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Background Acute kidney Injury (AKI) in children undergoing cardiac surgery (CS) is strongly associated with hospital morbidity. Post-discharge CS AKI outcomes are less clear. We evaluated associations between AKI and post-discharge (a) healthcare utilization, (b) chronic kidney disease (CKD) or hypertension and (c) mortality. Methods This is a retrospective two-centre cohort study of children surviving to hospital discharge after CS. Primary exposures were post-operative [greater than or equal to]Stage 1 AKI and [greater than or equal to]Stage 2 AKI defined by Kidney Disease Impoving Global Outcomes. Association of AKI with time to outcomes was determined using multivariable Cox-Proportional Hazards analysis. Results Of 350 participants included (age 3.1 (4.5) years), 180 [51.4%] developed AKI and 60 [17.1%] developed [greater than or equal to]Stage 2 AKI. Twenty-eight (9%) participants developed CKD or hypertension (composite outcome), and 17 (5%) died within 5 years of discharge. Post-operative [greater than or equal to]Stage 1 and [greater than or equal to]Stage 2 AKI were not associated with post-discharge hospitalizations, emergency room (ER) visits, physician visits or CKD or hypertension in adjusted analyses. A trend was observed between [greater than or equal to]Stage 2 AKI and mortality but was not statistically significant. In unadjusted stratified analyses, AKI was associated with post-discharge hospitalizations in children with RACHS-1 score [greater than or equal to]3, complex chronic disease classification and children living in urban areas. Conclusions Post-CS AKI is not associated with post-discharge healthcare utilization, death and CKD or hypertension, though it may be associated with healthcare utilization in more complex paediatric CS children. Studies should aim to better understand post-CS healthcare utilization patterns and non-AKI risk factors for CKD, hypertension and mortality, to reduce adverse long-term outcomes after CS., Author(s): Sophia Nunes [sup.1] , Erin Hessey [sup.1] [sup.2] , Marc Dorais [sup.3] , Sylvie Perreault [sup.4] , Philippe Jouvet [sup.5] , Véronique Phan [sup.6] , Jacques Lacroix [sup.5] , [...]

Background Baseline serum creatinine (bSCr) is required for diagnosing acute kidney injury (AKI). In children, bSCr is commonly defined as the lowest measurement within 3 months of admission. Measured values are often missing and estimating bSCr using height-based glomerular filtration rate (GFR) equations is problematic when height is unavailable. Methods This is a retrospective cohort study including 538 children admitted to the intensive care unit (ICU) between 2003 and 2005 at two centers in Canada, with measured bSCr, height, and ICU-SCr values. We evaluated the bias, accuracy, and precision of back-calculating bSCr from height-dependent and height-independent GFR equations. Agreement of AKI defined using measured and estimated bSCr was calculated. Multivariate analyses were performed to assess the impact of bSCr estimation methods on the association between AKI and ICU mortality, length of stay, and duration of mechanical ventilation. Results Both methods underestimated bSCr by 1-3%, showed good accuracy (~30% of patients with estimated bSCr within 10% of measured bSCr), but poor precision (wide 95% limits of agreement). The agreement between AKI defined by estimated versus measured bSCr was >80% ([kappa] >0.5). The height-independent method performed best in children >13 years old; however, overall, both methods performed similarly across age subgroups. AKI was associated with longer stay, prolonged mechanical ventilation, and ICU mortality using measured and estimated bSCr. Conclusions Height-dependent and height-independent bSCr estimation methods were comparable. This may have significant implications for performing pediatric AKI research using large databases, and in clinical care to define AKI when height is unknown., Author(s): Erin Hessey [sup.1] , Rami Ali [sup.2] [sup.3] , Marc Dorais [sup.4] , Geneviève Morissette [sup.5] , Michael Pizzi [sup.1] , Nikki Rink [sup.7] , Philippe Jouvet [sup.6] , [...]

Background Supportive care as a bridge to transplant or recovery remains challenging in children suffering from acute liver failure (ALF). We report our experience in children using the Molecular Absorbent Recirculating System (MARS®). Methods Retrospective data from children receiving therapy using MARS® from October 2009 to October 2012 were included in this single-center retrospective study. Patient characteristics, clinical presentation and complications of ALF, clinical and biological data before and after each MARS® session, technical modalities and adverse events were recorded. Results A total of six children underwent 17 MARS® sessions during the study period. Two adolescents were treated with the adult filter MARSFLUX® and four infants were treated with the MiniMARS® filter. The mean PEdiatric Logistic Dysfunction (PELOD) score at admission was 19 (range 11-33). All patients were mechanically ventilated, and four had acute kidney injury. The neurological course improved in one case, judged as stable in two cases and worsened in one case; data were unavailable in two cases. Mean serum ammonia levels decreased significantly following treatment with MARS® from an initial 89 ± 29 to 58 ± 35 mcmol/L (p = 0.02). No other significant biological improvement was observed. Hemodynamic status improved/remained unchanged in the adolescent group, but in the infants four of the seven sessions were poorly tolerated and two sessions were aborted. Three patients died, two were successfully transplanted and one recovered without transplantation. Conclusion In our experience, treatment with MARS® is associated with encouraging results in adolescents, but it needs modification for very sick infants to improve tolerance. Keywords: Children * Acute liver failure * Molecular Absorbant Recycling System (MARS®) * Clinical experience, Introduction Acute liver failure (ALF) in children is defined as a multisystem disorder that includes severe impairment of liver function [1]. In contrast with the adult definition, in which encephalopathy [...]

Purpose Duration of weaning from mechanical ventilation is decreased with the use of written protocols in adults. In children, the use of written protocols has not had such an impact. Methods and measurements We conducted a single-center trial to assess the feasibility of conducting a multicenter randomized clinical trial comparing the duration of weaning from mechanical ventilation in those managed by a computer-driven explicit protocol versus usual care. Mechanically ventilated children aged between 2 and 17 years on pressure support and not receiving inotropes were included. After randomization, children were weaned either by usual care (n = 15) that was characterized by no protocolized decisions by attending physicians, or by a computer-driven protocol (Smartcare/PS[TM], Drager Medical) (n = 15). Weaning duration until first extubation was the primary outcome. For comparison, a Mann-Whitney U test was employed (p < 0.05). Results Patients characteristics at inclusion were similar. The median duration of weaning was 21 h (range 3-142 h) in the SmartCare/PS[TM] group and 90 h (range 4-552 h) in the usual care group, p = 0.007. The rate of reintubation within 48 h after extubation and the rate of noninvasive ventilation after extubation in the SmartCare/PS[TM] and usual care groups were 2/15 versus 1/15 and 2/15 versus 2/15, respectively. Conclusions A pediatric randomized trial on mechanical ventilation with a computerized protocol in North America is feasible. A computer-driven protocol that also manages children younger than 2 years old would help to decrease the number of PICU admissions screened in a multicentre trial on this topic., Author(s): Philippe A. Jouvet [sup.1] , Valérie Payen [sup.1] , France Gauvin [sup.1] , Guillaume Emeriaud [sup.1] , Jacques Lacroix [sup.1] Author Affiliations: (1) grid.411418.9, 0000000121736322, Pediatric ICU, Soins Intensifs [...]

Author(s): Martin C. J. Kneyber [sup.1] [sup.2], Philippe A. Jouvet [sup.3], Peter C. Rimensberger [sup.4] Author Affiliations: (1) grid.4830.f, 0000000404071981, Division of Pediatric Intensive Care, Department of Pediatrics, Beatrix Children's [...]

Byline: Miriam Santschi (1), France Gauvin (1), Georges Hatzakis (2), Jacques Lacroix (1), Philippe Jouvet (1) Keywords: Children; Mechanical ventilation; Critical care; Pediatric intensive care; Practice pattern; Survey Abstract: Objective The aim of this survey was to characterize the physiological limits considered appropriate during weaning from mechanical ventilation in children. Design Two hundred twenty-two (222) intensivists from 63 pediatric intensive care units (PICUs) were asked to provide the limits they considered acceptable for respiratory rate (RR), tidal volume (V.sub.T) and end-tidal CO.sub.2 (PetCO.sub.2) during weaning from mechanical ventilation of a 3-month-old, a 2-year-old and a 10-year-old patient. Setting Pediatric intensivists working in Canada, France, Switzerland and Belgium. Patients None. Interventions None. Results Ninety-seven intensivists (43%) from 49 PICUs responded to the survey. The median minimal RR (25th 75th percentile) was: 20 breaths per minute (bpm) (15 25) for the 3-month-old, 15a-bpm (10 15) for the 2-year-old and 10a-bpm (10 15) for the 10-year-old patient. The median maximal RR was 50a-bpm (40 60) for the 3-month-old, 40a-bpm (30 40) for the 2-year-old and 30a-bpm (30 40) for the 10-year-old child. The median minimal V.sub.T was 5a-ml/kg (4 6) for the 3-month-old and 2-year-old patients and 5a-ml/kg (5 6) for the 10-year-old. The median maximal PetCO.sub.2 was 55a-mmHg (50 60) for the 3-month-old, 50a-mmHg (45 50) for the 2-year-old and 50a-mmHg (50 55) for the 10-year-old. Conclusion This survey indicated that acceptable weaning limits are broad, as stated by the responders. We need to organize and consolidate our thinking on weaning children from mechanical ventilation before guidelines can be established. Author Affiliation: (1) Pediatric Intensive Care Unit, Hopital Sainte-Justine, Universite de Montreal, 3175 chemin Cote Sainte Catherine, Montreal, Quebec, H3T 1C5, Canada (2) McGill University Health Centre, Montreal Children's Hospital, Montreal, Canada Article History: Registration Date: 22/09/2006 Received Date: 09/01/2006 Accepted Date: 14/09/2006 Online Date: 25/10/2006 Article note: A survey on stated practice pattern

Abstract Maple syrup urine disease (MSUD, MIM 248600) can be complicated by metabolic crises necessitating extracorporeal removal therapy (ECRT). Since leucine levels are usually not immediately available during therapy, an [...]

Byline: Philippe Jouvet (1), Myriam Jugie (1), Daniel Rabier (2), Jean Desgres (4), Philippe Hubert (1), Jean Marie Saudubray (1), Nguyen Khoa Man (3) Keywords: Maple syrup urine disease Children Neonates Hemofiltration Abstract: Objective: The authors assessed the efficiency, tolerance and outcome of neonates and children with maple syrup urine disease (MSUD) in acute decompensation managed by endogenous and extracorporeal removal of accumulated MSUD metabolites. Design: Single center cohort study. Setting: Pediatric and neonatal intensive care unit in a tertiary care hospital. Patients: Between January, 1991, and June, 1999, six neonates and six children in acute decompensation of MSUD were included in the study. Each of them had two of the three following criteria: comatose state, gastrointestinal intolerance, leucine plasma levels over 1700 Aumol/l. Interventions: Patients were treated by combined nutrition manipulation and continuous venovenous extracorporeal removal therapies (CECRT) including hemofiltration, hemodialysis or hemodiafiltration. A clinical and biological evaluation was performed before, during and following the treatment. Results: Eleven out of the 12 patients survived. One child had two acute episodes at 6.5 and 9 years old. Eight patients recovered a normal cerebral performance category score. In all cases, plasma leucine level decreased according to a logarithmic mode within 11--24 h hemodiafiltration combined with nutritional support whereas, with nutrition alone after stopping CECRT, the decrease in leucine plasma levels was slower, following a linear mode. Eight patients were supplemented with valine and isoleucine for mean plasma values of 177+-92 and 68+-66, respectively. Conclusion: In severe acute decompensation of MSUD, CECRT combined with nutritional support limit central nervous system damage, by dramatically decreasing branched chain amino and keto acid levels. Author Affiliation: (1) Federation de Pediatrie Medicale, Service de Reanimation Pediatrique, Hopital Necker Enfants Malades, 149 rue de Sevres, 75743 Paris cedex 15, France (2) Biochemistry Department, Hopital Necker Enfants Malades, 149 rue de Sevres, 75743 Paris cedex 15, France (3) Nephrology Department -- INSERM U 507, Hopital Necker Enfants Malades, 149 rue de Sevres, 75743 Paris cedex 15, France (4) Biochemistry Department, 10 Boulevard Marechal de Lattre de Tassigny, 21034 Dijon cedex, France Article History: Received Date: 07/12/2000 Accepted Date: 04/09/2001 Article note: Final revision received: 3 May 2001 Electronic Publication

Author(s): Alice Bordessoule [sup.1], Guillaume Emeriaud [sup.1] [sup.2], Nancy Delnard [sup.2], Jennifer Beck [sup.3], Philippe Jouvet [sup.1] Author Affiliations: (1) grid.411418.9, 0000000121736322, Pediatric Intensive Care Unit, CHU Sainte Justine, , [...]

Byline: Matteo Fontana (1), Antoine Payot (1), Sylvain Morneau (2), Philippe Jouvet (3) Author Affiliation: (1) Departement de Pediatrie, Service de Neonatologie, CHU Sainte-Justine, Universite de Montreal, Montreal, QC, Canada (2) Service d'Inhalotherapie, CHU Sainte-Justine, Montreal, QC, Canada (3) Soins Intensifs Pediatriques, CHU Sainte-Justine, 3175 Chemin Cote Sainte Catherine, Montreal, QC, H3T 1C5, Canada Article History: Registration Date: 23/03/2009 Accepted Date: 20/03/2009 Online Date: 02/04/2009 Article note: An author's reply to this comment is available at: 10.1007/s00134-009-1475-7.