Pediatric Critical Care Medicine最新文献

Objectives: To describe the deployment of pediatric Calculated Assessment of Risk and Triage (pCART), a machine learning (ML) model to predict the risk of the direct ward to the ICU transfer within 12 hours, and the associated improved outcomes among hospitalized children.

Design: Pre- vs. post-implementation study.

Setting: An urban, tertiary-care, academic hospital.

Patients: Pediatric (age < 18 yr) admissions from May 1, 2019, to April 30, 2023.

Interventions: None.

Measurements and main results: Patients were divided into baseline, pre-pCART implementation (May 1, 2019, to April 30 2021), and post-pCART implementation (May 1, 2021, to April 30, 2023) cohorts. First-ward admissions with a high-risk score (pCART score ≥ 92) were considered as the main cohort. The primary outcome was the occurrence of critical events, defined as invasive mechanical ventilation, vasoactive drug administration, or death within 12 hours of the first high-risk pCART score. There were 2763 and 3943 patients in the baseline and implementation cohorts, respectively. pCART implementation was associated with a decrease in the percentage of the primary outcome from baseline 1.4% to 0.4% (p < 0.001), which converted to more than two-thirds lower adjusted odds of the primary outcome (odds ratio, 0.22 [95% CI, 0.11-0.40]; p < 0.001). pCART implementation was also associated with a decreased prevalence of critical events at 24 and 48 hours after a first high-risk score. We failed to identify any association between cohort period and overall hospital and ICU length-of-stay, number of ICU transfers, and time to ICU transfer. However, there was a difference in hospital length-of-stay among a subpopulation of patients transferred to the ICU (median 6 vs. 7 d; p < 0.001). Analysis of compliance metrics indicates sustained compliance achievements over time.

Conclusions: The deployment of pCART, a ML-based pediatric risk stratification tool, for clinical decision support for pediatric ward patients, was associated with lower odds of critical events among high-risk patients.

Objectives: The Pediatric Sepsis Definition Task Force developed and validated a new organ dysfunction score, the Phoenix Sepsis Score (PSS), as a predictor of mortality in children with suspected or confirmed infection. The PSS showed improved performance compared with prior scores. However, the criteria were derived in a general pediatric population, in which only 10% had cancer. Given that pediatric cancer patients with sepsis have higher mortality compared with noncancer patients with sepsis, we aimed to assess the PSS in PICU patients with cancer and sepsis.

Design: Retrospective multicenter cohort study.

Setting: Twelve PICUs across Europe.

Patients: Each PICU identified patients 18 years young or younger, with underlying malignancy and suspected or proven sepsis, and admission between January 1, 2018, and January 1, 2020.

Interventions: None.

Measurements and main results: The PSS and three other scores, including Phoenix-8, Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score, and pediatric Sequential Organ Failure Assessment (pSOFA) score, were calculated for comparison. The primary outcome was 90-day all-cause mortality. We compared score performance using area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) analyses. Among 383 patients with proven or suspected sepsis, 90-day mortality was 19.3% (74/383). We failed to identify an association between a particular score and performance for 90-day mortality. The mean (95% CI) values for the AUROC of each score was: PSS 0.66 (0.59-0.72), Phoenix-8 0.65 (0.58-0.72), PELOD-2 0.64 (0.57-0.71), and pSOFA 0.67 (0.60-0.74) and for the AUPRC of each score: PSS 0.32 (0.23-0.42), Phoenix-8 0.32 (0.23-0.42), PELOD-2 0.32 (0.22-0.43), and pSOFA 0.36 (0.26-0.46). Similar results were obtained for PICU mortality or sepsis-related PICU mortality.

Conclusions: Contrary to the general PICU population, our retrospective test of the PSS in a PICU oncology dataset with suspected or proved sepsis from European PICUs, 2018-2020, failed to identify improved performance in association with mortality. This unique patient population deserves development of organ dysfunction scores that reflect organ dysfunction and mortality data specifically from these patients and will require prospective validation in future studies.

Objectives: To examine citrate anticoagulation in continuous renal replacement therapy (CRRT) in the PICU.

Design: Post hoc analysis of a curated, multicenter dataset collected from January 1, 2022, to June 1, 2023.

Setting: Seven PICUs in Turkey.

Patients: PICU admissions in need of CRRT, 28 days to 18 years old.

Interventions: None.

Measurements and main results: In 128 filters used in 73 patients, the effective filter life (EFL) restricted to 72 hours was a median (interquartile range [IQR]) of 40.5 hours (IQR, 21-58 hr); total EFL was a median of 59 hours (IQR, 28-89 hr). Analysis of the receiver operating characteristic curve for initial citrate infusion dose (CID) and whether EFL reached 72 hours identified a cutoff level for initial CID of greater than 2.64 mmol citrate per liter of patient blood flow (mmol/L-bf). As expected, the two filter groups categorized by initial CID (≥ 2.7 vs. < 2.7 mmol/L-bf) showed filters in children receiving higher initial dosing had longer total EFL (72 hr [IQR, 48-104 hr] vs. 38.5 hr [IQR, 18-84 hr]; p = 0.03). We failed to identify an association between CRRT for over 24 or 48 hours and greater odds (odds ratio [OR], 95% CI) of citrate accumulation (OR, 2.23; 95% CI, 0.82-6.13; p = 0.118 or OR, 1.78; 95% CI, 0.84-3.8; p = 0.134, respectively). However, we cannot exclude up to 6.1- or 3.8-fold odds of citrate accumulation; of note, CRRT over 72 hours was associated with greater odds of citrate accumulation (OR, 2.17; 95% CI, 1.01-4.68; p = 0.04). Citrate lock syndrome occurred in eight of 128 (6.3%; 95% CI, 3-11.4%) filters, and resolved without termination of CRRT. On multivariable analysis, a higher patient initial lactate concentration was associated with an 18% (95% CI, 7-30%) greater hazard of developing citrate accumulation.

Conclusions: Citrate anticoagulation for CRRT is an option for children. Choosing an initial CID greater than or equal to 2.7 mmol/L-bf provides longer EFL but with the associated potential of citrate accumulation. Further studies are needed on initial CID and duration of EFL.

Objectives: To assess antithrombin and activated protein C (aPC) levels in relation to disseminated intravascular coagulation (DIC) and severe outcomes in pediatric sepsis.

Design: Prospective, observational study conducted between April 2023 and October 2024. Coagulation profiles including conventional coagulation, antithrombin activity, and aPC were obtained at PICU admission.

Setting: PICU in the Vietnam National Children's Hospital, Hanoi, Vietnam.

Subjects: PICU admissions, 1 month to 18 years old, with sepsis.

Interventions: None.

Measurements and main results: One hundred thirty children (78 males; median age 7.5 mo) with mortality 23/130 (17.7%). The prevalence of overt DIC was 37 of 130 (28.5%). Nonsurvival at 28 days, compared with survival, was associated with hemorrhage and/or thrombosis at presentation, and higher number of dysfunctional organs, and overt DIC. Those with overt DIC, compared with not, had longer activated partial thromboplastin time, higher international normalized ratio and d -dimer, and lower antithrombin, and aPC. Activity of antithrombin and aPC correlated inversely with the Vasoactive-Inotropic Score in survivors ( p = 0.002 and 0.009, respectively). Patients with a cutoff value for antithrombin less than 63.5% had a mortality risk with area under the receiver operating characteristic (AUROC) curve 0.64, with sensitivity 0.51 and specificity 0.74, and positive predictive value 0.30. Regarding overt DIC, a cutoff value for antithrombin less than 55.5% had an AUROC 0.78, sensitivity 0.72 and specificity of 0.73, and positive predictive value 0.52.

Conclusions: In this observational study of pediatric sepsis patients, first 24-hour coagulation data in those who did not-survive to 28 days, vs. survivors showed an associated prior lower level of antithrombin in nonsurvivors. Furthermore, using the outcome of overt DIC and nonovert DIC in the first 72 hours, we found that lower levels of antithrombin or aPC are each associated with overt DIC and nonovert DIC in pediatric sepsis. Further validation work is needed in larger case series of pediatric sepsis.

Objectives: There are several options for durable venous access for pediatric cardiac patients and the insertion techniques, locations, and complications potentially differ. The study aimed to evaluate our experience of upper extremity peripherally inserted central catheters (PICCs) and durable tunneled femoral central venous catheters (TF-CVCs) in young pediatric cardiac ICU (PCICU) patients.

Design: Retrospective cohort study, 2015-2021.

Setting: PCICU in a tertiary medical care center.

Patients: All patients younger than 1.5 years old who underwent bedside insertion of TF-CVC or upper extremity PICC between December 2015 and December 2021.

Interventions: None.

Measurements and main results: The cohort included 226 durable lines, inserted in patients 2-550 days old, with 111 upper extremity PICCs and 115 TF-CVCs. In the two groups, receipt of PICC vs. TF-CVC placement was associated with older age (125.6 vs. 53.4 d; p = 0.005), and shorter duration of mechanical ventilation (9.0 vs. 25.5 d; p < 0.001). PICC vs. TF-CVC use was associated with a higher rate of central line-associated bloodstream infection (CLABSI) (7.14 vs. 2.38/1000 line days; p = 0.004) and more thrombosis events (5 vs. 0; p = 0.008). When adjusted for CLABSI-free line days, TF-CVCs (relative to upper limb PICCs) was associated with close to one-third of the odds of CLABSI (odds ratio [OR], 0.31 [95% CI, 0.13-0.78]); similarly, when adjusted for line days close to one-third of the odds of any complication, that is, CLABSI, dislodgment, occlusion, or thrombosis (OR, 0.31 [95% CI, 0.14-0.65]).

Conclusions: In our 2015-2021 PCICU experience of using durable TF-CVC inserted at the bedside, vs. upper extremity PICCs, in neonates and infants, we found an associated one-third the odds of CLABSI and overall complications. A prospective study of subcutaneous tunneling in various locations of catheters on CLABSI and overall complication rates is needed.