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Mechanical Thromboprophylaxis and Hospital-Acquired Venous Thromboembolism Among Critically Ill Adolescents: A U.S. Pediatric Health Information Systems Registry Study, 2016-2023. 重症青少年的机械性血栓预防和医院获得性静脉血栓栓塞症:2016-2023年美国儿科健康信息系统注册研究》。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-20 DOI: 10.1097/PCC.0000000000003601
Marisol Betensky, Nikhil Vallabhaneni, Neil A Goldenberg, Anthony A Sochet

Objectives: To estimate the rate of mechanical thromboprophylaxis (mTP) prescription among critically ill adolescents using a multicenter administrative database and determine whether mTP prescription is inversely associated with hospital-acquired venous thromboembolism.

Design: Multicenter, observational, retrospective study of the Pediatric Health Information Systems (PHIS) Registry cohort, January 2016 to December 2023.

Setting: Thirty PICUs located within quaternary pediatric referral centers in the United States.

Patients: Critically ill children 12-17 years old, excluding encounters with a principal diagnosis at admission of venous thromboembolism.

Interventions: mTP prescription within the first 24 hours of hospitalization.

Measurements and main results: A total of 107,804 children met the study criteria, of which 21,124 (19.6%) were prescribed mTP. Hospital center prescribing rates ranged from 1.4% to 65.4% and decreased by 1.6% per year from 28.2% in 2016 to 17.1% in 2023. As compared with those without mTP, those with mTP more frequently had a concurrent central venous catheter (17.2% vs. 9.4%, p < 0.001), underwent invasive mechanical ventilation (37.4% vs. 24.8%, p < 0.001), were admitted for a primary surgical indication (30.9% vs. 12.7%, p < 0.001), and experienced a longer median duration of hospitalization (7 [interquartile range (IQR): 4-15] vs. 4 [IQR: 2-9] d, p < 0.001). Hospital-acquired venous thromboembolism occurred in 2.7% of the study sample and was more common among those with, as compared with without, prescription of mTP (4% vs. 2.4%, p < 0.001). In multivariable logistic regression models for hospital-acquired venous thromboembolism adjusting for salient prothrombotic risk factors, we failed to identify an association between mTP and greater odds of hospital-acquired venous thromboembolism (HA-VTE) among low-, moderate-, and high-risk tiers. However, we cannot exclude the possibility of 17-50% greater odds of HA-VTE in this population.

Conclusions: In the multicenter PHIS cohort, 2016-2023, the prescribing patterns for mTP among critically ill adolescents showed a low rate of mTP prescription (19.6%) that varied widely across institutions, decreased annually over the study period by 1.6%/year, and was not independently associated with HA-VTE risk reduction.

目的利用多中心管理数据库估算重症青少年的机械性血栓预防(mTP)处方率,并确定mTP处方是否与医院获得性静脉血栓栓塞成反比:多中心、观察性、回顾性儿科健康信息系统(PHIS)注册队列研究,2016年1月至2023年12月:美国四级儿科转诊中心内的 30 个 PICU:干预措施:住院后 24 小时内开具 mTP 处方:共有 107,804 名儿童符合研究标准,其中 21,124 人(19.6%)获得了 mTP 处方。医院中心处方率从1.4%到65.4%不等,每年下降1.6%,从2016年的28.2%降至2023年的17.1%。与未使用 mTP 的患者相比,使用 mTP 的患者更常同时使用中心静脉导管(17.2% vs. 9.4%,p < 0.001)、进行有创机械通气(37.4% vs. 24.8%,p < 0.001),因主要手术指征入院(30.9% vs. 12.7%,P < 0.001),住院时间中位数更长(7 [四分位距(IQR):4-15] d vs. 4 [四分位距(IQR):2-9] d,P < 0.001)。在研究样本中,2.7%的患者发生了医院获得性静脉血栓栓塞,与未处方 mTP 的患者相比,处方 mTP 的患者发生静脉血栓栓塞的比例更高(4% 对 2.4%,P < 0.001)。在医院获得性静脉血栓栓塞症的多变量逻辑回归模型中,在调整了显著的血栓前危险因素后,我们未能在低、中、高风险层级中发现 mTP 与更高的医院获得性静脉血栓栓塞症(HA-VTE)发生几率之间存在关联。然而,我们不能排除在这一人群中发生 HA-VTE 的几率比正常人高出 17%-50% 的可能性:在2016-2023年多中心PHIS队列中,重症青少年的mTP处方模式显示,mTP处方率较低(19.6%),各机构间差异较大,在研究期间每年下降1.6%,且与HA-VTE风险降低无独立关联。
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引用次数: 0
Diagnostic Identification of Acute Brain Dysfunction in Pediatric Sepsis and Septic Shock in the Electronic Health Record: A Comparison of Four Definitions in a Reference Dataset. 电子病历中小儿败血症和败血症休克急性脑功能障碍的诊断鉴定:参考数据集中四种定义的比较。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-05-13 DOI: 10.1097/PCC.0000000000003529
Alicia M Alcamo, Andrew E Becker, Gregory J Barren, Katie Hayes, Jeffrey W Pennington, Martha A Q Curley, Robert C Tasker, Fran Balamuth, Scott L Weiss, Julie C Fitzgerald, Alexis A Topjian

Objectives: Acute brain dysfunction (ABD) in pediatric sepsis has a prevalence of 20%, but can be difficult to identify. Our previously validated ABD computational phenotype (CP ABD ) used variables obtained from the electronic health record indicative of clinician concern for acute neurologic or behavioral change. We tested whether the CP ABD has better diagnostic performance to identify confirmed ABD than other definitions using the Glasgow Coma Scale or delirium scores.

Design: Diagnostic testing in a curated cohort of pediatric sepsis/septic shock patients.

Setting: Quaternary freestanding children's hospital.

Subjects: The test dataset comprised 527 children with sepsis/septic shock managed between 2011 and 2021 with a prevalence (pretest probability) of confirmed ABD of 30% (159/527).

Measurements and main results: CP ABD was based on use of neuroimaging, electroencephalogram, and/or administration of new antipsychotic medication. We compared the performance of the CP ABD with three GCS/delirium-based definitions of ABD-Proulx et al, International Pediatric Sepsis Consensus Conference, and Pediatric Organ Dysfunction Information Update Mandate. The posttest probability of identifying ABD was highest in CP ABD (0.84) compared with other definitions. CP ABD also had the highest sensitivity (83%; 95% CI, 76-89%) and specificity (93%; 95% CI, 90-96%). The false discovery rate was lowest in CP ABD (1-in-6) as was the false omission rate (1-in-14). Finally, the prevalence threshold for the definitions varied, with the CP ABD being the definition closest to 20%.

Conclusions: In our curated dataset of pediatric sepsis/septic shock, CP ABD had favorable characteristics to identify confirmed ABD compared with GCS/delirium-based definitions. The CP ABD can be used to further study the impact of ABD in studies using large electronic health datasets.

目的:小儿败血症急性脑功能障碍(ABD)的发病率为 20%,但很难识别。我们之前验证的急性脑功能障碍计算表型(CPABD)使用了从电子健康记录中获取的变量,这些变量表明临床医生对急性神经或行为变化的关注。我们测试了 CPABD 在识别确诊 ABD 方面的诊断性能是否优于使用格拉斯哥昏迷量表或谵妄评分的其他定义:设计:对小儿败血症/败血症休克患者进行诊断测试:环境:四级独立儿童医院:测试数据集包括2011年至2021年间接受治疗的527名脓毒症/败血症休克患儿,确诊ABD的患病率(测试前概率)为30%(159/527):CPABD基于神经影像学、脑电图和/或新抗精神病药物的使用。我们比较了 CPABD 与三种基于 GCS/谵妄的 ABD 定义--Proulx 等人、国际儿科败血症共识会议和儿科器官功能障碍信息更新规定--的性能。与其他定义相比,CPABD 确定 ABD 的检验后概率最高(0.84)。CPABD 的灵敏度(83%;95% CI,76-89%)和特异性(93%;95% CI,90-96%)也最高。CPABD 的错误发现率最低(1/6),错误遗漏率也最低(1/14)。最后,各种定义的患病率阈值各不相同,其中 CPABD 是最接近 20% 的定义:结论:在我们整理的小儿败血症/败血症休克数据集中,与基于 GCS/谵妄的定义相比,CPABD 在识别确诊 ABD 方面具有良好的特性。CPABD 可用于在使用大型电子健康数据集的研究中进一步研究 ABD 的影响。
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引用次数: 0
Clinical Outcomes After Tracheostomy in Children With Single Ventricle Physiology: Collaborative Research From the Pediatric Cardiac Intensive Care Society Multicenter Cohort, 2010-2021. 单心室生理学儿童气管切开术后的临床结果:儿科心脏重症监护协会多中心队列合作研究,2010-2021 年。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-04-29 DOI: 10.1097/PCC.0000000000003523
Christopher W Mastropietro, Peter Sassalos, Christine M Riley, Kurt Piggott, Kiona Y Allen, Elizabeth Prentice, Raya Safa, Jason R Buckley, David K Werho, Martin Wakeham, Arthur Smerling, Andrew R Yates, Ilias Iliopoulos, Hitesh Sandhu, Saurabh Chiwane, Asaad Beshish, David M Kwiatkowski, Saul Flores, Sukumar Suguna Narashimhulu, Rohit Loomba, Christine A Capone, Francis Pike, John M Costello

Objectives: Multicenter studies reporting outcomes following tracheostomy in children with congenital heart disease are limited, particularly in patients with single ventricle physiology. We aimed to describe clinical characteristics and outcomes in a multicenter cohort of patients with single ventricle physiology who underwent tracheostomy before Fontan operation.

Design: Multicenter retrospective cohort study.

Setting: Twenty-one tertiary care pediatric institutions participating in the Collaborative Research from the Pediatric Cardiac Intensive Care Society.

Patients: We reviewed 99 children with single ventricle physiology who underwent tracheostomy before the Fontan operation at 21 institutions participating in Collaborative Research from the Pediatric Cardiac Intensive Care Society between January 2010 and December 2020, with follow-up through December 31, 2021.

Interventions: None.

Measurements and main results: Death occurred in 51 of 99 patients (52%). Cox proportional hazard analysis was performed to determine factors associated with death after tracheostomy. Results are presented as hazard ratio (HR) with 95% CIs. Nonrespiratory indication(s) for tracheostomy (HR, 2.21; 95% CI, 1.14-4.32) and number of weeks receiving mechanical ventilation before tracheostomy (HR, 1.06; 95% CI, 1.02-1.11) were independently associated with greater hazard of death. In contrast, diagnosis of tricuspid atresia or Ebstein's anomaly was associated with less hazard of death (HR, 0.16; 95% CI, 0.04-0.69). Favorable outcome, defined as survival to Fontan operation or decannulation while awaiting Fontan operation with viable cardiopulmonary physiology, occurred in 29 of 99 patients (29%). Median duration of mechanical ventilation before tracheostomy was shorter in patients who survived to favorable outcome (6.1 vs. 12.1 wk; p < 0.001), and only one of 16 patients with neurologic indications for tracheostomy and 0 of ten patients with cardiac indications for tracheostomy survived to favorable outcome.

Conclusions: For children with single ventricle physiology who undergo tracheostomy, mortality risk is high and should be carefully considered when discussing tracheostomy as an option for these children. Favorable outcomes are possible, although thoughtful attention to patient selection and tracheostomy timing are likely necessary to achieve this goal.

目的:报告先天性心脏病儿童气管切开术后疗效的多中心研究非常有限,尤其是单心室生理学患者。我们的目的是描述在丰坦手术前接受气管切开术的单心室生理学多中心队列患者的临床特征和预后:多中心回顾性队列研究:21家参与儿科心脏重症监护协会合作研究的三级儿科医疗机构:我们回顾了2010年1月至2020年12月期间,在21家参与儿科心脏重症监护协会合作研究的机构中,在Fontan手术前接受气管切开术的99名单心室生理学患儿,随访至2021年12月31日:干预措施:无:99例患者中有51例(52%)死亡。为确定气管切开术后死亡的相关因素,进行了 Cox 比例危险分析。结果以危险比(HR)和 95% CIs 表示。气管切开术的非呼吸指征(HR,2.21;95% CI,1.14-4.32)和气管切开术前接受机械通气的周数(HR,1.06;95% CI,1.02-1.11)与更高的死亡风险独立相关。相比之下,诊断出三尖瓣闭锁或埃布斯坦畸形与较低的死亡风险相关(HR,0.16;95% CI,0.04-0.69)。99名患者中有29名患者(29%)的治疗结果良好,即患者在等待丰坦手术期间存活或在心肺生理功能尚存活的情况下停止通气。气管切开术前机械通气的中位持续时间在顺利存活的患者中更短(6.1对12.1周;P<0.001),有神经系统适应症的16例气管切开术患者中只有1例顺利存活,有心脏适应症的10例气管切开术患者中只有0例顺利存活:单心室生理学儿童接受气管切开术的死亡风险很高,在讨论气管切开术作为这些儿童的一种选择时应仔细考虑。尽管要实现这一目标,必须对患者的选择和气管切开术的时机给予周到的关注,但良好的结果是可能的。
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引用次数: 0
Anthropometric-Targeted Cardiopulmonary Resuscitation: As Good as It Can Get? 以人体测量为目标的心肺复苏术:效果如何?
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-08-05 DOI: 10.1097/PCC.0000000000003524
Lindsay N Shepard, Akira Nishisaki
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引用次数: 0
Decrypting Sepsis-Associated Brain Dysfunction: A Computational Phenotype That Can Hack It. 解密败血症相关脑功能障碍:能破解它的计算表型。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-08-05 DOI: 10.1097/PCC.0000000000003549
Sydney Rooney, Christopher M Horvat
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引用次数: 0
You Say Potato, I Say Potatoe: Seizure Prophylaxis After Pediatric Traumatic Brain Injury. 你说土豆,我说土豆:小儿脑外伤后的癫痫预防。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-08-05 DOI: 10.1097/PCC.0000000000003543
Ayush Lacoul, Matthew P Kirschen
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引用次数: 0
Levetiracetam or Phenytoin as Prophylaxis for Status Epilepticus: Secondary Analysis of the "Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial" (ADAPT) Dataset, 2014-2017. 左乙拉西坦或苯妥英作为癫痫状态的预防药物:2014-2017年 "急性小儿创伤性脑损伤试验的方法和决定 "数据集二次分析。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-05-08 DOI: 10.1097/PCC.0000000000003526
Nasim Ahmed, Larissa Russo, Yen-Hong Kuo

Objectives: To compare levetiracetam and phenytoin as prophylaxis for the short-term development of status epilepticus (SE) during care of pediatric patients with acute severe traumatic brain injury (TBI).

Design: Nonprespecified secondary analysis using propensity score matching.

Setting: We used the Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT NCT04077411) dataset (2014-2017).

Subjects: Patients less than 18 years old with Glasgow Coma Scale Score less than or equal to 8 who received levetiracetam or phenytoin as a prophylactic anticonvulsant therapy.

Intervention: None.

Measurement and main results: Of the 516 total patients who qualified for the case-control study, 372 (72.1%) patients received levetiracetam, and 144 (27.9%) received phenytoin. After propensity score matching, the pair-matched analysis with 133 in each group failed to identify an association between levetiracetam versus phenytoin use and occurrent of SE (3.8% vs. 0.8%, p = 0.22), or mortality (i.e., in-hospital, 30-d and 60-d). However, on closer inspection of the statistical testing, we cannot exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with the following: up to a mean difference of 7.3% greater prevalence of SE; up to a mean difference of 13.9%, 12.1%, and 13.9% greater mortality during the hospital stay, and 30-, and 60-days after hospital arrival, respectively. Last, analysis of 6 months Glasgow Outcome Scale Extended score in those without premorbid comorbidities, there was an association between favorable outcomes and use of phenytoin rather than levetiracetam prophylaxis.

Conclusions: In ADAPT, the decision to use prophylactic levetiracetam versus phenytoin failed to show an association with occurrence of subsequent SE, or mortality. However, we are unable to exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with greater prevalence of SE and mortality. We are unable to make any recommendation about one prophylactic anticonvulsant medication over the other, but recommend that further larger, contemporary studies in severe pediatric TBI are carried out.

目的:比较左乙拉西坦和苯妥英作为急性严重创伤性脑损伤(TBI)儿科患者短期癫痫状态(SE)的预防药物:比较左乙拉西坦和苯妥英作为急性严重创伤性脑损伤(TBI)儿科患者护理期间预防癫痫状态(SE)短期发展的药物:设计:使用倾向评分匹配进行非指定二次分析:我们使用了急性儿科 TBI 试验(ADAPT NCT04077411)数据集(2014-2017 年):小于18岁、格拉斯哥昏迷量表评分小于或等于8分、接受左乙拉西坦或苯妥英作为预防性抗惊厥治疗的患者:测量和主要结果在符合病例对照研究条件的516名患者中,372人(72.1%)接受了左乙拉西坦治疗,144人(27.9%)接受了苯妥英治疗。经过倾向评分匹配后,每组 133 人的配对匹配分析未能发现左乙拉西坦与苯妥英的使用与 SE 发生率(3.8% 对 0.8%,P = 0.22)或死亡率(即院内、30 天和 60 天)之间存在关联。然而,仔细观察统计检验结果,我们不能排除选择左乙拉西坦而非苯妥英进行预防治疗与以下情况相关的可能性:SE发生率的平均差异高达7.3%;住院期间、入院后30天和60天的死亡率分别高达13.9%、12.1%和13.9%。最后,对无合并症的患者6个月格拉斯哥结果量表扩展评分进行分析,结果良好与使用苯妥英而非左乙拉西坦预防治疗有关:在ADAPT中,使用左乙拉西坦预防性治疗与使用苯妥英预防性治疗的决定并未显示出与后续SE的发生或死亡率有关。然而,我们无法排除这样一种可能性,即选择左乙拉西坦而非苯妥英作为预防药物与更高的SE发生率和死亡率有关。我们无法就一种预防性抗惊厥药物优于另一种药物提出任何建议,但建议对严重小儿创伤性脑损伤进一步开展更大规模的当代研究。
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引用次数: 0
A Conspicuously Absent Commandment: Thou Shall Not Tracheotomize. 一条明显缺失的戒律:不得进行气管切开术。
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-08-05 DOI: 10.1097/PCC.0000000000003537
Sinead L Murphy Salem, Robert J Graham
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引用次数: 0
Is Rapid Bedside Echocardiography in Septic Shock Possible? 脓毒性休克时可以进行快速床旁超声心动图检查吗?
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-08-05 DOI: 10.1097/PCC.0000000000003538
Suchitra Ranjit
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引用次数: 0
Randomized Trials to Reduce Clinical Uncertainty: Gold Standard or Fool's Gold? 减少临床不确定性的随机试验:黄金标准还是傻瓜黄金?
IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-08-01 Epub Date: 2024-08-05 DOI: 10.1097/PCC.0000000000003533
Mark J Peters, Padmanabhan Ramnarayan
{"title":"Randomized Trials to Reduce Clinical Uncertainty: Gold Standard or Fool's Gold?","authors":"Mark J Peters, Padmanabhan Ramnarayan","doi":"10.1097/PCC.0000000000003533","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003533","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":"25 8","pages":"775-777"},"PeriodicalIF":4.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141889883","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}
引用次数: 0
期刊
Pediatric Critical Care Medicine
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