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Objectives: To determine the reliability of the Bleeding Assessment Scale in critically Ill Children (BASIC) definition of bleeding severity in a diverse cohort of critically ill children., Design: Prospective cohort study., Setting: Eight mixed PICUs in the Netherlands, Israel, and the United States., Subjects: Children ages 0-18 years admitted to participating PICUs from January 1, 2020, to December 31, 2022, with bleeding noted by bedside nurse., Interventions: None., Measurements and Main Results: The bleeding events were classified as minimal, moderate, or severe, according to the BASIC definition, by two independent physicians at two different time points. Patient demographic data, laboratory values, and clinical outcomes were collected. Three hundred twenty-eight patients were enrolled. The overall inter-rater reliability was substantial (weighted kappa coefficient, 0.736; 95% CI, 0.683-0.789), and the intra-rater reliability was "almost-perfect" (weighted kappa coefficient, 0.816; 95% CI, 0.769-0.863). The platelet count (p = 0.008), prothrombin time (p = 0.004), activated partial thromboplastin time (p = 0.025), and fibrinogen levels (p = 0.035) were associated with the bleeding severity, but the international normalized ratio was not (p = 0.195). Patients were transfused blood components in response to any bleeding in 31% of cases and received hemostatic medications in 9% of cases. More severe bleeding was associated with increased 28-day mortality, longer hospital length of stay, and more days receiving inotropic support., Conclusions: The BASIC definition is a reliable tool for identifying and classifying bleeding in critically ill children. Implementing this definition into clinical and research practice may provide a consistent and reliable evaluation of bleeding., Competing Interests: Dr. Nellis received funding from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: In post hoc analyses of our previous phase 2b Bayesian randomized clinical trial (RCT), prophylaxis with enoxaparin reduced central venous catheter (CVC)-associated deep venous thrombosis (CADVT) in critically ill older children but not in infants. The goal of the Catheter-Related Early Thromboprophylaxis with Enoxaparin (CRETE) Studies is to investigate this newly identified age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against CADVT in critically ill children., Design: Two parallel, multicenter Bayesian superiority explanatory RCTs, that is, phase 3 for older children and phase 2b for infants, and an exploratory mechanistic nested case-control study (Trial Registration ClinicalTrials.gov NCT04924322, June 7, 2021)., Setting: At least 15 PICUs across the United States., Patients: Older children 1-17 years old ( n = 90) and infants older than 36 weeks corrected gestational age younger than 1 year old ( n = 168) admitted to the PICU with an untunneled CVC inserted in the prior 24 hours. Subjects with or at high risk of clinically relevant bleeding will be excluded., Interventions: Prophylactic dose of enoxaparin starting at 0.5 mg/kg then adjusted to anti-Xa range of 0.2-0.5 international units (IU)/mL for older children and therapeutic dose of enoxaparin starting at 1.5 mg/kg then adjusted to anti-Xa range of greater than 0.5-1.0 IU/mL or 0.2-0.5 IU/mL for infants while CVC is in situ., Measurements and Main Results: Randomization is 2:1 to enoxaparin or usual care (no enoxaparin) for older children and 1:1:1 to either of 2 anti-Xa ranges of enoxaparin or usual care for infants. Ultrasonography will be performed after removal of CVC to assess for CADVT. Subjects will be monitored for bleeding. Platelet poor plasma will be analyzed for markers of thrombin generation. Samples from subjects with CADVT will be counter-matched 1:1 to subjects without CADVT from the opposite trial arm. Institutional Review Board approved the "CRETE Studies" on July 1, 2021. Enrollment is ongoing with planned completion in July 2025 for older children and July 2026 for infants., Competing Interests: Dr. Faustino’s institution received funding from the National Center for Advancing Translational Sciences (NCATS). Drs. Faustino’s, Glau’s and Shabanova’s institutions received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Drs. Faustino, Leroue, Sochet, Kong, Nellis, Pinto, Chegondi, Ramirez, Schreiber, Kerris, Glau, Kolmar, Muisyo, Silva, McPartland, and Shabanova received support for article research from the National Institutes of Health (NIH). Drs. Faustino, Kandil, Kerris, Glau, Silva, McPartland, and Shabanova disclosed off-label use of Enoxaparin. Dr. Kandil’s institution received funding from the NICHD (R01 HD106326) and the NCATS (UL1 TR001863); she received funding from the NIH (1R18HS027401-01A1) and the Children’s Hospital Association’s Improving Pediatric Sepsis Outcomes Steering Committee. Drs. Sochet’s, Kong’s, Schreiber’s, Kerris’, Kolmar’s, and Silva’s institutions received funding from the NIH. Dr. Glau received funding from the Medical University of South Carolina. Dr. Sharathkumar is a site investigator for a Pfizer study. Dr. Polikoff received funding from Novavax. Dr. Taylor’s institution received funding from Prolacta Bioscience and Ferring Pharmaceuticals; she received funding from Mother’s Milk Is Best. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Introduction: The use of extracorporeal membrane oxygenation (ECMO) in children continues to increase nationally, including patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. Survival of pediatric patients with MRSA sepsis has not improved over the last 20 years. We sought to review our institutional experience and outcomes of ECMO support among children with MRSA infection. Methods: Children aged 0-19 years who received ECMO support from October 2014 to June 2021 were reviewed retrospectively. Patients with laboratory confirmed MRSA infections were identified. Results: Out of 88 unique pediatric patients requiring ECMO support, eight patients had documented MRSA infections. The duration of mechanical ventilation prior to ECMO initiation was an average of seven days (range 0.7 to 21.8 days). The median ECMO duration was 648.1 h (range 15.5 to 1580.5 h). Five patients were successfully decannulated; however, only two patients survived to discharge. The two surviving patients were both cannulated via VV-ECMO. Mechanical ventilation prior to ECMO was 4.5 and 21.8 days in these cases with run durations of 18.9 and 29.9 days, respectively. Conclusions: Our institutional survival of patients with MRSA on ECMO is lower than what has been reported in recent database studies, but notably, 62.5% were successfully decannulated. While both surviving patients were supported with VV-ECMO, there was no other clear trend in factors that contributed to survival. MRSA continues to be a source of significant morbidity and mortality among pediatric patients. On-going investigation of outcomes and factors contributing to survival in patients with MRSA infection on ECMO is warranted., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers., Methods: I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians., Results: Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use., Conclusion: I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Histoplasma-mediated pericarditis is rare, and it occurs due to host-mediated inflammatory or immune response to adjacent mediastinal adenitis or pneumonitis. It is usually self-limited and rarely progresses to a disseminated infection in an immunocompetent individual. In rare instances, it can occur without pulmonary manifestations, making the diagnosis challenging given the broad list of differentials that can be considered as in our patient who initially presented with an isolated pericardial effusion with tamponade needing emergent pericardiocentesis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The Fontan procedure is the final palliative surgery in a series of staged surgeries to reroute the systemic venous blood flow directly to the lungs, with the ventricle(s) pumping oxygenated blood to the body. Advances in medical and surgical techniques have improved patients' overall survival after the Fontan procedure. However, Fontan-associated chronic comorbidities are common. In addition to chronic cardiac dysfunction and arrhythmias, complications involving other organs such as the liver, lungs, intestine, lymphatic system, brain, and blood frequently occur. This narrative review focuses on the immediate and late consequences in children, pregnant women, and other adults with Fontan circulation. In addition, we describe the technical advancements that might change the way single-ventricle patients are managed in future., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Objective: Blood transfusion therapy (BTT) is widely used in trauma patients. However, the adverse effects of BTT in pediatric trauma patients with traumatic brain injury (TBI) were poorly studied. The objective of this study is to evaluate the effect of BTT on mortality in children with severe TBI., Methods: In this retrospective cohort analysis, we analyzed 2012 and 2016 Kids' Inpatient Databases and used a weighted sample to obtain national outcome estimates. We included children aged 1 month to 21 years with TBI who were mechanically ventilated, considered severe TBI; we then compared the demographics, comorbidities, and mortality rates of those patients who had undergone BTT to those who did not. Statistical analysis was performed using the chi-squared test and regression models. In addition, in a correlative propensity score matched analysis, cases (BTT) were matched 1:1 with controls (non-BTT) based on age, gender, hospital region, income quartiles, race, and All Patients Refined Diagnosis Related Groups (APRDRG) severity of illness scores to minimize the effect of confounding variables between the groups., Results: Out of 87,980 children with a diagnosis of TBI, 17,199 (19.5%) with severe TBI were included in the analysis. BTT was documented in 3184 (18.5%) children. Among BTT group, the mortality was higher compared to non-BTT group [31.6% (29.7-33.5%) vs. 14.4 (13.7-15.1%), (OR 2.2, 95% CI 1.9-2.6; p<0.05)]. In the BTT group, infants and adolescents, white race, APRDRG severity of illness, cardiac arrest, platelet, and coagulation factor transfusions were associated with higher mortality. In a propensity-matched analysis, BTT associated with a higher risk of mortality (32.1% [30.1-34.2] vs. 17.4% [15.8-19.1], p<0.05; OR: 2.2, 95% CI: 1.9-2.6)., Conclusion: In children with severe TBI, blood transfusion therapy is associated with higher mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Chegondi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: To determine the effects of non-ictal electroencephalogram (EEG) changes on cerebrovascular autoregulation (AR) using the cerebral oximetry index (COx). Materials and Methods: Mean arterial blood pressure (MAP), cerebral tissue oxygenation (CrSO2), and EEG were acquired for 96 h. From all of the EEG recordings, 30 min recording segments were extracted using the endotracheal suction events as the guide. EEG recordings were classified as EEG normal and EEG abnormal groups. Each 30 min segment was further divided into six 5 min epochs. Continuous recordings of MAP and CrSO2 by near-infrared spectroscopy (NIRS) were extracted. The COx value was defined as the concordance (R) value of the Pearson correlation between MAP and CrSO2 in a 5 min epoch. Then, an Independent-Samples Mann-Whitney U test was used to analyze the number of epochs within the 30 min segments above various R cutoff values (0.2, 0.3, and 0.4) in normal and abnormal EEG groups. A p-value < 0.05 was considered significant, and all analyses were two-tailed. Results: Among 16 sedated, mechanically ventilated children, 382 EEG recordings of 30 min segments were analyzed. The proportions of epochs in each 30 min segment above the R cutoff values were similar between the EEG normal and EEG abnormal groups (p > 0.05). The median concordance values for CSrO2 and MAP in EEG normal and EEG abnormal groups were similar (0.26 (0.17−0.35) and 0.18 (0.12−0.31); p = 0.09). Conclusions: Abnormal EEG patterns without ictal changes do not affect cerebrovascular autoregulation in sedated and mechanically ventilated children.

Extracorporeal Membrane Oxygenation (ECMO) is often used in critically ill children with severe cardiopulmonary failure. Worldwide, about 3600 children are supported by ECMO each year, with an increase of 10% in cases per year. Although anticoagulation is necessary to prevent circuit thrombosis during ECMO support, bleeding and thrombosis are associated with significantly increased mortality risk. In addition, maintaining balanced hemostasis is a challenging task during ECMO support. While heparin is a standard anticoagulation therapy in ECMO, recently, newer anticoagulant agents are also in use. Currently, there is a wide variation in anticoagulation management and diagnostic monitoring in children receiving ECMO. This review intends to describe the pathophysiology of coagulation during ECMO support, review of literature on current and newer anticoagulant agents, and outline various diagnostic tests used for anticoagulation monitoring. We will also discuss knowledge gaps and future areas of research.

Objective: Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO), leading to increased mortality. Since one of its main complications is bleeding, platelet transfusions are frequently prescribed for children on ECMO. However, there is currently very little information on the effect of platelet transfusions on the function of the ECMO oxygenator. Our objective was to describe the effect of platelet transfusions on oxygenator function., Methods: In this retrospective study, we included all children (<18 years) who received ECMO support in our pediatric intensive care unit (PICU) between January 2017 and December 2019. Oxygenator function, measured before and after platelet transfusion, was assessed by post-oxygenator P ECMO O 2 and the gradient in pre- post-oxygenator pressures (Delta Pressure)., Results: Over 3 years, we analyzed 235 platelet transfusions from 55 children who received ECMO support. Thirty-two (80%) of children were on veno-arterial ECMO and majority of them were peripherally cannulated. When looking at all transfusions, the post-transfusion change in delta-pressure was 0.1 mmHg ( p = 0.69) and post-membrane P ECMO O 2 was 6 mmHg ( p = 0.49). However, in the subgroup with the lowest quartile of pre-transfusion oxygenator function, the post-transfusion change in delta-pressure was -5.2 ± 2.7 mmHg ( p < 0.001) and the post-transfusion change in P ECMO O 2 was -118 ± 49 ( p < 0.001). The area under the ROC curve for the pre-transfusion delta-pressure and P ECMO O 2 to predict a worsening of the oxygenator function were 0.72 (95%CI 0.63-0.81) and 0.71 (95%CI 0.64-0.78), respectively. Using regression models, pre-transfusion delta-pressure and P ECMO O 2 were the only independent factors associated with oxygenator function worsening ( p < 0.001)., Conclusion: Our study suggests that overall, platelet transfusions do not seem to impact the ECMO oxygenator's function. However, in the subgroup of patients with the lowest pre-transfusion oxygenator function, platelet transfusions were independently associated with a worsening function. Future studies should investigate if this warrants adjustments of the anticoagulation strategy around the platelet transfusion, especially among patients with lower oxygenator function., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chegondi, Vijayakumar, Badheka and Karam.)

Objective: To determine the performance of risk assessment models that were developed for adults, in predicting venous thromboembolism (VTE) and bleeding in critically ill adolescents., Study Design: We conducted a retrospective cohort study of adolescents 12 to 17 years old admitted to the pediatric intensive care unit who received cardiopulmonary support but did not have VTE on admission nor received anticoagulation. Discrimination, using areas under the receiver operating characteristic (AUROC) and precision-recall (AUPRC) curves, and calibration, using Hosmer-Lemeshow test, of the Geneva, Padua, IMPROVE VTE and IMPROVE Bleed models were calculated., Results: Of 536 adolescents analyzed, 7 (1.3%) developed VTE and 13 (2.4%) bled. AUROCs of the Geneva, Padua and IMPROVE VTE models ranged from 0.46 to 0.59, with 95% confidence intervals (CI) including 0.5. AUPRCs ranged from 0.011 to 0.017, with 95% CIs including 0.013. Only IMPROVE VTE model had non-statistically significant Hosmer-Lemeshow test. IMPROVE Bleed model had AUROC and AUPRC of 0.75 and 0.062, with 95% CIs excluding 0.5 and 0.024, respectively. Hosmer-Lemeshow test was not statistically significant., Conclusion: Despite similarities in coagulation between adolescents and adults, risk assessment models for VTE in adults should not be used for critically ill adolescents. The model for bleeding may be useful., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Inflammatory myofibroblastic tumors (IMTs) represent mesenchymal tumors that occur in the lungs, abdomen, or pelvis. Cardiac IMTs are rare, usually right-sided, and when left-sided can cause sudden cardiac death by coronary occlusion. We report a child with symptoms of embolization to the right kidney and the femoral artery, and a mobile mass in the left atrium attached to the mitral valve. Upon surgical removal, histopathology revealed IMT. Our case illustrates a unique presentation of systemic thromboembolism.

Background: Pediatric tuberculosis (TB) is an indicator of the recent transmission of TB in the community. However, the diagnosis of pediatric TB poses a challenge to clinicians., Aims: We aimed to evaluate and compare the clinical and laboratory profile of pulmonary TB (PTB) and extra PTB (EPTB) in children and adolescents., Methods: In this retrospective observational study, children attending the pediatric TB clinic of All India Institute of Medical Sciences, Rishikesh, from August 2015 to July 2017 were included in the study. The medical case records of patients were reviewed for demography, clinical findings, investigations, and diagnosis. The clinical and laboratory characteristics of patients with PTB and EPTB were compared., Results: A total of 58 children included. Out of which, 33 (56.9%) had PTB, and 25 (43.1%) had EPTB. The EPTB cases included 15 (60%) pleural TB, 9 (36%) lymph node TB, and 1 (4%) TB meningitis patient. Fever, cough, and weight loss were the most common symptoms. Hilar lymphadenopathy was the most common radiological abnormality. Microbiological confirmation was possible in 54.5% of patients with PTB. Cough (aOR 70.326; 95% CI: 5.370-921.032) and microbiological confirmation (aOR 46.011; 95% CI: 2.073-1021.201) were more in PTB as compared to EPTB., Conclusions: PTB and EPTB are common in children and adolescents. The typical clinical manifestations and positive microbiological confirmation are less common in EPTB than PTB., Relevance for Patients: TB is one of the common communicable diseases in the developing world. Diagnosis of TB in children is often challenging. Our study results help in better understanding childhood TB and EPTB clinical features and have potential to increase diagnostic yield., Competing Interests: The authors declare no conflicts of interest., (Copyright: © Whioce Publishing Pte. Ltd.)

Platelet mass index (PMI) as a prognostic indicator in pediatric sepsis has not been previously reported. In this retrospective observational study, we evaluated PMI's performance as a prognostic indicator in children aged younger than 18 years with sepsis and septic shock in relationship with survival. Over 5 years, we collected data from 122 children admitted to our pediatric intensive care unit (PICU). PMI accuracy was assessed with sensitivity and specificity and its discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Median PMI values on days 1 and 3 of PICU admission were lower among nonsurvivors. On day 1 of PICU admission, a cutoff PMI value of 1,450 fL/nL resulted in a sensitivity of 72% and a specificity of 69%, and the AUC was 0.70 (95% confidence interval [CI]: 0.55-0.86). Similarly, on day 3, a cutoff of 900 fL/nL resulted in a sensitivity of 71% and a specificity of 70%, and the AUC was 0.76 (95% CI: 0.59-0.92). Our exploratory study suggests that low PMI in children with septic shock is associated with increased mortality. Considering the PMI's fair performance, further studies should be performed to assess its clinical value., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Introduction: We sought to investigate the predictors of catheter-related thrombosis (CRT) in a cohort of critically ill hospitalized infants and using a novel approach (the artificial neural network - ANN) in combination with conventional statistics to identify/confirm those predictors., Methods: We performed a retrospective analysis of all infants with a central or peripherally inserted central venous catheter (CVC/PICC) between 2015 and 2018. ANN was generated to investigate the predictors of CRT. The predictive variables examined in the ANN were age, gender, weight, co-morbid conditions, line type, use of ultrasound (USG), emergent line placement, location of line tip, any major surgical procedures, use of mechanical ventilation, exposure to cardio-pulmonary bypass (CPB), past-history of CVC/PICC, or thrombosis. Binary logistic regression was performed to calculate odds ratios (ORs) and determine which factors were significant in predicting CRT., Results: Of total of 613 infants, 59.9% of patients had a history of previous CVC or PICC and 12.2% had a history of thrombus as documented by USG in the past three months. CPB exposure was present in 48.1%. The incidence of CRT was 10.7%. Independent predictors of CRT were the line tip in IVC (OR: 2.37, 1.08-5.21, P = 0.032), history of thrombosis (OR: 2.40, 1.16-4.96, P = 0.019), previous CVC/PICC (OR: 2.80, 1.24-6.33, P = 0.014) and exposure to CPB (OR: 2.749, 1.08-6.98, P = 0.034). A sensitivity analysis was performed to determine the normalized importance of each variable used to create the ANN. The most important variables were age (with normalized importance of 100%), history of thrombosis, weight, and exposure to CPB (normalized importance of 68.2%)., Conclusions: Nearly 1 in 10 infants developed CRT. We found that catheter tip in IVC, exposure to CPB, history of vein thrombosis and history of CVC/PICC placement in the past 3 months are independently associated with a higher risk of CRT in infants by using conventional and neural network methods., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Rescuing patients with the development of acute respiratory distress syndrome and right heart failure after left ventricular assist device placement remains a challenge in patients with congenital heart disease. TandemLife Protek Duo (TandemLife, Pittsburg, PA) is a double-lumen cannula introduced via the internal jugular vein that can provide veno-venous extra-corporeal membrane oxygenation and right heart support. To our knowledge, we report the first case of successfully using the TandemLife Protek Duo cannula to provide veno-venous extra-corporeal membrane oxygenation and right ventricle support in an adolescent male with an existing right ventricle-pulmonary artery conduit and the melody pulmonary valve who developed severe acute respiratory distress syndrome after the placement of left ventricular assist device. The stability of the cannula enabled minimal recirculation-related hypoxia events, early mobilization, and ambulation. Our patient was discharged home after lung recovery and currently awaiting a heart transplant.

Background: Kidney replacement therapy (KRT) is frequently used in critically ill children. The objective of this study is to investigate if the requirement for hemodialysis (HD) is an independent risk factor for mortality in mechanically ventilated children METHODS: In this retrospective cohort study, we analyzed the 2012 and 2016 Kids Inpatient Database and used a weighted sample to obtain a national outcome estimate. For our analysis, we included children aged one month to 17 years who were mechanically ventilated; we then compared the demographics, comorbidities, and mortality rates of those patients who had undergone HD with those who did not. Statistical analysis was performed using the chi-squared test and regression models. The patients were matched 1:2 with a correlative propensity score using age, weekend admission, elective admission, gender, hospital region, income quartiles, race, presence of kidney failure, bone marrow transplantation (BMT), cardiac surgery, trauma, and All Patients Refined Diagnosis Related Groups (APR-DRG) severity score. The mortality rate was compared between the matched groups., Results: Out of 100,289 mechanically ventilated children, 1393 (1.4%) underwent HD. The mortality rate was 32.5% in the HD group, compared with 8.8% in the control group (p < 0.05). Factors that were associated with higher mortality in HD patients included severe sepsis, BMT, cardiopulmonary resuscitation (CPR), and extracorporeal membrane oxygenation therapy (ECMO). After propensity score-matched analysis, HD was still significantly associated with a higher risk of mortality (31.9% vs. 22.0%, p < 0.05) CONCLUSIONS: The requirement for HD in mechanically ventilated children is associated with higher mortality.

Influenza-associated encephalopathy/encephalitis (IAE) can result in serious neurological complications. We report a 4-year-old healthy female child with the diagnosis of IAE. Her clinical course was complicated by temporary visual impairment and significant motor deficits. Her unique ophthalmological findings have little precedent in previous literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Metabolic bone disease (MBD) is an important cause of morbidity in premature, very low birth weight (VLBW) and sick infants and, if left undiagnosed, may lead to structural deformities and spontaneous fractures. MBD is defined as impaired bone mineralization in a neonate with lower than expected bone mineral levels in either a fetus or a neonate of comparable gestational age and/or weight, coupled with biochemical abnormalities with or without accompanying radiological manifestations. MBD has been reported to occur in 16% to 40% of extremely low birth weight neonates and presents by 6-16 weeks after birth. Insufficient calcium and phosphorous stores during the phase of accelerated growth predispose to MBD in neonates along with the use of some medications such as caffeine or steroids, prolonged parenteral nutrition and chronic immobilization. Enhanced physical activity in preterm infants facilitates bone mineralization and weight gain. Biochemical abnormalities tend to worsen significantly, as the severity of disease progresses. These abnormalities may include hypocalcemia, hypophosphatemia, hyperphosphatasia and secondary hyperparathyroidism. In addition, urinary phosphate wasting and hypovitaminosis D can be additional complications. Conversely, biochemical abnormalities may not be accompanied by rachitic changes. Newer diagnostic modalities include non-invasive bone densitometry by quantitative ultrasound over the mid-tibial shaft. The management of MBD includes adequate calcium, phosphorous and vitamin D supplementation, along with optimum nutrition and physical activity. Similarly, preventive strategies for MBD should target nutritional enhancement in combination with enhanced physical activity. MBD usually results in preventable morbidity in preterm and VLBW neonates. Treatment consists of optimum nutritional supplementation and enhanced physical activity.

Critically ill children are a unique population who frequently receive plasma and platelet transfusions for both active bleeding and mitigation of bleeding risk. While these products are frequently administered, transfusion indications in this population remain unclear, and practice varies across institutions and providers. In this manuscript, we will outline the current evidence regarding plasma and platelet transfusions for hemostasis in the pediatric intensive care setting. For both products, we will describe the product composition, epidemiology, and product indications and discuss the potential risks and benefits involved with the transfusion. We will also discuss knowledge gaps and future areas of research., (Copyright © 2020 Kahn, Chegondi, Nellis and Karam.)

Background: Vitamin D deficiency is one of the major nutritional deficiencies and an important contributor to nutritional and growth failure in infants, especially in those with low socioeconomic status., Aim: The primary objective of this study was to determine the proportion of vitamin D deficiency in infants, and the secondary objective was to assess the correlation between infant and maternal vitamin D levels., Methods: This prospective, observational study was carried out at a tertiary care center, All India Institute of Medical Sciences in Rishikesh, Uttarakhand, India, in the Department of Pediatrics from January 2017 to December 2018. Children aged less than one year and their mothers were enrolled in the study. All the infants attending the Department of Pediatrics for well-child visits and sick-child visits were enrolled after obtaining written, informed consent. Infants with major congenital malformations and liver and kidney dysfunction were excluded. Serum vitamin D level of <20 ng/mL was defined as vitamin D deficiency., Results: A total of 200 infants and 200 mothers were enrolled in the study. Among the study infants, 80% were neonates, and 20% were infants beyond the neonatal period. The prevalence of vitamin D deficiency was 74% in infants and 85.5% in mothers. Nearly half of the infants and mothers had severe vitamin D deficiency. Logistic regression analysis showed a positive correlation between maternal and infant vitamin D levels (r=0.074, p<0.001) and also with neonatal age group and low socioeconomic status. Hyperphosphatemia and hypocalcemia were predominant biochemical manifestations., Conclusion: The prevalence of vitamin D deficiency among the study infants was 74%. Neonatal age group, lower socioeconomic status, and maternal vitamin D deficiency were major determinants of vitamin D deficiency in infants., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Chacham et al.)

Objective: To explore the epidemiology and outcomes of takotsubo cardiomyopathy in children., Methods: A retrospective analysis of the Healthcare Cost and Utilization 2012 and 2016 Kids' Inpatient Database was performed. Patients admitted with the diagnosis of takotsubo cardiomyopathy in the age group of 1 month-20 years were identified using International Classification of Diseases (ICD)-9 code 429.83 and ICD-10 code I51.81., Results: Among a total of 4,860,859 discharges, there were 153 with the diagnosis of takotsubo cardiomyopathy (3.1 per 100,000 discharges). Among patients with takotsubo cardiomyopathy, 55.0% were male, 62.4% were white, and 16.7% were black. Eighty-nine percent of patients were between 12 and 20 years. Psychiatric diagnosis was documented in 46% and substance use disorder in 36.2%. Sepsis was documented in 22.8% of patients. The median length of stay was 5 days (interquartile range: 2.7-15), and median total charges were $75,080 (interquartile range: 32,176-198,336). The overall mortality for takotsubo cardiomyopathy was 7%. On multivariable regression analysis, mortality was higher in the presence of anoxic injury (odds ratio = 34.42, 95% confidence interval: 4.85-320.11, p = 0.00)., Conclusions: Takotsubo cardiomyopathy is uncommon in children and carries a mortality rate of 7%. Most children with takotsubo cardiomyopathy are adolescent males, many of whom have psychiatric disorder or substance use disorder or both. Takotsubo cardiomyopathy should be considered in the differential diagnosis for patients who present with cardiac dysfunction and have underlying psychiatric disorders or drug abuse.

Introduction The objective of this study was to describe the course and the outcomes of children with convulsive status epilepticus and to evaluate the differences between two groups of children with new-onset seizures and known seizure disorders. Methods This is a retrospective, single-center study. Children with convulsive status epilepticus admitted to our tertiary care pediatric intensive care unit were included in the study. Medical records were reviewed to obtain the demographic- and seizure-related variables. Results Among 139 children with status epilepticus, 69.7% ( n = 99) had a known seizure disorder. Focal seizures were present in 23.9% of children, and 34.6% required intubation; there was an overall mortality rate of 1.2%. The children with new-onset seizures were younger and received electroencephalography (EEG) and neuroimaging more often compared to children with known seizure disorders ( p < 0.05). However, an abnormal EEG was more common among children with known seizure disorders ( p < 0.001). Conclusions Sub-therapeutic anti-epileptic drugs levels were common among children with known seizure disorders presenting with status epilepticus. Gender, race, insurance status, type of seizures, intubation requirement, lengths of stay, and mortality were not significantly different between the two groups., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To evaluate the effects of closed endotracheal tube suctioning on systemic oxygen saturation, cerebral regional oxygen saturation, and somatic regional (renal) oxygen saturation and hemodynamic variables in children., Design: Prospective observational., Setting: A tertiary care PICU., Subjects: Children aged 0-18 years, requiring invasive mechanical ventilation and with an arterial line., Interventions: Closed endotracheal suction., Measurements and Main Results: The study included 19 sedated and intubated children, 0-18 years old. They were enrolled in an ongoing prospective observational study. We used near-infrared spectroscopy for cerebral regional oxygen saturation and somatic regional (renal) oxygen saturation. The timing of each closed endotracheal tube suctioning event was accurately identified from video recordings. We extracted systemic oxygen saturation, cerebral regional oxygen saturation, somatic regional (renal) oxygen saturation, heart rate, and systolic blood pressure and diastolic blood pressure for 5 minutes before and 5 minutes after each event and used these data for analysis. One-minute average values of these variables were used for repeated-measures analysis. We analyzed 287 endotracheal tube suctioning episodes in 19 children. Saline was instilled into the endotracheal tube during 61 episodes. The mean heart rate (107.0 ± 18.7 vs 110.2 ± 10.4; p < 0.05), mean arterial blood pressure (81.5 ± 16.1 vs 83.0 ± 15.6 mm Hg; p < 0.05), and the mean cerebral regional oxygen saturation (64.8 ± 8.3 vs 65.8 ± 8.3; p < 0.05) were increased after suctioning. The mean systemic oxygen saturation (96.9 ± 2.7 vs 96.7 ± 2.7; p = 0.013) was decreased, whereas the mean somatic regional (renal) oxygen saturation was not significantly different after endotracheal tube suctioning. Repeated-measures analysis revealed transient increases in heart rate, respiratory rate, systolic blood pressure, and diastolic blood pressure; a sustained increase in cerebral regional oxygen saturation; and transient decreases in systemic oxygen saturation and somatic regional (renal) oxygen saturation. Saline instillation did not affect oxygenation or hemodynamic variables., Conclusions: Closed endotracheal tube suctioning in sedated children is associated with transient but clinically insignificant changes in heart rate, blood pressure, cerebral regional oxygen saturation, systemic oxygen saturation, and somatic regional (renal) oxygen saturation. Saline instillation during endotracheal tube suctioning had no adverse effects on systemic or cerebral oxygenation.

Objective To evaluate the threshold for platelet transfusion in children admitted to a pediatric intensive care unit (PICU). This is a retrospective chart review study, conducted at our tertiary level PICU and is related to critically ill pediatric patients who required platelet transfusion. Methods We retrieved the target patient population data from our blood bank database. The patients were subdivided into four subgroups: hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, and sickle cell disease), surgical (post-surgical, trauma and acute bleeding), the unstable fraction of inspired oxygen (FiO 2 > 0.6 and/or inotropic support), and the stable patients. Critically ill children between one month and 21 years of age were enrolled. We excluded patients who underwent extracorporeal membrane oxygenation (ECMO). Results A total of 197 transfusion episodes in 64 patients were analyzed. The distribution of transfusions episodes included hematologic 82% (n=161), surgical 7% (n=13), unstable 8% (n=16), stable 3% (n=7). The mean standard deviation (SD) of pre-transfusion platelet count (x1000) in all the patients and children in hematologic, surgical, unstable and stable groups were 29 (22), 29 (19), 47 (46), 28 (19), and 24 (14), respectively. The platelet count threshold for transfusion among the surgical group was higher compared to hematologic and unstable groups (p <0.001; analysis of variance (ANOVA) with multiple comparison tests). The mean platelet count during all episodes increased from 29 (22) to 71 (57) (p <0.05; paired t-test). The post-transfusion increase in platelet count was significantly higher among surgical and unstable patients compared to hematologic patients (p <0.001; ANOVA with multiple comparison tests). Conclusion The most common indication for platelet transfusion in the pediatric intensive care unit (PICU) is the underlying hematologic condition. The platelet count threshold for transfusion varied with the clinical condition and is higher among the surgical patients. The rise of platelet count after transfusion was higher among the surgical and unstable patients., Competing Interests: The authors have declared that no competing interests exist.

Objective: To evaluate the hemoglobin threshold for red cell transfusion in children admitted to a pediatric intensive care unit (PICU)., Methods: Retrospective chart review study. Tertiary care PICU. Critically ill pediatric patients requiring blood transfusion. No intervention., Results: We analyzed the charts of all children between 1 month and 21 years of age who received packed red blood cell (PRBC) transfusions during a 2-year period. The target patients were identified from our blood bank database. For analysis, the patients were subdivided into four groups: acute blood loss (postsurgically, trauma, or acute gastrointestinal bleeding from other causes), hematologic (hematologic malignancies, bone marrow suppression, hemolytic anemia, or sickle cell disease), unstable (FiO 2 > 0.6 and/or on inotropic support), and stable groups. We also compared the pre-transfusion hemoglobin threshold in all unstable patients with that of all stable patients. A total of 571 transfusion episodes in 284 patients were analyzed. 28% (n = 160) of transfusions were administered to patients in the acute blood loss group, 36% (n = 206) to hematologic patients, 17% (n = 99) to unstable patients, and 18% (n = 106) to stable patients. The mean pre-transfusion hemoglobin (± SD) in all children as well as in the acute blood loss, hematologic, unstable and stable groups was 7.3 ± 1.20, 7.83 ± 1.32, 6.97 ± 1.31, 7.96 ± 1.37, 7.31 ± 1.09 g/dl, respectively. The transfusion threshold for acute blood loss and unstable groups was higher compared to hematologic and stable groups (p < 0.001; ANOVA with multiple comparisons). The mean pre-transfusion hemoglobin threshold for stable and unstable patients among all groups was 7.3 ± 1.3 and 7.9 ± 1.3 (p < 0.0001), respectively. The observed mortality rate was higher among children who received transfusion compared to other children admitted to PICU., Conclusion: The hemoglobin threshold for transfusion varied according to clinical conditions. Overall, the hemoglobin threshold for transfusion was 7.3 ± 1.20 g/dl.