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The purpose of this study is to explore factors influencing sleep in pediatric intensive care units as perceived by parents of critically ill children. This descriptive qualitative study used individual semistructured interviews. Parents were recruited through purposive sampling from two pediatric intensive care units at two locations in one university hospital in Norway. Ten parents were interviewed. The interviews were analyzed using a six-phase reflexive thematic analysis. The analysis produced 17 subthemes under four main themes: environmental factors in the pediatric intensive care unit disturb children's sleep, children need trust and safety to sleep, nurses' cooperation with parents influences children's sleep, and nurses' structuring of their practices is fundamental to sleep promotion. The parents found that the environment disturbed their children's sleep, and environmental factors were easier to control in single rooms than in multibed rooms. Children slept better when they felt safe and trusted the nurses, and parents desired more cooperation in promoting sleep for their children, which may be an essential and overlooked part of sleep promotion. Nurses varied considerably in how they prioritized sleep and structured their practices to promote sleep. Nurses should take parents' experiences into account to better promote sleep for patients. By limiting environmental disturbances, building relationships with children to make them feel safe, including parents in sleep promotion, and prioritizing sleep in their practices, nurses could improve sleep quality and limit the consequences of sleep disturbance. • Environmental factors in the Pediatric Intensive Care Unit disturb children's sleep. • Children's feeling of trust and safety and the involvement of parents improved children's sleep. • The way nurses structure their practice to avoid disturbing sleep is fundamental to sleep promotion. [ABSTRACT FROM AUTHOR]

Bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH) are potentially fatal complications in prematurely born infants. Extracorporeal membrane oxygenation (ECMO) may be a life-saving option for managing infants with BPD and PH. We present 2 patients who were successfully weaned off mechanical ventilators (MVs) through the application of ECMO. The patients were transferred to our institution after receiving MV care for 8 and 10 months, respectively, for BPD and PH. We were able to remove the patients from MVs after a period of ECMO-mediated lung rest. Although more research is required to determine specific criteria for ECMO use in patients with BPD and PH, our clinical experiences may contribute to the early application of ECMO in MV-dependent patients.

BACKGROUND:Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that “specific values to guide therapy have not been established in children.” METHODS: This prospective observational cohort study was a National Heart, Lung, and Blood Institute–funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks post-gestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate).RESULTS: Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04–1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00–1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups. CONCLUSIONS: In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics. [ABSTRACT FROM AUTHOR]

Objective: To assess the longitudinal distribution of the number of pediatric hospitalizations for acute viral bronchiolitis in the Brazilian Health System and the expenses with hospitalizations corresponding to each macro-region at the Brazilian national level. Methods: This is a quantitative, observational, ecological study based on a retrospective and longitudinal analysis of data from the Brazilian Health System Information Technology Department from 2012 to 2021, using descriptive statistics and Tukey's paired test. Results: There was a statistically significant difference regarding hospitalization costs in macro-regions at the national level over the years (p=0.017), but Tukey's multiple comparisons indicated that there was no significant difference between 2 consecutive years, when comparing the years 2020 and 2021 and the mean value of hospitalizations by regions. The mean proportions of the number of hospitalizations in the macro-regions in the 10 years of study were 461.1 in the Midwest, 528.27 in the North, 1,026 in the South, 1,127 in the Northeast and 3,044 in the Southeast, considering that the highest incidence in terms of the mean of hospitalization was in the Southeast and there was a statistically significant difference in the number of hospitalizations over the years (p=0.001). Conclusion: There was a significant increase in the occurrence of hospitalizations for cases of acute viral bronchiolitis in children under 4 years old, especially in infants, which showed an increasing incidence of hospitalizations in this age group and hospital expenses in Brazil in most macro-regions, mainly in the Southeast. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Kawasaki disease (KD), a systemic vasculitis, affects children aged <5 years and is the leading acquired cardiovascular disease in developed countries. Although intravenous immunoglobulin is an effective treatment for KD and decreases the rate of cardiovascular complications, some patients still develop coronary sequelae, including coronary aneurysms and myocardial infarction. Case Report: A 9-year-old boy was diagnosed with KD at the age of 6 years. For coronary sequelae of a giant coronary artery aneurysm (CAA) 8.8 mm in diameter, he was prescribed aspirin and warfarin. At 9 years old, he visited the Emergency Department because of acute chest pain. Electrocardiography revealed an incomplete right bundle branch block and ST-T change over right and inferior leads. Also, troponin I was elevated. Coronary angiography found acute thrombotic occlusion of the right CAA. We performed aspiration thrombectomy with intravenous tirofiban. Coronary angiography and optical coherence tomography (OCT) images later found white thrombi, calcification, destruction of media layer, irregular intimal thickening, and uneven intima edge. We prescribed antiplatelet therapy and warfarin, and he was doing well at a 3-year follow-up. Conclusions: OCT is a promising modality that can impact the clinical care in patients with coronary artery disease. This report presents treatment management and OCT images of KD complicated with a giant CAA and acute myocardial infarction. We used aspiration thrombectomy in combination with medical treatments as the initial intervention strategy. Afterward, the OCT images showed vascular wall abnormalities, which were helpful for defining the future risk and decision making of further coronary interventions and medical treatments. [ABSTRACT FROM AUTHOR]

The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions. A retrospective cohort study. At a tertiary teaching hospital. Patients younger than 18, with congenital heart disease, who underwent cardiac surgery. Commencement of NMBA infusion in the first 2 hours after surgery The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001). Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease. [ABSTRACT FROM AUTHOR]

Staphylococcus aureus (SA) is one of the main pathogens responsible for healthcare-associated infection (HCAI) in pediatrics. The aim of this study was to describe the prevalence of SA-HCAI among colonized patients and the factors associated with it in the pediatric intensive care unit (PICU). We designed a 6-year retrospective cohort study of a PICU in a French university children's hospital including all children admitted to the PICU from January 1, 2011, to December 31, 2016, who had SA colonization on PICU admission. For each patient, the past medical history and the hospitalization data were collected. HCAIs related to SA were verified according to the criteria of the United States Centers for Disease Control and Prevention. Among all patients colonized with SA (n = 1381, 26%), 105 (8%) had methicillin-resistant SA carriage and 41 (3%) developed an HCAI caused by SA. The main HCAIs were ventilator-associated pneumonia (51%) and central line-associated bloodstream infections (27%). Patients developing HCAI caused by SA had a significantly longer length of hospital stay and a higher mortality rate than the rest of the population. Using a multivariate logistic regression model, the presence of mechanical ventilation, the implementation of a surgical procedure during the PICU stay, and the onset of at least one episode of anemia during the PICU stay were significantly associated with the occurrence of HCAI due to SA. HCAIs linked to SA carriage are rare but severe. Mechanical ventilation, surgery during the PICU stay, and anemia are factors associated with SA-HCAI. [ABSTRACT FROM AUTHOR]

• COVID-19 required urgent clinical changes to promote Intensive Care Unit staff safety. • Information dissemination and high-volume team training demands a multimodal approach. • We employed videos, webinars, superusers, small-group simulation and cognitive aids. Coronavirus disease (COVID-19) required innovative training strategies for emergent aerosol generating procedures in intensive care units. This manuscript summarizes institutional operationalization of COVID-specific training, standardized across four intensive care units. An interdisciplinary team collaborated with the Simulator Program and OpenPediatrics refining logistics using process maps, walkthroughs and simulation. A multimodal approach to information dissemination, high-volume team training in modified resuscitation practices and technical skill acquisition included instructional videos, training superusers, small-group simulation using a flipped classroom approach with rapid cycle deliberate practice, interactive webinars, and cognitive aids. Institutional data on application of this model are presented. Success was founded in interdisciplinary collaboration, resource availability and institutional buy in. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective: To reveal the experience of family members after learning their child would adopt palliative care. Method: Phenomenological research on Heidegger’s perspective. The participants were eleven family members of children who were recommended palliative care in the Pediatric Intensive Care Unit from a university hospital in southern Brazil. The statements were obtained in a semi-structured interview, from January to November/2017, and submitted to Heidegger’s theoretical-philosophical analysis. Research approved by the institution’s Ethical Committee. Results: The communication of palliative care triggers the perception of the child’s existencial facticity in the Family, revealing reactions explained in the thematic dimensions: “Coping with the finiteness of the child when confronted with the proposal of adopting palliative care” and “The need for compassionate and attentive care”. Final considerations: Phenomenology allows us to understand the parent's existential purpose. An understanding perspective can help interdisciplinary teams to communicate the adoption of palliative care in a sensitive and ethical way, focusing on the best interest of the child.

Background: Viral respiratory infections are one of the main causes of hospitalization in children. Even if mortality rate is low, 2% to 3% of the hospitalized children need mechanical ventilation. Risk factors for admission to the pediatric intensive care unit (PICU) are well known, while few studies have described risk factors for invasive ventilator support and prolonged hospitalization. Methods: A retrospective study including all patients aged between 2 and 18 months with a confirmed viral respiratory infection, requiring admission to PICU from September to March between 2015 and 2019, was conducted at Bambino Gesù Children's Hospital in Rome, Italy. Results: One hundred ninety patients were enrolled, with a median age of 2.7 months; 32.1% had at least one comorbidity, mainly prematurity. The most frequent isolated viruses were RSV‐B, rhinovirus, and RSV‐A; 38.4% needed mechanical ventilation. This subgroup of patients had lower median birth weight compared with patients not requiring mechanical ventilation (2800 g vs. 3180 g, p = 0.02); moreover, comorbidities were present in 43.8% of intubated patients and in 24.8% of patients treated with non‐invasive ventilation (p = 0.006). Viral coinfection did not result to be a risk factor for mechanical support, while virus–bacteria coinfection was significantly associated with mechanical ventilation (p < 0.001). Similar risk factors were identified for prolonged hospitalization. Conclusions: Early identification of patients who could have a sudden respiratory deterioration and need of mechanical ventilation is crucial to reduce complications due to orotracheal intubation and prolonged hospitalization in PICU. Further studies are needed to define high‐risk group of patients and to design targeted interventions. [ABSTRACT FROM AUTHOR]

Background: Drug-related problems (DRPs) are frequently observed in intensive care units, resulting in a higher occurrence of drug side effects and increased treatment expenses. This study aimed to assess the prevalence of DRPs in pediatric patients admitted to the most prominent surgical and medical pediatric intensive care units (PICUs) in southern Iran, given the susceptibility of children to the effects of DRPs., Method: This cross-sectional study was conducted at Namazi Hospital, which is affiliated with Shiraz University of Medical Sciences in Shiraz, Iran, from June 2022 to March 2023. The research focused on identifying and detecting drug-related problems (DRPs) among pediatric patients during their hospital stays across three medical wards, two pediatric intensive care units, and a surgical intensive care unit. The identification process occurred concurrently with patient treatment and utilized the Pharmaceutical Care Network of Europe's data collection form for DRPs version 8.01. Before any documentation, all cases were thoroughly reviewed and validated by a professional focus group. The data gathered were then statistically analyzed using SPSS to evaluate the study's outcomes., Result: During the study, 323 pediatric patients were involved, of whom 57% experienced at least one DRP. The primary issues identified during the study were suboptimal drug treatment, accounting for 41.13% of cases, followed by concerns related to treatment safety, which constituted 38.53% of cases. Drug-drug interactions were found to be the leading cause of DRPs, accounting for 36.26% of cases. Two significant factors associated with DRP occurrence were the number of prescribed drugs and the number of prescribed anticonvulsants. Out of all clinical pharmacist interventions, 97% were accepted., Conclusion: Patients admitted to the PICUs experience a high occurrence of DRPs. It is essential to consider optimal dosage adjustment, particularly for pediatric patients with impaired kidney function., (© 2024. The Author(s).)

Objective: This study aimed to investigate the relationship between serum lactate levels at admission to the intensive care unit (ICU) and the clinical outcomes of children with sepsis., Methods: We used the Pediatric Intensive Care (PIC) database to identify 288 pediatric patients with sepsis. We analyzed the relationship between lactate levels and hospital and ICU mortality in sepsis by establishing a segmented multivariable Cox regression model. We also conducted subgroup analysis as well as analyzed the restricted cubic spline curves., Results: After adjusting for all potential confounding factors, an increase of 1 mmol/L in lactate levels was found to be associated with an 17% rise in the 28-day hospital mortality risk among sepsis patients (HR: 1.17, 95% CI: 1.08-1.27, P = 0.0002). When considering lactate as a categorical variable, the mortality risk of patients with lactate levels ≥ 2.2 mmol/L was significantly increased (HR: 3.61, 95% CI: 1.24-10.54, P = 0.0189). The restricted cubic spline curve analysis revealed a nonlinear correlation between lactate and 28-day mortality, with an inflection point at 2.2 mmol/L. Similar findings were also observed in the assessment of secondary outcomes., Conclusions: Our study demonstrates a non-linear correlation between lactate levels and 28-day mortality in pediatric sepsis, with a critical threshold of 2.2mmol/l for lactate levels in septic patients. Early assessment of lactate levels is recommended for children with sepsis to facilitate prompt intervention and mitigate the risk of fatality., (© 2024. The Author(s).)

Background: A considerable proportion of cellular phones (cell phones) used by healthcare workers (HCWs) have been shown to be contaminated with pathogenic micro-organisms, making these devices reservoirs to infect susceptible patients. Although many units have well-defined infection control protocols, methods for the decontamination of cell phones are scarce., Objectives: To compare the efficacy of ultraviolet C (UVC) light with that of 70% isopropyl alcohol in disinfecting cell phones used by HCWs in a paediatric intensive care unit (ICU)., Methods: A randomised controlled study in a paediatric ICU setting was conducted. Cell phones of HCWs or other personnel entering the ICU were swabbed prior to and after decontamination with either the 70% isopropyl alcohol or UVC light method. The reduction ratio of colony-forming units (CFUs) before and after intervention was analysed using the Mann-Whitney U-test. In addition, the effectiveness of the disinfection methods was compared using the Wilcoxon signed-rank paired test., Results: A total of 74 cell phones were acquired from HCWs working in the paediatric ICU. After excluding 5, 69 samples were therefore available for statistical analysis, with 34 samples subjected to disinfection using 70% isopropyl alcohol-based swabs and 35 samples treated with UVC light disinfection. Disinfection with 70% isopropyl alcohol (z=5.16; p<0.000001) and with UVC light (z=3.28; p<0.005) were individually statistically significantly effective in reducing CFUs. The CFU reduction ratio indicated that disinfection using a 70% isopropyl alcohol solution was 67% more effective than UVC light disinfection (Mann-Whitney U-test score 968; p<0.001)., Conclusion: Although both 70% isopropyl alcohol and UVC light disinfection effectively reduced CFUs following decontamination, 70% isopropyl alcohol was determined to be much more effective.

Objective: To investigate the clinical features, pathogen composition, and prognosis of septic shock in pediatric intensive care units (PICU) in China. Methods: A multicenter retrospective cohort study. A retrospective analysis was conducted on the clinical data of children with septic shock from 10 hospitals in China between January 2018 and December 2021. The clinical features, pathogen composition, and outcomes were collected. Patients were categorized into malignant tumor and non-malignant tumor groups, as well as survival and mortality groups. T test, Mann Whitney U test or Chi square test were used respectively for comparing clinical characteristics and prognosis between 2 groups. Multiple Logistic regression was used to identify risk factors for mortality. Results: A total of 1 247 children with septic shock were included, with 748 males (59.9%) and the age of 3.1 (0.9, 8.8) years. The in-patient mortality rate was 23.2% (289 cases). The overall pathogen positive rate was 68.2% (851 cases), with 1 229 pathogens identified. Bacterial accounted for 61.4% (754 strains) and virus for 24.8% (305 strains). Among all bacterium, Gram negative bacteria constituted 64.2% (484 strains), with Pseudomonas aeruginosa and Enterobacter being the most common; Gram positive bacteria comprised 35.8% (270 strains), primarily Streptococcus and Staphylococcus species. Influenza virus (86 strains (28.2%)), Epstein-Barr virus (53 strains (17.4%)), and respiratory syncytial virus (46 strains (17.1%)) were the top three viruses. Children with malignant tumors were older and had higher pediatric risk of mortality (PRISM) Ⅲ score, paediatric sequential organ failure assessment (pSOFA) score (7.9 (4.3, 11.8) vs. 2.3 (0.8, 7.5) years old, 22 (16, 26) vs. 16 (10, 24) points, 10 (5, 14) vs. 8 (4, 12) points, Z =11.32, 0.87, 4.00, all P <0.05), and higher pathogen positive rate, and in-hospital mortality (77.7% (240/309) vs. 65.1% (611/938), 29.7% (92/309) vs. 21.0% (197/938), χ 2 =16.84, 10.04, both P <0.05) compared to the non-tumor group. In the death group, the score of PRISM Ⅲ, pSOFA (16 (22, 29) vs. 14 (10, 20) points, 8 (12, 15) vs. 6 (3, 9) points, Z =4.92, 11.88, both P <0.05) were all higher, and presence of neoplastic disease, positive rate of pathogen and proportion of invasive mechanical ventilation in death group were also all higher than those in survival group (29.7% (87/289) vs. 23.2% (222/958), 77.8% (225/289) vs. 65.4% (626/958), 73.7% (213/289) vs. 50.6% (485/958), χ 2 =5.72, 16.03, 49.98, all P <0.05). Multiple Logistic regression showed that PRISM Ⅲ, pSOFA, and malignant tumor were the independent risk factors for mortality ( OR =1.04, 1.09, 0.67, 95% CI 1.01-1.05, 1.04-1.12, 0.47-0.94, all P <0.05). Conclusions: Bacterial infection are predominant in pediatric septic shock, but viral infection are also significant. Children with malignancies are more severe and resource consumptive. The overall mortality rate for pediatric septic shock remains high, and mortality are associated with malignant tumor, PRISM Ⅲ and pSOFA scores.

Background: The aim of the study is to investigate doctors' and nurses' beliefs and attitudes towards family presence and open visiting policies in Pediatric Intensive Care Units (PICUs) in Italy., Methods: A multicentric nationwide study was carried out in all 30 Italian PICUs. All doctors and nurses were asked to complete the Italian version of the Beliefs and Attitudes toward Visitation in ICU Questionnaire (BAVIQ). The questionnaire consists of 20 questions on beliefs and 14 on attitudes towards visiting., Results: The response rate was 89% (925 questionnaires), with 87% of nurses and 94% of doctors responding. Most respondents (85%) believed that visiting has a beneficial effect on the patient and that an open visiting policy can reduce parental anxiety (68%). However, nearly half the respondents believed that an open policy interferes with direct nursing care (45%) and makes them feel checked up on (49%). Multiple logistic regression conducted on the eight most representative items showed that factors associated with beliefs and attitudes opposing open visiting policies were: being a nurse, geographic area (working in PICUs in Central Italy or the South and Islands) and working in a cardiac surgery unit. Age showed a trend of younger professionals being more convinced that an open visiting policy can be beneficial for patients., Conclusions: Most healthcare professionals in Italian PICUs believe that an open visiting policy for families is beneficial for both the patient and his/her family. However, despite an overall positive attitude among PICU staff members, there is still some resistance in Italy, particularly among nurses and in cardiac surgery units.

Background: Parents of children in pediatric intensive care units have varied communication experiences with health care professionals. Little is known about factors associated with parents' perceptions of miscommunication., Objective: To examine children's clinical and parents' demographic and psychosocial factors associated with perceptions of miscommunication in the pediatric intensive care unit., Methods: This study was a cross-sectional survey of parents of children admitted to the pediatric intensive care unit between January 1, 2018, and February 29, 2020, with a stay of greater than 24 hours., Results: Most of the 200 parent respondents were female (83.4%), White (71.4%), and non-Hispanic (87.9%); median age was 39 years (mean [SD], 40.2 [8.75] years); 17.6% were Black or African American. Among 210 children, mean (SD) age was 6.1 (6.02) years, mean (SD) stay was 4.5 (6.2) days, 38.6% were admitted because of respiratory illness, and the admission was the first for 51.0%. Of the parents, 16.5% reported miscommunication in the pediatric intensive care unit. In multivariable linear regressions, parents' stress (β = 0.286), parents' views of clinician communication (β = -0.400), parents' trust in physicians (β = -0.147), and length of stay (β = 0.122) accounted for 45% of the explained variance in parent-perceived miscommunication (R2 = 0.448, F = 41.19, P < .001)., Conclusions: Parental stress and trust in physician scores were associated with perceived miscommunication. Further research is needed to understand the causes and consequences of miscommunication in order to support hospitalized children and their parents., (©2024 American Association of Critical-Care Nurses.)

Background: The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation., Methods: A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds., Results: Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613)., Conclusions: PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: To determine if ChatGPT can incorporate patient-specific information to provide high-quality answers to parental questions in the PICU. We hypothesized that ChatGPT would generate high-quality, patient-specific responses., Methods: In this cross-sectional study, we generated assessments and plans for 3 PICU patients with respiratory failure, septic shock, and status epilepticus and paired them with 8 typical parental questions. We prompted ChatGPT with instructions, an assessment and plan, and 1 question. Six PICU physicians evaluated the responses for accuracy (1-6), completeness (yes/no), empathy (1-6), and understandability (Patient Education Materials Assessment Tool, PEMAT, 0% to 100%; Flesch-Kincaid grade level). We compared answer quality among scenarios and question types using the Kruskal-Wallis and Fischer's exact tests. We used percent agreement, Cohen's Kappa, and Gwet's agreement coefficient to estimate inter-rater reliability., Results: All answers incorporated patient details, utilizing them for reasoning in 59% of sentences. Responses had high accuracy (median 5.0, [interquartile range (IQR), 4.0-6.0]), empathy (median 5.0, [IQR, 5.0-6.0]), completeness (97% of all questions), and understandability (PEMAT % median 100, [IQR, 87.5-100]; Flesch-Kincaid level 8.7). Only 4/144 reviewer scores were <4/6 in accuracy, and no response was deemed likely to cause harm. There was no difference in accuracy, completeness, empathy, or understandability among scenarios or question types. We found fair, substantial, and almost perfect agreement among reviewers for accuracy, empathy, and understandability, respectively., Conclusions: ChatGPT used patient-specific information to provide high-quality answers to parental questions in PICU clinical scenarios., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: As pediatric mortality improves, approaches to pediatric critical care now focus on understanding long-term implications of survivorship on patients and families. We aimed to characterize how patients recall time spent sedated and recovering to identify areas for improvement in patient outcomes., Methods: We undertook qualitative analysis using semistructured interviews of pediatric patients requiring extra-corporeal support in our intensive care units from 2018 to 2023. All patients were English-speaking, >12 years old at time of hospitalization, and able to communicate at an age-appropriate level. Priority sampling was given to those with more recent hospitalizations to improve recall. Interviews were recorded and transcribed before thematic, inductive analysis., Results: Forty-one patients met inclusion criteria; 14 patients were enrolled before achieving thematic saturation. Several themes emerged, centering on cognitive, physical, and socioemotional experiences during and after hospitalization. Notable findings include profound awareness under sedation, impaired sleep, challenges with communication, physical discomfort, frustration with activities of daily living limitations, and gratitude for provider and family presence. Postdischarge, patients highlighted persistent memory, concentration, sleep, and physical impairments, as well as emotional processing of their illness and mortality., Conclusions: Our findings describe how pediatric critical illness impacts short and long term cognitive, physical, and socioemotional outcomes for children in the ICU. Future research is necessary to study if there are specific, modifiable factors in patients' care that impacts their experience of critical illness, such as specific medication choices, diagnoses, communication styles, or physical and speech therapy interventions., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: Sleep promotion bundles being tested in PICUs use elements adapted from adult bundles. As children may react differently than adults in ICU environments, this study investigated what parents report disrupted the sleep of their child in a PICU., Design: Secondary analysis of a multicenter validation study of the Survey of Sleep quality in the PICU., Setting: Four Northeastern U.S. PICUs, one hospital-based pediatric sleep laboratory., Patients: Parents sleeping at the bedside of a child in the PICU or hospital-based sleep laboratory., Interventions: Anonymous one-time survey eliciting parts of hospital or ICU environments that have been described as disruptive to sleep in validated adult ICU and pediatric inpatient questionnaires., Measurements and Main Results: Level of sleep disruption was scored by Likert scale, with higher scores indicating more disruption. Age, demographics, baseline sleep, and PICU exposures were used to describe causes of sleep disruption in a PICU. Of 152 PICU parents, 71% of their children's sleep was disrupted significantly by at least one aspect of being in the PICU. The most prevalent were "being in pain or uncomfortable because they are sick" (38%), "not sleeping at home" (30%), "alarms on machines" (28%), and "not sleeping on their home schedule" (26%). Only 5% were disrupted by excessive nocturnal light exposure. Overall sleep disruption was not different across four PICUs or in those receiving sedation. The validation study control group, healthy children undergoing polysomnography, had less sleep disruption than those in a PICU despite sleeping in a hospital-based sleep laboratory., Conclusions: There are multiple aspects of critical care environments that affect the sleep of children, which are different from that of adults, such as disruption to home schedules. Future interventional sleep promotion bundles should include sedated children and could be applicable in multicenter settings., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Renal chloride metabolism is currently poorly understood but may serve as both a diagnostic and a treatment approach for acute kidney injury. We investigated whether plasma chloride, ammonia and glutamine as well as urinary chloride, ammonium and glutamine concentrations may serve as markers for acute kidney injury in paediatric patients. We conducted a prospective observational trial in a tertiary care paediatric intensive care unit. Ninety-one patients after cardiopulmonary bypass surgery were enrolled. Plasma glutamine, creatinine, (serum) albumin, urinary electrolytes and glutamine were collected pre-cardiopulmonary bypass surgery, at paediatric intensive care unit admission, and at 6, 12, 24, 48 and 72 h after paediatric intensive care unit admission. The urinary strong ion difference was calculated. The median urinary chloride excretion decreased from 51 mmol/L pre-cardiopulmonary bypass to 25 mmol/L at paediatric intensive care unit admission, and increased from 24 h onwards. Patients with acute kidney injury had lower urinary chloride excretion than those without. The median urinary strong ion difference was 59 mmol/L pre-cardiopulmonary bypass, rose to 131 mmol/L at 24 h and fell to 20 mmol/L at 72 h. The plasma chloride rose from 105 mmol/L pre-cardiopulmonary bypass to a maximum of 109 mmol/L at 24 h. At 24 h the plasma chloride concentration was associated with the presence of acute kidney injury. There was no association between plasma or urinary amino acids and chloride excretion or kidney injury. In conclusion, renal chloride excretion decreased in all patients, although this decrease was more pronounced in patients with acute kidney injury. Our findings may reflect a response of the kidneys to critical illness, and acute kidney injury may make these changes more pronounced. Targeting chloride metabolism may offer treatment approaches to acute kidney injury., Competing Interests: Declaration of conflicting interestsThe author(s) have no financial or non-financial interests or benefits related to the work published in this article to declare.

Background: Chest X-ray, the established standard of confirming endotracheal tube (ETT) position, has important drawbacks including radiation exposure. Point-of-care airway ultrasound, which has been insufficiently studied in children, can overcome these problems., Materials and Methods: This was a prospective cross-sectional study done on children aged 2 months to 17 years undergoing intubation with cuffed ETT in the PICU. The ETT cuff was filled with saline and three ultrasonographic techniques were used- 1) Suprasternal (SS) method 2) Cricoid (CC) metho and 3) Tracheal ring (TR) method. Position of the ETT as determined by ultrasound and X-ray were compared. The main outcomes were sensitivity, specificity, and area under curve (AUC) for ultrasound-based methods vs. X-ray. For the TR method, concordance between the X-ray and ultrasound categories were taken., Results: Total 62 patients were enrolled. The sensitivity and specificity of SS method were 71% (95% CI: 57-83%) and 100% (40-100%). The CC distance method had an AUC of 0.94 (95% CI: 0.86, 1.0). In the TR method, 98% of correct position on X-ray were correctly classified by USG. The agreement between X-ray and ultrasound categories with the cuff between the first and third tracheal rings, was very good [kappa (95% CI): 0.87 (0.70, 1.00), p ≤0.001)]., Conclusion: Bedside ultrasound is a good method to confirm ETT depth in children. The tracheal ring method had the best diagnostic accuracy and is easy to perform. The new method using cricoid cuff distance needs further validation in different ICU settings., Competing Interests: Declaration of competing interest The authors report no conflict of interest related to this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objectives: Manual blood exchange (MBE) is a leukoreduction therapy for hyperleukocytosis in Bordetella spp., Infection: We describe the impact of BE on clinical and biological parameters in critically ill children with malignant pertussis., Materials and Methods: This is a monocentric retrospective review of patients with malignant pertussis infection treated with MBE. It describes the evolution of haemodynamic, ventilatory, haematologic and metabolic characteristics before and after MBE., Results: Between January 2006 and December 2021, nine patients (median age 43 days, range: 13-80 days) had 16 MBE for malignant pertussis. All patients were mechanically ventilated, and 7/9 patients developed pulmonary hypertension during their paediatric intensive care unit (PICU) stay. Overall, 3/9 patients survived, and the mean PICU length of stay was 8.5 days (range: 1-52 days). We found a significant reduction of the leukocyte count (pre-MBE: 61.8 G/L [interquartile range (IQR): 55.8-74.8] vs. post-MBE: 19.4 G/L [IQR: 17.7-24.1]; p ≤ 0.001) and significant oxygenation improvement (pre-MBE SpO 2 /FiO 2 : 190 [IQR: 106-200] vs. post-MBE SpO 2 /FiO 2 : 242 [IQR: 149-250]; p = 0.03). The main side effects were a significant reduction of thrombocytes (pre-MBE: 411 G/L [IQR: 166.5-563.5] vs. post-MBE: 66 G/L [IQR: 46-82.5]; p = <0.001) and of ionized calcium (iCa) (pre-MBE iCa: 1.3 [IQR: 1.22-1.37] vs. post-MBE iCa: 1.25 [IQR: 1.85-2.24]; p = 0.03)., Conclusion: MBE efficiently reduces leukocytes and improves oxygenation in severe Bordetella pertussis infection in infants. Careful monitoring of calcium and thrombocytes seems mandatory., (© 2024 The Author(s). Vox Sanguinis published by John Wiley & Sons Ltd on behalf of International Society of Blood Transfusion.)

Objectives: We previously derived the updated Pediatric Sepsis Biomarker Risk for Acute Kidney Injury (PERSEVERE-II AKI) prediction model, which had robust diagnostic test characteristics for severe AKI on day 3 (D3 severe AKI) of septic shock. We now sought to validate this model in an independent cohort of children to the one in which the model was developed., Design: A secondary analysis of a multicenter, prospective, observational study carried out from January 2019 to December 2022., Setting: Ten PICUs in the United States., Patients: Children with septic shock 1 week to 18 years old admitted to the PICU., Interventions: None., Measurements and Main Results: Seventy-nine of 363 patients (22%) had D3 severe AKI, defined as Kidney Disease Improving Global Outcomes stage 2 or higher. Patients were assigned a probability of D3 severe AKI using the PERSEVERE-II AKI model. The model predicted D3 severe AKI with an area under the receiver operating characteristic curve of 0.89 (95% CI, 0.85-0.93), sensitivity of 77% (95% CI, 66-86%), specificity of 88% (95% CI, 84-92%), positive predictive value of 65% (95% CI, 54-74%), and negative predictive value of 93% (95% CI, 89-96%). These data represent an increase in post-test probability of D3 severe AKI with a positive test from 22% to 65%, and a prevalence threshold of 28%. On multivariable regression, the PERSEVERE-II AKI prediction model demonstrated greater adjusted odds ratio (aOR) for D3 severe AKI (aOR, 11.2; 95% CI, 4.9-25.3) and lesser aOR for failure of D3 renal recovery from early AKI (aOR, 0.31; 95% CI, 0.13-0.69)., Conclusions: The PERSEVERE-II AKI model demonstrates consistently robust performance for prediction of new or persistent D3 severe AKI in children with septic shock. A major limitation is that actual D3 severe AKI prevalence is below the prevalence threshold for the test, and thus future work should focus on evaluating use in enriched populations., Competing Interests: Dr. Stanski’s institution received funding from the National Institute of General Medical Sciences (NIGMS); she disclosed that they hold a provisional patent for the Pediatric Sepsis Biomarker Risk for Acute Kidney Injury (AKI) Prediction Model. Drs. Stanski, Cvijanovich, Fitzgerald, Thomas, Weiss, Atreya, Lautz, and Kaplan received support for article research from the National Institutes of Health. Dr. Cvijanovich’s institution received funding from the Cincinnati Children’s Hospital Medical Center, the Nationwide Children’s Hospital, the Boston Children’s Hospital, and the Collaborative Pediatric Critical Care Research Network. Dr. Fitzgerald received funding from the National Institute of Diabetes and Digestive and Kidney Diseases (K23DK119463, P50DK114786) and the Commonwealth of Pennsylvania Department of Health Cure Grant. Dr. Jain received funding from AltaThera Pharmaceuticals. Dr. Lautz received funding from the NIGMS (K08GM148957-01, R21GM150093-01, and L40GM134527-03). Dr. Atreya’s institution received funding from the Cincinnati Children’s Research Foundation; he disclosed that they hold a provisional patent for the integrated PERSEVERE and endothelial biomarker risk model to predict sepsis-associted acute kidney injury (PERSEVEREnce SA-AKI model); and he received funding through the Procter K to R Scholar program awarded by the Cincinnati Children’s Research Foundation and the NIGMS (R21GM151703 and R21GM15009). Dr. Weiss received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD102396, R01HD101528) and the U.S. Centers for Disease Control and Prevention (75D30123C17693). Dr. Zingarelli’s institution received funding from the NIGMS (R01 GM115973, R21 GM151734, 1R21GM150093, and R01GM145698); she received funding from the National Heart, Lung, and Blood Institute (R01 HL141229); and she disclosed that they are editor of the Shock journal. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: The development of new morbidities has become increasingly identified in paediatric critical care medicine. To date, there has been limited research of long-term outcomes following paediatric critical illness in Australia., Objectives: The objective of this study was to quantify neurodevelopmental impairments in children following paediatric intensive care unit (PICU) discharge and their association with health-related quality of life (HRQoL)., Methods: A single-centre ambidirectional cohort study at an Australian hospital. Parents of children admitted to the PICU between 2015 and 2017 were invited to participate. Neurodevelopmental outcome and HRQoL was prospectively evaluated, using the Ages and Stages Questionnaire (<5 years), Strengths and Difficulties Questionnaire (≥5 years), and Pediatric Quality of Life Inventory™, respectively., Results: A total of 230 parents of critically ill children participated. Children were 1.9 years old (median, interquartile range [IQR]: 0.2, 7.5), male (59.6%), and ventilated (49.1%) at PICU admission. The median time to follow-up was 24.4 months (IQR: 16.3, 36.7). Parent respondents were more likely to be female (85.5%), White (88.3%), and partnered (81.1%). The incidence of overall neurodevelopmental impairment was 30% (33% in children aged <5 years; 24% in children aged ≥5 years). The incidence of poor HRQoL was 37.9%. History of developmental delay was independently associated with overall neurodevelopmental impairment (adjusted odds ratio [aOR]: 4.21, 95% confidence interval: 2.05, 8.63) and poor HRQoL (aOR: 7.29, 95% confidence interval: 3.26, 16.27). Two or more PICU admissions (aOR: 4.10, IQR: 1.82, 9.26) was also associated with poor HRQoL., Conclusions: This is the first contemporary view of PICU long-term outcomes conducted in Australia and significantly informs ongoing research in this area. Approximately one-third of PICU survivors demonstrate neurodevelopmental impairment and reduced quality of life. Multiple domains of post-intensive care syndrome-paediatrics must be considered to have a comprehensive understanding of child outcomes. Assessment of baseline/premorbid functioning is also essential in order to understand the true impact of illness and PICU admission., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Background: There is scarcity of data on the incidence and factors associated with the occurrence of ocular lesions in critically ill children., Aim: Test the applicability and utility of an ocular assessment scale and to identify risk factors of ocular lesions., Study Design: Prospective observational study. A tertiary care medical-surgical Paediatric Intensive Care Unit. 194 children without previous ocular disease who stayed in the Paediatric Intensive Care Unit for more than 48 h. An ocular lesions risk scale was designed including risk factors lagophthalmos, eye dryness, conjunctival hyperemia, slow blinking, intubation, sedation, relaxation, face mask and hemodynamic instability. Patients were classified as high-, medium-, and low-risk patients. Corneal lesions were examined by fluorescein staining according to their risk and were confirmed by an ophthalmologist., Results: 76 patients were examined with fluorescein staining. Thirty-two ocular lesions were detected by nursing staff, 26 confirmed by the ophthalmologist. 53.6% of the high-risk patients developed a corneal lesion. Univariate analysis revealed an association between ocular damage and all factors included in the scale, except for face mask. In the multivariate analysis, ocular lesions were associated with lagophthalmos, hyperemia, invasive mechanical ventilation and inotropic support., Conclusions: The scale was useful to detect corneal lesions in critically ill children. The identification of risk factors will enable the development of measures to reduce the incidence of ocular lesions., Relevance for Clinical Practice: A new, non-validated scale allowed staff to detect eye injuries, study this problem and improve future prevention., (© 2023 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Objectives: Advances in critical care technology have lowered mortality rates among critically ill individuals. Nonetheless, survivors and their families may develop new physical, mental, cognitive, and social challenges due to paediatric intensive care unit (PICU) treatments, impacting their quality of life. The aim of this study was to investigate the survival journey and post-traumatic growth process of children and their families following PICU admission within the Chinese cultural context., Methods: Twenty-six children who have been or are currently admitted to the PICU, alongside their parents and three PICU nurses, were chosen through purposive and theoretical sampling. Data collection involved face-to-face interviews and observations, with data analysis conducted through continuous comparison, open coding, and selective coding techniques., Findings: A model outlining the survival journey and post-traumatic growth process of critically ill children and their families post PICU admission has been established. This model encompasses two central trajectories: an upward trajectory consisting of confusion, charging, action, and sublimation phases and a downward trajectory comprising confusion, doubt and fear, inhibition (including confrontation and avoidance), and drowning phases., Conclusions: Critically ill children and their families encounter diverse survival experiences and psychological journeys following traumatic events in the PICU. The survival experience has alternative upwards or downwards trajectories that are flexible/adaptable. Hence, offering timely psychological support can alter their developmental trajectories and foster post-traumatic growth., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Although a child- and family-centred care (CFCC) philosophy has been emphasized and adopted for decades in paediatric critical care settings in several countries, numerous issues from parents' perspectives regarding the philosophy remain unresolved. To facilitate the full translation of CFCC into clinical practice, health care professionals need an in-depth understanding of family experiences. Real-life mothering experiences, including maternal roles and identities, remain largely unknown at paediatric intensive care units (PICUs) in the Republic of Korea, where family visitation, presence, and participation are restricted., Aim: To explore mothering experiences at a PICU where family visitation is strictly constrained, and to identify maternal needs and values., Study Design: We conducted a qualitative descriptive study of eight individual in-depth interviews with seven mothers of hospitalized children. Qualitative data were analysed using inductive thematic analysis., Findings: Five major themes, along with four subthemes, emerged: (1) shifts in maternal roles and responsibilities, (2) shifts in interpersonal relationships, (3) desire for CFCC in the PICU, (4) practising self-defined mothering roles, and (5) reconstructing maternal identities. The themes revealed the experiences of becoming mothers of a child in a constrained PICU. Ultimately, mothers demanded that the unit improve its physical and cultural environments through, for example, liberalized family visitation and participation in the care of their children., Conclusions: Nursing professionals should lead the charge for humanizing a restrictive PICU in the Republic of Korea by ensuring a safe and open environment and mothering continuity based on child- and family-centred holistic care., Relevance to Clinical Practice: Effective interventions must be developed and tested to globally establish and fully implement strong evidence-based CFCC in PICUs; constant co-commitment among children, families, health care professionals, and institutions is also necessary., (© 2023 British Association of Critical Care Nurses.)

Objective: To assess the outcome of patients with cancer-related sepsis requiring continuous renal replacement therapy (CRRT) in a single-center pediatric intensive care unit (PICU)., Method: Children with sepsis who necessitate CRRT from January 2017 to December 2021 were enrolled. The patients with leukemia/lymphoma or solid tumors were defined as underlying cancer. Multivariate logistic regression analysis was performed to identify the death risk factors in patients with cancer-related sepsis., Results: A total of 146 patients were qualified for inclusion. Forty-six (31.5%) patients with cancer-related sepsis and 100 (68.5%) non-cancer-related sepsis. The overall PICU mortality was 28.1% (41/146), and mortality was significantly higher in cancer-related sepsis patients compared with non-cancer patients (41.3% vs. 22.0%, p = 0.016). Need mechanical ventilation, p-SOFA, acute liver failure, higher fluid overload at CRRT initiation, hypoalbuminemia, and high inotropic support were associated with PICU mortality in cancer-related sepsis patients. Moreover, levels of IL-6, total bilirubin, creatinine, blood urea nitrogen, and international normalized ratio were significantly higher in non-survivors than survivors. In multivariate logistic regression analysis, pediatric sequential organ failure assessment (p-SOFA) score (OR:1.805 [95%CI: 1.047-3.113]) and serum albumin level (OR: 0.758 [95%CI: 0.581 -0.988]) were death risk factors in cancer-related sepsis receiving CRRT, and the AUC of combined index of p-SOFA and albumin was 0.852 (95% CI: 0.730-0.974)., Conclusion: The overall PICU mortality is high in cancer-related sepsis necessitating CRRT. Higher p-SOFA and lower albumin were independent risk factors for PICU mortality., Competing Interests: Conflicts of interest The authors declare no potential conflicts of interest with respect to the study, authorship, and/or publication of this article. The authors emphasize that none of the corporations were involved in the laboratory method or sponsoring the study., (Copyright © 2024 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Objectives: To evaluate echocardiographic parameters, especially the Tei index as a predictor of outcome in critically ill children on continuous renal replacement therapy (CRRT)., Methods: This cohort study included all critically ill patients admitted at the Pediatric intensive care unit (PICU) and underwent CRRT. Functional echocardiography and Pediatric Risk of Mortality Index (PRISM) III were used to evaluate the participants. Both the Tei index and the Vasoactive inotropic score (VIS) were estimated., Results: The study included 35 patients with an age range of 6 mo to 14 y. The Tei indexes, VIS, and PRISM III were reported as predictors of mortality with a sensitivity of 88%, 83%, and 94% and a specificity of 73%, 79%, and 89% respectively. In survivors, the mean Tei index score, median VIS, and mean PRISM values were 0.44 ± 0.1, 3.8 (0-40), and 12.06 ± 3.35, respectively. However, in non-survivors, the mean Tei index, median VIS, and mean PRISM score were 0.59 ± 0.16, 0.60 (0-342.5), and 22.94 ± 8.93, respectively., Conclusions: The Tei index could be used as a predictor for poor outcomes in children receiving CRRT. It is correlated to the PRISM score and VIS., (© 2023. The Author(s).)

This retrospective study aims to analyze the baseline characteristics and factors associated with poor outcomes in patients with necrotizing enterocolitis (NEC) complicating respiratory syncytial virus (RSV) infection. Using the Virtual Pediatric Systems data registry, patients under 2 years admitted to the pediatric intensive care unit (PICU) were screened. Patients with documented RSV infection and NEC, intestinal perforation, noninfectious gastroenteritis/colitis, or pneumatosis intestinalis occurring around the timing of RSV bronchiolitis diagnosis were included. Out of the screened patients, 41 were analyzed. Most patients (93%) were aged 30 days to 2 years, one-third had baseline anatomical cardiac defects, and 20% history of prematurity. Median PICU length of stay was 11.7 days. Seven patients died before hospital discharge. While not statistically significant, nonsurvivors tended to exhibit higher PRISM-3 scores, more acidemia, and lower systolic blood pressure. These findings emphasize the need for cautious assessment of gastrointestinal symptoms in critically ill patients with RSV infection., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Cardiovascular dysfunction is a significant factor contributing to weaning failure in mechanically ventilated children. Understanding the cardiopulmonary pathophysiological changes that occur during weaning is a prerequisite for the early recognition of weaning failure of cardiovascular origin. This study aimed to assess the effect of weaning trials on central hemodynamics and to identify the indices predictive of cardiac-related weaning failure., Methods: This prospective observational study was conducted in the Pediatric Intensive Care Unit (PICU) and included mechanically ventilated patients aged between 2 and 30 months who were on minimal ventilatory settings and ready for weaning. Patients who were hemodynamically unstable, diagnosed with neuromuscular diseases, or diagnosed with cardiac diseases were excluded. Hemodynamic parameters were evaluated during weaning from ventilation via echocardiography and noninvasive cardiometry during pressure support (PS) ventilation and at the end of the spontaneous breathing trial (SBT)., Results: The study included 50 patients, comprising 30 males (60%) and 20 females (40%) with ages ranging from 2 to 30 months. Echocardiography revealed a significant increase in the cardiac index (CI), tricuspid annular plane systolic excursion (TAPSE), and the E/A ratio at the end of SBT. Moreover, right ventricular systolic pressure (RVSP) significantly decreased. Noninvasive cardiometry revealed a significant increase in the index of contractility (ICON) and CI at the end of SBT (p-value = 0.023 and < 0.001, respectively). Of the 12 (25%) patients who failed their first extubation trial, they exhibited a significantly lower CI and TAPSE (p values = 0.001 and 0.001, respectively)., Conclusion: This study identified that weaning from mechanical ventilation in children is associated with hemodynamic changes, which can impact weaning success and reveal potential ventricular dysfunction. Bedside echocardiography was found to detect cardiac dysfunctions during weaning, and noninvasive cardiometry was considered a reliable tool that supports echocardiography for detecting changing trends in CI in PICUs. However, accurate values should be confirmed by echocardiography., (© 2024. The Author(s).)

Objectives: To validate a method for continuously estimating the Pao 2 /Fio 2 (PF) ratio in all critically ill pediatric patients using only standard continuous data monitoring., Design: Retrospective study on a high temporal resolution database., Setting: PICU in Montreal, QC, Canada., Patients/subjects: We included any patients admitted from May 2015 to May 2023 who had an arterial blood gas (ABG) with concurrent continuous pulsed oximetry saturation (Spo 2 ) values. We used our previously validated mathematical model to determine the magnitude of hypoxemia by computing the estimated ePao 2 /Fio 2 (ePF) ratio and comparing it to the Spo 2 /Fio 2 (SF), using PF ratio as the reference standard., Interventions: None., Measurements and Main Results: We analyzed a total of 20,828 ABGs. When Spo 2 was below or equal to 97%, the ePF ratio showed a significantly better hypoxemia classification (none, light/moderate, or severe) than the SF ratio (0.80 vs. 0.72; p < 0.001), a lower fixed bias (16.26 vs. -35.24; p < 0.001), a lower mean absolute error (37.92 vs. 63.93; p < 0.001) and a lower proportional bias (slope of 1.01 vs. 0.81; p < 0.001). ePF ratio has also a better limits of agreement difference from Bland-Altman plot (248.10 vs. 292.45; p < 0.001) and coefficient of determination (0.68 vs. 0.59; p < 0.001). When Spo 2 was above 97%, the ePF ratio had better classification with Kappa (0.53 vs. 0.43; p < 0.001) and lower fixed bias (-0.63 vs. 65.68; p < 0.001)., Conclusions: The PF ratio based on ePF allows for a continuous estimation of hypoxemia severity with a better performance than the SF ratio., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Though 60-80% of hospitalized patients have an intravascular device placed during hospitalization, there is a substantial risk of complication related to the placement, maintenance and removal of these devices. The objectives of this study were to describe vascular access device use, device complications and lumen dysfunction., Methods: An observational cohort study was conducted over a 4.5 years period, in two quaternary, university-affiliated paediatric intensive care units (ICU). Eligible patients were admitted to either the paediatric or cardiac ICU and had one or more vascular access devices in-situ at the time of enrolment. Vascular access devices were defined as any external connection directly into the circulation including peripheral and central veins, arteries or bone marrow. Consistent with practice in the studied ICUs removal of peripheral catheters was regarded as due to dysfunction or complication., Results: 220 patients, 683 devices and 924 lumens were observed. The device complication rate was 21% and the lumen complication rate was 25%. The median duration without complication was 18 days for arterial catheters, 14 days for central venous catheters; 13 days for peripherally inserted central catheters and 4 days for peripheral intravenous catheters. On one third of all patient days, the volume of fluid administered to maintain VADs was equal to or greater than 20% of the total hourly total fluid intake., Conclusion: Approximately 1 in 5 vascular devices had one or more complications in ICU, most devices continued to be used without removal, and some complications resolved. The implications of the fluids infused to maintain device function warrants further study, as do strategies to resolve or limit the their complications in children., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gaetani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Importance: Postoperative thrombosis is a significant complication in pediatric cardiac surgery patients, contributing to morbidity and mortality. Identifying clinical factors associated with thrombosis can improve patient outcomes by guiding early detection and intervention., Objectives: This study aimed to assess factors associated with postoperative thrombosis or thromboembolism in pediatric patients under 12 months old who underwent surgery for congenital heart disease (CHD). Design, Setting, and Participants: This retrospective cohort study analyzed electronic medical records from pediatric patients admitted to the Pediatric Cardiovascular Intensive Care Unit (PCICU) at the German Paediatric Heart Center, Bonn, between March 1, 2020, and March 1, 2021. A total of 197 children under 12 months old who underwent cardiac surgery were included in the analysis., Main Outcomes and Measures: Thrombosis was diagnosed postoperatively using imaging modalities such as ultrasound, echocardiography, and computed tomography. The primary outcome was the incidence of thrombosis and its association with clinical factors such as age, central venous catheter (CVC) duration, CRP levels, and D-dimer levels., Results: Among 197 patients, the incidence of thrombosis was 8.63%, predominantly venous (70.6%). Initial associations were observed between thrombosis and younger age, lower body weight, higher hematocrit, cyanosis, longer central venous catheter (CVC) use, and elevated C-reactive protein (CRP) and d-dimer levels. Receiver operating characteristic analysis indicated a higher risk in patients with d-dimer levels above 5.47 mg/L. The stepwise multiregression analysis identified longer CVC duration in situ (β = 0.553; p < 0.001), higher CRP levels (β = 0.217; p = 0.022), and younger age at admission (β = -0.254; p = 0.006) as significant predictors of thrombosis. Decision tree analysis identified CVC use longer than 12.5 days and CRP levels above 118.01 mg/L as the most critical risk factors., Conclusions and Relevance: Postoperative thrombosis is a notable risk in pediatric CHD patients, particularly in neonates. Prolonged CVC use and elevated CRP levels are critical risk factors. Routine monitoring of D-dimer and CRP levels, along with timely sonographic screening, can aid early thrombosis detection and intervention. Further research is warranted to optimize thrombosis prevention strategies in this population., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Nutrition significantly impacts the outcomes of critically ill children in intensive care units (ICUs). Due to the evolving metabolic, neuroendocrine, and immunological disorders associated with severe illness or trauma, there are dynamically changing phases of energy needs requiring tailored macronutrient intake., Objectives: This study aims to assess the changing dietary needs from the acute phase through recovery, provide recommendations for implementing evidence-based strategies to ensure adequate energy and nutrient provision in pediatric ICUs, and optimize patient outcomes., Methods: A comprehensive search of the MEDLINE-PubMed database was conducted, focusing on randomized controlled trials, meta-analyses, and systematic reviews related to the nutrition of critically ill children. The study highlights recent guidelines using the GRADE approach, supplemented by relevant adult studies, current clinical practices, challenges, gaps in knowledge, and future directions for research aimed at improving nutritional interventions., Results: Early personalized, incremental enteral feeding helps mitigate the negative energy balance during the acute phase, aids organ function restoration in the stabilization phase, and supports growth during the recovery phase and beyond. Conversely, early full nutritional support, high protein doses, or isolated micronutrient administration have not demonstrated benefits due to anabolic resistance in these patients. Moreover, early parenteral nutrition during the acute phase may suppress autophagy and lead to worse outcomes. Accurate assessment of nutritional status and monitoring of daily energy and protein needs are crucial., Conclusions: Strong evidence supports the establishment of a dedicated nutritional team and the implementation of individualized nutritional protocols in the ICU to reduce morbidity and mortality in critically ill children.

Objectives: Identifying high-risk paediatric patients with a poor prognosis and providing timely and adequate treatment are critical. This study aimed to evaluate the effects of different types of cardiac enzyme spectrum within 24 hours of admission on the short-term prognosis of patients in paediatric intensive care units., Design: A retrospective study., Setting: A single-centre, tertiary care hospital in China, with patient data from 2010 to 2018., Participants: A total of 4343 critically ill children were enrolled., Intervention: None., Primary and Secondary Outcome Measures: The main outcome measure was in-hospital mortality, which was defined as death from any cause during hospitalisation. The secondary outcome was 30-day mortality, intensive care unit (ICU) length of stay (LOS) and total LOS., Results: Using the local polynomial regression fitting method, an approximately linear increase in in-hospital mortality was detected for creatine kinase (CK), creatine kinase MB (CK-MB), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH). Among the different types of cardiac enzyme spectrum, LDH had the highest area under the curve value (0.729), followed by AST (0.701), CK-MB (0.613) and CK (0.557). The Kaplan‒Meier analysis showed that the patients in the high LDH group had higher 30-day mortality. The multivariate logistic regression revealed that high LDH was independently associated with in-hospital mortality (OR 2.45, 95% CI 1.84 to 3.24). After propensity score matching (PSM) and sensitivity analysis, the results remained consistent., Conclusions: LDH is a reliable outcome predictor in critically ill children, including those with various comorbidities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Inborn errors of immunity (IEI) are a heterogeneous group of genetic diseases characterized by impaired immune system function. This prospective study aimed to determine the frequency, characteristics, and clinical course of IEI patients admitted to the pediatric intensive care unit (PICU) and identify mortality-related factors. Using a comprehensive immunological evaluation protocol, we screened 753 PICU admissions for potential IEIs during three years. Patients with pre-existing IEI diagnoses, chronic diseases, ongoing chronic medication regimens, other known comorbidities, trauma cases, post-surgical cases, and poisonings were excluded. Thirty-three patients were newly diagnosed with IEIs during or as a result of their PICU stay, representing an incidence of 4.39%. The most common disorders were immunodeficiencies with immune dysregulation (48.5%), followed by combined immunodeficiencies (24.2%). Severe viral infections (61%) and life-threatening infections (51.7%) were the most frequent warning signs. Only 31% of patients exhibited at least two Jeffrey Modell Foundation warning signs. The mortality rate was 58%, highlighting the need for early diagnosis and treatment. Newborn screening and family segregation studies are crucial to improving outcomes for IEI patients in intensive care settings., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: This retrospective study aimed to analyze the clinical characteristics and toxicological spectrum of acute poisoning in children treated at our pediatric intensive care unit. The findings provide a basis for the treatment and prevention of acute poisoning in children., Methods: Clinical data of hospitalized children aged 0 to14 years with acute poisoning, treated between January 2015 and December 2023, were collected and analyzed. The analysis included the types of poisoning, sex and age distribution of children, routes and causes of poisoning, time from poisoning to medical consultation, length of hospital stays, and treatment outcomes., Results: Among the 493 cases of acute poisoning in children, pesticide poisoning (n = 252, 51.1%) was the most common type, followed by medication poisoning (n = 182, 36.9%). Chemical poisoning accounted for 7.7% (n = 38), while food poisoning and inhalation of harmful gases accounted for 3.0% (n = 15) and 1.2% (n = 6), respectively. The main route of poisoning was oral ingestion (n = 477, 96.8%), while accidental ingestion accounted for a large proportion (n = 379, 79.4%), and adolescents aged 11 to 14 years accounted for 20.6% (n = 98).Apart from the predominance of girls attempting suicide by self-administering antipsychotic medications (n = 88, 75.9%) due to depression, there was no significant difference in sex distribution among other types of poisoning children. The highest incidence of poisoning except children who self-administer antipsychotic drugs occurred in children aged 1-3 years (n = 267, 54.2%) and 8-14 years (n = 135, 27.4%), with the highest proportion in the preschool age group. The average time from poisoning to medical consultation was 33.4 ± 54.9 h, and majority of children received treatment within 48 h after poisoning (n = 423, 85.8%). The overall effective treatment rate was 96.8%., Conclusion: Acute poisoning in children has complex and diverse causes, with accidental ingestion being the main route. Prevention should be emphasized, including strengthening child safety education and improving parental supervision. Moreover, psychological health education is crucial for adolescents during their puberty. In the event of acute poisoning, prompt medical consultation and appropriate treatment are necessary to mitigate adverse outcomes., (© 2024. The Author(s).)

Objective: To analyze the diagnosis and treatment of children with rare diseases in the pediatric intensive care unit (PICU), the distribution of disease types and populations, clinical characteristics, and the use of orphan drugs. Methods: A retrospective case summary was conducted. Data were collected from 105 children aged 29 days to <18 years with a confirmed diagnosis of rare diseases according to the "First Batch of Rare Disease Catalogue in China" who were admitted to the PICU of Beijing Children's Hospital, Capital Medical University from January 2020 to December 2022. Data including general information, auxiliary examinations, and treatment details for each patient were collected from the hospital's electronic medical record system. Patients were divided into age groups: infancy (29 days to<1 year), early childhood (1 to <3 years), preschool age (3 to<7 years), school age (7 to<13 years), and adolescence (13 to<18 years) . The chi-square test was used to compare gender distribution differences among various rare diseases. Results: A total of 105 patients with 130 cases meeting the diagnostic criteria were included, accounting for 4.7% (130/2 754) of the total admissions to the PICU. The age at PICU admission was 5.3 (0.8, 9.5) years and there were 81 cases in male. The 3 most common types of diseases were endocrine, nutritional, and metabolic diseases (37 cases); followed by neurological disorders(32 cases); and congenital malformations, deformities, and chromosomal abnormalities(17 cases). The 5 most common rare diseases were methylmalonic acidemia (14 cases), mitochondrial encephalomyopathy (14 cases), atypical hemolytic uremic syndrome (12 cases), autoimmune encephalitis (12 cases), and idiopathic cardiomyopathy (9 cases). The distributions of common rare diseases varied among different age groups. In infants, atypical hemolytic uremic syndrome was most common (6 children). There was no statistically significant difference regarding gender among children with mitochondrial encephalomyopathy (13.6% (11/81) vs. 6.1% (3/49), χ 2 =1.77, P =0.184). Respiratory failure (36 cases) was the primary reason for rare diseases children to be admitted to the PICU. A total of 95 cases underwent mechanical ventilation, 39 cases received multidisciplinary collaborative diagnosis and treatment, and only 6 children received orphan drug therapy during their stay in the PICU. Conclusions: Rare diseases are not uncommon in PICU. Endocrine, nutritional and metabolic disorders, neurological disorders, congenital malformations, deformities, and chromosomal abnormalities were common. Methylmalonic acidemia, mitochondrial encephalomyopathy, atypical hemolytic uremic syndrome and autoimmune encephalitis have higher cases. Many children with rare diseases in the PICU have complex conditions those are challenging to treat, requiring multidisciplinary collaboration. The utilization rate of orphan drugs among children with rare diseases in PICU needs to be improved.

Objectives: Patients with liver transplant can present to a pediatric emergency department with short- and long-term complications of transplant. Here, we described clinical features of pediatric liver transplant patients admitted to the pediatric emergency department and identified risk factors that may lead to pediatric intensive care unit admission., Materials and Methods: We retrospectively evaluated pediatric liver transplant patients admitted posttransplant to Baskent University Hospital's pediatric emergency department in 2023. We noted symptoms, laboratory tests, hospitalization status, and final diagnoses. We compared clinical and laboratory features of patients admitted or not admitted to the intensive care unit., Results: In 2023, 108 presentations of 33 liver transplant patients presented to our pediatric emergency department: 46.3% were girls, mean age was 7.79 ± 4.40 years, and median posttransplant day at time of emergency department visit was 622 days. Common symptoms were vomiting (48%), fever (46%), and rhinorrhea and cough (34%). Forty-nine visits (45.4%) resulted in hospitalization; 5 visits (4.6%) resulted in PICU admission, with 2 mortalities (1.8%). Final diagnoses included acute gastroenteritis and upper respiratory tract infections (23 patients) and lower respiratory tract infections (13 patients). Seven patients had cholangitis, 6 had intra-abdominal infection, and 5 had sepsis. Seizures and sepsis were significantly correlated with intensive care unit admission (P <.001). Patients admitted to the intensive care unit had significantly shorter time posttransplant versus other patients (518 ± 324 vs 1498 ± 1658 days; P < .001)., Conclusions: Half of patients who presented to the emergency department required hospitalization mainly for observation and supportive treatment, with a small number requiring intensive care unit admission. Nevertheless, physicians caring for liver transplant patients should be aware of serious complications and monitor patients closely, especially early posttransplant when intensive immunosuppressive treatment regimens are used.

Objective: To test the validity of the paediatric early warning score (PEWS) and to identify the patients with deteriorating clinical conditions who were reviewed by a rapid response team (RRT) and were advised higher level of care., Study Design: Observational study. Place and Duration of the Study: Paediatric ward and high dependency unit (HDU) of The Aga Khan University Hospital (AKUH), Karachi, Pakistan, from January 2021 to March 2022., Methodology: All children aged 1 month to 18 years, admitted with non-surgical diagnoses at AKUH and referred for an RRT consultation were identified by non-probability consecutive sampling. The bedside nurse assessed the PEWS and alerted the clinical team. The patient's further course of action was decided based on the PEWS, detailed systemic examination, and laboratory workup. This aided in deciding the level of care (General ward, HDU, Paediatric Intensive Care Unit) required by the patients. Patients with length of stay >24 hours were included and those with did not resuscitate orders were excluded., Results: Overall 10,032 patients were admitted to the ward and high dependency unit (HDU). Out of which, 323 (3.2%) patients had an RRT call and were included in the study. The median age of the study population was 3.15 years during the study period, and 30.3% were <1 year. System-wise admission diagnoses included respiratory (33.2%) and neurological diseases (16.1%). Median [interquartile range (IQR)] PEWS at RRT call was 2 (IQR, 1-2) on median admission day 2 (IQR, 1-3). The cumulative data at PEWS ≥3 demonstrated an area under the curve of 63% with a sensitivity of 90% and a specificity of 30%., Conclusion: PEWS >3 can probably identify the patients at risk of deterioration with excellent sensitivity., Key Words: Paediatrics, Rapid response team, Early warning score.

Globally, sepsis is the primary cause of death for children. While research conducted on adults has a significant impact on the diagnosis and treatment of sepsis in newborns and young children, there are significant factors that are pertinent to pediatrics as well. This prospective case-control study was conducted during the period from August 2020 to October 2022 after approval by the institutional ethical committee. The study included 48 critically ill children admitted at the Pediatric intensive care unit and 30 apparently healthy children as a control group. Laboratory investigations including complete blood picture, C-reactive protein (CRP), blood culture and sensitivity and plasma level of cluster of differentiation 64 (CD64) and myeloperoxidase (MPO) were investigated for all participants. A daily follow up for the signs of systemic inflammatory response syndrome (SIRS) or sepsis was done, and the patients were divided into SIRS and non-SIRS subgroups then patients were divided into two groups according to the presence of severe sepsis. A follow up CD64 and MPO sample were withdrawn from them to assess their prognostic value. SIRS was reported in 39.58 % of patients while severe sepsis was reported in 20.8%. CD64 and MPO were significantly higher in cases than controls (p= 0.003, p < 0.001, respectively) and, in patients with SIRs and severe sepsis CD64 was 1559.00± 367.09 pg/ml and 1547.9 4± 436.14 pg/ml, respectively. Also, MPO was significantly higher in patients with SIRS (113.58± 25.19 mU/ml) and severe sepsis (111.70± 26.50 mU/ml). CD64 and MPO significantly increased after development of sepsis in admitted patients. ROC was significantly higher for CD64 and MPO at admission than that for CRP at admission (p=0.123, p=0.014, respectively). In conclusion, plasma level of CD64 and MPO in peripheral blood can be considered an early sensitive marker for the detection and follow up of pediatric sepsis., (Copyright© by the Egyptian Association of Immunologists.)

Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

Competing Interests: Dr. Loscalzo received support for article research from the American Academy of Pediatrics. Dr. Liu disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Competing Interests: Dr. Carlton’s institution received funding from the National Heart, Lung, and Blood Institute (K12), the National Center for Advancing Translational Sciences (KL2), and the Agency for Healthcare Research and Quality (R03). Dr. Pinto has disclosed that she does not have any potential conflicts of interest.

Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

To evaluate the hemodynamic effects and the safety profile of fluid bolus resuscitation with hypertonic saline albumin (HSA) in critically ill children, we performed a prospective observational pilot study between October 2018 and May 2021 in the pediatric intensive care unit (PICU) in a tertiary hospital in Madrid, Spain. Sixty-four HSA boluses were analyzed in 23 patients. A mean volume of 5.7 ml/kg (Standard Deviation, SD 2.3 ml/kg) per bolus was infused. Acute hypotension was the main indication. 91% of the patients had a cardiac disease, 56% of them had undergone cardiac surgery in the previous 72 h, and 47.8% associated right ventricular dysfunction. A significant increase in systolic, mean, and diastolic blood pressure and a decrease in the vasoactive index was observed after the infusion of HSA. This effect lasted for twenty-four hours (p < 0.05). Moreover, the amount of fluid requirements decreased significantly in the 6 h following HSA infusion [8.7 ml/kg (SD 9.6) vs. 15.1 ml/kg (SD 13.6) in the previous 6 h (p < 0.05)]. Serum levels of sodium and chloride increased after the infusion, reaching their peak concentration after one hour (143 mEq/L (SD 3.5) and 109.7 mEq/L (SD 6) respectively). HSA-related metabolic acidosis or acute kidney injury were not observed in this study. Hypertonic saline albumin is safe and effective when infused at a dose of 5 ml/kg in critically ill children. However, further research is required to confirm our findings., (© 2024. The Author(s).)

Objectives: To investigate which independent factor(s) have an impact on the pharmacokinetics of vancomycin in critically ill children, develop an equation to predict the 24-hour area under the concentration-time curve from a trough concentration, and evaluate dosing regimens likely to achieve a 24-hour area under the concentration-time curve to minimum inhibitory concentration ratio (AUC24/MIC) greater than or equal to 400., Design: Prospective population pharmacokinetic study of vancomycin., Setting: Critically ill patients in quaternary care PICUs., Patients: Children 90 days old or older to younger than 18 years who received IV vancomycin treatment, irrespective of the indication for use, in the ICUs at the University of Maryland Children's Hospital and Texas Children's Hospital were enrolled., Interventions: Vancomycin was prescribed at doses and intervals chosen by the treating clinicians., Measurements and Main Results: A median of four serum levels of vancomycin per patient were collected along with other variables for up to 7 days following the first administration. These data were used to characterize vancomycin pharmacokinetics and evaluate the factors affecting the variability in achieving AUC24/MIC ratio greater than or equal to 400 in PICU patients who are not on extracorporeal therapy. A total of 302 children with a median age of 6.0 years were enrolled. A two-compartment model described the pharmacokinetics of vancomycin with the clearance of 2.76 L/hr for a typical patient weighing 20 kg. The glomerular filtration rate estimated using either the bedside Schwartz equation or the chronic kidney disease in children equation was the only statistically significant predictor of clearance among the variables evaluated, exhibiting equal predictive performance. The trough levels achieving AUC24/MIC = 400 were 5.6-10.0 μg/mL when MIC = 1 μg/mL. The target of AUC24/MIC greater than or equal to 400 was achieved in 60.4% and 36.5% with the typical dosing regimens of 15 mg/kg every 6 and 8 hours (q6h and q8h), respectively., Conclusions: The pharmacokinetics of vancomycin in critically ill children were dependent on the estimated glomerular filtration rate only. Trough concentrations accurately predict AUC24. Typical pediatric vancomycin dosing regimens of 15 mg/kg q6h and q8h will often lead to AUC24/MIC under 400., Competing Interests: Dr. Gobburu is a co-founder of Pumas-AI, which commercializes Pumas and Lyv and a co-founder of Vivpro Corp, which commercializes Research and Development Intelligence Assistant software. The remaining authors have disclosed that they do not have any potential conflicts of interest.