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

Acute hyperammonemia may induce a neurologic impairment leading to an acute life-threatening condition. Coma duration, ammonia peak level, and hyperammonemia duration are the main risk factors of hyperammonemia-related neurologic deficits and death. In children, hyperammonemia is mainly caused by severe liver failure and inborn errors of metabolism. In an acute setting, obtaining reliable plasma ammonia levels can be challenging because of the preanalytical difficulties that need to be addressed carefully. The management of hyperammonemia includes 1) identification of precipitating factors and cerebral edema presence, 2) a decrease in ammonia production by reducing protein intake and reversing catabolism, and 3) ammonia removal with pharmacologic treatment and, in the most severe cases, with extracorporeal therapies. In case of severe coma, transcranial Doppler ultrasound could be the method of choice to noninvasively monitor cerebral blood flow and titrate therapies. [ABSTRACT FROM AUTHOR]

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

Background: Preliminary studies suggested that Aboriginal Canadians had disproportionately higher rates of infection, hospitalization, and critical illness due to pandemic Influenza A(H1N1)pdm09. Methods: We used a prospective cohort study of critically ill patients with laboratory confirmed or probable H1N1 infection in Canada between April 16 2009 and April 12 2010. Baseline characteristics, medical interventions, clinical course and outcomes were compared between Aboriginal and non-Aboriginal patients. The primary outcome was hospital mortality. Results: Of 647 critically ill adult patients with known ethnicity, 81 (12.5%) were Aboriginal, 566 (87.5%) were non-Aboriginal. Aboriginal patients were younger (mean [SD] age 40.7[13.7] v. 49.0[14.9] years, p < 0.001) and more frequently female (64.2% v. 51.1%, p = 0.027). Rates of any co-morbid illnesses (Aboriginal v. non-Aboriginal, 92.6% v. 91.0%, p = 0.63), time from symptom onset to hospital admission (median [interquartile range] 4 [2–7] v. 4 [2–7] days, p = 0.84), time to ICU admission (5 [3–8] v.5 [3–8] days, p = 0.91), and severity of illness (mean APACHE II score (19.9 [9.6] v. 21.1 [9.9], p = 0.33) were similar. A similar proportion of Aboriginal patients received antiviral medication before ICU admission than non-Aboriginal patients (91.4% v. 93.8%, p = 0.40). Among Aboriginal versus non-Aboriginal patients, the need for mechanical ventilation (93.8% v. 88.6%, p = 0.15), ventilator-free days (14 [3–23] v. 17 [0–24], p = 0.62), durations of stay in ICU (13[7-19.5] v. 11 [5–8] days, p = 0.05), hospital (19 [12.5-33.5] v. 18 [11-35] days, p = 0.63), and hospital mortality were similar (19.8% v. 22.6%, p = 0.56). In multiple logistic regression analyses, higher APACHE II score (1.06; 1.04-1.09, p<0.001) was independently associated with an increased risk of death; antiviral treatment with a lower risk of death (0.34; 0.15 – 0.78, p = 0.01). Ethnicity was not associated with mortality. Interpretation: During the 2009-2010 Influenza A (H1N1) pandemic, Aboriginal and non-Aboriginal Canadians with H1N1-related critical illness had a similar risk of death, after adjusting for potential confounding factors. [ABSTRACT FROM AUTHOR]

Background: Baseline serum creatinine (bSCr) is required for diagnosing acute kidney injury (AKI). In children, bSCr is commonly defined as the lowest measurement within 3 months of admission. Measured values are often missing and estimating bSCr using height-based glomerular filtration rate (GFR) equations is problematic when height is unavailable. Methods: This is a retrospective cohort study including 538 children admitted to the intensive care unit (ICU) between 2003 and 2005 at two centers in Canada, with measured bSCr, height, and ICU-SCr values. We evaluated the bias, accuracy, and precision of back-calculating bSCr from height-dependent and height-independent GFR equations. Agreement of AKI defined using measured and estimated bSCr was calculated. Multivariate analyses were performed to assess the impact of bSCr estimation methods on the association between AKI and ICU mortality, length of stay, and duration of mechanical ventilation. Results: Both methods underestimated bSCr by 1-3%, showed good accuracy (∼30% of patients with estimated bSCr within 10% of measured bSCr), but poor precision (wide 95% limits of agreement). The agreement between AKI defined by estimated versus measured bSCr was >80% (κ >0.5). The height-independent method performed best in children >13 years old; however, overall, both methods performed similarly across age subgroups. AKI was associated with longer stay, prolonged mechanical ventilation, and ICU mortality using measured and estimated bSCr. Conclusions: Height-dependent and height-independent bSCr estimation methods were comparable. This may have significant implications for performing pediatric AKI research using large databases, and in clinical care to define AKI when height is unknown. [ABSTRACT FROM AUTHOR]

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

Background: Although secondary infections are recognized as a cause of morbidity and mortality in seasonal influenza, their frequency, characteristics, and associated clinical outcomes in 2009 influenza A(H1N1) (A[H1N1])-related critical illness are unknown.Methods: In a prospective cohort of adult patients admitted to Canadian ICUs with influenza A(H1N1) infection, the frequency and associated clinical outcomes of prevalent (culture taken within 72 h of ICU admission) and ICU-acquired (culture taken after 72 h from ICU admission) positive bacterial cultures were determined.Results: Among 681 patients, the mean age was 47.9 years (SD, 15.1), APACHE (Acute Physiology and Chronic Health Examination) II score was 21.0 (9.9), and 573 patients (84.0%) were invasively mechanically ventilated. Positive cultures were obtained in 259 patients (38.0%): 77 (29.7%) had prevalent, 115 (44.4%) had ICU-acquired, and 40 (15.4%) had both; culture date was unavailable in 27 (10.4%). The most common bacterial organisms isolated were coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas species, and Streptococcus pneumoniae. Antibiotics were prescribed in 661 (97.1%), with 3.8 (1.9) prescriptions per patient. Patients with any positive culture had longer days of mechanical ventilation (mean [SD], 15.2 [10.7] vs 10.7 [9.0]; P<.0001), ICU stay (median [interquartile range (IQR)], 18.2 [12.5] days vs 10.8 [9.0] days, P<.0001), and hospitalization (median [IQR], 30.7 [20.7] days vs 19.2 [17.4] days, P<.0001) and a trend toward increased hospital mortality (25.1% vs 19.9%, P=.15). Patients with ICU-acquired positive cultures had worse outcomes compared with those with positive prevalent cultures or who were culture-negative.Conclusion: Culture-based evidence of secondary infections commonly complicates A(H1N1)-related critical illness and is associated with worse clinical outcomes despite nearly ubiquitous antibiotic administration. [ABSTRACT FROM AUTHOR]

Background. In chronic pediatric patients treated with intermittent hemodialysis (IHD), blood volume monitoring (BVM) is commonly used to assess and manage volume status during the dialysis session. Minimal data exists on its use during IHD in critically ill children with acute kidney injury (AKI). In these cases, fluid removal may be limited by hemodynamic instability. Methods. We present a retrospective study conducted in our pediatric intensive care unit. For eligible patients, demographic data and IHD treatment characteristics were recorded including BVM use, ultrafiltration (UF) volume per session, hypotensive episodes and intradialysis interventions. Hypotensive episodes and UF per IHD session were compared between IHD sessions with BVM (BVM group) and IHD sessions without BVM (control group). Results. Twenty-three AKI patients with a median age of 11 years (1.8–18) and body weight of 36 kg (10–85) received 134 IHD sessions (70 with BVM and 64 without BVM). Hypotensive episodes occurred in 34% of all sessions with no significant difference between the BVM group and the control group: (95% CI: 22%, 44%) and 36% (95% CI: 24%, 48%), respectively, but UF per session was higher in the BVM group as compared to control (48 6 27 mL/kg and 33 6 26 mL/kg, respectively, P ¼ 0.0001). The mean decrease in BVM did not exceed 13% over an entire dialysis session in patients without hypotension. Conclusion. In conclusion, in our experience of IHD sessions in critically ill children with AKI, the use of BVM allowed a higher UF in those with BVM without influencing the frequency of hypotensive episodes. Applying specific guidelines on BVM use may decrease hypotensive episodes during IHD treatment in critically ill patients. [ABSTRACT FROM AUTHOR]

The article discusses a study which described the characteristics, treatment and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection. The study used 168 critically ill patients with 2009 influenza A(H1N1) infection in various Canadian adult and pediatric intensive care units (ICUs) during the period April 16-August 12, 2009. Primary outcome measures for the study were 28-day and 90-day mortality, while secondary measures included frequency and duration of mechanical ventilation and duration of stay in the ICU. Occurrence of critical illness in 215 patients with community-acquired 2009 influenza A(H1N1) infection was observed in the study. It also concluded that critical illness due to the virus has occurred rapidly after hospital admission.

The article presents a study to evaluate the humidification performance of a large number of adult heat and moisture exchangers (HMEs). It assesses 48 devices using a bench test apparatus that simulated real-life physiologic ventilation conditions, and performs three hygrometric measurements for each device. The research suggests that several HMEs performed poorly and should not be used as HMEs.

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

Maple syrup urine disease (MSUD, MIM 248600) can be complicated by metabolic crises necessitating extracorporeal removal therapy (ECRT). Since leucine levels are usually not immediately available during therapy, an accurate kinetic model of leucine plasma levels during removal would be useful to establish the duration of ECRT. Such a kinetic model is available for neonates undergoing continuous ECRT (CECRT) with a leucine clearance ≥35 ml min−1 1.73 m−2. The current study tests the validity of this model in older children. Plasma leucine levels were obtained from eleven ECRT sessions [seven CECRT and four intermittent hemodialysis (HDi) sessions] in seven children aged 1–14 years. No hemodynamic instability or neurological complications were observed during treatment. HDi provided a higher leucine clearance and required shorter sessions than CECRT (5.4±0.6 vs. 17.1±6.0 h). All patients regained precrisis neurological status except for one patient who had severe neurological damage (severe cerebral edema) at the time of dialysis and subsequently died despite efficient leucine removal. A leucine clearance ≥50 ml min−1 1.73 m−2 is required to obtain a kinetic model similar to that reported in neonates, both with CECRT and HDi. This model should be helpful in predicting the duration of therapy needed to attain desired leucine levels. [ABSTRACT FROM AUTHOR]

Assessment of respiratory function allows early detection of potential disorders in the respiratory system and provides useful information for medical management. There is a wide range of applications for breathing assessment, from measurement systems in a clinical environment to applications involving athletes. Many studies on pulmonary function testing systems and breath monitoring have been conducted over the past few decades, and their results have the potential to broadly impact clinical practice. However, most of these works require physical contact with the patient to produce accurate and reliable measures of the respiratory function. There is still a significant shortcoming of non-contact measuring systems in their ability to fit into the clinical environment. The purpose of this paper is to provide a review of the current advances and systems in respiratory function assessment, particularly camera-based systems. A classification of the applicable research works is presented according to their techniques and recorded/quantified respiration parameters. In addition, the current solutions are discussed with regards to their direct applicability in different settings, such as clinical or home settings, highlighting their specific strengths and limitations in the different environments. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the use of an oesophageal probe to examine the recovery of diaphragmatic paralysis.

Mechanical ventilation is a very effective therapy, but with many complications. Simulators are used in many fields, including medicine, to enhance safety issues. In the intensive care unit, they are used for teaching cardiorespiratory physiology and ventilation, for testing ventilator performance, for forecasting the effect of ventilatory support, and to determine optimal ventilatory management. They are also used in research and development of clinical decision support systems (CDSSs) and explicit computerized protocols in closed loop. For all those reasons, cardiorespiratory simulators are one of the tools that help to decrease mechanical ventilation duration and complications. This paper describes the different types of simulators described in the literature for physiologic simulation and modeling of the respiratory system, including a new simulator (SimulResp), and proposes a validation process for these simulators. [ABSTRACT FROM AUTHOR]

Purpose: In children with acute respiratory distress syndrome receiving mechanical ventilation, the peak inspiratory pressure (PIP) is close to plateau pressure (P PLAT ) when inspiratory flow approaches zero. We aimed to evaluate the reliability of PIP to estimate P PLAT in infants with severe respiratory viral infection (SRVI), characterized by increased airway resistance, and the accuracy of an equational model to estimates P PLAT (eP PLAT ) based on PIP., Methods: This was a retrospective observational study including mechanically ventilated children (1 to 24 month old) with SRVI, whose respiratory mechanics measurements were performed to evaluate PIP and P PLAT. The measured P PLAT was compared with the result of the equation: eP PLAT  = PIP - [5.067 - (0.858 × static compliance) - (0.018 × inspiratory resistance) - (0.390 × pressure above positive-end expiratory pressure) + (4.989 × inspiratory time)]., Results: Thirty-seven patients were included, with a median age of 3 (2-5) months. They presented a high inspiratory and expiratory resistance (136 ± 43 and 168 ± 66 cmH 2 O/L/s, respectively) and a moderate reduction in static compliance: 0.75 ± 0.3 mL/kg/cmH 2 O. PIP overestimated P PLAT (33 ± 3 and 26 ± 5 cmH 2 O, p = 0.01), with a mean difference of 7.3 ± 4 cmH 2 O. Moreover, the Bland-Altman analysis demonstrated a mean difference between P PLAT and eP PLAT of 1.0 ± 4.0 cmH 2 O, with 95% limits of agreement of -6.9 and 8.8., Conclusions: A significant difference between PIP and P PLAT was observed in infants with SRVI. The equation model was inaccurate for estimating P PLAT based on PIP. Any estimation of P PLAT from PIP needs to consider the resistance component of the respiratory system., (© 2024 Wiley Periodicals LLC.)

Purpose: Renal replacement therapy (RRT) is used in hyperammonemia to reduce the concentration of ammonia in the blood. In the case of plasma hyperosmolarity, RRT can also rapidly decrease plasma osmolarity, which may increase cerebral edema in these patients and favor the occurrence of brain herniation., Methods: We conducted a retrospective clinical study in a tertiary care university-affiliated hospital. All patients admitted in a Pediatric Intensive Care Unit (PICU), less than 18 years old with ammonemia >150 µmol/L and who underwent RRT between January 2015 and June 2023 were included. We collected data on plasma osmolarity levels, osmolar gap and blood ammonia levels before and during RRT., Results: Eleven patients were included (10 with acute liver failure and 1 with a urea cycle disorders). Their mean age was 36.2 months. Before RRT, the median highest measured osmolarity was 320 (305-324) mOsm/L, whereas the median calculated osmolarity was 303 (293-314) mOsm/L, corresponding to an osmolar gap of 14 mOsm/L. Ammonia blood level over 400 µmol/L are significantly associated with higher plasma osmolarity ( P -Value <0.001). In one case, a patient had a brain herniation episode after a quick osmolar drop. This episode was reversed by the administration of hyperosmolar agents and the temporary suspension of RRT., Conclusion: This study highlights the hyperosmolarity and high osmolar gap that occur in children with hyperammonemia. A careful monitoring and control of plasma osmolarity evolution may alert clinician on the risk of occurrence of neurological complication such as brain herniation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2024 Maghmoul, Wiedemann, Barcat, Parente, Allard, Alvarez and Jouvet.)

Background: Bloodstream infections (BSIs) are associated with significant mortality and morbidity, including multiple organ dysfunction. We explored if delayed adequate antimicrobial treatment for children with BSIs is associated with change in organ dysfunction as measured by PELOD-2 scores., Methods: We conducted a multicenter, retrospective cohort study of critically ill children <18 years old with BSIs. The primary outcome was change in PELOD-2 score between days 1 (index blood culture) and 5. The exposure variable was delayed administration of adequate antimicrobial therapy by ≥3 h from blood culture collection. We compared PELOD-2 score changes between those who received early and delayed treatment., Results: Among 202 children, the median (interquartile range) time to adequate antimicrobial therapy was 7 (0.8-20.1) hours; 124 (61%) received delayed antimicrobial therapy. Patients who received early and delayed treatment had similar baseline characteristics. There was no significant difference in PELOD-2 score changes from days 1 and 5 between groups (PELOD-2 score difference -0.07, 95% CI -0.92 to 0.79, p = 0.88)., Conclusions: We did not find an association between delayed adequate antimicrobial therapy and PELOD-2 score changes between days 1 and 5 from detection of BSI. PELOD-2 score was not sensitive for clinical effects of delayed antimicrobial treatment., Impact: In critically ill children with bloodstream infections, there was no significant change in organ dysfunction as measured by PELOD-2 scores between patients who received adequate antimicrobial therapy within 3 h of their initial positive blood culture and those who started after 3 h. Higher PELOD-2 scores on day 1 were associated with larger differences in PELOD-2 scores between days 1 and 5 from index positive blood cultures. Further study is required to determine if PELOD-2 or alternative measures of organ dysfunction could be used as primary outcome measures in trials of antimicrobial interventions in pediatric critical care research., (© 2023. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Clinical decision-making is a complex cognitive process that relies on the interpretation of a large variety of data from different sources and involves the use of knowledge bases and scientific recommendations. The representation of clinical data plays a key role in the speed and efficiency of its interpretation. In addition, the increasing use of clinical decision support systems (CDSSs) provides assistance to clinicians in their practice, allowing them to improve patient outcomes. In the pediatric intensive care unit (PICU), clinicians must process high volumes of data and deal with ever-growing workloads. As they use multiple systems daily to assess patients' status and to adjust the health care plan, including electronic health records (EHR), clinical systems (eg, laboratory, imaging and pharmacy), and connected devices (eg, bedside monitors, mechanical ventilators, intravenous pumps, and syringes), clinicians rely mostly on their judgment and ability to trace relevant data for decision-making. In these circumstances, the lack of optimal data structure and adapted visual representation hinder clinician's cognitive processes and clinical decision-making skills., Objective: In this study, we designed a prototype to optimize the representation of clinical data collected from existing sources (eg, EHR, clinical systems, and devices) via a structure that supports the integration of a home-developed CDSS in the PICU. This study was based on analyzing end user needs and their clinical workflow., Methods: First, we observed clinical activities in a PICU to secure a better understanding of the workflow in terms of staff tasks and their use of EHR on a typical work shift. Second, we conducted interviews with 11 clinicians from different staff categories (eg, intensivists, fellows, nurses, and nurse practitioners) to compile their needs for decision support. Third, we structured the data to design a prototype that illustrates the proposed representation. We used a brain injury care scenario to validate the relevance of integrated data and the utility of main functionalities in a clinical context. Fourth, we held design meetings with 5 clinicians to present, revise, and adapt the prototype to meet their needs., Results: We created a structure with 3 levels of abstraction-unit level, patient level, and system level-to optimize clinical data representation and display for efficient patient assessment and to provide a flexible platform to host the internally developed CDSS. Subsequently, we designed a preliminary prototype based on this structure., Conclusions: The data representation structure allows prioritizing patients via criticality indicators, assessing their conditions using a personalized dashboard, and monitoring their courses based on the evolution of clinical values. Further research is required to define and model the concepts of criticality, problem recognition, and evolution. Furthermore, feasibility tests will be conducted to ensure user satisfaction., (©Najia Yakob, Sandrine Laliberté, Philippe Doyon-Poulin, Philippe Jouvet, Rita Noumeir. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.02.2024.)

Background: Mathematical models based on the physiology when programmed as a software can be used to teach cardiorespiratory physiology and to forecast the effect of various ventilatory support strategies. We developed a cardiorespiratory simulator for children called "SimulResp." The purpose of this study was to evaluate the quality of SimulResp., Methods: SimulResp quality was evaluated on accuracy, robustness, repeatability, and reproducibility. Blood gas values (pH, PaCO 2 , PaO 2,  and SaO 2 ) were simulated for several subjects with different characteristics and in different situations and compared to expected values available as reference. The correlation between reference and simulated data was evaluated by the coefficient of determination and Intraclass correlation coefficient. The agreement was evaluated with the Bland & Altman analysis., Results: SimulResp produced healthy child physiological values within normal range (pH 7.40 ± 0.5; PaCO 2 40 ± 5 mmHg; PaO 2 90 ± 10 mmHg; SaO 2 97 ± 3%) starting from a weight of 25-35 kg, regardless of ventilator support. SimulResp failed to simulate accurate values for subjects under 25 kg and/or affected with pulmonary disease and mechanically ventilated. Based on the repeatability was considered as excellent and the reproducibility as mild to good. SimulResp's prediction remains stable within time., Conclusions: The cardiorespiratory simulator SimulResp requires further development before future integration into a clinical decision support system., (© 2023 Wiley Periodicals LLC.)

Purpose: Acute respiratory distress syndrome (ARDS) is a life-threatening condition that can cause a dramatic drop in blood oxygen levels due to widespread lung inflammation. Chest radiography is widely used as a primary modality to detect ARDS due to its crucial role in diagnosing the syndrome, and the x-ray images can be obtained promptly. However, despite the extensive literature on chest x-ray (CXR) image analysis, there is limited research on ARDS diagnosis due to the scarcity of ARDS-labeled datasets. Additionally, many machine learning-based approaches result in high performance in pulmonary disease diagnosis, but their decisions are often not easily interpretable, which can hinder their clinical acceptance. This work aims to develop a method for detecting signs of ARDS in CXR images that can be clinically interpretable., Approach: To achieve this goal, an ARDS-labeled dataset of chest radiography images is gathered and annotated for training and evaluation of the proposed approach. The proposed deep classification-segmentation model, Dense-Ynet, provides an interpretable framework for automatically diagnosing ARDS in CXR images. The model takes advantage of lung segmentation in diagnosing ARDS. By definition, ARDS causes bilateral diffuse infiltrates throughout the lungs. To consider the local involvement of lung areas, each lung is divided into upper and lower halves, and our model classifies the resulting lung quadrants., Results: The quadrant-based classification strategy yields the area under the receiver operating characteristic curve of 95.1% (95% CI 93.5 to 96.1), which allows for providing a reference for the model's predictions. In terms of segmentation, the model accurately identifies lung regions in CXR images even when lung boundaries are unclear in abnormal images., Conclusions: This study provides an interpretable decision system for diagnosing ARDS, by following the definition used by clinicians for the diagnosis of ARDS from CXR images., (© 2023 Society of Photo-Optical Instrumentation Engineers (SPIE).)

Introduction: Low cardiac output syndrome in the postoperative period after cardiac surgery leads to an increase in tissue oxygen extraction, assessed by the oxygen extraction ratio. Measurement of the oxygen extraction ratio requires blood gases to be taken. However, the temperature of the skin and various parts of the body is a direct result of blood flow distribution and can be monitored using infrared thermography. Thus, we conducted a prospective clinical study to evaluate the correlation between the thermal gradient obtained by infrared thermography and the oxygen extraction ratio in children at risk for low cardiac output after cardiac surgery., Methods: Children aged 0 to 18 years, having undergone cardiac surgery with cardio-pulmonary bypass in a pediatric intensive care unit were included in the study. One to 4 thermal photos were taken per patient using the FLIR One Pro thermal imaging camera. The thermal gradient between the central temperature of the inner canthus of the eye and the peripheral temperature was compared to the concomitant oxygen extraction ratio calculated from blood gases., Results: 41 patients were included with a median age of 6 months (IQR 3-48) with median Risk Adjustment for Congenital Heart Surgery-1 score was 2 (IQR 2-3). Eighty nine thermal photos were analyzed. The median thermal gradient was 2.5 °C (IQR 1,01-4.04). The median oxygen extraction ratio was 35% (IQR 26-42). Nine patients had an oxygen extraction ratio ≥ 50%. A significant but weak correlation was found between the thermal gradient and the oxygen extraction ratio (Spearman's test p  = 0.25, p  = 0.016). Thermal gradient was not correlated with any other clinical or biologic markers of low cardiac output. Only young age was an independent factor associated with an increase in the thermal gradient., Conclusion: In this pilot study, which included mainly children without severe cardiac output decrease, a significant but weak correlation between thermal gradient by infrared thermography and oxygen extraction ratio after pediatric cardiac surgery was observed. Infrared thermography is a promising non-invasive technology that could be included in multimodal monitoring of postoperative cardiac surgery patients. However, a clinical trial including more severe children is needed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Bridier, Shcherbakova, Kawaguchi, Poirier, Said, Noumeir and Jouvet.)

Acute respiratory distress syndrome (ARDS), including severe pulmonary COVID infection, is associated with a high mortality rate. It is crucial to detect ARDS early, as a late diagnosis may lead to serious complications in treatment. One of the challenges in ARDS diagnosis is chest X-ray (CXR) interpretation. ARDS causes diffuse infiltrates through the lungs that must be identified using chest radiography. In this paper, we present a web-based platform leveraging artificial intelligence (AI) to automatically assess pediatric ARDS (PARDS) using CXR images. Our system computes a severity score to identify and grade ARDS in CXR images. Moreover, the platform provides an image highlighting the lung fields, which can be utilized for prospective AI-based systems. A deep learning (DL) approach is employed to analyze the input data. A novel DL model, named Dense-Ynet, is trained using a CXR dataset in which clinical specialists previously labelled the two halves (upper and lower) of each lung. The assessment results show that our platform achieves a recall rate of 95.25% and a precision of 88.02%. The web platform, named PARDS-CxR, assigns severity scores to input CXR images that are compatible with current definitions of ARDS and PARDS. Once it has undergone external validation, PARDS-CxR will serve as an essential component in a clinical AI framework for diagnosing ARDS.

When dealing with clinical text classification on a small dataset, recent studies have confirmed that a well-tuned multilayer perceptron outperforms other generative classifiers, including deep learning ones. To increase the performance of the neural network classifier, feature selection for the learning representation can effectively be used. However, most feature selection methods only estimate the degree of linear dependency between variables and select the best features based on univariate statistical tests. Furthermore, the sparsity of the feature space involved in the learning representation is ignored., Goal: Our aim is, therefore, to access an alternative approach to tackle the sparsity by compressing the clinical representation feature space, where limited French clinical notes can also be dealt with effectively., Methods: This study proposed an autoencoder learning algorithm to take advantage of sparsity reduction in clinical note representation. The motivation was to determine how to compress sparse, high-dimensional data by reducing the dimension of the clinical note representation feature space. The classification performance of the classifiers was then evaluated in the trained and compressed feature space., Results: The proposed approach provided overall performance gains of up to 3% for each test set evaluation. Finally, the classifier achieved 92% accuracy, 91% recall, 91% precision, and 91% f1-score in detecting the patient's condition. Furthermore, the compression working mechanism and the autoencoder prediction process were demonstrated by applying the theoretic information bottleneck framework. Clinical and Translational Impact Statement- An autoencoder learning algorithm effectively tackles the problem of sparsity in the representation feature space from a small clinical narrative dataset. Significantly, it can learn the best representation of the training data because of its lossless compression capacity compared to other approaches. Consequently, its downstream classification ability can be significantly improved, which cannot be done using deep learning models., (© 2023 The Authors.)

Objectives: The use of electronic algorithms, clinical decision support systems, and other clinical informatics interventions is increasing in critical care. Pediatric acute respiratory distress syndrome (PARDS) is a complex, dynamic condition associated with large amounts of clinical data and frequent decisions at the bedside. Novel data-driven technologies that can help screen, prompt, and support clinician decision-making could have a significant impact on patient outcomes. We sought to identify and summarize relevant evidence related to clinical informatics interventions in both PARDS and adult respiratory distress syndrome (ARDS), for the second Pediatric Acute Lung Injury Consensus Conference., Data Sources: MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost)., Study Selection: We included studies of pediatric or adult critically ill patients with or at risk of ARDS that examined automated screening tools, electronic algorithms, or clinical decision support systems., Data Extraction: Title/abstract review, full text review, and data extraction using a standardized data extraction form., Data Synthesis: The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-six studies were identified for full text extraction to address the Patient/Intervention/Comparator/Outcome questions, and 14 were used for the recommendations/statements. Two clinical recommendations were generated, related to the use of electronic screening tools and automated monitoring of compliance with best practice guidelines. Two research statements were generated, related to the development of multicenter data collaborations and the design of generalizable algorithms and electronic tools. One policy statement was generated, related to the provision of material and human resources by healthcare organizations to empower clinicians to develop clinical informatics interventions to improve the care of patients with PARDS., Conclusions: We present two clinical recommendations and three statements (two research one policy) for the use of electronic algorithms and clinical informatics tools for patients with PARDS based on a systematic review of the literature and expert consensus., Competing Interests: Dr. Sanchez-Pinto’s institution received funding from the National Institutes of Health (NIH) (R01 and R21 grants); he disclosed that he has angel investments in companies developing cancer diagnostics and therapeutics. Dr. Sauthier received funding from Fonds de recherche en santé du Quebec (FRQS); he received support for article research from FRQS. Dr. Jouvet’s institution received funding from VitaTracer and Dymedso. Dr. Newth received funding from Philips Research North America. The remaining authors have disclosed that they do not have any potential c conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: Computerised provider order entry (CPOE) systems have been implemented around the world as a solution to reduce ordering and transcription errors. However, previous literature documented many challenges to attain this goal, especially in paediatric settings. The objectives of this study were to (1) analyse the impact of a paediatric CPOE system on medication safety and (2) suggest potential error prevention strategies., Methods: A pre-post observational study was conducted at the pilot ward (n=60 beds) of a paediatric academic health centre through mixed methods. The implementation project and medication management workflows were described through active participation to the project management team, observation, discussions and analysis of related documents. Furthermore, using incident reports, the nature of each error and error rate was compared between the preperiod and postperiod., Results: The global error rate was lower, but non-statistically significant, in the post implementation phase, which was mostly driven by a significant reduction in errors during order acknowledgement, transmission and transcription. Few errors occurred at the prescription step, and most errors occurred during medication administration. Furthermore, some errors could have been prevented using a CPOE in the pre-implementation period, and the CPOE led to few technology-related errors., Discussion and Conclusion: This study identified both intended and unintended effects of CPOE adoption through the entire medication management workflow. This study revealed the importance of simplifying the acknowledgement, transmission and transcribing steps through the implementation of a CPOE to reduce medication errors. Improving the usability of the electronic medication administration record could help further improve medication safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed., Design: International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science., Setting: Not applicable., Patients: Patients with or at risk for PARDS., Interventions: None., Measurements and Main Results: Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%., Conclusions: PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients., Competing Interests: Dr. Barbaro is currently receiving grant support (R01 HL153519; R01 HD015434) from the National Institutes of Health (NIH); he is currently Chair of the Extracorporeal Life Support Organization Registry. Dr. Bembea receives research funding to her institution from the NIH/National Institute of Neurological Disorders and Stroke (R01NS106292) and the Grifols Investigator Sponsored Research Grant. She serves as Chair of the Scientific Committee of the Pediatric Acute Lung Injury and Sepsis Investigators Research Network. Dr. Cheifetz is a medical consultant for Phillips and Medtronic. His institution receives research grant funding from the NIH. Dr. Cruces received funding from the Chilean Ministry of Sciences (Fondecyt 1220322). Dr. Curley received funding from the NIH (UH3HL141736, R01HD098269, R01HL149910, R01HL153519, R01HD104618). Dr. Dahmer received funding from the NIH (National Institute of Child Health and Human Development [NICHD], R21 HD097387; National Heart, Lung and Blood Institute [NHLBI] R01 HL149910). Dr. Dalton received funding from the Department of Defense (No. 13363072). She is a consultant for Innovative Extracorporeal Membrane Oxygenation Concepts, Hemocue, Entegrion, Medtronic, and advisory board member for Abiomed. Dr. Emeriaud’s research program is supported by the Fonds de Recherche du Québec-Santé and the Quebec Respiratory Health Network. Dr. Emeriaud is leading a study, which is financially supported by Maquet. Dr. Jouvet’s research program and salary is supported by the Fonds de Recherche du Québec-Santé and the Quebec Respiratory Health Network. Dr. Jouvet is leading studies, which is financially supported by VitalTracer, Dymedso and public financial agencies (Canadian Foundation for innovation, Institut TransMedTech, Quebec Ministry of Health, Sainte-Justine Hospital). Dr. Killien received funding from the NIH (NICHD K23HD100566). Dr. Kneyber received research funding from the NIH/NICHD (UG3 HL141736-01/U24 HL141723-01) and ZorgOnderzoek Nederland and the area Medical (848041002), Stichting Vrienden Beatrix Kinderziekenhuis, Fonds NutsOhra, University Medical Center Groningen, VU University Medical Center, and the Royal Academy of Dutch Sciences (TerMeulen stipend). Dr. Kneyber’s research program is technically supported by Vyaire, Applied Biosignals, and Timpl. Dr. Kneyber received honoraria from Vyaire. Dr. Kneyber serves as consultant for Metran and served as consultant for Vyaire. Dr. Kudchadkar received funding to her institution from the NIH/NICHD (R01HD103811 & R21HD093369) and the Donaghue Foundation. Dr. López-Fernández is funded by an academic grant from the Instituto de Salud Carlos III, Madrid, Spain (PI19/00141). Dr. Maddux received funding to her institution from the NIH/NICHD (K23HD096018). Dr. Morrow has received honoraria for Continuing Medical Education presentations from EduPro Health. Her research is part-funded by the National Research Foundation of South Africa, through the Incentive Funding for Rated Researchers program. Dr. Nadkarni receives unrestricted research grants to his institution from the NIH, U.S. Department of Defense, Agency for Healthcare Research and Quality, Laerdal Foundation, RQI Partners, Zoll Medical, Defibtech, HeartHero, and Nihon-Kohden. Dr. Nadkarni is an elected member of the Executive Committee (Council) of the Society of Critical Care Medicine. Dr. Napolitano research and consulting relationships with: Drager, Timpel, VERO-Biotech, Actuated Medical, and Philips/Respironics. Dr. Pons has been on the speaker’s bureau of Philips, ResMed and Fisher & Paykel; Hospital Sant Joan de Déu has received disposable material from these companies. Dr. Randolph receives funding from the Centers for Disease Control and Prevention, NIH (National Institute of Allergy and Infectious Diseases AI154470). Dr. Rowan receives funding from the NHLBI (NHLBI K23HL150244). Dr. Sanchez-Pinto received funding from the NIH (NICHD R01 HD105939). Dr. Sauthier research program and salary is supported by the Fonds de Recherche du Québec-Santé. Dr. Takeuchi receives funding from Japan Society for the Promotion of Science grant (KAKENHI 21K09063). Dr. Tse receives research funding to her institution from the Canadian Institute of Health Research and salary support from the Fonds de Recherche du Québec—Santé. Dr. Watson receives research funding to his institution from the NIH. Dr. Zimmerman received research funding from NIH and Biomedical Advanced Research and Development Authority; royalties from Elsevier Publishing. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

In a pediatric intensive care unit (PICU) of 32 beds, clinicians manage resources 24 hours a day, 7 days a week, from a large-screen dashboard implemented in 2017. This resource management dashboard efficiently replaces the handwriting information displayed on a whiteboard, offering a synthetic view of the bed's layout and specific information on staff and equipment at bedside. However, in 2020 when COVID-19 hit, the resource management dashboard showed several limitations. Mainly, its visualization offered to the clinicians limited situation awareness (SA) to perceive, understand and predict the impacts on resource management and decision-making of an unusual flow of patients affected by the most severe form of coronavirus. To identify the SA requirements during a pandemic, we conducted goal-oriented interviews with 11 clinicians working in ICUs. The result is the design of an SA-oriented dashboard with 22 key indicators (KIs): 1 on the admission capacity, 15 at bedside and 6 displayed as statistics in the central area. We conducted a usability evaluation of the SA-oriented dashboard compared to the resource management dashboard with 6 clinicians. The results showed five usability improvements of the SA-oriented dashboard and five limitations. Our work contributes to new knowledge on the clinicians' SA requirements to support resource management and decision-making in ICUs in times of pandemics.

Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.

As pediatricians, we all have to deal with new childhood inflammatory disorder due to COVID 19: the Multisystem Inflammatory Syndrome in Children (MIS-C). The recent article by Savorgnan et al. on the physiologic profiles associated with MIS-C proposed a classification through the "MIS-C severity score" (MSS). The authors also identified a combination of seven variables collected during the first 3 h of admission in the PICU that contributes to stratify MIS-C severity with an area under the receiver operating characteristic curve (AUC) >0.90. This work represents an important first step in the development of a MIS-C severity score and is a call for collaborative groups to validate the prediction model through multicenter studies and thereby refine the management of MIS-C. IMPACT: The recent article by Savorgnan et al. on physiologic profile associated with MIS-C represents an important first step in the development of an MIS-C severity score and is a call for collaborative groups to validate the prediction model through multicenter studies and thereby refine the management of MIS-C. Our manuscript helps in the methodology interpretation of the manuscript by Savorgnan et al. And our manuscript promotes collaborative work on MIS-C., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

The rapid progress in clinical data management systems and artificial intelligence approaches enable the era of personalized medicine. Intensive care units (ICUs) are ideal clinical research environments for such development because they collect many clinical data and are highly computerized. Goal: We designed a retrospective clinical study on a prospective ICU database using clinical natural language to help in the early diagnosis of heart failure in critically ill children. Methods: The methodology consisted of empirical experiments of a learning algorithm to learn the hidden interpretation and presentation of the French clinical note data. This study included 1386 patients' clinical notes with 5444 single lines of notes. There were 1941 positive cases (36% of total) and 3503 negative cases classified by two independent physicians using a standardized approach. Results: The multilayer perceptron neural network outperforms other discriminative and generative classifiers. Consequently, the proposed framework yields an overall classification performance with 89% accuracy, 88% recall, and 89% precision. Conclusions: This study successfully applied learning representation and machine learning algorithms to detect heart failure in a single French institution from clinical natural language. Further work is needed to use the same methodology in other languages and institutions.

Objectives: We used modified contingent valuation methodology to determine how noninferiority margin sizes influence clinicians' willingness to accept clinical trial results that compare mortality in critically ill children., Methods: We surveyed pediatric infectious diseases and critical care clinicians in Canada, Australia, and New Zealand and randomized respondents to review 1 of 9 mock abstracts describing a noninferiority trial of bacteremic critically ill children assigned to 7 or 14 d of antibiotics. Each scenario showed higher mortality in the 7-d group but met noninferiority criterion. We explored how noninferiority margins and baseline mortality rates influenced respondent acceptance of results., Results: There were 106 survey respondents: 65 (61%) critical care clinicians, 28 (26%) infectious diseases physicians, and 13 (12%) pharmacists. When noninferiority margins were 5% and 10%, 73% (24/33) and 79% (27/33) respondents would accept shorter treatment, compared with 44% (17/39) when the margin was 20% ( P = 0.003). Logistic regression adjusted for baseline mortality showed 5% and 10% noninferiority margins were more likely to be associated with acceptance of shorter treatment compared with 20% margins (odds ratio [OR] 3.5, 95% confidence interval [CI]: 1.3-9.6, P = 0.013; OR 5.1, 95% CI: 1.8-14.6, P = 0.002). Baseline mortality was not a significant predictor of acceptance of shorter treatment., Conclusions: Clinicians are more likely to accept shorter treatment when noninferiority margins are ≤10%. However, nearly half of respondents who reviewed abstracts with 20% margins were still willing to accept shorter treatment. This is a novel application of contingent valuation methodology to elicit acceptance of research results among end users of the medical literature., Highlights: Clinicians are more likely to accept shorter treatment durations based on noninferior mortality results when the noninferiority margin is 5% or 10% than if the margin is 20%.However, nearly half of clinicians would still accept shorter-duration treatment as noninferior with margins of 20%.Baseline mortality does not independently predict acceptance of shorter-duration treatment.Contingent valuation is a novel approach to elicit the acceptance of research design parameters from the perspective of endusers of the medical literature.

Background: Bloodstream infections (BSIs) cause significant morbidity and mortality in critically ill children but treatment duration is understudied. We describe the durations of antimicrobial treatment that critically ill children receive and explore factors associated with treatment duration., Methods: We conducted a retrospective observational cohort study in six pediatric intensive care units (PICUs) across Canada. Associations between treatment duration and patient-, infection- and pathogen-related characteristics were explored using multivariable regression analyses., Results: Among 187 critically ill children with BSIs, the median duration of antimicrobial treatment was 15 (IQR 11-25) days. Median treatment durations were longer than two weeks for all subjects with known sources of infection: catheter-related 16 (IQR 11-24), respiratory 15 (IQR 11-26), intra-abdominal 20 (IQR 14-26), skin/soft tissue 17 (IQR 15-33), urinary 17 (IQR 15-35), central nervous system 33 (IQR 15-46) and other sources 29.5 (IQR 15-55) days. When sources of infection were unclear, the median duration was 13 (IQR 10-16) days. Treatment durations varied widely within and across PICUs. In multivariable linear regression, longer treatment durations were associated with severity of illness (+ 0.4 days longer [95% confidence interval (CI), 0.1 to 0.7, p = 0.007] per unit increase in PRISM-IV) and central nervous system infection (+ 17 days [95% CI, 6.7 to 27.4], p = 0.001). Age and pathogen type were not associated with treatment duration., Conclusions: Most critically ill children with BSIs received at least two weeks of antimicrobial treatment. Further study is needed to determine whether shorter duration therapy would be effective for selected critically ill children., (© 2022. The Author(s).)

Objectives: To describe the patient characteristics, clinical management, and infectious etiology in critically ill children with bronchiolitis. The secondary objective was to determine the association between antibiotic use and hospital length of stay among patients without concomitant bacterial infections., Methods: Retrospective cohort study including patients ≤2 years old with bronchiolitis admitted to 3 Canadian pediatric intensive care units between 2016 and 2018., Results: We included 372 patients with a median age of 2.1 months (interquartile range 1.2-6.6) and Pediatric Risk of Mortality III score 3.0 (interquartile range 0-3.0). Initial ventilatory management included high flow nasal cannula (28.2%) and noninvasive positive pressure ventilation (53.7%), of which 41.9% and 87.5%, respectively, did not require escalation of ventilatory support. Chest radiographs (81.7%) and respiratory virus testing (95.4%) were performed in most patients; 14.0% received systemic steroids. Respiratory syncytial virus was detected in 61.3% patients, and 7.5% had a culture-positive concomitant bacterial infection. Of 258 (69.4%) patients with a viral infection, only 45.3% received antibiotics. In this group, antibiotic use beyond 72 hours was not associated with hospital length of stay (ratio 1.14, 95% confidence interval 0.97-1.34)., Conclusions: High flow nasal canulae and noninvasive ventilation are commonly used in severe bronchiolitis. Despite contrary evidence, steroids and antibiotics were also frequently used. Evidence-based guidelines specific to children with severe bronchiolitis are needed to improve the care delivered to this patient population., (Copyright © 2022 by the American Academy of Pediatrics.)

Introduction: The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals., Methods: This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient's health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination)., Results: Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis., Conclusions: This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.

Objectives: To determine the association between the implementation of an antimicrobial stewardship program at a local PICU and to determine the association between the presence of an antimicrobial stewardship programs and antimicrobial use across three Canadian PICUs, among critically ill children with bronchiolitis., Design: A multicenter retrospective cohort study., Setting: Three Canadian PICUs over two winter seasons., Interventions: An antimicrobial stewardship program was implemented at PICU 1 at the end of season 1., Patients: Patients less than or equal to 2 years old admitted with bronchiolitis., Measurements and Main Results: We used regression models with an interaction term between site (PICU 1 and PICU 2) and season (1 and 2) as the primary analysis to determine the association between implementation of an antimicrobial stewardship program at PICU 1 and 1) the proportion of antimicrobials discontinued 72 hours after hospital admission (logistic regression), 2) antimicrobial treatment duration (negative binomial regression), and 3) antimicrobial prescriptions within 48 hours of hospital admission (logistic regression). As a secondary analysis, we determined the association between having an antimicrobial stewardship program present and the aforementioned outcomes across the three PICUs. A total of 372 patients were included. During seasons 1 and 2, median age was 2.2 months (interquartile range, 1.2-6.2 mo) and 2.1 months (interquartile range, 1.3-6.8 mo), respectively. Among patients with viral bronchiolitis, implementation of an antimicrobial stewardship program at PICU 1 was associated with increased odds of discontinuing antimicrobials (odds ratio, 25.63; 95% CI, 2.86-326.29), but not with antimicrobial duration (odds ratio, 0.56; 95% CI, 0.31-1.02) or antimicrobial prescriptions (odds ratio, 0.33; 95% CI, 0.10-1.04). The presence of an antimicrobial stewardship program was similarly associated with antimicrobial discontinuation among patients with viral bronchiolitis (odds ratio, 20.79; 95% CI, 2.46-244.92), but not with antimicrobial duration (odds ratio, 0.57; 95% CI, 0.32-1.03) or antimicrobial prescriptions (odds ratio, 0.37; 95% CI, 0.12-1.11)., Conclusions: Antimicrobial stewardship programs were associated with increased likelihood of discontinuing antimicrobial treatments in the PICU patients with viral bronchiolitis. However, larger studies are needed to further determine the role of an antimicrobial stewardship programs in reducing unnecessary antimicrobial use in this patient population., Competing Interests: Dr. Papenburg’s institution received funding from MedImmune; he received funding from AbbVie, Cepheid, BD Diagnostics, MedImmune, Sanofi Pasteur, Seegene, and Janssen Pharmaceutical. Dr. Quach’s institution received funding from the McGill University Health Centre, Research Institute. Dr. Jouvet received funding from the Mallinckrodt. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)