Pediatric Critical Care Medicine最新文献

Objectives: An increasing number of pediatric centers use the femoral vein in neonates and smaller children to provide venovenous multisite (VVMS) extracorporeal membrane oxygenation (ECMO), but there are no studies comparing surgical vs. percutaneous approaches. We investigated the thrombosis risk associated with VVMS, comparing outcomes between the surgical and percutaneous approach.

Design: Retrospective data analysis.

Setting: Evelina London Children's Hospital, Heim Pal Hospital and Semmelweis University, 2017-2024.

Patients: We included 58 neonatal and pediatric patients weighing less than 15 kg, supported with VVMS ECMO for respiratory disease.

Interventions: None.

Measurements and main results: We collected patient and venovenous ECMO details. Thrombosis of cannulated vessels, as determined by a pediatric radiologist via follow-up vascular ultrasound, was the primary outcome. In total, 58 patients received VVMS, survived and were assessed for thrombosis. There were 34 surgically cannulated patients with median (interquartile range [IQR]) weight 3.6 kg (IQR, 2.8-7 kg) vs. 24 percutaneously cannulated patients (median weight, 8 kg [IQR, 3.7-12.3 kg]) who were cannulated by pediatric anesthetists or intensive care physicians. Surgical placement of cannulas, in comparison with percutaneous placement, was associated with greater odds of thrombosis of internal jugular and femoral veins (odds ratio, 37; 95% CI, 7-266), although the surgical group were younger and of lower weight ( p < 0.05). For any given weight, percutaneously placed cannulas were smaller than those placed surgically, yet they still provided adequate ECMO flow.

Conclusions: This retrospective case series of VVMS in neonates and small children (< 15 kg) shows that surgical cannulation was associated with greater odds of vascular thrombosis at vessel sites, but a potential confounder may be that the surgical group were younger and of smaller weight. Overall, for any given weight, percutaneous cannulas were smaller than those placed surgically.

Objectives: Subspeciality pediatric palliative care (SPPC) team consultation is an integral component of comprehensive care provided to critically ill children. Little is known about the utilization of SPPC following out-of-hospital cardiac arrest (OHCA) in the United States. Our objectives were to examine SPPC utilization following OHCA and compare characteristics between children who did and did not receive SPPC consultation.

Design: Retrospective cohort study.

Setting: Forty-seven U.S. children's hospitals participating in the Pediatric Health Information Systems database.

Patients: Children younger than 21 years old with PICU admissions from 2013 to 2023 following OHCA.

Interventions: None.

Measurements and main results: The primary outcome was receipt of SPPC consultation, as identified by International Classification of Diseases codes. Patient characteristics and outcomes were compared between those with and without SPPC consultation. Multiple logistic regression models were fitted to identify factors associated with greater odds of receiving SPPC. Of 1530 pediatric patients hospitalized after OHCA, 198 (13%) received SPPC consultation. SPPC consultation, vs. not, was more common among patients with complex chronic conditions (CCCs; 97% vs. 85%; p < 0.001) and was associated with longer hospital stay (median 4 vs. 2 d; p < 0.001), new medical technology (feeding tube 8.1% vs. 3.8%; p = 0.006 and tracheostomy 8.6% vs. 3.2%; p < 0.001), and in-hospital mortality (82% vs. 66%; p < 0.001). Multivariable analysis suggested the odds (using odds ratio [OR]; 95% CI) of SPPC consultation increased by 21% for each additional CCC (OR, 1.21 [95% CI, 1.11-1.32]) and by 12% annually between 2013 and 2023 (OR, 1.12 [95% CI, 1.06-1.18]).

Conclusions: Despite the high morbidity and mortality associated with pediatric OHCA, SPPC consultations were used infrequently and disproportionately concentrated among children with preexisting medical complexity or imminent death. Since all PICU children post-OHCA may benefit from SPPC consultation, future studies should focus on barriers and opportunities for SPPC integration into standard care.

Objective: The Society of Critical Care Medicine PICU Liberation ABCDEF (A-F) Campaign Collaborative aimed to implement best practices for analgesia (A), breathing (B), comfort/consciousness (C), delirium (D), early mobilization (E), and family engagement and empowerment (F). Our post hoc study of Mayo Clinic data sought to compare the pre-implementation rounding process, which used a nursing script organized by organ systems, with a novel, liberation-focused rounding process emphasizing A-F bundle elements.

Design: Secondary analysis of pre- vs. post-implementation surveys collected by independent observers during rounds.

Setting: Medical/surgical PICU in a quaternary-care, academic medical center during April to July 2017.

Subjects: The observed participants included PICU physicians, nurses, respiratory therapists, pharmacists, and dietitians.

Interventions: None.

Measurements and main results: Survey responses from 145 team members pre-implementation and 67 post-implementation showed improved team satisfaction, communication, and understanding of daily plans (all p < 0.05). Respondents reported an increased frequency of discussions on bundle components A-E (all p < 0.01). Observations of 41 pre-implementation and 46 post-implementation rounds showed an increase in the frequency of discussion of all components of the bundle (all p < 0.01). However, this finding was not at the expense of increased duration of individual rounds since we failed to find a difference in pre- vs. post-implementation duration per patient (480 vs. 544 s per patient, p = 0.20).

Conclusions: In 2017, around the time of introducing the nurse-led PICU Liberation rounding process to our practice, we found that after implementation, there was an associated increase in discussions about bundle elements and improved communications and satisfaction in team members.

Objective: To evaluate the frequency of hospital-acquired venous thromboembolism (HA-VTE, including limb and neck deep venous thrombosis, pulmonary embolism, and organ-specific VTE) among critically ill children with tracheostomy and determine whether surrogate markers of impaired mobility (i.e., invasive mechanical ventilation [IMV] or a high-intensity neurologic diagnosis) are associated with HA-VTE.

Design: Multicenter, retrospective study of the Virtual Pediatric Systems database from January 1, 2016 to December 31, 2023.

Setting: One-hundred forty-two North American PICUs.

Patients: Children younger than 18 years with a preexisting tracheostomy, excluding neonatal and postoperative encounters, those with a PICU length of stay less than 1 day, and those with VTE present at admission.

Interventions: None.

Measurements and main results: Of 25,560 encounters, 181 (0.7%) developed a HA-VTE, identified at a median of 9.5 days (interquartile range: 4-19) following hospitalization. Although a larger proportion of children who developed a HA-VTE as compared with not had a high-intensity neurologic diagnosis (66.9% vs. 56.6%, p = 0.006) and greater rate of IMV exposure (92.8% vs. 81.6%, p < 0.001), these immobility surrogate markers were not associated with HA-VTE in an adjusted logistic regression model. Features independently associated with HA-VTE included: prior VTE (adjusted odds ratio [aOR]: 19.2; 95% CI, 7.1-52); central venous catheterization (CVC, aOR: 3; 95% CI, 2.1-4.2); comorbid infection (aOR: 2.2; 95% CI, 1.6-3.2); and an inherited hypercoagulability (aOR: 3.5; 95% CI, 2.6-5.7) (all p < 0.001). Among patients with CVC, concomitant high-intensity neurologic impairment diagnosis (aOR 1.7; 95% CI, 1.1-2.8) was independently associated with HA-VTE.

Conclusions: In this multicenter study of critically ill children with tracheostomy, HA-VTE occurred in 0.7% of encounters and was associated with presence of a CVC, comorbid infection, prior VTE and inherited hypercoagulability. A surrogate marker of immobility (i.e., high-intensity neurologic diagnoses) was associated with HA-VTE among patients with a CVC.

Objectives: To explore whether baseline serum vitamin C levels are associated with 28-day mortality and organ dysfunction in pediatric sepsis.

Design: Single-center, prospective cohort, 2021 to 2023.

Setting: Tertiary children's hospital PICU in China.

Patients: Patients 18 years old or younger with suspected infection and organ dysfunction.

Interventions: None.

Measurements and main results: Serum vitamin C concentrations were measured in 141 patients within 24 hours of PICU admission. The median (interquartile range) vitamin C level was 4.3 μg/mL (2.5-7.2). Patients were categorized into quartiles (Q) and the primary endpoint was 28-day mortality; the secondary endpoint was the pediatric Sequential Organ Failure Assessment (pSOFA) score on day 1. Overall, a quarter of our cohort were deficient in vitamin C (< 2.5 μg/mL). In multivariable Cox and linear regression analyses, each 1 sd (3.04 μg/mL) increase in vitamin C was associated with a 52% reduction in 28-day mortality (adjusted hazard ratio [HR] 0.48; 95% CI, 0.30-0.76) and a 0.67-point decrease in pSOFA (β -0.67; 95% CI, -1.1 to -0.22). Compared with Q1, Q3 had the lowest adjusted hazard of mortality (HR 0.19; 95% CI, 0.05-0.70) and the least severe organ dysfunction (β -1.5; p = 0.018). Restricted cubic spline analysis suggested a linear inverse relationship between vitamin C and mortality, but a nonlinear inverse association with pSOFA. Subgroup analyses demonstrated more pronounced associations in patients not receiving corticosteroids and in those with normal renal function.

Conclusions: In children with suspected infection and organ dysfunction, subsequent 28-day mortality and organ dysfunction are associated with serum vitamin C level in the first 24 hours of PICU admission.

Objectives: Chylothorax after vascular ring (VR) repair is likely secondary to direct injury to the lymphatic collection system and may benefit from tailored management. We have reviewed the management of patients with chylothorax following VR repair and compared the approaches to chylothorax care after all other cardiac surgeries.

Design: Retrospective multicenter cohort.

Setting: Ten pediatric cardiac surgical centers in the United States.

Patients: Children with chylothorax after VR repair at participating pediatric cardiac surgical centers from 1/1/2021-12/31/2023. Analysis was stratified by chylothorax patients with VR surgery vs all other cardiac surgeries.

Results: Overall, 45 patients had chylothorax following VR repair (45/340, 13.2%) in comparison to 384 patients who had chylothorax following all cardiac surgeries (including VR repair and Fontan procedure) (384/8,494, 4.5%). Compared with all other cardiac surgeries, a higher proportion of VR patients, than other cardiac surgical cases, underwent invasive lymphatic intervention including thoracic duct ligation, embolization, and pleurodesis (10/45 vs. 19/314. p = 0.001) and at an earlier median interval from index surgery (3.5 vs. 28 d, p < 0.001). The 10 patients with VR who underwent a lymphatic intervention had higher chest tube output on postoperative days (PODs) 2 (9.2 vs. 2.6 mL/kg/d, p = 0.005) and 3 (4.9 vs. 0.6 mL/kg/d, p = 0.002) compared with those who resolved without an invasive lymphatic intervention. Following lymphatic intervention, chylothorax resolved a median of 1 day later and there were 0 of 10 procedure-related complications.

Conclusions: Patients with chylothorax after VR more commonly undergo invasive intervention when compared with those with other surgeries. Chest tube output on PODs 2 and 3 may help differentiate VR patients who will need invasive intervention. Chylothorax resolves soon after invasive intervention in VR patients, and in our cohort of 10 there were no procedural-related complications.