusion: Nephrotoxic medication exposure significantly increased the risk of AKI development among critically ill children. The use of nephrotoxic medications among critically ill children at risk for AKI should be monitored frequently. [ABSTRACT FROM AUTHOR]

Resumen: Introducción: Existen factores clínicos o sociodemográficos que pueden tener un impacto en el confort del paciente crítico pediátrico. El objetivo principal fue determinar el grado de disconfort de los pacientes pediátricos ingresados en las UCIP de diversos hospitales nacionales y analizar su relación con variables sociodemográficas y clínicas, sedoanalgesia y síndrome de abstinencia. Métodos: Estudio observacional, analítico, transversal y multicéntrico en 5 hospitales españoles. Se valoró el grado de analgosedación mediante el sensor BIS y las escalas de dolor adaptadas a la edad pediátrica, una vez por turno durante 24 h. El grado de abstinencia se determinó con la escala Withdrawal Assessment Tool (WAT-1), una vez por turno durante 3 días consecutivos. Además, se valoró simultáneamente el grado de disconfort mediante la COMFORT Behavior Scale-versión española (CBS-ES). Resultados: Se incluyeron un total de 261 pacientes críticos pediátricos con una mediana de edad de 1,61 años (RIQ = 0,35-6,55). Se objetivaron puntuaciones globales de disconfort de 10,79 ± 3,7 en el turno de mañana versus 10,31 ± 3,3 en el de noche. Se observó asociación estadística al comparar al grupo de pacientes analgosedados con el grupo de no analgosedados en ambos turnos (χ2: 45,48; p = 0,001). A la vez, también se observó una relación estadísticamente significativa (p

Abstract Background The coronavirus disease-19 (COVID-19) pandemic had a relatively minimal direct impact on critical illness in children compared to adults. However, children and paediatric intensive care units (PICUs) were affected indirectly. We analysed the impact of the pandemic on PICU admission patterns and patient characteristics in the UK and Ireland. Methods We performed a retrospective cohort study of all admissions to PICUs in children

Aim: We aim to explore the experiences of nursing staff in paediatric intensive care units (PICUs) and wards when transporting and caring for patients being discharged from PICU. Background: PICU discharge is a challenging and complex procedure with risks and complications for patients. Nursing staff in PICU and paediatric wards play a pivotal role in the transition and are responsible for the quality of care, but their perspectives have rarely been explored. Methods: Focus groups were conducted between December 2021 and January 2022 with purposively sampled PICU nurses and ward nurses. Four focus groups were formed, and data were analysed using qualitative content analysis. Results: The overarching themes were as follows: communication during handover, attitudes towards follow‐up, a challenging transition for nurses and parents and suggestions for optimizing transitional procedure. Conclusion: Our findings provide nurses' insights and knowledge regarding the transition of patients from the PICU to the ward. Nursing strategies including the use of liaison nurses and critical training for ward nurses were considered essential to maintaining competence during transition. A well‐structured handover checklist as well as interdisciplinary cooperation and transitional care units are important for the patient's quality of care. Implication for nursing management: Communication, cooperation, planning and professional care are vital during the transition process. Nurse managers should work to develop collaborative approaches to facilitate safe patient transition. [ABSTRACT FROM AUTHOR]

Aim: We aim to explore parental experience in transitioning from a paediatric intensive care unit to a general ward and to investigate parental involvement in caring for their critical illness children. Background: Parents have a major responsibility in caring for seriously ill children, but nursing staff fail to meet the expectations of parents regarding nursing care. Few studies have investigated the challenges and needs of Chinese parents during the transition from paediatric intensive care unit to general ward. Methods: Semi‐structured interviews were conducted with 24 parents of children with critical illness in a paediatric hospital in Shanghai, mainland China to explore their views. Transcripts were entered into NVivo. Framework analysis was used to analyse the qualitative data. Results: Four themes were identified by data analysis: changes in the child during post paediatric intensive care unit periods; experiencing a wide range of emotions; factors involved in the transition; and suggestions for improving transitional care. Conclusions: Due to the unmet needs of parents, a more flexible visiting policy and social media support were highly desirable. Getting accurate information, establishing family integrated care, and strengthening ward‐based critical support services were also listed as important needs of parents caring for critically ill children. Implications for Nursing Management: A profound understanding of parental experiences during the transitional period can help nursing staff to assess the effects on children and their families, improve ward‐based intensive care, support parental participation, and improve visitation policies. Based on these findings, nurse managers can develop reasonable intervention programmes in order to improve nursing quality and patient outcomes [ABSTRACT FROM AUTHOR]

Adenotonsillectomy is the commonest otorhinolaryngology surgery for paediatrics. The purpose of this study was to determine the safety and outcome of adenotonsillectomy in a tertiary center in Malaysia. This was achieved by studying the demographics, indications, co-morbidities of patients and its association with the complications of the procedure. This retrospective study was conducted from November 2011 until October 2016. Medical records of patients aged 2–12 years old who had adenotonsillectomy done in our center were retrieved for data collection. A total of 143 patients who fulfilled the inclusion and exclusion criteria were recruited. Median age was 7.52 (± 2.98 SD) years old. Allergic rhinitis was the commonest co-morbidity (40%). Recurrent tonsillitis was the main indication (60%), followed by sleep disordered breathing (SDB) without apnea (29%), obstructive sleep apnea (OSA) (7%) and other indications (4%). Post-operative paediatric intensive care unit (PICU) admission was very low (1.4%) and was reserved for those with severe OSA with complications. None of the patients admitted to PICU post-operative had respiratory complications. The prevalence of post-tonsillectomy bleeding was only 2.1%. There was no significant association between patient's co-morbidity with operative complications (p = 0.269). Adenotonsillectomy is indicated for children with recurrent tonsillitis and paediatric SDB. The two most severe complications, namely post-tonsillectomy haemorrhage and respiratory complications occurred but incidence was low. Criteria of post-operative PICU or paediatric high dependency unit admission for paediatric SDB has to be based on multiple clinical and logistics factors and not only patients co-morbidity and indication of surgery. [ABSTRACT FROM AUTHOR]

Paediatric acute liver failure (PALF) is a rare but devastating condition with high mortality. An exaggerated inflammatory response is now recognised as pivotal in the pathogenesis and prognosis of ALF, with cytokine spill from the liver to systemic circulation implicated in development of multi-organ failure associated with ALF. With advances in medical management, especially critical care, there is an increasing trend towards spontaneous liver regeneration, averting the need for emergency liver transplantation or providing stability to the patient awaiting a graft. Hence, research is ongoing for therapies, including extracorporeal liver support devices, that can bridge patients to transplant or spontaneous liver recovery. Considering the immune-related pathogenesis and inflammatory phenotype of ALF, plasma exchange serves as an ideal liver assist device as it performs both the excretory and synthetic functions of the liver and, in addition, works as an immunomodulatory therapy by suppressing the early innate immune response in ALF. After a recent randomised controlled trial in adults demonstrated a beneficial effect of high-volume plasma exchange on clinical outcomes, this therapy was incorporated in European Association for the Study of Liver (EASL) recommendations for managing adult patients with ALF, but no guidelines exist for PALF. In this review, we discuss rationale, timing, practicalities, and existing evidence regarding the use of plasma exchange as an immunomodulatory treatment in PALF. We discuss controversies in delivery of this therapy as an extracorporeal device, and practicalities of use of plasma exchange as a 'hybrid' therapy alongside other extracorporeal liver assist devices, before finally reviewing outstanding research questions for the future. [ABSTRACT FROM AUTHOR]

Objective: To study the serum sodium levels in patients of lower respiratory tract infections admitted in the paediatric intensive care unit with their prognosis. Study Design: Prospective observational study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan to Jun 2018. Methodology: Eighty patients suffering from lower respiratory tract infections who were admitted to the paediatric intensive care unit were selected at consecutive sampling. The outcome was recorded in the form of discharge or mortality. Serum sodium was done at the time of admission and then periodically after every 24-48 hours. The Association of patients’ serum sodium with their prognosis was studied using chi-square test and p-value was calculated. Results: A total of 80 patients were enrolled in our study out of which 50 (62.50%) were males and 30 (37.50%) were females. Out of the total, 48 patients suffered from hyponatremia. These 48 patients had a mean serum sodium concentration of 131.24 ± 3.31 mEq/L. The mean age of patients suffering from hyponatremia was 5.78 ± 3.4 years. Mortality occurred in 5 (80.12%) of patients suffering from severe hyponatremia. Conclusion: There was a significant association of hyponatremia with mortality in children admitted in paediatric intensive care settings with lower respiratory tract infections. Therefore, proper management hence correction of serum sodium levels can improve survival in, particularly children admitted in a pediatric intensive care setting.

Summary: Background: To understand critical paediatric coronavirus disease 2019 (COVID-19) and evaluate factors associated with mortality in children from high and low-middle income countries. Methods: Prospective, observational study of critically ill children hospitalised for COVID-19 in 18 countries throughout North America, Latin America, and Europe between April 1 and December 31, 2020. Associations with mortality were evaluated using logistic regression. Findings: 557 patients (median age, 8 years; 24% 2 years old. Interpretation: We identified factors associated with COVID-19 mortality in critically ill children from both high and low-middle income countries, including higher mortality with younger age and COVID-related pulmonary disease but lower mortality in MIS-C. Further research is needed on optimal treatments for younger children and respiratory failure in paediatric COVID-19. Funding: None.

Abstract Background H syndrome (HS) is a rare autoinflammatory disease caused by a mutation in the solute carrier family 29, member 3 (SCL29A3) gene. It has a variable clinical presentation and little phenotype-genotype correlation. The pathognomonic sign of HS is cutaneous hyperpigmentation located mainly in the inner thighs and often accompanied by other systemic manifestations. Improvement after tocilizumab treatment has been reported in a few patients with HS. We report the first patient with HS who presented cardiogenic shock, multiorgan infiltration, and digital ischemia. Case presentation 8-year-old boy born to consanguineous parents of Moroccan origin who was admitted to the intensive care unit during the Coronavirus Disease-2019 (COVID-19) pandemic with tachypnoea, tachycardia, and oliguria. Echocardiography showed dilated cardiomyopathy and severe systolic dysfunction compatible with cardiogenic shock. Additionally, he presented with multiple organ dysfunction syndrome. SARS-CoV-2 polymerase chain reaction (PCR) and antibody detection by chromatographic immunoassay were negative. A previously ordered gene panel for pre-existing sensorineural hearing loss showed a pathological mutation in the SCL29A3 gene compatible with H syndrome. Computed tomography scan revealed extensive alveolar infiltrates in the lungs and multiple poor defined hypodense lesions in liver, spleen, and kidneys; adenopathy; and cardiomegaly with left ventricle subendocardial nodules. Invasive mechanical ventilation, broad antibiotic and antifungal coverage showed no significant response. Therefore, Tocilizumab as compassionate use together with pulsed intravenous methylprednisolone was initiated. Improvement was impressive leading to normalization of inflammation markers, liver and kidney function, and stabilising heart function. Two weeks later, he was discharged and has been clinically well since then on two weekly administration of Tocilizumab. Conclusions We report the most severe disease course produced by HS described so far in the literature. Our patient’s manifestations included uncommon, new complications such as acute heart failure with severe systolic dysfunction, multi-organ cell infiltrate, and digital ischemia. Most of the clinical symptoms of our patient could have been explained by SARS-CoV-2, demonstrating the importance of a detailed differential diagnosis to ensure optimal treatment. Although the mechanism of autoinflammation of HS remains uncertain, the good response of our patient to Tocilizumab makes a case for the important role of IL-6 in this syndrome and for considering Tocilizumab as a first-line treatment, at least in severely affected patients.

The subject of nutrition in intensive care is being discussed among the pediatric intensivists since long. The nutritional supplementation plays a vital role in treatment of pediatric intensive care patients. In recent past, due to technological advances the pathophysiology of critical diseases is being better understood so better nutritional strategies are being implemented in critical care units. As a result the prognosis of intensive care patients is improving resulting in decreased length of stay and less number of deaths of these patients. The metabolic stress in sick patients is an important factor to be considered while calculating the nutritional requirements of patients. The body's physiological mechanisms in the event of stress due to critical illness, need to be understood to make nutritional assessment of pediatric critical patients. The purpose of the current review is to recognize the recent nutritional supplementation guidelines of pediatric critical patients and to discuss any controversial issues. A meticulous study of the published literature regarding supplemental nutrition, energy calculation and algorithmic protocols for nutritional targets in pediatric critical population was done and areas in need of future research were identified. [ABSTRACT FROM AUTHOR]

Background. Extubation failure contributes to poor outcome of mechanically ventilated children, yet the prevalence and risk factors have been poorly studied in South African (SA) children. Objective. To determine the prevalence, risk factors and outcomes of extubation failure in an SA paediatric intensive care unit (PICU). Methods. This was a prospective, observational study of all mechanically ventilated children admitted to a tertiary PICU in Cape Town, SA. Extubation failure was defined as requiring re-intubation within 48 hours of planned extubation. Results. There were 219 episodes of mechanical ventilation in 204 children (median (interquartile range (IQR)) age 8 (1.6 - 44.4) months). Twenty-one of 184 (11.4%) planned extubations (95% confidence interval (CI) 7.2% - 16.9%) failed. Emergency cardiac admissions (adjusted odds ratio (aOR) 7.58 (95% CI 1.90 - 30.29), dysmorphology (aOR 4.90; 95% CI 1.49 - 16.14), prematurity (aOR 4.39; 95% CI 1.24 - 15.57), and ventilation ≥48 hours (aOR 6.42 (95% CI 1.57 - 26.22) were associated with extubation failure. Children who failed extubation had longer durations of ventilation (231 hours (146.0 - 341.0) v. 53 hours (21.7 - 123.0); p<0.0001); longer duration of PICU (15 (9 - 20) days v. 5 (2 - 9) days; p<0.0001) and hospital length of stay (32 (21 - 53) days v. 15 (8 - 27) days; p=0.009); and higher 30-day mortality (28.6% v. 6.7%; p=0.001) than successfully extubated children. Conclusions. Extubation failure was associated with significant morbidity and mortality in our setting. Risk factors for extubation failure identified in our context were similar to those reported in other settings. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19) has caused mild illness in children, until the emergence of the novel hyperinflammatory condition paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS). PIMS-TS is thought to be a post-SARS-CoV-2 immune dysregulation with excessive inflammatory cytokine release. We studied 25 hydroxyvitamin D (25OHD) concentrations in children with PIMS-TS, admitted to a tertiary paediatric hospital in the UK, due to its postulated role in cytokine regulation and immune response. Eighteen children (median (range) age 8·9 (0·3-14·6) years, male = 10) met the case definition. The majority were of Black, Asian and Minority Ethnic (BAME) origin (89 %, 16/18). Positive SARS-CoV-2 IgG antibodies were present in 94 % (17/18) and RNA by PCR in 6 % (1/18). Seventy-eight percentage of the cohort were vitamin D deficient (< 30 nmol/l). The mean 25OHD concentration was significantly lower when compared with the population mean from the 2015/16 National Diet and Nutrition Survey (children aged 4–10 years) (24 v. 54 nmol/l (95 % CI −38·6, −19·7); P < 0·001). The paediatric intensive care unit (PICU) group had lower mean 25OHD concentrations compared with the non-PICU group, but this was not statistically significant (19·5 v. 31·9 nmol/l; P = 0·11). The higher susceptibility of BAME children to PIMS-TS and also vitamin D deficiency merits contemplation. Whilst any link between vitamin D deficiency and the severity of COVID-19 and related conditions including PIMS-TS requires further evidence, public health measures to improve vitamin D status of the UK BAME population have been long overdue. [ABSTRACT FROM AUTHOR]

According to Dr John Papadatos, the first paediatric intensivist and paediatric intensive care unit (PICU) clinical director in Greece, the operation of the first Greek PICU commenced in January, 1986 and was located at the ‘P. & A. Kyriakou’ Children's Hospital in Athens, Greece. After having devoted 35 years to the PICU, he feels content with the development of paediatric intensive care in his country, Greece, where today there are six PICUs and four intermediate units under the national health system. Dr Papadatos earnestly believes that paediatric intensive care is really fascinating as intensivists deal with all branches of paediatrics, including infections, septicaemia, cancer, neurosurgery, accidents, poisoning and cardiology. Dr Papadatos values teamwork and effective communication with parents as the key factors to success in intensive care. He also believes that the PICU is an excellent school for general paediatricians, infectious diseases specialists and future paediatric virologists on paediatric viral infectious diseases. [ABSTRACT FROM AUTHOR]

Objective: Epidemiological description of paediatric patients admitted in the resuscitation room, identify the main pathologies that lead to admittance, and analyse risk factors for intensive care admittance. Design: A retrospective study was conducted between January 2014 and December 2017. Data regarding epidemiology, provenance, means of transport, triage evaluation, clinical status, and attitudes employed before admission and in the resuscitation room, destination, and prognosis were collected. Collected data was then compared between admitted and non-admitted patients in any intensive care unit. Setting: Resuscitation Room of the Paediatric Emergency Department in a tertiary hospital in the north of Portugal. Patients: All paediatric patients (newborn to 17 years and 364 days of age). Three hundred and sixty-three patients were admitted. Measurements and results: Main causes for admission were active seizures (35%) and severe traumatic brain injuries (TBI) (18.8%). Fortyfour point one percent were admitted to the intensive care unit (ICU). Multivariate analysis through binary logistic regression determined that admittance with a spinal board (p=0.012) and ventilatory support requirement (p=0.001) were independent positive risk factors for ICU admission, while being a frequent user of emergency services (p=0.016) and admission for active seizure (p=0.007) were negative risk factors. Trauma patients were the ones most likely to be admitted to the Paediatric Intensive Care Unit (PICU) (p<0.001). Among these, TBI was the most frequent cause for admission (p<0.031). Conclusions: Active seizure and trauma are the two situations most frequently addressed, the latter with the worst prognosis. It is paramount to hold frequent training and simulation sessions for health professionals to prepare the approach to these pathologies. [ABSTRACT FROM AUTHOR]

Background: Bisphenol A (BPA) is found in many medical materials used in the paediatric intensive care unit (PICU). Our aim was to evaluate how the urinary free-BPA(fBPA) and total-BPA(tBPA) levels were associated with the use of medical devices in the PICU in a prospective study. Methods: The procedures applied to the patient were recorded during the follow-up period. Three urine samples were taken on the first day of hospitalization; the seventh day, and after 30 days or when the patients were discharged. Urinary tBPA and fBPA levels were determined using high-pressure liquid chromatography. Generalized estimating equations with repetitive measures were used to determine the associations between PICU procedures and BPA levels. Results: A total of 115 urine samples of 40 children were studied. Mean urinary levels were 189.2 μg/g-creatinine for tBPA and 27.8 μg/g-creatinine for fBPA, and the fBPA/tBPA ratio was 27.9%. Endotracheal intubation, catheter, and haemodialysis procedures caused higher urinary fBPA levels. External drains, inhaler treatment, and the use of four or more medical devices were associated with considerably higher values of fBPA%. The increase in tBPA was positively correlated with fBPA. Conclusions: fBPA levels and the fBPA/tBPA ratio varied according to the procedure and level of BPA exposure in children. [ABSTRACT FROM AUTHOR]