Pediatric Critical Care Medicine最新文献

Objectives: High-dose insulin (HDI) is a unique therapy for beta-blocker (BB) and calcium channel-blocker (CCB) poisonings. We have examined pediatric patients with BB and/or CCB poisonings who received HDI therapy with the purpose of describing the clinical characteristics associated with these poisonings and the treatment.

Design: Retrospective database study using our regional, three-state poison center at the Minnesota Regional Poison Center. We identified all children treated with HDI for BB and/or CCB poisonings between the years 2000 and 2024.

Setting: Regional poison center data.

Patients: Pediatric patients 18 years old or younger.

Interventions: None.

Measurements and main results: We identified 36 patients with a median age of 16 years (range 7 mo-18 yr). There were 24 of 36 females, and 14 of 36 patients were poisoned with BBs, 16 of 36 patients by CCBs, and 6 of 36 patients by both drugs. The median peak insulin infusion rate was 1 unit/kg/hr (range 0.5-11 unit/kg/hr); the median insulin infusion duration was 23 hours (range 1-136 hr). The mean dextrose infusion concentration was 37% (range 5-70%). Vasopressors were used in 23 of 36 cases; median vasopressor duration was 38 hours (range 1-199 hr). Cardiac arrest occurred in 4 of 36 patients. Life support with extracorporeal membrane oxygenation (ECMO) was used in one patient. Three patients died as a result of poisoning.

Conclusions: In our three-state poison center, over a 25-year period (2000-2024), HDI was predominantly used in adolescents with intentional BB/CCB overdoses. No adverse events required early discontinuation of HDI. Escalation to ECMO support was rare. More experience is needed to evaluate the safety and effectiveness of HDI in small children.

Objectives: To derive and externally validate supervised machine learning (ML) models predictive of cardiac surgery-associated acute kidney injury (CS-AKI).

Design: Retrospective cohort analysis.

Setting: Multicenter (4), cardiac surgical centers from January 2019 to February 2022.

Patients: Seven days to 18 years old who had undergone cardiac surgery.

Interventions: None.

Measurements and main results: CS-AKI was defined using Kidney Disease: Improving Global Outcomes criteria, with stages 2/3 classified as severe, during the first 7 postoperative days. Data analysis followed two approaches: 1) combining three centers for derivation and using a fourth for external validation and 2) randomly dividing the entire dataset into derivation and validation cohorts in a 4:1 ratio. Forty ML models were developed across five derivation-validation pairs using four ML algorithms (light gradient-boosting machine, extreme gradient boosting, categorical boosting, and histogram gradient boosting) to predict two outcomes (any and severe CS-AKI) utilizing preoperative, intraoperative, and immediate postoperative variables. SHapley Additive exPlanations was used for input variable importance analysis. A cohort of 1100 patients was analyzed. Any CS-AKI and severe CS-AKI occurred in 49.1% and 23.1% patients, respectively. Wide range of variations in external validation of model performance were observed among all 40 ML models. For any CS-AKI, the range in metrics were: area under the receiver operating characteristic curve (AUROC) 0.64-0.83, sensitivity 0.29-0.86, specificity 0.46-0.95, positive predictive value (PPV) 0.50-0.85, and negative predictive value (NPV) 0.60-0.86. For severe CS-AKI, we found the range in metrics with AUROC 0.65-0.77, sensitivity 0.04-0.58, specificity 0.77-0.99, PPV 0.32-0.75, and NPV 0.78-0.90. Preoperative serum creatinine, cardiopulmonary bypass, aortic cross-clamp duration, weight, and age at surgery were the most important predictors associated with CS-AKI.

Conclusions: This analysis of a retrospective multicenter dataset shows that external performance of ML models vary, highlighting challenges in generalizability, which may be due to center-based differences in practice.

Objective: Critically ill children are at risk for preventable morbidities due to immobility. Early mobility, a key component of the ICU Liberation Bundle, improves outcomes and reduces mortality. Internationally, adherence to early-mobility protocols is low and nurses are pivotal for success. This quality improvement (QI) initiative aimed to assess whether an in situ early-mobility simulation for PICU nurses increased nurse-led mobilization of critically ill children.

Design: QI initiative with an observational, pre-post design.

Setting: PICU in a tertiary academic hospital in the United States.

Patients: Critically ill pediatric patients admitted to the PICU.

Intervention: An in situ early-mobility simulation session for PICU nurses.

Measurements and main results: Data were collected and analyzed from February to October 2024 on randomly selected shifts in the pre-intervention (n = 22 day shifts) and post-intervention (n = 26 day shifts) phases. One hundred and one children 1-17 years old who were admitted to the PICU and had length of stay greater than or equal to 72 hours were included. Eighty percent of all critical care nurses (80/100) participated in the simulation session. Post-intervention, the median number of nurse-led mobilizations per patient in a 12-hour shift increased from 5 to 6 (p = 0.02). Participation in the simulation was associated with an increase of 1.9 mobilizations per patient in a 12-hour shift after adjusting for age, illness severity, functional status and mobility level. (p = 0.004). Nursing knowledge of patients' mobility levels improved (p = 0.004), and self-efficacy in mobilizing critically ill children increased from 67% to 93% (p < 0.001). No significant increase in safety events was observed.

Conclusions: In situ early-mobility simulations for PICU nurses increased nurse-led mobilizations of critically ill children without compromising safety. Further research is needed to explore the long-term impact and generalizability of this curriculum.

Objectives: Despite its numerous limitations, especially in predicting fluid responsiveness, trends in central venous pressure (CVP) values may be useful for managing certain critically ill pediatric patients. Although ultrasound parameters of the inferior vena cava (IVC) cannot be used to estimate CVP in adults under mechanical ventilation (MV), the pediatric literature reports highly contradictory results.

Design: Prospective, multicenter observational study.

Setting: Six PICUs in France.

Patients: Children 2 days to 12 years old undergoing MV and had a central venous catheter in the superior vena cava to monitor CVP, from November 1, 2021, to June 30, 2023.

Interventions: None.

Measurements and main results: Ultrasound measurements (i.e., IVC maximum diameter [IVCdmax], IVC minimum diameter [IVCdmin]) were performed by experienced intensivists in order to calculate the following parameters: 1) IVC-Collapsibility: ([IVCdmax-IVCdmin]/IVCdmax) × 100; 2) IVC-Distensibility: ([IVCdmax-IVCdmin]/IVCdmin) × 100; and 3) IVC/Aortic: (IVCdmax/Ao) × 100. The search for correlation was studied using Spearman correlation tests because of monotonic relationships. We included 120 children with a median (interquartile range] age of 11.5 months (2.0-46.3 mo) and a median weight of 9.0 kg (5.0-15.0 kg). A third of the patients were admitted for postoperative care, including cardiac surgery, and a quarter for respiratory failure, with a median CVP of 7.5 mm Hg (5.0-10.3 mm Hg). No significant relationship was found between CVP and IVC-Collapsibility (Spearman ρ = -0.09; p = 0.32), IVC/Ao (Spearman ρ = 0.17; p = 0.06), or IVC-Distensibility (Spearman ρ = -0.09; p = 0.29).

Conclusions: There is no correlation between CVP and IVC-ultrasound parameters in children under MV.

Objectives: To evaluate the Phoenix Sepsis Score (PSS) and criteria in PICU children with suspected or confirmed infection. Additionally, to assess PSS performance in relation to in-hospital mortality.

Design: Retrospective data from a 2019-2024 cohort.

Setting: Single-center, multidisciplinary, tertiary PICU in China.

Patients: In 2584 patient encounters, 0-18 years old, there were 2396 separate encounters with suspected or confirmed infection.

Interventions: None.

Measurements and main results: The PSS was calculated as the sum of four organ subscores (respiratory, cardiovascular, neurologic, and coagulation) using the worst post-admission data from the first 24 hours. Sepsis was defined as a PSS greater than or equal to 2 points and septic shock as sepsis with greater than or equal to 1 point in the cardiovascular subscore. In 2396 patient encounters with suspected or confirmed infection, 1261 (52.6%) with sepsis had a 19.9% (251/1261) mortality rate, and 573/1261 (45.4%) with septic shock had a 34.9% (200/573) mortality rate. Nonsurvival vs. survival was associated with higher median (interquartile range [IQR]) PSS (5 points [IQR, 3-7 points] vs. 2 points [IQR, 2-3 points]; p < 0.001). Also, in-hospital mortality rate increased with progressively higher PSS points. A PSS greater than or equal to 2 points had an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.78-0.84) for in-hospital mortality. Comparison with the International Pediatric Sepsis Consensus Conference (IPSCC) criteria or the pediatric Sequential Organ Failure Assessment (pSOFA) score showed that the PSS had better performance in identifying death rate for those patients with sepsis and for those with septic shock.

Conclusions: In our single-center PICU cohort (2019-2024) from China, among patient encounters with suspected or confirmed infection, the PSS showed good discriminatory ability in identifying sepsis or septic shock. It also outperformed the IPSCC criteria and the pSOFA score in classifying in-hospital mortality. These analyses support the potential utility of the PSS for risk stratification in our international PICU setting.

Objectives: Nursing turnover is a significant vulnerability in healthcare systems. Although adult critical care nurses are among the highest group of nurses leaving the workforce, we do not have information about pediatric cardiac critical care (PCCC) nurse turnover. We have, therefore, explored PCCC nursing turnover in focus groups recruited from interprofessional members of the Pediatric Cardiac Intensive Care Society (PCICS).

Design: Qualitative descriptive inquiry using focus groups and interviews.

Setting: Interprofessional focus group discussions in 2022-2023.

Subjects: Thirty-four participants (representing < 4% of the PCICS membership) were involved in focus groups and interviews.

Interventions: The transcripts of focus groups/interviews were used to explore perspectives regarding PCCC nurse turnover, its potential impact, and the potential solutions to enhance retention. Content analysis coding was used to identify themes and subcategories to support data interpretation.

Measurements and main results: Data were organized into three main themes: Nursing Turnover, Nursing Retention, and Solutions. For the themes of nursing turnover and nursing retention, there were two subcategories, meaning and impact. All participants reported that increased levels of nursing turnover impacted ICU morale. Higher turnover was also believed to increase patient vulnerability at the bedside, requiring higher levels of surveillance and support from the interprofessional team. Potential solutions to enhance retention included competitive salary and benefits packages, professional development for the multigenerational workforce, and a commitment to a healthy work environment.

Conclusions: In 2022-2023, 34 PCICS members from the United States gave their perspectives and understanding of turnover in PCCC nurses. Nursing turnover and its impact on the team highlights the urgent need to collaboratively identify and implement solutions to enhance nurse retention in this area of highly specialized practice. The PCICS and other such organizations may have a role in addressing nursing shortages and continued turnover.