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Importance: The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known.Objective: To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support.Design, Setting, and Participants: Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022.Interventions: Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299).Main Outcomes and Measures: The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation.Results: Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI -10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, -3 days [95% CI, -5.1 to -1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, -7.6 days [95% CI, -13.2 to -1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]).Conclusions and Relevance: Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support.Trial Registration: ISRCTN.org Identifier: ISRCTN60048867. [ABSTRACT FROM AUTHOR]

Background: Hospital-acquired and ventilator-associated pneumonias (HAP and VAP) are common in critical care and can be life-threatening. Rapid microbiological diagnostics, linked to an algorithm to translate their results into antibiotic choices, could simultaneously improve patient outcomes and antimicrobial stewardship.Methods: The INHALE Randomised Controlled Trial is a multi-centre, parallel study exploring the potential of the BioFire FilmArray molecular diagnostic to guide antibiotic treatment of HAP/VAP in intensive care units (ICU); it identifies pathogens and key antibiotic resistance in around 90 min. The comparator is standard care whereby the patient receives empirical antibiotics until microbiological culture results become available, typically after 48-72 h. Adult and paediatric ICU patients are eligible if they are about to receive antibiotics for a suspected lower respiratory infection (including HAP/VAP) for the first time or a change in antibiotic because of a deteriorating clinical condition. Breathing spontaneously or intubated, they must have been hospitalised for 48 h or more. Patients are randomised 1:1 to receive either antibiotics guided by the FilmArray molecular diagnostic and its trial-based prescribing algorithm or standard care, meaning empirical antibiotics based on local policy, adapted subsequently based upon local microbiology culture results. Co-primary outcomes are (i) non-inferiority in clinical cure of pneumonia at 14 days post-randomisation and (ii) superiority in antimicrobial stewardship at 24 h post-randomisation (defined as % of patients on active and proportionate antibiotics). Secondary outcomes include further stewardship reviews; length of ICU stay; co-morbidity indicators, including septic shock, change in sequential organ failure assessment scores, and secondary pneumonias; ventilator-free days; adverse events over 21 days; all-cause mortality; and total antibiotic usage. Both cost-effectiveness of the molecular diagnostic-guided therapy and behavioural aspects determining antibiotic prescribing are being explored. A sample size of 552 will be required to detect clinically significant results with 90% power and 5% significance for the co-primary outcomes.Discussion: This trial will test whether the potential merits of rapid molecular diagnostics for pathogen and resistance detection in HAP/VAP are realised in patient outcomes and/or improved antibiotic stewardship.Trial Registration: ISRCTN Registry ISRCTN16483855 . Retrospectively registered on 15 July 2019. [ABSTRACT FROM AUTHOR]

Objective: To compare the predictive performance of 18 paediatric early warning systems (PEWS) in predicting critical deterioration.Design: Retrospective case-controlled study. PEWS values were calculated from existing clinical data, and the area under the receiver operator characteristic curve (AUROC) compared.Setting: UK tertiary referral children's hospital.Patients: Patients without a 'do not attempt resuscitation' order admitted between 1 January 2011 and 31 December 2012. All patients on paediatric wards who suffered a critical deterioration event were designated 'cases' and matched with a control closest in age who was present on the same ward at the same time.Main Outcome Measures: Respiratory and/or cardiac arrest, unplanned transfer to paediatric intensive care and/or unexpected death.Results: 12 'scoring' and 6 'trigger' systems were suitable for comparative analysis. 297 case events in 224 patients were available for analysis. 244 control patients were identified for the 311 events. Three PEWS demonstrated better overall predictive performance with an AUROC of 0.87 or greater. Comparing each system with the highest performing PEWS with Bonferroni's correction for multiple comparisons resulted in statistically significant differences for 13 systems. Trigger systems performed worse than scoring systems, occupying the six lowest places in the AUROC rankings.Conclusions: There is considerable variation in the performance of published PEWS, and as such the choice of PEWS has the potential to be clinically important. Trigger-based systems performed poorly overall, but it remains unclear what factors determine optimum performance. More complex systems did not necessarily demonstrate improved performance. [ABSTRACT FROM AUTHOR]

A commentary on a single-centre prospective study of 544 children with paediatric acute respiratory distress syndrome (PARDS) is presented. Topics covered include weakness of the approach of lumping together ARDS patients with different ages, aetiologies, time courses and co-morbidities, challenges posed by ARDS cases to paediatric intensivists and variation in the role of immunodeficiency through paediatric intensive care unit (PICU) stay.

The article discusses a study which described the systolic and mean blood pressure (BP) distribution according to sex and age in children admitted to two pediatric intensive care unit (PICU) in London, England. Topics include the use of electronic health records to yield blood pressure measurement, analysis made to account for multiple measurements in each patient, and finding on BP measurements of younger children included in the study.

The article reports publications from intensive care on severe infections, septic shock, healthcare and ventilator associated pneumonia, highly resistant bacteria, antimicrobial therapy, invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics. Topics discussed include the physiology of circulation, venous return and hypovolemia and the role of the hypothalamic-pituitary-adrenal axis (HPA) in critically ill patients.

The article highlights research and developments related to intensive care medicine in 2014. Topics discussed include recent findings about airway management in critically ill patients, evidence showing that there is no indication for using statins either in infection or acute respiratory distress syndrome (ARDS) in intensive care unit (ICU) patients, and research about the pathophysiology of acute liver failure (ALF).

The article presents several medical research papers that were published in the 2014 issues of the journal "Intensive Care (IC) Medicine." Topics covered include cardiac dysfunction, neurocritical care, acute kidney injury, neuromonitoring, neuromuscular disorders that develop after an IC unit admission, and nutrition in the critically ill patient.

The article presents several studies on intensive care medicine published in the 2013 issue of the journal "Intensive Care Medicine," particularly on sepsis, infections, respiratory diseases, pediatric health. It cites several intensive care medicine research, including immune dysfunction during sepsis and antimicrobial dose variability, ventilator-acquired pneumonia, prognostic biomarkers in severe sepsis and septic shock, and antibiotic pharmacokinetics in severe sepsis.

The article discusses various studies which appeared in "Intensive Care Medicine" journal in 2013. Information is presented on the study in Malaysia which assessed whether early sedation depth was independently associated with delayed extubation and increased mortality. An overview of a review article about efficient weaning and automatic ventilation modes for failing patients.

Purpose: Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication. Methods: Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats. Results: 333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0–1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15–83]). During intubation the median number of lost beats was 8 [1]–[32] when atropine was not used compared to 0 [0–0] when atropine was used (p<0.001). Conclusions: A reduction in heart rate during intubation of <50 bpm reliably predicted a minimal loss of beats. When the reduction in heart rate was >50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range. [ABSTRACT FROM AUTHOR]

Fluid management has a major impact on the duration, severity and outcome of critical illness. The overall strategy for the acutely ill child should be biphasic. Aggressive volume expansion to support tissue oxygen delivery as part of early goal-directed resuscitation algorithms for shock—especially septic shock—has been associated with dramatic improvements in outcome. Recent data suggest that the cost-benefit of aggressive fluid resuscitation may be more complex than previously thought, and may depend on case-mix and the availability of intensive care. After the resuscitation phase, critically ill children tend to retain free water while having reduced insensible losses. Fluid regimens that limit or avoid positive fluid balance are associated with a reduced length of hospital stay and fewer complications. Identifying the point at which patients change from the ‘ early shock’ pattern to the later ‘ chronic critical illness’ pattern remains a major challenge. Very little data are available on the choice of fluids, and most of the information that is available arises from studies of critically ill adults. There is therefore an urgent need for high-quality trials of both resuscitation and maintenance fluid regimens in critically ill children. [ABSTRACT FROM AUTHOR]

Introduction Poor communication is a source of risk. This can be particularly significant in areas of high clinical acuity such as intensive care. Ward rounds are points where large amounts of information must be communicated in a time-limited environment with many competing interests. This has the potential to reduce effective communication and risk patient safety. Checklists have been used in many industries to improve communication and mitigate risk. We describe the introduction of a ward round safety checklist 'DEFAULT' on a paediatric intensive care unit. Methods A non-blinded, pre- and post-intervention observational study was undertaken in a 12 bedded Level 3 tertiary PICU between July 2009 and December 2011. Results Ward round stakeholders subjectively liked the checklist and felt it improved communication. Introduction of the ward round checklist was associated with an increase in median days between accidental extubations from 14 (range 2-86) to 150 (56 - 365) (Mann Whitney p < 0.0001). The ward round checklist was also associated with an increase in the proportion of invasively ventilated patients with target tidal volumes of <8ml/kg which fell from 35 of 71 patients at 08.00 representing a proportion of 0.49 (95%CI 0.38-0.60) to 23 of 38 (0.61, 0.45-0.74). This represented a trend towards an increased proportion of cases in the target range (z = 1.68, p = 0.09). Conclusions The introduction of a ward round safety checklist was associated with improved communication and patient safety. [ABSTRACT FROM AUTHOR]

Background: Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality. Methodology/Principal Findings: A 2-year prospective, observational study of all first non-planned intubations, September 2007–9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19–0.95, p = 0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06–0.85, p = 0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31–5.1 p = 0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3–57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5–61.5 bpm, p<0.001). Conclusions/Significance: Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine’s capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology. [ABSTRACT FROM AUTHOR]

The author discusses the measurement of child-centred health-related quality of life after paediatric intensive care. Topics covered include how the World Health Organization's (WHO) definition of health does not take into consideration resilience and the capacity to adapt and function well with chronic disease or disability and how paediatric intensive care is transitioning from a specialty dealing with acute illness to a component of a multidisciplinary team for chronically ill children.

The article discusses the higher pediatric intensive care unit (PICU) mortality amongst haematology/oncology cases. Topics discussed include the very high risk diagnoses on leukaemia/lymphoma outside of first induction or bone marrow transplant recipient, different assessments of risk and benefit and comparison of the predicted mortality risk for children with sepsis-induced multiple organ dysfunction syndrome (MODS) or acute respiratory distress syndrome (ARDS) on PICU.

The author reflects on the study on early goal directed therapy (EGDP) for septic shock in children. He argues that the study insinuates inexpensive remedy, therefore compromising other more effective conventional means of cure. An overview of the effects of different treatment of sepsis shock is offered, including fluid resuscitation, transfusion and vosoactive drug administration. The author suggests that pro- or anti-inflammatory responses have not developed into therapies.

Background: The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations. Methods: A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios. Results: Among the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in < 20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specific situations, whereas the use of high-flow hemofiltration was considered for 44%. Conclusions: This pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these findings outline some limitation of existing pediatric guidelines in regard to context and patient's specificity. [ABSTRACT FROM AUTHOR]

The article discusses a study to assess whether mitochondrial oxidative phosphorylation gene expression alters early enough in the clinical course of sepsis to remain a candidate element of multi-organ failure (MOF) pathophysiology in children. Topics covered include the difference between sepsis-induced critical illness in children and adults, and the gene set enrichment analysis (GSEA) performed to investigate the time-course of gene expression in peripheral blood.

The article discusses a study on the efficacy of triage protocols in critical patients during a pandemic. The study used a mathematical model based on queuing theory to evaluate short-term survival in critical care. It noted that some patient groups were not included in the study based on their anticipated length of stay. It found that triage can not be assumed to lower death rates.

Context: Early and accurate recognition of the deteriorating hospitalised child is complex. Paediatric track and trigger systems (PTTS) support clinical decision-making by 'tracking' the child's condition through monitoring of clinical signs and 'triggering' a request for an appropriate review when pre-determined criteria are breeched.Objective: To describe the number and nature of published PTTS and appraise the evidence on their validity, calibration, and effect on important patient outcomes (death, cardiac and/or respiratory arrest, unplanned transfer to intensive/high dependency care, immediate/urgent request for review, rapid response system activation).Method: GRADE methodology. Papers identified through electronic database and citation searching.Results: Thirty-three PTTS were identified from 55 studies. There was considerable variety in the number and type of parameters, although all contained one or more vital signs. The evidence to support PTTS implementation was very low and the majority of outcomes did not achieve statistical significance. When PTTS was implemented as part of a rapid response system, the evidence was moderate to low but there was some evidence of a statistically significant improvement in outcome.Conclusion: There is now some limited evidence for the validity and clinical utility of PTTS scores. The high (and increasing) number of systems is a significant confounder. Further research is needed particularly around the thresholds for the vital signs and the reliability, accuracy and calibration of PTTS in different settings. [ABSTRACT FROM AUTHOR]

Background: The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as judged by the outcome of multiple-organ dysfunction. Methods: In this noninferiority trial, we enrolled 637 stable, critically ill children who had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients to a threshold of 9.5 g per deciliter (liberal-strategy group). Results: Hemoglobin concentrations were maintained at a mean (±SD) level that was 2.1±0.2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7±0.4 and 10.8±0.5 g per deciliter, respectively; P<0.001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, –4.6 to 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other outcomes, including adverse events. Conclusions: In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes. (Controlled-trials.com number, ISRCTN37246456.) [ABSTRACT FROM AUTHOR]