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Objective: To characterize sedation weaning patterns in typical practice settings among children recovering from critical illness. Design: A descriptive secondary analysis of data that were prospectively collected during the prerandomization phase (January to July 2009) of a clinical trial of sedation management. Setting: Twenty-two PICUs across the United States. Patients: The sample included 145 patients, aged 2 weeks to 17 years, mechanically ventilated for acute respiratory failure who received at least five consecutive days of opioid exposure. Interventions: None. Measurements and Main Results: Group comparisons were made between patients with an intermittent weaning pattern, defined as a 20% or greater increase in daily opioid dose after the start of weaning, and the remaining patients defined as having a steady weaning pattern. Demographic and clinical characteristics, tolerance to sedatives, and iatrogenic withdrawal symptoms were evaluated. Sixty-six patients (46%) were intermittently weaned; 79 patients were steadily weaned. Prior to weaning, intermittently weaned patients received higher peak and cumulative doses and longer exposures to opioids and benzodiazepines, demonstrated more sedative tolerance (58% vs 41%), and received more chloral hydrate and barbiturates compared with steadily weaned patients. During weaning, intermittently weaned patients assessed for withdrawal had a higher incidence of Withdrawal Assessment Tool-version 1 scores of greater than or equal to 3 (85% vs 46%) and received more sedative classes compared with steadily weaned patients. Conclusions: This study characterizes sedative administration practices for pediatric patients prior to and during weaning from sedation after critical illness. It provides a novel methodology for describing weaning in an at-risk pediatric population that may be helpful in future research on weaning strategies to prevent iatrogenic withdrawal syndrome.

Herein, we propose a blueprint for action to completely measure and recognize the care provided by acute and critical care nurses to be incorporated into policy that shapes and supports practice. We address the nature of nurses' work by identifying nine practice domains, hospital practice environment assumptions, and expected outcomes. Nurses' work, as a cross-system process, needs to be included in hospital-based core measures to fully reflect nurses' impact on patient care. We call for a balanced measurement portfolio focused on patient/family-, unit-, and systems-level outcomes. We focus on what nurses do and what patients and their families can expect rather than only on the elimination of select adverse events. We provide a way forward to allow measure development and implementation with incentives for their use. This approach to making nurses' contributions and impact on outcomes visible will enhance acute and critical care nursing practice and benefit patients and their families., Competing Interests: Declaration of Competing Interest Lauren R. Sorce is an elected member of the Executive Committee and serves as President of the Society of Critical Care Medicine (SCCM) 2024 to 2025. The views presented are those of the author and are not intended to represent the views of SCCM., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: To identify self-reported meaningful decisions made by parents in the PICU and to determine patient and parent characteristics associated with the development of parental decision regret, a measurable, self-reported outcome associated with psychologic morbidity., Design: Secondary analysis of the Navigate randomized comparative trial (NCT02333396)., Setting: Two tertiary, academic PICUs., Patients: Spanish- or English-speaking parents of PICU patients aged less than 18 years who were expected to remain in the PICU for greater than 24 hours from time of enrollment or who had a risk of mortality greater than 4% based on Pediatric Index of Mortality 2 score., Interventions: None., Measurements and Main Results: Between April 2015 and March 2017, 233 parents of 209 patients completed a survey 3-5 weeks post-PICU discharge which included the Decision Regret Scale (DRS), a 5-item, 5-point Likert scale tool scored from 0 (no regret) to 100 (maximum regret). Two hundred nine patient/parent dyads were analyzed. The decisions parents reported as most important were categorized as: procedure, respiratory support, medical management, parent-staff interactions and communication, symptom management, fluid/electrolytes/nutrition, and no decision. Fifty-one percent of parents had some decision regret (DRS > 0) with 19% scoring in the moderate-severe range (DRS 26-100). The mean DRS score was 12.7 ( sd 18.1). Multivariable analysis showed that parental Hispanic ethnicity was associated with greater odds ratio (OR 3.12 [95% CI, 1.36-7.13]; p = 0.007) of mild regret. Being parents of a patient with an increased PICU length of stay (LOS) or underlying respiratory disease was associated with greater odds of moderate-severe regret (OR 1.03 [95% CI, 1.009-1.049]; p = 0.004 and OR 2.91 [95% CI, 1.22-6.94]; p = 0.02, respectively)., Conclusions: Decision regret was experienced by half of PICU parents in the 2015-2017 Navigate study. The characteristics associated with decision regret (parental ethnicity, PICU LOS, and respiratory disease) are easily identifiable. Further study is needed to understand what contributes to regret in this population and what interventions could provide support and minimize the development of regret., Competing Interests: Drs. Michelson, Frader, Sorce, Clayman, and White’s institutions received from Patient-Centered Outcomes Research Institute. Dr. Sorce disclosed she is a member of the Executive Committee Board of the Society of Critical Care Medicine. Dr. White was supported by the National Institute of Health grant K24HL148314. Dr. White reports personal fees from American Thoracic Society and personal fees from UpToDate. Dr. Frader received funding from Direct Relief/Takeda Pharmaceuticals and Premier Research/Dicerna Pharmaceutical; he disclosed government work. Dr. Michelson’s institution received funding from the Greenwall Foundation and the National Institutes of Health; he received funding from the Friends of Prentice Northwestern Alliance for Research in Chicagoland Communities. 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: Data support the protective effects of human breast milk (HBM) feeding in acute illness but little is known about the impact of HBM feeding on the criticality of infants., Aim: To explore the relationship between early HBM feeding and severity of illness and recovery in critically ill children requiring intubation and mechanical ventilation for acute respiratory failure (ARF)., Study Design: Prospective cohort study of mothers of patients aged 1-36 months who participated in the acute and follow-up phases of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial. Participants completed a survey describing HBM dose fed during their infant's first month of life., Results: Of 138 patients, 70 (51%) received exclusive HBM feedings (90%-100% total feeds) and 68 (49%) did not. We found no group differences in severity of illness on paediatric intensive care unit (PICU) admission or severity of paediatric acute respiratory distress syndrome (PARDS) within the first 24-48 h of intubation/mechanical ventilation (Pediatric Risk of Mortality [PRISM] III-12 score median: 5 vs. 5, p = .88; moderate/severe PARDS: 53% vs. 54%, p = .63). While median time to recovery from ARF was reduced by 1 day in patients who received exclusive HBM feedings, the difference between groups was not statistically significant (median 1.5 vs. 2.6 days, hazard ratio 1.40 [95% confidence interval, 0.99-1.97], p = .06)., Conclusions: Human breast milk dose was not associated with severity of illness on PICU admission in children requiring mechanical ventilation for ARF., Relevance to Clinical Practice: Data support the protective effects of HBM during acute illness and data from this study support a clinically important reduction in time to recovery of ARF. Paediatric nurses should continue to champion HBM feeding to advance improvements in infant health., (© 2024 The Author(s). Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Importance: Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children., Objective: To update and evaluate criteria for sepsis and septic shock in children., Evidence Review: The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria., Findings: Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively., Conclusions and Relevance: The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Importance: The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach., Objective: To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings., Design, Setting, and Participants: Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set., Exposure: Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock., Main Outcomes and Measures: The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity., Results: Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings., Conclusions and Relevance: The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.

Objectives: To describe challenges experienced by parents of children hospitalized in the PICU during PICU admission as reported by family navigators., Design: A preplanned secondary analysis of open-response data coded via inductive qualitative approach from the Navigate randomized controlled trial (RCT) dataset (ID NCT02333396)., Setting: Two university-affiliated PICUs in the Midwestern United States as part of an RCT., Patients: Two hundred twenty-four parents of 190 PICU patients., Interventions: In 2015-2017, trained family navigators assessed and addressed parent needs, offered weekly family meetings, and provided post-PICU discharge parent check-ins as part of a study investigating the effectiveness of a communication support intervention ("PICU Supports")., Measurements and Main Results: We analyzed qualitative data recorded by family navigators weekly across 338 encounters. Navigators described families' "biggest challenge," "communication challenges," and ways the team could better support the family. We used an inductive qualitative coding approach and a modified member-checking exercise. The most common difficulties included home life , hospitalization , and diagnosis distress (45.2%, 29.0%, and 17.2% of families, respectively). Navigators often identified that parents had co-occurring challenges. Communication was identified as a "biggest challenge" for 8% of families. Communication challenges included lack of information, team communication , and communication quality (7.0%, 4.8%, and 4.8% of families, respectively). Suggestions for improving care included better medical communication, listening, rapport, and resources., Conclusions: This study describes families' experiences and challenges assessed throughout the PICU stay. Family navigators reported families frequently experience stressors both internal and external to the hospital environment, and communication challenges between families and providers may be additional sources of distress. Further research should develop and assess interventions aimed at improving provider-family communication and reducing stressors outside the hospitalization itself, such as home life difficulties., Competing Interests: Drs. Tager and Balistreri were supported by the UWM Cialdini Fellowship. The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, Award Number UL1TR001436, and by the generosity of Froedtert Hospital. The content is solely the responsibility of the author(s) and does not necessarily represent the official views of the NIH. Drs. Charleston and Michelson’s institutions received funding from the Patient-Centered Outcomes Research Institute (PCORI). Dr. Charleston received support for article research from the PCORI. Dr. White received support for article research from the National Institutes of Health. Dr. Source disclosed she is on the Executive Board for the Society of Critical Care Medicine. Dr. Michelson’s institution received funding from the NIH, the Greenwall Foundation, and Friends of Prentice; They received funding from Northwestern Alliance for Research in the Chicagoland Communities; They disclosed they are a board member of Normal Moments; They disclosed they are the co-founder of Missing Pieces of the HAP Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: To explore gamification as an alternative approach to healthcare education and its potential applications to critical care., Data Sources: English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023)., Study Selection: Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches., Data Extraction: Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior., Data Synthesis: Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized., Conclusions: Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional needs of multidisciplinary clinicians and health system administrators in resource-poor settings., Design: Semistructured qualitative focus groups and interviews with 35 clinicians (8 nurses, 27 physicians) and 5 administrators at health systems that regularly provide care for children with sepsis, April-May 2022., Setting: Health systems in Africa, Asia and Latin America, where sepsis has a large impact on child health and healthcare resources may be limited., Participants: Participants had a mean age of 45 years, a mean of 15 years of experience, and were 45% female., Results: Emergent themes were related to the decisional needs of clinicians caring for children with sepsis and to the needs of health system administrators as they make decisions about which CDS tools to implement. Themes included variation across regions and institutions in infectious aetiologies of sepsis and available clinical resources, the need for CDS tools to be flexible and customisable in order for implementation to be successful, and proposed features and format of an ideal paediatric sepsis CDS tool., Conclusion: Findings from this study will directly contribute to the design and implementation of CDS tools to increase the uptake and impact of the new paediatric sepsis criteria in resource-poor settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers., Competing Interests: Dr. Alexander has received funding from the National Institutes of Health (NIH)/Eunice Kennedy Shriver National Institute of Child Health and Human Development (R13HD104432), Food and Drug Administration (FP01029501), US Department of Defense (W81XWH2210301), and unrestricted grants from the Extracorporeal Life Support Organization (ELSO). Her institution received funding from Novartis (end-point adjudication committee PANORAMA-HF) and she serves as the ELSO Treasurer of the Board of Directors. Dr. Barreto received funding from Wolters-Kluwer. Dr. Morrow’s institution received funding from the Society of Critical Care Medicine (SCCM) for her role as Senior Associate Editor for Pediatric Critical Care Medicine, the National Research Foundation of Southern Africa, and EuroQual; she received funding from the Brazilian Physiotherapy Association. Dr. Mayer’s institution received funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (no. K23-AR079583); he received support for article research from the NIH. Dr. Lane-Fall’s institution receives funding from NIH (R01HL153735, P30AG059302, UM1HL088957, U01OD033246, R01HD105446, R01HD109229), Agency for Healthcare Research and Quality (K12HS026372), Patient-Centered Outcomes Research Institute (21106), and the American Heart Association (962544). She serves as the Vice President of the Anesthesia Patient Safety Foundation and is on the Board of Directors of the Foundation for Anesthesia Education and Research. Dr. Kudchadkar has received funding from NIH/NICHD (R01HD103811) and NIH/NIDDK (R01DK132348). Dr. Rech has received research funding from Spero Pharmaceuticals. Ms. Napolitano receives funding from NIH (1R44HD105552, 1R21HD103927-01A1, 1R01HD106996) and FDA (5P50FD006427) and also has research/consulting relationships with Drager, Philips/Respironics, Timpel, Actuated Medical, and Vero-Biotech. Dr. Sorce disclosed that she is an SCCM Executive Board Member. Dr. Tasker is the Editor-in-Chief for Pediatric Critical Care Medicine. Dr. Buchman is Editor-in-Chief for Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objectives: Clinical decision support systems (CDSSs) are used in various aspects of healthcare to improve clinical decision-making, including in the ICU. However, there is growing evidence that CDSS are not used to their full potential, often resulting in alert fatigue which has been associated with patient harm. Clinicians in the ICU may be more vulnerable to desensitization of alerts than clinicians in less urgent parts of the hospital. We evaluated facilitators and barriers to appropriate CDSS interaction and provide methods to improve currently available CDSS in the ICU., Design: Sequential explanatory mixed-methods study design, using the BEhavior and Acceptance fRamework., Setting: International survey study., Patient/subjects: Clinicians (pharmacists, physicians) identified via survey, with recent experience with clinical decision support., Interventions: An initial survey was developed to evaluate clinician perspectives on their interactions with CDSS. A subsequent in-depth interview was developed to further evaluate clinician (pharmacist, physician) beliefs and behaviors about CDSS. These interviews were then qualitatively analyzed to determine themes of facilitators and barriers with CDSS interactions., Measurements and Main Results: A total of 48 respondents completed the initial survey (estimated response rate 15.5%). The majority believed that responding to CDSS alerts was part of their job (75%) but felt they experienced alert fatigue (56.5%). In the qualitative analysis, a total of five facilitators (patient safety, ease of response, specificity, prioritization, and feedback) and four barriers (excess quantity, work environment, difficulty in response, and irrelevance) were identified from the in-depth interviews., Conclusions: In this mixed-methods survey, we identified areas that institutions should focus on to improve appropriate clinician interactions with CDSS, specific to the ICU. Tailoring of CDSS to the ICU may lead to improvement in CDSS and subsequent improved patient safety outcomes., Competing Interests: Dr. Bates reports grants and personal fees from EarlySense, personal fees from Center for Digital Innovation Negev, equity from ValeraHealth, equity from Clew, equity from MDClone, personal fees and equity from AESOP, personal fees and equity from Feelbetter, equity from Guided Clinical Solutions, and grants from International Business Machines Corporation Watson Health, outside the submitted work. Dr. Bates has a patent pending (PHC-028564 US Patent Cooperation Treaty), on intraoperative clinical decision support. Dr. Kane-Gill receives grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases R01DK121730 and U01DK130010, the National Center for Complementary and Integrative Health U54AT008909, and the Jewish Healthcare Foundation. Drs. Sorce and Kane-Gill also hold executive positions in the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Sepsis is a leading cause of global mortality in children, yet definitions for pediatric sepsis are outdated and lack global applicability and validity. In adults, the Sepsis-3 Definition Taskforce queried databases from high-income countries to develop and validate the criteria. The merit of this definition has been widely acknowledged; however, important considerations about less-resourced and more diverse settings pose challenges to its use globally. To improve applicability and relevance globally, the Pediatric Sepsis Definition Taskforce sought to develop a conceptual framework and rationale of the critical aspects and context-specific factors that must be considered for the optimal operationalization of future pediatric sepsis definitions. It is important to address challenges in developing a set of pediatric sepsis criteria which capture manifestations of illnesses with vastly different etiologies and underlying mechanisms. Ideal criteria need to be unambiguous, and capable of adapting to the different contexts in which children with suspected infections are present around the globe. Additionally, criteria need to facilitate early recognition and timely escalation of treatment to prevent progression and limit life-threatening organ dysfunction. To address these challenges, locally adaptable solutions are required, which permit individualized care based on available resources and the pretest probability of sepsis. This should facilitate affordable diagnostics which support risk stratification and prediction of likely treatment responses, and solutions for locally relevant outcome measures. For this purpose, global collaborative databases need to be established, using minimum variable datasets from routinely collected data. In summary, a "Think globally, act locally" approach is required., Competing Interests: Dr. Carrol received support for article research from the U.K. National Institute for Health and Care Research. Dr. Bennett’s institution received funding from the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences. Drs. Bennett and Zimmerman’s institutions received funding from the National Institute of Child Health and Human Development. Drs. Bennett and Randolph received support for article research from the National Institutes of Health. Dr. Zimmerman’s institution received funding from Immunexpress; he received funding from Elsevier Publishing. Dr. Sorce disclosed she is a Society of Critical Care Medicine (SCCM) Executive Board Member. Dr. Randolph’s institution received funding from the U.S. Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases; she received funding from UpToDate; she disclosed she is Chair of the International Sepsis Forum. Ms. Harmon disclosed she is an employee of SCCM. Dr. Argent received travel, accommodation, and registration fees to attend a number of conferences as an invited guest speaker and received fees for provision of expert opinion in a number of medicolegal cases (from several legal firms in South Africa). The remaining authors have disclosed that they do not have any potential conflicts of interest.., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Repeated exposure to death and dying increases health care professionals' risk for burnout and secondary traumatic stress. Pediatric critical care providers are at particularly high risk because the death and dying of children are associated with even greater psychological impact., Local Problem: A charge nurse in the pediatric intensive care unit identified a need for additional staff support after critical patient events., Methods: The aim of this quality improvement project was to design and implement a debriefing process, the Rapid Review of Resuscitation, in a 40-bed, high-acuity pediatric intensive care unit at an urban children's hospital in the midwestern United States. A preintervention-postintervention survey used the Professional Quality of Life Scale, version 5, to evaluate staff members' compassion satisfaction, burnout, and secondary traumatic stress before and 1 year after implementation. The debriefing process was designed and implemented on the basis of interview data and literature review., Results: Preimplementation (104 of 222 staff members [47%]) and postimplementation (72 of 184 staff members [39%]) survey responses were compared. Compassion satisfaction scores (mean [SD] T scores: preimplementation, 54.10 [7.52]; postimplementation, 56.71 [6.62]) were significantly higher (P = .02) 1 year after implementation. Burnout (P = .69) and secondary traumatic stress (P = .06) scores were not significantly different. After implementation, 74% of respondents reported that the debriefing process was "very helpful" or "somewhat helpful" after critical patient events., Conclusions: Compassion satisfaction improved and burnout and secondary traumatic stress did not change with implementation of the debriefing process after critical patient events., (©2023 American Association of Critical-Care Nurses.)

Objective: Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children., Data Sources and Selection: We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis., Data Extraction: Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories., Data Synthesis: SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict., Conclusions: We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis., Competing Interests: Dr. Menon is funded by Canadian Institutes of Health for a trial on hydrocortisone in pediatric septic shock. Drs. Bennett and Sanchez-Pinto are funded by the National Institutes of Health (NIH)/National Institute of Child Health and Human Development (NICHD) grant: R01HD105939-01. Dr. Carrol is a BioFire Diagnostics Scientific Advisory Board member for the FilmArray System, Surviving Sepsis Campaign Pediatrics Guideline panel member, and has National Institutes of Health and Care Research-funded research collaboration with Biomerieux. Dr. Wynn is funded by NIH grants for work on neonatal sepsis: GM128452, HD097081, and EB029863. Dr. Zimmerman is funded by NIH/NICHD for a sepsis interventional trial and Immunexpress for a sepsis prospective descriptive cohort investigation. Dr. Menon’s institution received funding from the Canadian Institutes of Health Research. Dr. Argent received funding from legal firms in South Africa and for travel and accommodation costs for conferences as a speaker. Drs. Bennett’s, Sanchez-Pinto’s, and Zimmerman’s institutions received funding from the NICHD. Dr. Bennett’s institution received funding from the National Center for Advancing Translational Sciences and the National Heart, Lung, and Blood Institute. Drs. Bennett, Sanchez-Pinto, and Wynn received support for article research from the NIH. Dr. Watson received funding from Society of Critical Care Medicine for a travel meeting. Dr. Wynn received funding from the American Academy of Pediatrics, Developmental Symposium, the NIH, and Roche Diagnostics. Dr. Zimmerman’s institution received funding from Immunexpress; he received funding from Elsevier Publishing. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Purpose: To describe existing guidance for qualifications of principal investigator s (PI s) of human subjects research and explore how they are operationalized for pediatric nurse scientists and clinical nurses in children's hospitals., Design and Methods: After reviewing federal regulations, accreditation guidelines, and the literature, a convenience sample of members of the National Pediatric Nurse Scientist Collaborative (NPNSC). Participants completed a 33-item survey that included questions about Institutional Review Board (IRB), guidelines, and policies for PI status at their affiliated children's hospitals., Results: The survey was electronically disseminated to 179 members of NPNSC through the Collaborative's listserv. Of the 39 members who responded, 90% hold a PhD and 80% practice in a free-standing children's hospital, nearly all of which (93%) are recognized as Magnet® hospitals. While the majority of respondents indicated that nurse scientists and other nurses were allowed to be PIs of research studies, educational requirements for PI status varied, with 3% requiring a PhD, 15% a baccalaureate degree, and 10% a graduate degree. 54% of respondents reported there was no degree requirement for PI status; however15% reported that even doctorally prepared nurse scientists cannot serve as PIs of research studies at their affiliated children''s hospitals., Conclusions: The survey identified substantial variability in requirements for PI status and potential barriers to pediatric nurses conducting independent research as PIs at children's hospitals., Practice Implications: Operationalizing existing guidance will expand inclusion of nurse scientist expertise in human subjects research., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objectives: Definitions for pediatric sepsis were established in 2005 without data-driven criteria. It is unknown whether the more recent adult Sepsis-3 definitions meet the needs of providers caring for children. We aimed to explore the use and applicability of criteria to diagnose sepsis and septic shock in children across the world., Methods: This is an international electronic survey of clinicians distributed across international and national societies representing pediatric intensive care, emergency medicine, pediatrics, and pediatric infectious diseases. Respondents stated their preferences on a 5-point Likert scale., Results: There were 2835 survey responses analyzed, of which 48% originated from upper-middle income countries, followed by high income countries (38%) and low or lower-middle income countries (14%). Abnormal vital signs, laboratory evidence of inflammation, and microbiologic diagnoses were the criteria most used for the diagnosis of "sepsis." The 2005 consensus definitions were perceived to be the most useful for sepsis recognition, while Sepsis-3 definitions were stated as more useful for benchmarking, disease classification, enrollment into trials, and prognostication. The World Health Organization definitions were perceived as least useful across all domains. Seventy one percent of respondents agreed that the term sepsis should be restricted to children with infection-associated organ dysfunction., Conclusions: Clinicians around the world apply a myriad of signs, symptoms, laboratory studies, and treatment factors when diagnosing sepsis. The concept of sepsis as infection with associated organ dysfunction is broadly supported. Currently available sepsis definitions fall short of the perceived needs. Future diagnostic algorithms should be pragmatic and sensitive to the clinical settings., (Copyright © 2022 by the American Academy of Pediatrics.)

Objective: To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock., Data Sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020., Study Selection: Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract., Data Extraction: Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed., Data Synthesis: One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001)., Conclusions: Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce., Competing Interests: Dr. Menon has a Canadian Institutes of Health Research grant for the study of corticosteroids in pediatric septic shock. Dr. Menon’s institution received funding from Crowdsourcing; he disclosed that he is a principal investigator on an international trial on Steroids in Pediatric Sepsis Shock. Drs. Menon and Watson received funding from Society of Critical Care Medicine. Dr. Argent received funding from the World Federation of Pediatric Intensive and Critical Care Societies as a part of the process of working with the Pediatric Sepsis Definitions working group. Dr. Biban received funding from Chiesi and Getinge. Dr. Nadel received funding from Abbvie. Dr. Sadeghirad received funding from the Pre-Interventional Preventative Risk Assessment AG, Mitacs Canada, and Accelerate internship in partnership with Nestlé Canada. Dr. Scott’s institution received funding from the Agency for Healthcare Research and Quality (AHRQ K08HS025696); he received support for article research from the AHRQ. Dr. Tissieres received funding from Sedana, Inotrem, and Baxter. Dr. Wynn received funding from the National Institutes of Health (NIH) (R01GM128452; R01HD089939, R01HD097081, R43EB029863). Dr. Zimmerman’s institution received funding from the NIH, the National Institute of Child Health and Human Development, and Immunexpress; he received funding from Elsevier Publishing. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Competing Interests: Dr. Martin serves as president of the Society of Critical Care Medicine (SCCM). Drs. Kane-Gill, Nadkarni, Sorce, and Kaplan serve as members of the Society of Critical Care Medicine Executive Committee. Drs. Cecconi, Azoulay, Teboul, Forni and Kesecioglu serve as members of the ESICM Executive Committee. Drs. Martin, Kane-Gill, Cecconi, and Azoulay serve as members of the Surviving Sepsis Campaign Executive Committee. Dr. Kaplan received funding from SCCM. Dr. Cecconi received funding from Edwards Lifesciences and Directed Systems. Dr. Azoulay’s institution received funding from Fisher & Paykel, Jazz Pharma, MSD, and Alexion; he received funding from Pfizer, Sanofi, Alexion, and Gilead. Drs. Azoulay and Forni received funding from Baxter Medical. Dr. Teboul received funding from Getinge. Dr. Forni received funding from Exthera Medical and Biomerieux. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Competing Interests: Drs. Kane-Gill, Nadkarni, Sorce, and Kaplan serve on the Executive Committee of the Society of Critical Care Medicine. Dr. Martin is the President of the Society of Critical Care Medicine. Dr. Winkle serves as the current Chancellor of the American College of Critical Care Medicine. Drs. Kaplan and Martin received funding from the Society of Critical Care Medicine. Ms. Harmon disclosed that she is an employee of the Society of Critical Care Medicine and contributed to the development of the referenced guidelines and toolkits as a component of her job as Director of Quality. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Introduction: Maternal recall of infant feeding, a potential measurement bias, is used to identify the relationship between mothers' own milk (MOM) feeding and subsequent health outcomes. This study describes maternal recall certainty of MOM feedings at four time periods., Method: In this secondary analysis, mothers of children ages 4-36 months describe infants' MOM feeding and rate certainty of their recall., Results: MOM was the first feeding for 78.5% of infants and received by 83% the first week, 85% the first month, and 62% the fourth month. Ratings of recall certainty were > 95% for each time period. Recall certainty was significantly different for four time periods (χ 2  = 9.67, p = 0.02), with no two periods significantly different in post hoc analyses., Discussion: Maternal recall certainty of infant feeding was high regardless of elapsed time. Measuring maternal recall certainty may be useful in clinical practice and studies linking MOM exposure to subsequent health outcomes., (Copyright © 2020 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Objectives: Communication breakdowns in PICUs contribute to inadequate parent support and poor post-PICU parent outcomes. No interventions supporting communication have demonstrated improvements in parental satisfaction or psychologic morbidity. We compared parent-reported outcomes from parents receiving a navigator-based parent support intervention (PICU Supports) with those from parents receiving an informational brochure., Design: Patient-level, randomized trial., Setting: Two university-based, tertiary-care children's hospital PICUs., Participants: Parents of patients requiring more than 24 hours in the PICU., Interventions: PICU Supports included adding a trained navigator to the patient's healthcare team. Trained navigators met with parents and team members to assess and address communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and did a post-PICU discharge parent check-in. The comparator arm received an informational brochure providing information about PICU procedures, terms, and healthcare providers., Measurements and Main Results: The primary outcome was percentage of "excellent" responses to the Pediatric Family Satisfaction in the ICU 24 decision-making domain obtained 3-5 weeks following PICU discharge. Secondary outcomes included parental psychologic and physical morbidity and perceptions of team communication. We enrolled 382 families: 190 received PICU Supports, and 192 received the brochure. Fifty-seven percent (216/382) completed the 3-5 weeks post-PICU discharge survey. The mean percentage of excellent responses to the Pediatric Family Satisfaction in the ICU 24 decision-making items was 60.4% for PICU Supports versus 56.1% for the brochure (estimate, 3.57; SE, 4.53; 95% CI, -5.77 to 12.90; p = 0.44). Differences in secondary outcomes were not statistically significant. Most parents (91.1%; 113/124) described PICU Supports as "extremely" or "somewhat" helpful., Conclusions: Parents who received PICU Supports rated the intervention positively. Differences in decision-making satisfaction scores between those receiving PICU Supports and a brochure were not statistically significant. Interventions like PICU Supports should be evaluated in larger studies employing enhanced recruitment and retention of subjects.

Background: Communication in the pediatric intensive care unit (PICU) between families and the health care team affects the family experience, caregiver psychological morbidity, and patient outcomes., Objective: To test the feasibility of studying and implementing a PICU communication intervention called PICU Supports, and to assess families' and health care teams' perceptions of the intervention., Methods: This study involved patients requiring more than 24 hours of PICU care. An interventionist trained in PICU-focused health care navigation, a "navigator," met with parents and the health care team to discuss communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and checked in with parents after PICU discharge. The feasibility of implementing the intervention was assessed by tracking navigator activities. Health care team and family perceptions were assessed using surveys, interviews, and focus groups., Results: Of 53 families approached about the study, 35 (66%) agreed to participate. The navigator met with parents on 71% and the health care team on 85% of possible weekdays, and completed 86% of the postdischarge check-ins. Family meetings were offered to 95% of eligible patients. The intervention was rated as helpful by 97% of parents, and comments during interviews were positive., Conclusions: The PICU Supports intervention is feasible to implement and study and is viewed favorably by parents., (© 2020 American Association of Critical-Care Nurses.)

Objectives: Sepsis is responsible for a substantial proportion of global childhood morbidity and mortality. However, evidence demonstrates major inaccuracies in the use of the term "sepsis" in clinical practice, coding, and research. Current and previous definitions of sepsis have been developed using expert consensus but the specific criteria used to identify children with sepsis have not been rigorously evaluated. Therefore, as part of the Society of Critical Care Medicine's Pediatric Sepsis Definition Taskforce, we will conduct a systematic review to synthesize evidence on individual factors, clinical criteria, or illness severity scores that may be used to identify children with infection who have or are at high risk of developing sepsis-associated organ dysfunction and separately those factors, criteria, and scores that may be used to identify children with sepsis who are at high risk of progressing to multiple organ dysfunction or death., Data Sources: We will identify eligible studies by searching the following databases: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials., Study Selection: We will include all randomized trials and cohort studies published between January 1, 2004, and March 16, 2020., Data Extraction: Data extraction will include information related to study characteristics, population characteristics, clinical criteria, and outcomes., Data Synthesis: We will calculate sensitivity and specificity of each criterion for predicting sepsis and conduct a meta-analysis if the data allow. We will also provide pooled estimates of overall hospital mortality., Conclusions: The potential risk factors, clinical criteria, and illness severity scores from this review which identify patients with infection who are at high risk of developing sepsis-associated organ dysfunction and/or progressing to multiple organ dysfunction or death will be used to inform the next steps of the Pediatric Sepsis Definition Taskforce., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objectives: To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation., Design: Retrospective review of the literature and expert consensus., Setting: Series of in-person meetings, conference calls, and emails from January 2018 to March 2019., Subjects: A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field., Interventions: A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9., Measurements and Main Results: The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead., Conclusions: The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.

Problem: Breastfed infants experience less severe infections while actively breastfeeding. However, little is known about whether a history of prior breastfeeding affects severity of illness. Therefore, the purpose of this integrative review was to examine the relationship between previous exposure to mother's own milk (MOM) feeding and severity of respiratory infectious illness in infants and children., Eligibility Criteria: Studies meeting the following criteria were included: human subjects, term birth, ages 0-35 months at time of study, diagnosis of pneumonia, bronchiolitis or croup, MOM feeding, and statistical analyses reporting separate respiratory infectious illness outcomes when combined with other infections., Sample: Twelve articles met eligibility criteria., Results: Major findings were inconsistent definitions of both dose and exposure period of breastfeeding and the severity of illness. In particular, the severity of illness measure was limited by the use of proxy variables such as emergency room visits or hospitalizations that lacked reliability and validity. However, given this limitation, the data suggested that exclusive breastfeeding for four to six months was associated with reduced severity of illness as measured by frequency of visits to the primary care provider office, emergency department or hospitalization., Conclusions: Future research in this area should incorporate reliable and valid measures of MOM dose and exposure period and severity of illness outcomes in the critically ill child., Implications: Among many positive outcomes associated with breastfeeding, an additional talking point for encouragement of exclusive breastfeeding for four to six months may be protective against severe respiratory infectious illness after cessation of breastfeeding., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Patterns and outcomes of multiple organ dysfunction syndrome are unknown in critically ill children with hyperglycemia. We aimed to determine whether tight glycemic control to a lower vs. higher range influenced timing, duration, or resolution of multiple organ dysfunction syndrome as well as characterize the clinical outcomes of subgroups of multiple organ dysfunction syndrome in children enrolled in the Heart And Lung Failure-Pediatric INsulin Titration trial., Design: Planned secondary analysis of the multicenter Heart And Lung Failure-Pediatric INsulin Titration trial., Setting: Thirty-five PICUs., Patients: Critically ill children with hyperglycemia who received the Heart And Lung Failure-Pediatric INsulin Titration protocol from 2012 to 2016., Interventions: Randomization to a lower versus higher glucose target group., Measurements and Main Results: Of 698 patients analyzed, 48 (7%) never developed multiple organ dysfunction syndrome, 549 (79%) had multiple organ dysfunction syndrome without progression, 32 (5%) developed new multiple organ dysfunction syndrome, and 69 (10%) developed progressive multiple organ dysfunction syndrome. Of those whose multiple organ dysfunction syndrome resolved, 192 (34%) experienced recurrent multiple organ dysfunction syndrome. There were no significant differences in the proportion of multiple organ dysfunction syndrome subgroups between Heart And Lung Failure-Pediatric INsulin Titration glucose target groups. However, patients with new or progressive multiple organ dys function syndrome had fewer ICU-free days through day 28 than those without new or progressive multiple organ dysfunction syndrome, and progressive multiple organ dysfunction syndrome patients had fewer ICU-free days than those with new multiple organ dysfunction syndrome: median 25.1 days for never multiple organ dysfunction syndrome, 20.2 days for multiple organ dysfunction syndrome without progression, 18.6 days for new multiple organ dysfunction syndrome, and 0 days for progressive multiple organ dysfunction syndrome (all comparisons p < 0.001). Patients with recurrent multiple organ dysfunction syndrome experienced fewer ICU-free days than those without recurrence (median, 11.2 vs 22.8 d; p < 0.001)., Conclusions: Tight glycemic control target range was not associated with differences in the proportion of new, progressive, or recurrent multiple organ dysfunction syndrome. New or progressive multiple organ dysfunction syndrome was associated with poor clinical outcomes, and progressive multiple organ dysfunction syndrome was associated with worse outcomes than new multiple organ dysfunction syndrome. In future studies, new multiple organ dysfunction syndrome and progressive multiple organ dysfunction syndrome may need to be considered separately, as they represent distinct subgroups with different, potentially modifiable risk factors. Patients with recurrent multiple organ dysfunction syndrome represent a newly characterized, high-risk group which warrants attention in future research.

Rationale: Whether a nurse-implemented goal-directed sedation protocol resulting in more awake yet calm intubated children affects postdischarge functional status, health-related quality of life, or risk for post-traumatic stress disorder is unknown., Objectives: To compare postdischarge outcomes in children with acute respiratory failure cluster-randomized to a sedation protocol or usual care., Methods: A stratified random sample of 1,360 patients from 31 centers in the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) trial was assessed by mail, electronically, and/or telephone 6 months after ICU discharge. In treatment group comparisons, we controlled for age, baseline functional status, and severity of illness., Measurements and Main Results: We used the Pediatric Overall Performance Category and the Pediatric Cerebral Performance Category to characterize functional status, the Infant and Toddler Quality of Life Questionnaire (97-item full-length version) (<2 yr old) or Pediatric Quality of Life Inventory (≥2 yr old), and the Child Post-traumatic Stress Disorder Symptom Scale (≥8 yr old and developmentally able). Functional status worsened from baseline to follow-up in 20%. Decline in functional status did not differ by treatment arm and was more common among those with baseline impairment than those with baseline normal function (27 vs. 18%; P < 0.001). There were no significant differences in health-related quality of life total scores by treatment arm. Scores indicating risk of post-traumatic stress disorder occurred in 30%, with no difference between treatment arms., Conclusions: A sedation strategy that allows patients to be more awake and exposes them to fewer sedative and analgesic medications produces no long-term harm. However, postdischarge morbidity after acute respiratory failure is common. Clinical trial registered with www.clinicaltrials.gov (NCT00814099).

Respiratory syncytial virus (RSV) is a common disease in pediatrics. Certain subpopulations of children are at greatest risk for serious disease. However, previously healthy children also may become critically ill. In the clinic or the intensive care unit, children with RSV pose the challenge of how to treat a disease when evidence to support therapeutic options is severely limited. Prophylaxis is an option for certain children, although many do not qualify. RSV has been implicated in continued wheezing and the subsequent development of asthma. While evidence for this implication is still being sought, researchers are working on finding new ways to treat and prevent RSV.

Advanced practice nurses (APNs) prescribe sedation, analgesia, and neuromuscular blocking agents in the management of critically ill children. Although most children are unscathed from the use of the medications, some suffer adverse responses. This article elucidates adverse responses to these medications for the APN, including withdrawal syndrome, muscle weakness, decreased gastric motility, corneal abrasions, and costs associated with these morbidities.