Pediatric Critical Care Medicine最新文献

Objectives: To identify factors associated with the development of death by neurologic criteria (DNC) in neonates treated with extracorporeal membrane oxygenation (ECMO).

Design: Retrospective registry study.

Setting: Data reported to the Extracorporeal Life Support Organization registry from 2010 to 2023.

Patients: Neonates (≤ 28 d old) who were supported with ECMO, excluding those born before 37 weeks' gestation or with missing gestational age data. The final cohort comprised 14,970 neonates.

Interventions: None.

Measurements and main results: DNC occurred in 70 neonates in the cohort (0.5%), accounting for 2% of overall mortality rate. Pre-ECMO factors associated with greater relative risk ratio (RRR) of DNC included pre-ECMO cardiac arrest (RRR, 2.64), pH less than 7.08 (25th percentile: RRR, 2.06), and cardiac support type (RRR, 2.04). On-ECMO, factors independently associated with DNC included pH less than 7.35 (25th percentile: RRR, 2.76), Pao2 greater than 162 mm Hg (75th percentile: RRR, 2.75), and central cannulation (RRR, 2.36). We failed to identify an association between relative change in Paco2 greater than 50% and DNC, but it correlated with other causes of death. Most DNC diagnoses (84%) occurred after 24 hours of ECMO.

Conclusions: DNC is rarely diagnosed in neonatal ECMO cases. Both pre-ECMO and on-ECMO factors associated with DNC included pre-ECMO cardiac arrest, severe metabolic acidosis, and cannulation type. These findings underscore the importance of optimizing pre-ECMO and on-ECMO management and may indicate certain modifiable risk factors such as optimization of cardiopulmonary resuscitation and hyperoxia. Future research should explore preventive strategies and interventions to mitigate the risk of DNC in neonates receiving ECMO.

Objective: Pediatric patients with congenital heart disease (CHD) are at risk of non-cardiac complications that impact outcome. Early prognostication is necessary to tailor treatment and improve parent counseling. This systematic review assessed the prognostic value of perioperative near-infrared spectroscopy (NIRS) monitoring of regional oxygen saturation (rSO₂) with regard to brain injury, brain development, neurodevelopment, acute kidney injury (AKI), and necrotizing enterocolitis (NEC) in pediatric CHD patients.

Data sources: PubMed and Embase databases.

Study selection: We searched for original research articles published up to 2023 describing children (younger than 18 yr) with CHD using perioperative rSO₂ monitoring, and reporting their association with at least one of the following outcomes: AKI, NEC, brain injury, brain development, or neurodevelopment.

Data extraction: Ten studies, including a total of 562 patients, were included for brain injury, 4 studies with 229 patients for brain development, 15 studies with 1024 patients for neurodevelopment, 15 studies with 1168 patients for AKI, and 3 studies including 250 patients for NEC. The majority of the studies had a moderate to high risk of bias as assessed by the Cochrane Quality in Prognosis Studies tool. High heterogeneity in study populations and NIRS measurements was found.

Data synthesis: Of the studies we identified, 5 of 10 in brain injury, 3 of 4 in brain development, 10 of 15 in neurodevelopment, 9 of 15 in AKI, and 1 of 3 in NEC reported associations with rSO₂. No meta-analysis could be performed due to heterogeneity.

Conclusions: Our findings highlight the need to improve methodological quality and reduce intra- and interstudy heterogeneity. Several methodological recommendations to improve future research were formulated.

Objectives: To explore the perspectives of healthcare professionals and the experience of families concerning post-PICU follow-up to identify key points for the further development of these programs.

Design: Qualitative study.

Setting: PICUs in France involved in post-PICU patient follow-up.

Subjects: Sixteen healthcare professionals involved in post-PICU follow-up at 11 centers, and 18 family participants in enrolled in longitudinal post-PICU follow-up at a tertiary center, took part in semi-structured interviews and observations from January 2022 to June 2024.

Interventions: None.

Measurements and main results: Three main themes emerged. First, therapeutic alliance as a cornerstone: families stressed the importance of maintaining relationships with PICU professionals throughout follow-up, which facilitated recovery and helped them deal with periods of doubt. Second, professional commitment despite institutional constraints: healthcare providers were highly motivated to maintain follow-up programs despite limited resources. Third, barriers to follow-up engagement: families reported a financial burden, and emotional challenges related to traumatic memories during consultations.

Conclusions: Our study highlights the need for structured support for post-PICU follow-up programs that take account of both institutional constraints and family needs. The work suggests that maintenance of the therapeutic relationships established during the PICU stay is crucial for successful follow-up. Future guidelines should address resource allocation and accessibility while preserving the human dimension of care.

Objectives: There is a critical need for advanced modeling tools that can provide data-driven insights into optimizing resource utilization and patient flow in hospitals. We developed and evaluated a flexible, data-driven discrete event simulation (DES) model to optimize capacity utilization and patient flow through a multiunit hospital system, particularly focusing on the PICU and its downstream units.

Design: Retrospective discrete-event simulation modeling and validation study.

Setting: Quaternary referral hospital.

Patients: All patients admitted to Boston Children's Hospital between January 2012 and February 2025.

Interventions: None.

Measurements and main results: The model was validated against a real-world PICU expansion (from 30 to 48 beds) using historical data (83,315 encounters pre-expansion, 4,108 post-expansion). Simulating PICU expansion, without considering limitations in capacity of downstream units to which patients were transferred, resulted in a predicted average PICU length of stay (LOS) of 4.56 days and capacity utilization of 65.6%. These figures significantly differed from the actual observed post-expansion LOS of 5.82 (p = 0.004; 95% predictive interval, 4.38-4.81 d) and utilization of 82.6% (p = 0.004; 95% predictive interval, 62.7-69.6%). However, when the model incorporated actual downstream unit capacities, the predicted post-expansion PICU LOS was 5.27 days (p = 0.083; 95% predictive interval, 4.85-5.90 d) and utilization was 75.6% (p = 0.124; 95% predictive interval, 69.4-84.5% d), closely aligning with observed outcomes and highlighting the critical impact of downstream bottlenecks. Using synthetic data simulations, we have further demonstrated the model's utility for capacity planning and optimizing new service line scheduling.

Conclusions: The proposed open-source DES model effectively simulates patient flow across multiple hospital units, offering a powerful tool to administrators for optimizing hospital operations and resource allocation. The model handles complexity, is flexible, and considers interdependencies between units, enhancing decision-making capabilities. Our model is readily transferrable to other healthcare systems and is easily adaptable to a variety of scenarios.

Objectives: To evaluate the quality improvement (QI) of a structured, context-specific care bundle for reducing unplanned extubation (UPE) rates of endotracheal tubes (ETTs) in a resource-limited PICU in India using the Plan-Do-Study-Act (PDSA) QI methodology.

Design: Prospective, QI study using pre- and post-intervention comparison.

Setting: Fifteen-bed multidisciplinary PICU at the Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Patients: All intubated children 1 month to 12 years old admitted to the PICU during the 14-month study period (2022-2023). Children with tracheostomies, planned extubations, or tube changes for obstruction were excluded.

Interventions: Structured care bundle targeting root causes of UPE implemented in four PDSA cycles over 4 months, followed by a 2-month sustainment phase. Bundle components included standardized ETT fixation (YY method), Comfort-B sedation scoring, high-risk procedure protocols, real-time UPE documentation, and structured staff training.

Measurements and main results: The primary outcome was the rate of UPEs per 100 intubated patient-days. Process measures included staff training coverage, compliance with ETT fixation, sedation documentation, and event reporting. Over 14 months, data from 421 intubated patients (3556 ventilator days) were analyzed. UPE rates declined from 1.9 to 1.3 per 100 ventilator days post-intervention. Process compliance improved substantially (e.g., sedation scoring rose from 65% to 98%). No UPEs occurred in the final PDSA cycle, and rates remained less than 0.6 during the sustainment phase. The care bundle was implemented with minimal cost and without additional staff or technology.

Conclusions: Over 2022-2023, our low-cost, structured care bundle reduced UPE rates and improved safety practices in a high-burden PICU. The findings demonstrate the feasibility and sustainability of QI-driven airway safety interventions in resource-constrained settings and support broader adoption of such strategies across low- and middle-income countries.

Objective: To describe those neonates with dextro-transposition of the great arteries (d-TGA) who undergo preoperative support with extracorporeal membrane oxygenation (ECMO) and to compare outcomes in those undergoing the arterial switch operation (ASO) on-ECMO vs. those who undergo ASO after weaning from ECMO.

Design: Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry data, 2000-2022.

Patients: Neonates aged up to 21 days with d-TGA supported by ECMO before ASO.

Interventions: None.

Measurements and main results: We identified 100 neonates with a median (interquartile range [IQR]) age at ECMO initiation of 4 days (IQR 1-9) and median weight of 3.4 kg (IQR 3-3.7). Mortality, as opposed to survival, was associated with the following: older age at ECMO initiation (7 d [IQR 2-12] vs. 2 d [IQR 1-6], p = 0.01), lower birthweight (3.2 kg [IQR 2.8-3.7] vs. 3.5 kg [IQR 3.1-3.7], p = 0.04), longer aortic clamp time (129 min [IQR 94-191] vs. 98 min [IQR 72-121], p = 0.02), longer cardiopulmonary bypass time (326 min [IQR 217-415] vs. 174 min [IQR 137-241], p < 0.001), and longer duration of ECMO support (7 d [IQR 4-11] vs. 4 d [IQR 2-5], p < 0.001). Also, mortality, compared with survival, was associated with occurrence of any complication and the need for renal replacement therapy (both p < 0.001). Overall, 64 of 91 (70%) neonates supported with preoperative ECMO underwent ASO on ECMO. In comparison with those undergoing ASO after ECMO, these patients had more complications (53/64 [83%] vs. 16/27, p = 0.02) and had higher mortality than those weaned from ECMO preoperatively (24/64 [38%] vs. 4/27, p = 0.03).

Conclusions: In the ELSO 2000-2022 cohort of neonates with d-TGA, supported with preoperative ECMO, overall mortality was 33%. Continued postoperative ECMO support was associated with worse mortality. Therefore, we wonder whether successful weaning from ECMO before ASO may be associated with improved outcomes.

Objectives: Septic shock accounts for approximately 8% of PICU admissions worldwide, carries significant morbidity, and has a reported mortality rate between 5% and 50% depending upon the geographic region in which it occurs. The high morbidity and mortality of this condition have led clinicians to consider corticosteroids when usual management does not achieve hemodynamic stability. However, the evidence for or against the use of corticosteroids in pediatric septic shock is currently unclear.

Design: Pragmatic, multicenter, international, randomized, double-blinded, placebo-controlled interventional trial (ClinicalTrials.gov, NCT03401398).

Setting: Approximately 50 PICUs from 11 countries in North America, South America and Asia.

Patients: Up to 500 eligible pediatric patients aged one month to 17 years and 8 months with septic shock.

Interventions: Patients randomized to the hydrocortisone arm receive an initial bolus of 2 mg/kg IV hydrocortisone, followed by 1 mg/kg every six hours until all vasoactive-inotropic infusions have been discontinued for at least 12 h or for a maximum of 7 days. Patients randomized to the placebo arm receive an equivalent volume of normal saline with the identical dosing schedule.

Measurements and main results: The primary outcome is the frequency of new or progressive multiple-organ dysfunction syndrome up to 28 days following enrollment, death or discharge, whichever comes first. The secondary outcome is a composite of the frequency of death or greater than or equal to 25% decrease in health-related quality of life from baseline, assessed at 28 days.

Conclusions: The current Pediatric Surviving Sepsis Guidelines do not provide definitive recommendations regarding the use of corticosteroids in pediatric septic shock. Our study will be the first pediatric trial that is adequately powered to assess both potential benefits and adverse effects of corticosteroids in patients with septic shock. The results of this study will provide definitive data upon which to base future recommendations for corticosteroid administration in pediatric septic shock.