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In children, vital distress events, particularly respiratory, go unrecognized. To develop a standard model for automated assessment of vital distress in children, we aimed to construct a prospective high-quality video database for critically ill children in a pediatric intensive care unit (PICU) setting. The videos were acquired automatically through a secure web application with an application programming interface (API). The purpose of this article is to describe the data acquisition process from each PICU room to the research electronic database. Using an Azure Kinect DK and a Flir Lepton 3.5 LWIR attached to a Jetson Xavier NX board and the network architecture of our PICU, we have implemented an ongoing high-fidelity prospectively collected video database for research, monitoring, and diagnostic purposes. This infrastructure offers the opportunity to develop algorithms (including computational models) to quantify vital distress in order to evaluate vital distress events. More than 290 RGB, thermographic, and point cloud videos of each 30 s have been recorded in the database. Each recording is linked to the patient's numerical phenotype, i.e., the electronic medical health record and high-resolution medical database of our research center. The ultimate goal is to develop and validate algorithms to detect vital distress in real time, both for inpatient care and outpatient management.

Background: Few studies have characterized follow-up after pediatric acute kidney injury (AKI). Our aim was to describe outpatient AKI follow-up after pediatric intensive care unit (PICU) admission., Methods: Two-center retrospective cohort study (0-18 years; PICU survivors (2003-2005); noncardiac surgery; and no baseline kidney disease). Provincial administrative databases were used to determine outcomes., Exposure: AKI (KDIGO (Kidney Disease: Improving Global Outcomes) definitions)., Outcomes: post-discharge nephrology, family physician, pediatrician, and non-nephrology specialist visits. Regression was used to evaluate factors associated with the presence of nephrology follow-up (Cox) and the number of nephrology and family physician or pediatrician visits (Poisson), among AKI survivors., Results: Of n = 2041, 355 (17%) had any AKI; 64/355 (18%) had nephrology; 198 (56%) had family physician or pediatrician; and 338 (95%) had family physician, pediatrician, or non-nephrology specialist follow-up by 1 year post discharge. Only 44/142 (31%) stage 2-3 AKI patients had nephrology follow-up by 1 year. Inpatient nephrology consult (adjusted hazard ratio (aHR) 7.76 [95% confidence interval (CI) 4.89-12.30]), kidney admission diagnosis (aHR 4.26 [2.21-8.18]), and AKI non-recovery by discharge (aHR 2.65 [1.55-4.55]) were associated with 1-year nephrology follow-up among any AKI survivors., Conclusions: Nephrology follow-up after AKI was uncommon, but nearly all AKI survivors had follow-up with non-nephrologist physicians. This suggests that AKI follow-up knowledge translation strategies for non-nephrology providers should be a priority., Impact: Pediatric AKI survivors have high long-term rates of chronic kidney disease (CKD) and hypertension, justifying regular kidney health surveillance after AKI. However, there is limited pediatric data on follow-up after AKI, including the factors associated with nephrology referral and extent of non-nephrology follow-up. We found that only one-fifth of all AKI survivors and one-third of severe AKI (stage 2-3) survivors have nephrology follow-up within 1 year post discharge. However, 95% are seen by a family physician, pediatrician, or non-nephrology specialist within 1 year post discharge. This suggests that knowledge translation strategies for AKI follow-up should be targeted at non-nephrology healthcare providers., (© 2021. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Rationale: High data quality is essential to ensure the validity of clinical and research inferences based on it. However, these data quality assessments are often missing even though these data are used in daily practice and research., Aims and Objectives: Our objective was to evaluate the data quality of our high-resolution electronic database (HRDB) implemented in our paediatric intensive care unit (PICU)., Methods: We conducted a prospective validation study of a HRDB in a 32-bed paediatric medical, surgical, and cardiac PICU in a tertiary care freestanding maternal-child health centre in Canada. All patients admitted to the PICU with at least one vital sign monitored using a cardiorespiratory monitor connected to the central monitoring station., Results: Between June 2017 and August 2018, data from 295 patient days were recorded from medical devices and 4645 data points were video recorded and compared to the corresponding data collected in the HRDB. Statistical analysis showed an excellent overall correlation (R 2 = 1), accuracy (100%), agreement (bias = 0, limits of agreement = 0), completeness (2% missing data), and reliability (ICC = 1) between recorded and collected data within clinically significant pre-defined limits of agreement. Divergent points could all be explained., Conclusions: This prospective validation of a representative sample showed an excellent overall data quality., (© 2020 John Wiley & Sons, Ltd.)

Objective: The main purpose of our study was to subjectively assess the quality of a paediatric intensive care unit (PICU) database according to the Directory of Clinical Databases (DoCDat) criteria., Design and Setting: A survey was conducted between April 1 and June 15, 2018, among the Sainte Justine PICU research group., Population: Every member of this group whose research activity required the use of the database and/or who was involved in the development/validation of the database., Interventions: None., Measurements and Main Results: All 10 research team members (one Information Technology specialist, one junior medical student, and eight clinician researchers) who used the high-resolution database fulfilled the survey (100% response rate). The median quality level of the Sainte Justine PICU database across all the 10 criteria was 3 (2-4), rated on a 1 (worst) to 4 (best) numeric scale. When compared with previously assessed databases through the DoCDat criteria, we found that the Sainte Justine PICU database performance was similar., Conclusions: The PICU high-resolution database appeared of good quality when subjectively assessed by the DoCDat criteria. Further validation procedures are mandatory. We suggest that data quality assessment and validation procedures should be reported when creating a new database., (© 2019 John Wiley & Sons, Ltd.)

Objective: The aim of this study was to assess the feasibility of implementing a synchronous telemedicine platform in a pediatric intensive care unit (STEP-PICU)., Method: A prospective mixed study was conducted. Two sources of data were mobilised: a survey with structured questionnaires and direct non-intrusive observation. The study site was the PICU of a university hospital. Users' perceptions of six aspects of the STEP-PICU were studied: telemedicine system quality, data quality, quality of technical support, use of the new system, overall satisfaction and system benefits., Results: During the 6-month experimentation period, use of the telemedicine platform was rather limited and fell short of the promoter's expectations.The mean scores for the six user perception dimensions were low, with no differences between the two groups of users. A Mann-Whitney test showed that being an off-site pediatric intensivist or on-site fellow did not make a statistically significant difference in responses on system quality (p = .518), data quality (p = 1.00), quality of technical support (p = 1.00), system use (p = .556), overall satisfaction (p = .482), or benefits (p = .365). The low use of the STEP-PICU was attributed to three root causes: human factors, the platform's functionalities, and technical problems., Discussion: The synchronous telemedicine service for PICU was feasible but would need good pre-implementation preparation to be truly helpful. Its usefulness during the night shift and holiday on-call periods was scored as low by the off-site pediatric intensivists and the on-site fellows. It would appear that such a service could be more beneficial for communications with other remote healthcare facilities, where there is a greater need for the expertise of a pediatric critical care intensivist., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Paediatric acute respiratory distress syndrome (PARDS) is associated with high mortality in children, but until recently no paediatric-specific diagnostic criteria existed. The Pediatric Acute Lung Injury Consensus Conference (PALICC) definition was developed to overcome limitations of the Berlin definition, which was designed and validated for adults. We aimed to determine the incidence and outcomes of children who meet the PALICC definition of PARDS., Methods: In this international, prospective, cross-sectional, observational study, 145 paediatric intensive care units (PICUs) from 27 countries were recruited, and over a continuous 5 day period across 10 weeks all patients were screened for enrolment. Patients were included if they had a new diagnosis of PARDS that met PALICC criteria during the study week. Exclusion criteria included meeting PARDS criteria more than 24 h before screening, cyanotic heart disease, active perinatal lung disease, and preparation or recovery from a cardiac intervention. Data were collected on the PICU characteristics, patient demographics, and elements of PARDS (ie, PARDS risk factors, hypoxaemia severity metrics, type of ventilation), comorbidities, chest imaging, arterial blood gas measurements, and pulse oximetry. The primary outcome was PICU mortality. Secondary outcomes included 90 day mortality, duration of invasive mechanical and non-invasive ventilation, and cause of death., Findings: Between May 9, 2016, and June 16, 2017, during the 10 study weeks, 23 280 patients were admitted to participating PICUs, of whom 744 (3·2%) were identified as having PARDS. 95% (708 of 744) of patients had complete data for analysis, with 17% (121 of 708; 95% CI 14-20) mortality, whereas only 32% (230 of 708) of patients met Berlin criteria with 27% (61 of 230) mortality. Based on hypoxaemia severity at PARDS diagnosis, mortality was similar among those who were non-invasively ventilated and with mild or moderate PARDS (10-15%), but higher for those with severe PARDS (33% [54 of 165; 95% CI 26-41]). 50% (80 of 160) of non-invasively ventilated patients with PARDS were subsequently intubated, with 25% (20 of 80; 95% CI 16-36) mortality. By use of PALICC PARDS definition, severity of PARDS at 6 h after initial diagnosis (area under the curve [AUC] 0·69, 95% CI 0·62-0·76) discriminates PICU mortality better than severity at PARDS diagnosis (AUC 0·64, 0·58-0·71), and outperforms Berlin severity groups at 6 h (0·64, 0·58-0·70; p=0·01)., Interpretation: The PALICC definition identified more children as having PARDS than the Berlin definition, and PALICC PARDS severity groupings improved the stratification of mortality risk, particularly when applied 6 h after PARDS diagnosis. The PALICC PARDS framework should be considered for use in future epidemiological and therapeutic research among children with PARDS., Funding: University of Southern California Clinical Translational Science Institute, Sainte Justine Children's Hospital, University of Montreal, Canada, Réseau en Santé Respiratoire du Fonds de Recherche Quebec-Santé, and Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care Medicine., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Assessment of respiratory activity in pediatric intensive care unit allows a comprehensive view of the patient's condition. This allows the identification of high-risk cases for prompt and appropriate medical treatment. Numerous research works on respiration monitoring have been conducted in recent years. However, most of them are unsuitable for clinical environment or require physical contact with the patient, which limits their efficiency. In this paper, we present a novel system for measuring the breathing pattern based on a computer vision method and contactless design. Our 3D imaging system is specifically designed for pediatric intensive care environment, which distinguishes it from the other imaging methods. Indeed, previous works are mostly limited to the use of conventional video acquisition devices, in addition to not considering the constraints imposed by intensive care environment. The proposed system uses depth information captured by two (Red Green Blue-Depth) RGB-D cameras at different view angles, by considering the intensive care unit constraints. Depth information is then exploited to reconstruct a 3D surface of a patient's torso with high temporal and spatial resolution and large spatial coverage. Our system captures the motion information for the top of the torso surface as well as for its both lateral sides. For each reconstruction, the volume is estimated through a recursive subdivision of the 3D space into cubic unit elements. The volume change is then calculated through a subtraction technique between successive reconstructions. We tested our system in the pediatric intensive care unit of the Sainte-Justine university hospital center, where it was compared to the gold standard method currently used in pediatric intensive care units. The performed experiments showed a very high accuracy and precision of the proposed imaging system in estimating respiratory rate and tidal volume., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: To evaluate the impact of synchronous telemedicine models on the clinical outcomes in pediatric acute care settings., Data Sources: Citations from EBM Reviews, MEDLINE, EMBASE, Global Health, PubMed, and CINAHL., Study Selection: We identified studies that evaluated the impact of synchronous telemedicine on clinical outcomes between January 2000 and April 2018. All studies involving acutely ill children in PICUs, pediatric cardiac ICUs, neonatal ICUs, and pediatric emergency departments were included. Publication inclusion criteria were study design, participants characteristics, technology type, interventions, settings, outcome measures, and languages., Data Extraction: Two authors independently screened each article for inclusion and extracted information, including telecommunication method, intervention characteristics, sample characteristics and size, outcomes, and settings., Data Synthesis: Out of the 789 studies initially identified, 24 were included. The six main outcomes of interest published were quality of care, hospital and standardized mortality rate, transfer rate, complications and illness severity, change in medical management, and length of stay. The use of synchronous telemedicine results improved quality of care and resulted in a decrease in the transfer rate (31-87.5%) (four studies), a shorter length of stay (8.2 vs 15.1 d) (six studies), a change or reinforcement of the medical care plan, a reduction in complications and illness severity, and a low hospital and standardized mortality rate. Overall, the quality of the included studies was weak., Conclusions: Despite the broad recommendations found for using telemedicine in pediatric acute care settings, high-quality evidence of its impacts is still lacking. Further robust studies are needed to better determine the clinical effectiveness and the associated impacts of telemedicine in pediatric acute care settings.

Objectives: Ventilator-associated pneumonia is the second most common nosocomial infection in pediatric intensive care. The Centers for Disease Control and Prevention recently issued diagnosis criteria for pediatric ventilator-associated pneumonia and for ventilator-associated events in adults. The objectives of this pediatric study were to determine the prevalence of ventilator-associated pneumonia using these new Centers for Disease Control and Prevention criteria, to describe the risk factors and management of ventilator-associated pneumonia, and to assess a simpler method to detect ventilator-associated pneumonia with ventilator-associated event in critically ill children., Design: Retrospective, observational, single-center., Setting: PICU in a tertiary-care university hospital., Patients: Consecutive critically ill children mechanically ventilated for greater than or equal to 48 hours between November 2013 and November 2015., Interventions: None., Measurements and Main Results: Of 304 patients mechanically ventilated for greater than or equal to 48 hours, 284 were included. Among them, 30 (10.6%) met clinical and radiologic Centers for Disease Control and Prevention criteria for ventilator-associated pneumonia, yielding an prevalence of 7/1,000 mechanical ventilation days. Median time from mechanical ventilation onset to ventilator-associated pneumonia diagnosis was 4 days. Semiquantitative culture of tracheal aspirates was the most common microbiological technique. Gram-negative bacteria were found in 60% of patients, with a predominance of Haemophilus influenzae and Pseudomonas aeruginosa. Antibiotic therapy complied with adult guidelines. Compared with patients without ventilator-associated pneumonia, those with ventilator-associated pneumonia had significantly longer median durations of mechanical ventilation (15 vs 6 d; p < 0.001) and PICU stay (19 vs 9 d; p < 0.001). By univariate analysis, risk factors for ventilator-associated pneumonia were younger age, reintubation, acute respiratory distress syndrome, and continuous enteral feeding. Among the 30 patients with ventilator-associated pneumonia, 17 met adult ventilator-associated event's criteria (sensitivity, 56%)., Conclusions: Ventilator-associated pneumonia is associated with longer times on mechanical ventilation and in the PICU. Using the ventilator-associated event criteria is of interest to rapidly screen for ventilator-associated pneumonia in children. However, sensitivity must be improved by adapting these criteria to children.

Background and Objectives: Little is known about the long-term burden of AKI in the pediatric intensive care unit. We aim to evaluate if pediatric AKI is associated with higher health service use post-hospital discharge., Design, Setting, Participants, & Measurements: This is a retrospective cohort study of children (≤18 years old) admitted to two tertiary centers in Montreal, Canada. Only the first admission per patient was included. AKI was defined in two ways: serum creatinine alone or serum creatinine and/or urine output. The outcomes were 30-day, 1-year, and 5-year hospitalizations, emergency room visits, and physician visits per person-time using provincial administrative data. Univariable and multivariable Poisson regression were used to evaluate AKI associations with outcomes., Results: A total of 2041 children were included (56% male, mean admission age 6.5±5.8 years); 299 of 1575 (19%) developed AKI defined using serum creatinine alone, and when urine output was included in the AKI definition 355 of 1622 (22%) children developed AKI. AKI defined using serum creatinine alone and AKI defined using serum creatinine and urine output were both associated with higher 1- and 5-year hospitalization risk (AKI by serum creatinine alone adjusted relative risk, 1.42; 95% confidence interval, 1.12 to 1.82; and 1.80; 1.54 to 2.11, respectively [similar when urine output was included]) and higher 5-year physician visits (adjusted relative risk, 1.26; 95% confidence interval, 1.14 to 1.39). AKI was not associated with emergency room use after adjustments., Conclusions: AKI is independently associated with higher hospitalizations and physician visits postdischarge., (Copyright © 2018 by the American Society of Nephrology.)

Objectives: To assess caregivers' patient care time before and after the implementation of a reorganization of care plan with electronic medical records., Design: A prospective, observational, time-motion study., Setting: A level 3 PICU., Participants: Nurses and orderlies caring for intubated patients during an 8-hour work shift before (2008-2009) and after (2016) implementation of reorganization of care in 2013., Interventions: The reorganization plan included improved telecommunication for healthcare workers, increased tasks delegated to orderlies, and an ICU-specific electronic medical record (Intellispace Critical Care and Anesthesia information system, Philips Healthcare)., Measurements and Main Results: Time spent completing various work tasks was recorded by direct observation, and proportion of time in tasks was compared for each study period. A total of 153.7 hours was observed from 22 nurses and 14 orderlies. There was no significant difference in the proportion of nursing patient care time before (68.8% [interquartile range, 48-72%]) and after (55% [interquartile range, 51-57%]) (p = 0.11) the reorganization with electronic medical record. Direct patient care task time for nurses was increased from 27.0% (interquartile range, 30-37%) before to 34.7% (interquartile range, 33-75%) (p = 0.336) after, and indirect patient care tasks decreased from 33.6% (interquartile range, 23-41%) to 18.6% (interquartile range, 16-22%) (p = 0.036). Documentation time significantly increased from 14.5% (interquartile range, 12-22%) to 26.2% (interquartile range, 23-28%) (p = 0.032). Nursing productivity ratio improved from 28.3 to 26.0. A survey revealed that nursing staff was satisfied with the electronic medical record, although there was a concern for the maintenance of oral communication in the unit., Conclusions: The reorganization of care with the implementation of an ICU-specific electronic medical record in the PICU did not change total patient care provided but improved nursing productivity, resulting in improved efficiency. Documentation time was significantly increased, and concern over reduced oral communication arose, which should be a focus for future electronic improvement strategies.

Objective: Our objective was to construct a prospective high-quality and high-frequency database combining patient therapeutics and clinical variables in real time, automatically fed by the information system and network architecture available through fully electronic charting in our PICU. The purpose of this article is to describe the data acquisition process from bedside to the research electronic database., Design: Descriptive report and analysis of a prospective database., Setting: A 24-bed PICU, medical ICU, surgical ICU, and cardiac ICU in a tertiary care free-standing maternal child health center in Canada., Patients: All patients less than 18 years old were included at admission to the PICU., Interventions: None., Measurements and Main Results: Between May 21, 2015, and December 31, 2016, 1,386 consecutive PICU stays from 1,194 patients were recorded in the database. Data were prospectively collected from admission to discharge, every 5 seconds from monitors and every 30 seconds from mechanical ventilators and infusion pumps. These data were linked to the patient's electronic medical record. The database total volume was 241 GB. The patients' median age was 2.0 years (interquartile range, 0.0-9.0). Data were available for all mechanically ventilated patients (n = 511; recorded duration, 77,678 hr), and respiratory failure was the most frequent reason for admission (n = 360). The complete pharmacologic profile was synched to database for all PICU stays. Following this implementation, a validation phase is in process and several research projects are ongoing using this high-fidelity database., Conclusions: Using the existing bedside information system and network architecture of our PICU, we implemented an ongoing high-fidelity prospectively collected electronic database, preventing the continuous loss of scientific information. This offers the opportunity to develop research on clinical decision support systems and computational models of cardiorespiratory physiology for example.

Objective: To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations., Study Design: This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included., Results: A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers., Conclusion: Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Respiratory complications associated with RBC transfusions may be underestimated in PICUs because current definitions exclude patients with preexisting respiratory dysfunction. This study aims to determine the prevalence and characterize the risk factors and outcomes of new or progressive respiratory dysfunction observed after RBC transfusion in critically ill children., Design: Prospective cohort study of all children admitted over a 1-year period., Setting: A multidisciplinary PICU in a tertiary pediatric university hospital., Patients: Patients who received a RBC transfusion while in PICU., Interventions: None., Measurements and Main Results: Two independent adjudicators established the diagnosis of respiratory dysfunction. A respiratory dysfunction associated with transfusion was considered new if it appeared after the first RBC transfusion in PICU. A progressive respiratory dysfunction associated with transfusion was diagnosed if the respiratory dysfunction was present before the transfusion and the PaO2/FIO2 or the SpO2/FIO2 ratio dropped by at least 20% thereafter. Among 842 children admitted into the PICU, 136 received at least one RBC transfusion and were analyzed. Fifty-eight cases of respiratory dysfunction associated with transfusion (43% of transfused patients) were detected, including nine new respiratory dysfunction associated with transfusion (7%) and 49 progressive respiratory dysfunction associated with transfusion (36%). Higher severity of illness, multiple organ dysfunction syndrome prior to transfusion, and volume (mL/kg) of RBC transfusion were independently associated with respiratory dysfunction associated with transfusion. A dose-response relationship was observed between transfusion volume (mL/kg) and the prevalence of respiratory dysfunction associated with transfusion. Patients with respiratory dysfunction associated with transfusion had more progressive multiple organ dysfunction and less ventilation-free and PICU-free days at day 28., Conclusions: Development of respiratory dysfunction associated with transfusion is frequent in PICU and occurs mainly in patients with prior respiratory dysfunction, who would not be identified using current definitions for transfusion-associated complications. A cause-effect relationship cannot be confirmed. However, the high prevalence and the serious adverse outcomes associated with respiratory dysfunction associated with transfusion suggest that this complication should be further studied.

Purpose: Diaphragm function should be monitored in critically ill patients, as full ventilatory support rapidly induces diaphragm atrophy. Monitoring the electrical activity of the diaphragm (EAdi) may help assess the level of diaphragm activity, but such monitoring results are difficult to interpret because reference values are lacking. The aim of this study was to describe EAdi values in critically ill children during a stay in the pediatric intensive care unit (PICU), from the acute to recovery phases, and to assess the impact of ventilatory support on EAdi., Methods: This was a prospective longitudinal observational study of children requiring mechanical ventilation for ≥24 h. EAdi was recorded using a validated method in the acute phase, before extubation, after extubation, and before PICU discharge., Results: Fifty-five critically ill children were enrolled in the study. Median maximum inspiratory EAdi (EAdimax) during mechanical ventilation was 3.6 [interquartile range (IQR) 1.2-7.6] μV in the acute phase and 4.8 (IQR 2.0-10.7) μV in the pre-extubation phase. Periods of diaphragm inactivity (with no detectable inspiratory EAdi) were frequent during conventional ventilation, even with a low level of support. EAdimax in spontaneous ventilation was 15.4 (IQR 7.4-20.7) μV shortly after extubation and 12.6 (IQR 8.1-21.3) μV before PICU discharge. The difference in EAdimax between mechanical ventilation and post-extubation periods was significant (p < 0.001). Patients intubated mainly because of a lung pathology exhibited higher EAdi (p < 0.01), with a similar temporal increase., Conclusions: This is the first systematic description of EAdi evolution in children during their stay in the PICU. In our patient cohort, diaphragm activity was frequently low in conventional ventilation, suggesting that overassistance or oversedation is common in clinical practice. EAdi monitoring appears to be a helpful tool to detect such situations.

Objective: To investigate the possibility of pediatric intensive care unit shortfalls, using pandemic models for a range of attack rates and durations. The emergence of the swine origin pH1N1 virus has led to concerns about shortfalls in our ability to provide pediatric ventilation and critical care support., Design: Modeling of pediatric intensive care demand based on pH1N1 predictions using simulation techniques., Setting: Simulation laboratory., Patients: None., Interventions: None., Measurements and Main Results: Data collected during the first wave of the pH1N1 in children in Canada were applied to several second wave pandemic models to explore potential pediatric intensive care unit ventilatory demands for Canada and to investigate the impact of vaccination upon these demands. In almost all cases studied, even for relatively low attack rates of 15%, significant pediatric intensive care unit shortages would be expected to occur. Vaccination strategies targeting 50% of the population significantly reduced demand, but shortages may still be expected. Although shortfalls can occur in all provinces, Ontario and British Columbia may experience the greatest supply-demand difference, even at low attack rates., Conclusion: Reducing the attack rate among children, whether through vaccination or additional measures, such as social distancing, will be critical to ensure sufficient pediatric intensive care unit capacity for continued pediatric care.

Objective: To describe characteristics, treatment, and outcomes of critically ill children with influenza A/pandemic influenza A virus (pH1N1) infection in Canada., Design: An observational study of critically ill children with influenza A/pH1N1 infection in pediatric intensive care units (PICUs)., Setting: Nine Canadian PICUs., Patients: A total of 57 patients admitted to PICUs between April 16, 2009 and August 15, 2009., Interventions: None., Measurements and Main Results: Characteristics of critically ill children with influenza A/pH1N1 infection were recorded. Confirmed intensive care unit cases were compared with a national surveillance database containing all hospitalized pediatric patients with influenza A/pH1N1 infection. Risk factors were assessed with a Cox proportional hazard model. The PICU cohort and national surveillance data were compared, using chi-square tests. Fifty-seven children were admitted to the PICU for community-acquired influenza A/pH1N1 infection. One or more chronic comorbid illnesses were observed in 70.2% of patients, and 24.6% of patients were aboriginal. Mechanical ventilation was used in 68% of children, 20 children (35.1%) had acute lung injury on the first day of admission, and the median duration of ventilation was 6 days (range, 0-67 days). The PICU mortality rate was 7% (4 of 57 patients). When compared with nonintensive care unit hospitalized children, PICU children were more likely to have a chronic medical condition (relative risk, 1.73); aboriginal ethnicity was not a risk factor of intensive care unit admission., Conclusions: During the first outbreak of influenza A/pH1N1 infection, when the population was naïve to this novel virus, severe illness was common among children with underlying chronic conditions and aboriginal children. Influenza A/pH1N1-related critical illness in children was associated with severe hypoxemic respiratory failure and prolonged mechanical ventilation. However, this higher rate and severity of respiratory illness did not result in an increased mortality when compared with seasonal influenza.

Background & Aims: The aims of this study were to determine the impact of a nutritional support team (NST) intervention in a pediatric intensive care unit (PICU) and to identify the factors at admission that were associated to a delay to achieve a sustained optimal caloric intake (SOCI)., Methods: Caloric and protein intake and nutritional parameters were compared in 82 children in 2000 and 2003, respectively before and after the introduction of a NST. Predictive factors of a delay to achieve the SOCI were identified using multivariate analysis., Results: There was no difference in 2000 and 2003, respectively, regarding cumulative caloric deficits (19+/-15.7 vs. 20.7+/-14.8 kcal/kg day), cumulative protein deficits (0.26+/-0.31 vs. 0.22+/-0.20 g/kg day), time to achieve a SOCI (7 vs. 7 days). Factors at admission associated with a delay to achieve a SOCI were a pediatric risk of mortality (PRISM) score > 10 (hazard ratio 0.58; 95% CI 0.44-0.77), a CRP > 50 mg/L (hazard ratio 0.49; 95% CI 0.35-0.70), a fluid restriction (hazard ratio 0.51; 95% CI 0.37-0.71), and a weight for age > 3rd centile (hazard ratio 0.54; 95% CI 0.41-0.72)., Conclusions: The intervention of a NST has not modified significantly the nutritional management. In pediatric intensive care, many factors identified at admission are associated with impairing appropriate nutrition.

The authors conducted a retrospective analysis of the patients admitted to a pediatric intensive care unit (PICU) during a five-year period, with specific focus on those with a suspected or confirmed diagnosis of inborn errors of metabolism (IEM), in order to ascertain the resources required to care for these patients. Medical records were reviewed for all admissions between January 1998 and December 2002 in a single metabolic referral center, and a subset of patients were identified with suspected IEM at admission or diagnosed IEM at hospital discharge. These patient charts were then further reviewed and the following information was extracted: IEM diagnosis, demographic data, biochemical characteristics at admission, need for mechanical ventilation, use of extracorporeal removal therapy, and outcome at PICU discharge. The study population comprised 70 patients (2.2% of all admissions during the study period) and included 33 neonates and 37 children aged >28 days. IEM diagnosis was known at the time of admission to the PICU in 9/33 of the neonates and 23/37 of the older children. Forty-three of the patients required invasive mechanical ventilation, while continuous extracorporeal removal therapy was used in 27 children. The median length of PICU stay was 3 days (range, 1 to 13 days) and 20 patients (28.6%) died. In conclusion, these observations show that inherited metabolic disease may be as frequent a primary diagnosis as septic shock in some PICUs. In neonates, these diseases are not usually diagnosed prior to PICU admission. Patients with IEM admitted to a PICU require aggressive support (including mechanical ventilation and extracorporeal removal therapies), and consume significant resources for relatively short PICU stays. These patients constitute a significant diagnostic and therapeutic challenge for pediatric intensivists.

Objective: The aim of this survey was to characterize the physiological limits considered appropriate during weaning from mechanical ventilation in children., Design: Two hundred twenty-two (222) intensivists from 63 pediatric intensive care units (PICUs) were asked to provide the limits they considered acceptable for respiratory rate (RR), tidal volume (V(T)) and end-tidal CO(2) (PetCO(2)) during weaning from mechanical ventilation of a 3-month-old, a 2-year-old and a 10-year-old patient., Setting: Pediatric intensivists working in Canada, France, Switzerland and Belgium., Patients: None., Interventions: None., Results: Ninety-seven intensivists (43%) from 49 PICUs responded to the survey. The median minimal RR (25th;75th percentile) was: 20 breaths per minute (bpm) (15;25) for the 3-month-old, 15 bpm (10;15) for the 2-year-old and 10 bpm (10;15) for the 10-year-old patient. The median maximal RR was 50 bpm (40;60) for the 3-month-old, 40 bpm (30;40) for the 2-year-old and 30 bpm (30;40) for the 10-year-old child. The median minimal V(T) was 5 ml/kg (4;6) for the 3-month-old and 2-year-old patients and 5 ml/kg (5;6) for the 10-year-old. The median maximal PetCO(2) was 55 mmHg (50;60) for the 3-month-old, 50 mmHg (45;50) for the 2-year-old and 50 mmHg (50;55) for the 10-year-old., Conclusion: This survey indicated that acceptable weaning limits are broad, as stated by the responders. We need to organize and consolidate our thinking on weaning children from mechanical ventilation before guidelines can be established.