Pediatric Critical Care Medicine最新文献

Objectives: To evaluate the Phoenix Sepsis Score (PSS) and criteria in PICU children with suspected or confirmed infection. Additionally, to assess PSS performance in relation to in-hospital mortality.

Design: Retrospective data from a 2019-2024 cohort.

Setting: Single-center, multidisciplinary, tertiary PICU in China.

Patients: In 2584 patient encounters, 0-18 years old, there were 2396 separate encounters with suspected or confirmed infection.

Interventions: None.

Measurements and main results: The PSS was calculated as the sum of four organ subscores (respiratory, cardiovascular, neurologic, and coagulation) using the worst post-admission data from the first 24 hours. Sepsis was defined as a PSS greater than or equal to 2 points and septic shock as sepsis with greater than or equal to 1 point in the cardiovascular subscore. In 2396 patient encounters with suspected or confirmed infection, 1261 (52.6%) with sepsis had a 19.9% (251/1261) mortality rate, and 573/1261 (45.4%) with septic shock had a 34.9% (200/573) mortality rate. Nonsurvival vs. survival was associated with higher median (interquartile range [IQR]) PSS (5 points [IQR, 3-7 points] vs. 2 points [IQR, 2-3 points]; p < 0.001). Also, in-hospital mortality rate increased with progressively higher PSS points. A PSS greater than or equal to 2 points had an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.78-0.84) for in-hospital mortality. Comparison with the International Pediatric Sepsis Consensus Conference (IPSCC) criteria or the pediatric Sequential Organ Failure Assessment (pSOFA) score showed that the PSS had better performance in identifying death rate for those patients with sepsis and for those with septic shock.

Conclusions: In our single-center PICU cohort (2019-2024) from China, among patient encounters with suspected or confirmed infection, the PSS showed good discriminatory ability in identifying sepsis or septic shock. It also outperformed the IPSCC criteria and the pSOFA score in classifying in-hospital mortality. These analyses support the potential utility of the PSS for risk stratification in our international PICU setting.

Objectives: Nursing turnover is a significant vulnerability in healthcare systems. Although adult critical care nurses are among the highest group of nurses leaving the workforce, we do not have information about pediatric cardiac critical care (PCCC) nurse turnover. We have, therefore, explored PCCC nursing turnover in focus groups recruited from interprofessional members of the Pediatric Cardiac Intensive Care Society (PCICS).

Design: Qualitative descriptive inquiry using focus groups and interviews.

Setting: Interprofessional focus group discussions in 2022-2023.

Subjects: Thirty-four participants (representing < 4% of the PCICS membership) were involved in focus groups and interviews.

Interventions: The transcripts of focus groups/interviews were used to explore perspectives regarding PCCC nurse turnover, its potential impact, and the potential solutions to enhance retention. Content analysis coding was used to identify themes and subcategories to support data interpretation.

Measurements and main results: Data were organized into three main themes: Nursing Turnover, Nursing Retention, and Solutions. For the themes of nursing turnover and nursing retention, there were two subcategories, meaning and impact. All participants reported that increased levels of nursing turnover impacted ICU morale. Higher turnover was also believed to increase patient vulnerability at the bedside, requiring higher levels of surveillance and support from the interprofessional team. Potential solutions to enhance retention included competitive salary and benefits packages, professional development for the multigenerational workforce, and a commitment to a healthy work environment.

Conclusions: In 2022-2023, 34 PCICS members from the United States gave their perspectives and understanding of turnover in PCCC nurses. Nursing turnover and its impact on the team highlights the urgent need to collaboratively identify and implement solutions to enhance nurse retention in this area of highly specialized practice. The PCICS and other such organizations may have a role in addressing nursing shortages and continued turnover.

Objectives: Decannulation after pediatric extracorporeal life support (ECLS) may be accompanied by arterial reconstruction. There is a paucity of data on arterial morphology following reconstruction. We sought to characterize morphology of reconstructed arteries to better understand long-term risk of arterial narrowing and blood flow alteration.

Design: Retrospective, single-institution review, 2002-2022.

Setting: Free-standing, 420-bed quaternary care children's hospital in the U.S. Pacific Northwest.

Patients: We identified children of any age who were decannulated from ECLS with arterial reconstruction, using a 20-year registry. We excluded patients who did not survive.

Interventions: None.

Measurements and main results: We collected patient demographics data, indications for ECLS, reconstruction strategies, surgeon specialty, and any available post-decannulation imaging results. Associations between variables and morphologic changes were assessed on univariate analysis and then combined into a forward stepwise multivariable regression model (using p = 0.20 as a threshold). Among surviving patients, 144 underwent carotid artery reconstruction and 25 femoral, with 59 of 144 (41.0%) and 23 of 25, respectively, undergoing post-reconstruction imaging. Follow-up imaging was performed at a median of 21 and 9 days, respectively. On follow-up, 25 of 59 patients (42%) undergoing carotid reconstruction and eight of 23 patients undergoing femoral reconstruction had occlusion or other morphologic changes on imaging. Neonatal age at reconstruction was a significant risk factor for these changes.

Conclusions: A considerable proportion of patients undergoing arterial reconstruction after decannulation from ECLS develop vessel occlusion or other morphologic changes in short-term follow-up. Longer-term imaging is critical to aid risk stratification as ECLS survivors enter adulthood with attendant risks for atherosclerotic vascular disease.

Objective: To identify factors associated with fluid overload (FO) and early outcomes in pediatric patients with moderate or severe traumatic brain injury (TBI).

Design: Retrospective cohort study using patient electronic medical records.

Setting: Hospital Universitario Fundación Valle del Lili, a tertiary care university hospital in Cali, Colombia.

Patients: Pediatric patients 1-16 years old treated in the PICU for moderate or severe TBI between 2011 and 2022.

Measurements and main results: We identified 158 pediatric patients who met study inclusion criteria. We recorded baseline clinical characteristics and interventions administered in the PICU. FO was defined as a cumulative fluid balance greater than or equal to 10% of body weight on the third day after trauma. Outcomes included mechanical ventilation (MV) duration, acute kidney injury (AKI), functional status, and mortality. Hypothesis tests and multivariable models assessed associations. FO occurred in 32 of 158 (20.2%) of patients at 72 hours and its presence was associated with lower weight ( p < 0.001) and age ( p < 0.001). On comparing those with and without FO, we failed to identify an association with mortality or AKI, respectively: 2 of 32 vs. 11 of 126 (mean difference 2.5% [95% CI, -11.9 to 10.2%], p = 0.65); 1 of 32 vs. 8 of 126 (mean difference 3.2% [95% CI, -9.8 to 9.4%], p = 0.49). However, FO compared with not, was associated with adjusted relative increases in MV duration (1.49 [95% CI, 1.08-2.04], p = 0.040) and PICU length of stay (1.44 [95% CI, 1.04-2.00], p < 0.001).

Conclusions: In our retrospective cohort from 2011 to 2022, FO occurred in approximately one in five pediatric TBI patients with moderate or severe injury. We also found that FO was associated with an adjusted relative increase in MV duration, but we failed to identify an association with other outcomes.

Objectives: U.S. multicenter pediatric data from 2001 to 2014 indicate that the prevalence of pediatric pulmonary embolism (PE) is rising, yet it remains rare at individual centers. Evaluation and management vary due to the low frequency of events. And, therefore, we aimed to develop, implement, and evaluate a clinical management pathway and PE response team (PERT) at our center.

Design: Single-center observational implementation study with pre- vs. post-implementation comparisons.

Setting: Quaternary care pediatric hospital.

Patients: Pediatric patients younger than 21 years old with acute PE who presented for care between January 2005 and August 2022 (pre-implementation) and between September 2022 and August 2024 (post-implementation).

Interventions: Implementation of a PE clinical pathway and PERT.

Measurements and main results: A PE clinical pathway and PERT were developed by a multidisciplinary team of pharmacists, quality improvement experts, and physicians from six clinical specialties. Electronic medical record tools were created to support the implementation of this pathway and PERT, and research and quality databases were created for ongoing evaluation. PE evaluation was standardized with the implementation of the PE clinical pathway. In the 23 months post-implementation, there have been 33 patients with acute PE (24 low-risk, seven intermediate-risk, and two high-risk PE), which we compared with our pre-pathway experience of 175 episodes. The proportion of patients who had laboratory testing with brain natriuretic peptide and troponin, or underwent echocardiogram during their admission increased, pre-vs.-post-implementation, respectively (50/175 vs. 30/33; p < 0.01; 55/175 vs. 30/33; p < 0.01; and 142/175 vs. 32/33; p < 0.02). The multidisciplinary PERT was successfully activated for seven patients with intermediate- or high-risk PE.

Conclusions: Implementation of a pediatric PE clinical pathway and PERT improved standardization of PE evaluation and provided rapid multidisciplinary care for intermediate and high-risk PE. Future reports will evaluate both short- and long-term clinical outcomes in these patients.

Objectives: To explore the association between geospatial determinants of health and prevalence of delirium in the PICU.

Design: Nonprespecified secondary analysis of an observational study dataset.

Setting: Urban academic tertiary care PICU.

Patients: All children admitted over a 12-month period in 2014-2015.

Interventions: None.

Measurements and main results: Of 1547 admissions, there were individual 1264 patients, with race and ethnicity subgroup recorded for 961 (76%), insurance status for 1240 (98%), and language for 1227 (97%). Child Opportunity Index (COI) was determined by a patient's 2010 Census Tract and was available for 1246 (98%). Data were grouped from 1 to 5 (very low to very high). PICU delirium (PD) was present in 193 patients during PICU admission, with PD rates highest in Asian/Pacific Islander, Black non-Hispanic, and Hispanic (respectively, 26, 29, and 39 patients) as compared with White non-Hispanic children ( n = 45; p < 0.001). PD was higher for patients with public insurance (113/573 [20%]) compared with those with private insurance (67/583 [12%]) and those with "other" (8/84 [10%]) forms of support ( p < 0.001). We failed to identify a difference in delirium rates by language preference. A higher prevalence of delirium was present among patients in the lowest COI groups (1-3) as compared with highest (4-5; 135/748 [18%] vs. 55/494 [11%]; p = 0.003). In multivariable analysis, COI was associated with greater adjusted odds of delirium (after adjusting for other demographic and clinical predictors of delirium, including age, developmental disability, severity of illness at admission, need for invasive mechanical ventilation, depth of sedation, and medication exposures), with adjusted odds ratio of 1.55 (95% CI, 1.05-2.3; p = 0.028).

Conclusions: In a 2014-2015 PICU dataset, we have identified an association between lower COI and greater adjusted odds of delirium. This finding calls for further study to investigate potential mediators of this relationship.