Pediatric Critical Care Medicine最新文献

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.

Objective: We assembled a workgroup within the Pediatric Research Collaborative on Critical UltraSound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), to define early guidance for point-of-care ultrasound (POCUS) institutional practice and foster future comprehensive guidelines for its broad adoption in pediatric critical care medicine.

Design: A modified Delphi method was used for creating the statements. The first meeting was an open proposal session for workgroup members to suggest items for consideration. This was followed by a cycle of voting for levels of agreement along a 7-point Likert-type scale. Items were reviewed, with only items receiving a score of greater than or equal to 6 progressing to the next stage of voting and lower-scoring items reconsidered, with only consensus items proceeding to the next stage for additional rounds of voting until consensus was reached.

Setting: Multi-institutional, multidisciplinary, workgroup of experts on POCUS organized within PeRCCUS as a subgroup of PALISI.

Interventions: None.

Measurements and main results: Consensus was obtained for 25 recommendations across five domains: clinical application, quality assurance, equipment, education, and research.

Conclusions: We report consensus recommendations for institutions on clinical use, educational programs, quality assurance, technical requirements, and future research opportunities for the adoption of pediatric critical care medicine POCUS.

Objectives: In neonates, the carotid artery can be ligated or reconstructed at the time of decannulation from venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, there is a paucity of data on the neurologic outcomes of one approach vs. the other. We therefore aimed to compare the brain MRI of VA-ECMO patients who had either undergone carotid reconstruction or ligation at the time of decannulation in our NICU.

Design: Single-center retrospective study.

Setting: Tertiary-level neonatal care, that is, level IV NICU.

Patients: Neonates younger than 28 days old who survived to VA-ECMO decannulation and underwent routine post-decannulation brain MRI between June 2009 and September 2022.

Interventions: None.

Measurements and main results: Eighty-one patients were included in this study: 38 of 81 (47%) with carotid reconstruction and 43 of 81 (53%) who underwent carotid ligation. We failed to identify associations between decannulation strategy and demographics, ECMO indication, cannulation duration, head ultrasound abnormalities during ECMO, and survival to hospital discharge. Overall, 54 of 81 patients (67%) displayed at least one abnormality on post-decannulation brain MRI. We failed to identify an association between decannulation strategy and focal ischemic lesions, MRI injury score, and proportion with intraventricular hemorrhage. However, there was an association between strategy and grade 2-4 IVH (reconstruction vs. ligation: 10 of 38 vs. 3 of 43; mean difference 19.3% [95% CI, 3.1-35.6%], p = 0.02).

Conclusions: In our neonatal VA-ECMO series from 2009 to 2022, follow-up brain MRI shows a high frequency of abnormalities or lesions. Overall, we failed to identify an association between decannulation strategy (i.e., carotid ligation or reconstruction) and proportion with ischemic findings. However, there appears to be an association between carotid reconstruction and higher-grade IVH. Further studies are needed to help with decision-making at the time of decannulation, to discern the mechanisms underlying the radiographic differences we identified in our series, and to investigate the connection between structural changes and long-term neurocognitive outcomes.

Objectives: In a cohort of children with septic shock, we evaluated the association between vasoactive agent use within 1 hour of starting our sepsis bundle and mortality. Secondarily, we assessed the relationship between sepsis bundle adherence and mortality and other outcomes.

Design: Nonpreplanned, secondary analysis of a national multicenter dataset collected in a resource-limited setting.

Setting: Dataset from 14 centers in Bolivia collected between January 2023 and December 2023.

Patients: Children under 15 years old with sepsis or septic shock defined using altitude-adjusted Phoenix criteria.

Interventions: None.

Measurements and main results: We included 268 patients in this secondary analysis, with median (interquartile range [IQR]) age 17 months (IQR, 6-63 mo). The sepsis bundle was used within 3 hours in 131 of 268 patients (49%). Vasopressors were used in 102 of 268 patients (38%) and 85 of 102 (83%) had received peripheral administration within the 1 hour of persistent hypotension, without any record of adverse events. Early vasopressor use within 1 hour of septic shock recognition, and antibiotic administration within 1 hour of sepsis recognition, were independently associated with lower odds (using adjusted odds ratio [aOR] and 95% CI) of mortality, respectively: 0.49 (95% CI, 0.28-0.89) and 0.41 (95% CI, 0.24-0.71; both p = 0.001). Failure to complete the sepsis bundle within 3 hours was associated with greater odds of mortality (aOR, 3.61 [95% CI, 1.64-7.91]; p = 0.001) and greater odds of longer interval before emergency consultation (aOR, 1.04 [95% CI, 1.01-1.07]; p = 0.023).

Conclusions: Early initiation of vasoactive agents in children with septic shock and timely sepsis bundle completion were independently associated with lower hazard of mortality. Historically, in Bolivia in 2023, bundle adherence was suboptimal, yet feasible interventions were associated with greater odds of better outcomes in pediatric sepsis and septic shock.