Stephen M. Gorga, Alexander L. Sliwicki, J. Sturza, E. Carlton, R. Barbaro, Rajit K. Basu
Abstract Intravenous (IV) fluids are commonly administered to critically ill children, but clinicians lack effective guidance for the correct dose and duration of therapy resulting in variation of prescribing habits which harm children. It is unknown if clinicians recognize the amount of IV fluid that patients receive. We aimed to determine clinician's accuracy in the identification of the volume of IV fluids patients will receive over the next 24 hours. Prospective cohort study enrolled all patients admitted to the pediatric intensive care unit (PICU) from May to August 2021 at the University of Michigan's C.S. Mott Children's Hospital PICU. For each patient, clinicians estimated the volume of IV fluid that patients will receive in the next 24 hours. The primary outcome was accuracy of the estimation defined as predicted volume of IV fluids versus actual volume administered within 10 mL/kg or 500 mL depending on patient's weight. We tested for differences in accuracy by clinician type using chi-square tests. There were 259 patients for whom 2,295 surveys were completed by 177 clinicians. Clinicians' estimates were accurate 48.8% of the time with a median difference of 10 (1–26) mL/kg. We found that accuracy varied between clinician type: bedside nurses were most accurate at 64.3%, and attendings were least accurate at 30.5%. PICU clinicians have poor recognition of the amount of IV fluids their patients will receive in the subsequent 24-hour period. Estimate accuracy varied by clinician's role and improved over time, which may suggest opportunities for improvement.
{"title":"Variability in Clinician Awareness of Intravenous Fluid Administration in Critical Illness: A Prospective Cohort Study","authors":"Stephen M. Gorga, Alexander L. Sliwicki, J. Sturza, E. Carlton, R. Barbaro, Rajit K. Basu","doi":"10.1055/s-0042-1758476","DOIUrl":"https://doi.org/10.1055/s-0042-1758476","url":null,"abstract":"Abstract Intravenous (IV) fluids are commonly administered to critically ill children, but clinicians lack effective guidance for the correct dose and duration of therapy resulting in variation of prescribing habits which harm children. It is unknown if clinicians recognize the amount of IV fluid that patients receive. We aimed to determine clinician's accuracy in the identification of the volume of IV fluids patients will receive over the next 24 hours. Prospective cohort study enrolled all patients admitted to the pediatric intensive care unit (PICU) from May to August 2021 at the University of Michigan's C.S. Mott Children's Hospital PICU. For each patient, clinicians estimated the volume of IV fluid that patients will receive in the next 24 hours. The primary outcome was accuracy of the estimation defined as predicted volume of IV fluids versus actual volume administered within 10 mL/kg or 500 mL depending on patient's weight. We tested for differences in accuracy by clinician type using chi-square tests. There were 259 patients for whom 2,295 surveys were completed by 177 clinicians. Clinicians' estimates were accurate 48.8% of the time with a median difference of 10 (1–26) mL/kg. We found that accuracy varied between clinician type: bedside nurses were most accurate at 64.3%, and attendings were least accurate at 30.5%. PICU clinicians have poor recognition of the amount of IV fluids their patients will receive in the subsequent 24-hour period. Estimate accuracy varied by clinician's role and improved over time, which may suggest opportunities for improvement.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"20 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82385469","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jasmin Moradi, Mirriam Mikhail, Laurie Lee, C. Traube, A. Sarti, K. Choong
Abstract The aim of this study was to understand the lived experiences of delirium in critically ill children. We conducted phenomenological qualitative interviews with critically ill pediatric survivors aged 0 to 18 years who had experienced delirium, along with their family caregivers and health care providers, from pediatric intensive care units in two tertiary care children's hospitals in Canada. Cases were identified if they had a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Thirteen interviews were conducted, representing 10 index patients with delirium (age range: 7 weeks to 17 years). Participants shared experiences that were divided into themes of delirium symptoms, the impact of delirium, and their experience with the care of delirium. Within each theme, subthemes were identified. Symptoms of delirium included hallucinations, fluctuating symptoms, and lack of eye contact. Children were often described as “not himself/herself.” Delirium had long-lasting impact on patients; memories remained prominent even after the hospital stay. Family members and health care providers often felt helpless and ill-prepared to manage delirium. The delirium experience had significant impact on loved ones, causing persistent and vicarious suffering after the critical illness course. Family members and health care providers prioritized nonpharmacological strategies, family presence, and education as key strategies for delirium management. The lived experience of delirium in both infants and older children is physically, psychologically, and emotionally distressing. Given the traumatic long-term consequences, there is an urgent need to target delirium education, management, and prevention to improve long-term outcomes in PICU survivors and their families. Trial Registration number: NCT04168515.
{"title":"Lived Experiences of Delirium in Critically Ill Children: A Qualitative Study","authors":"Jasmin Moradi, Mirriam Mikhail, Laurie Lee, C. Traube, A. Sarti, K. Choong","doi":"10.1055/s-0042-1758695","DOIUrl":"https://doi.org/10.1055/s-0042-1758695","url":null,"abstract":"Abstract The aim of this study was to understand the lived experiences of delirium in critically ill children. We conducted phenomenological qualitative interviews with critically ill pediatric survivors aged 0 to 18 years who had experienced delirium, along with their family caregivers and health care providers, from pediatric intensive care units in two tertiary care children's hospitals in Canada. Cases were identified if they had a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Thirteen interviews were conducted, representing 10 index patients with delirium (age range: 7 weeks to 17 years). Participants shared experiences that were divided into themes of delirium symptoms, the impact of delirium, and their experience with the care of delirium. Within each theme, subthemes were identified. Symptoms of delirium included hallucinations, fluctuating symptoms, and lack of eye contact. Children were often described as “not himself/herself.” Delirium had long-lasting impact on patients; memories remained prominent even after the hospital stay. Family members and health care providers often felt helpless and ill-prepared to manage delirium. The delirium experience had significant impact on loved ones, causing persistent and vicarious suffering after the critical illness course. Family members and health care providers prioritized nonpharmacological strategies, family presence, and education as key strategies for delirium management. The lived experience of delirium in both infants and older children is physically, psychologically, and emotionally distressing. Given the traumatic long-term consequences, there is an urgent need to target delirium education, management, and prevention to improve long-term outcomes in PICU survivors and their families. Trial Registration number: NCT04168515.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"12 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82134467","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Melissa Nater, J. Wong, Nobuyuki Ikeda, Brian Heenan, Rohit S. Loomba, Jamie S. Penk
Abstract Acute kidney injury (AKI) after pediatric cardiac surgery is manifested by injury along multiple pathways. One of these is oxidative injury related to hemolysis and subsequent deposition of hemoglobin in the kidney. Acetaminophen inhibits hemoprotein-catalyzed lipid peroxidation associated with hemolysis and in turn, may attenuate renal injury. We performed a retrospective chart review of patients undergoing pediatric cardiac surgery. A randomized controlled trial previously performed dictated a regimented, high dosage, acetaminophen. A historical cohort who received ad hoc acetaminophen prior to that study and that met the same inclusion/exclusion criteria were also analyzed, as patients from that era were likely to have less acetaminophen administered. The patients were divided into those who developed AKI and those who did not and those groups were compared by total acetaminophen dose. Important inclusion criteria included age 3 months to 4 years who underwent cardiac surgery via midline sternotomy and were extubated within 3 hours of admission. Patients with preexisting or chronic kidney disease were excluded. A total of 181 patients were included. Of these, 69 (38%) developed AKI. There were no significant pre- or intraoperative risk differences in characteristics between those who developed AKI and those who did not. Acetaminophen dose did significantly differ between those who developed AKI and those who did not with lower acetaminophen dose in the AKI group (30 vs. 50 mg/kg, p -value = 0.01). A multivariate analysis was performed which found that higher acetaminophen dosage and lower immediate postoperative hemoglobin were independently associated with a lower risk of AKI. AKI occurs in ∼38% after pediatric cardiac surgery. Most often this is stage 1 AKI and resolves after a day. After adjusting for other covariables, higher acetaminophen dose may be associated with lower risk of AKI. This does not prove that acetaminophen given prospectively will reduce AKI. Further studies are needed.
儿童心脏手术后急性肾损伤(AKI)表现为多途径损伤。其中之一是与溶血和随后的肾脏血红蛋白沉积有关的氧化损伤。对乙酰氨基酚抑制与溶血相关的血红蛋白催化的脂质过氧化，进而可能减轻肾损伤。我们对接受小儿心脏手术的患者进行了回顾性的图表回顾。先前进行的一项随机对照试验规定了一种高剂量的对乙酰氨基酚。在该研究之前接受临时对乙酰氨基酚治疗并符合相同纳入/排除标准的历史队列也被分析，因为那个时代的患者可能服用的对乙酰氨基酚较少。将患者分为发生AKI的患者和未发生AKI的患者，通过对乙酰氨基酚的总剂量对两组进行比较。重要的入选标准包括年龄3个月至4岁，经胸骨中线切开术行心脏手术并在入院后3小时内拔管的患者。既往存在或慢性肾脏疾病的患者被排除在外。共纳入181例患者。其中69例(38%)发展为AKI。发生AKI的患者和未发生AKI的患者在术前或术中没有明显的风险差异。在AKI组中，对乙酰氨基酚剂量较低(30 vs 50 mg/kg, p值= 0.01)，发生AKI组与未发生AKI组之间对乙酰氨基酚剂量有显著差异。一项多因素分析发现，较高的对乙酰氨基酚剂量和较低的术后立即血红蛋白与较低的AKI风险独立相关。小儿心脏手术后AKI发生率约为38%。大多数情况下，这是一期AKI，并在一天后消退。在调整了其他协变量后，对乙酰氨基酚剂量越高，AKI风险越低。这并不能证明预期给予对乙酰氨基酚会减少AKI。需要进一步的研究。
{"title":"Higher Dosage of Acetaminophen Associated with Lower Risk of Acute Kidney Injury after Pediatric Cardiac Surgery","authors":"Melissa Nater, J. Wong, Nobuyuki Ikeda, Brian Heenan, Rohit S. Loomba, Jamie S. Penk","doi":"10.1055/s-0043-57234","DOIUrl":"https://doi.org/10.1055/s-0043-57234","url":null,"abstract":"Abstract Acute kidney injury (AKI) after pediatric cardiac surgery is manifested by injury along multiple pathways. One of these is oxidative injury related to hemolysis and subsequent deposition of hemoglobin in the kidney. Acetaminophen inhibits hemoprotein-catalyzed lipid peroxidation associated with hemolysis and in turn, may attenuate renal injury. We performed a retrospective chart review of patients undergoing pediatric cardiac surgery. A randomized controlled trial previously performed dictated a regimented, high dosage, acetaminophen. A historical cohort who received ad hoc acetaminophen prior to that study and that met the same inclusion/exclusion criteria were also analyzed, as patients from that era were likely to have less acetaminophen administered. The patients were divided into those who developed AKI and those who did not and those groups were compared by total acetaminophen dose. Important inclusion criteria included age 3 months to 4 years who underwent cardiac surgery via midline sternotomy and were extubated within 3 hours of admission. Patients with preexisting or chronic kidney disease were excluded. A total of 181 patients were included. Of these, 69 (38%) developed AKI. There were no significant pre- or intraoperative risk differences in characteristics between those who developed AKI and those who did not. Acetaminophen dose did significantly differ between those who developed AKI and those who did not with lower acetaminophen dose in the AKI group (30 vs. 50 mg/kg, p -value = 0.01). A multivariate analysis was performed which found that higher acetaminophen dosage and lower immediate postoperative hemoglobin were independently associated with a lower risk of AKI. AKI occurs in ∼38% after pediatric cardiac surgery. Most often this is stage 1 AKI and resolves after a day. After adjusting for other covariables, higher acetaminophen dose may be associated with lower risk of AKI. This does not prove that acetaminophen given prospectively will reduce AKI. Further studies are needed.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"53 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86721194","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Kuok, Mei Lam Natalie Hsu, Stephanie Hui Fung Lai, K. Wong, W. Chan
Abstract Objectives: This study aimed to evaluate the prevalence of acute kidney injury (AKI) and hemolytic uremic syndrome (HUS) in severe pediatric pneumonia due to Streptococcus pneumoniae and to identify factors associated with AKI and HUS in these patients. Methods: We retrospectively analyzed pediatric patients who were admitted to our pediatric intensive care unit due to severe pneumococcal pneumonia between 2013 and 2019. Results: Forty-two patients with a median age of 4.3 years were included. Among these patients, 14 (33.3%) developed AKI, including seven (16.7%) stage 1, two (4.8%) stage 2, and five (11.9%) stage 3 AKI. Features of HUS were present in all of the patients with stage 3 AKI, and four required renal replacement therapy (RRT), with a median duration of 10.5 days (range 3 to 16 days). All patients with HUS required mechanical ventilation and inotropic supports. Patients with lower leukocyte and platelet counts, serum sodium and bicarbonate levels, positive urine dipstick (heme or protein ≥ 2 + ), and presence of bacteremia were associated with stage 2 and 3 AKI. Conclusions: Pediatricians should be aware of the relatively high prevalence of kidney involvement in severe pneumococcal pneumonia, with one-third having AKI and 11.9% developing HUS. Majority (80%) of HUS patients required RRT. Positive urine dipstick, serum sodium, and bicarbonate at presentation, which can be measured in point-of-care tests, may potentially be useful as quick tests to stratify the risks of moderate-to-severe AKI.
{"title":"Acute Kidney Injury and Hemolytic Uremic Syndrome in Severe Pneumococcal Pneumonia—A Retrospective Analysis in Pediatric Intensive Care Unit","authors":"C. Kuok, Mei Lam Natalie Hsu, Stephanie Hui Fung Lai, K. Wong, W. Chan","doi":"10.1055/s-0042-1759528","DOIUrl":"https://doi.org/10.1055/s-0042-1759528","url":null,"abstract":"Abstract Objectives: This study aimed to evaluate the prevalence of acute kidney injury (AKI) and hemolytic uremic syndrome (HUS) in severe pediatric pneumonia due to Streptococcus pneumoniae and to identify factors associated with AKI and HUS in these patients. Methods: We retrospectively analyzed pediatric patients who were admitted to our pediatric intensive care unit due to severe pneumococcal pneumonia between 2013 and 2019. Results: Forty-two patients with a median age of 4.3 years were included. Among these patients, 14 (33.3%) developed AKI, including seven (16.7%) stage 1, two (4.8%) stage 2, and five (11.9%) stage 3 AKI. Features of HUS were present in all of the patients with stage 3 AKI, and four required renal replacement therapy (RRT), with a median duration of 10.5 days (range 3 to 16 days). All patients with HUS required mechanical ventilation and inotropic supports. Patients with lower leukocyte and platelet counts, serum sodium and bicarbonate levels, positive urine dipstick (heme or protein ≥ 2 + ), and presence of bacteremia were associated with stage 2 and 3 AKI. Conclusions: Pediatricians should be aware of the relatively high prevalence of kidney involvement in severe pneumococcal pneumonia, with one-third having AKI and 11.9% developing HUS. Majority (80%) of HUS patients required RRT. Positive urine dipstick, serum sodium, and bicarbonate at presentation, which can be measured in point-of-care tests, may potentially be useful as quick tests to stratify the risks of moderate-to-severe AKI.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"37 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75564626","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Data regarding a terminal withdrawal of mechanical ventilation (TWMV) in pediatric patients, in particular the time to death, would be helpful to family and hospital staff. This retrospective case series will review the TWMV in pediatric intensive care unit (PICU) patients at our hospital between 2015 and 2020. There were 222 PICU deaths and 53 of these patients died following a TWMV. The time to death was <1 hour in 37 patients, from 1 to 24 hours in 12 patients, and >24 hours in 4 patients. Neither age nor the duration of mechanical ventilation prior to TWMV was associated with time to death. TWMV was complicated by concurrent withdrawal of cardiac support devices in 9 patients and by a recent cardiac arrest in 3 patients (1 of whom also had a cardiac support device withdrawal), and the time to death for these 11 patients was less than 1 hour ( p = 0.01 vs. all others). The time to death for those without concurrent withdrawal of cardiac support devices or recent cardiac arrest was shorter in those with a higher fraction of inspired oxygen but was not associated with positive end expiratory pressure. Time to death following a TWMV was less than a day in more than 90% of our patients and was not associated with patient age or the duration of mechanical ventilation. However, in patients without a recent cardiac arrest or concurrent withdrawal of cardiac support devices, nearly 1 in 10 survived a TWMV for more than a day, while those with a recent cardiac arrest or concurrent withdrawal of cardiac support devices survived for less than an hour.
{"title":"Terminal Withdrawal of Mechanical Ventilation in a PICU","authors":"J. Baird, N. Piracha, Max E. Lindeman","doi":"10.1055/s-0043-1768031","DOIUrl":"https://doi.org/10.1055/s-0043-1768031","url":null,"abstract":"Abstract Data regarding a terminal withdrawal of mechanical ventilation (TWMV) in pediatric patients, in particular the time to death, would be helpful to family and hospital staff. This retrospective case series will review the TWMV in pediatric intensive care unit (PICU) patients at our hospital between 2015 and 2020. There were 222 PICU deaths and 53 of these patients died following a TWMV. The time to death was <1 hour in 37 patients, from 1 to 24 hours in 12 patients, and >24 hours in 4 patients. Neither age nor the duration of mechanical ventilation prior to TWMV was associated with time to death. TWMV was complicated by concurrent withdrawal of cardiac support devices in 9 patients and by a recent cardiac arrest in 3 patients (1 of whom also had a cardiac support device withdrawal), and the time to death for these 11 patients was less than 1 hour ( p = 0.01 vs. all others). The time to death for those without concurrent withdrawal of cardiac support devices or recent cardiac arrest was shorter in those with a higher fraction of inspired oxygen but was not associated with positive end expiratory pressure. Time to death following a TWMV was less than a day in more than 90% of our patients and was not associated with patient age or the duration of mechanical ventilation. However, in patients without a recent cardiac arrest or concurrent withdrawal of cardiac support devices, nearly 1 in 10 survived a TWMV for more than a day, while those with a recent cardiac arrest or concurrent withdrawal of cardiac support devices survived for less than an hour.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"39 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88676217","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Daigle, Elizabeth K Laverriere, B. Bruins, J. Lockman, J. Fiadjoe, Nancy McGowan, N. Napolitano, J. Shults, V. Nadkarni, A. Nishisaki
Abstract Difficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was sent to PICU physicians supervising TIs from November 2019 through December 2020 to identify the presence of difficult BMV, attempted interventions used, and perceptions about intervention success. The dataset was linked and merged with the local TI quality database to assess safety outcomes. Among 305 TIs with response (87% response rate), 267 (88%) clinicians performed BMV during TI. Difficult BMV was reported in 28 of 267 patients (10%). Commonly reported reasons for difficult BMV included: facial structure (50%), high inspiratory pressure (36%), and improper mask fit (21%). Common interventions were jaw thrust (96%) and an airway adjunct (oral airway 50%, nasal airway 7%, and supraglottic airway 11%), with ventilation improvement in 44% and 73%, respectively. Most difficult BMV was identified before neuromuscular blockade (NMB) administration (96%) and 67% (18/27) resolved after NMB administration. The overall success in improving ventilation was 27/28 (96%). TI adverse outcomes (hemodynamic events, emesis, and/or hypoxemia <80%) are associated with the presence of difficult BMV (10/28, 36%) versus non-difficult BMV (20/239, 8%, p < 0.001). Difficult BMV is common in critically ill children and is associated with increased TI adverse outcomes. Airway adjunct placement and NMB use are often effective in improving ventilation.
{"title":"Mitigation and Outcomes of Difficult Bag-Mask Ventilation in Critically Ill Children","authors":"C. Daigle, Elizabeth K Laverriere, B. Bruins, J. Lockman, J. Fiadjoe, Nancy McGowan, N. Napolitano, J. Shults, V. Nadkarni, A. Nishisaki","doi":"10.1055/s-0042-1760413","DOIUrl":"https://doi.org/10.1055/s-0042-1760413","url":null,"abstract":"Abstract Difficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was sent to PICU physicians supervising TIs from November 2019 through December 2020 to identify the presence of difficult BMV, attempted interventions used, and perceptions about intervention success. The dataset was linked and merged with the local TI quality database to assess safety outcomes. Among 305 TIs with response (87% response rate), 267 (88%) clinicians performed BMV during TI. Difficult BMV was reported in 28 of 267 patients (10%). Commonly reported reasons for difficult BMV included: facial structure (50%), high inspiratory pressure (36%), and improper mask fit (21%). Common interventions were jaw thrust (96%) and an airway adjunct (oral airway 50%, nasal airway 7%, and supraglottic airway 11%), with ventilation improvement in 44% and 73%, respectively. Most difficult BMV was identified before neuromuscular blockade (NMB) administration (96%) and 67% (18/27) resolved after NMB administration. The overall success in improving ventilation was 27/28 (96%). TI adverse outcomes (hemodynamic events, emesis, and/or hypoxemia <80%) are associated with the presence of difficult BMV (10/28, 36%) versus non-difficult BMV (20/239, 8%, p < 0.001). Difficult BMV is common in critically ill children and is associated with increased TI adverse outcomes. Airway adjunct placement and NMB use are often effective in improving ventilation.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"26 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81528578","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Karryn R. Crisamore, P. Empey, Jonathan H. Pelletier, R. Clark, Christopher M. Horvat
The objective of this study was to evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. A retrospective cross-sectional analysis of electronic health record-derived data spanning 10 years for patients admitted with a primary respiratory diagnosis at a quaternary children's hospital and who received a dexmedetomidine continuous infusion (n = 346 patients) was conducted. Penalized regression was used to select demographic, clinical, and medication characteristics associated with a median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/h (range: 0.1–1.8), median daily dose of 6.7 mcg/kg/d (range: 0.9–38.4), and median infusion duration of 1.6 days (range: 0.25–5.0). Of 26 variables tested, 15 were selected in the final model with days of dexmedetomidine infusion (β: 1.9; 95% confidence interval [CI]: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/d) (β: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/d) (β: 0.2; 95% CI: 0.1, 0.3), male sex (β: −1.1; 95% CI: −2.0, −0.2), and non-Black reported race (β: −1.2; 95% CI: −2.3, −0.08) significantly associated with median daily dexmedetomidine dose. Approximately 56% of dose variability was explained by the model. Readily obtainable information such as demographics, concomitant medications, and duration of infusion accounts for over half the variability in dexmedetomidine dosing. Identified factors, as well as additional environmental and genetic factors, warrant investigation in future studies to inform precision dosing strategies.
{"title":"Patient-Specific Factors Associated with Dexmedetomidine Dose Requirements in Critically Ill Children","authors":"Karryn R. Crisamore, P. Empey, Jonathan H. Pelletier, R. Clark, Christopher M. Horvat","doi":"10.1055/s-0042-1753537","DOIUrl":"https://doi.org/10.1055/s-0042-1753537","url":null,"abstract":"The objective of this study was to evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. A retrospective cross-sectional analysis of electronic health record-derived data spanning 10 years for patients admitted with a primary respiratory diagnosis at a quaternary children's hospital and who received a dexmedetomidine continuous infusion (n = 346 patients) was conducted. Penalized regression was used to select demographic, clinical, and medication characteristics associated with a median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/h (range: 0.1–1.8), median daily dose of 6.7 mcg/kg/d (range: 0.9–38.4), and median infusion duration of 1.6 days (range: 0.25–5.0). Of 26 variables tested, 15 were selected in the final model with days of dexmedetomidine infusion (β: 1.9; 95% confidence interval [CI]: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/d) (β: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/d) (β: 0.2; 95% CI: 0.1, 0.3), male sex (β: −1.1; 95% CI: −2.0, −0.2), and non-Black reported race (β: −1.2; 95% CI: −2.3, −0.08) significantly associated with median daily dexmedetomidine dose. Approximately 56% of dose variability was explained by the model. Readily obtainable information such as demographics, concomitant medications, and duration of infusion accounts for over half the variability in dexmedetomidine dosing. Identified factors, as well as additional environmental and genetic factors, warrant investigation in future studies to inform precision dosing strategies.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"30 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86915329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rebecca K. Aures, J. Rosenthal, Ashley Chandler, T. Raybould, M. Flaherty
Drowning remains a leading cause of death in children. Knowledge of outcomes of these patients who survive drowning but require critical care is lacking. We aim to study the current mortality rate, describe interventions and associated diagnoses, and examine factors related to risk of death in drowning victims admitted to the pediatric intensive care unit (PICU). We conducted a retrospective multicenter cohort study utilizing data from the Virtual Pediatric Systems Database in 143 PICUs between January 1, 2010, and December 31, 2019. Patients between 0 and 18 years of age admitted to a PICU with a diagnosis of drowning were included. The primary outcome was death prior to hospital discharge. Predictors included demographics, critical care interventions, and associated diagnoses. Odds ratios were calculated using multivariate logistic regression. There were 4,855 patients admitted with drowning across the study period. The overall PICU mortality rate in this cohort was 18.7%. Factors associated with an increased odds of death included being transported from an outside hospital, mechanical ventilation, central line placement, cardiac arrest, respiratory failure, and hypoxic ischemic encephalopathy. In 2,479 patients requiring mechanical ventilation, 63 were treated with extracorporeal membrane oxygenation which was not associated with mortality. This data provide updated insight into pediatric drowning victims requiring critical care and their prognosis, as it relates to the interventions they receive. Overall PICU mortality rates for drowning are higher than overall PICU mortality and mortality from other causes of injury. These findings have implications for the care of drowned children in ICU environments and in continued preventive efforts.
{"title":"Outcomes of Pediatric Drowning in the Pediatric Intensive Care Unit","authors":"Rebecca K. Aures, J. Rosenthal, Ashley Chandler, T. Raybould, M. Flaherty","doi":"10.1055/s-0042-1751267","DOIUrl":"https://doi.org/10.1055/s-0042-1751267","url":null,"abstract":"Drowning remains a leading cause of death in children. Knowledge of outcomes of these patients who survive drowning but require critical care is lacking. We aim to study the current mortality rate, describe interventions and associated diagnoses, and examine factors related to risk of death in drowning victims admitted to the pediatric intensive care unit (PICU). We conducted a retrospective multicenter cohort study utilizing data from the Virtual Pediatric Systems Database in 143 PICUs between January 1, 2010, and December 31, 2019. Patients between 0 and 18 years of age admitted to a PICU with a diagnosis of drowning were included. The primary outcome was death prior to hospital discharge. Predictors included demographics, critical care interventions, and associated diagnoses. Odds ratios were calculated using multivariate logistic regression. There were 4,855 patients admitted with drowning across the study period. The overall PICU mortality rate in this cohort was 18.7%. Factors associated with an increased odds of death included being transported from an outside hospital, mechanical ventilation, central line placement, cardiac arrest, respiratory failure, and hypoxic ischemic encephalopathy. In 2,479 patients requiring mechanical ventilation, 63 were treated with extracorporeal membrane oxygenation which was not associated with mortality. This data provide updated insight into pediatric drowning victims requiring critical care and their prognosis, as it relates to the interventions they receive. Overall PICU mortality rates for drowning are higher than overall PICU mortality and mortality from other causes of injury. These findings have implications for the care of drowned children in ICU environments and in continued preventive efforts.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"3 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90445371","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jesseca A. Paulsen, Karen M. Wang, Isabella M. Masler, Jessica Hicks, S. Green, Jeremy M. Loberger
Pediatric sepsis screening is recommended. The 2005 Goldstein criteria, the basis of our institutional sepsis screening tool (ISST), correlate poorly with clinically diagnosed sepsis. The study objective was to retrospectively evaluate the ISST sensitivity compared with the Pediatric Sequential Organ Failure Assessment (pSOFA). This was a single-center retrospective cohort study. The primary outcome was pSOFA score and ISST sensitivity for severe sepsis. Secondary outcomes included clinical outcome measures. In this severe sepsis cohort (N = 491), pSOFA and ISST sensitivity were 57.6 and 61.1%, respectively. In regression analysis for a positive pSOFA, positive blood culture (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1–4.3, p = 0.025), older age (OR 1.006, 95% CI 1.003–1.009, p < 0.001), and pulmonary infectious source (OR 3.3, 95% CI 1.6–6.5, p = 0.001) demonstrated independent association. In regression analysis for a positive ISST, older age (OR 1.003, 95% CI 1–1.006, p = 0.031) and intra-abdominal infectious source (OR 0.3, 95% CI 0.1–0.8, p = 0.014) demonstrated independent association. A negative ISST was associated with higher intensive care unit (ICU) admission prevalence (p = 0.01) and fewer ICU-free days (p = 0.018). A positive pSOFA score was associated with higher ICU admission prevalence, vasopressor requirement, and vasopressor days as well as fewer ICU, hospital, and mechanical ventilation-free days (all p < 0.001). Exploratory analysis combining the ISST and pSOFA into a hybrid screen demonstrated superior sensitivity (84.3%) and outcome discrimination. The pSOFA demonstrated noninferior sensitivity to a Goldstein-based institutional sepsis screening model. Further, pSOFA was a better discriminator of poor clinical outcomes. An exploratory hybrid screening model shows superior performance but will require prospective study.
建议进行儿童败血症筛查。2005年Goldstein标准，我们机构脓毒症筛查工具(ISST)的基础，与临床诊断的脓毒症相关性很差。研究目的是回顾性评价ISST与儿童序贯器官衰竭评估(pSOFA)的敏感性。这是一项单中心回顾性队列研究。主要终点是pSOFA评分和ISST对严重脓毒症的敏感性。次要结果包括临床结果测量。在这个严重脓毒症队列中(N = 491)， pSOFA和ISST的敏感性分别为57.6%和61.1%。在pSOFA阳性的回归分析中，血培养阳性(比值比[OR] 2.2, 95%可信区间[CI] 1.1-4.3, p = 0.025)、年龄(比值比[OR] 1.006, 95% CI 1.003-1.009, p < 0.001)和肺部传染源(比值比[OR] 3.3, 95% CI 1.6-6.5, p = 0.001)显示出独立的相关性。在ISST阳性的回归分析中，年龄(OR 1.003, 95% CI 1-1.006, p = 0.031)和腹腔内传染源(OR 0.3, 95% CI 0.1-0.8, p = 0.014)表现出独立的相关性。ISST阴性与较高的重症监护病房(ICU)入院率(p = 0.01)和较少的无ICU天数(p = 0.018)相关。pSOFA评分阳性与较高的ICU入院率、血管加压素需求、血管加压素天数以及较少的ICU、住院和无机械通气天数相关(均p < 0.001)。探索性分析将ISST和pSOFA结合到一个混合筛选中，显示出更高的灵敏度(84.3%)和结果辨别能力。pSOFA对基于goldstein的机构脓毒症筛查模型表现出良好的敏感性。此外，pSOFA是较好的鉴别不良临床结果的指标。探索性混合筛选模型表现出优越的性能，但需要前瞻性研究。
{"title":"Beyond Vital Signs: Pediatric Sepsis Screening that Includes Organ Failure Assessment Detects Patients with Worse Outcomes","authors":"Jesseca A. Paulsen, Karen M. Wang, Isabella M. Masler, Jessica Hicks, S. Green, Jeremy M. Loberger","doi":"10.1055/s-0042-1753536","DOIUrl":"https://doi.org/10.1055/s-0042-1753536","url":null,"abstract":"Pediatric sepsis screening is recommended. The 2005 Goldstein criteria, the basis of our institutional sepsis screening tool (ISST), correlate poorly with clinically diagnosed sepsis. The study objective was to retrospectively evaluate the ISST sensitivity compared with the Pediatric Sequential Organ Failure Assessment (pSOFA). This was a single-center retrospective cohort study. The primary outcome was pSOFA score and ISST sensitivity for severe sepsis. Secondary outcomes included clinical outcome measures. In this severe sepsis cohort (N = 491), pSOFA and ISST sensitivity were 57.6 and 61.1%, respectively. In regression analysis for a positive pSOFA, positive blood culture (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1–4.3, p = 0.025), older age (OR 1.006, 95% CI 1.003–1.009, p < 0.001), and pulmonary infectious source (OR 3.3, 95% CI 1.6–6.5, p = 0.001) demonstrated independent association. In regression analysis for a positive ISST, older age (OR 1.003, 95% CI 1–1.006, p = 0.031) and intra-abdominal infectious source (OR 0.3, 95% CI 0.1–0.8, p = 0.014) demonstrated independent association. A negative ISST was associated with higher intensive care unit (ICU) admission prevalence (p = 0.01) and fewer ICU-free days (p = 0.018). A positive pSOFA score was associated with higher ICU admission prevalence, vasopressor requirement, and vasopressor days as well as fewer ICU, hospital, and mechanical ventilation-free days (all p < 0.001). Exploratory analysis combining the ISST and pSOFA into a hybrid screen demonstrated superior sensitivity (84.3%) and outcome discrimination. The pSOFA demonstrated noninferior sensitivity to a Goldstein-based institutional sepsis screening model. Further, pSOFA was a better discriminator of poor clinical outcomes. An exploratory hybrid screening model shows superior performance but will require prospective study.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"13 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88270627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objectives We aimed to compare the efficacy of oral versus intravenous (IV) fluid therapy in correcting dehydration in diabetic ketoacidosis (DKA) when pH was ≥ 7.25 and Glasgow coma scale (GCS) score was ≥12. We also compared the time to resolution of DKA. Subjects Children aged ≤18 years with DKA were included in the study. In our pilot study, 40 children were enrolled from June 2018 to April 2019 and divided into two groups after achieving pH ≥ 7.25 and GCS score ≥ 12. Materials and Methods This was an open-label, parallel-arm, randomized control trial conducted in the pediatric intensive care unit of a tertiary referral hospital in North India. The IV group (control group) received treatment as per the standard protocol, whereas the oral group (trial group) received only oral fluids; IV fluid was withheld for 48 hours. Dehydration was clinically assessed on admission and after 48 hours, and the proportion of children achieving correction of dehydration was compared. Biochemical parameters were measured over time, and the time taken for resolution was compared between groups. Results Both groups achieved successful correction of dehydration. No significant difference was observed in the time taken from randomization to complete resolution of DKA. Hyperchloremia improved significantly earlier in the oral group after randomization. Conclusion Early institution of oral rehydration strategy after achieving pH ≥ 7.25 and GCS score ≥ 12 was effective in correcting dehydration at a rate comparable to standard IV rehydration. Hyperchloremia was observed to resolve earlier in patients that received oral rehydration therapy.
{"title":"Early Oral Rehydration Therapy in Diabetic Ketoacidosis: A Randomized Controlled Study","authors":"S. Kola, Shalu Gupta, Virendra Kumar","doi":"10.1055/s-0042-1753459","DOIUrl":"https://doi.org/10.1055/s-0042-1753459","url":null,"abstract":"\u0000 Objectives We aimed to compare the efficacy of oral versus intravenous (IV) fluid therapy in correcting dehydration in diabetic ketoacidosis (DKA) when pH was ≥ 7.25 and Glasgow coma scale (GCS) score was ≥12. We also compared the time to resolution of DKA.\u0000 Subjects Children aged ≤18 years with DKA were included in the study. In our pilot study, 40 children were enrolled from June 2018 to April 2019 and divided into two groups after achieving pH ≥ 7.25 and GCS score ≥ 12.\u0000 Materials and Methods This was an open-label, parallel-arm, randomized control trial conducted in the pediatric intensive care unit of a tertiary referral hospital in North India. The IV group (control group) received treatment as per the standard protocol, whereas the oral group (trial group) received only oral fluids; IV fluid was withheld for 48 hours. Dehydration was clinically assessed on admission and after 48 hours, and the proportion of children achieving correction of dehydration was compared. Biochemical parameters were measured over time, and the time taken for resolution was compared between groups.\u0000 Results Both groups achieved successful correction of dehydration. No significant difference was observed in the time taken from randomization to complete resolution of DKA. Hyperchloremia improved significantly earlier in the oral group after randomization.\u0000 Conclusion Early institution of oral rehydration strategy after achieving pH ≥ 7.25 and GCS score ≥ 12 was effective in correcting dehydration at a rate comparable to standard IV rehydration. Hyperchloremia was observed to resolve earlier in patients that received oral rehydration therapy.","PeriodicalId":44426,"journal":{"name":"Journal of Pediatric Intensive Care","volume":"41 1","pages":""},"PeriodicalIF":0.7,"publicationDate":"2022-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89569287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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