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Objectives: Ventilator-associated pneumonia (VAP) is a severe care-related disease. The Centers for Disease Control defined the diagnosis criteria; however, the pediatric criteria are mainly subjective and retrospective. Clinical decision support systems have recently been developed in healthcare to help the physician to be more accurate for the early detection of severe pathology. We aimed at developing a predictive model to provide early diagnosis of VAP at the bedside in a pediatric intensive care unit (PICU). Methods: We performed a retrospective single-center study at a tertiary-care pediatric teaching hospital. All patients treated by invasive mechanical ventilation between September 2013 and October 2019 were included. Data were collected in the PICU electronic medical record and high-resolution research database. Development of the clinical decision support was then performed using open-access R software (Version 3.6.1®). Measurements and main results: In total, 2077 children were mechanically ventilated. We identified 827 episodes with almost 48 h of mechanical invasive ventilation and 77 patients who suffered from at least one VAP event. We split our database at the patient level in a training set of 461 patients free of VAP and 45 patients with VAP and in a testing set of 199 patients free of VAP and 20 patients with VAP. The Imbalanced Random Forest model was considered as the best fit with an area under the ROC curve from fitting the Imbalanced Random Forest model on the testing set being 0.82 (95% CI: (0.71, 0.93)). An optimal threshold of 0.41 gave a sensitivity of 79.7% and a specificity of 72.7%, with a positive predictive value (PPV) of 9% and a negative predictive value of 99%, and with an accuracy of 79.5% (95% CI: (0.77, 0.82)). Conclusions: Using machine learning, we developed a clinical predictive algorithm based on clinical data stored prospectively in a database. The next step will be to implement the algorithm in PICUs to provide early, automatic detection of ventilator-associated pneumonia. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To describe antibiotic treatment durations that pediatric infectious diseases (ID) and critical care clinicians usually recommend for bloodstream infections in critically ill children. Design: Anonymous, online practice survey using five common pediatric-based case scenarios of bloodstream infections. Setting: Pediatric intensive care units in Canada, Australia and New Zealand. Participants: Pediatric intensivists, nurse practitioners, ID physicians and pharmacists. Main outcome measures: Recommended treatment durations for common infectious syndromes associated with bloodstream infections and willingness to enrol patients into a trial to study treatment duration. Results: Among 136 survey respondents, most recommended at least 10 days antibiotics for bloodstream infections associated with: pneumonia (65%), skin/soft tissue (74%), urinary tract (64%) and intra-abdominal infections (drained: 90%; undrained: 99%). For central vascular catheter-associated infections without catheter removal, over 90% clinicians recommended at least 10 days antibiotics, except for infections caused by coagulase negative staphylococci (79%). Recommendations for at least 10 days antibiotics were less common with catheter removal. In multivariable linear regression analyses, lack of source control was significantly associated with longer treatment durations (+5.2 days [95% CI: 4.4–6.1 days] for intra-abdominal infections and +4.1 days [95% CI: 3.8–4.4 days] for central vascular catheter-associated infections). Most clinicians (73–95%, depending on the source of bloodstream infection) would be willing to enrol patients into a trial of shorter versus longer antibiotic treatment duration. Conclusions: The majority of clinicians currently recommend at least 10 days of antibiotics for most scenarios of bloodstream infections in critically ill children. There is practice heterogeneity in self-reported treatment duration recommendations among clinicians. Treatment durations were similar across different infectious syndromes. Under appropriate clinical conditions, most clinicians would be willing to enrol patients into a trial of shorter versus longer treatment for common syndromes associated with bloodstream infections. [ABSTRACT FROM AUTHOR]

Background: Bloodstream infections (BSIs) cause significant morbidity and mortality in critically ill children but treatment duration is understudied. We describe the durations of antimicrobial treatment that critically ill children receive and explore factors associated with treatment duration.Methods: We conducted a retrospective observational cohort study in six pediatric intensive care units (PICUs) across Canada. Associations between treatment duration and patient-, infection- and pathogen-related characteristics were explored using multivariable regression analyses.Results: Among 187 critically ill children with BSIs, the median duration of antimicrobial treatment was 15 (IQR 11-25) days. Median treatment durations were longer than two weeks for all subjects with known sources of infection: catheter-related 16 (IQR 11-24), respiratory 15 (IQR 11-26), intra-abdominal 20 (IQR 14-26), skin/soft tissue 17 (IQR 15-33), urinary 17 (IQR 15-35), central nervous system 33 (IQR 15-46) and other sources 29.5 (IQR 15-55) days. When sources of infection were unclear, the median duration was 13 (IQR 10-16) days. Treatment durations varied widely within and across PICUs. In multivariable linear regression, longer treatment durations were associated with severity of illness (+ 0.4 days longer [95% confidence interval (CI), 0.1 to 0.7, p = 0.007] per unit increase in PRISM-IV) and central nervous system infection (+ 17 days [95% CI, 6.7 to 27.4], p = 0.001). Age and pathogen type were not associated with treatment duration.Conclusions: Most critically ill children with BSIs received at least two weeks of antimicrobial treatment. Further study is needed to determine whether shorter duration therapy would be effective for selected critically ill children. [ABSTRACT FROM AUTHOR]

This article describes a new approach for quantitative evaluation of respiration in the pediatric intensive care unit (PICU). Video sequences of thorax movements are recorded by two depth cameras to cover the 3-D surface of the torso and its lateral sides. The breathing activity implies a frame-by-frame surface deformation, which can be described by the volume variation of reconstructed surfaces between the consecutive video frames. A quantitative evaluation of the breathing pattern is then performed through a subtraction technique, thereby detecting the volume variation between the subsequent frames. A high-fidelity simulation was performed in a realistic environment designed for critically ill children. The simulation was then followed by a real-world evaluation, involving two newborn babies (one female and one male) who required ventilator support. The breathing signal patterns resulting from our approach were compared to those measured by mechanical ventilation in terms of their waveforms, evaluating the most significant dynamic parameters: tidal volume, respiratory rate, and minute ventilation. Our experimental study showed a significant agreement between the proposed 3-D imaging system and the gold standard method in estimating respiratory waveforms and parameters. This article presents the following innovations. First, we suggest a 3-D imaging system specifically designed for PICUs based on a contactless design. Second, we propose an efficient positioning mechanism for the cameras, offering a very high spatial coverage of the thoracoabdominal zone and considering the PICU constraints. Finally, we propose an objective vision-based method to quantitatively measure respiration for spontaneous breathing patients in PICUs. [ABSTRACT FROM AUTHOR]

Background: We aimed (1) to describe the characteristics of patient-ventilator asynchrony in a population of critically ill children, (2) to describe the risk factors associated with patient-ventilator asynchrony, and (3) to evaluate the association between patient-ventilator asynchrony and ventilator-free days at day 28. Methods: In this single-center prospective study, consecutive children admitted to the PICU and mechanically ventilated for at least 24 h were included. Patient-ventilator asynchrony was analyzed by comparing the ventilator pressure curve and the electrical activity of the diaphragm (Edi) signal with (1) a manual analysis and (2) using a standardized fully automated method. Results: Fifty-two patients (median age 6 months) were included in the analysis. Eighteen patients had a very low ventilatory drive (i.e., peak Edi < 2 µV on average), which prevented the calculation of patient-ventilator asynchrony. Children spent 27% (interquartile 22-39%) of the time in conflict with the ventilator. Cycling-off errors and trigger delays contributed to most of this asynchronous time. The automatic algorithm provided a NeuroSync index of 45%, confirming the high prevalence of asynchrony. No association between the severity of asynchrony and ventilator-free days at day 28 or any other clinical secondary outcomes was observed, but the proportion of children with good synchrony was very low. Conclusion: Patient-ventilator interaction is poor in children supported by conventional ventilation, with a high frequency of depressed ventilatory drive and a large proportion of time spent in asynchrony. The clinical benefit of strategies to improve patient-ventilator interactions should be evaluated in pediatric critical care. [ABSTRACT FROM AUTHOR]

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 (EAdi) 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. EAdi 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 EAdi 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The authors assessed the efficiency, tolerance and outcome of neonates and children with maple syrup urine disease (MSUD) in acute decompensation managed by endogenous and extracorporeal removal of accumulated MSUD metabolites. Design: Single center cohort study. Setting: Pediatric and neonatal intensive care unit in a tertiary care hospital. Patients: Between January, 1991, and June, 1999, six neonates and six children in acute decompensation of MSUD were included in the study. Each of them had two of the three following criteria: comatose state, gastrointestinal intolerance, leucine plasma levels over 1700 µmol/l. Interventions: Patients were treated by combined nutrition manipulation and continuous venovenous extracorporeal removal therapies (CECRT) including hemofiltration, hemodialysis or hemodiafiltration. A clinical and biological evaluation was performed before, during and following the treatment. Results: Eleven out of the 12 patients survived. One child had two acute episodes at 6.5 and 9 years old. Eight patients recovered a normal cerebral performance category score. In all cases, plasma leucine level decreased according to a logarithmic mode within 11–24 h hemodiafiltration combined with nutritional support whereas, with nutrition alone after stopping CECRT, the decrease in leucine plasma levels was slower, following a linear mode. Eight patients were supplemented with valine and isoleucine for mean plasma values of 177±92 and 68±66, respectively. Conclusion: In severe acute decompensation of MSUD, CECRT combined with nutritional support limit central nervous system damage, by dramatically decreasing branched chain amino and keto acid levels. [ABSTRACT FROM AUTHOR]

Delirium is well-recognized in adult inpatient care. However, it is often overlooked in children, being mistaken for pain, anxiety, or age-appropriate agitation. To assess the impact of a formal teaching session on the diagnostic rates and management of pediatric delirium (PD) in a tertiary care center, we conducted a retrospective chart review of all hospitalized children diagnosed with PD between August 2003 and August 2018 at the CHU Sainte-Justine (Montreal, Canada). Diagnostic incidence and management were compared before (2003 to 2014) and after (2015 to 2018) a formal teaching session provided to pediatric residents, staff pediatricians, and intensive care physicians in December 2014. The two cohorts displayed similar demographics, PD symptomatology, PD duration (median: 2 days), and hospital stay duration (median: 11.0 and 10.5 days). However, we saw a major increase in diagnosis frequency after 2014 (from 1.84 to 7.09 cases/year). This increased diagnostic rate was most striking in the pediatric intensive care unit setting. Although symptomatic treatment with antipsychotics and alpha-2 agonists was similar between the two cohorts, patients diagnosed after 2014 were more often weaned from offending medications (benzodiazepines, anesthetics, and anticholinergics). All patients recovered fully. Formal teaching on the symptoms and management of PD was associated with an increase in diagnostic rate and an improved management of PD in our institution. Larger studies are required to assess standardized screening tools that may further enhance diagnostic rates and improve care for children with PD. [ABSTRACT FROM AUTHOR]

Highlights • A novel computer vision system for intensive care respiratory monitoring. • An efficient positioning for the cameras in an intensive care room is proposed. • Our system offers a very high spatial coverage of the thoraco-abdominal zone. • Our system is evaluated by comparison to a mechanical ventilator. • The experiments demonstrate a high performance in estimating breathing parameters. Abstract 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. [ABSTRACT FROM AUTHOR]

Background & Aims: Hyperammonemia results from reduction of hepatocyte function or enzyme of urea cycle deficiency. Hyperammonemia contributes to cerebral edema that may lead to cerebral herniation. The threshold of toxicity of ammonemia is unknown. Methods: We conducted a retrospective observational study in our pediatric intensive care unit. All children who developed hyperammonemia from January 2000 to April 2009 were included. Clinical and laboratory data at admission, specific treatments implemented, and ammonemias the first 7days after inclusion were collected. The outcome assessed was 28day mortality. Risk of mortality was estimated by a logistic regression model. Results: Ninety patients with liver failure (63.3%) and primary or secondary urea cycle defect (23.3%) were included. Patients with urea cycle defects were more likely to receive ammonia scavengers than patients with liver failure (47.6% versus 3.5%). The 28day mortality rate was 31.1%. Risk of mortality increased according to the ammonemia within 48h: odds ratio 1.5, 1.9, 3.3, 2.4 for ammonemia above 100, 150, 200, and 300μmol/L, respectively. Peak ammonemia ⩾200μmol/L within the first 48h was an independent risk factor for mortality, with greater risk found in liver failure than in urea cycle defect. Conclusions: Our study identifies a threshold of exposure to ammonia (⩾200μmol/L) above which mortality increases significantly, especially in liver failure. Specific treatments of hyperammonemia are rarely used in liver failure when compared with urea cycle defect even though use of ammonia scavengers may help to decrease ammonemia. [ABSTRACT FROM AUTHOR]