Pediatric Critical Care Medicine最新文献

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.

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.

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 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.

Objective: To evaluate the financial consequence of admission to PICU during the COVID-19 pandemic in the United States.

Design: Retrospective cohort study.

Setting: PICUs in the Pediatric Health Information System (PHIS) and Virtual Pediatric System (VPS) databases.

Patients: PICU admissions in children younger than 18 years from January 2017 to March 2023.

Interventions: None.

Measurements and main results: We queried 29 diagnostic categories using two unlinked national databases, PHIS and VPS. Costs were calculated from PHIS charges using the hospital's specific cost to charge ratio. From PHIS, median charges and costs per PICU day were determined for each diagnosis, year, region, and hospital status. The median charges and costs per PICU days were matched to VPS PICU days. Multivariable mixed modeling was used, controlling for center, length of stay (LOS), and severity of illness which included use of mechanical ventilation, extracorporeal membrane oxygenation support, and Pediatric Risk of Mortality score. The primary outcomes were PICU charges and costs per day. The secondary outcomes were bed days, cumulative charges and costs. There were 484,328 PHIS and 331,740 VPS encounters. Percent change (95% CI) in encounter-level costs per PICU day increased (8.9% [95% CI, 8.8-9.1], p < 0.001) at a greater rate than encounter-level charges (4.1% [95% CI, 1.2-7.2], p = 0.006)) when comparing pre-COVID-19 to COVID-19 years, after controlling for LOS, severity of illness and diagnosis. Bed days for bronchiolitis, asthma, pneumonia, and respiratory failure decreased by 28-94% compared with the average pre-COVID-19 years. After combining all diagnoses, bed days decreased by 70,100 (33%), and PICU charges decreased by $1.2 billion during COVID year 1, when compared with the average pre-COVID-19 years.

Conclusions: The COVID-19 pandemic exposed the financial vulnerability of PHIS/VPS contributing PICUs in the United States. Bed days are a key driver to maintaining financial margins.

Objective: Develop a consensus-based framework for point-of care ultrasound in pediatric critical care, or critical care ultrasound (CCUS) education using entrustable professional activities (EPAs).

Design: A modified Delphi method utilizing cycles of meetings and surveys for consensus-building.

Setting: The endeavor involved members of the Pediatric Research Collaborative on Critical Ultrasound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury And Sepsis Investigators.

Subjects: An expert panel consisting of 23 members representing 17 institutions, including diverse healthcare professionals involved in pediatric critical care ultrasound.

Interventions: Three iterative modified Delphi rounds were conducted to propose and refine critical care ultrasound EPAs.

Measurements and main results: The endeavor achieved a 74% response rate. Fourteen EPAs were formulated across five domains: Cardiac, Pulmonary, Abdomen, Procedures, and Vascular, along with two consensus opinions on educational content and methods. EPAs were evaluated using 5-point Likert items, requiring a median score of greater than or equal to 4.5 for progression.

Conclusions: This collaborative effort led to the establishment of fourteen EPAs for pediatric critical care ultrasound, offering a structured approach for education and competency assessment in pediatric critical care. This initiative lays the groundwork for evolving standards in pediatric critical care ultrasound education and practice.