Search

Background: Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non‐invasive ventilation (NIV) associated with mechanical insufflation–exsufflation (MI‐E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI‐E to improve the postoperative outcome of NMD children (IT‐NEUMA‐Ped). Method: We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals. Results: We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2‐14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS. Conclusion: Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI‐E can help in preventing and resolve PPCs. [ABSTRACT FROM AUTHOR]

The objective was to assess the incidence of sepsis, severe sepsis and septic shock and their mortality in Italian Pediatric Intensive Care Units (PICUs). This is a prospective, observational, multi-center, 1-year study. Fifteen medical-surgical PICUs participated in this study. Two-thousand and seven hundred and forty-one children (2,741), aged 0–16 years, who were consecutively admitted in the participating PICUs, from 1 March 2004 to 28 February 2005, were enrolled in the study. There were no interventions in this study. Data on infection, systemic inflammatory response syndrome (SIRS), severe sepsis and septic shock were collected using criteria defined by Proulx in 1996. Sepsis-related diagnosis was stratified for five age groups (neonates, infant, preschool, school, adolescent) and type of admission (medical, surgical, trauma). The presence of existing comorbidities has been considered for children with and without sepsis diagnosis. The results showed a lower overall incidence of sepsis, severe sepsis and septic shock (7.9, 1.6 and 2.1%, respectively) if compared with other studies. Children with sepsis diagnosis had a higher morbidity and higher mortality than those without sepsis. Severe sepsis and septic shock had a mortality rate of 17.7 and 50.8%, respectively. Mortality is significantly higher for children with existing comorbidities than those without existing comorbidities. Septic shock mortality is still high in Italian PICUs and attempts to improve medical treatment are necessary. We suggest that application of the new definitions for sepsis diagnosis and diffusion of guidelines for early recognition and aggressive treatment of severe sepsis and septic shock in Italy represent a high priority to reduce mortality. The descriptor is pediatrics. [ABSTRACT FROM AUTHOR]

Objectives: To assess the performance of the Pediatric Index of Mortality (PIM) 2 score in Italian pediatric intensive care units (PICUs).Design: Prospective, observational, multicenter, 1-year study.Setting: Eighteen medical-surgical PICUs.Patients: Consecutive patients (3266) aged 0-16 years admitted between 1 March 2004 and 28 February 2005.Interventions: None.Measurements and Main Results: To assess the performance of the PIM2 score, discrimination and calibration measures were applied to all children admitted to the 18 PICUs, in the entire population and in different groups divided for deciles of risk, age and admission diagnosis. There was good discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.89 (95% CI 0.86-0.91) and good calibration of the scoring system [non-significant differences between observed and predicted deaths when the population was stratified according to deciles of risk (chi2 9.86; 8 df, p = 0.26) for the whole population].Conclusions: The PIM2 score performed well in this sample of the Italian pediatric intensive care population. It may need to be reassessed in the injury and postoperative groups in larger studies. [ABSTRACT FROM AUTHOR]

This prospective, multicenter, epidemiological study was carried out in 99 Italian ICUs, distributed throughout the country, from April 1993 to March 1994. In the study, we applied the new ACCP/SCCM classification system for sepsis (SIRS, sepsis, severe sepsis and septic shock) and determined the prevalence, incidence, evolution and outcome of these categories in critically ill patients. The preliminary analysis of 1101 patients showed that on admission SIRS accounted for about half of the diagnoses (52%) with sepsis, severe sepsis and septic shock accounting for 4.5%, 2.1% and 3% of patients, respectively. Patients with severe sepsis or septic shock more frequently had high SAPS scores than patients without sepsis. Mortality rates were similar in patients with SIRS (26.5%) and without SIRS or infection (24%), but rose to 36% in patients with sepsis, to 52% in those with severe sepsis and to 81.8% in those with septic shock. Sepsis, severe sepsis and septic shock were more common in patients with medical diagnoses, and neither severe sepsis nor septic shock was observed in trauma patients. With respect to evolution, the incidence of septic shock was progressively higher in patients admitted with more severe "sepsis-related" diagnoses, while only a trivial difference in rates of incidence was observed between SIRS patients and those admitted without SIRS or any septic disorder (nil). The breakdown of the various ACCP/SCCM "sepsis-related" diagnoses at any time during the study was: SIRS in 58% of the population, sepsis in 16.3%, severe sepsis in 5.5% and septic shock in 6.1%. It seems reasonable to expect from the final evaluation of our study answers to the questions raised by the ACCP/SCCM Consensus Conference about the correlations between "sepsis-related" diagnosis, severity score, organ dysfunction score and outcome. [ABSTRACT FROM AUTHOR]

Objectives: We aim to describe the use of continuous infusion of neuromuscular blocking agents in mechanically ventilated critically ill children and to test its association with in-hospital mortality.Design: Multicenter, registry-based, observational, two-cohort-comparison retrospective study using prospectively collected data from a web-based national registry.Setting: Seventeen PICUs in Italy.Patients: We included children less than 18 years who received mechanical ventilation and a neuromuscular blocking agent infusion from January 2010 to October 2017. A propensity score-weighted Cox regression analysis was used to assess the relationship between the use of neuromuscular blocking agents and in-hospital mortality.Interventions: None.Measurements and Main Results: Of the 23,227 patients admitted to the PICUs during the study period, 3,823 patients were included. Patients who received a continuous infusion of neuromuscular blocking agent were more likely to be younger (p < 0.001), ex-premature (p < 0.001), and presenting with less chronic respiratory insufficiency requiring home mechanical ventilation (p < 0.001). Reasons for mechanical ventilation significantly differed between patients who received a continuous infusion of neuromuscular blocking agent and patients who did not receive a continuous infusion of neuromuscular blocking agent, with a higher frequency of respiratory and cardiac diagnosis among patients who received neuromuscular blocking agents compared with other diagnoses (all p < 0.001). The covariates were well balanced in the propensity-weighted cohort. The mortality rate significantly differed among the two cohorts (patients who received a continuous infusion of neuromuscular blocking agent 21% vs patients who did not receive a continuous infusion of neuromuscular blocking agent 11%; p < 0.001 by weighted logistic regression). Patients who received a continuous infusion of neuromuscular blocking agent experienced longer mechanical ventilation and PICU stay (both p < 0.001 by weighted logistic regression). A weighted Cox regression analysis found the use of neuromuscular blocking agents to be a significant predictor of in-hospital mortality both in the unadjusted analysis (hazard ratio, 1.7; 95% CI, 1.3-2.2) and in the adjusted one (hazard ratio, 1.6; 95% CI, 1.2-2.1).Conclusions: Thirteen percent of mechanically ventilated children in PICUs received neuromuscular blocking agents. When adjusting for selection bias with a propensity score approach, the use of neuromuscular blocking agent was found to be a significant predictor of in-hospital mortality. [ABSTRACT FROM AUTHOR]

Northern Italy has been the first European area affected by the COVID-19 pandemic and related social restrictive measures. We sought to evaluate the impact of the COVID-19 outbreak on PICU admissions in Northern Italy, using data from the Italian Network of Pediatric Intensive Care Units Registry. We included all patients admitted to 4 PICUs from 8-weeks-before to 8-weeks-after February 24 th , 2020, and those admitted in the same period in 2019. Incidence rate ratios (IRR) evaluating incidence rate differences between pre- and post-COVID-19 periods in 2020 (IRR-1), as well as between the post-COVID-19-period with the same period in 2019 (IRR-2), were computed using zero-inflated negative binomial or Poisson regression modeling. A total of 1001 admissions were included. The number of PICU admissions significantly decreased during the COVID-19 outbreak compared to pre-COVID-19 and compared to the same period in 2020 (IRR-1 0.63 [95%CI 0.50-0.79]; IRR-2 0.70 [CI 0.57-0.91]). Unplanned and medical admissions significantly decreased (IRR-1 0.60 [CI 0.46-0.70]; IRR-2 0.67 [CI 0.51-0.89]; and IRR-1 0.52, [CI 0.40-0.67]; IRR-2 0.77 [CI 0.58-1.00], respectively). Intra-hospital, planned (potentially delayed by at least 12 h), and surgical admissions did not significantly change. Patients admitted for respiratory failure significantly decreased (IRR-1 0.55 [CI 0.37-0.77]; IRR-2 0.48 [CI 0.33-0.69]).Conclusions: Unplanned and medical PICU admissions significantly decreased during COVID-19 outbreak, especially those for respiratory failure. What is Known: • Northern Italy has been the first European area affected by the COVID-19 pandemic. • Although children are relatively spared from the severe COVID-19 disease, the pediatric care system has been affected by social restrictive measures, with a reported 73-88% reduction in pediatric emergency department admissions. What is New: • Unplanned and medical PICU admissions significantly decreased during the COVID-19 outbreak compared to pre-COVID-19 and to the same period in 2019, especially those for respiratory failure. Further studies are needed to identify associated factors and new prevention strategies.

Background: Pediatric anesthesia nowadays requires specific knowledge and expertise. The Anesthesia PRactice In Children Observational Trial (APRICOT) was a European multicenter study designed for the identification of perioperative severe critical events and management. We aimed at analyzing the Italian database in an attempt to determine the practice of anesthesia and the incidence of severe critical events in Italy., Methods: Secondary analyses of the database consisted in extracting the raw data from the 25 Italian centers that participated to APRICOT. Descriptive statistics and comparison with the reference data were made for all the variables collected., Results: The study analyzed 2087 children. The Italian cohort represents 6.7% of the overall study population. Most of the children were ASA 1-2 (90.6%) and underwent a surgical procedure (62.8%). In more than 84% of the cases, anesthesia management was performed by an expert with main or frequent activity in pediatric anesthesia with on an average 15 years of experience. The overall incidence of severe critical events was 3% (95% CI: 2.2-3.8). The most frequently reported severe critical incidents were of respiratory (2%; CI: 1.4-2.6) and cardiovascular origin (0.7%; CI. 0.3-1), while drug error, anaphylaxis and bronchial aspiration were very rare. There were no reports of perioperative cardiac arrest or patients with neurological damage., Conclusions: This secondary analysis demonstrates that the incidence of severe critical incidence was lower in Italy in comparison to that reported for Europe. This low rate of critical events may be related to the high expertise and experience of the anesthesiologists in charge of the children in the Italian centres that participated to APRICOT.

Background: The only pharmacologic prophylaxis against respiratory syncytial virus (RSV) infection in preterm infants is the humanized monoclonal antibody palivizumab. After the 2014 modification of the American Academy of Pediatrics (AAP) recommendations, the Italian Medicines Agency (AIFA) limited the financial coverage for palivizumab prescriptions to otherwise healthy preterm infants with < 29 weeks of gestational age (wGA) aged < 12 months at the beginning of the 2016-2017 RSV season. However, due to the effect on disease severity and hospitalizations following this limitation, shown by several Italian clinical studies, in November 2017 AIFA reinstated the financial coverage for these infants. In this systematic review, we critically summarize the data that show the importance of palivizumab prophylaxis., Methods: Data from six Italian pediatric institutes and the Italian Network of Pediatric Intensive Care Units (TIPNet) were retrieved from the literature and considered. The epidemiologic information for infants 29-36 wGA, aged < 12 months and admitted for viral-induced acute lower respiratory tract infection were retrospectively reviewed. RSV-associated hospitalizations were compared between the season with running limitation, i.e. 2016-2017, versus 2 seasons before (2014-2015 and 2015-2016) and one season after (2017-2018) the AIFA limitation., Results: During the 2016-2017 RSV epidemic season, when the AIFA limited the financial coverage of palivizumab prophylaxis based on the 2014 AAP recommendation, the study reports on a higher incidences of RSV bronchiolitis and greater respiratory function impairment. During this season, we also found an increase in hospitalizations and admissions to the Pediatric Intensive Care Units and longer hospital stays, incurring higher healthcare costs. During the 2016-2017 epidemic season, an overall increase in the number of RSV bronchiolitis cases was also observed in infants born full term, suggesting that the decreased prophylaxis in preterm infants may have caused a wider infection diffusion in groups of infants not considered to be at risk., Conclusions: The Italian results support the use of palivizumab prophylaxis for otherwise healthy preterm (29-36 wGA) infants aged < 6 months at the beginning of the RSV season.

Background: Pediatric ARDS still represents a difficult challenge in Pediatric Intensive Care Units (PICU). Among different treatments proposed, exogenous surfactant showed conflicting results. Aim of this multicenter retrospective observational study was to evaluate whether poractant alfa use in pediatric ARDS might improve gas exchange in children less than 2 years old, according to a shared protocol., Methods: The study was carried out in fourteen Italian PICUs after dissemination of a standardized protocol for surfactant administration within the Italian PICU network. The protocol provides the administration of surfactant (50 mg/kg) divided in two doses: the first dose is used as a bronchoalveolar lavage while the second as supplementation. Blood gas exchange variations before and after surfactant use were recorded., Results: Sixty-nine children, age 0-24 months, affected by Acute Respiratory Distress Syndrome treated with exogenous porcine surfactant were enrolled. Data collection consisted of patient demographics, respiratory variables and arterial blood gas analysis. The most frequent reasons for PICU admission were acute respiratory failure, mainly bronchiolitis and pneumonia, and septic shock. Fifty-four children (78.3%) had severe ARDS (define by oxygen arterial pressure and inspired oxygen fraction ratio (P/F) < 100), 15 (21.7%) had moderate ARDS (100 < P/F < 200). PO 2 , P/F, Oxygenation Index (OI) and pH showed a significant improvement after surfactant use with respect to baseline (p < 0.001 at each included time-point for each parameter). No significant difference in blood gas variations were observed among four different subgroups of diseases (bronchiolitis, pneumonia, septic shock and others). Overall, 11 children died (15.9%) and among these, 10 (90.9%) had complex chronic conditions. Two children (18.2%) died while being treated with Extracorporeal Membrane Oxygenation (ECMO). Mortality for severe pARDS was 20.4%., Conclusion: The use of porcine Surfactant improves oxygenation, P/F ratio, OI and pH in a population of children with moderate or severe pARDS caused by multiple diseases. A shared protocol seems to be a good option to obtain the same criteria of enrollment among different PICUs and define a unique way of use and administration of the drug for future studies.

Objectives: To translate and validate the EMpowerment of PArents in THe Intensive Care questionnaire to measure parent satisfaction and experiences in Italian PICUs., Design: Prospective, multicenter study., Setting: Four medical/surgical Italian PICUs in three tertiary hospitals., Patients: Families of children, 0-16 years old, admitted to the PICUs were invited to participate. Inclusion criteria were PICU length of stay greater than 24 hours and good comprehension of Italian language by parents/guardians. Exclusion criteria were readmission within 6 months and parents of a child who died in the PICU., Interventions: Distribution, at PICU discharge, of the EMpowerment of PArents in THe Intensive Care questionnaire with 65 items divided into five domains and a six-point rating scale: 1 " certainly no" to 6 "certainly yes.", Measurements and Main Results: Back and forward translations of the EMpowerment of PArents in THe Intensive Care questionnaire between Dutch (original version) and Italian languages were deployed. Cultural adaptation of the instrument was confirmed by a consultation with a representative parent group (n = 10). Totally, 150 of 190 parents (79%) participated in the study. On item level, 12 statements scored a mean below 5.0. The Cronbach's α, measured for internal consistency, on domain level was between 0.67 and 0.96. Congruent validity was measured by correlating the five domains with four gold standard satisfaction measures and showed adequate correlations (rs, 0.41-0.71; p < 0.05). No significant differences occurred in the nondifferential validity testing between three children's characteristics and the domains; excepting parents with a child for a surgical and planned admission were more satisfied on information and organization issues., Conclusions: The Italian version of the EMpowerment of PArents in THe Intensive Care questionnaire has satisfactory reliability and validity estimates and seems to be appropriate for Italian PICU setting. It is an important instrument providing benchmark data to be used in the process of quality improvement toward the development of a family-centered care philosophy within Italian PICUs.

Objective: To evaluate the performance of the newest version of the Pediatric Index of Mortality 3 score and compare it with the Pediatric Index of Mortality 2 in a multicenter national cohort of children admitted to PICU., Design: Retrospective, prospective cohort study., Setting: Seventeen Italian PICUs., Patients: All children 0 to 15 years old admitted in PICU from January 2010 to October 2014., Interventions: None., Measurement and Main Results: Eleven thousand one hundred nine children were enrolled in the study. The mean Pediatric Index of Mortality 2 and 3 values of 4.9 and 3.9, respectively, differed significantly (p < 0.05). Overall mortality rate was 3.9%, and the standardized mortality ratio was 0.80 for Pediatric Index of Mortality 2 and 0.98 for Pediatric Index of Mortality 3 (p < 0.05). The area under the curve of the receiver operating characteristic curves was similar for Pediatric Index of Mortality 2 and Pediatric Index of Mortality 3. The Hosmer-Lemeshow test was not significant for Pediatric Index of Mortality 3 (p = 0.21) but was highly significant for Pediatric Index of Mortality 2 (p < 0.001), which overestimated death mainly in high-risk categories., Conclusions: Mortality indices require validation in each country where it is used. The new Pediatric Index of Mortality 3 score performed well in an Italian population. Both calibration and discrimination were appropriate, and the score more accurately predicted the mortality risk than Pediatric Index of Mortality 2.

Objective: To assess how clinical practice of noninvasive ventilation has evolved in the Italian PICUs., Design: National, multicentre, retrospective, observational cohort., Setting: Thirteen Italian medical/surgical PICUs that participated in the Italian PICU Network., Patients: Seven thousand one-hundred eleven admissions of children with 0-16 years old admitted from January 1, 2011, to December 31, 2012., Interventions: None., Measurements and Main Results: Cause of respiratory failure, length and mode of noninvasive ventilation, type of interfaces, incidence of treatment failure, and outcome were recorded. Data were compared with an historical cohort of children enrolled along 6 months from November 1, 2006, to April 30, 2007, over the viral respiratory season. Seven thousand one-hundred eleven PICU admissions were analyzed, and an overall noninvasive ventilation use of 8.8% (n = 630) was observed. Among children who were admitted in the PICU without mechanical ventilation (n = 3,819), noninvasive ventilation was used in 585 patients (15.3%) with a significant increment among the three study years (from 11.6% in 2006 to 18.2% in 2012). In the endotracheally intubated group, 17.2% children received noninvasive ventilation at the end of the weaning process to avoid reintubation: 11.9% in 2006, 15.3% in 2011, and 21.6% in 2012. Noninvasive ventilation failure rate raised from 10% in 2006 to 16.1% in 2012., Conclusions: Noninvasive ventilation is increasingly and successfully used as first respiratory approach in several, but not all, Italian PICUs. The current study shows that noninvasive ventilation represents a feasible and safe technique of ventilatory assistance for the treatment of mild acute respiratory failure. Noninvasive ventilation was used as primary mode of ventilation in children with low respiratory tract infection (mainly in bronchiolitis and pneumonia), in acute on chronic respiratory failure or to prevent reintubation.

Background: Noninvasive continuous positive airway pressure (CPAP) is usually applied with a nasal or facial mask to treat mild acute respiratory failure (ARF) in infants. A pediatric helmet has now been introduced in clinical practice to deliver CPAP. This study compared treatment failure rates during CPAP delivered by helmet or facial mask in infants with respiratory syncytial virus-induced ARF., Methods: In this multicenter randomized controlled trial, 30 infants with respiratory syncytial virus-induced ARF were randomized to receive CPAP by helmet (n = 17) or facial mask (n = 13). The primary endpoint was treatment failure rate (defined as due to intolerance or need for intubation). Secondary outcomes were CPAP application time, number of patients requiring sedation, and complications with each interface., Results: Compared with the facial mask, CPAP by helmet had a lower treatment failure rate due to intolerance (3/17 [17%] vs 7/13 [54%], P = .009), and fewer infants required sedation (6/17 [35%] vs 13/13 [100%], P = .023); the intubation rates were similar. In successfully treated patients, CPAP resulted in better gas exchange and breathing pattern with both interfaces. No major complications due to the interfaces occurred, but CPAP by mask had higher rates of cutaneous sores and leaks., Conclusions: These findings confirm that CPAP delivered by helmet is better tolerated than CPAP delivered by facial mask and requires less sedation. In addition, it is safe to use and free from adverse events, even in a prolonged clinical setting., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: To date, few studies have been published regarding the number of children in Italy who require long-term mechanical ventilation (LTV) and their underlying diagnoses, ventilatory needs and hospital discharge rate., Methods: A preliminary national postal survey was conducted and identified 535 children from 57 centers. Detailed data were then obtained for 378 children from 30 centers., Results: The estimated prevalence in Italy of this population was 4.3/100000. The majority of children (72.2%) were followed in pediatric units. The primary physicians who cared for these patients were either pediatric intensivists or pediatric pulmonologists. Neurological patients (78.2% of cases) represented the principal disorder category. 57.2% of the patients were non-invasively ventilated, with a nasal mask being the most common interface (85% of cases). The presence of clinical symptoms that were associated with abnormal findings on diagnostic testing was the primary indication for ventilatory support, whereas weaning failure was the primary indication for tracheotomy. Invasive ventilation was significantly related to younger age, longer daily hours on ventilation and cerebral palsy. Ventilatory modes with guaranteed minimal tidal volume were more often used in patients with tracheotomy. Despite their age, illness severity and need for technological care, 98% of the study population were successfully home discharged., Conclusion: Managing pediatric home LTV requires tremendous effort on the part of the patient's family and places a significant strain on community financial resources. In particular, neurological patients require more health care than patients in other categories. To further improve the quality of care for these patients, it is essential to establish a dedicated national database.

Background: Improved technology, as well as professional and parental awareness, enable many ventilator-dependent children to live at home. However, the profile of this growing population, the quality and adequacy of home care, and patients' needs still require thorough assessment., Objectives: To define the characteristics of Italian children receiving long-term home mechanical ventilation (HMV) in Italy., Methods: A detailed questionnaire was sent to 302 National Health Service hospitals potentially involved in the care of HVM in children (aged <17 years). Information was collected on patient characteristics, type of ventilation, and home respiratory care., Results: A total of 362 HMV children was identified. The prevalence was 4.2 per 100,000 (95% CI: 3.8-4.6), median age was 8 years (interquartile range 4-14), median age at starting mechanical ventilation was 4 years (1-11), and 56% were male. The most frequent diagnostic categories were neuromuscular disorders (49%), lung and upper respiratory tract diseases (18%), hypoxic (ischemic) encephalopathy (13%), and abnormal ventilation control (12%). Medical professionals with nurses (for 62% of children) and physiotherapists (20%) participated in the patients' discharge from hospital, though parents were the primary care giver, and in 47% of cases, the sole care giver. Invasive ventilation was used in 41% and was significantly related to young age, southern regional residence, longer time spent under mechanical ventilation, neuromuscular disorders, or hypoxic (ischemic) encephalopathy., Conclusions: Care and technical assistance of long-term HMV children need assessment, planning, and resources. A wide variability in pattern of HMV was found throughout Italy. An Italian national ventilation program, as well as a national registry, could be useful in improving the care of these often critically ill children., (Copyright © 2011 Wiley-Liss, Inc.)