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Purpose To evaluate the usefulness and feasibility of sedation/agitation monitoring using a wearable device with a built-in accelerometer for children on mechanical ventilation in a pediatric intensive care unit (PICU). Methods A prospective observational study was performed in a single PICU in a children’s hospital, including children aged ≤ 15 years admitted to the PICU on mechanical ventilation after cardiac catheterization between December 2021 and April 2022. The wearable device was attached to either the upper limb, and accelerations were measured for two hours after admission or to the time of extubation, whichever earliest. Accelerations were measured at 0.02-s intervals, with the mean acceleration calculated for each 1-min interval. The State Behavioral Scale (SBS) was completed at 1-min intervals, with the SBS score (-1, 0, 1, or 2) compared to the mean acceleration. Results The study included 20 children with a median (interquartile range [IQR]) age of 12 (8–24) months. The number of observations for each SBS score was as follows: -1, n = 1, 395; 0, n = 217; 1, n = 95; 2, n = 13. The mean accelerations and SBS scores were positively correlated (Kendall’s tau, 0.22; p 2; SBS 0, 0.202 (0.190–0.235) m/s2; SBS, 1, 0.312 (0.236–0.427) m/s2; SBS 2, 0.455 (0.332–0.517) m/s2. No adverse events or complications were observed. Conclusion Continuous, objective sedation/agitation monitoring of children on mechanical ventilation was feasible using a wearable accelerometry device. Trial registration: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000046203; December 1, 2021). https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052488

We aimed to identify the threshold for P0.1 in a breath-by-breath manner measured without airway occlusion for high respiratory drive. In this prospective observational study, we found P0.1 measured without airway occlusion, esophageal P0.1 and esophageal pressure swing had a positive correlation. However, the P0.1 threshold for high respiratory drive was calculated at approximately 1.0 cmH2O from the regression equation. Our calculations suggest a lower threshold of P0.1 measured without airway occlusion than that which has been previously reported.

Objectives We elucidate to investigate the prevalence of and factors associated with the use of physical restraints among critically ill or injured children in PICUs. Design This was a multicenter, longitudinal point prevalence study. Setting We included 26 PICUs in Japan. Patients Included children were 1 month to 10 years old. We screened all admitted patients in the PICUs on three study dates (in March, June, and September 2019). Intervention None. Measurements and main results We collected prevalence and demographic characteristics of critically ill or injured children with physical restraints, as well as details of physical restraints, including indications and treatments provided. A total of 398 children were screened in the participating PICUs on the three data collection dates. The prevalence of children with physical restraints was 53% (211/398). Wrist restraint bands were the most frequently used means (55%, 117/211) for potential contingent events. The adjusted odds of using physical restraint in patients 1-2 years old was 2.3 (95% CI, 1.3-4.0) compared with children less than 1 year old. When looking at the individual hospital effect, units without a prespecified practice policy for physical restraints management or those with more than 10 beds were more likely to use physical restraints. Conclusions The prevalence of physical restraints in critically ill or injured children was high, and significant variation was observed among PICUs. Our study findings suggested that patient age, unit size, and practice policy of physical restraint could be associated with more frequent use of physical restraints.

The aim of this study was to evaluate our prenatal risk stratification system for risk-adjusted management in fetuses with isolated congenital diaphragmatic hernia (CDH).Ninety-four infants prenatally diagnosed with isolated CDH treated between 1998 and 2017 at our institution were included in this retrospective single-center cohort study.The patients were prenatally classified into four risk groups: Group A (n = 54), which consisted of infants with neither liver-up nor a contralateral lung-to-thorax transverse area (L/T) ratio0.08. The infants in group A were divided into two subgroups: Group A-1 (n = 24) consisted of mild conditions; and Group A-2 (n = 30) consisted of severe conditions; Group B (n = 23), which consisted of infants with either liver-up or L/T ratio0.08; and Group C (n = 17), which consisted of infants with both liver-up and L/T ratio0.08. The rates of survival to discharge in Groups A-1, A-2, B, and C were 100.0%, 100.0%, 87.0%, and 58.8%, respectively. The rates of intact discharge were 91.7%, 90.0%, 52.1%, and 23.5%, respectively.Our prenatal risk stratification system demonstrated a significant difference in the severity of postnatal status and clinical outcomes between the groups.Case Series, Retrospective Review.LEVEL IV.

Objective The use of pediatric rapid response systems (RRSs) to improve the safety of hospitalized children has spread in various western countries including the United States and the United Kingdom. We aimed to determine the prevalence and characteristics of pediatric RRSs and barriers to use in Japan, where epidemiological information is limited. Design A cross-sectional online survey. Setting All 34 hospitals in Japan with pediatric intensive care units (PICUs) in 2019. Participants One PICU physician per hospital responded to the questionnaire as a delegate. Main outcome measures Prevalence of pediatric RRSs in Japan and barriers to their use. Results The survey response rate was 100%. Pediatric RRSs had been introduced in 14 (41.2%) institutions, and response teams comprised a median of 6 core members. Most response teams employed no full-time members and largely comprised members from multiple disciplines and departments who served in addition to their main duties. Of 20 institutions without pediatric RRSs, 11 (55%) hoped to introduce them, 14 (70%) had insufficient knowledge concerning them and 11 (55%) considered that their introduction might be difficult. The main barrier to adopting RRSs was a perceived personnel and/or funding shortage. There was no significant difference in hospital beds (mean, 472 vs. 524, P = 0.86) and PICU beds (mean, 10 vs. 8, P = 0.34) between institutions with/without pediatric RRSs. Conclusions Fewer than half of Japanese institutions with PICUs had pediatric RRSs. Operating methods for and obstructions to RRSs were diverse. Our findings may help to popularize pediatric RRSs.

Objectives To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children. Design Multinational cross-sectional questionnaire survey conducted in 2018. Setting The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand. Measurement Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula. Interventions None. Main results We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents. Conclusions Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.

Pneumomediastinum is a known complication of mechanical ventilation. Infrequently, it secondarily arises from pneumoperitoneum or pneumoretroperitoneum, when air travels along the fascial planes to enter the mediastinum. Conversely, pneumoretroperitoneum secondary to pneumomediastinum is even rare but could occur in mechanically ventilated patients.

Although a few studies have reported the efficacy of ultrasound-guided peripherally inserted central catheter placement for pediatric patients, the procedure still is challenging. Ultrasound-guided dynamic needle tip positioning technique is useful for vascular catheterization. There have been no reports on using dynamic needle tip positioning for peripherally inserted central catheter placement. The authors assessed the rate of successful peripherally inserted central catheter placement with dynamic needle tip positioning.Case series.Single tertiary institution.Forty patients5 years old who were admitted to the pediatric intensive care unit after cardiac surgeries and required peripherally inserted central catheter placement.Peripherally inserted central catheter placement was performed under ultrasound guidance with dynamic needle tip positioning. The authors recorded the first attempt and overall success rates of peripherally inserted central catheter and outer cannula placement, time needed for outer cannula and peripherally inserted central catheter placement, and number of attempts.The first attempt and overall success rates of peripherally inserted central catheter placement were 85% (n = 34) and 97.5% (n = 39), respectively. The first attempt and overall success rates of outer cannula placement were 87.5% (n = 35) and 100% (n = 40), respectively. Time needed for outer cannula placement was 59.5 (interquartile range 40.5-80.5) seconds and for peripherally inserted central catheter placement was 112.5 (interquartile range 91.5-159.5) seconds. The number of attempts was 1 (interquartile range 1-1 [range 1-5]).In pediatric patients, ultrasound-guided peripherally inserted central catheter placement using dynamic needle tip positioning attained a high success rate.

Objectives Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. Design Retrospective, single-center, observational study. Setting PICU at a tertiary children's hospital. Patients Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. Interventions None. Measurements and main results We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176-0.446; p = 0.003). Conclusions In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.

The objective of the study is to develop a correction method for estimating the change in pleural pressure (ΔPpl) and plateau transpulmonary pressure (PL) by using the change in central venous pressure (ΔCVP). Seven children (aged

In 2014, our hospital introduced inhaled nitric oxide (iNO) therapy combined with high-flow nasal cannula (HFNC) oxygen therapy after extubation following the Fontan procedure in patients with unstable hemodynamics. We report the benefits of HFNC-iNO therapy in these patients. This was a single-center, retrospective review of 38 patients who underwent the Fontan procedure between January 2010 and June 2016, and required iNO therapy before extubation. The patients were divided into two groups: patients in Epoch 1 (n = 24) were treated between January 2010 and December 2013, receiving only iNO therapy; patients in Epoch 2 (n = 14) were treated between January 2014 and June 2016, receiving iNO therapy and additional HFNC-iNO therapy after extubation. There were no significant differences between Epoch 1 and 2 regarding preoperative cardiac function, age at surgery, body weight, initial diagnosis (hypoplastic left heart syndrome, 4 vs. 2; total anomalous pulmonary venous return, 5 vs. 4; heterotaxy, 7 vs. 8), intraoperative fluid balance, or central venous pressure upon admission to the intensive care unit. Epoch 2 had a significantly shorter duration of postoperative intubation [7.2 (3.7-49) vs. 3.5 (3.0-4.6) hours, p = 0.033], pleural drainage [23 (13-34) vs. 9.5 (8.3-18) days, p = 0.007], and postoperative hospitalization [36 (29-49) vs. 27 (22-36) days, p = 0.017]. Two patients in Epoch 1 (8.3%), but none in Epoch 2, required re-intubation. Our results suggest that HFNC-iNO therapy reduces the duration of postoperative intubation, pleural drainage, and hospitalization.

OBJECTIVES To compare the pathogen identification rate and use of antibiotics before and after the implementation of multiplex polymerase chain reaction testing in children with respiratory infections in a PICU. DESIGN Single-center, pre-post study. SETTING PICU of Osaka Women's and Children's Hospital, Osaka, Japan. PATIENTS Consecutive children with respiratory infections who were admitted to the PICU between December 2017 and November 2018 (premultiplex polymerase chain reaction period) and between March 2019 and February 2020 (postmultiplex polymerase chain reaction period). INTERVENTIONS Conventional rapid antigen tests and bacterial culture tests were performed throughout the study period. Multiplex polymerase chain reaction testing using the FilmArray respiratory panel (BioFire Diagnostics, Salt Lake City, UT) was conducted to detect 17 viruses and three bacterial pathogens. During the postmultiplex polymerase chain reaction period, we did not recommend prescribing antibiotics for stable children, depending on the virus species and laboratory test results. MEASUREMENTS AND MAIN RESULTS Ninety-six and 85 children were enrolled during the pre- and postmultiplex polymerase chain reaction periods, respectively. Rapid antigen tests identified pathogens in 22% of the children (n = 21) during the premultiplex polymerase chain reaction period, whereas rapid antigen tests and/or multiplex polymerase chain reaction testing identified pathogens in 67% of the children (n = 57) during the postmultiplex polymerase chain reaction period (p < 0.001). The most commonly identified pathogen using multiplex polymerase chain reaction testing was human rhino/enterovirus. Bacterial pathogens were identified in 50% of the children (n = 48) and 60% of the children (n = 51) during the pre- and postmultiplex polymerase chain reaction periods (p = 0.18). There were no differences in antibiotic use (84% vs 75%; p = 0.14), broad-spectrum antibiotic use (33% vs 34%; p = 0.91), or the duration of antibiotic use within 14 days of admission (6.0 vs 7.0 d; p = 0.45) between the pre- and postmultiplex polymerase chain reaction periods. CONCLUSIONS Although the pathogen identification rate, especially for viral pathogens, increased using multiplex polymerase chain reaction testing, antibiotic use did not reduce in children with respiratory infections in the PICU. Definitive identification of bacterial pathogens and implementation of evidence-based antimicrobial stewardship programs employing multiplex polymerase chain reaction testing are warranted.

OBJECTIVES To synthesize the literature describing quality improvement in PICUs and to appraise the quality of extant research. DATA SOURCES We searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials databases between May and June 2020. STUDY SELECTION Peer-reviewed articles in English that report quality improvement interventions in PICUs were included. Titles and abstracts were screened, and articles were reviewed to determine whether they met quality improvement criteria. DATA EXTRACTION Data were abstracted using a structured template. The quality of the included articles was assessed using the Quality Improvement Minimum Quality Criteria Set and scored on a scale of 0-16. DATA SYNTHESIS Of the 2,449 articles identified, 158 were included in the analysis. The most common targets of quality improvement interventions were healthcare-associated infections (n = 17, 10.8%), handoffs (n = 15, 9.5%), rounds (n = 13, 8.2%), sedation/pain/delirium (n = 13, 8.2%), medication safety (n = 11, 7.0%), and unplanned extubation (n = 9, 5.7%). Of the six domains of healthcare quality described by the Institute of Medicine, patient-centeredness and timeliness were infrequently addressed, and none of the studies addressed equity. The median quality score based on the Quality Improvement Minimum Quality Criteria Set was 11.0 (25-75th interquartile range, 9.0-13.0). Although the quantity and quality of articles have been increasing, only 17% of the studies were deemed "high quality," having a score between 14 and 16. Only eight articles (5%) cited Standards for QUality Improvement Reporting Excellence guidelines for reporting quality improvement works. CONCLUSIONS The number of publications, including high-quality publications, on quality improvement interventions in PICUs has been increasing. However, low-quality articles continue to be published, even in recent years. Therefore, there is room for improvement in the quality of reporting.

BackgroundIt is important to evaluate the size of respiratory effort to prevent patient self-inflicted lung injury and ventilator-induced diaphragmatic dysfunction. Esophageal pressure (Pes) measurement is the gold standard for estimating respiratory effort, but it is complicated by technical issues. We previously reported that a change in pleural pressure (ΔPpl) could be estimated without measuring Pes using change in CVP (ΔCVP) that has been adjusted with a simple correction among mechanically ventilated, paralyzed pediatric patients. This study aimed to determine whether our method can be used to estimate ΔPpl in assisted and unassisted spontaneous breathing patients during mechanical ventilation.MethodsThe study included hemodynamically stable children (aged 2O). The cΔCVP-derived ΔPpl value was calculated as follows: cΔCVP-derived ΔPpl = k × ΔCVP, where k was the ratio of the change in airway pressure (ΔPaw) to the ΔCVP during airway occlusion test.ResultsOf the 14 patients enrolled in the study, 6 were excluded because correct positioning of the esophageal balloon could not be confirmed, leaving eight patients for analysis (mean age, 4.8 months). Three variables that reflected ΔPpl (ΔPes, ΔCVP, and cΔCVP-derived ΔPpl) were measured and yielded the following results: -6.7 ± 4.8, − -2.6 ± 1.4, and − -7.3 ± 4.5 cmH2O, respectively. The repeated measures correlation between cΔCVP-derived ΔPpl and ΔPes showed that cΔCVP-derived ΔPpl had good correlation with ΔPes (r = 0.84, p< 0.0001).ConclusionsΔPpl can be estimated reasonably accurately by ΔCVP using our method in assisted and unassisted spontaneous breathing children during mechanical ventilation.

OBJECTIVES: Inspiratory holds with measures of airway pressure to estimate driving pressure (elastic work) are often limited to patients without respiratory effort. We sought to evaluate if measures of airway pressure during inspiratory holds could be used for patients with spontaneous respiratory effort during mechanical ventilation to estimate the degree of spontaneous effort and elastic work. DESIGN: We compared the direction and degree of change in airway pressure during inspiratory holds versus esophageal pressure through secondary analysis of physiologic data. SETTING: ICUs at Children's Hospital Los Angeles. PATIENTS: Children with pediatric acute respiratory distress syndrome with evidence of spontaneous respiration while on pressure control or pressure support ventilation. INTERVENTIONS: Inspiratory hold maneuvers. MEASUREMENTS AND MAIN RESULTS: From airway pressure, we defined "plateau - peak pressure" as Pmusc, index, which was divided into three categories for analysis (< -1 ["negative"], between -1 and 1 ["neutral"], and > 1 cm H2O ["positive"]). A total of 30 children (age 36.8 mo [16.1-70.3 mo]) from 65 study days, comprising 118 inspiratory holds were included. Pmusc, index was "negative" in 29 cases, was "neutral" in 17 cases, and was "positive" in 72 cases. As Pmusc, index went from negative to neutral to positive, there was larger negative deflection in esophageal pressure -5.0 (-8.2 to 1.9), -5.9 (-7.6 to 4.3), and -10.7 (-18.1 to 7.9) cm H2O (p < 0.0001), respectively. There was a correlation between max negative esophageal pressure and Pmusc, index (r = -0.52), and when Pmusc, index was greater than or equal to 7 cm H2O, the max negative esophageal pressure was greater than 10 cm H2O. There was a stronger correlation between Pmusc, index and markers of elastic work from esophageal pressure (r = 0.84). CONCLUSIONS: The magnitude of plateau minus peak pressure during an inspiratory hold is correlated with the degree of inspiratory effort, particularly for those with high elastic work. It may be useful to identify patients with excessively high effort or high driving pressure.

OBJECTIVES We aimed to identify the occurrence and risk factors for unplanned catheter removal due to catheter-associated complications and the effects on catheter survival probability in a PICU. DESIGN Retrospective, single-center, observational study of cases involving conventional central venous catheters or peripherally inserted central venous catheters. SETTING The PICU of a tertiary children's hospital. PATIENTS Consecutive PICU patients with central venous catheters between April 2016 and February 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified unplanned catheter removals that were related to central line-associated bloodstream infection, thrombosis, and mechanical complications. During the study period, 582 central venous catheters and 474 peripherally inserted central venous catheters were identified. The median durations of catheter placement were 4.0 days for central venous catheters and 13.0 days for peripherally inserted central venous catheters (p < 0.001), and unplanned catheter removals due to catheter-associated complications were in 52 (8.9%) central venous catheter cases and 132 (27.8%) peripherally inserted central venous catheter cases (p < 0.001) (15.0 and 16.0 per 1,000 catheter-days, respectively [p = 0.75]). Unplanned catheter removal was associated with a peripheral catheter tip position among both central venous catheters and peripherally inserted central venous catheters (p < 0.001 and p = 0.001), and it was associated with surgical patient status among peripherally inserted central venous catheters (p = 0.009). In contrast, the use of ultrasound-guided insertion was associated with a lower occurrence of unplanned catheter removal among peripherally inserted central venous catheters (p = 0.01). With regard to catheter survival probability, there was no significant difference between central venous catheters and peripherally inserted central venous catheters (p = 0.23). However, peripherally inserted central venous catheters had a lower occurrence of central line-associated bloodstream infection than central venous catheters (p = 0.03), whereas there was no significant difference in the rates of thrombosis (p = 0.29) and mechanical complications (p = 0.84) between central venous catheters and peripherally inserted central venous catheters. CONCLUSIONS In a PICU, peripherally inserted central venous catheters had lower occurrence of central line-associated bloodstream infection than central venous catheters; however, similar catheter survival probabilities were observed between both catheters. A central catheter tip position for both catheters and ultrasound-guided insertion for peripherally inserted central venous catheters may help limit unplanned catheter removal due to catheter-associated complications.

Background Acute encephalitis/encephalopathy (AE) associated with viral and other pathogens leads to neurological sequelae and mortality. Knowing the prognostic factors is therefore important for immediate interventions. We examined early-phase unfavorable prognostic factors among children with AE using a nationwide database. Methods We performed a retrospective cohort study using the Diagnosis Procedure Combination database, which includes approximately half of acute-care inpatients across Japan. We enrolled children aged ≤ 18 years who were hospitalized for AE and discharged from April 2010 to March 2018. The composite unfavorable outcome included the following at discharge: in-hospital death, tracheostomy, enteral tube feeding, and physical rehabilitation. Unfavorable prognostic factors were assessed using a multivariable Poisson regression model including patient characteristics, associated pathogens, and interventions within 2 days of admission adjusting for within-hospital clustering. Results This study included 9386 children with AE (median age, 3 years). A total of 241 (2.6%) in-hospital deaths occurred, and 2027 (21.6%) patients had the composite unfavorable outcome. Significant unfavorable prognostic factors were age 12–18 years, congenital anomalies, epilepsy, and Japan Coma Scale score of 100–300 at admission (ie, worse levels of consciousness). In contrast, herpes simplex virus infection and influenza virus infection were associated with favorable outcomes. Conclusions We identified early-phase (within 2 days of admission) unfavorable prognostic factors among children with AE. These findings will help identify patients who may benefit from early aggressive therapeutic interventions.

The indications for tracheostomy after prolonged mechanical ventilation among pediatric patients with heart disease are multifactorial and difficult to determine; therefore, knowing the risk factors and outcomes of tracheostomy may be useful for selecting patients who require tracheostomy. The aim of this study was to identify the risk factors and outcomes of tracheostomy after prolonged mechanical ventilation in pediatric patients with heart disease. We performed a retrospective, single-center observational study in consecutive patients with heart disease aged ≤18 years admitted to a pediatric intensive care unit at a tertiary children's hospital between January 2010 and December 2016. Patients who required prolonged mechanical ventilation (≥14 days) were included. Clinical characteristics and outcomes were compared between the patients with and without tracheostomy and the risk factors for receiving tracheostomy were assessed. Of the 85 patients who required prolonged mechanical ventilation, 20 (24%) underwent tracheostomy. The duration of mechanical ventilation before tracheostomy was 51 days, and pediatric intensive care unit lengths of stay in patients with and without tracheostomy were 83 and 34 days, respectively ( P 2 O after 14 days of mechanical ventilation. In patients with tracheostomy, six (30%) were successfully weaned from mechanical ventilation and two (10%) were de-cannulated. Tracheostomy complications included granulation tissue in three cases and airway obstruction in one. There was no difference in the survival rates of patients with and without tracheostomy (70% vs. 74%; P = 0.73). Although the mortality rate of patients with and those without tracheostomy were not significantly different, the baseline illness severity might be different. Further studies that adjust for patient factors, such as disease severity, are needed to determine the effect of tracheostomy on patient outcomes; however, this was beyond the scope of our study.

Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU.We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group).Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group.Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.

OBJECTIVE To investigate whether elevated central venous to arterial CO2 difference is associated with delayed extubation and prolonged ICU stay in children after cardiac surgery with cardiopulmonary bypass. DESIGN Retrospective review of medical records. SETTING PICU in a tertiary children's hospital. PATIENTS Pediatric patients younger than 18 years old who underwent cardiac surgery with cardiopulmonary bypass between January 2014 and December 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 114 patients were included in this study. On ICU admission, blood samples were obtained simultaneously from an arterial line and a central venous line. There were no strong correlations between central venous to arterial CO2 difference (median, 11.1 [8.4-13] mm Hg) and other commonly used variables for the assessment of oxygen delivery including arteriovenous oxyhemoglobin saturation difference (R = 0.16) and blood lactate concentration (R = 0.02). When the patients were divided into two groups, based on the CO2 difference, the high group (difference ≥ 6 mm Hg; n = 103 [90%]) and the low group (difference < 6 mm Hg; n = 11 [10%]) showed no difference in the time to extubation (6 vs 5 hr, respectively; p = 0.80) or in the time to discharge from ICU (4 vs 5 d, respectively; p = 0.49). There was no mortality within 30 days of surgery. CONCLUSIONS Elevation of central venous to arterial CO2 difference on ICU admission in children after cardiac surgery with cardiopulmonary bypass does not appear to be associated with delayed extubation or prolonged ICU stay.

Additional file 1.

AIM To demonstrate that unrecognised situation awareness failures events (UNSAFE) transfers are associated with poorer outcomes in the intensive care unit (ICU) at a Japanese children's hospital lacking a rapid response system. METHODS This retrospective cohort study was conducted between January 2013 and February 2016. UNSAFE transfers were defined as unplanned in-hospital ward-to-ICU transfers requiring tracheal intubation, vasoactive medications or ≥3 fluid boluses before arrival or in the first 60 min of ICU care. We compared ICU stay duration and mortality between UNSAFE and non-UNSAFE transfers. RESULTS There were 2126 admissions to the paediatric ICU during the study period, and 244 cases met the definition of an unscheduled in-hospital transfer (11.5%). Of these, the number of patients transferred following cardiopulmonary resuscitation, in the UNSAFE group and in the non-UNSAFE group were 9 (3.7%), 68 (28%) and 167 (68%), respectively. In the UNSAFE group, the number of patients who required tracheal intubation, initiation of vasoactive medications or ≥ 3 fluid boluses in the first 60 min of ICU care or before arrival in the ICU was 61 (90%), 38 (56%) and 9 (13%), respectively. ICU stay duration and mortality were significantly poorer in the UNSAFE group than in the non-UNSAFE group (9 vs. 4 days, P

Objectives To identify the effects of healthcare-associated infections on length of PICU stay and mortality. Design Retrospective, single-center, observational study. Setting PICU of a tertiary children's hospital. Patients Consecutive patients who stayed greater than 48 hours in the PICU between January 2013 and December 2017. Interventions None. Measurements and main results Data were retrospectively collected from medical records. We identified occurrences of common healthcare-associated infections, including bloodstream infection, pneumonia, and urinary tract infection, defined according to the 2008 definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the effects of each healthcare-associated infection on length of PICU stay and PICU mortality using multivariable analysis. Among 1,622 admissions with a PICU stay greater than 48 hours, the median age was 299 days and male patients comprised 51% of admissions. The primary diagnostic categories were cardiovascular (58% of admissions), respiratory (21%), gastrointestinal (8%), and neurologic/muscular (6%). The median length of PICU stay was 6 days, and the PICU mortality rate was 2.5%. A total of 167 healthcare-associated infections were identified, including 67 bloodstream infections (40%), 43 pneumonias (26%), and 57 urinary tract infections (34%). There were 152 admissions with at least one healthcare-associated infection (9.4% of admissions with a stay > 48 hr). On multivariable analysis, although each healthcare-associated infection was not significantly associated with mortality, bloodstream infection was associated with an extra length of PICU stay of 10.2 days (95% CI, 7.9-12.6 d), pneumonia 14.2 days (11.3-17.2 d), and urinary tract infection 6.5 days (4.0-9.0 d). Accordingly, 9.7% of patient-days were due to these three healthcare-associated infections among patients with a stay greater than 48 hours. Conclusions Although healthcare-associated infections were not associated with PICU mortality, they were associated with extra length of PICU stay. As 9.7% of patient-days were due to healthcare-associated infections, robust prevention efforts are warranted.

OBJECTIVES In pediatric patients, indwelling peripheral venous catheters are sometimes displaced to extravascular positions, causing infiltration or extravasation. No reliable techniques are available to confirm accurate IV catheterization. However, ultrasonographic detection of micro-bubble turbulence in the right atrium after saline injection has been reported to be useful in confirming central venous catheter positions in both adults and children. This study evaluated whether this micro-bubble detection test can offer better confirmation of peripheral venous catheter positions compared with the smooth saline injection technique in pediatric patients. DESIGN Randomized controlled study. SETTING Single tertiary PICU. PATIENTS Pediatric patients (weighing < 15 kg) who already had or required a peripheral venous catheter. INTERVENTIONS Patients were randomly allocated to either of the two groups (150 patients per group): undergoing either the micro-bubble detection test (M group) or the smooth saline injection test (S group). MEASUREMENTS AND MAIN RESULTS The peripheral venous catheters were confirmed to be IV located in the final position in 137 and 139 patients in the M and S groups, respectively. In properly located catheters, the tests were positive in 100% (n = 137/137; sensitivity, 100%; 95% CI, 97.8-100), and in 89% (n = 124/139; 95% CI, 82.8-93.8) of the M and S groups, respectively (p = 0.0001). Among the catheters located in extravascular positions, the tests were negative in 100% (n = 13/13; specificity, 100%; 95% CI, 79.4-100), and in 64% (n = 7/11; 95% CI, 30.8-89.1) of the M and S groups, respectively (p = 0.017). CONCLUSIONS The micro-bubble detection test is a useful technique for detecting extravasation and confirming proper positioning of peripheral IV catheters in pediatric patients.

Objectives This study evaluated whether the dynamic needle tip positioning technique increased the success rate of ultrasound-guided peripheral venous catheterization in pediatric patients with a small-diameter vein compared with the static ultrasound-guided technique. Design Randomized controlled study. Setting Single institution, Osaka Women's and Children's Hospital. Patients The study population included 60 pediatric patients less than 2 years old who required peripheral venous catheterization in the PICU. Interventions Patients were randomly divided into the dynamic needle tip positioning (n = 30) or static group (n = 30). Each group received ultrasound-guided peripheral venous catheterization with or without dynamic needle tip positioning, respectively. The Fisher exact test, Kaplan-Meier curve plots, log-rank tests, and Mann-Whitney U test were used in the statistical analysis. Measurements and main results The first-attempt success rate was higher in the dynamic needle tip positioning group than in the static group (86.7% vs 60%; p = 0.039; relative risk = 1.44; 95% CI, 1.05-2.0). The overall success rate within 10 minutes was higher in the dynamic needle tip positioning group than in the static group (90% vs 63.3%; p = 0.03; relative risk = 1.42; 95% CI, 1.06-1.91). Significantly fewer attempts were made in the dynamic needle tip positioning group than in the static group (median [interquartile range, range] = 1 [1-1, 1-2] vs 1 [1-2, 1-3]; p = 0.013]). The median (interquartile range) catheterization times were 51.5 seconds (43-63 s) and 71.5 seconds (45-600 s) in the dynamic needle tip positioning and static groups, respectively (p = 0.01). Conclusions Dynamic needle tip positioning increased the first-attempt and overall success rates of ultrasound-guided peripheral venous catheterization in pediatric patients less than 2 years old.