Pediatric Critical Care Medicine最新文献

Objectives: Previously, we implemented a comprehensive decision support tool, a "New Fever Algorithm," to support the evaluation of PICU patients with new fever or instability. This tool was associated with a decline in culture rates without safety concerns. We assessed the impact of the algorithm on testing practices by identifying the proportion of cultures pre- vs. post-implementation that were discordant with algorithm guidance and may have been avoidable.

Design: Retrospective evaluation 12 months pre- vs. post-quality improvement intervention.

Setting: Single-center academic PICU and pediatric cardiac ICU.

Subjects: All admitted patients.

Interventions: Implementing the "New Fever Algorithm" in July 2020.

Measurements and main results: Patient medical records were reviewed to categorize indications for all blood, respiratory, and urine cultures. Among cultures obtained for new fever or new clinical instability, we assessed specific testing patterns that were discordant from the algorithm's guidance such as blood cultures obtained without documented concern for sepsis without initiation of antibiotics, respiratory cultures without respiratory symptoms, urine cultures without a urinalysis or pyuria, and pan-cultures (concurrent blood, respiratory, and urine cultures). Among 2827 cultures, 1950 (69%) were obtained for new fever or instability. The proportion of peripheral blood cultures obtained without clinical concern for sepsis declined from 18.6% to 10.4% ( p < 0.0007). Respiratory cultures without respiratory symptoms declined from 41.5% to 27.4% ( p = 0.01). Urine cultures without a urinalysis did not decline (from 27.6% to 25.1%). Urine cultures without pyuria declined from 83.0% to 73.7% ( p = 0.04). Pan-cultures declined from 22.4% to 10.6% ( p < 0.0001). Overall, algorithm-discordant testing declined from 39% to 30% ( p < 0.0001).

Conclusions: The majority of cultures obtained were for new fever or instability and introduction of the "New Fever Algorithm" was associated with reductions in algorithm-discordant testing practices and pan-cultures. There remain opportunities for improvement and additional strategies are warranted to optimize testing practices for in this complex patient population.

Objective: To characterize surface-bound proteins and to measure the thickness of fibrin fibers bound to extracorporeal membrane oxygenation (ECMO) circuits used in children.

Design: Single-center observational prospective study, April to November 2021.

Setting: PICU, Royal Children's Hospital, Melbourne, Australia.

Patients: Patients aged less than 18 years on venoarterial ECMO and without preexisting disorder.

Interventions: None.

Measurements and main results: ECMO circuits were collected from six patients. Circuit samples were collected from five different sites, and subsequently processed for proteomic and scanning electron microscopy (SEM) studies. The concentration of proteins bound to ECMO circuit samples was measured using a bicinchoninic acid protein assay, whereas characterization of the bound proteome was performed using data-independent acquisition mass spectrometry. The Reactome Over-representation Pathway Analyses tool was used to identify functional pathways related to bound proteins. For the SEM studies, ECMO circuit samples were prepared and imaged, and the thickness of bound fibrin fibers was measured using the Fiji ImageJ software, version 1.53c ( https://imagej.net/software/fiji/ ). Protein binding to ECMO circuit samples and fibrin networks showed significant intra-circuit and interpatient variation. The median (range) total protein concentration was 19.0 (0-76.9) μg/mL, and the median total number of proteins was 2011 (1435-2777). A total of 933 proteins were commonly bound to ECMO circuit samples from all patients and were functionally involved in 212 pathways, with signal transduction, cell cycle, and metabolism of proteins being the top three pathway categories. The median intra-circuit fibrin fiber thickness was 0.20 (0.15-0.24) μm, whereas the median interpatient fibrin fiber thickness was 0.18 (0.15-0.21) μm.

Conclusions: In this report, we have characterized proteins and fiber fibrin thickness bound to ECMO circuits in six children. The techniques and approaches may be useful for investigating interactions between blood, coagulation, and the ECMO circuit and have the potential for circuit design.

Objective: To describe characteristics associated with survival for pediatric patients with an oncologic diagnosis or hematopoietic cell transplant (HCT) supported with extracorporeal membrane oxygenation (ECMO).

Design: Multicenter, retrospective study.

Setting: Sixteen PICUs in the United States and Israel.

Patients: We included patients aged younger than 19 years with an oncologic diagnosis or HCT who required ECMO support between 2009 and 2021.

Interventions: None.

Measurements and main results: A total of 149 patients were included in the study cohort. There were 118 patients with an oncologic diagnosis and 31 that received HCT. The indications for ECMO were respiratory failure (46%), combined respiratory and cardiac failure (28%), and cardiac failure (25%). Venovenous (V-V) ECMO was used in 45% of patients, with 53% of patients being placed on venoarterial (V-A) ECMO. For oncologic and HCT groups, survival to ECMO decannulation was 52% (62/118) and 64% (20/31), and survival to hospital discharge was 36% (43/118) and 42% (13/31), respectively. After adjusting for other factors, requiring cardiopulmonary resuscitation was associated with greater odds ratio of mortality (3.0 [95% CI, 1.2-7.7]).

Conclusions: Survival to ECMO decannulation of pediatric oncologic and HCT patients in this study was 52-64%, depending upon diagnosis. However, survival to hospital discharge remains poor. Future research should prioritize understanding factors contributing to this survival gap within these patient populations.

Objectives: To evaluate the impact of point-of-care ultrasound (POCUS) use on clinicians within a PICU and to assess infrastructural elements of our POCUS program development.

Design: Retrospective observational study.

Setting: Large academic, noncardiac PICU in the United States.

Subjects: Patients in a PICU who had diagnostic POCUS performed.

Interventions: None.

Measurements and main results: Between January 1, 2017, and December 31, 2022, 7201 diagnostic POCUS studies were ordered; 1930 (26.8%) had a quality assurance (QA) record generated in an independent POCUS QA database. The cardiac domain was most frequently imaged (81.0% of ordered studies, 81.2% of reviewed studies). POCUS images changed clinician understanding of pathophysiology in 563 of 1930 cases (29.2%); when this occurred, management was changed in 318 of 563 cases (56.5%). Cardiac POCUS studies altered clinician suspected pathophysiology in 30.1% of cases (472/1568), compared with 21.5% (91/362) in noncardiac studies ( p = 0.06). Among cases where POCUS changed clinician understanding, management changed more often following cardiac than noncardiac POCUS ( p = 0.02). Clinicians identified a need for cardiology consultation or complete echocardiograms in 294 of 1568 cardiac POCUS studies (18.8%). Orders for POCUS imaging increased by 94.9%, and revenue increased by 159.4%, from initial to final study year. QA database use by both clinicians and reviewers decreased annually as QA processes evolved in the setting of technologic growth and unit expansion.

Conclusions: Diagnostic POCUS imaging in the PICU frequently yields information that alters diagnosis and changes management. As PICU POCUS use increased, QA processes evolved resulting in decreased use of our initial QA database. Modifications to QA processes are likely necessary as clinical contexts change over time.

Objectives: Burn centers offer specialized care to pediatric patients with burn injuries. However, data about outcome in relation to timing of transfer are limited. We examined these timings and outcomes among burn-injured pediatric patients.

Design: Single-center, retrospective cohort study of U.S. national and international practice.

Setting: Shriners ESO Trauma Burn Registry, 2005-2019.

Patients: Patients 0-17 years old admitted to a pediatric burn center with 10-80% total body surface area (TBSA) burn between 2005 and 2019.

Interventions: None.

Measurements and main results: The cohort of 761 patients was subcategorized according to timing of referral: early presentation (EP) (0-7 d), delayed presentation (DP) (8-60 d), and very delayed presentation (VDP) (> 60 d). Primary outcomes included hospital length of stay (LOS), ICU LOS, percent TBSA (%TBSA)/LOS ratio, mortality, and disposition. Dichotomous outcomes were analyzed using logistic regression and continuous outcomes were compared using median regression, both utilizing multivariable analysis adjusting for a priori confounders and presented as adjusted coefficients (ACs) with 95% CI. Delayed referral (DP and VDP) was associated with higher %TBSA burn and with fewer referrals from high-income countries. Compared with EP, VDP was associated with higher LOS/%TBSA (AC, 0.2 [0.01-0.4]). On univariate analysis, in comparison with EP, DP and VDP were associated with higher ICU (DP 16 [6-29]; VDP 8 [0-18]) and hospital LOS (DP 34 [21-55]; VDP 32 [18-58]). Overall, ten of 761 patients died (1.3%), and we found no association between timing of referral and mortality. Also, in 751 survivors, 635 patients (84.6%) were discharged home without home health, and we found no association with timing of referral on multivariable analysis.

Conclusions: In this report, we have reviewed our single-center, international burn-injured pediatric cohort, operating in the United States (2005-2019). We find that referral with VDP as opposed to EP was associated with increased LOS/%TBSA.