Pediatric Critical Care Medicine最新文献

Objectives: Small studies of extracorporeal membrane oxygenation (ECMO) support for children with refractory septic shock (RSS) suggest that high-flow (≥ 150 mL/kg/min) venoarterial ECMO and a central cannulation strategy may be associated with lower odds of mortality. We therefore aimed to examine a large, international dataset of venoarterial ECMO patients for pediatric sepsis to identify outcomes associated with flow and cannulation site.

Design: Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database from January 1, 2000, to December 31, 2021.

Setting: International pediatric ECMO centers.

Patients: Patients 18 years old young or younger without congenital heart disease (CHD) cannulated to venoarterial ECMO primarily for a diagnosis of sepsis, septicemia, or septic shock.

Interventions: None.

Measurements and main results: Of 1242 pediatric patients undergoing venoarterial ECMO runs in the ELSO dataset, overall mortality was 55.6%. We used multivariable logistic regression analyses to evaluate explanatory factors associated with adjusted odds ratios (aORs) and 95% CI of mortality. In the regression analysis of data 4 hours after ECMO initiation, logarithm of the aOR, plotted against ECMO flow as a continuous variable, showed that higher flow was associated with lower aOR of mortality (p = 0.03). However, at 24 hours, we failed to find such a relationship. Finally, peripheral cannulation, as opposed to central cannulation, was independently associated with greater odds of mortality (odds ratio, 1.7 [95% CI, 1.1-2.6]).

Conclusions: In this 2000-2021 international cohort of venoarterial ECMO for non-CHD children with sepsis, we have found that higher ECMO flow at 4 hours after support initiation, and central- rather than peripheral-cannulation, were both independently associated with lower odds of mortality. Therefore, flow early in the ECMO run and cannula location are two important factors to consider in future research in pediatric patients requiring cannulation to venoarterial ECMO for RSS.

Objectives: To report the feasibility of a fluid management practice bundle and describe the pre- vs. post-implementation prevalence and odds of cumulative fluid balance greater than 10% in critically ill pediatric patients with respiratory failure.

Design: Retrospective cohort from May 2022 to December 2022.

Setting: Quaternary care PICU in Pittsburgh, PA.

Patients: Children older than 28 days receiving invasive mechanical ventilation for greater than 48 hours.

Interventions: None.

Measurements and main results: We reviewed data from 205 patients; 104 before bundle implementation and 101 after bundle implementation. At the time of implementation in 2022, our PICU clinicians were educated on the use of the fluid management practice bundle, which included the following during daily rounds: goal-setting for daily fluid balance; assessing transition to enteral nutrition; and fluid conservation measures such as concentrating infusions or using enteral formulations of medications. A cumulative fluid balance greater than 10% occurred in 46 of 104 patients (44%) pre-implementation and 26 of 101 patients (26%) post-implementation. We failed to identify an association between implementation epoch grouping (pre- and post-) and adverse outcomes, including mortality, duration of mechanical ventilation, acute kidney injury, and ICU length of stay. In a multivariable logistic regression model, management during the fluid management bundle was associated with lower odds of a cumulative fluid balance greater than 10% (adjusted odds ratio, 0.35 [95% CI, 0.18-0.68]).

Conclusions: In our PICUs 2022 peri-implementation testing of a fluid management bundle in critically ill children with respiratory failure, we have first found that such a practice change is feasible. Second, we identified an associated decrease in the prevalence and lower odds of fluid accumulation. We continue to use this fluid management bundle in our center but more widespread prospective studies are needed to test the benefit in clinical practice.

Objectives: A conservative oxygenation strategy is recommended in adult and pediatric guidelines for the management of acute respiratory distress syndrome to reduce iatrogenic lung damage. In the recently reported Oxy-PICU trial, targeting peripheral oxygen saturations (Spo2) between 88% and 92% was associated with a shorter duration of organ support and greater survival, compared with Spo2 greater than 94%, in mechanically ventilated children following unplanned admission to PICU. We investigated whether this benefit was greater in those who had severely impaired oxygenation at randomization.

Design: Post hoc analysis of a pragmatic, open-label, multicenter randomized controlled trial.

Setting: Fifteen PICUs across England and Scotland.

Patients: Children between 38 weeks old corrected gestational age and 15 years accepted to a participating PICU as an unplanned admission and receiving invasive mechanical ventilation with supplemental oxygen for abnormal gas exchange.

Interventions: A mixed-effects ordinal regression model was used to explore the effect of severity of lung injury, dichotomized to an oxygen saturation index (OSI) less than 12 or greater than or equal to 12 at randomization, the trial group allocation, age, and Pediatric Index of Mortality-3 on the composite ordinal outcome measure of duration of organ support at day 30 and mortality, with death being the worst outcome. An interaction term was included to specifically understand the effect of trial arm allocation on those with and OSI less than 12 and OSI greater than or equal to 12.

Measurements and main results: Data were available for 1775 of 1986 eligible children. Two hundred twelve of 1775 children had an OSI greater than or equal to 12 at randomization. The trial primary outcome did not vary significantly according to OSI category. Both children with OSI less than 12 (odds ratio [OR], 0.85; 95% CI, 0.71-1.01) and OSI greater than or equal to 12 (OR, 0.95; 95% CI, 0.49-1.84) benefited from conservative arm allocation, with relative benefit greater for those with an OSI less than 12.

Conclusions: These data do not provide evidence that a conservative oxygenation strategy should be limited to mechanically ventilated children with severely impaired oxygenation.

Objectives: To assess characteristics and outcomes of children with suspected or confirmed infection requiring emergency transport and PICU admission and to explore the association between the 2024 Phoenix Sepsis Score (PSS) criteria and mortality.

Design: Retrospective analysis of curated data from a 2014-2016 multicenter cohort study.

Setting: PICU admission following emergency transport in South East England, United Kingdom, from April 2014 to December 2016.

Patients: Children 0-16 years old (n = 663) of whom 444 (67%) had suspected or confirmed infection.

Interventions: None.

Measurements and main results: The PSS was calculated as a sum of four individual organ subscores (respiratory, cardiovascular, neurological, and coagulation) using the worst values during transport (i.e., from referral until the time of PICU admission). A score cutoff of greater than or equal to 2 points was used to define sepsis; and septic shock was defined as sepsis plus 1 or more cardiovascular subscore points. Sepsis occurred in 260 of 444 children (58.6%) with suspected or confirmed infection, with septic shock occurring in 177 of 260 (68.1%) of those with sepsis. A PSS score greater than or equal to 2 points occurred in 37 of 67 bronchiolitis cases, 19 of 35 meningoencephalitis cases, 30 of 47 pneumonia/empyema cases, 38 of 46 septic/toxic shock cases, nine of 15 severe sepsis cases, and 58 of 118 definite viral infections. Overall, 14 of 444 children died (3.2%). There were 12 deaths in the 260 children with PSS greater than or equal to 2, and two deaths in the 184 children with PSS less than 2 (4.6% vs. 1.1%; absolute difference, 3.5%; 95% CI, 0.1-6.9%; p = 0.04).

Conclusions: In 2014-2016, over half of the critically ill children undergoing emergency transport to PICU with presumed or confirmed infection, and meeting retrospectively applied PSS criteria for sepsis, had a range of clinical diagnoses including bronchiolitis, meningoencephalitis, and pneumonia/empyema. Furthermore, the PSS criteria for categorization of sepsis and septic shock were associated with outcome and may be of value in future risk-stratification in clinical trials.

Objectives: To test feasibility of a randomized controlled trial (RCT) with an endpoint of time at goal anticoagulation in children on extracorporeal membrane oxygenation (ECMO) randomized to receive bivalirudin vs. unfractionated heparin.

Design: Open-label pilot RCT (NCT03318393) carried out 2018-2021.

Setting: Single-center quaternary U.S. pediatric hospital.

Patients: Children 0 days to younger than 18 years old supported with ECMO in the PICU or cardiovascular ICU.

Interventions: Randomization to bivalirudin vs. unfractionated heparin while on ECMO.

Measurements and main results: Sixteen patients were randomized to bivalirudin, and 14 patients were randomized to heparin. There was no difference in the primary outcome, time spent at goal anticoagulation, for patients randomized to bivalirudin compared with those randomized to heparin. While hemorrhagic complications were similar between study groups, thrombotic complications were higher with six of 16 patients in the bivalirudin group having one or more circuit changes compared with 0 of 14 patients in heparin group (mean difference, 37.5% [95% CI, 8.7-61.4%]; p = 0.02). Patients in the bivalirudin group received less packed RBC transfusions vs. those receiving heparin (median [interquartile range], 6.3 mL/kg/d [2.5-8.4 mL/kg/d] vs. 12.2 mL/kg/d [5.5-14.5 mL/kg/d]; p = 0.02).

Conclusions: In this single-center pilot RCT carried out 2018-2021, we found that the test of anticoagulation therapy of bivalirudin vs. heparin during ECMO was feasible. Larger multicenter studies are required to further assess the safety and efficacy of bivalirudin for pediatric ECMO.