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Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015.To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS.Retrospective cohort study of children 1 month to18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU).At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIOIn a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO

OBJECTIVE To identify associations between weight status and clinical outcomes in children with lower respiratory tract infection (LRTI) or asthma requiring hospitalization. METHODS We performed a retrospective cohort study of 2 to 17 year old children hospitalized for LRTI and/or asthma from 2009 to 2019 using electronic health record data from the PEDSnet clinical research network. Children RESULTS We identified 65 132 hospitalizations; 6.7% with underweight, 57.8% normal weight, 14.6% overweight, 13.2% class 1 obesity, 5.0% class 2 obesity, and 2.8% class 3 obesity. Overweight and obesity were associated with positive pressure respiratory support (class 3 obesity versus normal weight odds ratio [OR] 1.62 [1.38–1.89]) and ICU admission (class 3 obesity versus normal weight OR 1.26 [1.12–1.42]), with significant associations for all categories of overweight and obesity. Underweight was also associated with positive pressure respiratory support (OR 1.39 [1.24–1.56]) and ICU admission (1.40 [1.30–1.52]). CONCLUSIONS Both underweight and overweight or obesity are associated with increased severity of LRTI or asthma in hospitalized children.

Objectives This article observes the mean daily dose of fentanyl required for adequate sedation in critically ill, mechanically ventilated children randomized to receive dexmedetomidine or placebo. Methods We conducted Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multicenter, double-blind, randomized, placebo-controlled, dose-escalating trial. We enrolled children aged 35 weeks postmenstrual to 17 years (inclusive) admitted across 13 pediatric multidisciplinary and cardiac intensive care units. Adequate sedation was based on a State Behavioral Score and Richmond Agitation-Sedation Scale of –1 or lower. Only the first two dexmedetomidine dosing cohorts opened for enrollment, due to early trial closure during the coronavirus 2019 pandemic. Thirty children were randomized over 13 months and included in the analyses. Results Demographic and baseline characteristics were not different between dexmedetomidine and placebo cohorts. Similarly, mean daily fentanyl use was not different, using an unadjusted mixed regression model that considered treatment, time, and a treatment-by-time interaction. Adverse events and safety events of special interest were not different between cohorts. Conclusion The DOSE trial revealed that dexmedetomidine added to fentanyl does not impact safety and may not spare fentanyl use in critically ill children, although the trial did not meet its recruitment goals, due to early closure during the coronavirus 2019 pandemic. More rigorous inpatient pediatric trials like DOSE that study critically ill, mechanically ventilated children are needed. Despite the many obstacles faced, the DOSE trial presents challenges from which the greater research community can learn and use to optimize future therapeutic trials in children.

Objectives To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs. Design Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017. Setting One hundred and seventeen PICUs in the United States. Patients Patients less than 18 years old admitted with an active diagnosis of burn at admission. Interventions None. Measurements and main results A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state. Conclusions Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Timely trial start-up is a key determinant of trial success; however, delays during start-up are common and costly. Moreover, data on start-up metrics in pediatric clinical trials are sparse. To expedite trial start-up, the Trial Innovation Network piloted three novel mechanisms in the trial titled Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multi-site, randomized, double-blind, placebo-controlled trial in the pediatric intensive care setting.The three novel start-up mechanisms included: 1) competitive activation; 2) use of trial start-up experts, called site navigators; and 3) supplemental funds earned for achieving pre-determined milestones. After sites were activated, they received a web-based survey to report perceptions of the DOSE start-up process. In addition to perceptions, metrics analyzed included milestones met, time to start-up, and subsequent enrollment of subjects.Twenty sites were selected for participation, with 19 sites being fully activated. Across activated sites, the median (quartile 1, quartile 3) time from receipt of regulatory documents to site activation was 82 days (68, 113). Sites reported that of the three novel mechanisms, the most motivating factor for expeditious activation was additional funding available for achieving start-up milestones, followed by site navigator assistance and then competitive site activation.Study start-up is a critical time for the success of clinical trials, and innovative methods to minimize delays during start-up are needed. Milestone-based funds and site navigators were preferred mechanisms by sites participating in the DOSE study and may have contributed to the expeditious start-up timeline achieved.gov #: NCT03938857.

OBJECTIVES To identify associations between weight category and hospital admission for lower respiratory tract disease (LRTD), defined as asthma, community-acquired pneumonia, viral pneumonia, or bronchiolitis, among children evaluated in pediatric emergency departments (PEDs). METHODS We performed a retrospective cohort study of children 2 to RESULTS Among 107 446 children with 218 180 PED evaluations for LRTD, 4.5% had underweight, 56.4% had healthy normal weight, 16.1% had overweight, 14.6% had class 1 obesity, 5.5% had class 2 obesity, and 3.0% had class 3 obesity. Underweight was associated with increased risk of hospital admission compared with normal weight (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.69–1.84). Overweight (OR 0.87; 95% CI 0.85–0.90), class 1 obesity (OR 0.88; 95% CI 0.85–0.91), and class 2 obesity (OR 0.91; 95% CI 0.87–0.96) had negative associations with hospital admission. Class 1 and class 2, but not class 3, obesity had small positive associations with 7- and 30-day PED revisits. CONCLUSIONS We found an inverse relationship between patient weight category and risk for hospital admission in children evaluated in the PED for LRTD.

Supplemental Digital Content is available in the text., OBJECTIVES: To characterize the impact of public health interventions on the volume and characteristics of admissions to the PICU. DESIGN: Multicenter retrospective cohort study. SETTING: Six U.S. referral PICUs during February 15, 2020–May 14, 2020, compared with the same months during 2017–2019 (baseline). Patients: PICU admissions excluding admissions for illnesses due to severe acute respiratory syndrome coronavirus 2 and readmissions during the same hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was admission volumes during the period of stay-at-home orders (March 15, 2020–May 14, 2020) compared with baseline. Secondary outcomes were hospitalization characteristics including advanced support (e.g., invasive mechanical ventilation), PICU and hospital lengths of stay, and mortality. We used generalized linear mixed modeling to compare patient and admission characteristics during the stay-at-home orders period to baseline. We evaluated 7,960 admissions including 1,327 during March 15, 2020–May 14, 2020. Daily admissions and patients days were lower during the period of stay-at-home orders compared with baseline: median admissions 21 (interquartile range, 17–25) versus 36 (interquartile range, 30–42) (p < 0.001) and median patient days 93.0 (interquartile range, 55.9–136.7) versus 143.6 (interquartile range, 108.5–189.2) (p < 0.001). Admissions during the period of stay-at-home orders were less common in young children and for respiratory and infectious illnesses and more common for poisonings, endocrinopathies and for children with race/ethnicity categorized as other/unspecified. There were no differences in hospitalization characteristics except fewer patients received noninvasive ventilation during the period of stay-at-home orders. CONCLUSIONS: Reductions in PICU admissions suggest that much of pediatric critical illness in younger children and for respiratory and infectious illnesses may be preventable through targeted public health strategies.

Viral respiratory infections are a leading cause of illness and hospitalization in young children worldwide. Case fatality rates in pediatric patients with adenoviral lower respiratory tract infection requiring intensive care unit (ICU) admission have been reported between 7 and 22%. We investigated the demographics and clinical characteristics in pediatric mortalities associated with adenoviral respiratory infection at 12 academic children's hospitals in the United States. There were 107 mortality cases included in our study, 73% of which had a chronic medical condition. The most common chronic medical condition was immunocompromised state in 37 cases (35%). The incidences of pediatric acute respiratory distress syndrome (78%) and multiple organ dysfunction syndrome (94%) were profound. Immunocompetent cases were more likely to receive mechanical ventilation within the first hour of ICU admission (60 vs. 14%, p

With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers.National 2-day point prevalence study.Eighty-two PICUs in 65 hospitals across the United States.All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day.None.The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6).Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.

Background Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation. Case Report A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death. Why Should an Emergency Physician be Aware of This? HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function.

Pediatric obesity is highly prevalent and has been associated with poor outcomes for hospitalized children. Vascular access is essential in critically ill patients. The aim of this study was to evaluate whether critically ill children with obesity are more likely to undergo vascular device insertion (excluding peripheral IV catheters) and develop related complications.Multi-institutional retrospective observational cohort study.Ninety-four U.S. PICUs included in the Virtual Pediatric Systems, LLC database.120,272 unique patients 2 to less than 18 years old admitted between January 2009 and December 2014.None.Patients were categorized into normal weight, overweight, and obese (class 1, 2, or 3); underweight patients were excluded. We used mixed-effects multivariable logistic regression to test body mass index category as an independent predictor of vascular device placement and associated complications, adjusted for age, sex, severity of illness, primary diagnosis, presence of a complex chronic condition, and admission related to trauma or surgery. A total of 73,964 devices were placed in 45,409 patients (37.8% of the total cohort received a vascular device). Most device types placed differed significantly by weight status. Subjects with class 3 obesity were less likely (odds ratio, 0.74; 95% CI, 0.67-0.81) to undergo placement of any device compared with normal weight patients. Patients with all classes of obesity were more likely to undergo placement of a peripherally inserted central catheter, with the strongest association in those with class 2 obesity (odds ratio, 1.26; 95% CI, 1.14-1.40). Class 1 and class 3 obesity were independent risk factors for developing a complication, with odds ratio of 1.31 (95% CI, 1.11-1.53) and 1.45 (95% CI, 1.07-1.99), respectively.Severe obesity is associated with decreased overall likelihood of placement of a vascular access device but increased likelihood of peripherally inserted central catheter placement and of device-related complications.

1. Kelsey Poisson, MD* 2. Jen-Jar Lin, MD† 3. Ashton Chen, DO† 4. Michael C. McCrory, MD, MS†,‡ 1. *Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 2. †Department of Pediatrics and 3. ‡Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, NC A 7-day-old boy is referred to the emergency department by his pediatrician for increased work of breathing. He was born at 39 weeks’ gestation by spontaneous vaginal delivery with prolonged rupture of membranes. His newborn nursery stay was uncomplicated, and the results of his congenital heart screen were normal. His mother reports difficulties with breastfeeding due to poor latch, for which he has been receiving supplemental formula. She also reports increased fussiness and “brownish-red spots” in his diapers. There is no cyanosis or choking during feeds. There is no history of fever, vomiting, diarrhea, rashes, cough, sick contacts, or decreased urine output. On examination he is alert, afebrile, and mildly tachycardic, with a blood pressure (BP) of 70/22 mm Hg. Weight is 3,270 g (birthweight, 3,785 g). Oxygen saturation is 84% on room air and improves to 98% with supplemental oxygen. He is tachypneic, with subcostal retractions, grunting, and head bobbing during respirations. Lungs are clear to auscultation. Capillary refill is normal, and femoral pulses are strong. There are no rashes. Abdomen is soft, with mild hepatosplenomegaly. Laboratory evaluation is notable for a white blood cell count of 28,000/μL (28×109/L), blood urea nitrogen level of 42 mg/dL (15.0 mmol/L), and creatinine concentration of 0.72 mg/dL (63.65 μmol/L). Results of cultures and viral studies are pending. Liver enzyme levels, troponin level, B-type natriuretic peptide level, prothrombin time, and D-dimer level are significantly elevated; ammonia level is 96.6 μg/dL (69 μmol/L). A capillary blood gas analysis shows mixed respiratory and metabolic acidosis with an elevated lactate level. …

Objectives To evaluate for any association between time of admission to the PICU and mortality. Design Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014. Setting One hundred and twenty-nine PICUs in the United States. Patients Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass. Interventions None. Measurements and main results A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons. Conclusions Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

The etiology of inflammatory heart disease encompasses a wide array of pathologic processes, including infectious, rheumatic, autoimmune, toxic, allergic diseases, and idiopathic, among others. The manifestations of such disease usually present clinically with pericarditis or myocarditis, with or without pericardial effusion. Myocardial or pericardial involvement may be the primary, isolated component of the disease process or just one manifestation of a systemic, multiorgan disease. The cardiac involvement may be the first manifestation of a systemic disease or may occur years after the primary disease process has been identified. The cardiologist, intensivist, and surgeon must often collaborate in the management of these patients because the clinical manifestations of such disease may be associated with life-threatening cardiac dysfunction, may require invasive procedures to treat or monitor such conditions, or may progress to chronic heart failure, for which transplantation may be the only option.

Purpose. To investigate the impact of severe respiratory adenoviral infection on morbidity and case fatality in immunocompromised children.Methods. Combined retrospective-prospective cohort study of patients admitted to the intensive care unit (ICU) in four children’s hospitals with severe adenoviral respiratory infection and an immunocompromised state between August 2009 and October 2013. We performed a secondary case control analysis, matching our cohort 1 : 1 by age and severity of illness score with immunocompetent patients also with severe respiratory adenoviral infection.Results. Nineteen immunocompromised patients were included in our analysis. Eleven patients (58%) did not survive to hospital discharge. Case fatality was associated with cause of immunocompromised state (p=0.015), multiple organ dysfunction syndrome (p=0.001), requirement of renal replacement therapy (p=0.01), ICU admission severity of illness score (p=0.011), and treatment with cidofovir (p=0.005). Immunocompromised patients were more likely than matched controls to have multiple organ dysfunction syndrome (p=0.01), require renal replacement therapy (p=0.02), and not survive to hospital discharge (p=0.004). One year after infection, 43% of immunocompromised survivors required chronic mechanical ventilator support.Conclusions. There is substantial case fatality as well as short- and long-term morbidity associated with severe adenoviral respiratory infection in immunocompromised children.

Objectives: The objective of this study was to explore perceptions of communication quality at pediatric rapid response events and to determine whether these perceptions differed between rapid response team (RRT) members (RRTm) and floor providers (FP). Methods: This survey study was conducted of clinical providers involved in RRT events at a tertiary care children’s hospital. Perceptions of RRT communication were assessed by using a 5-point Likert scale, and qualitative comments were collected. Responses were compared between RRTm (responder nurses and intensive care fellows) and FP (floor nurses and resident physicians). Results: Survey response was 64% (18 of 28) for RRTm and 70% (194 of 278) for FP. RRTm gave lower ratings than FP for communication of: (1) the purpose of the call; (2) airway and breathing; (3) circulation; (4) background information; and (5) possible diagnosis and treatment. RRTm were more likely than FP to indicate that description of background information delayed communication of critical management problems (“often”: RRTm, 7 of 17 [41%]; FP, 23 of 175 [13%]; “always”: RRTm, 2 of 18 [12%]; FP, 19 of 175 [11%]; P = .001 for overall comparison). A structured approach for communication was generally supported, although less strongly among floor nurses. Themes from qualitative responses included role confusion, fractured room entry, and a dismissive attitude by RRTm. Conclusions: A disconnect in perceived quality of communication was observed between RRTm and FP at pediatric rapid response events. A structured approach with well-defined roles may improve communication quality.

SummaryBackground The objective of this study was to determine factors predictive of need for mechanical ventilation (MV) upon discharge from the pediatric intensive care unit (PICU) among patients who receive a tracheostomy during their stay. Methods This was a retrospective cohort study using the Virtual PICU Systems (VPS) database. Patients

BACKGROUND: Critically ill patients are admitted to the pediatric ICU at all times, while staffing and other factors may vary by day of the week or time of day. The purpose of this study was to evaluate whether admission during off-hours is independently associated with mortality in PICUs. METHODS: A retrospective cohort study of admissions of patients RESULTS: Data from 234 192 admissions to 99 PICUs from January 2009 to September 2012 were included. When compared with regular weekday admissions, off-hours admissions were less likely to be elective, had a higher risk for mortality by PIM2, and had a higher observed ICU mortality (off-hours 2.7% vs weekdays 2.2%; P < .001). Multivariable regression revealed that, after adjustment for other significant factors, off-hours admission was associated with lower odds of mortality (odds ratio, 0.91; 95% confidence interval, 0.85–0.97; P = .004). Post hoc multivariable analysis revealed that admission during the morning period 6:00 am to 10:59 am was independently associated with death (odds ratio, 1.27; 95% confidence interval, 1.16–1.39; P < .0001). CONCLUSIONS: Off-hours admission does not independently increase odds of death in the PICU. Admission from 6:00 am to 10:59 am is associated with increased risk for death and warrants further investigation in the PICU population.

AIM To evaluate the use of a computerized physician order entry (CPOE) protocol on manual red blood cell (RBC) exchange transfusion in critically ill children with sickle cell disease. METHODS We conducted a retrospective study of children with sickle cell disease who received a manual RBC exchange transfusion before (2001 to 2008, n=22) and after (2008 to 2009, n=11) implementation of a CPOE protocol. Outcomes included compliance with protocol, percentage reduction in sickle hemoglobin, and peak hemoglobin during exchange. RESULTS Compliance with the manual exchange protocol improved after introduction of CPOE (pre-CPOE: 20 protocol violations vs. post-CPOE: 3 violations, P=0.02). Percentage reduction in sickle hemoglobin also improved (pre-CPOE: 55% vs. post-CPOE: 70%, P=0.04), whereas peak hemoglobin during RBC exchange was similar (pre-CPOE: 12.0 g/dL vs. post-CPOE: 11.5 g/dL, P=0.25). However, hemoglobin levels after the mean of 7 hours of exchange were significantly higher pre-CPOE (pre-CPOE: 11.5 g/dL vs. post-CPOE: 10.5 g/dL, P=0.006). CONCLUSIONS Use of CPOE for manual RBC exchange transfusion in children is associated with improved protocol compliance, improved reduction of sickle hemoglobin, and better maintenance of hemoglobin levels in a goal range during prolonged exchanges.

BACKGROUND: Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions.METHODS: This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer-Lemeshow test).RESULTS: Four hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71-0.81) and the Hosmer-Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1.CONCLUSIONS: In a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.

The objective of this study was to determine factors predictive of need for mechanical ventilation (MV) upon discharge from the pediatric intensive care unit (PICU) among patients who receive a tracheostomy during their stay.This was a retrospective cohort study using the Virtual PICU Systems (VPS) database. Patients18 years old admitted between 2009-2011 who required MV for at least 3 days and received a tracheostomy during their PICU stay were included.A total of 680 pediatric patients from 74 PICUs were included, of whom 347 (51%) remained on MV at the time of PICU discharge. Neonates (30/38, 79%) and infants (129/203, 64%) required MV at PICU discharge after tracheostomy more often than adolescents (66/141, 47%) and children (122/298, 41%). Time on MV pre-tracheostomy was longer among those who required MV at discharge (median 18.3 vs. 13.8 days, P 0.0001); however, number of failed extubations was similar (median 1 for both groups, P = 0.97). On mixed-effects multivariable regression analysis, the age categories of neonate (OR 2.9, 95%CI 1.1-7.6, P = 0.03), and infant (OR 1.7, 95%CI 1.1-2.8, P = 0.03), and ventilator days prior to tracheostomy (OR 1.01, 95%CI 1.0-1.02, P = 0.01) were significantly associated with increased odds of MV upon PICU discharge, while being a trauma admission was associated with decreased odds (OR 0.45, 95%CI 0.28-0.73, P = 0.001).Younger patients and those with prolonged courses of MV prior to tracheostomy are more likely to continue to need MV upon PICU discharge.

We report a 16-year-old, previously healthy female who presented with disseminated mucormycosis leading to multiorgan failure and death with newly diagnosed type 1 diabetes mellitus and ketoacidosis. We review previous reported cases of mucormycosis in children with diabetes to demonstrate that this uncommon invasive infection may cause significant morbidity and mortality in this population.

The purpose of the present study is to describe the use of tracheostomy, specifically frequency, timing (in relation to initiation of mechanical ventilation), and associated factors, in a large cohort of children admitted to North American pediatric intensive care units (PICUs) and requiring prolonged mechanical ventilation. This was a retrospective cohort study. De-identified data were obtained from the VPSLLC database, a multi-site, clinical PICU database. Admissions between 1 July 2009 and 30 June 2011 were enrolled in the study if the patient required mechanical ventilation for at least 72 h and did not have a tracheostomy tube at initiation of mechanical ventilation. A total of 13,232 PICU admissions from 82 PICUs were analyzed in the study; of these, 872 (6.6 %) had a tracheostomy tube inserted after initiation of mechanical ventilation. The rate varied significantly (0–13.4 %, p

This study was done to assess whether a modified "ABC-SBAR" mnemonic (airway, breathing, circulation followed by situation, background, assessment, and recommendation) improves hand-offs by pediatric interns in a simulated critical patient scenario.Each of 26 interns reviewed a scenario involving a decompensating pediatric patient and gave a simulated hand-off to a responder. They received a didactic session on ABC-SBAR, then performed a second hand-off using another scenario. Two blinded reviewers assessed 52 video-recorded hand-offs for inclusion, order, and elapsed time to essential hand-off information using a scoring tool.Mean score of hand-offs increased after ABC-SBAR training (preintervention: 3.1/10 vs postintervention: 7.8/10, P0.001). In hand-offs after ABC-SBAR training, the reason for the emergency call was more often prioritized before background information (preintervention: 4% vs postintervention: 81%, P0.001) and stated earlier (elapsed time preintervention: 19 seconds vs postintervention: 7 seconds, P0.001). Hand-offs including an airway or breathing assessment increased after training (preintervention: 35% vs postintervention: 85%, P = 0.001), and this information was also stated earlier (preintervention: 25 seconds vs postintervention: 5 seconds, P0.001). Total hand-off duration was increased (preintervention: 29 seconds vs postintervention: 36 seconds, P = 0.004).Unstructured hand-off by interns in a simulated patient emergency emphasizes background information, leaving essential information (such as reason for the call and ABCs) delayed or omitted. ABC-SBAR was associated with improved inclusion and timeliness of essential information in simulated critical patient hand-offs by pediatric interns; however, hand-off duration was increased. Further studies are needed to elucidate optimal hand-off in an emergency situation.

Objectives To summarize a) epidemiology of arterial and venous thromboembolism, pulmonary embolism, and deep venous thrombosis in children; b) the risk factors for thrombosis in the pediatric intensive care unit; c) diagnostic techniques for arterial/venous thromboembolism; and d) the current recommendations for management and prevention of thromboembolic disease in critically ill children. Data source Literature review, using National Library of Medicine PubMed and the following terms: arterial, venous thromboembolism; deep venous thrombosis; pulmonary embolism; thrombosis; as well as citations of interest from these articles. Study selection Both pediatric and adult literature addressing thrombotic disease were reviewed. Data extraction and synthesis Articles were chosen for more extensive discussion when containing prospective studies, guidelines for practice, or data in critically ill patients. When data in children were unavailable, applicable data in adults were referenced. Due to the paucity of data in critically ill children, available adult and pediatric data were combined with institutional experience to provide suggestions for current practice and future inquiry. Conclusions Increasing awareness regarding the recognition and current approaches to management and prevention of thromboembolic disease in children is needed among pediatric intensivists, so outcome of these life-threatening processes might be improved.