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Background: Paediatric critical care nurses face challenges in promptly detecting patient deterioration and delivering high-quality care, especially in low-resource settings (LRS). Patient monitors equipped with data-driven algorithms that monitor and integrate clinical data can optimise scarce resources (e.g. trained staff) offering solutions to these challenges. Poor algorithm output design and workflow integration, however, are important factors hindering successful implementation. This study aims to explore nurses' perspectives to inform the development of a data-driven algorithm and user-friendly interface for future integration into a continuous vital signs monitoring system for critical care in LRS. Methods: Human-centred design methods, including contextual inquiry, semi-structured interviews, prototyping and co-design sessions, were carried out at the high-dependency units of Queen Elizabeth Central Hospital and Zomba Central Hospital in Malawi between March and July 2023. Triangulating these methods, we identified what algorithm could assist nurses and used co-creation methods to design a user interface prototype. Data were analysed using qualitative content analysis. Results: Workflow observations demonstrated the effects of personnel shortages and limited monitor equipment for vital signs monitoring. Interviews identified four themes: workload and workflow, patient prioritisation, interaction with guardians, and perspectives on data-driven algorithms. The interviews emphasised the advantages of predictive algorithms in anticipating patient deterioration, underlining the need to integrate the algorithm's output, the (constant) monitoring data, and the patient's present clinical condition. Nurses preferred a scoring system represented with familiar scales and colour codes. During co-design sessions, trust, usability and context specificity were emphasised as requirements for these algorithms. Four prototype components were examined, with nurses favouring scores represented by colour codes and visual representations of score changes. Conclusions: Nurses in the LRS studied, perceived that data-driven algorithms, especially for predicting patient deterioration, could improve the provision of critical care. This can be achieved by translating nurses' perspectives into design strategies, as has been carried out in this study. The lessons learned were summarised as actionable pre-implementation recommendations for the development and implementation of data-driven algorithms in LRS. [ABSTRACT FROM AUTHOR]

Background: High flow nasal cannula therapy (HFNC) and continuous positive airway pressure (CPAP) are two widely used modes of non-invasive respiratory support in paediatric critical care units. The FIRST-ABC randomised controlled trials (RCTs) evaluated the clinical and cost-effectiveness of HFNC compared with CPAP in two distinct critical care populations: acutely ill children ('step-up' RCT) and extubated children ('step-down' RCT). Clinical effectiveness findings (time to liberation from all forms of respiratory support) showed that HFNC was non-inferior to CPAP in the step-up RCT, but failed to meet non-inferiority criteria in the step-down RCT. This study evaluates the cost-effectiveness of HFNC versus CPAP. Methods: All-cause mortality, health-related Quality of Life (HrQoL), and costs up to six months were reported using FIRST-ABC RCTs data. HrQoL was measured with the age-appropriate Paediatric Quality of Life Generic Core Scales questionnaire and mapped onto the Child Health Utility 9D index score at six months. Quality-Adjusted Life Years (QALYs) were estimated by combining HrQoL with mortality. Costs at six months were calculated by measuring and valuing healthcare resources used in paediatric critical care units, general medical wards and wider health service. The cost-effectiveness analysis used regression methods to report the cost-effectiveness of HFNC versus CPAP at six months and summarised the uncertainties around the incremental cost-effectiveness results. Results: In both RCTs, the incremental QALYs at six months were similar between the randomised groups. The estimated incremental cost at six months was − £4565 (95% CI − £11,499 to £2368) and − £5702 (95% CI − £11,328 to − £75) for step-down and step-up RCT, respectively. The incremental net benefits of HFNC versus CPAP in step-down RCT and step-up RCT were £4388 (95% CI − £2551 to £11,327) and £5628 (95% CI − £8 to £11,264) respectively. The cost-effectiveness results were surrounded by considerable uncertainties. The results were similar across most pre-specified subgroups, and the base case results were robust to alternative assumptions. Conclusions: HFNC compared to CPAP as non-invasive respiratory support for critically-ill children in paediatric critical care units reduces mean costs and is relatively cost-effective overall and for key subgroups, although there is considerable statistical uncertainty surrounding this result. [ABSTRACT FROM AUTHOR]

Abstract Background Paediatric critical care nurses face challenges in promptly detecting patient deterioration and delivering high-quality care, especially in low-resource settings (LRS). Patient monitors equipped with data-driven algorithms that monitor and integrate clinical data can optimise scarce resources (e.g. trained staff) offering solutions to these challenges. Poor algorithm output design and workflow integration, however, are important factors hindering successful implementation. This study aims to explore nurses’ perspectives to inform the development of a data-driven algorithm and user-friendly interface for future integration into a continuous vital signs monitoring system for critical care in LRS. Methods Human-centred design methods, including contextual inquiry, semi-structured interviews, prototyping and co-design sessions, were carried out at the high-dependency units of Queen Elizabeth Central Hospital and Zomba Central Hospital in Malawi between March and July 2023. Triangulating these methods, we identified what algorithm could assist nurses and used co-creation methods to design a user interface prototype. Data were analysed using qualitative content analysis. Results Workflow observations demonstrated the effects of personnel shortages and limited monitor equipment for vital signs monitoring. Interviews identified four themes: workload and workflow, patient prioritisation, interaction with guardians, and perspectives on data-driven algorithms. The interviews emphasised the advantages of predictive algorithms in anticipating patient deterioration, underlining the need to integrate the algorithm’s output, the (constant) monitoring data, and the patient’s present clinical condition. Nurses preferred a scoring system represented with familiar scales and colour codes. During co-design sessions, trust, usability and context specificity were emphasised as requirements for these algorithms. Four prototype components were examined, with nurses favouring scores represented by colour codes and visual representations of score changes. Conclusions Nurses in the LRS studied, perceived that data-driven algorithms, especially for predicting patient deterioration, could improve the provision of critical care. This can be achieved by translating nurses’ perspectives into design strategies, as has been carried out in this study. The lessons learned were summarised as actionable pre-implementation recommendations for the development and implementation of data-driven algorithms in LRS.

Abstract Background Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. Methods A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. Results The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. Conclusion Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.

Abstract Critical illness-related corticosteroid insufficiency or CIRCI is characterized by acute and life-threatening disfunction of hypothalamic–pituitary–adrenal (HPA) axis observed among intensive care unit- staying patients. It is associated with increased circulating levels of biological markers of inflammation and coagulation, morbidity, length of ICU stay, and mortality. Several mechanisms are involved in CIRCI pathogenesis: reduced CRH-stimulated ACTH release, peripheral resistance to glucocorticoids, altered cortisol synthesis, impaired cortisol-free fraction and bioavailability. Diagnostic and therapeutic management of this condition in children is still debated, probably because of the lack of agreement among intensive care specialists and endocrinologists regarding diagnostic criteria and prevalence of CIRCI in paediatric age. In the present narrative review, we focused on definition of CIRCI in paediatric age and we advise on how to diagnose and treat this poorly understood condition, based on current literature data.

Aims: The aim of this study was to assess the incidence, nature, preventability and severity of adverse drug events (ADEs) across three paediatric intensive care units (PICUs) in England. Methods: A prospective observational cohort study was conducted across three PICUs over a three‐month period during 2019. Included patients were aged ≤18 years and stayed in PICU for a minimum of 24 hours. Identification of suspected ADEs was performed by trained PICU pharmacists. A multidisciplinary expert panel assessed causality, preventability and severity of events. Results: A total of 302 patients were included and 62 ADEs were confirmed (definite/probable causality). One in six patients experienced one or more ADEs. The estimated incidence of ADEs were 20.5 per 100 patients (95% CI 15.3–27.5) and 16.7 per 1000 patient‐days (95% CI 9.3–29.9). The majority of ADEs were judged preventable by the expert panel (36/62, 58.1%). ADEs were commonly involved with medicines prescribing (29/62, 46.8%) and caused temporary patient harm (42/62, 67.7%). Medications for the central nervous system (14/62, 22.6%), infections (13/62, 20.9%) and cardiovascular system (12/62, 19.4%) were commonly implicated with ADEs. Multivariable analysis revealed that patients who stayed in PICU for ≥7 days (OR 6.29, 95% CI 2.42–16.32) were more likely to experience an ADE compared to patients with a stay of 1–6 days. Conclusion: ADEs are common in English PICUs and most of them may be preventable. There is a strong association between ADE occurrence and duration of PICU stay, which represents a target for remedial interventions. Exploring contributory factors of preventable ADEs is now necessary to inform preventive policies. [ABSTRACT FROM AUTHOR]

Abstract Background Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. Methods Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. Results Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. Conclusions GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.

Introduction: Numerous scoring systems have been proposed in an effort to increase the prognostic accuracy and predicting outcome. In order to measure the risk of mortality, scores are employed that establish a numerical scale and in this way, they compare estimated mortality in % with the observed mortality. Known as prognostic scores, these can be used to evaluate the quality of medical care and to optimise the employment of resources, aiming at improving the cost-benefit relationship. Since, they compare mortality adjusted by disease severity these scores can also be used for comparisons between clinical trials and for planning technological resources. Aim: To compare the performance of the Paediatric Risk of Mortality III (PRISM III), the Paediatric Index of Mortality 3 (PIM 3) and Paediatric Logistic Organ Dysfunction-2 (PELOD-2) scores in a Paediatric Intensive Care Unit (PICU) in a tertiary care hospital. Materials and Methods: The present study was prospective observational study which included children from one month to 14 years of age admitted to PICU, and who remained in PICU after 24 hours. Within the first hour of admission PIM 3 was assessed. Further at 24 hours of admission, PRISM III and PELOD-2 score were assessed. Performance of different scores were evaluated. Calibration by HosmerLemeshow goodness-of-fit test {12(p)} Discrimination was assessed by the ROC curve. Standardised Mortality Rate (SMR) was calculated to predict the mortality. Results: Total 281 children were enrolled in the study, out of which 62 patients died. Neurological illness was the most common cause of death (12, 19.35%) followed by respiratory and haemato-onco cases (10, 16.13%) each. The Area Under the ROC Curve-Receiver Operating Characteristics (AUC-ROC) of PELOD-2, PIM 3 and PRISM III were 0.862, 0.847 and 0.838, respectively. Among the three scores PELOD-2 had poor calibration for the study population (2=18.837, p=0.016, d=8). PIM 3 was a better predictor of mortality (with SMR of 1.33) when compared with PRISM III and PELOD-2 (which had SMR of 1.57 and 1.83, respectively). Conclusion: All the three scores had good discrimination, however PELOD-2 had poor calibration for the given study population, with respect to better predictor of mortality all the scores underestimate the mortality. Among these, the better predictor mortality was PIM 3. Since, PIM 3 also had good calibration for the study population and is associated with less variables to monitor there is ease of estimation and hence it is more suitable to score and to assess mortality. [ABSTRACT FROM AUTHOR]

Introduction: Numerous scoring systems have been proposed in an effort to increase the prognostic accuracy and predicting outcome. In order to measure the risk of mortality, scores are employed that establish a numerical scale and in this way, they compare estimated mortality in % with the observed mortality. Known as prognostic scores, these can be used to evaluate the quality of medical care and to optimise the employment of resources, aiming at improving the cost-benefit relationship. Since, they compare mortality adjusted by disease severity these scores can also be used for comparisons between clinical trials and for planning technological resources. Aim: To compare the performance of the Paediatric Risk of Mortality III (PRISM III), the Paediatric Index of Mortality 3 (PIM 3) and Paediatric Logistic Organ Dysfunction-2 (PELOD-2) scores in a Paediatric Intensive Care Unit (PICU) in a tertiary care hospital. Materials and Methods: The present study was prospective observational study which included children from one month to 14 years of age admitted to PICU, and who remained in PICU after 24 hours. Within the first hour of admission PIM 3 was assessed. Further at 24 hours of admission, PRISM III and PELOD-2 score were assessed. Performance of different scores were evaluated. Calibration by HosmerLemeshow goodness-of-fit test {χ2(p)} Discrimination was assessed by the ROC curve. Standardised Mortality Rate (SMR) was calculated to predict the mortality. Results: Total 281 children were enrolled in the study, out of which 62 patients died. Neurological illness was the most common cause of death (12, 19.35%) followed by respiratory and haemato-onco cases (10, 16.13%) each. The Area Under the ROC Curve-Receiver Operating Characteristics (AUC-ROC) of PELOD-2, PIM 3 and PRISM III were 0.862, 0.847 and 0.838, respectively. Among the three scores PELOD-2 had poor calibration for the study population (χ2=18.837, p=0.016, d=8). PIM 3 was a better predictor of mortality (with SMR of 1.33) when compared with PRISM III and PELOD-2 (which had SMR of 1.57 and 1.83, respectively). Conclusion: All the three scores had good discrimination, however PELOD-2 had poor calibration for the given study population, with respect to better predictor of mortality all the scores underestimate the mortality. Among these, the better predictor mortality was PIM 3. Since, PIM 3 also had good calibration for the study population and is associated with less variables to monitor there is ease of estimation and hence it is more suitable to score and to assess mortality.

Background: Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi.Methods: Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed.Results: Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias.Conclusions: GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting. [ABSTRACT FROM AUTHOR]

Abstract Background Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care. Methods In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT. Results Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2). Conclusions Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients. Trial registration clinicaltrials.gov, NCT02612415. Registered on 23 November 2015.

Background: Syringe infusion pumps are used for the precise continuous administration of intravenous drugs. Their compliance and mechanical deficiencies have been found to cause considerable start-up delays, flow irregularities during vertical displacement, as well extensive delays of occlusion alarms at low infusion rates. The aim of this study was to evaluate the performance of several modern syringe infusion pumps at low infusion rates and the impact on drug concentration.Methods: Seven currently marketed syringe infusion pump assemblies were assessed in an in vitro study during start-up, vertical displacement manoeuvres, and infusion line occlusion at a set flow rate of 1 ml h-1. The measured data were used as input for a pharmacokinetic simulation modelling plasma concentration during a standard neonatal continuous epinephrine infusion.Results: The mean time from starting the infusion pump to steady-state flow varied from 89 to 1622 s. The zero-drug delivery time after lowering the pump ranged from 145 to 335 s. In all assemblies tested, occlusion alarm delays and measured flow irregularities during vertical displacement manoeuvres resulted in relevant deviations in plasma epinephrine concentration (>25%) as calculated by the pharmacokinetic simulation model.Conclusion: Problems with the performance of syringe infusion pump assemblies can have considerable impact on plasma drug concentration when highly concentrated short-acting cardiovascular drugs are administered at low flow rates. The problems, which affected all assemblies tested, are mainly related to the functional principle of syringe infusion pumps and will only partially be solved by incremental improvements of existing equipment. [ABSTRACT FROM AUTHOR]

Respiratory syncytial virus (RSV) bronchiolitis is a leading cause of global child morbidity and mortality. Every year, seasonal RSV outbreaks put high pressure on paediatric intensive care units (PICUs) worldwide, including in the Netherlands, and this burden appears to be increasing. Weather conditions have a strong influence on RSV activity, and climate change has been proposed as a potential important determinant of future RSV-related health care utilisation. In this national study spanning a total of 13 years with 2161 PICU admissions for RSV bronchiolitis, we aimed (1) to identify meteorological variables that were associated with the number of PICU admissions for RSV bronchiolitis in the Netherlands and (2) to determine if longitudinal changes in these variables occurred over time as a possible explanation for the observed increase in PICU burden. Poisson regression modelling was used to identify weather variables (aggregated in months and weeks) that predicted PICU admissions, and linear regression analysis was used to assess changes in the weather over time. Maximum temperature and global radiation best predicted PICU admissions, with global radiation showing the most stable strength of effect in both month and week data. However, we did not observe a significant change in these weather variables over the 13-year time period. Based on our study, we could not identify changing weather conditions as a potential contributing factor to the increased RSV-related PICU burden in the Netherlands.

Resumen: La unidad de cuidados intensivos pediátricos (UCIP) es una unidad física asistencial hospitalaria independiente especialmente diseñada para el tratamiento de pacientes pediátricos quienes debido su gravedad o condiciones potencialmente letales requieren observación y asistencia médica intensiva integral y continua por un equipo médico que haya obtenido competencia especial en medicina intensiva pediátrica. La aplicación oportuna de terapia intensiva a los pacientes críticos reduce la mortalidad, el tiempo de estancia y los costes asistenciales. Con los objetivos de respetar el derecho del niño al disfrute del más alto nivel posible de salud y a servicios para el tratamiento de las enfermedades y la rehabilitación de la salud y de garantizar la calidad asistencial y la seguridad de los pacientes pediátricos críticos, la Asociación Española de Pediatría (AEP), la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) y la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) han desarrollado y aprobado las guías de ingreso, alta y triage para las UCIP en España. Mediante la aplicación de estas guías se puede optimizar el uso de las UCIP españolas de forma que los pacientes pediátricos reciban el nivel de cuidados médicos más apropiado para su situación clínica. Abstract: A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.

Introduction: Ultrasound has been used to quantify and qualify muscle morphology in critically ill children and can detect changes in muscle thickness. The aim of this study was to assess the reliability of ultrasound measurement of muscle thickness in critically ill children and to compare the assessments made by an expert with those made by inexperienced sonographers., Material and Methods: Cross-sectional observational study conducted in the paediatric intensive care unit of a tertiary care university hospital in Brazil. The sample included patients aged 1 month to 12 years who received invasive mechanical ventilation for at least 24 h. Ultrasound images of the biceps brachii/brachialis and quadriceps femoris were obtained by one experienced sonographer and several inexperienced sonographers. We assessed intrarater and inter-rater reliability by means of the intraclass correlation coefficient (ICC) and Bland-Altman plot analysis., Results: Muscle thickness was measured in 10 children with a mean age of 15.5 months. The mean thickness of the assessed muscles as 1.14 cm for the biceps brachii/brachialis (standard deviation [SD], 0.27) and 1.85 cm for the quadriceps femoris (SD, 0.61). The intrarater and inter-rater reliability were good for all sonographers (ICC > 0.81). The differences were small, there was no significant bias in the Bland-Altman plots and all measurements were within the limits of agreement, except for 1 measurement of biceps and quadriceps., Conclusion: Sonography can be used in critically ill children to accurately assess changes in muscle thickness, even by different evaluators. More studies are needed to establish a standardised approach to the use of ultrasound for monitoring muscle loss in order to incorporate it in clinical practice., (Copyright © 2023 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Background In many health systems, specialist services for critically ill children are typically regionalised or centralised. Studies have shown that high-risk paediatric patients have improved survival when managed in specialist centres and that volume of cases is a predictor of care quality. In acute cases where distance and time impede access to specialist care, clinical advice may be provided remotely by telephone. Emergency retrieval services, attended by medical and nursing staff may be used to transport patients to specialist centres. Even with the best quality retrieval services, stabilisation of the patient and transport logistics may delay evacuation to definitive care. Several studies have examined the use of telemedicine for providing specialist consultations for critically ill children. However, no studies have yet formally examined the clinical effectiveness and economic implications of using telemedicine in the context of paediatric patient retrieval. Methods/Design The study is a pragmatic, multicentre randomised controlled trial running over 24 months which will compare the use of telemedicine with the use of the telephone for paediatric retrieval consultations between four referring hospitals and a tertiary paediatric intensive care unit. We aim to recruit 160 children for whom a specialist retrieval consultation is required. The primary outcome measure is stabilisation time (time spent on site at the referring hospital by the retrieval team) adjusted for initial risk. Secondary outcome measures are change in patient’s physiological status (repeated measure, two time points) scored using the Children’s Emergency Warning Tool; change in diagnosis (repeated measure taken at three time points); change in destination of retrieved patients at the tertiary hospital (general ward or paediatric intensive care unit); retrieval decision, and length of stay in the Paediatric Intensive Care Unit for retrieved patients. The trial has been approved by the Human Research Ethics Committees of Children’s Health Services Queensland and The University of Queensland, Australia. Discussion Health services are adopting telemedicine, however formal evidence to support its use in paediatric acute care is limited. Generalisable evidence is required to inform clinical use and health system policy relating to the effectiveness and economic implications of the use in telemedicine in paediatric retrieval. [ABSTRACT FROM AUTHOR]

Objective: To describe remote triage of 'potentially' critically ill or injured children in a western Canadian province and to examine the associated factors with 'missings' in vital sign items recorded in centralized telephone triage consultations., Methods: This is a provincial-wide prospective cohort study. We included all children under 17 years of age consulted through the central transport coordination centres in Alberta from June 2016 to July 2017. We labeled a value as 'missing' when the actual value was not identified in the audio records., Results: In total, 429 cases were included in this study. The median duration of triage calls was 6.8 minutes. Although the patients' demographics and primary diagnoses were similar, backgrounds of the referring physicians and hospitals were significantly different between the two cohorts (i.e., patients referred to Calgary versus Edmonton). The proportion of 'missings' among the vital sign items varied significantly, in which capillary refilling time (60%), pupils (86%), Glasgow Coma Scale (GCS) (79%), and level of respiratory effort (50%) were not well recorded, whereas heart rate (proportion of 'missings': 12%), SpO 2 (20%), and respiratory rate (26%) were recorded reasonably well. The lower proportion of 'missings' was observed in older aged patients for several vital sign items including systolic blood pressure and GCS., Conclusions: The proportion of missing vital signs recorded varied significantly. The 'missings' could be associated with referring physician's background and patients' demographics such as 'age' that should be considered for the improvement of triage quality in the future., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care.Methods: In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT.Results: Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2).Conclusions: Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients.Trial Registration: clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015. [ABSTRACT FROM AUTHOR]

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition., (Copyright © 2017 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Human beings are constituted mainly of water. In particular, children's total body water might reach 75-80% of their body weight, compared to 60-70% in adults. It is therefore not surprising, that children, especially hospitalized newborns and infants, are markedly prone to water and electrolyte imbalances. Parenteral fluid therapy is a cornerstone of medical treatment and is thus of exceptional relevance in this patient population. It is crucial to appreciate the fact that intravenous fluids are drugs with very different characteristics, different indications, contraindications and relevant side effects. In the present review, we will summarize the physiology and pathophysiology of water and electrolyte balance, underlining the importance and high prevalence of non-osmotic antidiuretic hormone release in hospitalized and critically ill children. Furthermore, we will discuss the characteristics and potential side effects of available crystalloids for the paediatric population, making a clear distinction between fluids that are hypotonic or isotonic as compared to normal plasma. Finally, we will review the current clinical practice regarding the use of different parenteral fluids in children, outlining both the current consensus on fluids employed for resuscitation and replacement and the ongoing debate concerning parenteral maintenance fluids.

Traumatic brain injury (TBI) is a major cause of death and disability in children. Severe TBI is a leading cause of death and often leads to life changing disabilities in survivors. The modern management of severe TBI in children on intensive care unit focuses on preventing secondary brain injury to improve outcome. Standard neuroprotective measures are based on management of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) to optimize the cerebral blood flow and oxygenation, with the intention to avoid and minimise secondary brain injury. In this article, we review the current trends in management of severe TBI in children, detailing the general and specific measures followed to achieve the desired ICP and CPP goals. We discuss the often limited evidence for these therapeutic interventions in children, extrapolation of data from adults, and current recommendation from paediatric guidelines. We also review the recent advances in understanding the intracranial physiology and neuroprotective therapies, the current research focus on advanced and multi-modal neuromonitoring, and potential new therapeutic and prognostic targets.