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OBJECTIVES: To present the recommendations and supporting literature for RBC transfusions in critically ill children with nonhemorrhagic shock developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.DESIGN: Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.METHODS: The panel of 38 experts developed evidence-based, and when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The nonhemorrhagic shock subgroup included five experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.RESULTS: Transfusion and Anemia Expertise Initiative Consensus Conference experts developed and voted on a total of four clinical and four research recommendations focused on RBC transfusion in the critically ill child with nonhemorrhagic shock. All recommendations reached agreement (> 80%). Of the four clinical recommendations, three were based on consensus panel expertise, whereas one was based on weak pediatric evidence. In hemodynamically stabilized critically ill children with a diagnosis of severe sepsis or septic shock, we recommend not administering a RBC transfusion if the hemoglobin concentration is greater than or equal to 7 g/dL. Future studies are needed to determine optimum transfusion thresholds for critically ill children with nonhemorrhagic shock undergoing acute resuscitation.CONCLUSIONS: The Transfusion and Anemia Expertise Initiative Consensus Conference developed pediatric-specific clinical and research recommendations regarding RBC transfusion in the critically ill child with nonhemorrhagic shock. Although agreement among experts was strong, available pediatric evidence was scant-revealing significant gaps in the existing literature.

The objectives of this review are to discuss the pathophysiology, clinical impact and treatment of hyperglycemia, and disturbances in thyroid and adrenal function prior to and following cardiac surgery in children. MEDLINE and PubMed. Disturbances in glucose metabolism and thyroid and adrenal function are common in critically ill children with cardiac disease and in particular in children undergoing cardiac surgery for complex congenital heart disease. An understanding of the pathophysiology, clinical impact and treatment of these disturbances is essential for the management of these at risk patients.

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

OBJECTIVE: To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome.DESIGN: Consensus conference of experts in pediatric acute lung injury.METHODS: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized.RESULTS: The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies.CONCLUSIONS: The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

OBJECTIVE: Extracorporeal life support has undergone a revolution in the past several years with the advent of new, miniaturized equipment and success in supporting patients with a variety of illnesses. Most experience has come with the use of extracorporeal membrane oxygenation, a modified form of cardiopulmonary bypass that can support the heart, lungs, and circulation for days to months at a time. To describe the recommendations for the use of extracorporeal membrane oxygenation in children with pediatric acute respiratory distress syndrome based on a review of the literature and expert opinion.DESIGN: Consensus conference of experts in pediatric acute lung injury.METHODS: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The extracorporeal support subgroup comprised two international experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used.RESULTS: The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 11 of which related to extracorporeal support. All recommendations had agreement, with 10 recommendations (91%) achieving strong agreement. These recommendations included the utilization of extracorporeal support for reversible causes of pediatric acute respiratory distress syndrome, consideration of quality of life when making the decision to use extracorporeal support, and the use of the Extracorporeal Life Support Organization registry to report all extracorporeal support activity, among others.CONCLUSIONS: Pediatric extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome could benefit from more specific data collection and collaboration of focused investigators to establish validated criteria for optimal application of extracorporeal membrane oxygenation and patient management protocols. Until that time, consensus opinion offers some insight into guidelines.

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.MethodsThe European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.ResultsThe Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with ?strong agreement?. The final iteration of the recommendations had none with equipoise or disagreement.ConclusionsThese recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.; Une grande partie de la pratique courante en ventilation mécanique pédiatrique est basée sur des expériences personnelles et ce que les praticiens en soins intensifs pédiatriques ont adopté à partir de l'expérience adulte et néonatale.

Optimal strategies for reducing catheter-related blood stream infection (CR-BSI) differ for adults and children. National guidelines do not make child-specific recommendations. We determined whether evidence explained the inconsistencies between guidelines and reported practice in paediatric intensive care units (PICUs). We conducted a survey of eight interventions for reducing CR-BSI in all 25 British PICUs in 2009. Interventions were categorised as requiring child-specific evidence, generalisable to adults and children, or organisational recommendations. Twenty-four of the 25 PICUs responded. For child-specific interventions, practice diverged from guidelines for “Insert into subclavian/jugular veins” (18 PICUs frequently used femoral veins, supported by observational evidence for increased safety in children). Practice reflected guidelines for “Use standard but consider antimicrobial-impregnated central venous catheters (CVCs) for high-risk patients” (14 used standard only, 3 used standard and antimicrobial-impregnated despite no randomised controlled trial (RCT) evidence for antimicrobial-impregnated CVCs in children, 7 used heparin-bonded for some or all children); “Use 2% chlorhexidine for skin preparation” (20 PICUs); “Avoid routine CVC replacement” (20 PICUs). For generalisable interventions, practice was consistent with guidelines for “Administration set replacement” (21 PICUs) but deviated for “Maintenance of CVC asepsis” (11 PICUs used alcohol due to inconclusive evidence for chlorhexidine). Practice diverged from guidelines for organisational interventions: “Train healthcare workers in CVC care” (9 PICUs); “Monitor blood stream infection (BSI) rates” (8 PICUs). Guidelines should explicitly address paediatric practice and report the quality of evidence and strength of recommendations. Organisations should ensure doctors are trained in CVC insertion and invest in BSI monitoring, especially in PICUs. The type of CVC and insertion site are important gaps in evidence for children.

Year in review in Intensive Care Medicine, 2008 : I. Brain injury and neurology, renal failure and endocrinology, metabolism and nutrition, sepsis, infections and pneumonia

Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome

Objective: To provide an overview of the current literature on pulmonary-specific therapeutic approaches to pediatric acute respiratory distress syndrome to determine recommendations for clinical practice and/or future research.Data Sources: PubMed, EMBASE, CINAHL, SCOPUS, and the Cochrane Library were searched from inception until January 2013 using the following keywords in various combinations: ARDS, treatment, nitric oxide, heliox, steroids, surfactant, etanercept, prostaglandin therapy, inhaled beta adrenergic receptor agonists, N-acetylcysteine, ipratroprium bromide, dornase, plasminogen activators, fibrinolytics or other anticoagulants, and children. No language restrictions were applied. References from identified articles were searched for additional publications.Study Selection: All clinical studies pertaining to pulmonary-specific therapeutic approaches to pediatric acute respiratory distress syndrome were reviewed. If clinical pediatric data were sparse or unavailable, the findings from studies of adult acute respiratory distress syndrome and animal models that might be relevant to pediatric acute respiratory distress syndrome were examined.Data Extraction: All relevant studies were reviewed and pertinent data abstracted.Data Synthesis: Over the course of three international meetings, the pertinent findings of the literature review were discussed by a panel of 24 experts in the field representing 21 academic institutions and 8 countries. Recommendations developed and the supporting literature were distributed to all panel members without a conflict of interest and were scored by using the Research ANd Development/University of California, Los Angeles Appropriateness method. The modified Delphi approach was used as the methodology to achieve consensus among the panel.Conclusions: Overall, the routine use of surfactant, inhaled nitric oxide, glucocorticoids, prone positioning, endotracheal suctioning, and chest physiotherapy cannot be recommended. Inhaled nitric oxide should only be used for patients with documented pulmonary hypertension and/or right ventricular failure. Prone positioning may be considered in patients with severe pediatric acute respiratory distress syndrome. Future studies are definitely warranted to establish the role, if any, of these ancillary treatment modalities in pediatric acute respiratory distress syndrome.

OBJECTIVE: To critically review the potential role of monitoring technologies in the management of pediatric acute respiratory distress syndrome, and specifically regarding monitoring of the general condition, respiratory system mechanics, severity scoring parameters, imaging, hemodynamic status, and specific weaning considerations.DESIGN: Consensus conference of experts in pediatric acute lung injury.METHODS: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The monitoring subgroup comprised two experts. When published data were lacking a modified Delphi approach, emphasizing strong professional agreement was used.RESULTS: The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 21 of which related to monitoring of a child with pediatric acute respiratory distress syndrome. All 21 recommendations had agreement, with 19 (90%) reaching strong agreement.CONCLUSIONS: The Consensus Conference developed pediatric-specific recommendations related to monitoring children with pediatric acute respiratory distress syndrome. These include interpreting monitored values such as tidal volume using predicted body weight, monitoring tidal volume at the end of the endotracheal tube in small children, and continuous monitoring of exhaled carbon dioxide in intubated children with pediatric acute respiratory distress syndrome, among others. These recommendations for monitoring in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

OBJECTIVE: This article describes the methodology used for the Pediatric Acute Lung Injury Consensus Conference.DESIGN: Consensus conference of international experts in pediatric acute respiratory distress syndrome using the Research ANd Development/University of California, Los Angeles appropriateness method and an expert recommendations process developed by the French-speaking intensive care society. Topics related to pediatric acute respiratory distress syndrome were divided into nine subgroups with a review of the literature.SETTING: A group of 27 experts met three times over the course of 2 years and collaborated in their respective subgroups to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and future research priorities.MAIN RESULTS: The consensus conference resulted in summary of recommendations published in Pediatric Critical Care Medicine, the present Pediatric Acute Lung Injury Consensus Conference methodology article, articles on the nine pediatric acute respiratory distress syndrome subtopics, and a review of pediatric acute respiratory distress syndrome pathophysiology published in this supplement of Pediatric Critical Care Medicine.CONCLUSIONS: The methodology described involved experts from around the world and the use of modern information technology. This resulted in recommendations for pediatric acute respiratory distress syndrome management, the identification of current research gaps, and future priorities.

Objective: To describe the final recommendations of the Pediatric Acute Lung Injury Consensus Conference.Design: Consensus conference of experts in pediatric acute lung injury.Setting: Not applicable.Subjects: PICU patients with evidence of acute lung injury or acute respiratory distress syndrome.Interventions: None.Methods: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. When published, data were lacking a modified Delphi approach emphasizing strong professional agreement was used.Measurements and Main Results: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. When published data were lacking a modified Delphi approach emphasizing strong professional agreement was used. The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the following topics related to pediatric acute respiratory distress syndrome: 1) Definition, prevalence, and epidemiology; 2) Pathophysiology, comorbidities, and severity; 3) Ventilatory support; 4) Pulmonary-specific ancillary treatment; 5) Nonpulmonary treatment; 6) Monitoring; 7) Noninvasive support and ventilation; 8) Extracorporeal support; and 9) Morbidity and long-term outcomes. There were 132 recommendations with strong agreement and 19 recommendations with weak agreement. Once restated, the final iteration of the recommendations had none with equipoise or disagreement.Conclusions: The Consensus Conference developed pediatric-specific definitions for acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

OBJECTIVE: Despite the widespread use of noninvasive ventilation in children and in children with acute lung injury and pediatric acute respiratory distress syndrome, there are few scientific data on the utility of this therapy. In this review, we examine the literature regarding noninvasive positive pressure ventilation and use the Research ANd Development/University of California, Los Angeles appropriateness methodology to provide strong or weak recommendations for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome.DATA SOURCES: Electronic searches were made in PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus with the following specific keywords: noninvasive ventilation, noninvasive positive pressure ventilation, continuous positive airway pressure, and high-flow nasal cannula.STUDY SELECTION: Studies were eligible for inclusion if they included 10 or more children between 1 month and 18 years old. Randomized and nonrandomized controlled trials, controlled before-and-after studies, concurrent cohort studies, interrupted time series studies, historically controlled studies, cohort studies, cross-sectional studies, and uncontrolled longitudinal studies were included for data synthesis.DATA SYNTHESIS: The literature provides a solid physiological rationale for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. The addition of noninvasive positive pressure ventilation can improve gas exchange and potentially prevent intubation and mechanical ventilation in some children with mild pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation is not indicated in severe pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation should be performed only in acute care setting with experienced team, and patient-ventilator synchrony is crucial for success. An oronasal interface provides superior support, but close monitoring of children is required due to the risk of progressive respiratory failure and the potential need for intubation. The use of high-flow nasal cannula is a promising treatment for respiratory disease; however, at this time, the efficacy of high-flow nasal cannula compared with noninvasive positive pressure ventilation is unknown.CONCLUSION: Noninvasive positive pressure ventilation can be beneficial in children with pediatric acute respiratory distress syndrome, particularly in those with milder disease. However, further research is needed into the use of noninvasive positive pressure ventilation in children.

OBJECTIVE: To describe the recommendations of the Pediatric Acute Lung Injury Consensus Conference for mechanical ventilation management of pediatric patients with acute respiratory distress syndrome.DESIGN: Consensus Conference of experts in pediatric acute lung injury.METHODS: The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 27 recommendations focused on the optimal mechanical ventilation approach of the patient with pediatric acute respiratory distress syndrome. Topics included ventilator mode, tidal volume delivery, inspiratory plateau pressure, high-frequency ventilation, cuffed endotracheal tubes, and gas exchange goals. When experimental data were lacking, a modified Delphi approach emphasizing the strong professional agreement was used.RESULTS: There were 17 recommendations with strong agreement and 10 recommendations with weak agreement. There were no recommendations with equipoise or disagreement. There was weak agreement on recommendations concerning approach to tidal volume and inspiratory pressure limitation (88% to 72% agreement, respectively), whereas strong agreement could be achieved for accepting permissive hypercapnia. Using positive end-expiratory pressure levels greater than 15 cm H2O in severe pediatric acute respiratory distress syndrome, under the condition that the markers of oxygen delivery, respiratory system compliance, and hemodynamics are closely monitored as positive end-expiratory pressure is increased, is strongly recommended. The concept of exploring the effects of careful recruitment maneuvers during conventional ventilation met an agreement level of 88%, whereas the use of recruitment maneuvers during rescue high-frequency oscillatory ventilation is highly recommended (strong agreement).CONCLUSIONS: The Consensus Conference developed pediatric-specific recommendations regarding mechanical ventilation of the patient with pediatric acute respiratory distress syndrome as well as future research priorities. These recommendations are intended to initiate discussion regarding optimal mechanical ventilation management for children with pediatric acute respiratory distress syndrome and identify areas of controversy requiring further investigation.

Inhaled nitric oxide (iNO) has been used for treatment of acute respiratory failure and pulmonary hypertension since 1991 in adult patients in the perioperative setting and in critical care. This contribution assesses evidence for the use of iNO in this population as presented to a expert group jointly organised by the European Society of Intensive Care Medicine and the European Association of Cardiothoracic Anaesthesiologists. Expert recommendations on the use of iNO in adults were agreed on following presentation of the evidence at the expert meeting held in June 2004.

Year in review in Intensive Care Medicine 2012 : I. Neurology and neurointensive care, epidemiology and nephrology, biomarkers and inflammation, nutrition, experimentals

Interest in the effects of insulin on the heart came with the recognition that hyperglycemia in the context of myocardial infarction is associated with increased risks of mortality, congestive heart failure, or cardiogenic shock.1–3 More recently, instigated by research findings on stress hyperglycemia in critical illness, this interest has been extended to the influence of insulin on clinical outcome after cardiac surgery. Even in nondiabetic individuals, stress hyperglycemia commonly occurs as a key metabolic response to critical illness, eg, after surgical trauma. It is recognized as a major pathophysiological feature of organ dysfunction in the critically ill. The condition stems from insulin resistance brought about by dysregulation of key homeostatic processes, which implicates immune/inflammatory, endocrine, and metabolic pathways.4 It has been associated with adverse clinical outcomes, including increased mortality, increased duration of mechanical ventilation, increased intensive care unit (ICU) and hospital stay, and increased risk of infection.5–8 Hyperglycemia in critical illness is managed with exogenous insulin as standard treatment; however, there is considerable disagreement among experts in the field as to what target blood glucose level is optimal for the critically ill patient. Conventionally, the aim of insulin therapy has been to maintain blood glucose levels below the renal threshold, typically 220 mg/dL (12.2 mmol/L). In recent years, some have advocated tight glycemic control (TGC) with intensive insulin therapy (IIT) to normalize blood glucose levels to within the euglycemic range, typically 80 to 110 mg/dL (4.4–6.1 mmol/L). Current evidence on the applicability of TGC to critical illness in general is inconclusive. Although early studies showed that IIT reduced mortality and morbidity in the ICU,9–11 more recent systematic studies and meta-analyses have largely failed to support some or all of these findings, with some suggesting that IIT may increase the risk …

Year in review in Intensive Care Medicine 2011. II. : Cardiovascular, infections, pneumonia and sepsis, critical care organization and outcome, education, ultrasonography, metabolism and coagulation

AimsEnrolling children into several trials could increase recruitment and lead to quicker delivery of optimal care in paediatric intensive care units (PICU). We evaluated decisions taken by clinicians and parents in PICU on co-enrolment for two large pragmatic trials: the CATCH trial (CATheters in CHildren) comparing impregnated with standard central venous catheters (CVCs) for reducing bloodstream infection in PICU and the CHIP trial comparing tight versus standard control of hyperglycaemia.MethodsWe recorded the period of trial overlap for all PICUs taking part in both CATCH and CHiP and reasons why clinicians decided to co-enrol children or not into both studies. We examined parental decisions on co-enrolment by measuring recruitment rates and reasons for declining consent.ResultsFive PICUs recruited for CATCH and CHiP during the same period (an additional four opened CATCH after having closed CHiP). Of these five, three declined co-enrolment (one of which delayed recruiting elective patients for CATCH whilst CHiP was running), due to concerns about jeopardising CHiP recruitment, asking too much of parents, overwhelming amounts of information to explain to parents for two trials and a policy against co-enrolment. Two units co-enrolled in order to maximise recruitment to both trials. At the first unit, 35 parents were approached for both trials. 17/35 consented to both; 13/35 consented to one trial only; 5/35 declined both. Consent rates during co-enrolment were 29/35 (82%) and 18/35 (51%) for CATCH and CHiP respectively compared with 78% and 51% respectively for those approached for a single trial within this PICU. The second unit did not record data on approaches or refusals, but successfully co-enrolled one child.ConclusionsCo-enrolment did not appear to jeopardise recruitment or overwhelm parents. Strategies for seeking consent for multiple trials need to be developed and should include how to combine information for parents and patients.

Year in review in Intensive Care Medicine 2011 : I. Nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals

Our ability to directly monitor the mechanisms that govern cellular function, oxygen use, and survival is minimal. Therefore, in critically ill children, surrogate markers are used to try to detect evolving or established hypoxia. These surrogate markers are best used in combination and are complementary to clinical examination. Regardless of resource limitations, we propose that the availability of certain monitoring tools form a standard of care without which pediatric cardiac critical care cannot be safely or optimally provided. These tools include standard invasive hemodynamic monitoring with electrocardiography, lactate measurement, central venous oxygen saturation, and echocardiography. Ultimately, monitoring is only useful when the clinician observes a specific value or trend and has the expertise to act appropriately. (Pediatr Crit Care Med 2011; 12[Suppl.]:S76-S80)

Year in review in Intensive Care Medicine 2010 : III. ARDS and ALI, mechanical ventilation, noninvasive ventilation, weaning, endotracheal intubation, lung ultrasound and paediatrics

Year in review in Intensive Care Medicine 2010 : II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea

Year in review in Intensive Care Medicine 2009 : II. Neurology, cardiovascular, experimental, pharmacology and sedation, communication and teaching

Year in review in Intensive Care Medicine 2009 : I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control

OBJECTIVE To determine the use of anti-inflammatory therapies in infants and children undergoing cardiac surgery in the United Kingdom and Ireland. DESIGN Questionnaire survey. SUBJECTS All centers that undertake pediatric cardiac surgery in the United Kingdom and Ireland. RESULTS All centers use at least one anti-inflammatory therapy, with 46% of centers using more than one. Both modified ultrafiltration (80%) and steroids (80%) are widely used as anti-inflammatory strategies. Among centers that use steroids, dose, preparation, and timing of steroid administered was highly variable. Heparin-bonded circuits and aprotinin are infrequently used as anti-inflammatory techniques. CONCLUSION Although anti-inflammatory interventions are believed to contribute to improved patient outcome following cardiopulmonary bypass, this survey has shown that there are still widespread variations in practice. Rather than reflecting poor clinical practice, we believe this reflects a lack of good evidence supporting clinical benefit.

Year in review in Intensive Care Medicine, 2008 : II. Experimental, acute respiratory failure and ARDS, mechanical ventilation and endotracheal intubation

Year in review in Intensive Care Medicine, 2007. III. Ethics and legislation, health services research, pharmacology and toxicology, nutrition and paediatrics

Received: 22 January 2007Accepted: 22 January 2007Published online: 14 February 2007© Springer-Verlag 2007This review intends tosummarize all articlespublished in Intensive Care Medicine in2006, grouped by specific topicsP. AndrewsWestern General Hospital, Intensive CareMedicine Unit,Edinburgh, UKE. AzoulaySaint Louis Hospital, Intensive CareMedicine Unit,Paris, FranceM. AntonelliUniversita Cattolica del Sacre Cuore,Department of Intensive Care andAnesthesiology,Rome, ItalyL. Brochard (✉)AP-HP, Hopital Henri Mondor, UniversiteParis 12, Reanimation Medicale, INSERMU 651,94000 Creteil, Francee-mail: laurent.brochard@hmn.aphp.frTel.: +33-1-49812545Fax: +33-1-42079943C. Brun-BuissonAP-HP, Hopital Henri Mondor, UniversiteParis 12, Reanimation Medicale,Creteil, FranceD. De BackerErasme Hospital, Service des SoinsIntensifs,Brussels, BelgiumG. DobbRoyal Perth Hospital, Intensive CareMedicine Unit,Perth, AustraliaJ.-Y. FagonEuropean Georges Pompidou Hospital,Intensive Care Medicine Unit,H. GerlachVivantes-Klinikum Neukoelln, Departmentof Anesthesiology,Berlin, GermanyJ. GroeneveldVUMC, Intensive Care Medicine Unit,Amsterdam, The NetherlandsD. MacraeRoyal Brompton Hospital, PediatricIntensive Care Unit,London, UKJ. ManceboHospital Sant Pau, Intensive Care MedicineUnit,Barcelona, SpainP. MetnitzUniversity Hospital of Vienna, Departmentof Anesthesia and General Intensive CareMedicine,Vienna, AustriaS. NavaFondazione S. Maugeri, Intensive CareMedicine Unit,Pavia, ItalyJ. PuginUniversity Hospital of Geneva, IntensiveCare Medicine Unit,Geneva, SwitzerlandM. PinskyUniversity of Pittsburgh Medical Center,Intensive Care Medicine Unit,Pittsburgh Pennsylvania, USAP. RadermacherUniversity Medical School of Ulm,Department of Anesthesia,Ulm, GermanyC. RichardUniversity Hospital of Le Kremlin-Bicetre,Intensive Care Unit,Le Kremlin-Bicetre, France

This review summarizes all articles published in Intensive Care Medicine in 2006, grouped by specific topic.

Summary Background Although mechanical circulatory support might not increase the number of adults surviving to transplantation, because of the shortage of donor organs, the situation might be different for children. Our aim was to assess the effect of mechanical assist devices to bridge children with end-stage cardiomyopathy to heart transplantation. Methods A 5-year retrospective review was undertaken with data from the UK paediatric transplant programme and from bridging to transplant done at two paediatric transplant centres in the UK. Findings Between Jan 1, 1998 and Dec 31, 2002, 22 children with end-stage cardiomyopathy, median age 5·7 years (range 1·2−17), were supported by a mechanical assist device as a bridge to first heart transplantation, with a 77% survival rate to hospital discharge. Nine were supported by a paracorporeal ventricular assist device, six received transplantation, five survived to discharge (55%), with one late death. 13 were supported by extra-corporeal membrane oxygenation, and 12 were transplanted and survived to discharge (92%) with one late death. With urgent listing, the median waiting time for a heart was 7·5 days (range 1·5–22 days). The correlation between the proportion of patients bridged to transplantation and the proportion of patients dying while on the transplant waiting list was r=−0·93, p=0·02. Interpretation Our findings lend support to the hypothesis that a national mechanical assist programme to bridge children to transplantation can minimise the number dying while on the heart transplant waiting list. In the context of urgent listing and a short waiting time, extra-corporeal membrane oxygenation seems to provide the safest form of support.

Inhaled nitric oxide (iNO) was first used in neonatal practice in 1992 and has subsequently been used extensively in the management of neonates and children with cardiorespiratory failure. This paper assesses evidence for the use of iNO in this population as presented to a consensus meeting jointly organised by the European Society of Paediatric and Neonatal Intensive Care, the European Society of Paediatric Research and the European Society of Neonatology. Consensus Guidelines on the Use of iNO in Neonates and Children were produced following discussion of the evidence at the consensus meeting.

Summary Background Meningococcal disease is still associated with considerable mortality, despite the use of early antibiotics and management in specialised intensive care units, due principally to early refractory myocardial depression and hypotension as well as severe acute respiratory distress syndrome. Extracorporeal membrane oxygenation (BCMO) is a complex technology that uses a modified "heart-lung" machine to provide temporary cardiac and respiratory support. We reviewed the UK and Australian experience of the use of ECMO in patients with refractory cardiorespiratory failure due to meningococcal disease. Methods The records from all 12 known patients supported with ECMO for meningococcal disease in the UK and Australia since 1989 were reviewed. Findings 12 patients (aged 4 months to 18 years, median 26 months) with meningococcal disease received ECMO over 8 years. In seven patients, ECMO was required early for cardiac support for intractable shock within 36 h of admission to intensive care. In the other five patients, ECMO was indicated for respiratory failure due to severe adult respiratory distress syndrome, which tended to occur later in the disease. The paediatric risk of mortality score ranged from 13 to 40 (median 29, median predicted risk of mortality 72%). Six of the 12 patients required cardiopulmonary resuscitation before ECMO and the other six were deteriorating despite maximal conventional therapy. Overall, eight of the 12 patients survived, with six leading functionally normal lives at a median of 1 year (range 4 months to 4 years) of follow-up. Interpretation ECMO might be considered to support patients with intractable cardiorespiratory failure due to meningococcal disease who are not responding to conventional treatment.

Background Antibiotic surveillance is mandatory to optimise antibiotic therapy. Our objectives were to evaluate antibiotic use in our pediatric intensive care unit (PICU) and to implement a simple achievable intervention aimed at improving antibiotic therapy. Method Prospective, 3 months surveillance of antibiotic use on PICU (phase I) and evaluation according to the CDC 12-step campaign with development of an attainable intervention. 3 months surveillance (phase II) after implementation of intervention with comparison of antibiotic use. Results Appropriate antibiotic use for culture-negative infection-like symptoms and targeted therapy for proven infections were the main areas for potential improvement. The intervention was a mandatory checklist requiring indication and recording likelihood of infection at start of antibiotic therapy and a review of the continuing need for therapy at 48 h and 5 days, reasons for continuation and possible target pathogen. The percentage of appropriate empiric antibiotic therapy courses for culture-negative infection-like symptoms increased from 18% (10/53) to 74% (42/57; p Conclusions Antibiotic surveillance using the CDC 12-step campaign can help to evaluate institutional antibiotic therapy. Development of an attainable intervention using a checklist can show improved antibiotic use with minimal expense.

Year in review in Intensive Care Medicine 2010 : I. Acute renal failure, outcome, risk assessment and ICU performance, sepsis, neuro intensive care and experimentals

Year in review in Intensive Care Medicine 2012. II : Pneumonia and infection, sepsis, coagulation, hemodynamics, cardiovascular and microcirculation, critical care organization, imaging, ethics and legal issues

Year in review in Intensive Care Medicine 2009. Part III : mechanical ventilation, acute lung injury and respiratory distress syndrome, pediatrics, ethics, and miscellanea

Year in review in Intensive Care Medicine, 2007. I. Experimental studies. Clinical studies : brain injury and neurology, renal failure and endocrinology

Year in review in Intensive Care Medicine 2012 : III. Noninvasive ventilation, monitoring and patient-ventilator interactions, acute respiratory distress syndrome, sedation, paediatrics and miscellanea

SummaryOver recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paediatric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient's bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisciplinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least ‘150 major procedures per year in children’ and must provide a ‘specialized paediatric intensive care unit’.