Pediatric Critical Care Medicine最新文献

Objectives: To test whether indexing stroke volume change (ΔSV%) to body size during the passive leg raising (PLR) test in spontanoeusly breathing children improves accuracy to detect fluid responsiveness (FR).

Design: Observational study.

Setting: Two pediatric hospitals.

Patients: Children age 2-16 years.

Interventions: None.

Measurements and main results: In study phase 1, we measured ΔSV% by echocardiography during PLR in healthy children. A positive PLR test was defined as a mean ΔSV% greater than or equal to 10%. The correlation between ΔSV% with body size parameters was assessed, and optimal body size indexation was generated. In study phase 2, the PLR was performed in acutely ill children before a fluid challenge of 20 mL/kg of normal saline. ΔSV% was measured at 10 and 20 mL/kg and FR was defined as ΔSV% greater than or equal to 10% or greater than or equal to 15% (four possible definitions of FR). The diagnostic performance of the PLR using nonindexed and indexed ΔSV% to identify FR was assessed using the area under the receiver operating characteristic curve (AUC) analyses. We recruited 133 and 87 children in phase 1 and 2, respectively. Mean ΔSV% and the proportion of positive PLR test increased with age tertiles both in healthy children and children receiving a fluid challenge ( p ≤ 0.01). ΔSV% positively correlated with body size. Indexing by height (i.e., [ΔSV%/0.0006] × height 2.493 ) removed the effect of body size. The AUC of the PLR for FR ranged from 0.745 to 0.802, depending on the FR definition applied. The use of height-indexed ΔSV% improved diagnostic performance (AUC range, 0.852-0.894) compared to non-indexed ΔSV%, although the result was significant only when FR was defined as ΔSV% greater than 15% after 20 mL/kg (DeLong test < 0.05).

Conclusions: The response in ΔSV% to a PLR is greatly influenced by body size. Indexing the value by height may improve the diagnostic performance of the PLR in children.

Objectives: To create a simple scoring system to evaluate the extent of brain injury on MRI after pediatric out-of-hospital cardiac arrest (OHCA).

Design: Two-center retrospective cohort from 2016 to 2020.

Setting: Two tertiary care children's hospital serving northern California.

Patients: Children older than 48 hours and younger than 18 years old at admission who experienced OHCA within 24 hours before admission and underwent brain MRI within 8 days following arrest.

Intervention: None.

Measurements and main results: Brain abnormalities on diffusion-weighted and T2/fluid-attenuated inversion recovery MRI in six brain regions were summed to quantify severity of injury (0/1 point for each region) in: deep structures (basal ganglia, thalamus, and/or posterior limb of the internal capsule), cortex, white matter, brainstem, hippocampus, and cerebellum. Unfavorable neurologic outcome was defined using Pediatric Cerebral Performance Category (PCPC) score greater than or equal to 1 point above baseline resulting in a hospital discharge PCPC score greater than or equal to 3. There were 58 children included and 41 (71%) had unfavorable outcome. In those with unfavorable outcome, four of 41 had no evidence of injury (MRI score 0), whereas 15 of 17 with favorable outcome had a MRI score of 0 ( p < 0.001). No patient with favorable outcome had evidence of injury in deep structures ( p < 0.001), brainstem ( p = 0.003), cerebellum ( p = 0.024), or hippocampus ( p < 0.001). There were 28 of 41 unfavorable outcome patients who had a MRI score greater than or equal to 3, whereas no children (0/17) with favorable outcome had a MRI score greater than or equal to 3. After adjusting for presence of bystander cardiopulmonary resuscitation, witnessed arrest, and estimated time to return of spontaneous circulation, the pre- to post-test probability of unfavorable outcome with a MRI score greater than or equal to 3 went from 71% to greater than 99% (0.996 [95% CI, 0.8-1.0]).

Conclusions: Our simple six-point MRI scoring system developed in a 2016-2020 cohort of pediatric OHCA cases managed in two centers shows an association with outcome, with a post-test probability of unfavorable outcome greater than 99% with a MRI score greater than or equal to 3.

Objectives: IV calcium is used frequently in the pediatric cardiovascular ICU (CVICU) for neonates and infants undergoing congenital heart surgery (CHS). Since critical illness is associated with abnormal cellular calcium handling and adverse effects induced by hypercalcemia, we aimed to: describe calcium use across three CVICUs; determine explanatory factors related to hypercalcemia and calcium administration; and evaluate associations with outcome.

Design: Retrospective cohort analysis from January 2020 to December 2022.

Setting: Three university affiliated CVICUs.

Patients: Children younger than 6 months undergoing CHS receiving postoperative monitoring of ionized calcium (iCa).

Interventions: None.

Measurements and main results: Average iCa for every 24-hour period was calculated from tests drawn during the first 72 hours after CHS. Of 276 infants evaluated, 119 (43%) were neonates, 62 (23%) underwent The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 4 and 5 surgery, and 44 (16%) had single ventricle physiology. Median (interquartile range) age was 50 days (8-113 d). IV calcium utilization differed between centers, with calcium administered in 21%, 62%, and 96% of cohorts ( p < 0.001) at respective hospitals. Hypercalcemia was more prevalent in neonates ( p = 0.02), patients with longer cardiopulmonary bypass times ( p = 0.02), and patients with higher postoperative Vasoactive-Inotrope Scores ( p = 0.001). Children receiving top 10% of total calcium administration (compared with those receiving some calcium and no calcium) were younger ( p < 0.001), experienced higher rates of cardiac arrest ( p = 0.02), longer CVICU length of stay (LOS; p < 0.001), and lower survival rates ( p < 0.001). In multivariable analyses, we failed to identify associations between hypercalcemia and receiving top 10% calcium administration with LOS or mechanical ventilation duration.

Conclusions: In 2020-2022, post-CHS calcium management in neonates/infants varied across our three CVICUs. Increased calcium administration and hypercalcemia occurred in high-risk populations (e.g., neonates, STAT ≥ 4 category). Future experimental designs are needed to better understand these relationships and optimize CVICU postoperative calcium management.

Objectives: To compare the proportion of PICU patients returning to the emergency department (ED) or readmitted within 14 days of hospital discharge, between those discharged directly home from the PICU and those transferred to acute care before discharge home; we hypothesized that rates of return-to-care would be similar.

Design: Propensity-matched multicenter cohort study.

Setting: Forty-five U.S. hospitals participating in Pediatric Health Information Systems.

Patients: Children admitted to a non-neonatal cardiac or PICU from 2016 to 2023.

Interventions: None.

Measurements and main results: Of 560,815 PICU discharges, 150,126 (26.8%) were discharged directly home, although this proportion varied by center (9.8-55.6%). We matched 94,048 children (62.6%) discharged directly home to 153,887 ward-transferred children at admission year, admission type, principal diagnosis, and a propensity score estimating the likelihood of being discharged directly home. Compared with ward-transferred peers, children discharged directly home had similar rates of return-to-ED care (2.9% vs. 3.0%; odds ratio [OR], 0.94 [0.89-0.99]) and hospital readmission (4.8% vs. 4.9%; OR, 0.97 [0.94-1.01]) within 14 days. Once readmitted, however, children discharged directly home were more likely to be readmitted to a PICU (2.4% vs. 1.6%; OR, 1.58 [1.49-1.67]). Costs for the index hospitalization were lower for children discharged directly home compared with ward-transferred peers, leading to lower inpatient healthcare costs over 14 days (median, 15,023 [7,614.5-34,294.6] vs. 30,750 [14,558.3-68,830.6]; p ≤ 0.001).

Conclusions: Discharge directly home from the PICU is common; children discharged directly home have comparable likelihood of return-to-ED or inpatient care as matched, ward-discharged peers. Discharge directly home for appropriate patients may provide increased efficiency for healthcare systems.

Objectives: To use a multidimensional outcomes portfolio to assess neurodevelopmental sequelae among PICU survivors during the first 3 years after hospital discharge.

Design: Prospective study of a cohort recruited 2017-2018, with interval follow-up for 3 years.

Setting: PICU at an urban academic tertiary care center.

Patients: Children 0-17 years admitted to the PICU with anticipated discharge home.

Interventions: None.

Measurements and main results: We evaluated outcomes using a PICU Outcomes Portfolio (POP) survey, which combined a study-specific Healthcare and Neurodevelopmental Profile and the Family Impact Survey and standardized measurement tools, including the Pediatric Quality of Life Inventory, the Strengths and Difficulties Questionnaire, and the National Institute for Children's Health Quality Vanderbilt Assessment Scales, to identify various components of post-PICU challenges. Our POP survey identified a sustained impact of child health on family finances and parental employment. Our multidimensional outcomes assessment flagged more at-risk children than individual measures of neurodevelopmental functioning.

Conclusions: Children and families face diverse challenges during recovery from critical illness. Parent-reported outcomes and a multidimensional outcomes portfolio identify the broad impact of critical illness on family well-being as well as the long-term outcomes among PICU survivors. Future mixed-methods studies incorporating parental input regarding post-discharge needs are needed to enrich the evaluation of post-PICU outcomes using standardized measures and guide the development of post-PICU follow-up programs.

Objectives: To investigate whether the urine output trajectory is associated with dialysis independence in critically ill children with acute kidney injury (AKI).

Design: Retrospective cohort study.

Setting: A PICU in Japan.

Patients: Children younger than 16 years old who received continuous kidney replacement therapy (CKRT) for AKI between July 1, 2014, and June 30, 2023.

Interventions: None.

Measurements and main results: We identified 61 eligible patients, including 16 patients who remained dialysis-dependent 30 days after CKRT initiation. Compared with dialysis-independent patients, dialysis dependence was associated with lower urine output on days 3, 7, 14, and 21 after CKRT initiation. Dialysis independence, when compared with dialysis dependence, was associated with higher median (interquartile range) urine output (mL/kg/hr) at each timepoint (day 3: 0.3 [0.1-1.6] vs. 0.0 [0-0.2]; p = 0.001; day 7: 1.3 [0.4-2.0] vs. 0.0 [0-0.1]; p < 0.001; day 14: 1.8 [1.0-3.5] vs. 0.0 [0-0; p < 0.001]; and day 21: 2.1 [1.1-3.0] vs. 0.0 [0-0]; p < 0.001). The area under the receiver operating characteristic curve (AUROC with 95% CI) for identifying dialysis independence at day 30 after CKRT initiation, based on urine output on day 14, was 0.96 (95% CI, 0.88-1.00). Using the DeLong test, this AUROC was higher than that on day 7 (0.88 [95% CI, 0.77-0.99]; p = 0.009). Also, on day 14, with a pre-test probability of dialysis independence of 71%, the post-test probability increases to 97% when using a test urine output greater than or equal to 0.41 mL/kg/hr. The sensitivity analysis with the exclusion of neonates yielded similar results.

Conclusions: In this 2014-2023 cohort of critically ill children with AKI supported with CKRT, using a urine output greater than or equal to 0.41 mL/kg/hr on day 14, CKRT may be an effective diagnostic test of dialysis independence on day 30. Further validation studies are needed.