Pediatric Critical Care Medicine最新文献

Objective: To describe the use of nuclear medicine cerebral perfusion studies as an ancillary test for brain death/death by neurologic criteria (BD/DNC) in infants aged under 1 year.

Design: Retrospective case series.

Setting: Single-center, quaternary, academic children's hospital in the United States.

Patients: Patients younger than 1 year of age whose evaluation for BD/DNC included a nuclear medicine cerebral perfusion study as an ancillary test, 2005-2022.

Interventions: None.

Measurements and main results: Ten infants were identified from local databases. Mechanisms of brain injury included hypoxic-ischemic injury (8/10), traumatic brain injury (1/10), and intracranial hemorrhage (1/10). Testable components of the first BD/DNC examination were consistent with BD/DNC in all patients. Apnea testing was consistent with BD/DNC in 5 of 10 patients and deferred or terminated prematurely in 5 of 10 patients. All patients underwent ancillary testing with a nuclear medicine scan to assess cerebral perfusion using 99mTc-ethyl cysteinate dimer (99mTc-ECD). Indications were inability to complete the apnea test (5/10), presence of a confounder to the clinical examination (3/10), and clinician discretion (2/10). Nine studies were consistent with BD/DNC. The patient whose ancillary test was inconsistent with BD/DNC had their examination limited by the inability to assess the pupillary reflex and subsequently underwent withdrawal of life-sustaining technology.

Conclusions: Radionuclide cerebral perfusion studies using 99mTc-ECD were used in our setting to support the determination of BD/DNC in infants aged younger than 1 year of age.

Objectives: To describe physical, cognitive, emotional, and social health outcomes of children and their trajectory in the first 6 months after PICU discharge.

Design: Prospective, longitudinal observational cohort study.

Setting: PICU in a tertiary pediatric hospital in Singapore from January 2021 to June 2022.

Patients: One hundred thirty-five children (1 mo to 18 yr), admitted for greater than or equal to 48 hours with at least one organ dysfunction and received PICU therapy.

Interventions: None.

Measurements and main results: Serial self/parent proxy-reported assessments were obtained at: PICU admission, PICU discharge, and 1, 3, and 6 months after PICU discharge. The Pediatric Quality of Life Inventory (PedsQL) scale, Functional Status Scale (FSS), and measures of post-traumatic stress disorder (PTSD) using the Young Child PTSD Screen and the Child and Adolescent PTSD Screen-Parent Version were used. Trajectory groups were identified using group-based trajectory model. One hundred thirty-five children (mean [sd] age, 5.6 yr [5.5 yr]) were recruited. Seventy-eight (52%) were male. The mean (sd) Pediatric Index of Mortality III score was 3.2 (4.1) and PICU length of stay was 10.0 days (21.0 d). The mean (sd) PedsQL total scores were 66.5 (21.1) at baseline, 69.7 (21.4), 75.6 (19.7), and 78.4 (19.8) at 1, 3, and 6 months after PICU discharge, respectively. Overall, the PedsQL and FSS plateaued at 3 months. Our model revealed three distinct trajectory groups. Seventeen and 103 children in the mild and moderate trajectory groups, respectively, demonstrated recovery to baseline. Fifteen children in the severe trajectory group were older in age (mean [sd] 8.3 yr [6.4 yr]), with higher proportion (11/15) of preexisting illness. Five of 15 children in the severe group experienced posttraumatic stress syndrome (PTSS) at 6 months post-discharge.

Conclusions: In our cohort of PICU patients, we found three unique trajectory groups. Children in the severe group were older, more likely to have preexisting conditions and at increased risk for PTSS. Early identification and intervention may improve recovery in patients with severe PICU trajectories.

Objectives: Burn centers offer specialized care to pediatric patients with burn injuries. However, data about outcome in relation to timing of transfer are limited. We examined these timings and outcomes among burn-injured pediatric patients.

Design: Single-center, retrospective cohort study of U.S. national and international practice.

Setting: Shriners ESO Trauma Burn Registry, 2005-2019.

Patients: Patients 0-17 years old admitted to a pediatric burn center with 10-80% total body surface area (TBSA) burn between 2005 and 2019.

Interventions: None.

Measurements and main results: The cohort of 761 patients was subcategorized according to timing of referral: early presentation (EP) (0-7 d), delayed presentation (DP) (8-60 d), and very delayed presentation (VDP) (> 60 d). Primary outcomes included hospital length of stay (LOS), ICU LOS, percent TBSA (%TBSA)/LOS ratio, mortality, and disposition. Dichotomous outcomes were analyzed using logistic regression and continuous outcomes were compared using median regression, both utilizing multivariable analysis adjusting for a priori confounders and presented as adjusted coefficients (ACs) with 95% CI. Delayed referral (DP and VDP) was associated with higher %TBSA burn and with fewer referrals from high-income countries. Compared with EP, VDP was associated with higher LOS/%TBSA (AC, 0.2 [0.01-0.4]). On univariate analysis, in comparison with EP, DP and VDP were associated with higher ICU (DP 16 [6-29]; VDP 8 [0-18]) and hospital LOS (DP 34 [21-55]; VDP 32 [18-58]). Overall, ten of 761 patients died (1.3%), and we found no association between timing of referral and mortality. Also, in 751 survivors, 635 patients (84.6%) were discharged home without home health, and we found no association with timing of referral on multivariable analysis.

Conclusions: In this report, we have reviewed our single-center, international burn-injured pediatric cohort, operating in the United States (2005-2019). We find that referral with VDP as opposed to EP was associated with increased LOS/%TBSA.

Objectives: In the United Kingdom, the starting point for diagnosing and confirming death using neurologic criteria (DNC) is when death is suspected to have occurred following devastating brain injury in patients on an ICU who remain deeply comatose, have absent brainstem reflexes and are apneic with their lungs mechanically ventilated but in whom circulation and other bodily functions persist. In this report, we describe the U.K. experience of diagnosing DNC in children.

Design: Retrospective review of data collected by the U.K. National Health Service Blood and Transplant Potential Donor Audit.

Setting and patients: U.K. children from birth to younger than 18 years old with suspected DNC between April 1, 2015, and April 1, 2023.

Interventions: None.

Measurements and main results: A total of 824 children were suspected of DNC and 565 of 824 (68.6%) proceeded to have testing. Overall, 393 of 565 (69.5%) of the tested patients were cared for on a PICU, 164 of 565 (29%) on an adult ICU, three of 565 (0.5%) on a neonatal ICU, and the other five of 565 (1%) in other locations. After testing, 548 of 565 (97%) were confirmed as having died using neurologic criteria. During 2020 to 2023, we estimate that DNC occurred in 6.2% of all PICU deaths. Of 393 of 565 children undergoing testing on the PICU, 15 were younger than 2 months, 45 between 2 months to 1 year, and 31 between 1 and 2 years.

Conclusions: During the 8 years, 2015-2023, out of 824 children younger than 18 years old suspected of being dead using neurologic criteria, close to one-in-three did not proceed to formal testing. In 2020-2023, DNC in U.K. PICUs accounted for 6.2% of all death. Last, in young children up to 2 years old, the average experience of diagnosing and confirming DNC across each of the 30 U.K. PICUs was one patient every other year.