Pediatric Critical Care Medicine最新文献

Objective: To review the timing of death in children with sepsis referred for intensive care, 2018-2023, and compare with our previous 2005-2011 practice. We hypothesized that most deaths occur within 24 hours of referral to the PICU, with many before PICU admission.

Design, setting, and patients: We reviewed referrals to the Children's Acute Transport Service (CATS), North Thames regional pediatric intensive care transport service in the United Kingdom, between January 2018 and March 2023. We included referrals of children (younger than 16 yr) with a working diagnosis of "sepsis," "severe sepsis," "septicemia," or "septic shock." The primary outcome measure was time to death up to a year after referral.

Measurements and main results: Over the 62-month study period, 11,231 referrals were made to CATS, and 330 (3%) met the study inclusion criteria. Outcome data were available on 272, of whom 29 (11%) died in the first year after referral, which compares favorably with our 2005-2011 cohort from the same service in which the 1-year mortality was 21% (130/627): mean difference 10% (95% CI, 4.8-14.6%), p value equals 0.0003. Eighteen of the 29 deaths occurred in the first 24 hours after referral. Amongst children with comorbidities 12 of 139 (9%) died compared to 6 of 133 (5%) previously healthy children ( p = 0.22 Fisher exact test, odds ratio [OR] 2.0 with 95% CI, 0.73-5.5). By 1 year, mortality in children with comorbidities was 19 of 139 (13.9%) vs. mortality in previously healthy children of 10 of 133 (7.5%) ( p = 0.12; OR 1.8 [95% CI, 0.82-4.1]).

Conclusions: In 2018-2023, the proportion of referrals for PICU retrieval with a clinical diagnosis of "sepsis" was low at 3%. As with our 2005-2011 cohort, most deaths occurred within 24 hours of first referral. Therefore, early recognition and resuscitation still have the greatest potential for improving sepsis outcomes, which has implications for clinical trials.

Objectives: Elevated intracranial pressure (ICP) is a complication of severe traumatic brain injury (TBI) that carries a risk of secondary brain injury. This study investigated the association between ICP burden and brain injury patterns on MRI in children with severe TBI.

Design, setting, and patients: Secondary analysis of the Approaches and Decisions in Acute Pediatric TBI (ADAPT) study, which included children with severe TBI (Glasgow Coma Scale score < 9) who received a clinical MRI within 30 days of injury. We excluded patients who had ICP monitoring less than 24 hours, were missing ICP data for greater than 40% of monitoring time, or who underwent craniectomy.

Interventions: None.

Measurements and main results: ICP burden was defined as the trapezoidal area under the curve of hourly ICP greater than 20 mm Hg. ICP was standardized to total monitoring time, and patients were categorized to four levels of ICP burden. MRI was evaluated for number of diffuse axonal injury (DAI) microhemorrhages, intracerebral hemorrhage (ICH) volume, contusion volume, and number of regions with ischemia. Fisher exact or chi-square tests were used to test the independence between ICP burden and MRI injury amount. Of the 220 patients, 156 (71%) had DAI, 31 (14%) had ICH, 161 (73%) had contusions, and 70 (32%) had ischemia on MRI. Most patients (180, 82%) experienced episodes of ICP greater than 20 mm Hg. Contusion volume ( p = 0.02) and number of regions with ischemia ( p = 0.007) were associated with ICP burden, but we failed to identify such an association for DAI or ICH. Severe (but not mild or moderate) ICP burden was associated with presence of ischemia (odds ratio, 4.64 [95% CI, 1.30-19.5]; p = 0.02).

Conclusions: Elevated ICP was prevalent in the ADAPT cohort. Ischemia and contusion were associated with the burden of ICP. Further research is needed to determine temporal relationships between elevated ICP and ischemia.

Objectives: To assess the prevalence and factors associated with duration of postoperative invasive mechanical ventilation (IMV) in children with medical complexity undergoing spinal fusion.

Design: Retrospective cohort study of the Pediatric Health Information System database.

Setting: Forty-seven tertiary referral U.S. children's hospitals.

Patients: Patients 5-18 years old with an underlying neuromuscular or genetic disorder admitted to the ICU following thoracic-lumbar spinal fusion for scoliosis, with hospital discharge between January 1, 2016, and December 31, 2021.

Interventions: None.

Measurements and main results: There were 6511 patients who met inclusion criteria, of which 438 (6.7%) had established preoperative tracheostomy and ventilator dependence. Three hundred seventy-two (5.7%) and 458 (7%) patients underwent postoperative IMV for 4-6 days and greater than or equal to 7 days, respectively. Chronic conditions associated with greater odds of greater than or equal to 4 days of postoperative IMV (as shown by adjusted odds ratio [aOR, 95% CI]), included diseases affecting the following systems: neurologic (aOR, 3.5; 95% CI, 2.5-5.0), respiratory (aOR, 2.8; 95% CI, 2.3-3.5), skin/subcutaneous tissue (aOR, 1.5; 95% CI, 1.2-2.1), hematologic (aOR, 1.4; 95% CI, 1.1-1.7), endocrine/metabolic (aOR, 1.3; 95% CI, 1.1-1.6), genitourinary (aOR, 1.3; 95% CI, 1.1-1.7), and cardiac (aOR, 1.3; 95% CI, 1.0-1.7). Established preoperative tracheostomy was associated with lower odds of greater than or equal to 4 days of postoperative IMV (aOR, 0.1; 95% CI, 0.02-0.3). New tracheostomy procedures were uncommon ( n = 43, 0.7%). Finally, there was substantial regional variation in postoperative IMV after spinal fusion, with patients in the Northeast vs. Midwest region having greater odds of greater than or equal to 4 days of postoperative IMV (aOR, 3.1; 95% CI, 1.9-5.0).

Conclusions: One-in-eight children required greater than or equal to 4 days of IMV after spinal fusion. Chronic conditions affecting the neurologic, respiratory, skin/subcutaneous tissue, hematologic, endocrine/metabolic, genitourinary, and cardiac systems were associated with postoperative IMV. Further understanding of chronic conditions, clinical characteristics, and regional factors associated with duration of IMV may identify opportunities for improvements in care delivery.

Objectives: We aimed to reduce the rate of hospital-acquired venous thromboembolism (HA-VTE) in the PICU by 50% from 2.07 to 1.04 venous thromboembolism (VTE) per 1000 patient days by June 2023 and sustain this change for 6 months.

Design: Prospective quality improvement project.

Setting: The PICU of an urban academic free-standing children's hospital in the United States.

Patients: All patients admitted to the PICU between December 2020 and December 2023.

Interventions: We identified key drivers including: provider knowledge gaps surrounding VTE risk in our patient population, identification of patients at risk of VTE, the absence of appropriate screening and prevention tools, and central venous line duration and location. These key drivers were each addressed with the most significant intervention being the creation of a simple screening tool to identify and provide thromboprophylaxis recommendations for patients most at risk for developing VTE.

Measurements and main results: We identified the monthly occurrence rate of VTE as our outcome measure, the provision of VTE thromboprophylaxis as our process measure and the presence of bleeding events as our balancing measure. The rate of VTE in PICU patients decreased from 2.07 to 1.14 per 1000 patient days. There was an increase in the provision of pharmacologic thromboprophylaxis during our intervention period from 36% to 42% with no change in the rate of mechanical thromboprophylaxis. There were only two instances of clinically relevant non-major bleeding as defined by the International Society of Thrombosis and Haemostasis definition in nonsurgical patients on anti-hemostatic agents during our intervention period. There was a decrease in central venous catheter days from 43% to 31% of PICU patient days during the intervention period.

Conclusions: Upon implementing a protocolized screening and prevention tool for VTE, we observed a decreased occurrence of HA-VTE.