Pediatric Critical Care Medicine最新文献

Objectives: In survivors of illnesses or surgeries requiring PICU admission, there is a risk of posttraumatic stress disorder (PTSD). We aimed to estimate PTSD prevalence and potential contributing factors in survivors of PICU admission.

Data sources: We performed a PROSPERO registered systematic review (CRD42022348997; Registered August 2022) using MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, 2000 to 2022, with no language restrictions.

Study selection: Observational or interventional studies evaluating the incidence or prevalence of PTSD in patients' after PICU admission and/or contributing factors to PTSD. We used studies describing patients younger than 18 years old. Since there were a large number of citations, we used an integrated crowdsourcing and machine-learning model for citation screening. Each citation was reviewed independently and in duplicate by two reviewers at each stage of screening and abstraction.

Data extraction: Data items included study and participant demographics, details of case definition (PTSD screening), and risk factors.

Data synthesis: We followed the Preferred Reporting items for Systematic Reviews and Meta-analysis guidelines. Random-effects models were used to analyze PTSD prevalence and subgroup differences. In 24 citations meeting final review criteria, 19 had data for meta-analysis. There were 1898 PICU survivors with a median (interquartile range) cohort size of 59 (49-76). PTSD prevalence in the studies ranged from 3% to 37%; PTSD occurred in 529 of 1898 survivors (I2 = 72%). Factors influencing PTSD variability included timing of assessment (p < 0.01) with the highest prevalence (29%) at 6 months and the type of assessment instrument (n = 10; range, 4-27%; p = 0.04). There was lower prevalence of PTSD (8%) in postoperative cardiac patients (p < 0.01). Last, we failed to find an association between PICU length of stay and PTSD prevalence (p = 0.62; I2 = 80%).

Conclusions: PICU follow-up studies from 2000 to 2022 indicate that one-in-three of admissions surviving to 6 months have PTSD. However, there are population, study design factors and heterogeneity in PTSD assessment that indicate more standardization in this research is needed.

Objectives: Extubation failure (EF) in neonates recovering from congenital cardiac surgery is associated with morbidity and mortality. Adding continuous physiologic monitoring data and risk analytics algorithms to clinical factors has the potential to assist clinicians in identifying those neonates at high risk for EF. We aimed to evaluate the association of two physiologic risk analytics algorithms evaluating the probability of inadequate delivery of oxygen index (IDo2) and inadequate ventilation of carbon dioxide index (IVco2) with EF in neonates receiving mechanical ventilation (MV) after cardiac surgery. A secondary aim was to evaluate the clinical factors associated with EF.

Design: Multicenter retrospective cohort study.

Setting: Eight international pediatric cardiac ICUs.

Patients: Neonates (age < 1 mo at the time of surgery) receiving MV for longer than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2020.

Interventions: None.

Measurements and main results: Data from 736 neonates were analyzed with 102 (13.9%) having EF (defined as reintubation within 48 hr of extubation). In multivariable analysis (odds ratio [OR] and 95% CI), preoperative respiratory support (OR, 1.72 [95% CI, 1.11-2.67]) was associated with greater odds of EF. In all, 611 neonates had pre-extubation IDo2 data and 478 neonates had both pre-extubation IDo2 and IVco2 data. In multivariable analysis of patients with both pre-extubation IDo2 and IVco2 data, single ventricle anatomy (OR, 2.50 [95% CI, 1.27-4.92]) and high IDo2 (≥ 25) or high IVco2 (≥ 50) in the 2 hours preceding extubation (OR, 1.77 [95% CI, 1.01-3.12]) were associated with greater odds of EF.

Conclusions: In this 2017-2020 cohort, EF is high in post-cardiac surgery neonates receiving at least 48 hours of MV. The IDo2 and IVco2 algorithms may be useful in assessing risk of EF in such neonates.

Objective: Diagnosing bloodstream infections (BSIs) in patients on extracorporeal membrane oxygenation (ECMO) can be challenging due to circuit-controlled temperature, altered hemodynamics, and questionable reliability of inflammatory markers in critically ill patients. As a result, practice variability exists among ECMO centers regarding routine blood cultures for surveillance of BSI. Our study aimed to evaluate daily surveillance blood cultures in pediatric and neonatal ECMO patients.

Design: Retrospective review of daily surveillance blood cultures from January 2021 to July 2023. We evaluated signs, symptoms, and laboratory results in patients with positive blood cultures.

Setting: Academic children's hospital, New York, NY.

Patients: All pediatric and neonatal patients supported on ECMO.

Interventions: None.

Measurements and main results: We identified a cohort of 111 patients (39 neonates and 72 children) who were supported with ECMO. Daily blood cultures were obtained on 1059 (99%) of 1065 completed ECMO days. Overall, 3% (35/1059) of blood cultures were positive, affecting 6% (7/111) of patients. All seven patients had new evidence of infection on the day of their first positive blood culture; six had clinical signs of infection, including new-onset hypotension, hypothermia, or respiratory decline, and the remaining patients had newly elevated inflammatory markers.

Conclusions: Daily surveillance blood cultures are low-yield in our practice with pediatric and neonatal ECMO patients. Our experience shows that changes in clinical status, including abnormal physical or laboratory findings consistent with infection, are associated with BSI, allowing for timely diagnosis. These criteria should prompt as-needed blood cultures, reducing blood draws and preventing costly and unnecessary daily surveillance cultures.

Objectives: Poor communication during interfacility transfer to the PICU can harm critically ill children. Structured handoff communication can prevent harm; however, the landscape of interfacility referral communication practices across PICUs is unknown. Our objective was to describe interfacility referral communication practices among U.S. PICUs to begin identifying potential improvement opportunities.

Design: Mixed methods study including a cross-sectional survey and semi-structured interviews.

Setting: U.S. PICUs with greater than or equal to 10 beds in 2023.

Participants: Clinical/administrative PICU leaders.

Interventions: None.

Measurements and main results: Sixty surveys with greater than 70% completed questions were returned from 170 invited participants (35% response rate). Respondents were mainly pediatric critical care medicine division chiefs (48%) or PICU medical directors (32%). PICUs in all U.S. continental regions were represented, which had a median of 1200 (interquartile range [IQR], 1000-1500) admissions per year, of which 29.5% (IQR, 15-39%) were patients directly transferred from other institutions. In 93% of PICUs, a verbal interfacility handoff occurs between the referring clinician and a PICU physician; however, only 24% were always guided by a standard communication tool. In 72% of PICUs, medical records were only sometimes available before patient arrival. Semi-structured interviews with seven volunteer respondents revealed the following themes: 1) standardizing communication can result in organized and efficient handoffs but may also result in inefficiencies, 2) trained staff dedicated to interfacility referrals will improve communication quality, 3) integration of handoff information into the electronic health record will improve dissemination and decrease PICU physicians' workload, and 4) implementing a structured process will require staff support to change current workflows.

Conclusions: Referral communication for interfacility patient transfers to the PICU occurred mainly through unstructured verbal handoffs between referring clinicians and PICU physicians. PICU leaders identified several potential benefits and challenges of standardizing interfacility referral communication.

Objectives: To compare two blood glucose (BG) ranges in critically ill children with and without primary neurologic diagnoses in the Heart and Lung Failure-Pediatric Insulin Titration trial (HALF-PINT; ClinicalTrials.gov Identifier NCT01565941).

Design: Non-prespecified post hoc analysis.

Setting: Thirty-one PICUs in the United States, and one in Canada.

Patients: Non-diabetic children enrolled from April 2012 to September 2016 with cardiovascular or respiratory failure and hyperglycemia. Patients in the neurologic subgroup had primary neurologic diagnoses on ICU admission.

Interventions: Patients were randomized to insulin infusion to target lower-BG (80-110 mg/dL; 4.4-6.1 mmol/L) or higher-BG (150-180 mg/dL; 8.3-10 mmol/L).

Measurements and main results: Primary diagnosis (neurologic vs. non-neurologic), daily BG and insulin values, outcomes (number of PICU-free days through day 28 and 1-y post-PICU discharge adaptive behavior composite score of Vineland Adaptive Behavior Scales, Second Edition). Of 698 patients analyzed, 64 (30 lower-BG target, 34 higher-BG target) had primary neurologic diagnoses and 634 (319 lower-BG target, 315 higher-BG target) had non-neurologic diagnoses. Within the neurologic subgroup, patients in the lower-BG targeting group had fewer ICU-free days compared with those in the higher-BG targeting group (median 8.5 vs. 21.1 d), whereas there was no difference between BG groups in the non-neurologic subgroup (20.5 vs. 19.3 d; interaction p = 0.02). One-year adaptive behavior composite score was less favorable for the lower-BG targeting group in those with neurologic diagnoses (mean 63.3 vs. 87.6), but no different in those with non-neurologic diagnoses (81.9 vs. 78.4; interaction p = 0.02). Lower-BG targeting was associated with more hypoglycemia (< 60 mg/dL) in both diagnostic subgroups, with no differential effect across subgroups (p = 0.47).

Conclusions: In this non-prespecified analysis of the HALF-PINT trial data, lower-BG targeting in hyperglycemic critically ill children with primary neurologic diagnoses was associated with unfavorable outcomes, while such BG targeting in those with non-neurologic diagnoses was not associated with adverse outcomes.

Objectives: To perform: 1) external validation of the Phoenix Sepsis Score and Phoenix sepsis criteria in a multicenter cohort of critically ill children with infection and a comparison with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria; 2) a study of Phoenix sepsis criteria performance in patient subgroups based on age and comorbidities; 3) an assessment of microbiological profile of children with Phoenix sepsis; and 4) a study of the performance of the Phoenix-8 score.

Design: Secondary, retrospective analysis of a multicenter cohort study from 2012 to 2018.

Setting: Nine PICUs in the United States.

Patients: PICU admissions with suspected infection.

Interventions: None.

Measurements and main results: Among 25,680 encounters of children with suspected or confirmed infection on PICU admission (4.6% in-hospital mortality), 11,168 (43%) met Phoenix criteria for sepsis or septic shock (9% in-hospital mortality). The Phoenix criteria generally outperformed the IPSCC criteria at discriminating mortality in all critically ill children with infections and across all subgroup analyses, including age group, malignancy, or technology dependence. Of 11,168 patients who met Phoenix criteria, 28% were negative for IPSCC criteria for sepsis and these had higher in-hospital mortality than those who met IPSCC sepsis criteria but not Phoenix criteria (4.7% vs.1.7%; p < 0.001), which was similar to the mortality of patients without sepsis (1.3%). Sepsis was associated with respiratory or bloodstream infection, most commonly Pseudomonas aeruginosa or Staphylococcus aureus. The Phoenix-8 score had good discrimination of mortality in children with infections, comparable to or better than validated and widely used severity of illness and organ dysfunction scores.

Conclusions: In 2012-2018, among U.S. patients with suspected or confirmed infection admitted to nine PICUs, those with the highest risk of mortality can be identified using the Phoenix sepsis criteria, including in children of different age groups and those with major comorbidities.