Pediatric Critical Care Medicine最新文献

Objectives: Most pediatric residency programs introduce PICU rotations in postgraduate year (PGY) 2, although it is unclear whether this timing best supports trainees' skill development. Introduction during PGY1 may pose challenges due to clinical intensity, but could also have benefits in uniquely preparing residents for PGY2 responsibilities and autonomy. To address this question, this study explored the experiences and self-perceived impacts of a PGY1 PICU rotation among senior pediatric residents.

Design: A multi-institutional qualitative study was conducted using semi-structured interviews of senior (PGY2 and PGY3) residents who completed a PGY1 PICU rotation. Stratified purposive sampling was used at both institutional and resident levels. Data were coded using constant comparison and analyzed thematically.

Setting: Seven institutions requiring a 4-week PGY1 PICU rotation.

Participants: Senior pediatric residents at participating institutions.

Interventions: None.

Measurements and main results: Twenty-one interviews across seven institutions identified three key themes: 1) PGY1s can succeed in the PICU setting when supervisors actively cultivate a learning environment of inclusion, support, and appropriate autonomy; 2) PGY1 PICU rotations can foster self-perceived competence in skills that translate to the PGY2 year; and 3) Participants generally believed the benefits of early PICU exposure outweighed the challenges.

Conclusions: PGY1 PICU rotations can fall within the Zone of Proximal Development when the experience includes strong supervisory support. Findings highlighted the importance of psychologic safety for optimal learning, suggesting that strengthening psychologic safety may enhance the educational experience and outcomes. Further research exploring the impact of PGY1s on team dynamics and patient care, and comparing the effects of PGY1 vs. PGY2 introduction, could guide evidence-based recommendations on the optimal sequencing of PICU rotations for pediatric residents.

Objective: The use of post-extubation respiratory support in single-ventricle neonates undergoing the Norwood procedure is poorly described. We investigated the patterns of respiratory support following extubation as well as factors associated with prolonged exposure to post-extubation noninvasive respiratory support (NRS), defined as greater than or equal to 72 hours, in neonates recovering from the Norwood procedure.

Design: Two-center retrospective cohort study.

Setting: North American pediatric cardiac ICUs.

Patients: Neonates (< 1 mo at the time of surgery) undergoing a Norwood procedure between January 1, 2019, and December 31, 2023.

Measurements and main results: The study included 127 neonates of whom 60 (47%) experienced the primary outcome of prolonged NRS. In multivariable analysis, the presence of an airway anomaly (adjusted odds ratio [aOR] 3.6; 95% CI, 1.4-8.9; p = 0.006), an unplanned surgical or catheter-based reintervention (aOR 3.2; 95% CI, 1.3-7.5; p = 0.010), and longer postoperative mechanical ventilation (aOR 1.1; 95% CI, 1.0-1.2; p = 0.018) were independently associated with prolonged NRS. Patients with prolonged NRS had lower weight-for-age z score at cardiac ICU (CICU) discharge (-2.11 vs. -1.14; p = 0.004), longer CICU length of stay (25.1 vs. 11.1 d; p < 0.001), and longer postoperative sedative exposure (59.8 vs. 16.8 d; p < 0.001).

Conclusions: Prolonged NRS is common in neonates following the Norwood procedure. Patients receiving prolonged NRS experience worse clinical outcomes.

Objectives: The objective of this study was to investigate the validity of global lung ultrasound (LUS) scores among critically ill children with different etiologies and severities of acute respiratory failure as well as associations with outcomes.

Design: Prospective, observational study.

Setting: PICUs at two large children's hospitals.

Patients: Children receiving noninvasive or invasive mechanical ventilation and met criteria for acute respiratory distress syndrome (ARDS), lower respiratory tract infection (LRTI), or control group (no lung disease).

Interventions: None.

Measurements and main results: LUS was performed and LUS scores calculated at two time points: 1) within 24 hours of respiratory failure for all groups (time 1) and 2) at 24 hours of time 1 for patients with ARDS and LRTI (time 2). A total of 76 patients (25 ARDS, 26 LRTI, and 25 control) were included. There was a significant difference in median time 1 global LUS scores between groups (ARDS, 19; interquartile range [IQR], 12-24; LRTI, 8 [IQR, 2-11]; and control, 2 [IQR, 0-6]; p < 0.001). Global LUS scores remained similar from time 1 to time 2 in both ARDS (19 to 17) and LRTI (8 to 7) groups. There were moderate correlations between LUS scores and oxygen saturation index ( r = 0.67; p < 0.001), peripheral oxygen saturation/F io2 ratio ( r = -0.63; p < 0.001), mean airway pressure ( r = 0.63; p < 0.001), positive end-expiratory pressure ( r = 0.52; p < 0.001), and dynamic compliance ( r = -0.43; p = 0.001). Higher LUS scores were associated with fewer ventilator-free days at 28 days ( p < 0.001), fewer positive pressure ventilation-free days at 28 days ( p < 0.001), and fewer ICU-free days at 28 days ( p < 0.001).

Conclusions: In critically ill children with acute respiratory failure, global LUS scores within 24 hours of admission differed by severity of parenchymal lung disease, correlated with oxygenation parameters, and were associated with patient-centered outcomes of duration of respiratory support and PICU length of stay.

Objectives: Sedation in critically ill children is a complex challenge. Both inadequate sedation and oversedation are undesirable and carry consequences. Standardized sedation protocols aim to reduce practice variability, minimize drug exposure, and improve outcomes. Although widely used, adherence to sedation protocols remains poorly studied. We quantified the alignment between sedation protocols and infusion titration practices in a large single-center cohort.

Design: Retrospective cohort study.

Setting: Three PICUs within a single-tertiary care children's hospital.

Patients: Patients admitted between January 1, 2011, and December 31, 2023 who received mechanical ventilation for greater than 24 hours and at least one sedative infusion.

Interventions: None.

Measurements and main results: A total of 8,108 patients across 9,670 encounters, representing 172,136 ICU patient days were included. Adherence to five metrics was calculated as the proportion of protocol-defined titration opportunities in which the recommended action was taken. Protocol adherence was consistently low across all ICUs. Infusions were rarely increased when indicated (92.5% missed [95% CI, 92.4-92.6%]) and were often not decreased when recommended (95.5% missed [95.4-95.6%]). Increases in infusion dose were premature (i.e., not indicated by the protocol) in 54.7% (95% CI, 54.3-55.2%). Titration opportunities, determined by the protocols-defined titration recommendations using the number of as-needed doses, varied in frequency across encounters with a median of 3.0 (interquartile range [IQR], 1.1-7.6) increase opportunities and 2.4 (IQR, 1.6-3.6) decrease opportunities per infusion day. Only 16.2% (95% CI, 15.1-17.2%) of eligible short-duration infusions were discontinued when recommended. Infusions of greater than 5 days duration were weaned per protocol in 74.5% (74.0-75.1%) of opportunities.

Conclusions: Sedation titration in PICUs frequently deviates from protocol recommendations, leading to missed opportunities for active titration. Given the well-documented risks of prolonged sedation, including neurodevelopmental impact, iatrogenic withdrawal, and delirium, as well as the evidence that protocols diminish sedative exposure, improving adherence to sedation protocols is a key target for quality improvement. Future work should focus on identifying barriers to adherence and developing interventions, such as clinical decision support tools, to enhance compliance with evidence-based sedation management.

Objectives: To study the feasibility of integrating the nitrogen multiple breath wash-in/washout (NMBW) technique with the positive end-expiratory pressure-step (PEEP-step) method to estimate transpulmonary driving pressure (DPTP), strain, and lung-specific elastance (k).

Design: Prospective feasibility physiology study.

Setting: National board-affiliated 30-bed quaternary care hospital PICU.

Patients: Invasively ventilated children from 2 months to 16 years old between December 1, 2021, and August 30, 2022.

Interventions: In volume-control mode, functional residual capacity (FRC) was measured using the NMBW technique at zero end-expiratory pressure (ZEEP), and end-expiratory lung volume was measured during the PEEP-step method.

Measurements and results: Data from 33 of 63 eligible subjects were analyzed, of whom 18 of 33 had pediatric acute respiratory distress syndrome (PARDS). Median (interquartile range [IQR]) FRC normalized to body weight was 15.1 mL/kg (IQR, 10.6-20.4 mL/kg). A correlation was found between FRC and respiratory compliance at ZEEP (rho = 0.775; p < 0.001). Strain demonstrated a positive correlation with both the DPTP (rho = 0.55; p < 0.001) and plateau pressure (rho = 0.72; p < 0.001) at ZEEP. Median k was lower in PARDS than non-PARDS subjects (16.1 cm H2O [IQR, 10.8-18.6 cm H2O] vs. 19.84 cm H2O [IQR, 18.50-23.93 cm H2O]; p = 0.045), but this difference was not present when k was normalized to body weight and height.

Conclusions: Despite technical limitations, it appears possible to estimate DPTP, strain, and k by integrating the PEEP-step and NMBW methods. Validation against the gold standard esophageal pressure manometry is warranted.

Objectives: To develop a fine-tuned version of the generative pretrained transformer (GPT)-4o artificial intelligence (AI) model able to estimate Functional Status Scale (FSS) scores among critically ill children.

Design: Secondary analysis of a prospective, observational cohort of critically ill children 1 month to 18 years old who required invasive mechanical ventilation for greater than or equal to 3 days. Four patient notes from each of three hospitalization timepoints-baseline (history & physical), PICU transfer, and hospital discharge-along with retrospectively assigned FSS scores were used to train the model. The resulting custom GPT (hereafter, FSS-AI) was then applied to the remaining 428 notes. The GPT-generated FSS scores were then compared with the manually assigned scores determined prospectively during the original study.

Setting: A single, quaternary-care academic pediatric hospital.

Patients: Children who completed the original study, survived to discharge, and had FSS scores documented.

Interventions: None.

Measurements and main results: FSS-AI analyzed 428 notes from 147 patients over 255 minutes (averaging 35.7 s/note). FSS-AI demonstrated moderate agreement with manually determined total FSS scores at the pre-illness baseline (weighted Cohen's Kappa, 0.59; 95% CI, 0.49-0.70) and hospital discharge (0.51; 95% CI, 0.43-0.58) timepoints, with slightly lower agreement at PICU transfer (0.45; 95% CI, 0.37-0.54). For discrimination of normal total FSS scores (6-7) from abnormal scores (≥ 8), FSS-AI accuracy and positive predictive value were highest at the pre-illness baseline (0.90 and 0.95, respectively) and hospital discharge (0.81-0.75) timepoints. FSS-AI identified children with a new morbidity at hospital discharge (total FSS increase ≥ 3 or domain FSS increase ≥ 2) with accuracy and sensitivity of 0.75 and 0.56.

Conclusions: A custom version of GPT-4o was able to estimate FSS scores at multiple hospitalization timepoints. The tool demonstrated moderate agreement with manually determined scores, could discriminate children with normal vs. abnormal FSS (best performance at baseline and hospital discharge timepoints), and had fair accuracy for detecting new morbidities present at hospital discharge.

Objectives: To first evaluate the association between postoperative electroencephalography findings and 24-month neurodevelopmental outcomes in neonates with congenital heart disease (CHD) undergoing cardiac surgery. Secondarily to explore the association between perioperative medication exposure and outcome.

Design: Single-center retrospective cohort study in a University-affiliated tertiary pediatric center, between February 2013 and September 2020.

Patients: Neonates (postmenstrual age [PMA] > 36 wk) with CHD requiring cardiopulmonary bypass surgery at PMA younger than 44 weeks who had neurodevelopmental assessments at 24 months using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III).

Interventions: None.

Measurements and main results: Out of 345 neonates with complex CHD, there were 68 neonates in our clinical outcome cohort, and 32 of 68 (47%) in the postoperative electroencephalography cohort. In the electroencephalography group, a quantitative electroencephalography index of discontinuity index was calculated and averaged from postoperative recordings between 15 and 24 hours. Here, adjusted analyses showed greater postoperative electroencephalography discontinuity index was associated with lower BSID-III motor scores at 24 months (-0.48 [95% CI, -2.31 to -0.51]; p = 0.009). In the complete clinical cohort, linear regression models were used to explore the association between medication dosing (intraoperative, 24-hr postoperative, and cumulative doses) with BSID-III scores at 24 months. Higher early postoperative opioid doses were associated with better motor outcomes, as represented by the standardized coefficient, B, and its 95% CI, including: global motor composite scores (complete cohort, 0.33 [95% CI, 0.77-5.41]; p = 0.010 and d-transposition of the great arteries subgroup, 0.37 [95% CI, 0.67-5.41]; p = 0.013); fine motor scaled scores (complete cohort, 0.26 [95% CI, 0.01-0.97]; p = 0.049); and gross motor scaled scores (complete cohort, 0.26 [95% CI, 0.01-0.94]; p = 0.047).

Conclusions: Our single-center retrospective study shows an association between early postoperative electroencephalography findings and outcomes after neonatal cardiac surgery. Electroencephalography discontinuity may be a potential biomarker of later adverse motor outcomes. Future evaluations are needed to clarify the interaction between postoperative electroencephalography monitoring, pharmacologic exposures and later neurodevelopment.

Objective: We aim to evaluate the prevalence of food insecurity (FI) among pediatric patients admitted to the PICU, compare the prevalence between patients admitted to the PICU vs. hospital medicine (HM) floor, and determine associations between the presence of FI and clinical and demographic variables.

Design, setting, and patients: A retrospective chart review was conducted for patients 0-18 years old admitted for at least 24 hours between January 1 and December 31, 2023 to a tertiary pediatric hospital PICU or HM floor.

Interventions: None.

Measurements and main results: FI was measured using the Hunger Vital Sign tool. Self-identified demographic data were obtained and reported using descriptive statistics, and associations with FI were examined using chi-square testing and logistic regression. Of the 4457 identified patients, 2820 met inclusion criteria (621 in PICU, 2199 in HM). FI prevalence was higher in PICU patients compared with those admitted to the HM floor (9% PICU vs. 6.5% HM, p = 0.034; 95% CI, 0.504-0.962). Higher odds of FI were found in Black patients (aOR 2.40; 95% CI, 1.39-4.09, p = 0.001) and patients self-identifying as Hispanic (aOR 5.44; 95% CI, 2.94-9.81, p = < 0.001) as compared with White patients. Admission location, age, gender, and length of stay were not independently associated with FI.

Conclusions: This is the first study reported comparing the prevalence of FI between PICU vs. HM floor patients, and the largest study to date on FI prevalence in the PICU. FI was more prevalent among patients admitted to the PICU than HM floor and predominantly noted in Black patients and patients self-identifying as Hispanic. These findings highlight the need for screening and intervention strategies to address FI within the ICU setting.