Journal of Pediatric Intensive Care最新文献

Background  Multisystem inflammatory syndrome in children (MIS-C) is characterized by persistent fever, abdominal pain, vomiting, diarrhea, rash, conjunctivitis, headaches, and mucocutaneous manifestations and it can cause circulatory dysfunction, resulting in hypotension, shock, and end-organ injury in the heart and other organs and possibly death. In this study, we aimed to analyze the clinical spectrum, treatment options and outcomes of children with MIS-C who were admitted to our pediatric intensive care (PICU). Materials and Methods  Clinical and laboratory findings and treatment of the patients admitted to the PICU with MIS-C between April 2020 and January 2021 were recorded, and their outcomes were evaluated. Results  Nineteen patients with a median age of 12.5 years (interquartile range (IQR): 5.8-14.0 years) were admitted. Eleven (57.8%) were males. The most frequent clinical and laboratory features were fever (100%), abdominal pain (94.7%), rash (63.1%), headache (68.4%), diarrhea (47.3%), seizure (10.5%), cardiac dysfunction (52.6%), acute kidney injury (26.3%), lymphopenia (84.2%), and thrombocytopenia (36.8%). However, 8 patients needed mechanical respiratory support, 11 patients needed inotropes, 2 patients needed plasma exchange, and 1 patient needed continuous renal replacement therapy. All patients received corticosteroids, 17 patients (89.2%) received intravenous immunoglobulin, 2 patients received anakinra, 10 patients received acetylsalicylic acid, and 6 patients received enoxaparin. Median PICU length of stay was 3 days (IQR: 2-5) and only one patient died. Conclusion  In conclusion, MIS-C may present with a variety of clinical manifestations, and it can lead to life-threatening critical illness. Most children need intensive care and the response to immunomodulation is usually favorable.

Objective  There is recent interest in the association between hyperchloremic metabolic acidosis and adverse outcomes. In vitro, hyperchloremia causes renal vasoconstriction and fall in glomerular filtration rate (GFR). The objective of this retrospective, observational study is to examine associations between chloride level at admission to pediatric intensive care (PICU) and worst GFR and requirement for renal replacement therapy. Materials and Methods  All admissions to PICU between 2009 and 2019 who received invasive mechanical ventilation and had blood gas analysis performed were included. Data analyzed included patient characteristics (age, gender, diagnosis, pediatric index of mortality [PIM]-2 score); results of initial blood gas; and maximum serum creatinine (then used to calculate minimum GFR). Primary outcome measure was worst GFR during PICU stay. Secondary outcome measures were requirement for renal replacement therapy and PICU mortality. Multivariable regression analysis was used to assess if admission chloride level was independently predictive of minimum GFR during PICU stay and to examine associations between hyperchloremia (>110 mEq/L) at admission and requirement for renal replacement therapy after adjustment for confounders. Results  Data were available for 2,217 patients. Median age was 16.4 months and 39% of patients were hyperchloremic at admission to PICU. Admission chloride level was independently predictive of worst GFR during PICU stay after adjustment for known confounders. Patients with hyperchloremia were not more likely to require renal replacement therapy or die than patients with normochloremia. Conclusion  Prospective studies are necessary to determine if high chloride, specifically chloride containing resuscitation fluids, have a causal relationship with poor outcomes.

The coronavirus disease 2019 (COVID-19) pandemic and related community mitigation measures had a significant psychosocial impact. We suspected that more patients were admitted to our pediatric intensive care unit (PICU) for toxic ingestions since the start of the pandemic. We therefore investigated if PICU admissions related to toxic ingestions were higher in 2020 as a result of COVID-19 compared with previous years. We completed a cross-sectional study at a tertiary children's hospital comparing admissions to our PICU between April 2020 and October 2020, during which COVID-19 and community mitigation measures were in place, to those during the same 7-month period in the previous 3 years. Total PICU admissions, admissions for all toxic ingestions (intentional ingestions and accidental ingestions), and demographic and clinical characteristics of patients were compared. Total PICU admissions in 2020 during COVID-19 pandemic months were lower compared with the same months in the preceding 3 years (-16%, p < 0.001), however, admissions for toxic ingestions were higher during COVID-19 (+64%, p < 0.001). When separated by type, intentional (+55%, p  = 0.012) and accidental ingestions (+94%, p  = 0.021) were higher during COVID-19. COVID-19 with community mitigation measures has led to an increase in PICU admissions for intentional and accidental ingestions, indicating an increase in severity of toxic ingestions in children associated with the pandemic. Mental health of adolescents, and safety of infants and toddlers in their home environment, should be targeted with specific interventions in the ongoing COVID-19 pandemic.

Very little data is available to understand the drivers of burnout amongst health care workers in the pediatric intensive care unit. This is a survey-based, cross-sectional, point-prevalence analysis within a single children's health system with two free-standing hospitals (one academic and one private) to characterize the relationship of demographics, organizational support, organizational culture, relationship quality, conflict and work schedules with self-reported burnout. Burnout was identified in 152 (39.7%) of the 383 (38.7%) respondents. No significant relationship was identified between burnout and demographic factors or work schedule. A more constructive culture (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77-0.90; p  < 0.001), more organizational support (OR, 0.94; 95% CI, 0.92-0.96; p <0 0.001), and better staff relationships (OR, 0.54, 95% CI, 0.43-0.69; p  < 0.001) reduced odds of burnout. More conflict increased odds (OR, 1.25; 95% CI, 1.12-1.39; p  < 0.001). Less organizational support ( Z _β  = 0.425) was the most important factor associated with burnout overall. A work environment where staff experience defensive cultures, poor relationships, more frequent conflict, and feel unsupported by the organization is associated with significantly higher odds of burnout in pediatric critical care. The effect of targeted interventions to promote constructive cultures, collegiality, and organizational support on burnout in pediatric intensive care should be studied.

This study was aimed to evaluate the success rate of high-flow nasal cannula (HFNC) oxygen therapy and factors causing therapy failure. This prospective observational study included 131 children who received HFNC oxygen and followed-up in the pediatric emergency department, pediatric clinics, and pediatric intensive care unit between March 2018 and December 2019. The median age was 23.0 months (interquartile range [IQR]: 9.0-92.0) and 65 patients were male (49.6%). The most common reason for requiring HFNC oxygen therapy was pneumonia ( n  = 75, 57.3%). A complex chronic condition was present in 112 (85.5%) patients. Therapy success was achieved in 116 patients (88.5%). The reason for requiring treatment and the patients' complex chronic condition did not affect the success of the therapy ( p  = 0.294 and 0.091, respectively). In the first 24 hours of treatment, a significant improvement in pulse rate, respiratory rate, pH, and lactate level were observed in successful HFNC oxygen patients ( p  < 0.05). In addition, these patients showed a significant improvement in SpO ₂ and SpO ₂ /FiO ₂ ratio, and a significant decrease in FiO ₂ and flow rate ( p  < 0.05). HFNC oxygen success rate was 95.6% in patients with SpO ₂ /FiO ₂ ≥ 150 at the 24th hour; it was 58.0% in those with SpO ₂ /FiO ₂  < 150 ( p  < 0.001). Caution should be exercised in terms of HFNC oxygen failure in patients with no significant improvement in vital signs and with SpO ₂ /FiO ₂  < 150 during treatment.

Pediatric palliative care (PPC) provides an extra layer of support for families caring for a child with complex heart disease as these patients often experience lifelong morbidities with frequent hospitalizations and risk of early mortality. PPC referral at the time of heart disease diagnosis provides early involvement in the disease trajectory, allowing PPC teams to longitudinally support patients and families with symptom management, complex medical decision-making, and advanced care planning. We analyzed 113 hospitalized pediatric patients with a primary diagnosis of heart disease and a PPC consult to identify timing of first PPC consultation in relation to diagnosis, complex chronic conditions (CCC), and death. The median age of heart disease diagnosis was 0 days with a median of two CCCs while PPC consultation did not occur until a median age of 77 days with a median of four CCCs. Median time between PPC consult and death was 33 days (interquartile range: 7-128). Death often occurred in the intensive care unit ( n  = 36, 67%), and the most common mode was withdrawal of life-sustaining therapies ( n  = 31, 57%). PPC referral often occurred in the context of medical complexity and prolonged hospitalization. Referral close to the time of heart disease diagnosis would allow patients and families to fully utilize PPC benefits that exist outside of end-of-life care and may influence the mode and location of death. PPC consultation should be considered at the time of heart disease diagnosis, especially in neonates and infants with CCCs.

Accuracy of delirium diagnosis in mechanically ventilated children is often limited by their varying developmental abilities. The purpose of this study was to examine the performance of the Cornell Assessment of Pediatric Delirium (CAPD) scale in these patients. This is a single-center, prospective, observational study of patients requiring sedation and mechanical ventilation for 2 days or more. CAPD scale was implemented in our unit for delirium screening. Each CAPD assessment was accompanied by a physician assessment using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Sensitivity analysis was performed to determine the best cut-off score in our target population. We also evaluated ways to improve the accuracy of this scale in patients with and without developmental delay. A total of 837 paired assessments were performed. Prevalence of delirium was 19%. Overall, CAPD score ≥ 9 had sensitivity of 81.8% and specificity of 44.8%. Among typically developed patients, the sensitivity and specificity were 76.7 and 65.4%, respectively, whereas specificity was only 16.5% for developmentally delayed patients. The best cut-off value for CAPD was 9 for typically developed children and 17 for those with developmental delay (sensitivity 74.4%, specificity 63.2%). Some CAPD questions do not apply to patients with sensory and neurocognitive deficits; upon excluding those questions, the best cut-off values were 5 for typically developed and 6 for developmentally delayed children. In mechanically ventilated patients with developmental delay, CAPD ≥ 9 led to a high false-positive rate. This emphasizes the need for either a different cut-off score or development of a delirium scale specific to this patient population.