Pediatric Critical Care Medicine最新文献

Objectives: Elevated intracranial pressure (ICP) is a complication of severe traumatic brain injury (TBI) that carries a risk of secondary brain injury. This study investigated the association between ICP burden and brain injury patterns on MRI in children with severe TBI.

Design, setting, and patients: Secondary analysis of the Approaches and Decisions in Acute Pediatric TBI (ADAPT) study, which included children with severe TBI (Glasgow Coma Scale score < 9) who received a clinical MRI within 30 days of injury. We excluded patients who had ICP monitoring less than 24 hours, were missing ICP data for greater than 40% of monitoring time, or who underwent craniectomy.

Interventions: None.

Measurements and main results: ICP burden was defined as the trapezoidal area under the curve of hourly ICP greater than 20 mm Hg. ICP was standardized to total monitoring time, and patients were categorized to four levels of ICP burden. MRI was evaluated for number of diffuse axonal injury (DAI) microhemorrhages, intracerebral hemorrhage (ICH) volume, contusion volume, and number of regions with ischemia. Fisher exact or chi-square tests were used to test the independence between ICP burden and MRI injury amount. Of the 220 patients, 156 (71%) had DAI, 31 (14%) had ICH, 161 (73%) had contusions, and 70 (32%) had ischemia on MRI. Most patients (180, 82%) experienced episodes of ICP greater than 20 mm Hg. Contusion volume ( p = 0.02) and number of regions with ischemia ( p = 0.007) were associated with ICP burden, but we failed to identify such an association for DAI or ICH. Severe (but not mild or moderate) ICP burden was associated with presence of ischemia (odds ratio, 4.64 [95% CI, 1.30-19.5]; p = 0.02).

Conclusions: Elevated ICP was prevalent in the ADAPT cohort. Ischemia and contusion were associated with the burden of ICP. Further research is needed to determine temporal relationships between elevated ICP and ischemia.

Objectives: To assess the prevalence and factors associated with duration of postoperative invasive mechanical ventilation (IMV) in children with medical complexity undergoing spinal fusion.

Design: Retrospective cohort study of the Pediatric Health Information System database.

Setting: Forty-seven tertiary referral U.S. children's hospitals.

Patients: Patients 5-18 years old with an underlying neuromuscular or genetic disorder admitted to the ICU following thoracic-lumbar spinal fusion for scoliosis, with hospital discharge between January 1, 2016, and December 31, 2021.

Interventions: None.

Measurements and main results: There were 6511 patients who met inclusion criteria, of which 438 (6.7%) had established preoperative tracheostomy and ventilator dependence. Three hundred seventy-two (5.7%) and 458 (7%) patients underwent postoperative IMV for 4-6 days and greater than or equal to 7 days, respectively. Chronic conditions associated with greater odds of greater than or equal to 4 days of postoperative IMV (as shown by adjusted odds ratio [aOR, 95% CI]), included diseases affecting the following systems: neurologic (aOR, 3.5; 95% CI, 2.5-5.0), respiratory (aOR, 2.8; 95% CI, 2.3-3.5), skin/subcutaneous tissue (aOR, 1.5; 95% CI, 1.2-2.1), hematologic (aOR, 1.4; 95% CI, 1.1-1.7), endocrine/metabolic (aOR, 1.3; 95% CI, 1.1-1.6), genitourinary (aOR, 1.3; 95% CI, 1.1-1.7), and cardiac (aOR, 1.3; 95% CI, 1.0-1.7). Established preoperative tracheostomy was associated with lower odds of greater than or equal to 4 days of postoperative IMV (aOR, 0.1; 95% CI, 0.02-0.3). New tracheostomy procedures were uncommon ( n = 43, 0.7%). Finally, there was substantial regional variation in postoperative IMV after spinal fusion, with patients in the Northeast vs. Midwest region having greater odds of greater than or equal to 4 days of postoperative IMV (aOR, 3.1; 95% CI, 1.9-5.0).

Conclusions: One-in-eight children required greater than or equal to 4 days of IMV after spinal fusion. Chronic conditions affecting the neurologic, respiratory, skin/subcutaneous tissue, hematologic, endocrine/metabolic, genitourinary, and cardiac systems were associated with postoperative IMV. Further understanding of chronic conditions, clinical characteristics, and regional factors associated with duration of IMV may identify opportunities for improvements in care delivery.

Objectives: We aimed to reduce the rate of hospital-acquired venous thromboembolism (HA-VTE) in the PICU by 50% from 2.07 to 1.04 venous thromboembolism (VTE) per 1000 patient days by June 2023 and sustain this change for 6 months.

Design: Prospective quality improvement project.

Setting: The PICU of an urban academic free-standing children's hospital in the United States.

Patients: All patients admitted to the PICU between December 2020 and December 2023.

Interventions: We identified key drivers including: provider knowledge gaps surrounding VTE risk in our patient population, identification of patients at risk of VTE, the absence of appropriate screening and prevention tools, and central venous line duration and location. These key drivers were each addressed with the most significant intervention being the creation of a simple screening tool to identify and provide thromboprophylaxis recommendations for patients most at risk for developing VTE.

Measurements and main results: We identified the monthly occurrence rate of VTE as our outcome measure, the provision of VTE thromboprophylaxis as our process measure and the presence of bleeding events as our balancing measure. The rate of VTE in PICU patients decreased from 2.07 to 1.14 per 1000 patient days. There was an increase in the provision of pharmacologic thromboprophylaxis during our intervention period from 36% to 42% with no change in the rate of mechanical thromboprophylaxis. There were only two instances of clinically relevant non-major bleeding as defined by the International Society of Thrombosis and Haemostasis definition in nonsurgical patients on anti-hemostatic agents during our intervention period. There was a decrease in central venous catheter days from 43% to 31% of PICU patient days during the intervention period.

Conclusions: Upon implementing a protocolized screening and prevention tool for VTE, we observed a decreased occurrence of HA-VTE.

Objectives: To describe the prevalence of RBC transfusion in children admitted to PICUs in three European countries and to determine hemoglobin threshold, triggers, and outcomes for transfusions.

Design: International 4-week point prevalence study in 2023.

Setting: Forty-four PICUs across Spain, the United Kingdom, and Italy.

Patients: PICU patients 1 month to 17 years old receiving RBC transfusion.

Interventions: None.

Measurements and main results: During four prespecified 7-day blocks (from March 2023 to July 2023), 348 of 2713 patients (12.8%) received at least one RBC transfusion, accounting for 527 transfusions. The proportion of patients receiving RBC transfusion in Italy, the United Kingdom, and Spain was 17.3% (66/382), 13.9% (166/1195), and 10.2% (116/1136), respectively. The primary indication for transfusion in the 527 transfusion events was hemoglobin level (54.6%), followed by bleeding (10.6%), cardiovascular instability (10.5%), and extracorporeal support (10.1%). In 45.1% of RBC transfusions, there was no other physiologic trigger apart from hemoglobin. The median (interquartile range [IQR]) hemoglobin level before transfusion was 8.3 g/dL (IQR, 7.2-9.9 g/dL), with median values varying significantly among Spain, the United Kingdom, and Italy, respectively, 7.8 vs. 8.6 vs. 8.9 g/dL ( p < 0.001). When excluding cardiac patients, overall median hemoglobin threshold was 7.4 g/dL (IQR, 6.8-8.6 g/dL) and was comparable across the three countries ( p > 0.05). The overall 28-day PICU mortality in 348 patients receiving transfusions was 10.7%. The number of transfusions was associated with mortality, even after adjusting for reason for admission and admission Pediatric Index of Mortality score.

Conclusions: In 44 European PICUs in 28 days during 2023, 12.8% of critically ill children received one or more RBC transfusions during their PICU stay. Hemoglobin level was the primary determinant for transfusion, often exceeding the recommended 7.0 g/dL threshold. Other clinical triggers are rarely considered. Defining hemoglobin thresholds and adopting a goal-directed transfusion strategies may optimize clinical transfusion practices.

Objectives: First, to determine the resources and costs required to implement an early rehabilitation (ABCDEF) bundle. Second, to compare the impact of the bundle on costs pre- and post-implementation.

Design and setting: Cost analysis was conducted as part of an implementation study at McMaster Children's Hospital PICU in 2018-2020.

Measurements and main results: Resource estimates for all implementation activities from 2018 to 2020 were calculated from material costs and hours spent by personnel multiplied by wages. PICU and patient-level costs before (from January 2019 to March 2019) and after bundle implementation (from January 2020 to March 2020) were compared using case-costing data. Linear regression was used to analyze log-transformed costs adjusted for age, sex, and severity of illness score. Costs are reported in Canadian dollars (CAD). A total of 907 hours were spent over a 2-year implementation period, at an estimated cost of CAD 50,813. Physicians contributed the most hours, followed by the nurse educator and pharmacist. Material costs were CAD 860. There were 141 patients pre-implementation and 84 patients post-implementation in the analyses. Adjusted mean PICU cost per patient was CAD 17,342 and CAD 20,310, pre- to post-implementation, respectively; mean difference (95% CI) between post- and pre-implementation was 17% higher (95% CI, from 6.3% lower to 46% higher). Adjusted mean pharmacy cost per patient was CAD 834 pre-implementation and CAD 827 post-implementation; mean difference of 0.8% lower post-implementation (95% CI, from 27% lower to 35% higher).

Conclusions: Implementation of the ABCDEF bundle requires significant time and collaboration of key stakeholders. There was no impact on PICU or patient costs following bundle implementation, but the period of observation was limited by COVID-19. Future studies should include cost analyses that incorporate longer-term, patient-centered health outcomes to determine whether this intervention is cost-effective.

Objectives: The Breathing Assistance in Children with bronchiolitis (BACHb) trial aims to evaluate the clinical and cost-effectiveness of high-flow nasal cannula (HFNC) therapy compared with humidified standard oxygen (HSO) in infants with moderate bronchiolitis, and HFNC with continuous positive airway pressure (CPAP) in severe bronchiolitis.

Design: Pragmatic, group-sequential, two-stratum, multicenter, open-label randomized clinical trial.

Setting: Fifty hospitals across England, Scotland, and Wales.

Patients: Hospitalized infants younger than 12 months old with a clinical diagnosis of bronchiolitis, assessed at least twice 15 minutes apart to fulfill criteria for either severe bronchiolitis (one or more of: respiratory rate > 70 breaths/min, grunting, marked chest recession, recurrent short apneas) or moderate bronchiolitis (lack of response to low-flow oxygen, indicated by persistent hypoxemia and/or moderate respiratory distress).

Interventions: "Moderate bronchiolitis stratum": HFNC at a flow rate of 2 L/kg/min vs. HSO through a facemask or headbox at a flow rate up to 15 L/min. "Severe bronchiolitis stratum": HFNC at a flow rate of 2 L/kg/min vs. CPAP pressure set at 6-8 cm H 2 O.

Measurements and main results: In each stratum, eligible infants will be randomly allocated on a 1:1 basis to the trial treatments using a web-based system by permuted block randomization, stratified by site of recruitment and age (< 6 wk and ≥ 6 wk). Due to the emergency nature of the treatments, written informed consent will be deferred. The primary outcome is time from randomization to hospital discharge within 30 days. Baseline clinical characteristics and hospital course, including details of respiratory support, and discharge and cost-effectiveness outcomes will be collected. The trial received Health Research Authority and Research Ethics Committee approval from the Yorkshire and The Humber-South Yorkshire Research Ethics Committee on August 3, 2023 (reference: 23/YH/0166). The trial registration is ISRCTN52937119.

Conclusions: Trial findings will be disseminated in national and international conferences, in peer-reviewed journals and through social media.

Objectives: To determine whether patient race, ethnicity, preferred language, insurance type, and social deprivation index (SDI) are associated with differences in caregiver presence in the PICU and to explore caregiver perspectives on decision-making about time spent at and away from bedside.

Design: Single-center prospective, concurrent mixed-methods study including: 1) a quantitative point prevalence study of caregiver bedside presence, and 2) a qualitative study of interviews with caregivers.

Setting: Seventy-five-bed PICU in a quaternary children's hospital in Philadelphia, PA.

Patients: Over the period 2022-2023, we enrolled: 1) children with anticipated moderate-to-long PICU length of stay and 2) adult caregivers of children in our PICU.

Interventions: None.

Measurements and main results: Multivariable regression tested associations between caregiver presence and race, ethnicity, preferred language, insurance type, and SDI. Semi-structured interviews with caregivers were evaluated using thematic analysis. Among 159 subjects, Black patient race relative to White, and public insurance relative to private, were associated with 18 and 10 fewer hours of caregiver presence during a 48-hour period, respectively. Caregivers nearly universally shared a desire to be present, yet the ability to be present was affected by practical limitations, including job flexibility and family availability.

Conclusions: Public insurance and Black patient race were associated with decreased caregiver presence, disparities that may be explained by practical limitations. Additional work is necessary to explore ways to mitigate barriers to presence and equitable family-centered care and to investigate potential impacts of caregiver presence on health outcomes.