Pub Date : 2024-12-17DOI: 10.1097/PCC.0000000000003670
Brian F Flaherty, Cody S Olsen, Eric R Coon, Rajendu Srivastava, Lawrence J Cook, Heather T Keenan
Objectives: Describe β2-agonists, steroids, hypertonic saline (HTS), n-acetylcysteine (NAC), and dornase alfa (DA) use to treat bronchiolitis, factors associated with use, and associations between use and PICU length of stay (LOS).
Design: Retrospective, multicenter cohort study.
Setting: PICUs in the Pediatric Health Information System database.
Patients: PICU admitted children 24 months young or younger with bronchiolitis.
Interventions: None.
Measurements and main results: We analyzed 47,520 hospitalizations between July 1, 2018, and June 30, 2022. We calculated the rate of medication use overall and the median (range) rate for each hospital: β2-agonist (24,984/47,520 [52.6%]; median hospital, 51.7% [21.4-81.7%]), steroid (15,878/47,520 [33.4%]; median hospital, 33.4% [6.0-54.8%]), HTS (7,041/47,520 [14.8%]; median hospital, 10.5% [0-66.1%]), NAC (1,571/47,520 [3.3%]; median hospital, 0.8% [0-22.0%], and DA (840/47,520 [1.8%]; median hospital, 1.4% [0-13.6%]). Logistic regression using generalized estimating equations (GEEs) identified associations between concurrent asthma and β2-agonist (adjusted odds ratio [aOR], 8.68; 95% CI, 7.08-10.65; p < 0.001) and steroid (aOR, 10.10; 95% CI, 8.84-11.53; p < 0.001) use. Mechanical ventilation was associated with all medications: β2-agonists (aOR, 1.79; 95% CI, 1.57-2.04; p < 0.001), steroids (aOR, 2.33; 95% CI, 1.69-3.21; p < 0.001), HTS (aOR, 1.82; 95% CI, 1.47-2.25; p < 0.001), NAC (aOR, 3.29; 95% CI, 2.15-5.03; p < 0.001), and DA (aOR, 7.65; 95% CI, 4.30-13.61; p < 0.001). No medication was associated with decreased PICU LOS. To assess changes in medication use over time and associations with the 2014 American Academy of Pediatrics bronchiolitis guidelines, we expanded our analysis to 83,820 hospitalizations between July 1, 2009, and June 30, 2022. Logistic regression with GEEs found no change in β2-agonist use; steroid use increased after guideline publication (aOR, 1.05; 95% CI, 1.01-1.10; p = 0.02), HTS use changed from increasing prior to the guidelines (aOR, 1.32; 95% CI, 1.11-1.56; p = 0.001) to stable since guideline publication (aOR, 0.93; 95% CI, 0.81-1.07; p = 0.33).
Conclusions: β2-agonists, steroids, and HTS are commonly, but variably used for PICU bronchiolitis treatment. Medication use appears relatively stable over the last decade.
{"title":"Patterns of Use of β-2 Agonists, Steroids, and Mucoactive Medications to Treat Bronchiolitis in the PICU: U.S. Pediatric Health Information System 2009-2022 Database Study.","authors":"Brian F Flaherty, Cody S Olsen, Eric R Coon, Rajendu Srivastava, Lawrence J Cook, Heather T Keenan","doi":"10.1097/PCC.0000000000003670","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003670","url":null,"abstract":"<p><strong>Objectives: </strong>Describe β2-agonists, steroids, hypertonic saline (HTS), n-acetylcysteine (NAC), and dornase alfa (DA) use to treat bronchiolitis, factors associated with use, and associations between use and PICU length of stay (LOS).</p><p><strong>Design: </strong>Retrospective, multicenter cohort study.</p><p><strong>Setting: </strong>PICUs in the Pediatric Health Information System database.</p><p><strong>Patients: </strong>PICU admitted children 24 months young or younger with bronchiolitis.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We analyzed 47,520 hospitalizations between July 1, 2018, and June 30, 2022. We calculated the rate of medication use overall and the median (range) rate for each hospital: β2-agonist (24,984/47,520 [52.6%]; median hospital, 51.7% [21.4-81.7%]), steroid (15,878/47,520 [33.4%]; median hospital, 33.4% [6.0-54.8%]), HTS (7,041/47,520 [14.8%]; median hospital, 10.5% [0-66.1%]), NAC (1,571/47,520 [3.3%]; median hospital, 0.8% [0-22.0%], and DA (840/47,520 [1.8%]; median hospital, 1.4% [0-13.6%]). Logistic regression using generalized estimating equations (GEEs) identified associations between concurrent asthma and β2-agonist (adjusted odds ratio [aOR], 8.68; 95% CI, 7.08-10.65; p < 0.001) and steroid (aOR, 10.10; 95% CI, 8.84-11.53; p < 0.001) use. Mechanical ventilation was associated with all medications: β2-agonists (aOR, 1.79; 95% CI, 1.57-2.04; p < 0.001), steroids (aOR, 2.33; 95% CI, 1.69-3.21; p < 0.001), HTS (aOR, 1.82; 95% CI, 1.47-2.25; p < 0.001), NAC (aOR, 3.29; 95% CI, 2.15-5.03; p < 0.001), and DA (aOR, 7.65; 95% CI, 4.30-13.61; p < 0.001). No medication was associated with decreased PICU LOS. To assess changes in medication use over time and associations with the 2014 American Academy of Pediatrics bronchiolitis guidelines, we expanded our analysis to 83,820 hospitalizations between July 1, 2009, and June 30, 2022. Logistic regression with GEEs found no change in β2-agonist use; steroid use increased after guideline publication (aOR, 1.05; 95% CI, 1.01-1.10; p = 0.02), HTS use changed from increasing prior to the guidelines (aOR, 1.32; 95% CI, 1.11-1.56; p = 0.001) to stable since guideline publication (aOR, 0.93; 95% CI, 0.81-1.07; p = 0.33).</p><p><strong>Conclusions: </strong>β2-agonists, steroids, and HTS are commonly, but variably used for PICU bronchiolitis treatment. Medication use appears relatively stable over the last decade.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":4.0,"publicationDate":"2024-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142847319","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-11DOI: 10.1097/PCC.0000000000003650
Amy E Strong, Spandana Makeneni, Diego Campos, Rosanna Fulchiero, Todd J Kilbaugh, James Connelly, Benjamin L Laskin, Jarcy Zee, Michelle R Denburg
Objectives: Long-term kidney outcomes after extracorporeal membrane oxygenation (ECMO) are little quantified and understood. We aimed to describe the frequency of kidney dysfunction screening during follow-up and the prevalence of long-term kidney disease.
Design: Retrospective cohort of pediatric ECMO patients with estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2) using all post-discharge serum creatinine values to define three kidney outcomes: 1) acute kidney injury (AKI), with eGFR of less than 60 mL/min/1.73 m2, which subsequently improved to normal (≥ 90 mL/min/1.73 m2); 2) abnormal eGFR of less than 90 mL/min/1.73 m2 at last follow-up; and 3) chronic kidney disease (CKD) with eGFR of less than 90 mL/min/1.73 m2 on at least two occasions separated by greater than or equal to 90 days, without an intervening or subsequently normal eGFR.
Setting: Single-center tertiary care children's hospital system.
Patients: All pediatric patients surviving ECMO from 2009 to 2019.
Interventions: None.
Measurements and main results: In the 10-year cohort of 666 patients, 399 (60%) survived at least 3 months post-discharge. Of these, 382 of 399 (96%) were followed at our institution for a median of 5 years (interquartile range, 3-8 yr). Two hundred sixty-four of 382 (69%) had at least one creatinine value post-discharge, and 209 of 382 (55%) had at least two values three months apart. Of the 264 with at least one creatinine value, 61 (23%) had an abnormal eGFR; of the 209 with at least two values greater than or equal to 90 days apart, 18 (9%) met criteria for CKD. Of those with CKD, 12 of 18 had AKI during ECMO, and seven of 18 had AKI events post-discharge (range, 1-6 episodes).
Conclusions: This 2009-2019 pediatric ECMO cohort of survivors, followed for a median of 5 years, shows the subsequent high burden of kidney disease. We found that monitoring and following kidney function was not complete in this population, which is a concern since the rate of later AKI events and CKD is significant. Further study is needed to mitigate this post-ECMO vulnerability.
{"title":"Kidney Outcomes in Children Receiving Extracorporeal Membrane Oxygenation: A Single-Center Acute Cohort From 2009 to 2019, Followed to 2021.","authors":"Amy E Strong, Spandana Makeneni, Diego Campos, Rosanna Fulchiero, Todd J Kilbaugh, James Connelly, Benjamin L Laskin, Jarcy Zee, Michelle R Denburg","doi":"10.1097/PCC.0000000000003650","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003650","url":null,"abstract":"<p><strong>Objectives: </strong>Long-term kidney outcomes after extracorporeal membrane oxygenation (ECMO) are little quantified and understood. We aimed to describe the frequency of kidney dysfunction screening during follow-up and the prevalence of long-term kidney disease.</p><p><strong>Design: </strong>Retrospective cohort of pediatric ECMO patients with estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2) using all post-discharge serum creatinine values to define three kidney outcomes: 1) acute kidney injury (AKI), with eGFR of less than 60 mL/min/1.73 m2, which subsequently improved to normal (≥ 90 mL/min/1.73 m2); 2) abnormal eGFR of less than 90 mL/min/1.73 m2 at last follow-up; and 3) chronic kidney disease (CKD) with eGFR of less than 90 mL/min/1.73 m2 on at least two occasions separated by greater than or equal to 90 days, without an intervening or subsequently normal eGFR.</p><p><strong>Setting: </strong>Single-center tertiary care children's hospital system.</p><p><strong>Patients: </strong>All pediatric patients surviving ECMO from 2009 to 2019.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>In the 10-year cohort of 666 patients, 399 (60%) survived at least 3 months post-discharge. Of these, 382 of 399 (96%) were followed at our institution for a median of 5 years (interquartile range, 3-8 yr). Two hundred sixty-four of 382 (69%) had at least one creatinine value post-discharge, and 209 of 382 (55%) had at least two values three months apart. Of the 264 with at least one creatinine value, 61 (23%) had an abnormal eGFR; of the 209 with at least two values greater than or equal to 90 days apart, 18 (9%) met criteria for CKD. Of those with CKD, 12 of 18 had AKI during ECMO, and seven of 18 had AKI events post-discharge (range, 1-6 episodes).</p><p><strong>Conclusions: </strong>This 2009-2019 pediatric ECMO cohort of survivors, followed for a median of 5 years, shows the subsequent high burden of kidney disease. We found that monitoring and following kidney function was not complete in this population, which is a concern since the rate of later AKI events and CKD is significant. Further study is needed to mitigate this post-ECMO vulnerability.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":4.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142807592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-05DOI: 10.1097/PCC.0000000000003657
Aline B Maddux, Kristen R Miller, Yamila L Sierra, Tellen D Bennett, R Scott Watson, Matthew Spear, Laura L Pyle, Peter M Mourani
Objectives: To measure physical activity in a cohort of children who survived greater than or equal to 3 days of invasive ventilation.
Design: Prospective cohort study (2018-2021).
Setting: Quaternary children's hospital PICU.
Patients: Children (2-17 yr old) without a preexisting tracheostomy who were ambulatory pre-illness and received greater than or equal to 3 days of invasive ventilation.
Interventions: None.
Measurements and main results: We measured duration and intensity of physical activity using hip- (< 6 yr old) or wrist- (≥ 6 yr old) worn ActiGraph GT3XP-BTLE accelerometers (ActiGraph, Pensacola, FL) for 7 days at three timepoints: hospital discharge, 3 months, and 12 months post-discharge. We measured duration of moderate or vigorous physical activity (MVPA) and nonsedentary activity, both characterized as percent of total awake wear time and total minutes per day. We categorized participants based on when they first attained a "high activity" day defined as greater than or equal to 60 minutes of MVPA or a day with percent of MVPA in the top quartile of all days measured. We evaluated 55 children of whom 43 (78%) had data from greater than or equal to 1 timepoint including 19 (35%) with data from all timepoints. Maximum daily MVPA increased across the three post-discharge timepoints (median, 16.0 min [interquartile range (IQR), 8.0-42.8 min], 48.3 min [27.8-94.3 min], and 68.4 min [34.7-111.0 min], respectively) as did maximum daily percent of awake wear time in MVPA (median, 4.3% [IQR, 2.8-9.0%], 10.1% [5.7-14.4%], and 11.1% [7.1-17.5%], respectively). Of the 43 participants, 27 achieved a high activity day: nine of 43 during the hospital discharge period, 14 of 43 during the 3 months post-discharge period, and four of 43 during the 12 months post-discharge period; 16 of 43 did not demonstrate high activity during the post-discharge year.
Conclusions: In the 1-year after PICU discharge measuring physical activity with accelerometers in children 2-17 years old is feasible. Furthermore, demonstration of variable recovery trajectories in our pilot cohort suggests it has potential to be an outcome measure in clinical trials.
{"title":"Physical Activity Monitoring in Children in the 1-Year After 3 or More Days of Invasive Ventilation: Feasibility of Using Accelerometers.","authors":"Aline B Maddux, Kristen R Miller, Yamila L Sierra, Tellen D Bennett, R Scott Watson, Matthew Spear, Laura L Pyle, Peter M Mourani","doi":"10.1097/PCC.0000000000003657","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003657","url":null,"abstract":"<p><strong>Objectives: </strong>To measure physical activity in a cohort of children who survived greater than or equal to 3 days of invasive ventilation.</p><p><strong>Design: </strong>Prospective cohort study (2018-2021).</p><p><strong>Setting: </strong>Quaternary children's hospital PICU.</p><p><strong>Patients: </strong>Children (2-17 yr old) without a preexisting tracheostomy who were ambulatory pre-illness and received greater than or equal to 3 days of invasive ventilation.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We measured duration and intensity of physical activity using hip- (< 6 yr old) or wrist- (≥ 6 yr old) worn ActiGraph GT3XP-BTLE accelerometers (ActiGraph, Pensacola, FL) for 7 days at three timepoints: hospital discharge, 3 months, and 12 months post-discharge. We measured duration of moderate or vigorous physical activity (MVPA) and nonsedentary activity, both characterized as percent of total awake wear time and total minutes per day. We categorized participants based on when they first attained a \"high activity\" day defined as greater than or equal to 60 minutes of MVPA or a day with percent of MVPA in the top quartile of all days measured. We evaluated 55 children of whom 43 (78%) had data from greater than or equal to 1 timepoint including 19 (35%) with data from all timepoints. Maximum daily MVPA increased across the three post-discharge timepoints (median, 16.0 min [interquartile range (IQR), 8.0-42.8 min], 48.3 min [27.8-94.3 min], and 68.4 min [34.7-111.0 min], respectively) as did maximum daily percent of awake wear time in MVPA (median, 4.3% [IQR, 2.8-9.0%], 10.1% [5.7-14.4%], and 11.1% [7.1-17.5%], respectively). Of the 43 participants, 27 achieved a high activity day: nine of 43 during the hospital discharge period, 14 of 43 during the 3 months post-discharge period, and four of 43 during the 12 months post-discharge period; 16 of 43 did not demonstrate high activity during the post-discharge year.</p><p><strong>Conclusions: </strong>In the 1-year after PICU discharge measuring physical activity with accelerometers in children 2-17 years old is feasible. Furthermore, demonstration of variable recovery trajectories in our pilot cohort suggests it has potential to be an outcome measure in clinical trials.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":4.0,"publicationDate":"2024-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142786402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-03DOI: 10.1097/PCC.0000000000003627
Natalie Napolitano, Nadir Yehya, Garrett Keim
{"title":"Esophageal Manometry in Pediatric Acute Respiratory Distress Syndrome: Necessity or Simply a Neighbor of the Pulmonary Artery Catheter?","authors":"Natalie Napolitano, Nadir Yehya, Garrett Keim","doi":"10.1097/PCC.0000000000003627","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003627","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":4.0,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142780493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-26DOI: 10.1097/PCC.0000000000003624
Wesley Boland, Dibyadyuti Datta, Ruth Namazzi, Caitlin Bond, Andrea L Conroy, Kagan A Mellencamp, Robert O Opoka, Chandy C John, Michael Lintner Rivera
Objectives: Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality.
Design: Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017.
Setting: Two referral hospitals in Central and Eastern Uganda.
Patients: Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children.
Interventions: None.
Measurements and main results: PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%.
Conclusions: In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.
目的:连续、无创的外周灌注监测工具(如灌注指数(PI))可检测血液动力学异常,并有助于重症疟疾住院患儿的治疗。在这项针对重症疟疾住院患儿的研究中,我们旨在评估灌注指数是否与临床灌注指标相关,并确定将灌注指数与这些临床指标相结合是否能更好地识别死亡率较高的患儿:对2014年至2017年间进行的一项前瞻性多中心队列研究进行事后分析:乌干达中部和东部的两家转诊医院:600名5岁以下的重症疟疾患儿和120名无症状的社区儿童:测量和主要结果在住院的头 24 小时内,每隔 6 小时测量一次 PI。我们将 PI 与毛细血管再充盈时间、外周肢体是否冰冷或温度梯度等标准临床灌注测量指标进行了比较。入院 PI 与临床灌注测量结果高度相关。与无症状的社区儿童相比,重症疟疾患儿入院时的血流灌注指数较低;在重症疟疾患儿中,有血流灌注不良临床特征或重症疟疾并发症(如休克和高乳酸血症)的患儿的血流灌注指数较低(均 p <0.02)。在重症疟疾患儿中,在对年龄、性别和重症疟疾标准进行调整后,较低的入院 PI 与较高的死亡几率相关(调整后的几率比,PI 每下降 1 个对数,死亡几率为 2.4 [95% CI,1.0-5.9];P = 0.045)。在诊断上,连续两次出现低 PI(< 1%)可预测死亡率,灵敏度为 50%,特异度为 76%:结论:在重症疟疾中,PI 与临床并发症(包括休克和血清乳酸升高)相关,可作为一个客观、连续的解释变量,与较高的后期院内死亡率相关。
{"title":"Peripheral Perfusion Index in Ugandan Children With Plasmodium falciparum Severe Malaria: Secondary Analysis of Outcomes in a 2014-2017 Cohort Study.","authors":"Wesley Boland, Dibyadyuti Datta, Ruth Namazzi, Caitlin Bond, Andrea L Conroy, Kagan A Mellencamp, Robert O Opoka, Chandy C John, Michael Lintner Rivera","doi":"10.1097/PCC.0000000000003624","DOIUrl":"10.1097/PCC.0000000000003624","url":null,"abstract":"<p><strong>Objectives: </strong>Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality.</p><p><strong>Design: </strong>Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017.</p><p><strong>Setting: </strong>Two referral hospitals in Central and Eastern Uganda.</p><p><strong>Patients: </strong>Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%.</p><p><strong>Conclusions: </strong>In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"1117-1126"},"PeriodicalIF":4.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617272/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142351488","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-07-01DOI: 10.1097/PCC.0000000000003569
Martha A Q Curley
{"title":"It's Not Invisible.","authors":"Martha A Q Curley","doi":"10.1097/PCC.0000000000003569","DOIUrl":"10.1097/PCC.0000000000003569","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"1168"},"PeriodicalIF":4.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141469927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-12-04DOI: 10.1097/PCC.0000000000003626
Patricia Peña Jiménez, Wendy Leatherman Phipps, Elizabeth Jacob-Files, Elizabeth Lindo, Lauren C Rakes, Joan S Roberts, Jonna D Clark, Emily R Berkman, Katie R Nielsen
Objectives: To improve continuity of care, some PICUs assign a continuity attending (CA) physician for children with prolonged hospitalizations. Little is known about how this intervention impacts familial caregivers' experiences. The objective of this study was to provide in-depth descriptions of family perspectives about continuity of care during prolonged PICU hospitalizations for children with and without a PICU CA.
Design: Qualitative semi-structured interviews.
Setting: Single center cohort, from October 2021 to December 2022, at an academic PICU in the United States.
Participants: Familial caregivers (n = 39) of critically ill children hospitalized in the PICU for greater than or equal to 14 days were purposively sampled, stratified by group: 18 with a PICU CA and 21 without a PICU CA.
Interventions: None.
Measurements and main results: Semi-structured interviews were audio recorded, transcribed, coded, and analyzed in the context of the continuity of care model using a realist thematic approach. Familial caregivers described six themes related to relational, informational, and management continuity: 1) familiar providers who demonstrate empathy for the child improve family members' comfort and trust (Relational); 2) providers who know and use a child's baseline health status to inform clinical decision-making alleviate family members' stress (Relational, Management); 3) information loss during care team transitions frustrates families (Informational, Management); 4) known providers enhance caregiver communication (Informational); 5) familiar providers who value a family's expertise about their child's care (Relational, Management); and 6) take responsibility for the child's long-term care plan (Management) decrease parental stress.
Conclusions: As PICU patient medical complexity and length of stay increase, familial caregivers' needs transition from understanding day-to-day management to navigating care team transitions and partnering with providers to develop long-term care plans. Targeted interventions to increase provider continuity that consider relational, informational, and management continuity are needed to optimize patient outcomes and family experiences.
{"title":"Caregiver Perspectives on Provider Continuity During Prolonged PICU Hospitalizations: A Single-Center Qualitative Study, 2021-2022.","authors":"Patricia Peña Jiménez, Wendy Leatherman Phipps, Elizabeth Jacob-Files, Elizabeth Lindo, Lauren C Rakes, Joan S Roberts, Jonna D Clark, Emily R Berkman, Katie R Nielsen","doi":"10.1097/PCC.0000000000003626","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003626","url":null,"abstract":"<p><strong>Objectives: </strong>To improve continuity of care, some PICUs assign a continuity attending (CA) physician for children with prolonged hospitalizations. Little is known about how this intervention impacts familial caregivers' experiences. The objective of this study was to provide in-depth descriptions of family perspectives about continuity of care during prolonged PICU hospitalizations for children with and without a PICU CA.</p><p><strong>Design: </strong>Qualitative semi-structured interviews.</p><p><strong>Setting: </strong>Single center cohort, from October 2021 to December 2022, at an academic PICU in the United States.</p><p><strong>Participants: </strong>Familial caregivers (n = 39) of critically ill children hospitalized in the PICU for greater than or equal to 14 days were purposively sampled, stratified by group: 18 with a PICU CA and 21 without a PICU CA.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Semi-structured interviews were audio recorded, transcribed, coded, and analyzed in the context of the continuity of care model using a realist thematic approach. Familial caregivers described six themes related to relational, informational, and management continuity: 1) familiar providers who demonstrate empathy for the child improve family members' comfort and trust (Relational); 2) providers who know and use a child's baseline health status to inform clinical decision-making alleviate family members' stress (Relational, Management); 3) information loss during care team transitions frustrates families (Informational, Management); 4) known providers enhance caregiver communication (Informational); 5) familiar providers who value a family's expertise about their child's care (Relational, Management); and 6) take responsibility for the child's long-term care plan (Management) decrease parental stress.</p><p><strong>Conclusions: </strong>As PICU patient medical complexity and length of stay increase, familial caregivers' needs transition from understanding day-to-day management to navigating care team transitions and partnering with providers to develop long-term care plans. Targeted interventions to increase provider continuity that consider relational, informational, and management continuity are needed to optimize patient outcomes and family experiences.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":"25 12","pages":"1159-1167"},"PeriodicalIF":4.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142770887","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-12-04DOI: 10.1097/PCC.0000000000003633
Suzanne R Gouda, K Sarah Hoehn
{"title":"Starting From Scratch.","authors":"Suzanne R Gouda, K Sarah Hoehn","doi":"10.1097/PCC.0000000000003633","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003633","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":"25 12","pages":"1189-1191"},"PeriodicalIF":4.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142771023","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-08-20DOI: 10.1097/PCC.0000000000003599
Kelli Paice, Sonya Tang Girdwood, Tomoyuki Mizuno, Kathryn Pavia, Nieko Punt, Peter Tang, Min Dong, Calise Curry, Rhonda Jones, Abigayle Gibson, Alexander A Vinks, Jennifer Kaplan
Objectives: To determine the frequency of early meropenem concentration target attainment (TA) in critically ill children with severe sepsis; to explore clinical, therapeutic, and pharmacokinetic factors associated with TA; and to assess how fluid resuscitation and volume status relate to early TA.
Design: Retrospective analysis of prospective observational cohort study.
Setting: PICU in a single academic quaternary care children's hospital.
Patients: Twenty-nine patients starting meropenem for severe sepsis (characterized as need for positive pressure ventilation, vasopressors, or ≥ 40 mL/kg bolused fluid), of which 17 were newly escalated to PICU level care.
Interventions: None.
Measurements and main results: Concentration-time profiles were analyzed using modeling software employing opportunistic sampling, Bayesian estimation, and a population pharmacokinetic model. Time above four times minimum inhibitory concentration (T > 4×MIC), using the susceptibility breakpoint of 1 µg/mL, was determined for each patient over the first 24 hours of meropenem therapy, as well as individual clearance and volume of distribution (Vd) estimates. Twenty-one of 29 patients met a target of 40%T > MIC 4 μg/mL. Reaching TA, vs. not, was associated with lower meropenem clearance. We failed to identify a difference in Vd or an association between the TA group and age, weight, creatinine-based estimated glomerular filtration rate (eGFR), or the amount of fluid administered. eGFR was, however, negatively correlated with overall T > MIC.
Conclusions: Eight of 29 pediatric patients with early severe sepsis did not meet the selected TA threshold within the first 24 hours of meropenem therapy. Higher clearance was associated with failure to meet targets. Identifying patients likely to have higher meropenem clearance could help with dosing regimens.
{"title":"Pharmacokinetic Factors Associated With Early Meropenem Target Attainment in Pediatric Severe Sepsis.","authors":"Kelli Paice, Sonya Tang Girdwood, Tomoyuki Mizuno, Kathryn Pavia, Nieko Punt, Peter Tang, Min Dong, Calise Curry, Rhonda Jones, Abigayle Gibson, Alexander A Vinks, Jennifer Kaplan","doi":"10.1097/PCC.0000000000003599","DOIUrl":"10.1097/PCC.0000000000003599","url":null,"abstract":"<p><strong>Objectives: </strong>To determine the frequency of early meropenem concentration target attainment (TA) in critically ill children with severe sepsis; to explore clinical, therapeutic, and pharmacokinetic factors associated with TA; and to assess how fluid resuscitation and volume status relate to early TA.</p><p><strong>Design: </strong>Retrospective analysis of prospective observational cohort study.</p><p><strong>Setting: </strong>PICU in a single academic quaternary care children's hospital.</p><p><strong>Patients: </strong>Twenty-nine patients starting meropenem for severe sepsis (characterized as need for positive pressure ventilation, vasopressors, or ≥ 40 mL/kg bolused fluid), of which 17 were newly escalated to PICU level care.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Concentration-time profiles were analyzed using modeling software employing opportunistic sampling, Bayesian estimation, and a population pharmacokinetic model. Time above four times minimum inhibitory concentration (T > 4×MIC), using the susceptibility breakpoint of 1 µg/mL, was determined for each patient over the first 24 hours of meropenem therapy, as well as individual clearance and volume of distribution (Vd) estimates. Twenty-one of 29 patients met a target of 40%T > MIC 4 μg/mL. Reaching TA, vs. not, was associated with lower meropenem clearance. We failed to identify a difference in Vd or an association between the TA group and age, weight, creatinine-based estimated glomerular filtration rate (eGFR), or the amount of fluid administered. eGFR was, however, negatively correlated with overall T > MIC.</p><p><strong>Conclusions: </strong>Eight of 29 pediatric patients with early severe sepsis did not meet the selected TA threshold within the first 24 hours of meropenem therapy. Higher clearance was associated with failure to meet targets. Identifying patients likely to have higher meropenem clearance could help with dosing regimens.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"1103-1116"},"PeriodicalIF":4.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617271/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142004964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}