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Background: Children have been less affected by the COVID-19 pandemic, but its repercussions on pediatric illnesses may have been significant. This study examines the indirect impact of the pandemic on a population of critically ill children in the United States.Research Question: Were there significantly fewer critically ill children admitted to PICUs during the second quarter of 2020, and were there significant changes in the types of diseases admitted?Study Design and Methods: This retrospective observational cohort study used the Virtual Pediatric Systems database. Participants were 160,295 children admitted to the PICU at 77 sites in the United States during quarters 1 (Q1) and 2 (Q2) of 2017 to 2019 (pre-COVID-19) and 2020 (COVID-19).Results: The average number of admissions was similar between pre-COVID-19 Q1 and COVID-19 Q1 but decreased by 32% from pre-COVID-19 Q2 to COVID-19 Q2 (20,157 to 13,627 admissions per quarter). The largest decreases were in respiratory conditions, including asthma (1,327 subjects in pre-COVID-19 Q2 (6.6% of patients) vs 241 subjects in COVID-19 Q2 (1.8%; P < .001) and bronchiolitis (1,299 [6.5%] vs 121 [0.9%]; P < .001). The percentage of trauma admissions increased, although the raw number of trauma admissions decreased. Admissions for diabetes mellitus and poisoning/ingestion also increased. In the multivariable model, illness severity-adjusted odds of ICU mortality for PICU patients during COVID-19 Q2 increased compared with pre-COVID-19 Q2 (OR, 1.165; 95% CI, 1.00-1.357; P = .049).Interpretation: Pediatric critical illness admissions decreased substantially during the second quarter of 2020, with significant changes in the types of diseases seen in PICUs in the United States. There was an increase in mortality in children admitted to the PICU during this period. [ABSTRACT FROM AUTHOR]

BACKGROUND: High-flow nasal cannula (HFNC) has been used in the treatment of pediatric asthma, although high-quality data comparing HFNC to aerosol mask nebulizer are lacking. We hypothesized that HFNC would perform similarly to the aerosol mask for meaningful clinical outcomes in children with critical asthma. METHODS: We retrospectively reviewed the medical records of children with critical asthma (age 2-17 y) with a modified pulmonary index score (MPIS) 6 8 admitted to our pediatric ICU as part of a quality improvement project. Patients were managed with our MPIS-based, respiratory therapist-driven protocol. Subjects were divided into 2 cohorts by initial respiratory support: HFNC or aerosol mask. Data included demographics, initial respiratory support, and MPIS over time. Primary outcome was hospital length of stay (LOS). Secondary outcome was difference in MPIS over time. RESULTS: We included 171 subjects, with 104 in the HFNC group and 67 in the aerosol mask group. Median (interquartile range [IQR]) age was lower in the HFNC group (5 [IQR 4-9] vs 7 [IQR 5-10] y, P = .006)], while other demographic characteristics were similar. Initial MPIS was similar between HFNC and aerosol mask groups (11 [IQR 9-12] vs 10 [IQR 9-12], P = .15). There were no significant differences for hospital LOS (2.9 [IQR 2.1-3.9] vs 3.0 [IQR 2.3-4.4] d, P = .47), pediatric ICU LOS (1.9 [IQR 1.4-2.8] vs 1.8 [IQR 1.5-3.0] d, P = .92), or time to MPIS < 6 (1.0 [IQR 0.6-1.6] vs 1.3 [IQR 0.8-1.9) d, P = .09) between the HFNC and aerosol mask groups, respectively. Median time on continuous albuterol was shorter in the HFNC group compared to the aerosol mask group (1.0 [IQR 0.7-1.8] vs 1.5 [IQR 0.9-2.3] d, P = .048). Of note, 16 (24%) subjects in the aerosol mask group were eventually treated with HFNC. Use of a helium-oxygen mixture and noninvasive ventilation was similar between groups. CONCLUSIONS: HFNC performed similarly to aerosol mask in pediatric patients with critical asthma. [ABSTRACT FROM AUTHOR]

Background: Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU).Methods: A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities.Results: Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (n = 130) and a mortality rate of 2.8% (n = 79) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65-1.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%, p =  < 0.0001) and hyperkalemia (pre 3.2% vs. post 1.4%, p = 0.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%, p =  < 0.0001) and hypokalemia (pre 38.2% vs. post 47.2%, p =  < 0.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS.Conclusions: Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed. [ABSTRACT FROM AUTHOR]

Aim and objective: Pediatric acute liver failure (PALF) is a life-threatening condition. Extracorporeal support has been applied for toxic metabolite clearance and serves as a bridging therapy to liver transplantation (LT) or to the regeneration of the liver, but evidence for treatment approaches is still lacking in the pediatric population. We aim to report our experience on therapeutic plasma exchange with high-volume continuous renal replacement therapy (TPE + HV-CRRT) as a promising supportive treatment for PALF. Materials and methods: A total of eight PALF cases aged 9 months to 14 years, weighing 10--50 kg., who were admitted to PICU King Chulalongkorn Memorial Hospital, Thailand and treated with TPE + HV-CRRT from January 2016 to September 2019 were reviewed. Patient demographic data, indications, technical aspects, and clinical outcomes were recorded. Results: All patients who underwent TPE + HV-CRRT showed clinical improvement regarding serum bilirubin levels and coagulation studies after the therapy. Complications from the therapy were hemodynamic instability, symptomatic fluid overload, and bleeding from catheter sites. Among these, 6 (75%) patients survived with 4 (50%) successful LTs and 2 (25%) spontaneous recovery. Two children (25%) died while on the transplantation list. Conclusion: TPE + HV-CRRT can be used safely as a bridging therapy in children with PALF. As opposed to the adult population, higher volume of TPE or higher blood flow rate in pediatric patients might associate with hemodynamic instability during the procedure. [ABSTRACT FROM AUTHOR]

Aim and objective: To study the profile, indications, related complications, and predictors of decannulation and mortality in patients who underwent tracheostomy in the pediatric intensive care unit (PICU). Materials and methods: Retrospective analysis of prospectively collected data of tracheostomies was done on patients admitted at PICU. Demographics, primary diagnosis, indication of tracheostomy, and durations of endotracheal intubation, mechanical ventilation, and tracheostomy cannulation were recorded. The indication was recorded in one of the four categories--upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation, and peripheral neuromuscular disorders). Results: Two hundred ninety cases were analyzed. UAO (42%) and CNI (48.2%) were main indications in the halves of the study period, respectively. Decannulation was successful in 188 (64.8%) patients. Seventy-seven percentage UAO patients were decannulated successfully [OR (odds ratio); 95% CI (confidence interval), 2.647; 1.182--5.924, p = 0.018]. Age <1 year (0.378; 0.187--0.764; p = 0.007), nontraumatic, noninfectious central neurological diseases (0.398; 0.186--0.855; p = 0.018), and malignancy (0.078; 0.021--0.298; p <0.001), durations of posttracheostomy ventilation (0.937; 0.893--0.983; p = 0.008), and stay in the PICU (0.989; 0.979--0.999; p = 0.029) were predictors of unsuccessful decannulation. There were 91 (31.4%) deaths. Age <1 year (2.39 (1.13--5.05; p = 0.02), malignancy (17.55; 4.10--75.11; p <0.001), durations of posttracheostomy ventilation (1.06; 1.006--1.10; p = 0.028), and hospital stay (1.007; 1.0--1.013; p = 0.043) were independent predictors of mortality. Indication of UAO favored survivor (0.24; 0.09--0.57; p <0.001). Conclusion: The indications for tracheostomy in children had changed over the years. Infancy, primary diagnosis, length of posttracheostomy ventilation, and stay in the PICU and hospital were independent predictors of decannulation and mortality. What This Adds Similar to developed countries, the age at the time of tracheostomy and indication are changing. Inability to decannulate and mortality were associated with the age of a child at the time of tracheostomy, indication, medical diagnosis, and duration of postprocedure mechanical ventilation and stay in the hospital. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH2O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible. [ABSTRACT FROM AUTHOR]

The field of pediatric intensive care has come a long way, especially with the recognition that adequate sedation and analgesia form an imperative cornerstone of patient management. With various drugs available for the same, the debate continues as to which is the better: total intravenous anesthesia (TIVA) or inhalational agents. While each have their own advantages and disadvantages, in the present era of balance toward the IV agents, we should not forget the edge our volatile agents (VAs) might have in special scenarios. And ultimately as anesthesiologists, let us not forget that be it knob and dial, or syringe and plunger, our aim is to put pain to sleep and awaken a new faith to breathe. [ABSTRACT FROM AUTHOR]

Objectives: To study the impact of the implementation of the Pediatric Surviving Sepsis Campaign protocol on early recognition of sepsis, 1 -h treatment bundle and mortality. Methods: Retrospective, single-center study, before and after the implementation of the sepsis protocol. Outcomes: sepsis recognition, compliance with the 1 -h bundle (fluid resuscitation, blood culture, antibiotics), time interval to fluid resuscitation and antibiotics administration, and mortality. Patients with febrile neutropenia were excluded. The comparisons between the periods were performed using non-parametric tests and odds ratios or relative risk were calculated. Results: We studied 84 patients before and 103 after the protocol implementation. There was an increase in sepsis recognition (OR 21.5 [95% CI: 10.1-45.7]), in the compliance with the 1 -h bundle as a whole (62% x 0%), and with its three components: fluid resuscitation (OR 31.1 [95% CI: 3.9-247.2]), blood culture (OR 15.9 [95% CI: 3.9-65.2]), and antibiotics (OR 35.6 [95% CI: 8.9-143.2]). Significant reduction between sepsis recognition to fluid resuscitation (152min × 12min, p < 0.001) and to antibiotics administration (137min × 30min) also occurred. The risk of death before protocol implementation was four times greater (RR 4.1 [95% CI: 1.2-14.4]), and the absolute death risk reduction was 9%. Conclusion: Even if we considered the low precision of some estimates, the lower limits of the Confidence Intervals show that the implementation of the Pediatric Surviving Sepsis Campaign guidelines alongside a qualitive assurance initiative has led to improvements in sepsis recognition, compliance with the 1 -h treatment bundle, reduction in the time interval to fluid resuscitation and antibiotics, and reduction in sepsis mortality. [ABSTRACT FROM AUTHOR]

Multisystem inflammatory syndrome in children (MIS-C) is characterized by fever and multiorgan system dysfunction. Neurologic complications of MIS-C are not well described. We present 4 patients with MIS-C who had intracranial hypertension and discuss the unique management considerations when this occurs concurrently with significant myocardial dysfunction. [ABSTRACT FROM AUTHOR]

In 2005, the French-speaking task force on pediatric critical and emergency care [ Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws. [ABSTRACT FROM AUTHOR]

Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity.

Pediatric morbidity from meningitis remains considerable. Preventing complications is a major challenge to improve neurological outcome. Seizures may reveal the meningitis itself or some complications of this disease. Amplitude-integrated electroencephalography (aEEG) is gaining interest for the management of patients with acute neurological distress, beyond the neonatal age. This study aimed at evaluating the predictive value of aEEG monitoring during the acute phase in meningitis among a population of infants hospitalized in the pediatric intensive care unit (PICU), and at assessing the practicability of the technique. AEEG records of 25 infants younger than one year of age hospitalized for meningitis were retrospectively analyzed and correlated to clinical data and outcome. Recording was initiated, on average, within the first six hours for n = 18 (72%) patients, and overall quality was considered as good. Occurrence of seizure, of status epilepticus, and the background pattern were significantly associated with unfavorable neurological outcomes. AEEG may help in the management and prognostic assessment of pediatric meningitis. It is an easily achievable, reliable technique, and allows detection of subclinical seizures with minimal training. However, it is important to consider the limitations of aEEG, and combinate it with conventional EEG for the best accuracy.

Background: The purpose of this study is to assess the roles of pediatric surgeons and adult trauma surgeons in the management of pediatric torso trauma patients in a Level I adult trauma center. Methods: From 2015 to 2019, pediatric torso trauma patients (age < 18 years) were studied. A comparison between patients who did and did not undergo surgery was performed. Older children (age: 10–18 years) were compared with young adults (age: 18–35 years) selected with the same criteria using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Results: A total of 226 patients were included in the study. Patients who underwent surgery for torso trauma (N = 61) were significantly older than patients who did not undergo surgery (N = 165) (13.1 vs. 10.4 years, p = 0.019). Both PSM and IPTW showed that the older children and young adult groups had similar proportions of patients requiring surgery (32.6% vs. 32.6%, standard difference (SD) = 0.000), proportions of patients who required torso angioembolization (8.7% vs. 9.8%, SD = 0.072), length of hospital stay (LOS) (8.1 vs. 8.0 days, SD = 0.026), and intensive care unit admission LOS (2.6 vs. 2.7 days, SD = 0.033). However, 7.1% of older children received critical care from pediatric surgeons. Additionally, 31.9% of younger children were cared for by pediatric surgeons/pediatricians. Conclusions: Adult trauma surgeons can feasibly perform surgeries for older children with torso trauma in collaboration with pediatric surgeons who provide critical care.

Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity. [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 24th, 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. [ABSTRACT FROM AUTHOR]

Critical care has evolved dramatically over the past 50 years for both adult and pediatric critical care patients. Most often, advances in adult critical care have led the way, with pediatrics following in a few years. The vastly larger number of critically ill or injured adults compared with children has made clinical research easier and often more feasible in adults. There are areas, however, in which pediatrics has led the way. Children and adults may respond differently to illness and injury and their treatment, contributing to differences in the evolution of critical care. The founders of the Society of Critical Care Medicine (SCCM) had the foresight to include in their vision all physician disciplines of critical care, including pediatrics, as well as the vast array of other practitioners and services contributing to patient care. The field was then in its infancy, and they set the stage for the development of this specialty, emphasizing collaboration and unified, multiprofessional teamwork as major components necessary for the rapid advancement and success in the care of the critically ill. In this article we will look at the evolution of adult and pediatric critical care, their similarities and differences, how the fields have advanced, and the challenges facing them in the future. [ABSTRACT FROM AUTHOR]

Background/aim: The purpose of this study was to evaluate the etiology, clinical characteristics, and outcome of nontraumatic coma (NTC) among children admitted to a pediatric intensive care unit (PICU). Materials and methods: A total of 159 children with NTC were included in the study. The modified Glasgow coma scale (GCS) was used to assess consciousness. Patients were classified with regard to etiology. For each patient, demographic and clinical characteristics, survival and degree of disability at PICU discharge were recorded. Results: Median age was 55 months (IQR: 17.0 - 109.0). The most common cause of NTC was neuroinfection (31.4%) followed by toxicmetabolic conditions (25.8%) and epileptic disorder (15.1%). There was no significant relationship between the level of encephalopathy at admission and NTC etiology. A total of 13 patients died (8.2%). Among the survivors, 61.6% were discharged without any neurologic deficit, 2.8% had severe neurologic disability, and 3.4% were in a vegetative state. Complete neurological recovery was significantly more common in patients with toxic metabolic disease, whereas neurological deficits were more frequent in patients with tuberculous meningo-encephalitis (P = 0.01 and P = 0.04, respectively). Higher pediatric risk of mortality III (PRISM III) score at PICU admission (Odds ratio: 1.51, 95% CI: 1.19 - 1.92; P < 0.001) was the only variable that was independently associated with mortality. The length of stay (LOS) at hospital (Odds ratio: 0.73, 95% CI: 0.58-0.91; P = 0.006) was associated with improved odds of survival. Conclusions: Although results obtained from this single-center study cannot be generalized to the pediatric population, the contribution to the literature in terms of the relationships between NTC etiology, and outcome can be crucial for clinical decision-making. We report neuroinfection as the most common cause of NTC, and the only factor that was closely associated with mortality was PRISM III score. Length of hospital stay was inversely correlated to patient mortality. [ABSTRACT FROM AUTHOR]

Background: Medication Errors (MEs) are considered the most common type of error in pediatric critical care services. Moreover, the ME rate in pediatric patients is up to three times higher than the rate for adults. Nevertheless, information in pediatric population is still limited, particularly in emergency/critical care practice. The purpose of this study was to describe and analyze MEs in the pediatric critical care services during the prescription stage in a Mexican secondary-tertiary level public hospital.Methods: A cross-sectional study to detect MEs was performed in all pediatric critical care services [pediatric emergency care (PEC), pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and neonatal intermediate care unit (NIMCU)] of a public teaching hospital. A pharmacist identified MEs by direct observation as the error detection method and MEs were classified according to the updated classification for medication errors by the Ruíz-Jarabo 2000 working group. Thereafter, these were subclassified in clinically relevant MEs.Results: In 2347 prescriptions from 301 patients from all critical care services, a total of 1252 potential MEs (72%) were identified, and of these 379 were considered as clinically relevant due to their potential harm. The area with the highest number of MEs was PICU (n = 867). The ME rate was > 50% in all pediatric critical care services and PICU had the highest ME/patient index (13.1). The most frequent MEs were use of abbreviations (50.9%) and wrong speed rate of administration (11.4%), and only 11.7% of the total drugs were considered as ideal medication orders.Conclusion: Clinically relevant medication errors can range from mild skin reactions to severe conditions that place the patient's life at risk. The role of pharmacists through the detection and timely intervention during the prescription and other stages of the medication use process can improve drug safety in pediatric critical care services. [ABSTRACT FROM AUTHOR]

Introduction: The burden of critical illness in low- and middle-income countries (LMICs) is high; however, there is a paucity of data describing pediatric critical care outcomes in this setting.Methods: We performed a prospective observational study of the pediatric (≤18 years) intensive care population in Malawi, from August 2016 to May 2018. Data collected include patient demographics and clinical data, admission criteria and outcome. A multivariate Poisson regression was performed to determine risk factors for mortality.Results: Over the study period, 499 patients were admitted to the intensive care unit (ICU) and 105 (21.0%) were children. The average age was 10.6 ± 5.4 years. Primary indications for ICU admission were sepsis (n = 30, 30.3%) and traumatic brain injury (TBI, n = 23, 23.2%). Of those who died, sepsis (n = 18, 32.7%), acute respiratory failure (n = 11, 20.0%) and TBI (n = 11, 20.0%) were the primary admission diagnoses. Overall, ICU mortality was 54.3% (n = 57). Multivariate regression for increased ICU mortality revealed: age ≤5 years [risk ratio (RR) 1.96, 95% CI 1.10-2.26, p < 0.001], hemoglobin < 10 g/dl (RR 1.58, 95% CI 1.08-2.01, p = 0.01) and shock requiring epinephrine support (RR 2.76, 95% CI 1.80-4.23, p < 0.001).Conclusions: Pediatric ICU mortality is high. Predictors of mortality were age ≤5 years, anemia at ICU admission and the need for epinephrine support. Training of pediatric intensive care specialists and increased blood product availability may attenuate the high mortality for critically ill children in Malawi. [ABSTRACT FROM AUTHOR]

Abstract Background and Aims Bronchiolitis and asthma have a clinical overlap, and it has been shown that pediatric intensive care unit (PICU) patients with asthma undergoing endotracheal intubation in a community hospital emergency room (ER) have a shorter duration of mechanical ventilation (MV) and PICU length of stay (LOS) vs children undergoing intubation in a children's hospital. We aimed to determine if the setting of intubation (community vs children's hospital ER) is associated with the duration of MV and PICU LOS among children with bronchiolitis. Methods With IRB approval, data in the Virtual Pediatric Systems (VPS, LLC) database were queried for bronchiolitis patients

Introduction Acute lower respiratory tract infections are the top cause of nonneonatal mortality in children under 5 years of age. Since many resource-limited settings lack basic pediatric respiratory support modalities, introducing respiratory technology in these settings may improve survival. Unfortunately, data suggest that many interventions in these settings are not sustainable and that after several months, local staff are no longer comfortable using newly implemented technology. Methods We aimed to create training modules for implementation of a standardized extubation process and high flow nasal cannula for physician and nurse providers at a tertiary care center in Lima, Peru. This training curriculum combined a didactic lecture with hands-on practicum and clinical case discussion over multiple sessions spanning a year. We created all materials in English and translated to Spanish for use. Participants completed evaluations after the training program to determine whether objectives were met. This training was intended for critical care providers but could be modified for other audiences. Results A total of 76 providers (12 attending/fellow critical care physicians, 40 bedside nurses, eight pediatric residents, and 14 medical technicians) participated in this multiday training. Almost all (75, 99%) participants felt the objectives were clearly stated, and 70 (92%) felt objectives were met. Discussion We have provided materials to help instructors set up and implement a standardized training curriculum with recommended timing and improvements based on feedback. The tools provided allow for adaptation depending on the instructors’ primary objectives, language of audience (English or Spanish), and learners’ level of training.

Critical care is perhaps one of the most “climate-intensive” divisions of health care. As greenhouse gas emissions continue to rise, the unprecedented threat of climate change has belatedly prompted an increased awareness of critical care's environmental impact. Within our role as pediatric critical care providers, we have a dual responsibility not only to care for children at their most vulnerable, but also to advocate on their behalf. There are clear, demonstrable effects of our worsening climate on the health of children, with the resultant increased burden of pediatric critical illness and disruption to health care systems. From increasing wildfires and their effect on lung health, to the spread of vector-borne diseases such as dengue, and the increased migration of children due to a changing climate, the effects of a changing climate are here, and we are beginning to see the changing epidemiology of pediatric critical illness. Ensuring that the effects of ongoing changes are minimized, including its future effects on child health, requires a multifaceted approach. As part of this review, we will use the Lancet Countdown on Climate Change indicators to explore the impact of pediatric critical care on climate change and the inevitable influence climate change will have on the future practice of pediatric critical care globally.

Background: Evidence supporting continuous EEG monitoring in pediatric intensive care is increasing, but continuous full-channel EEG is a scarce resource. Amplitude-integrated EEG (aEEG) monitors are broadly available in children's hospitals due to their use in neonatology and can easily be applied to older patients.Objective: The aim of this survey was to evaluate the use of amplitude-integrated EEG in German and Swiss pediatric intensive care units (PICUs).Design: An online survey was sent to German and Swiss PICUs that were identified via databases provided by the German Pediatric Association (DGKJ) and the Swiss Society of Intensive Care (SGI). The questionnaire contained 18 multiple choice questions including the PICU size and specialization, indications for aEEG use, perceived benefits from aEEG, and data storage.Main results: Forty-three (26%) PICUs filled out the questionnaire. Two thirds of all interviewed PICUs use aEEG in non-neonates. Main indications were neurological complications or disease and altered mental state. Features assessed were mostly seizures and side differences, less frequently height of amplitude and background pattern. Interpretation of raw EEG also played an important role. All interviewees would appreciate the establishment of reference values for toddlers and children.Conclusions: aEEG is used in a large proportion of the interviewed PICUs. The wide-spread use without validation of data generates the need for further evaluation of this technique and the establishment of reference values for non-neonates.

Conventional echocardiography is an essential tool for the diagnosis, bedside management and follow-up evaluations of children with multisystem inflammatory syndrome associated with COVID-19. However, a more comprehensive echocardiographic exam, including myocardial deformation parameters, may allow early identification of subtle changes in ventricular function, provide risk stratification and, identify sub-clinical cardiac dysfunction at follow-up. Thus, myocardial deformation analysis should be routinely integrated to conventional echocardiography assessment in these patients.

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Objectives: Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation.Design: Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry.Setting: Thirteen PICUs (in 12 institutions) in the United States and Canada.Patients: All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation.Interventions: None.Measurements and Main Results: Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events.Conclusions: Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Tracheal intubation by respiratory therapists (RTs) is a well-established practice that has been described primarily in adult and neonatal patients. However, minimal data exist regarding RTs' intubation performance in pediatric ICUs. The purpose of this study was to describe the current landscape of intubations performed by RTs in pediatric ICUs. METHODS: A multicenter quality improvement database, the National Emergency Airway Registry for Children (NEAR4KIDs) was queried from 2015 to 2018. We performed a retrospective analysis of prospectively collected data on subject demographics, indication for intubation, difficult airway history and feature presence, provider discipline, medications, and device. Intubation outcomes included first-attempt and overall success rates, adverse events, and oxygen desaturation (ie, SpO2 < 80%). Overall intubation success was defined as intubation achieved in ≤ 2 attempts. RESULTS: There were 12,056 initial intubation encounters from 46 ICUs, with 109 (0.9%) first attempts performed by RTs. Nine (20%) ICUs reported at least one intubation encounter by RTs. The number of intubations performed by RTs at individual centers ranged from 1 to 46 (RT participation rate: 0.3% to 19.6%). RTs utilized video laryngoscopy more often than other providers (53.2% for RTs vs 28.1% for others, P < .001). RTs' first attempt success (RT 60.6% vs other 69.2%, P = .051), overall success (RT 76.2 % vs other 82.4%, P = .087), and oxygen desaturation SpO2 < 80% (RT 16.5% vs other 16.9%, P = .91) were similar to other providers. Adverse events were more commonly reported in intubations by RTs versus by other providers (22.9% vs 13.8%, P = .006). CONCLUSIONS: RTs infrequently intubate in pediatric ICUs, with success rates similar to other providers but higher adverse event rates. RTs were more likely to use video laryngoscopy than other providers. RTs' intubation participation, success, and adverse event rates varied greatly across pediatric ICUs. [ABSTRACT FROM AUTHOR]

Background: The SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) coronavirus has emerged as a highly contagious respiratory pathogen causing severe acute lung injury. Extracorporeal membrane oxygenation is a standard tool for the management of life-threatening acute respiratory distress syndrome, but the use of this resource-intensive therapy has come into question due to strained medical systems and limited proven treatments for COVID-19. Case summary: A 16-year-old female with obesity presented with fever, myalgias, cough, and tachypnea and was diagnosed with COVID-19. She progressed to severe pediatric acute respiratory distress syndrome requiring intubation on hospital day 4 and cannulation to veno-venous extracorporeal membrane oxygenation on hospital day 6. The patient received remdesivir, steroids, and anakinra. The patient was successfully decannulated on hospital day 12 and was discharged home on hospital day 21. Conclusion: We report the use of veno-venous extracorporeal membrane oxygenation as a bridge to lung recovery in a pediatric patient with severe pediatric acute respiratory distress syndrome due to COVID-19. [ABSTRACT FROM AUTHOR]

Objectives: Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients.Design: A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018.Setting: Forty-six international PICUs.Patients: Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU.Interventions: None.Measurements and Main Results: The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001).Conclusions: Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies. [ABSTRACT FROM AUTHOR]

Background:Postintensive care syndrome (PICS) is well-defined in the adult literature but has not received much attention in pediatrics. Introduction:We sought to use a telemedicine platform for the characterization of PICS by creating a convenient and effective virtual follow-up clinic. Materials and Methods:Prospective single-center study in a pediatric intensive care unit (ICU) of patients aged 4–17 years who underwent any invasive procedures while admitted to the ICU. Parents completed the Weiss Functional Impairment Rating Scale (WFIRS) based on baseline behaviors before ICU admission, with the scale readministered at 1 week, 1 month, and 3 months postdischarge via secure telehealth platform. Patients with a WFIRS baseline raw score of 10 or an interval increase of 2 were referred to psychiatry for evaluation and treatment. Results:Fifty patients were enrolled. Risk factors for PICS included number of procedural interventions, length of pediatric ICU stay, number of specialty consults, sex, race, and duration of sedation/airway instrumentation. In univariate analysis, age appeared to be the only statistically significant factor associated with the development of PICS. Variables associated with a higher change in WFIRS score showed a statistically significant correlation with the number of procedures completed, the number of specialists involved, and the need for a psychiatric referral. Only 34% of total telemedicine follow-ups were completed. Discussion:There is an association between age and the development of PICS and between change in WFIRS score and number of procedures, specialist involved, and psychiatric referral. Conclusions:The use of telemedicine did not result in an improved follow-up rate when compared to outpatient clinic studies. [ABSTRACT FROM AUTHOR]

Background: Communication between clinicians and families of dying children in the pediatric intensive care unit (PICU) is critically important for optimal care of the child and the family. Objective: We examined the current state of clinician perspective on communication with families of dying children in the PICU. Design: Prospective case series over a 15-month study period. Setting/Subjects: We surveyed nurses, psychosocial staff, and physicians who cared for dying children in PICUs at five U.S. academic hospitals. Measurements: Clinicians reported on the location of communication, perceived barriers to end-of-life care, and rated the quality of communication (QOC). Results: We collected 565 surveys from 287 clinicians who cared for 169 dying children. Clinicians reported that the majority of communication occurred at the bedside, and less commonly family conferences and rounds. Ten barriers to care were examined and were reported with frequencies of 2%–32%. QOC was rated higher when the majority of conversations occurred during family conferences (p = 0.01) and lower for patients of non-white race (p = 0.03). QOC decreased when 8 of the 10 barriers to care were reported. Conclusions: When a child is dying, clinicians report that communication with the family occurs most frequently at the child's bedside. This has important implications for future ICU communication research as the majority of previous research and education has focused on family care conferences. In addition, findings that QOC is perceived as lower for non-white patients and when clinicians perceive that barriers hindering care are present can help direct future efforts to improve communication in the PICU. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies using administrative data have demonstrated that the United States opioid epidemic is harming both adults and children, and is straining health care systems. Our objective is to describe the outcomes and trends in resource use among children with acute opioid ingestions using patient-level case report data. Materials and Methods: This study was a retrospective analysis of prospectively collected data from the 55 poison control centers in the United States which comprise the National Poison Data System (NPDS). Children under 19 years of age with a primary opioid ingestion between 1 January 2005 and 31 December 2018 were included in the analysis. Trends over three eras (2005–2009, 2010–2014, 2015–2018) were assessed using a Cochran-Armitage Trend Test. Yearly trends in the proportion of cases were calculated using generalized linear models. Multi-variable logistic regression analysis was used to calculate the adjusted odds of variables associated with having at least one Pediatric Intensive Care Unit (PICU) level intervention. Results: Children were involved in 207,543 (27.54%) of a total of 1,002,947 primary exposure-related opioid poisoning cases reported to US poison centers. The percentage of patients admitted to a critical care unit from these exposures increased in each era (6.6%, 8.5%, 9.6%). Suicidal intent increased in each era (14.0%, 15.3%, 21.2%), and was associated with increased adjusted odds of receiving a PICU procedure (OR 9.68, CI 7.97–11.76). Fentanyl (OR 12, CI 9.2–15.7), heroin (OR 11.1, CI 9.4–13.1), and methadone (OR 15, CI 13–17.3) were the opioids most associated with having a PICU procedure. Discussion and Conclusions: The severity of admissions for acute opioid ingestions, especially following attempted suicide, has increased over the studied time frame. Efforts focused on reducing access, especially to synthetic and illicit opioids, and addressing adolescent suicidality are needed to reduce these serious consequences of the opioid epidemic on children in the United States. [ABSTRACT FROM AUTHOR]

Background: Critically ill infants with congenital heart disease (CHD) are often prescribed stress ulcer prophylaxis (SUP) to prevent upper gastrointestinal bleeding, despite the low incidence of stress ulcers and limited data on the safety and efficacy of SUP in infants. Recently, SUP has been associated with an increased incidence of hospital-acquired infections, community-acquired pneumonia, and necrotizing enterocolitis. The objective of this pilot study is to investigate the feasibility of performing a randomized controlled trial to assess the safety and efficacy of withholding SUP in infants with congenital heart disease admitted to the cardiac intensive care unit.Methods: A single center, prospective, double-blinded, randomized placebo-controlled pilot feasibility trial will be performed in infants with CHD admitted to the cardiac intensive care unit and anticipated to require respiratory support for > 24 h. Patients will be randomized to receive a histamine-2 receptor antagonist (H2RA) or placebo until they are discontinued from respiratory support. Randomization will be performed within 2 strata defined by admission type (medical or surgical) and age (neonate, age < 30 days, or infant, 1 month to 1 year). Allocation will be a 1:1 ratio using permuted blocks to ensure balanced allocations across the two treatment groups within each stratum. The primary outcomes include feasibility of screening, consent, timely allocation of study drug, and protocol adherence. The primary safety outcome is the rate of clinically significant upper gastrointestinal bleeding. The secondary outcomes are the difference in the relative and absolute abundance of the gut microbiota and functional microbial profiles between the two study groups. We plan to enroll 100 patients in this pilot study.Discussion: Routine use of SUP to prevent upper gastrointestinal bleeding in infants is controversial due to a low incidence of bleeding events and concern for adverse effects. The role of SUP in infants with CHD has not been examined, and there is equipoise on the risks and benefits of withholding this therapy. In addition, this therapy has been discontinued in other neonatal populations due to the concern for hospital-acquired infections and necrotizing enterocolitis. Furthermore, exploring changes to the microbiome after exposure to SUP may highlight the mechanisms by which SUP impacts potential microbial dysbiosis of the gut and its association with hospital-acquired infections. Assessment of the feasibility of a trial of withholding SUP in critically ill infants with CHD will facilitate planning of a larger multicenter trial of safety and efficacy of SUP in this vulnerable population.Trial Registration: ClinicalTrials.gov , NCT03667703. Registered 12 September 2018, https://clinicaltrials.gov/ct2/show/NCT03667703?term=SUPPRESS+CHD&draw=2&rank=1 . All WHO Trial Registration Data Set Criteria are met in this manuscript. [ABSTRACT FROM AUTHOR]

Objectives: Developing effective therapies to reduce morbidity and mortality requires knowing the responsible pathophysiologies and the therapeutic advances that are likely to be impactful. Our objective was to determine at the individual patient level the important pathophysiological processes and needed therapeutic additions and advances that could prevent or ameliorate morbidities and mortalities.Design: Structured chart review by pediatric intensivists of PICU children discharged with significant new morbidity or mortality to determine the pathophysiologies responsible for poor outcomes and needed therapeutic advances.Setting: Multicenter study (eight sites) from the Collaborative Pediatric Critical Care Research Network of general and cardiac PICUs.Patients: First PICU admission of patients from December 2011 to April 2013.Interventions: None.Measurements and Main Results: Two-hundred ninety-two patients were randomly selected from 681 patients discharged with significant new morbidity or mortality. The median age was 2.4 years, 233 (79.8%) were in medical/surgical ICUs, 59 (20.2%) were in cardiac ICUs. Sixty-five (22.3%) were surgical admissions. The outcomes included 117 deaths and 175 significant new morbidities. The most common pathophysiologies contributing to the poor outcomes were impaired substrate delivery (n = 158, 54.1%) and inflammation (n = 104, 35.6%). There were no strong correlations between the pathophysiologies and no remarkable clusters among them. The most common therapeutic needs involved new drugs (n = 149, 51.0%), cell regeneration (n = 115, 39.4%), and immune and inflammatory modulation (n = 79, 27.1%). As with the pathophysiologies, there was a lack of strong correlations or meaningful clusters in the suggested therapeutic needs.Conclusions: There was no single dominant pathophysiology or cluster of pathophysiologies responsible for poor pediatric critical care outcomes. Therapeutic needs often involved therapies that are not close to implementation such as cell regeneration, improved organ transplant, improved extracorporeal support and artificial organs, and improved drugs. [ABSTRACT FROM AUTHOR]

The objective of this study was to identify the characteristics and tasks vital for individuals to successfully navigate a proactive rapid response role at a quaternary children's hospital. A qualitative thematic analysis of open-ended interviews was utilized to define the essential characteristics and functions of a WATCh (Watch, Assess, Triage for Children) nurse. The sample included both WATCh nurses and other healthcare providers that work with WATCh nurses. Effective WATCh nurses are excellent communicators with advanced skills who are experienced, confident, and visible. They work as an extension of the nurse and as a care facilitator for high-risk children, advocate, and educator. A more proactive approach is essential for successful pediatric rapid response teams in hospital settings to prevent patient decompensation and code blue events. This study has identified that a successful program requires defined tasks and essential role characteristics. Implications for integration into practice include a defined selection process and training program for the WATCh nurse role to provide standardization and consistency. Experience was identified as an essential characteristic for the role but an exact amount was not defined. Strong communication skills are also necessary and while training can help supplement the characteristic, a certain level of personality and confidence should be identified in potential candidates. Training will need to include not only practice skills, but also personal skills to be an effective role in the institution. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the performance of commercially available seizure detection algorithms in critically ill children.Design: Diagnostic accuracy comparison between commercially available seizure detection algorithms referenced to electroencephalography experts using quantitative electroencephalography trends.Setting: Multispecialty quaternary children's hospital in Canada.Subjects: Critically ill children undergoing electroencephalography monitoring.Interventions: Continuous raw electroencephalography recordings (n = 19) were analyzed by a neurophysiologist to identify seizures. Those recordings were then converted to quantitative electroencephalography displays (amplitude-integrated electroencephalography and color density spectral array) and evaluated by six independent electroencephalography experts to determine the sensitivity and specificity of the amplitude-integrated electroencephalography and color density spectral array displays for seizure identification in comparison to expert interpretation of raw electroencephalography data. Those evaluations were then compared with four commercial seizure detection algorithms: ICTA-S (Stellate Harmonie Version 7; Natus Medical, San Carlos, CA), NB (Stellate Harmonie Version 7; Natus Medical), Persyst 11 (Persyst Development, Prescott, AZ), and Persyst 13 (Persyst Development) to determine sensitivity and specificity in comparison to amplitude-integrated electroencephalography and color density spectral array.Measurements and Main Results: Of the 379 seizures identified on raw electroencephalography, ICTA-S detected 36.9%, NB detected 92.3%, Persyst 11 detected 75.9%, and Persyst 13 detected 74.4%, whereas electroencephalography experts identified 76.5% of seizures using color density spectral array and 73.7% using amplitude-integrated electroencephalography. Daily false-positive rates averaged across all recordings were 4.7 with ICTA-S, 126.3 with NB, 5.1 with Persyst 11, 15.5 with Persyst 13, 1.7 with color density spectral array, and 1.5 with amplitude-integrated electroencephalography. Both Persyst 11 and Persyst 13 had sensitivity comparable to that of electroencephalography experts using amplitude-integrated electroencephalography and color density spectral array. Although Persyst 13 displayed the highest sensitivity for seizure count and seizure burden detected, Persyst 11 exhibited the best trade-off between sensitivity and false-positive rate among all seizure detection algorithms.Conclusions: Some commercially available seizure detection algorithms demonstrate performance for seizure detection that is comparable to that of electroencephalography experts using quantitative electroencephalography displays. These algorithms may have utility as early warning systems that prompt review of quantitative electroencephalography or raw electroencephalography tracings, potentially leading to more timely seizure identification in critically ill patients. [ABSTRACT FROM AUTHOR]

Outcomes of conventional cardiopulmonary resuscitation are improved when the initial rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia). In children, the first documented rhythm is typically asystole or pulseless electrical activity. We evaluate the role the initial rhythm plays in outcomes for children undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest. Consecutive patients < 18 years with in-hospital ECPR events ≥ 10 minutes reported to the American Heart Association Get With The Guidelines® – Resuscitation registry from 2014 to 2019 were included. Primary outcome was survival to hospital discharge. Logistic regression modeling was used to compute propensity score matching based on patient, cardiac arrest event and hospital characteristics; patients with initial shockable rhythm were matched to patients with initial non-shockable rhythm. The final cohort included 466 patients, of which 82 (18%) had a shockable, and 384 (82%) had a non-shockable initial rhythm. After propensity score matching of 287 (62%) patients, there was no difference in survival to hospital discharge (risk ratio [RR] 1.2, 95% CI, 0.95–1.53, p = 0.13) or favorable neurologic outcome, defined as Pediatric Cerebral Performance Category (PCPC) of 1 or 2, or no decline from baseline (RR 1.28, 95% CI, 0.84–1.96, p = 0.25) between patients with and without shockable initial rhythm. In children with in-hospital cardiac arrest undergoing ECPR, there was no significant difference in survival or favorable neurologic outcome between those with initial shockable rhythm compared to non-shockable rhythm. Further investigation to evaluate ECPR patient characteristics and outcomes is warranted to help guide eligibility and ECMO deployment practices. [ABSTRACT FROM AUTHOR]

Abstract Background Despite sparse pediatric data on effectiveness, the majority of critically ill children receive medications to prevent gastrointestinal (GI) bleeding. Stress ulcer prophylaxis may have unintended consequences—increasing the risk of nosocomial infections—which may be more serious and common than the bleeding which these drugs are prescribed to prevent. Randomized controlled trials (RCTs) in pediatric critical care are exceptionally challenging to complete, thus a rigorous pilot RCT is crucial. The objective of this pilot RCT is to assess the feasibility of a large multicentre RCT of stress ulcer prophylaxis with pantoprazole to prevent upper GI bleeding vs. placebo. Methods A multi-centre blinded pilot RCT of 120 children in six Canadian PICUs. Children expected to require mechanical ventilation for more than 48 h will be randomized to receive intravenous pantoprazole 1 mg/kg or identical placebo once daily until they no longer need mechanical ventilation. We have four feasibility outcomes and will consider the trial successful if we achieve: 1. Effective screening: If >80% of eligible patients are approached for consent. 2. Timely enrollment: if >80% of participants receive their first dose of the assigned study drug within 1 day of becoming eligible. 3. Participant accrual: If the average monthly enrolment is two or more participants per centre per month. 4. Protocol adherence: if >90% of doses are administered according to the protocol. Discussion There are many uncertainties about the risks and benefits of stress ulcer prophylaxis. In an era of widespread use—where clinicians prescribe prophylaxis to the more severely ill—a large, rigorous RCT is required. A trial to determine if a strategy of withholding stress ulcer prophylaxis is not inferior to a strategy of routine stress ulcer prophylaxis will be challenging. A carefully designed and implemented pilot trial is essential. Trial registration ClinicalTrials.gov: NCT02929563 (Registered October 3, 2016).

Objective: To evaluate the safety and efficacy of moderate sedation in the Pediatric Intensive Care Unit (PICU) settings according to moderate sedation protocol using ketamine and midazolam and to determine areas for the improvement in our clinical practice. Settings and Design: A retrospective study was conducted in the PICU. Materials and Methods: Retrospective chart review was performed for patients who had received moderate sedation between January and the end of December 2011 and who are eligible to inclusion criteria. Results: In this study, 246 moderate sedation sessions were included. 5.3% were in infant age, while 94.7% were children (1-14 years). Their gender distributed as 59.8% males and 40.2% females. The majority of them had hematology-oncology disease nature, i.e., 80.89% (n = 199). Lumbar puncture accounted for 65.3% (n = 160) of the producers; the rests were bone marrow aspiration 32.7%, endoscopy 8.2%, and colonoscopy 2.9%. Two doses of ketamine (1-1.5 mg/kg) to achieve moderate sedation during the procedure were given to 44.1% (n = 108) of the patients. One dose of midazolam was given to 77.2% (n = 190), while 1.22% (n = 3) of sessions of moderate sedation was done without any dose of midazolam. Adverse events including apnea, laryngeal spasm, hypotension, and recovery agitation were observed during moderate sedation sessions, and it has been noticed in four sessions, i.e., 1.6%, which were mild to moderate and managed conservatively. Conclusion: Moderate sedation in the PICU using ketamine and midazolam is generally safe with minimal side effects as moderate sedation sessions were conducted by pediatric intensivist in highly monitored and equipped environment.