Pediatric Critical Care Medicine最新文献

Objectives: To first evaluate the association between postoperative electroencephalography findings and 24-month neurodevelopmental outcomes in neonates with congenital heart disease (CHD) undergoing cardiac surgery. Secondarily to explore the association between perioperative medication exposure and outcome.

Design: Single-center retrospective cohort study in a University-affiliated tertiary pediatric center, between February 2013 and September 2020.

Patients: Neonates (postmenstrual age [PMA] > 36 wk) with CHD requiring cardiopulmonary bypass surgery at PMA younger than 44 weeks who had neurodevelopmental assessments at 24 months using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III).

Interventions: None.

Measurements and main results: Out of 345 neonates with complex CHD, there were 68 neonates in our clinical outcome cohort, and 32 of 68 (47%) in the postoperative electroencephalography cohort. In the electroencephalography group, a quantitative electroencephalography index of discontinuity index was calculated and averaged from postoperative recordings between 15 and 24 hours. Here, adjusted analyses showed greater postoperative electroencephalography discontinuity index was associated with lower BSID-III motor scores at 24 months (-0.48 [95% CI, -2.31 to -0.51]; p = 0.009). In the complete clinical cohort, linear regression models were used to explore the association between medication dosing (intraoperative, 24-hr postoperative, and cumulative doses) with BSID-III scores at 24 months. Higher early postoperative opioid doses were associated with better motor outcomes, as represented by the standardized coefficient, B, and its 95% CI, including: global motor composite scores (complete cohort, 0.33 [95% CI, 0.77-5.41]; p = 0.010 and d-transposition of the great arteries subgroup, 0.37 [95% CI, 0.67-5.41]; p = 0.013); fine motor scaled scores (complete cohort, 0.26 [95% CI, 0.01-0.97]; p = 0.049); and gross motor scaled scores (complete cohort, 0.26 [95% CI, 0.01-0.94]; p = 0.047).

Conclusions: Our single-center retrospective study shows an association between early postoperative electroencephalography findings and outcomes after neonatal cardiac surgery. Electroencephalography discontinuity may be a potential biomarker of later adverse motor outcomes. Future evaluations are needed to clarify the interaction between postoperative electroencephalography monitoring, pharmacologic exposures and later neurodevelopment.

Objective: We aim to evaluate the prevalence of food insecurity (FI) among pediatric patients admitted to the PICU, compare the prevalence between patients admitted to the PICU vs. hospital medicine (HM) floor, and determine associations between the presence of FI and clinical and demographic variables.

Design, setting, and patients: A retrospective chart review was conducted for patients 0-18 years old admitted for at least 24 hours between January 1 and December 31, 2023 to a tertiary pediatric hospital PICU or HM floor.

Interventions: None.

Measurements and main results: FI was measured using the Hunger Vital Sign tool. Self-identified demographic data were obtained and reported using descriptive statistics, and associations with FI were examined using chi-square testing and logistic regression. Of the 4457 identified patients, 2820 met inclusion criteria (621 in PICU, 2199 in HM). FI prevalence was higher in PICU patients compared with those admitted to the HM floor (9% PICU vs. 6.5% HM, p = 0.034; 95% CI, 0.504-0.962). Higher odds of FI were found in Black patients (aOR 2.40; 95% CI, 1.39-4.09, p = 0.001) and patients self-identifying as Hispanic (aOR 5.44; 95% CI, 2.94-9.81, p = < 0.001) as compared with White patients. Admission location, age, gender, and length of stay were not independently associated with FI.

Conclusions: This is the first study reported comparing the prevalence of FI between PICU vs. HM floor patients, and the largest study to date on FI prevalence in the PICU. FI was more prevalent among patients admitted to the PICU than HM floor and predominantly noted in Black patients and patients self-identifying as Hispanic. These findings highlight the need for screening and intervention strategies to address FI within the ICU setting.

Objectives: Ketamine is a commonly administered sedative to facilitate painful procedures in children, and recommendations for its optimal practice require accurate estimates of the frequency and nature of adverse events. Our objective was to assess the frequency of critical and high-risk adverse events associated with ketamine as the primary sedative, and to identify clinical predictors of such adverse events.

Design: Retrospective analysis of a prospective registry of 38,910 children receiving ketamine for procedural sedation from July 1, 2004, to July 1, 2024.

Setting: Critical care units, sedation units, emergency departments, radiology suites, and other locations providing ketamine sedation in 84 participating institutions.

Patients: Children receiving ketamine used as their primary sedative, defined as ketamine as a single agent or with adjunctive benzodiazepines or dexmedetomidine, but excluding co-administered primary sedative agents such as propofol.

Interventions: None.

Measurements and main results: Of 38,910 unique sedation encounters of ketamine as a primary sedative, there were 15 critical adverse events (0.04% or 1 per 2,594 sedations): cardiac arrest (1), aspiration (3), intubation (8), anaphylaxis (1), and laryngeal mask airway (2). There were no reported deaths or descriptions of any permanent adverse outcomes. The strongest independent risk factor was upper respiratory infection, but only in those also receiving benzodiazepines or dexmedetomidine. Other predictors were opioids, and, to a lesser degree, age younger than 6 months or older than 10 years. We found no patterns of association with severe underlying illness, obstructive sleep apnea, preemptive supplemental oxygen, ketamine route (intramuscular vs. IV), or ketamine dose.

Conclusions: In this largest study of ketamine as a primary procedural sedative, we found that critical and high-risk adverse events were rare. The strongest risk factors were presence of an upper respiratory infection in association with added benzodiazepines or dexmedetomidine, and when opioids were also administered.

Objective: Lower positive end-expiratory pressure (PEEP) is commonly suggested in congenital heart disease (CHD) patients to prevent hemodynamic impairment and right ventricular (RV) dysfunction. We sought to study the effect of different levels of PEEP on cardiac index, lung mechanics, and RV function in subjects after cardiac surgery.

Design: Prospective, single-center physiology study conducted in a tertiary pediatric cardiac ICU between November 2023 and July 2024.

Setting: Operating room (OR) and cardiac ICU (CICU).

Patients: Subjects younger than 5 years post-cardiac surgery for CHD.

Interventions: Four consecutive PEEP levels: baseline (PEEPstart), high PEEP (baseline plus 4 cm H 2 O; PEEPhigh), low PEEP (baseline minus 4 cm H 2 O; PEEPlow), and return to baseline (PEEPend).

Measurements: In 58 subjects, cardiac index and RV function, static (Cstat) and dynamic compliance, and transpulmonary pressures were measured at each PEEP level and with constant driving pressure. Of these subjects, 81.0% underwent surgery with cardiopulmonary bypass (CPB). The median age was 4.9 months, and 55% of subjects were male. The mean baseline PEEP was 6.2 cm H₂O ( sd 1.4), the mean PEEPhigh was 10.2 cm H₂O ( sd 1.4), and the mean PEEPlow was 3.3 cm H₂O ( sd 0.7).

Main results: Overall, cardiac index and RV performance increased significantly with PEEPhigh ( p < 0.01). Cardiac index decreased in 7 of 58 patients (12%)with PEEPhigh and in 18 of 58 patients (31%) with PEEPlow. Directional change in measures of RV performance and Cstat over time was generally concordant; with manipulation of PEEP, both improved or worsened together, independent of the underlying lesion. Sensitivity analyses showed that the results remained consistent regardless of the location of the measurement (OR vs. CICU), whether inhaled nitric oxide or milrinone was used, whether RV outflow tract obstruction was present, and whether CPB was used.

Conclusions: In children with CHD who underwent biventricular repair, cardiac index, RV function, and Cstat generally improved with higher PEEP, indicating pulmonary recruitment. Changes in cardiac performance and Cstat were closely related, with both improving or worsening together with manipulation of PEEP. This study supports the use of PEEP to optimize lung volume and cardiopulmonary interactions after cardiac surgery.

Objective: The 2018-2019 DEPICT (Differences in Access to Emergency pediatric Intensive Care and care during Transport) study in the United Kingdom had a follow-up questionnaire component, 12 months after PICU admission. We now report the quality of life findings in the children and mental health outcomes (i.e., anxiety, depression, and post-traumatic stress disorder [PTSD]) in the parents.

Design: DEPICT cohort follow-up study using questionnaires and registered with ClinicalTrials.gov (NCT03520192) in 2017.

Setting: PICU transport teams and 24 PICUs admitting children transported between January 2018 and January 2019 in United Kingdom.

Patients: DEPICT cohort ( n = 419, depending on missingness) children and related parents/caregivers with 2020 outcome questionnaires.

Interventions: None.

Measurements and main results: We evaluated parental proxy-reported questionnaires covering their child's baseline characteristics, pediatric quality of life (PedsQL) and health utilities index (HUI-2), and healthcare utilization; we also assessed parent questionnaires testing for any anxiety, depression, and PTSD. At the time of transfer, 225 of 419 (53.7%) of the children were aged under 1-year; most required transfer for respiratory reasons; and, 194 of 419 (46.3%) had preexisting comorbidities. At 12-month post-PICU admission, around half of the children with a baseline comorbidity had impaired overall PedsQL quality of life scores (57.1%, 105/184), compared with around a quarter of previously healthy children (23.1%, 49/212). Both PedsQL and HUI-2 scores were significantly worse for children with baseline comorbidities. At follow-up, 105 of 340 (30.9%) of parents met screening thresholds for anxiety, 74 of 340 (21.8%) for depression, and 84 of 298 (28.2%) for PTSD. Parent anxiety, depression and PTSD were correlated with poor quality of life scores for their child.

Conclusions: The 2020, 12-month outcome findings of the 2018-2019 DEPICT study, highlights post-PICU impairments in child quality of life, and high rates of parental mental health issues. Further study of contemporary child and family support, as well as the optimal model for follow-up care, are needed.

Objectives: Healthcare improvement studies indicate a potential to reduce cardiac arrests in the PICU through anticipatory care and shared awareness. We developed a structured risk-assessment and anticipation tool (i.e., the Airway, Breathing, Circulation-Plan, Risk, Options [ABC-PRO]) for PICU patient handover and assessed the impact on cardiac arrest occurrence rate.

Design: Single-center, retrospective healthcare improvement audit of before- vs. after-ABC-PRO tool implementation.

Setting: Multidisciplinary, 25-bed PICU of the University Children's Hospital, Zurich.

Patients: Patients younger than 18 years admitted to the PICU (from January 2020 to September 2023) whose parents/guardians had not refused consent for general use of personal PICU administrative data.

Interventions: We implemented the ABC-PRO handover tool and the primary outcome was the occurrence rate of cardiac arrests necessitating cardiopulmonary resuscitation, before vs. after the implementation. Cardiac arrest incidence was calculated per 1000 PICU-days using Poisson regressions, adjusted for age, sex, and Pediatric Index of Mortality.

Measurements and main results: During 4,370 PICU admissions (21,804 PICU-days), there were 63 cardiac arrests in 59 patients. Of these, 43 occurred pre- (12,911 PICU-days), and eight post-implementation (6,156 PICU-days). The adjusted cardiac arrest occurrence rate pre- vs. post-implementation was 2.9 vs. 1.2 per 1000 PICU-days with an adjusted rate ratio (aRR, 0.42; 95% CI, 0.20-0.88) overall, 0.47 (95% CI, 0.20-1.1) among cardiac, and 0.48 (95% CI, 0.14-1.6) among noncardiac patients. Cardiac arrests decreased most in cardiac surgical patients (aRR, 0.23 [95% CI, 0.06-0.96]). However, we failed to identify a difference in cardiac arrest mortality pre- vs. post-implementation (17/41 vs. 1/8; mean percentage difference, 29%; 95% CI, 2-56%; p = 0.12).

Conclusions: The ABC-PRO PICU handover tool provides a structured approach to risk-assessment and anticipation and may be associated with a decreased cardiac arrest occurrence rate in the PICU, with effects most pronounced in cardiac surgical patients.

Objectives: To describe medical management surrounding withdrawal of life-sustaining therapy (WLST) in nine U.S. PICUs.

Design: Retrospective, secondary analysis of the "Death One Hour After Terminal Extubation" (DONATE) cohort (2009-2021) assessing usage patterns of: 1) analgesics and sedatives; 2) vasoactive infusions; 3) neuromuscular blockade; and 4) post-extubation respiratory support.

Setting: Nine U.S. PICUs.

Patients: Children and adolescents 0-21 years old, who had died after WLST (discontinuation of invasive mechanical ventilation).

Interventions: None.

Measurements and main results: Of 905 patients, 680 (75.1%) died within 1 hour of WLST. Opioids were administered in 721 of 905 patients (79.7%); across sites the range was 68-89% ( p < 0.001). We did not observe a temporal trend. Benzodiazepines were used in 507 of 905 patients (56.0%; site range, 41-66%; p < 0.001), with lower odds of usage per year (odds ratio [OR], 0.95 per year; 95% CI, 0.90-0.99 per year; p = 0.04). Dexmedetomidine was used in 140 of 905 patients (15.5%; sites range, 4-21%; p = 0.002), with greater odds of usage per year (OR, 1.16 per year; 95% CI, 1.05-1.27 per year; p = 0.004). Vasoactive infusions were discontinued in 458 of 520 patients (88.1%) receiving this medication (site range, 59-100%; p < 0.001), with greater odds of discontinuation per year (OR, 1.15 per year; 95% CI, 1.04-1.26 per year; p = 0.007). Neuromuscular blockade was used in 46 of 905 patients (5.1%; sites range, 0-13%; p < 0.001), with greater odds of usage per year (OR, 1.23 per year; 95% CI, 1.08-1.40 per year; p = 0.002). Use of any post-extubation respiratory support occurred in 50 of 905 patients (5.5%), and we did not identify an association with site or year-on-year trend.

Conclusions: The 2009-2021 DONATE dataset shows substantial institutional and temporal variability in WLST practices across our nine collaborating PICUs in the United States. Future studies should focus on understanding the drivers of variability to improve the consistency and quality of end-of-life management.

Objective: To reduce acute kidney injury (AKI) associated with nephrotoxic medication (NTM) exposure in critically ill pediatric patients through a structured quality improvement (QI) initiative.

Design: Prospective, multi-phased QI project.

Setting: A single-center, free-standing, quaternary care children's hospital.

Patients: All patients admitted to the PICU during the study period.

Interventions: A three-phase intervention strategy was implemented to increase awareness surrounding NTM exposures in PICU and their role in subsequent AKI development. Phase 1 introduced monthly pharmacist-led educational session for resident physicians. Phase 2 incorporated an informational handout reviewed during monthly resident orientations. In phase 3, clinical pharmacists provided daily notifications to attending physicians for patients meeting NTM exposure criteria, offering timely alternatives and AKI monitoring recommendations.

Measurements and main results: NTM exposure and NTM-associated AKI (NAKI) rates per 1000 patient-days were measured across pre-intervention and post-intervention periods. From May 1, 2021, to December 31, 2023, a total of 34,631 patient-days were included. During this period, 2410 and 388 patient-days, respectively, satisfied NTM exposure and NAKI criteria. This accounted for 1039 NTM exposure events in 742 patients and 159 NAKI episodes in 125 unique patients. Following interventions, NTM exposure rates declined from 30.6 to 26.9 per 1000 patient-days (a 12.4% reduction), and NAKI rates decreased from 5.6 to 2.5 per 1000 patient-days (a 55% reduction).

Conclusions: Targeted PICU-specific interventions, including routine stakeholder education and pharmacy-driven daily provider notifications, were associated with reductions in NTM exposure and subsequent NAKI rates in critically ill patients. Efforts to integrate and sustain these strategies at the institutional level are currently in progress.