Intensive care medicine. Paediatric and neonatal最新文献

Objective: Dexmedetomidine is an increasingly popular analgosedative in critically ill children receiving invasive mechanical ventilation (IMV). We conducted a systematic review to evaluate the efficacy of dexmedetomidine compared to other analgosedatives in this population.

Data sources: Seven electronic databases and trial registries to July 2024, without language restrictions.

Study selection: Randomized controlled trials comparing dexmedetomidine to other analgosedatives in critically ill children receiving IMV.

Data extraction and synthesis: Independently and in duplicate, we conducted data extraction, risk of bias assessment, and certainty assessment using Grading of Recommendations, Assessment, Development, and Evaluation. We conducted random-effects meta-analyses, calculating pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals.

Results: We identified 12 trials (n = 592 patients). Pooled analyses demonstrated dexmedetomidine has little to no effect on IMV duration (MD -2.2 h [-3.3, -1.1]; moderate certainty), clinically important bradycardia (RR 1.42 [0.45, 4.49]; moderate certainty), or clinically important hypotension (RR 1.35 [0.48, 3.82]; moderate certainty). Dexmedetomidine may reduce delirium risk (RR 0.83 [0.64, 1.07]; low certainty), but impact on withdrawal is uncertain (RR 0.93 [0.55, 1.59]; very low certainty). A narrative synthesis was used to evaluate dexmedetomidine sedation efficacy, demonstrating very low certainty in attaining sedation target. One trial reported on long-term outcomes.

Conclusions: Twelve trials evaluating dexmedetomidine have been conducted to date, with low or very low certainty for its impact upon delirium, withdrawal, and long-term outcomes. Future analgosedation trials require attention to intervention design, outcome selection and reporting to improve certainty in critical outcomes.

Supplementary information: The online version contains supplementary material available at 10.1007/s44253-025-00091-4.

Infants in intensive care environments encounter numerous stressors which may overlap or occur in close proximity. Recent literature suggests stressful encounters in the neonatal or early infant period are harmful to physiological, functional, and structural systems, both acutely and longitudinally. Identifying these stressors and assessing the stress burden in this vulnerable population is crucial for developing care models that minimize unnecessary stress, thereby enhancing recovery and survival. This scoping review identified sources of stress encountered by infants hospitalized in intensive care environments, as reported in empiric literature. A total of 51 studies met eligibility criteria. Identified stressors were categorized into environmental stressors, stressors associated with routine care, and stressors associated with noxious or painful procedures. Studies predominately focused on premature infants in neonatal intensive care units; research on stressors in general pediatric intensive care units or among infants with congenital heart disease or other congenital anomalies is lacking. Evaluation of infant stress varied across studies, though most utilized vital sign alterations, biochemical markers, biophysical assessment, or observational scales by clinician report. Across studies, findings suggest stress experienced by infants in intensive care settings may contribute to physiological disruptions and developmental vulnerabilities.

Acute kidney injury (AKI) is common in critically ill children and neonates and imparts an increased risk for morbidity and mortality. Despite a growing recognition of the untoward consequences of AKI, its management continues to rely on supportive care alone, after numerous clinical trials have failed to identify effective disease-modifying therapies. This failure to advance the field is likely due in large part to the heterogeneity of AKI, which demands a precision approach to diagnosis and management. Despite the emergence of several novel AKI biomarkers with the ability to refine the AKI diagnosis beyond what is afforded by changes in serum creatinine and/or urine output alone, widespread translation of these biomarkers to practice has been limited. In this review, we outline a roadmap for AKI risk-stratification, diagnosis, management, and follow-up that is rooted in precision medicine principles and feasible with the tools currently available in pediatric ICUs. This roadmap highlights the importance of dynamic (as opposed to static) assessment of the critically ill child with, at-risk for, and recovering from AKI, and introduces the concept of theragnostic biomarkers that are both the target of and change with treatment, thus helping guide the therapeutic approach. Finally, we highlight the need for re-defining appropriate endpoints in AKI clinical trials testing the interventions proposed here (and others) to ensure we are identifying treatments that will meaningfully improve outcomes for critically ill children with AKI.

Background: Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted.

Methods: We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO₂ > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI.

Results: A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759).

Conclusion: In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.