Pediatric Critical Care Medicine最新文献

Objectives: A conservative oxygenation strategy, targeting peripheral oxygen saturations (Sp o2 ) between 88% and 92% in mechanically ventilated children in PICU, was associated with a shorter duration of organ support and greater survival compared with Sp o2 greater than 94% in our recent Oxy-PICU trial. Sp o2 monitors may overestimate arterial oxygen saturation (Sa o2 ) in patients with higher levels of skin pigmentation compared with those with less skin pigmentation. We investigated if ethnicity was associated with changes in distributions of Sp o2 and F io2 and outcome.

Design: Post-hoc analysis of a pragmatic, open-label, multicenter randomized controlled trial.

Setting: Fifteen PICUs across the United Kingdom and Scotland.

Patients: Children aged 38 weeks corrected gestational age to 15 years accepted to a participating PICU as an unplanned admission and receiving invasive mechanical ventilation with supplemental oxygen for abnormal gas exchange.

Methods: Hierarchical regression models for Sp o2 and F io2 , and ordinal models for the primary trial outcome of a composite of the duration of organ support at 30 days and death, were used to examine the effects of ethnicity, accounting for baseline Sp o2 , F io2 , and mean airway pressure and trial allocation.

Measurements and main results: Ethnicity data were available for 1577 of 1986 eligible children, 1408 (89.3%) of which were White, Asian, or Black. Sp o2 and F io2 distributions did not vary according to Black or Asian ethnicity compared with White children. The trial primary outcome measure also did not vary significantly with ethnicity. The point estimate for the treatment effect of conservative oxygenation in Black children was 0.64 (95% CI, 0.33-1.25) compared with 0.84 (0.68-1.04) in the overall trial population.

Conclusions: These data do not suggest that the association between improved outcomes and conservative oxygenation strategy in mechanically ventilated children in PICU is modified by ethnicity.

Objective: Pediatric deaths often occur within hospitals and involve balancing aggressive treatment with minimization of suffering. This study first investigated associations between clinical/demographic features and the level of intensity of various therapies these patients undergo at the end of life (EOL). Second, the work used these data to develop a new, broader spectrum for classifying pediatric EOL trajectories.

Design: Retrospective, single-center study, 2013-2021.

Setting: Four hundred sixty-one bed tertiary, stand-alone children's hospital with 112 ICU beds.

Patients: Patients of age 0-26 years old at the time of death.

Interventions: None.

Measurements and main results: Of 1111 included patients, 85.7% died in-hospital. Patients who died outside the hospital were older. Among the 952 in-hospital deaths, most occurred in ICUs (89.5%). Clustering analysis was used to distinguish EOL trajectories based on the presence of intensive therapies and/or an active resuscitation attempt at the EOL. We identified five simplified categories: 1) death during active resuscitation, 2) controlled withdrawal of life-sustaining technology, 3) natural progression to death despite maximal therapy, 4) discontinuation of nonsustaining therapies, and 5) withholding/noninitiation of future therapies. Patients with recent surgical procedures, a history of organ transplantation, or admission to the Cardiovascular ICU had more intense therapies at EOL than those who received palliative care consultations, had known genetic conditions, or were of older age.

Conclusions: In this retrospective study of pediatric EOL trajectories based on the intensity of technology and/or resuscitation discontinued at the EOL, we have identified associations between these trajectories and patient characteristics. Further research is needed to investigate the impact of these trajectories on families, patients, and healthcare providers.

Recently, we took care of a teenage boy in our PICU who had been struggling with a lifelong chronic illness and accompanied him and his parents during the last few days of his life. We had the privilege of getting to know him and his parents quite well during the last few years, as he required hospitalization several times during this time. We saw how extremely dedicated his parents had been to him and his care, how they left no stone unturned and sacrificed everything they could to help him have the best quality of life possible. I happened to not be on service, nor know about the moment when he passed away. I also missed when his funeral took place. I wanted to reach out to his parents, to express how much his life and their love for him had meant to me, too, and to find some closure. So I wrote this short poem for them, and for all the other parents, who have to go through the most difficult time a parent can ever go through-as a pediatric intensivist, a Mom who has never been where they had to go, a fellow human being, and a grieving friend.

Objectives: An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use.

Design: Simulation-based randomized trial, conducted from May to December 2021.

Setting: Four pediatric simulation centers.

Subjects: Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box).

Interventions: Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales.

Measurements and main results: A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the "low" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand ( p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales ( p < 0.05).

Conclusions: The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the "low" range, and there was no significant difference between airway provider and assistant.