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Background/Objectives : Non-invasive ventilation (NIV) has emerged as a possible first-step treatment to avoid invasive intubation in pediatric intensive care units (PICUs) due to its advantages in reducing intubation-associated risks. However, the timely identification of NIV failure is crucial to prevent adverse outcomes. This study aims to identify predictors of first-attempt NIV failure in PICU patients by testing various machine learning techniques and comparing their predictive abilities. Methods : Data were sourced from the TIPNet registry, which comprised patients admitted to 23 Italian Paediatric Intensive Care Units (PICUs). We selected patients between January 2010 and January 2024 who received non-invasive ventilation (NIV) as their initial approach to respiratory support. The study aimed to develop a predictive model for NIV failure, selecting the best Machine Learning technique, including Generalized Linear Models, Random Forest, Extreme Gradient Boosting, and Neural Networks. Additionally, an ensemble approach was implemented. Model performances were measured using sensitivity, specificity, AUROC, and predictive values. Moreover, the model calibration was evaluated. Results : Out of 43,794 records, 1861 admissions met the inclusion criteria, with 678 complete cases and 97 NIV failures. The RF model demonstrated the highest AUROC and sensitivity equal to 0.83 (0.64, 0.94). Base excess, weight, age, systolic blood pressure, and fraction of inspired oxygen were identified as the most predictive features. A check for model calibration ensured the model's reliability in predicting NIV failure probabilities. Conclusions : This study identified highly sensitive models for predicting NIV failure in PICU patients, with RF as a robust option.

Background: The first post-COVID-19 pandemic year demonstrated an unusual bronchiolitis epidemic in both hemispheres and has been attributed to the removal of barriers implemented during SARS-CoV-2 infection. Several countries reported an increase in respiratory syncytial virus (RSV) bronchiolitis, with more hospitalizations and a greater need for respiratory support. We aimed to evaluate the consequences of the COVID-19 pandemic on the epidemiology and management of severe bronchiolitis in pediatric intensive care units (PICUs) in Italy., Methods: Multicenter, retrospective, cohort database analysis. All children younger than 24 months admitted to 7 PICUs from October 2017 to April 2023 diagnosed with bronchiolitis were included. We compared patients from pre-COVID and post-COVID eras, excluding patients from the 2020-2021 season due to low numbers. Logistic regression models were used to assess the impact of the pre-/post-COVID period on the need for invasive ventilation., Results: Seven hundred fifteen patients were admitted to PICU during the study period, 451 patients pre-COVID and 251 patients post-COVID. Patients in the post-COVID group were older, had more comorbidities, and had higher Pediatric Index of Mortality scores at admission but the need for respiratory support was not significantly different. There was high variability in bronchiolitis management across centers. Presenting pre-COVID was protective against the risk of mechanical ventilation, adjusted for age and disease severity at admission (OR 0.38, 95% CI 0.16-0.89), while RSV infection increased the risk of intubation (OR 2.49, 95% CI 1.1-5.63)., Conclusions: PICUs have faced an unexpected peak of significantly more severe cases of bronchiolitis after the COVID-19 pandemic, which did not require increased respiratory support., Competing Interests: Declarations. Ethics approval and consent to participate: The study used the electronic web-based national registry of the Italian Network of PICU Study Group (TIPNet) and all participants signed an informed consent to allow data to be inserted into the database. The registry’s use for nonprofit research purposes has been approved by the Ethics Committee of the Buzzi Hospital, the coordinating registry center (approval number 269–052014 of 23/05/2014 and number 0047897 of 16/11/2020). Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Severe plasmodium falciparum infection can induce respiratory distress and clinical ARDS in children, requiring intensive care admission and respiratory support. We present 3 cases of imported malarial acute respiratory distress syndrome requiring noninvasive ventilation in the pediatric intensive care unit, in the absence of any cerebral involvement. Radiological features and their relationship with severe hematological complications are also illustrated., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Severe traumatic brain injury (TBI) is one of the most dramatic events in pediatric age and, despite advanced neuro-intensive care, the survival rate of these patients remains low. Children suffering from severe TBI show long-term sequelae, more pronounced in behavioral, neurological and neuropsychological functions leading to, in the most severe cases, an unresponsive wakefulness syndrome (UWS). Currently, no effective treatments can restore neuronal loss or produce significant improvement in these patients. In experimental animal models, human- recombinant Nerve Growth Factor (hr-NGF) promotes neural recovery supporting neuronal growth, differentiation and survival of brain cells and up-regulating the neurogenesis-associated processes. Only a few studies reported the efficacy of intranasal hr-NGF administration in children with post- traumatic UWS., Methods: Children with the diagnosis of post-traumatic UWS were enrolled. These patients underwent a treatment with intranasal hr-NGF administration, at a total dose of 50 gamma/kg, three times a day for 7 consecutive days. The treatment schedule was performed for 4 cycles, at one month distance each. Neuroradiogical evaluation by Positron Emission Tomography scan (PET), Single Photon Emission Computed Tomography (SPECT), Electroencephalography (EEG), and Power Spectral Density (PSD) was determined before the treatment and one month after the end. Neurological assessment was also deepened by using modified Ashworth Scale, Gross Motor Function Measure, and Disability Rating Scale., Results: Three children with post-traumatic UWS were treated. hr-NGF administration improved functional (PET and SPECT) and electrophysiological (EEG and PSD) assessment. Also clinical conditions improved, mainly for the reduction of spasticity and with the acquisition of voluntary movements, facial mimicry, attention and verbal comprehension, ability to cry, cough reflex, oral motility, and feeding capacity, with a significant improvement of their neurological scores. No side effects were reported., Conclusion: These promising results and the ease of administration of this treatment make it worthwhile to be investigated further, mainly in the early stages from severe TBI and in patients with better baseline neurological conditions, to explore more thoroughly the benefits of this new approach on neuronal function recovery after traumatic brain damage., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Post-traumatic fat embolism syndrome (FES) is a severe complication consequent to bone fractures. The authors describe its clinical features and management in a population of teenagers by detailing demographics, organ involvement, laboratory, and imaging findings, as well as outcome. Moreover, a systematic review of pediatric published case reports of post-traumatic FES is provided. First, a series of eight episodes of post-traumatic FES that occurred in seven patients (median age 16.0 years, IQR 16.0-17.5) admitted to a pediatric intensive care unit (PICU) in an 8-year period was analyzed through a retrospective chart review. Secondly, a systematic research was performed on PUBMED database. Trauma patients ≤ 18 years without comorbidities in a 20-year period (2002-2022) were included in the review. Neurological impairment was present in five out of seven patients, and a patent foramen ovale was found in four cases. Hemodynamic instability requiring vasoactive drugs was recorded in four patients. A severe form of acute respiratory distress syndrome (ARDS) occurred in five cases, with the evidence of hemorrhagic alveolitis in three of them. In the literature review, eighteen cases were examined. Most cases refer to adolescents (median age 17.0 years). More than half of patients experienced two or more long bone fractures (median: 2 fractures). Both respiratory and neurological impairment were common (77.8% and 83.3%, respectively). 88.9% of patients underwent invasive mechanical ventilation and 33.3% of them required vasoactive drugs support. Neurological sequelae were reported in 22.2% of patients., Conclusion: Post-traumatic FES is an uncommon multi-faceted condition even in pediatric trauma patients, requiring a high level of suspicion. Prognosis of patients who receive prompt support in an intensive care setting is generally favorable., What Is Known: •Post-traumatic fat embolism syndrome is a severe condition complicating long bone or pelvic fractures. •Little is known about clinical features and management in pediatric age., What Is New: •Post-traumatic fat embolism syndrome can cause multiple organ failure, often requiring an intensive care management. •Prompt supportive care contributes to a favorable prognosis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Intrathecal nusinersen administration, a fundamental step in the treatment of spinal muscular atrophy, is challenging in children., Aims: This retrospective monocentric analysis of prospectively collected data evaluated the feasibility of needleless general anesthesia exclusively with sevoflurane, without imaging guidance, for children undergoing nusinersen administration in a 24-month period., Methods: Clinical data included demographics, type of spinal muscular atrophy, presence and severity of scoliosis. Primary outcome was defined by the number of predefined sentinel adverse events related to anesthesia. Secondary outcomes were assessed by duration of the procedure, number of lumbar puncture attempts, and number of failures. Other measures included number and type of moderate, minor and minimal adverse events, as well as number and type of puncture-related adverse events., Results: 116 patients (mean age: 8.7 (SD 6.9) years; with scoliosis: 49.1%) underwent 250 lumbar punctures; two cases of prolonged desaturation, considered as sentinel adverse events, (0.8%) were recorded during anesthesia (primary outcome). None of the patients underwent orotracheal intubation nor required an unplanned admission in the Pediatric Intensive Care Unit. No patient required an unplanned or prolonged hospitalization after the procedure. Mean number of puncture attempts was 1.6 (SD 1.3), and mean duration of the procedure was 14.1 (SD 8.3) minutes. No failure in the drug administration occurred (secondary outcomes)., Conclusion: In this single-center experience, needleless general anesthesia with inhaled sevoflurane without imaging guidance has been shown to be feasible for children with spinal muscular atrophy undergoing lumbar puncture for nusinersen administration., (© 2023 John Wiley & Sons Ltd.)

Competing Interests: Disclosure: The authors declare no conflict of interest.

Blunt chest injury is commonly observed in the Pediatric Emergency Department and Intensive Care Unit since up to 30% of children with traumatic injury sustain injury to the thorax. Differently from adults, who present with concomitant rib or sternoclavicular fractures in 70% of cases, more than half of childhood chest injuries occur without any bone fracture, mostly causing lung contusions. This lower rate of rib fractures and near absence of flail chest in children may be due to greater elasticity of the pediatric cartilaginous and bony skeleton. Whenever a rib fracture is present, underlying complications should be evaluated carefully (i.e., air leaks or blood effusions). Depending on the trauma mechanism, even minor injuries should raise the suspicion of pathologic bone fractures., (© 2022 Wiley Periodicals LLC.)

Objectives: We aim to describe the use of continuous infusion of neuromuscular blocking agents in mechanically ventilated critically ill children and to test its association with in-hospital mortality., Design: Multicenter, registry-based, observational, two-cohort-comparison retrospective study using prospectively collected data from a web-based national registry., Setting: Seventeen PICUs in Italy., Patients: We included children less than 18 years who received mechanical ventilation and a neuromuscular blocking agent infusion from January 2010 to October 2017. A propensity score-weighted Cox regression analysis was used to assess the relationship between the use of neuromuscular blocking agents and in-hospital mortality., Interventions: None., Measurements and Main Results: Of the 23,227 patients admitted to the PICUs during the study period, 3,823 patients were included. Patients who received a continuous infusion of neuromuscular blocking agent were more likely to be younger (p < 0.001), ex-premature (p < 0.001), and presenting with less chronic respiratory insufficiency requiring home mechanical ventilation (p < 0.001). Reasons for mechanical ventilation significantly differed between patients who received a continuous infusion of neuromuscular blocking agent and patients who did not receive a continuous infusion of neuromuscular blocking agent, with a higher frequency of respiratory and cardiac diagnosis among patients who received neuromuscular blocking agents compared with other diagnoses (all p < 0.001). The covariates were well balanced in the propensity-weighted cohort. The mortality rate significantly differed among the two cohorts (patients who received a continuous infusion of neuromuscular blocking agent 21% vs patients who did not receive a continuous infusion of neuromuscular blocking agent 11%; p < 0.001 by weighted logistic regression). Patients who received a continuous infusion of neuromuscular blocking agent experienced longer mechanical ventilation and PICU stay (both p < 0.001 by weighted logistic regression). A weighted Cox regression analysis found the use of neuromuscular blocking agents to be a significant predictor of in-hospital mortality both in the unadjusted analysis (hazard ratio, 1.7; 95% CI, 1.3-2.2) and in the adjusted one (hazard ratio, 1.6; 95% CI, 1.2-2.1)., Conclusions: Thirteen percent of mechanically ventilated children in PICUs received neuromuscular blocking agents. When adjusting for selection bias with a propensity score approach, the use of neuromuscular blocking agent was found to be a significant predictor of in-hospital mortality., Competing Interests: Dr. Biban received funding from Getinge and Chiesi Pharmaceutical. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Rhythm abnormalities are rare during COVID-19-related multisystem inflammatory syndrome in children (MIS-C). We are reporting the detection of type I Brugada pattern in a 6-year-old child with MIS-C. Following the start of treatment (systemic steroids and immunoglobulins), a gradual evolution of cardiac rhythm up to normalisation was observed, concomitantly with a progressive reduction of inflammatory markers., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury., Study Design: A single center observational cohort study., Setting: Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre)., Population: During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV., Inclusion/exclusion Criteria: Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation., Measurements and Results: Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated., Conclusions: AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.