Pediatric Critical Care Medicine最新文献

Objectives: To define and reduce the incidence of severe arterial catheter-associated proximal ischemic injuries (ACAPII).

Design: Quality improvement (QI) initiative.

Setting: University affiliated PICU in a quaternary children's hospital.

Patients: All patients with indwelling arterial catheters (ACs) in the PICU at the Children's Hospital of Philadelphia from January 2020 to December 2022.

Interventions: Phase I (January 2021 to December 2021) included defining ACAPII and daily rounding on all ACs by a dedicated PICU-specific vascular access team. Phase II (January 2022 to December 2022) introduced standardized recommendations and interventions including the use of topical nitroglycerin ointment (TNG) as a therapeutic option for mild injuries.

Measurements and main results: From January 2021 to December 2022, the rounding team evaluated 1916 ACs for a total of 5793 rounding episodes (line-days). During phase I, the overall number of ACAPII increased compared with prior year pre-QI (35 vs. 11, 318%). During phase II, the administration of TNG was associated with an increase in arterial line-days per AC in patients with mild injury (6.58 line-days per line, 158 d/24 lines) compared with pre-QI, phase I, and phase II mild injuries without use of TNG (3.27, 198/61; incident rate difference [95% CI], 3.31 [2.11-4.51]; p < 0.001). Special cause indicators shifted centerline from a weighted average 33.0-342.3 line-days between severe injuries. The cumulative severe ACAPII incidence rate decreased from its peak early in phase I (April 2021: 5.65 per 1000 line-days) to the end of phase II (December 2022: 2.11 per 1000 line-days). The overall rate of arterial line-days per AC during phase II increased compared with pre-QI (p < 0.01) and phase I (p < 0.01).

Conclusions: The development of a newly defined measurable harm index, ACAPII, and implementation of increased surveillance resulted in increased awareness and reduction of severe injury as measured by rates and line-days between severe injuries in our critically ill patients. Protocolized management during phase II, including introducing TNG as a therapeutic option, resulted in increased AC line-days per catheter with sustained reduction in severe ACAPII rates.

Objectives: To examine the utility of day 3 sepsis phenotype classifications compared with day 1 and whether these could be reliably identified using routine clinical data on day 1.

Design: Retrospective cohort study of pediatric patients managed 2010-2014 and 2018-2020.

Setting: Academic children's hospital.

Patients: One thousand eight hundred twenty-eight children (1 mo to 18 yr old) admitted to the PICU with suspected infection who received a minimum of 7 days of systemic antibiotics.

Interventions: None.

Measurements and main results: Subjects showed significant evolution of phenotype from day 1 to day 3, with 31.7-60.9% remaining the same type. Outcomes were worst in those classifying as type D on day 3, with mortality as high as 16.6% in those that were classified as type D on both days 1 and 3, as well as 11.3% in those initially classified as type C (a lower mortality type) on day 1 but type D on day 3. Accurate statistical prediction of day 3 types using multinomial logistic regression and random forest and day 1 data was poor, despite attempts to improve performance.

Conclusions: In our retrospective cohort of patients with sepsis, we identified significant evolution in phenotype over the first 3 days of illness. Day 3 phenotypes may provide more accurate statistical prediction of outcomes, but identification of day 3 phenotypes using data available early in the course of illness is challenging. New methods will likely be required to improve performance in this area.

Objectives: In children reported to the Extracorporeal Life Support Organization (ELSO) registry, to compare mortality, the need for additional cannulas, and complications associated with dual-lumen (DL) or multisite cannulation for venovenous extracorporeal membrane oxygenation (ECMO).

Design: Multicenter retrospective study using the ELSO registry.

Setting: Centers reporting to ELSO between January 1, 2000, and December 31, 2019.

Patients: Children 28 days to 18 years old supported with venovenous ECMO.

Interventions: We performed univariate and multivariable regression analyses to determine the association between venovenous ECMO cannulation strategy and in-hospital mortality, ECMO duration, and need for additional cannulas. We also compared the frequency of venovenous ECMO complications using univariate analysis.

Measurements and main results: We identified a cohort of 2034 patients, of whom 1441 (71%) were supported with DL. Support with DL, as opposed to multisite cannulation, was associated with median (interquartile range) of younger age (23 mo [6-89 mo] vs. 147 mo [64-189 mo]; p < 0.001). We failed to identify an association between in-hospital mortality and whether DL or multisite cannulation had been used (393/1441 [27%] vs. 184/593 [31%]); unadjusted and adjusted risk ratio (aRR) of death using DL as the reference group of 1.1 (95% CI, 0.7-1.9; p = 0.70). The other analyses failed to identify an association between cannulation type, ECMO duration, and the use of additional cannulas. ECMO complications were similar except for more frequent neurologic determination of death in the multisite group.

Conclusions: In the 2000-2019 ELSO pediatric dataset, we failed to identify an association between venovenous ECMO cannulation type-DL or multisite-and greater aRR of ECMO outcomes.

Objectives: To evaluate the outcomes associated with extubation during extracorporeal membrane oxygenation (ECMO) in pediatric patients.

Design: Retrospective cohort study using the Extracorporeal Life Support Organization (ELSO) registry, 2018-2022.

Setting: Multicenter and international database of all ECMO centers in the ELSO registry.

Patients: Patients between 30 days and 18 years old receiving pulmonary ECMO support.

Interventions: None.

Measurements and main results: Overall, 2178 patients were included, of which 105 were extubated during ECMO support (4.8%). Analysis of pre-ECMO data failed to identify an association between extubation strategy and severity using the Pediatric Pulmonary Rescue with ECMO Prediction (P-PREP) score. Use of extubation, vs. not, was associated with older age (median, 6.1 vs. 2.5 yr; p = 0.006), and longer ECMO duration (median 12.9 vs. 7.1 d; p < 0.0001). We failed to identify an association between the use of extubation, vs. not, and ECMO complications. In a propensity matching analysis with 3:1 matching of nonextubated to extubated cases, mortality was 34.3% and 43.8%, respectively (p = 0.08). In the matched subset, extubation, vs. not, was associated with shorter median PICU length of stay (LOS) after decannulation (6.6 vs. 12.2 d; p = 0.001) and higher use of mobilization (28.6% vs. 9.8%; p < 0.0001). In a multivariable analysis, we failed to identify an association between using the extubation strategy, vs. not, and greater odds of mortality (odds ratio, 1.74; 95% CI, 0.94-3.27; p = 0.08). However, we cannot exclude the possibility that the use of an extubation strategy is associated with greater odds of mortality.

Conclusions: In the 2018-2022 ELSO registry data, extubating pediatric patients on ECMO for pulmonary cause was an uncommon practice, associated with improved mobility and decreased ICU LOS after ECMO decannulation. However, given the concerns about mortality, careful consideration of patient candidacy and further studies are needed.

Objectives: We evaluated the Phoenix criteria and the Phoenix Sepsis Score in a multicenter retrospective cohort of critically ill children with a clinical diagnosis of sepsis or septic shock in Bolivia. In addition, we aimed to assess whether management in a PICU at high altitude in the Bolivian Andes was associated with the performance of the respiratory dysfunction component in the Phoenix Sepsis Score.

Design: Multicenter retrospective cohort study.

Setting: Fourteen PICUs in Bolivia.

Patients: Children admitted to the PICU with a clinical diagnosis of sepsis or septic shock from January 2023 to December 2023.

Interventions: None.

Measurements and main results: There were 273 patients with a diagnosis of sepsis in 2023, of which 257 (94.1%) met the 2024 Phoenix criteria for sepsis, and 166 (60.8%) met the systemic inflammatory response syndrome (SIRS)-based criteria for sepsis. Among the 257 patients meeting Phoenix sepsis criteria, 86 died (33.5%). Of the patients with Phoenix-based sepsis, there were 100 of 257 (38.9%) who were SIRS-negative, and 27 of 100 died (27.0%). After correcting the oxygenation indices for altitude, 149 of 273 patients (54.6%) had a lower Phoenix respiratory score and an associated mortality more consistent with the expected mortality of the newly derived subscore. Patients at higher altitudes had higher hemoglobin levels and higher estimated oxygen carrying capacity, and these data were independently associated with lower odds of mortality after controlling for altitude-corrected Phoenix score.

Conclusions: In this 2023, retrospective cohort of PICU patients with sepsis in Bolivia, we have found that the majority met the 2024 Phoenix sepsis criteria, but less than two-thirds met the SIRS-based criteria for diagnosis. However, the respiratory score in the Phoenix criteria overestimated the severity of respiratory dysfunction in more than half of the cohort, likely because the score does not take account of the Andean adaptation to high altitude, with higher oxygen carrying capacity.

Objectives: To define meropenem plasma concentrations and pharmacodynamic exposure metrics in children with septic shock during the first 3 days of PICU hospitalization.

Design: Pharmacokinetic sampling was undertaken in 19 subjects receiving standard meropenem dosing (20 mg/kg/dose, 8 hr) recruited from March 2019 to March 2022. Sampling occurred once each day following meropenem given 24 hours apart, during the first 3 PICU days. Data analysis was completed in 2023 and noncompartmental analysis was performed to assess pharmacodynamic exposure targets for sepsis. Clearance and volume of distribution at 20 mg/kg/dose were used to simulate mean exposures at 40 and 60 mg/kg/dose.

Setting: PICU in a tertiary care center.

Subjects: Patients 4 weeks old or older with hypotension requiring fluid resuscitation and vasopressor therapy, receiving meropenem as empiric therapy for sepsis.

Interventions: None.

Measurements and main results: Augmented renal clearance (ARC) was documented in eight of 19 subjects, previously associated with subtherapeutic plasma concentrations, while three of 19 had acute kidney injury and decreased renal clearance. When assessed by pharmacodynamic exposure targets for sepsis (plasma meropenem concentrations above the minimum inhibitory concentration [MIC] of Pseudomonas aeruginosa for 70% or 100% of the dosing interval), ten of 19 and nine of 19 children, respectively, had subtherapeutic plasma meropenem exposures during PICU day 1, even for pathogens with an MIC considered "susceptible" by U.S. Food and Drug Administration criteria. Therapeutic meropenem pharmacodynamic exposures were associated with a positive 24-hour fluid balance on PICU day 1 and a negative 24-hour fluid balance by day 3, although profound variability was noted in fluid administered and renal output.

Conclusions: Given the variability in meropenem systemic exposure in pediatric septic shock, therapeutic drug monitoring, or monitoring for ARC, is suggested during the first days of hospitalization to allow daily assessments of dosing needs to achieve pharmacodynamic exposure targets for sepsis.

Objectives: To report the 3-year follow-up results of the "Caring Intensively" study, which examined children's psychological and behavioral responses after PICU hospitalization.

Design: Prospective mixed methods, concurrent triangulation design. In the quantitative arm, study group (SG) and comparison group (CG) children and their parents were administered a battery of measures assessing psychological and behavioral outcomes, and telephone survey data were collected 6 weeks, 6 months, 1, 2, and 3 years post-discharge. In the qualitative arm, SG interviews were conducted 1 and 3 years post-discharge. Recruitment 2014-2018, with follow-up completed 2021.

Setting: SG recruited from PICUs of three Canadian quaternary care pediatric hospitals; CG from two hospitals' ear, nose, and throat (ENT) day surgery units.

Patients: Age (3-12 yr) and gender-matched PICU children (SG, 158) or day surgery ENT children (CG, 169) and their parents were recruited; 62% of families completed the study (SG, 97; CG, 106). Selected SG families were interviewed at year 1 (17 families, 30 participants) and year 3 (14 families, 27 participants).

Interventions: None.

Measurements and main results: No group differences on primary or secondary outcomes. Both groups reported emotional and behavioral changes in children via telephone survey; however, group findings diverged on their nature and attribution. SG parents attributed changes primarily to PICU hospitalization; CG parents attributed changes to other life events. At year 3, 40.3% of SG parents still reported negative emotional and behavioral changes in children suggesting a chronic trajectory of recovery. Qualitative interview findings converged with SG survey responses, reflecting the adaptive and relational challenges confronting children and families.

Conclusions: This study highlights children's emotional and behavioral responses over the 3 years post-PICU and the need to study child recovery within the family. These findings contribute to our understanding of the nature and duration of trajectories of recovery and emphasize the importance of providing clinical follow-up and prioritizing family-identified outcomes in future research.

Objective: To develop consensus statements that clinicians can apply to standardize and optimize endotracheal aspirate culture (EAC) practices in hospitalized children with artificial airways who are being evaluated for a bacterial lower respiratory tract infection (LRTI).

Design: A modified Delphi consensus process with expert panelists. Panelists conducted a "pre-survey" to itemize respiratory signs of bacterial LRTI. Round 1 included a literature summary and electronic survey of 50 potential statements sent to all panelists. We surveyed panelist opinions using a 5-point Likert scale. We grouped the responses "agree" and "strongly agree" as agreement. Consensus was defined as statements reaching greater than 75% agreement. Round 2 was moderated by an independent expert in consensus methodology. Panelists convened in person in November 2023, discussed any statements not reaching consensus or statements with disagreement, were resurveyed, and finalized statements in real time.

Setting: Electronic surveys and in-person meetings in Baltimore, MD.

Subjects: The BrighT STAR (Testing STewardship for Antibiotic Reduction) collaborative along with U.S.-based pediatric experts in critical care, cardiac critical care, infectious diseases, hospital medicine, otolaryngology, pulmonology, and clinical microbiology.

Interventions: None.

Measurements and main results: Thirty-eight of 40 invited panelists completed round 1. Of 50 initial statements, 28 reached greater than 90% agreement, 16 had 75-89% agreement, and 6 had less than 75% agreement. Twenty-eight statements were finalized. Round 2 involved 37 panelists: 23 statements were discussed, of which 17 reached an agreement and 6 did not reach consensus. We concluded with 30 statements and 15 sub-statements, 37 of which had greater than 90% agreement. Final statements informed a clinical decision support algorithm.

Conclusions: The BrighT STAR collaborative group achieved consensus for 45 clinical practice statements that can standardize EAC practices, including indications to consider for testing, reasons to defer, optimal specimen collection, and result interpretation. These statements offer a starting point for clinical decision support tools and diagnostic stewardship programs for EAC practices in patients with artificial airways.

Objective: To compare the level of agreement between proximal (near the subject) and distal (inside the ventilator) measured airway occlusion pressure at 100 ms (P0.1) and occlusion pressure (ΔPocc), and to study the correlation between ΔPocc and peak-to-trough esophageal pressure (ΔPes).

Design: Secondary analysis of prospectively collected physiology dataset (2021-2022).

Setting: Medical-surgical 20-bed PICU.

Patients: Children younger than 18 years with and without acute lung injury ventilated greater than 24 hours and spontaneously breathing with appropriate triggering of the ventilator.

Interventions: None.

Measurements and main results: Data from three expiratory hold maneuvers (with a maximum of three breaths during each maneuver) in 74 subjects (118 measurements) with median age 3 months (interquartile range 1-17), and primary respiratory failure due to a pulmonary infection in 41/74 (55.4%) were studied. The median proximal ∆Pocc was 6.7 cm H2O (3.1-10.7) and median P0.1 4.9 cm H2O (4.1-6.0) for the first breath from the maneuver; both increased significantly (p < 0.001) with the subsequent two breaths during the same maneuver. Median distal ∆Pocc was 6.8 (2.9-10.8) and P0.1 4.6 (3.9-5.6) cm H2O; both increased significantly (p < 0.001) with the two subsequent breaths. Proximal and distal ΔPocc (r > 0.99, p < 0.001) and P0.1 (r > 0.80, p < 0.001) were correlated. Correlation between ventilator displayed and Y-piece measured ΔPocc (r > 0.99) and P0.1 (r = 0.85) was good. Mean (sd) difference for ΔPocc was 0.13 (0.21); levels of agreement were -0.28 and 0.54. For P0.1, mean (sd) difference was -0.36 (1.14) and levels of agreement -2.61 and 1.88. There was a high correlation between ΔPes and ∆Pocc (r = 0.92) for the same breath and a good correlation with ΔPes from the preceding breath (r = 0.76). There was a poor correlation with the transpulmonary pressure (r = 0.37).

Conclusions: ΔPocc is not affected by measurement site, whereas P0.1 may be overestimated or underestimated. ΔPocc was highly correlated with the peak-to-trough esophageal pressure, supporting the concept that inspiratory effort can also be quantified noninvasively by measuring ΔPocc.