Pediatric Critical Care Medicine最新文献

Objective: Epidemiologic data on extracorporeal cardiopulmonary resuscitation (ECPR) use in children with cardiac disease after in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate trends in ECPR use over time in critically ill children with cardiac disease.

Data sources: We performed a secondary analysis of a recent systematic review (PROSPERO CRD42020156247) to investigate trends in ECPR use in children with cardiac disease. PubMed, Web of Science, Embase, and Cumulative Index to Nursing and Allied Health Literature were screened (inception to September 2021). For completeness of this secondary analysis, PubMed was also rescreened (September 2021 to March 2024).

Study selection: Observational studies including epidemiologic data on ECPR use in children with cardiac disease admitted to an ICU.

Data extraction: Data were extracted by two independent investigators. The risk of bias was assessed using the National Heart Lung and Blood Institutes Quality Assessment Tools. Random-effects meta-analysis was used to compute a pooled proportion of subjects undergoing ECPR; meta-regression was used to assess trends in ECPR use over time.

Data synthesis: Of the 2664 studies identified, 9 (17,669 patients) included data on ECPR use in children with cardiac disease. Eight were cohort studies, 1 was a case-control, 8 were retrospective, 1 was prospective, 6 were single-center, and 3 were multicenter. Seven studies were included in the meta-analysis; all were judged of good quality. By meta-analysis, we found that a pooled proportion of 21% (95% CI, 15-29%) of pediatric patients with cardiac disease experiencing IHCA were supported with ECPR. By meta-regression adjusted for category of patients (surgical vs. general cardiac), we found that the use of ECPR in critically ill children with cardiac disease significantly increased over time ( p = 0 .026).

Conclusions: About one-fifth of critically ill pediatric cardiac patients experiencing IHCA were supported with ECPR, and its use significantly increased over time. This may partially explain the increased trends in survival demonstrated for this population.

Objective: Parents experience psychologic distress during their child's admission to a PICU, but effective screening for parental mental health symptoms is not the standard of care. We aimed to test the feasibility and acceptability of a mobile phone-based mental health survey for parents/guardians of PICU patients to facilitate their support by the PICU team.

Design: Post hoc analysis of a single-institution pilot study conducted in 2022. Mental health surveys were delivered by text message to parents/guardians of PICU patients over 1 month, beginning 3 days after their child's PICU admission. In-person interviews 1 month after hospital discharge were used to solicit participants' opinions on the survey platform and content.

Setting: A quaternary U.S. academic medical center.

Participants: Parents/guardians of PICU patients.

Interventions: None.

Measurement and main results: Of the 53 participants who consented, 31 (58%) completed the study. Symptoms of acute stress (ASS) were the most common and most severe: 21 participants screened positive for ASS, and 20 of those that screened positive had "moderate" or "severe" symptoms. Among the 23 participants who screened positive for one mental health condition, 10 met the thresholds for all three. Scoring of the protocol's usability, acceptability, and feasibility showed a System Usability Scale equal to 82 of 100, an Acceptability of Intervention Measure score equal to 4.2 of 5, an Intervention Appropriateness Measure score equal to 4.5 of 5, and Feasibility of Intervention Measure score equal to 4.5 of 5.

Conclusions and relevance: Mobile phone-based screening for parental mental health symptoms is acceptable and may offer the advantage of privacy and flexibility.

Objectives: Current European guidelines for pediatric cardiopulmonary resuscitation (CPR) recommend the lower half of the sternum as the chest compression point (CP). In this study, we have used thoracic CT scans to evaluate recommended and optimal CP in relation to cardiac anatomy and structure.

Design: Analysis of routinely acquired thoracic CT scans acquired from 2000 to 2020.

Setting: Single-center pediatric department in a German University Hospital.

Patients: Imaging data were obtained from 290 patients of 3-16 years old.

Interventions: None.

Measurements and main results: We measured and analyzed 14 thoracic metrics in each thoracic CT scan. In 44 of 290 (15.2%) scans, the recommended CP did not match the level of the cardiac ventricles. Anatomically, the optimal CP was one rib or one vertebral body lower than the recommended CP, that is, the optimal CP was more caudal to the level of the body of the sternum in 67 of 290 (23.1%) scans. The recommended compression depth appeared reasonable in children younger than 12 years old. At 12 years old or older, the maximum compression depth of 6 cm is less than or equal to one-third of the thoracic depth.

Conclusions: In this study of thoracic CT scans in children 3-16 years old, we have found that optimal CP for CPR appears to be more caudal than the recommended CP. Therefore, it seems reasonable to prefer to use the lower part of the sternum for CPR chest compressions. At 12 years old or older, a compression depth similar to that used in adults-6 cm limit-may be chosen.

Objective: Health inequities are widespread and associated with avoidable poor health outcomes. In the PICU, we are increasingly understanding how health inequities relate to critical illness and health outcomes. Experts recommend assessing for health inequities by screening for social determinants of health (SDOH) and adverse childhood experiences (ACEs); however, guidance on screening is limited and screening has not been universally implemented. Our study aimed to understand parent perspectives on screening for SDOH/ACEs in the PICU, with the primary objective of determining whether screening would be acceptable in this setting.

Design: We conducted a qualitative study using semistructured interviews with a convenience sample of eleven PICU parents between November 2021 and January 2022.

Setting: Urban, quaternary free-standing children's hospital.

Subjects: Parents of children with a PICU hospitalization between November 2020 and October 2021.

Interventions: None.

Measurements and main results: Domains of interest included experience with and attitudes toward SDOH/ACEs screening, perspectives on addressing needs with/without resources and their relationship to health, and recommendations for screening. Interviews were transcribed verbatim and coded with an inductive approach using thematic analysis and constant comparative methods. Ann & Robert H. Lurie Children's Institutional Review Board approved this study (2021- 4781, Approved September 13, 2021). Ten participants found SDOH/ACEs screening to be acceptable and valuable in the PICU, even for topics without a readily available resource. Participants did not have broad experience with ACEs screening, though all believed this provided the medical team with valuable context regarding their child. Ten participants recommended screening occur after their child has been stabilized and that they are notified that screening is universal.

Conclusions: Participants found screening for SDOH/ACES to be acceptable and valuable in the PICU. Families have important insight that should be leveraged to improve the support of unmet needs through the development of strengths-based, parent-informed screening initiatives.

Objectives: Blood level of pancreatic stone protein (PSP) is a promising biomarker of sepsis both in adults and children. The aim of our study was to investigate the diagnostic accuracy of PSP in children with suspected sepsis and to compare diagnostic performance with other sepsis biomarkers approved for clinical use, that is, procalcitonin (PCT) and C-reactive protein (CRP).

Design: Prospective study.

Setting: PICU and pediatric emergency department.

Intervention: Blood levels of PSP were measured using a nanofluidic point-of-care immunoassay (abioSCOPE, Abionic SA, Switzerland) within 24 hours of admission.

Measurements and main results: We studied 99 children aged between older than 1 month and younger than 18 years with signs and symptoms of systemic inflammatory response syndrome (irrespective of associated organ dysfunction). The prevalence of sepsis was 35 of 99 (35.4%). Patients with sepsis had higher PSP levels ( p < 0.001) than patients with systemic inflammation of noninfectious cause. In this analysis, the optimal cutoff for the diagnosis of sepsis using PSP was 123 ng/mL, which resulted in a sensitivity of 0.63 (95% CI, 0.43-0.80), specificity of 0.89 (95% CI, 0.77-0.95). The PSP test area under the receiver operating characteristic curve (AUROC) was 0.82 (95% CI, 0.73-0.91) and, by comparison, procalcitonin and CRP AUROC were 0.70 (95% CI, 0.58-0.82) and 0.72 (95% CI, 0.60-0.84), respectively. Overall, the pretest to posttest probability of sepsis with a positive test changed from 0.35 to 0.73.

Conclusions: In this single-center prospective pediatric cohort, admitted to the high intensive care and to the PICU, our findings suggested the potential use of PSP as a sepsis biomarker. However, because of the clinical diagnostic uncertainty with a positive result, further investigation is needed particularly in combination with other biomarkers.

Objectives: To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices.

Design: A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168).

Setting: Six PICUs in the United States.

Patients: One thousand sixty-four patients who were admitted to a PICU for 3 or more days.

Interventions: None.

Measurements and main results: Of 1064 patients, 74% (95% CI, 71-76%) underwent delirium screening at least once during their PICU stay. On 57% of the 8965 eligible patient days, screening was conducted. The overall prevalence of delirium was 46% across all screened days, and 64% of screened patients experienced delirium at some point during their PICU stay. Factors associated with greater adjusted odds ratio (aOR) of increased daily delirium screening included PICU stay longer than 15 days compared with 1-3 days (aOR 3.36 [95% CI, 2.62-4.30]), invasive mechanical ventilation as opposed to room air (aOR 1.67 [95% CI, 1.32-2.12]), dexmedetomidine infusions (aOR 1.23 [95% CI, 1.04-1.44]) and propofol infusions (aOR 1.55 [95% CI, 1.08-2.23]). Conversely, decreased aOR of daily delirium screening was associated with female gender (aOR 0.78 [95% CI, 0.63-0.96]), and the administration of continuous infusions of opioids (aOR 0.75 [95% CI, 0.63-0.90]) or ketamine (aOR 0.48 [95% CI, 0.29-0.79]). Neither patient age, the presence of family or physical restraints, or benzodiazepine infusions were associated with daily delirium screening rates.

Conclusions: In the 2019-2020 PICU UP! cohort, across six PICUs, delirium screening occurred on only 57% of days, despite the presence of established practices. Female gender, patients in the early stages of their PICU stay, and patients not receiving mechanical ventilation were associated with lower odds of daily delirium screening. Our results highlight the need for structured quality improvement processes to both standardize and increase the frequency of delirium screening.