Pediatric Critical Care Medicine最新文献

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.

Objectives: To improve communication with caregivers who prefer a language other than English (LOE) by increasing interpreting encounters with an emphasis on face-to-face (in-person or video) modalities.

Design: Single-center quality improvement initiative.

Setting: Seventy-five-bed PICU in a quaternary children's hospital.

Patients: Patients whose caregivers preferred a LOE during the period from March 2023 to December 2024.

Interventions: Based on clinician and nursing input about barriers to using interpreting services, we enacted a bundle of interventions collectively known as the Speak Easy program which included: 1) multidisciplinary education; 2) preferred language signs; 3) a novel, standardized opt-out in-person interpreting program for caregivers whose preferred language was Spanish; and 4) increased number of video interpreting devices and presence of devices in patient rooms.

Measurements and main results: We analyzed total and face-to-face interpreting encounters during the intervention period (from March 2023 to December 2024) compared with the pre-intervention period (from November 2021 to February 2023) using statistical process control charts. Total interpreting encounters nearly tripled (from 43 to 121 encounters per 100 LOE patient-days) and face-to-face interpreting encounters increased by more than four times (from 23 to 104 encounters per 100 LOE patient-days). Significant shifts were driven by increases in the number of in-person Spanish interpreting encounters and video interpreting encounters following interventions 3 and 4. Pre-intervention surveys revealed that time constraints, unpredictability, and competing priorities represent barriers to using interpreting services that may be particularly relevant in high-acuity settings; post-intervention surveys showed that clinicians, nurses, and social workers viewed the changes that were made favorably.

Conclusions: A multidisciplinary approach emphasizing interventions to decrease the time and planning necessary to coordinate in-person and video interpreting can effectively engender cultural change and promote the delivery of language-concordant care.

Objectives: High-dose insulin (HDI) is a unique therapy for beta-blocker (BB) and calcium channel-blocker (CCB) poisonings. We have examined pediatric patients with BB and/or CCB poisonings who received HDI therapy with the purpose of describing the clinical characteristics associated with these poisonings and the treatment.

Design: Retrospective database study using our regional, three-state poison center at the Minnesota Regional Poison Center. We identified all children treated with HDI for BB and/or CCB poisonings between the years 2000 and 2024.

Setting: Regional poison center data.

Patients: Pediatric patients 18 years old or younger.

Interventions: None.

Measurements and main results: We identified 36 patients with a median age of 16 years (range 7 mo-18 yr). There were 24 of 36 females, and 14 of 36 patients were poisoned with BBs, 16 of 36 patients by CCBs, and 6 of 36 patients by both drugs. The median peak insulin infusion rate was 1 unit/kg/hr (range 0.5-11 unit/kg/hr); the median insulin infusion duration was 23 hours (range 1-136 hr). The mean dextrose infusion concentration was 37% (range 5-70%). Vasopressors were used in 23 of 36 cases; median vasopressor duration was 38 hours (range 1-199 hr). Cardiac arrest occurred in 4 of 36 patients. Life support with extracorporeal membrane oxygenation (ECMO) was used in one patient. Three patients died as a result of poisoning.

Conclusions: In our three-state poison center, over a 25-year period (2000-2024), HDI was predominantly used in adolescents with intentional BB/CCB overdoses. No adverse events required early discontinuation of HDI. Escalation to ECMO support was rare. More experience is needed to evaluate the safety and effectiveness of HDI in small children.

Objectives: To derive and externally validate supervised machine learning (ML) models predictive of cardiac surgery-associated acute kidney injury (CS-AKI).

Design: Retrospective cohort analysis.

Setting: Multicenter (4), cardiac surgical centers from January 2019 to February 2022.

Patients: Seven days to 18 years old who had undergone cardiac surgery.

Interventions: None.

Measurements and main results: CS-AKI was defined using Kidney Disease: Improving Global Outcomes criteria, with stages 2/3 classified as severe, during the first 7 postoperative days. Data analysis followed two approaches: 1) combining three centers for derivation and using a fourth for external validation and 2) randomly dividing the entire dataset into derivation and validation cohorts in a 4:1 ratio. Forty ML models were developed across five derivation-validation pairs using four ML algorithms (light gradient-boosting machine, extreme gradient boosting, categorical boosting, and histogram gradient boosting) to predict two outcomes (any and severe CS-AKI) utilizing preoperative, intraoperative, and immediate postoperative variables. SHapley Additive exPlanations was used for input variable importance analysis. A cohort of 1100 patients was analyzed. Any CS-AKI and severe CS-AKI occurred in 49.1% and 23.1% patients, respectively. Wide range of variations in external validation of model performance were observed among all 40 ML models. For any CS-AKI, the range in metrics were: area under the receiver operating characteristic curve (AUROC) 0.64-0.83, sensitivity 0.29-0.86, specificity 0.46-0.95, positive predictive value (PPV) 0.50-0.85, and negative predictive value (NPV) 0.60-0.86. For severe CS-AKI, we found the range in metrics with AUROC 0.65-0.77, sensitivity 0.04-0.58, specificity 0.77-0.99, PPV 0.32-0.75, and NPV 0.78-0.90. Preoperative serum creatinine, cardiopulmonary bypass, aortic cross-clamp duration, weight, and age at surgery were the most important predictors associated with CS-AKI.

Conclusions: This analysis of a retrospective multicenter dataset shows that external performance of ML models vary, highlighting challenges in generalizability, which may be due to center-based differences in practice.