Objective: Hemolytic uremic syndrome (HUS) is a triad of hemolytic anemia, thrombocytopenia, and acute renal failure. In critically ill children with HUS, extra-renal manifestations may require intensive care unit admission and extracorporeal membrane oxygenation (ECMO) support. Outcomes specific to HUS and ECMO in children have not been well investigated. The primary aim of this project was to query a multicenter database to identify risk factors associated with mortality in HUS patients supported on ECMO. A secondary aim was to identify factors associated with ECMO utilization in children with HUS. Methods: Utilizing the Pediatric Health Information System (PHIS (R)) database (January 2004 and September 2018), this retrospective, multicenter cohort study identified the index HUS hospitalization among children aged 0-18 years. Univariate analysis was used to compare demographics, clinical characteristics, and procedures to identify risk factors associated with adverse outcomes. Results: Among 4,144 subjects, 37 were supported on ECMO. Survival for those on ECMO support was 54%. Among non-survivors, 59% of deaths occurred within 14 days of hospitalization. The mean hospital LOS was 15.9 days in non-survivors vs 53.9 days for survivors (p<0.001). When comparing subjects supported on ECMO to those who were not, patients with ECMO support had statistically longer hospital length of stay (LOS) and higher rates of extra-renal involvement (p<0.001). Conclusion: This study found a mortality rate of 46% among HUS patients requiring ECMO. The investigated clinical risk factors were not associated with mortality amongst the ECMO population. The study identifies risk factors associated with ECMO utilization in children with HUS.
Objective: Extracorporeal Membrane Oxygenation (ECMO) support is increasingly used for refractory septic shock. There is lack of data on the outcomes of children requiring ECMO support for refractory septic shock. Our study objective was to describe the variables associated with survival, risk factors for mortality and outcomes of children requiring ECMO support for refractory shock. Materials and Methods: Retrospective registry study of 340 international centers contributing data to the ELSO Registry, analyzing children <18 years who received ECMO with septic shock, severe sepsis, sepsis, SIRS, toxic shock syndrome, shock associated with infection and septicemia from any organism from 1990 to 2015. Outcomes were analyzed by categorizing the data into survivors and non-survivors. Logistic regression models were used to describe the association of dependent variable and multiple independent variables. Results: A total of 1928 patients were identified which met the inclusion criteria. 744 (38.5%) of the cohort survived. Survivors in this cohort tend to have longer duration of ECMO (230 hrs vs 201 hrs, p =0.005) and shorter time from intubation to ECMO cannulation (87 hrs vs 116 hrs, p =0.0033) when compared to non-survivors. Survivors were also noted to have higher pH, higher serum bicarbonate, higher saturations, and higher systolic, diastolic, and mean arterial pressures compared to non-survivors. Conclusions: These results suggest that early initiation of ECMO therapy for refractory sepsis is associated with better patient outcomes. ECMO is unlikely to recover patients once circulatory and metabolic collapse has developed.
Background: Tracheal intubation in critically ill children is a life-saving, but high-risk procedure that involves multiple team members with diverse clinical skills. We aim to examine the association between the provider-reported teamwork rating and the occurrence of adverse tracheal intubation-associated events (TIAEs). Methods: A retrospective analysis of prospectively collected data from 45 pediatric intensive care units (PICUs) in the National Emergency Airway Registry for Children (NEAR4KIDS) database from January 2013 to March 2018 was performed. A composite teamwork score was generated using the average of each of five (7-point Likert scale) domains in the teamwork assessment tool. Poor teamwork was defined as an average score of 4 or lower. Team provider stress data were also recorded with each intubation. Results: 12,536 tracheal intubations (TIs) were reported from 2013 to 2018. Approximately 4.1% (n=520) rated a poor teamwork score. TIs indicated for shock were more commonly associated with a poor teamwork score, while those indicated for procedures and those utilizing neuromuscular blockade were less commonly associated with a poor teamwork score. TIs with poor teamwork were associated with a higher occurrence of adverse TIAE (24.4% vs. 14.4%, p<0.001), severe TIAE (13.7% vs. 5.9%, p<0.001), and peri-intubation hypoxemia < 80% (26.4% vs. 17.9%, p<0.001). After adjusting for indication, provider type, and neuromuscular blockade use, poor teamwork was associated with higher odds of adverse TIAEs (OR 1.77, 95% CI 1.35-2.34), severe TIAEs (OR 2.23, 95% CI 1.47-3.37) and hypoxemia (OR 1.63, 95% CI 1.25-2.03). Conclusion: TIs with poor teamwork were independently associated with a higher occurrence of TIAEs, severe TIAEs, and hypoxemia.
Background: Metabolic disturbances frequently occur in neonatal seizures either as an underlying cause or as an associated abnormality. A prompt recognition of metabolic abnormalities and early therapy are necessary to avoid poor neurological outcome. Methods: Neonates with clinical seizures were enrolled in the study. Diagnostic evaluation included complete blood count, sepsis screen, and estimation of blood glucose, serum sodium, calcium and magnesium before instituting any specific treatment. Metabolic abnormalities, were considered as isolated when hypoxicischemic encephalopathy (HIE), sepsis, intracranial hemorrhage and polycythemia were ruled out. Results: Among 80 newborns with clinical seizures, one metabolic abnormality was detected in 46 (57.5%). The commonest metabolic abnormality observed was hypoglycemia; noted in 22/80 (27.5%). Hypocalcemia was the second common abnormality; noted in 10/80 (12.5%). Isolated metabolic abnormalities were observed in 23.8% (19/80) of neonates with seizures. Associated morbidities with seizures included HIE in 21 (26.3%) and sepsis in 28 (35%). Hypoglycemia was the commonest isolated metabolic abnormality (12.5%). Metabolic abnormalities coexisted with HIE in 9 out of 21 neonates and with sepsis in 8 of 28 neonates. Hypoglycemia was the common abnormality associated with both the conditions. Inborn errors of metabolism constituted 8.8% of the cohort studied (7 of 80 patients). Conclusions: A metabolic abnormality was detected in more than of 50% neonates with clinical seizures enrolled in our study. Metabolic abnormality also co-exists in neonates with HIE as well as sepsis related seizures.
Objectives: We aim to determine if there is a difference in length of respiratory support between nasoduodenal (NDT) and nasogastric tube (NGT) feedings in patients with bronchiolitis on high flow nasal cannula (HFNC). Methods: A single-center non-blinded parallel randomized control trial at a tertiary care hospital was designed. Pediatric patients ≤ 12 months old with bronchiolitis, on HFNC, requiring nutrition via a feeding tube were eligible. Patients were randomized to NGT or NDT and stratified into low- and high-risk groups. Length of respiratory support was the primary outcome. Secondary outcomes included length of stay, number of emesis events, maximum level of respiratory support, number of x-rays to confirm tube placement, number of attempts to place the tube by staff, adverse events during placement, instances of PICU admission, and emergency room visits and hospital readmissions within 7 and 30 days after discharge. Results: Forty patients were randomized, 20 in each arm. There were no significant differences in baseline characteristics. We found no significant difference in length of respiratory support between the two groups (NGT 0.84 IRR, [0.58, 1.2], p = 0.34). None of the secondary outcomes showed significant differences. Each arm reported one adverse event: nasal trauma in the NGT group and pneumothorax in the NDT group. Conclusions: For infants with bronchiolitis on HFNC that need enteric tube feedings, we find no difference in duration of respiratory support or other clinically relevant outcomes for those with NGT or NDTs. These results should be interpreted in the context of a limited sample size and an indirect primary outcome of length of respiratory support that may be influenced by other factors besides aspiration events.
Abstract The pediatric sequential organ failure assessment (pSOFA) score has been recently validated from its adult version having included the six clinical and biochemical parameters of organ dysfunction (respiratory, coagulation, cardiovascular, neurological, hepatic, and renal) and adapting age-adjusted cutoffs. Our goal was to find out which among the pSOFA scores (recorded on admission, highest score, and the mean score i.e., pSOFA1, pSOFAh, and pSOFAm respectively) performed better to predict mortality among the patients admitted in our pediatric intensive care unit (PICU). This prospective observational study was conducted on 104 patients (1 month to 12 years of age) admitted in the eight bedded PICU of a tertiary care hospital in India who met the inclusion criteria. The highest values of serial pSOFA scores were recorded on every alternate day starting from the day of admission up to day 9. The mean and median values of the pSOFA1, pSOFAm, and pSOFAh were higher in the nonsurvivor group than in the survivors. The mean pSOFA (with a diagnostic accuracy of 92.3% at a mean cut-off value of 12.8) has outperformed the other two pSOFA scores. In this exploratory analysis, the pSOFAm is the best tool in predicting the mortality outcome of any critically ill child. The use of the pSOFA score at admission and the mean values helps the clinician to quantify the organ dysfunction, and it may be helpful for the clinicians to take steps for further management. It may be useful to communicate to the parents of the sick child for prognostication too. The pSOFA1 also reflects well on the early prognostication when multiple pSOFA scores are unavailable. In the resource constraint settings, one may rely on the pSOFA1 and the approximate pSOFAm value may be predicted from the pSOFA1 as pSOFAm=[(1.03 XpSOFA1) – 0.9] within limitations.
Objective: The novel coronavirus disease 2019 (COVID-19) pandemic disrupted the lives of many families, especially those of children with chronic health problems. Little is known about the impact of this pandemic on the health and well-being of critically ill children and their families after their discharge from pediatric intensive care unit (PICU) hospitalization. This study describes the repercussions of the COVID-19 related lockdown on the physical and psychological wellbeing, quality of life, and access to resources of PICU survivors and their families. Method: Prospective cohort study. Telephone encounter. Children and families followed at the Centre Hospitalier Universitaire Ste-Justine PICU Follow-Up clinic from October 2018 to February 2020. Families were contacted by phone to complete validated questionnaires (Pediatric Quality of Life Inventory, Hospital Anxiety and Depression Scale) and to evaluate the impact of the COVID-19 pandemic on their access to medical care and extrafamilial support. Results: 55 families were contacted between November and December 2020. Quality of life scores were 88.1 +/- 16.9 and 83.8 +/- 13.9 for physical and psychosocial aspects, respectively. Symptoms of anxiety and depression were detected in 23.6% and 3.6% of respondent parents, respectively. A significant proportion of families reported cancelled or delayed healthcare appointments (65.5%) and difficulty with medication access (12.7%). Twenty-five families (45.5%) reported a significant decrease in income. We could not identify any statistically significant predictors for lower quality of life scores. Difficulty accessing medical care was associated with higher symptoms of anxiety and/or depression in parents on multivariate analysis(p=0.02). Conclusions: The COVID-19 pandemic has had a significant negative impact on PICU survivors' access to medical resources and extrafamilial support.
Objective: 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 accuracy in the identification of the volume of IV fluids patients will receive over the next 24 hours. Methods: Prospective cohort study enrolled all patients admitted to the PICU from May-August 2021 at the University of Michigan's C.S. Mott Children's Hospital Pediatric Intensive Care Unit (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 weight. We tested for differences in accuracy by clinician type using chi-square tests. Results: There were 259 patients for whom 2295 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 types: bedside nurses were most accurate at 64.3% and attendings were least accurate at 30.5%. Conclusions: 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 role and improved over time, which may suggest opportunities for improvement.
Objectives: Lack of defined diagnostic criteria for acute myocarditis makes its diagnosis dependent on clinical suspicion. The objective of this study was to the current trends in demographics, clinical manifestations, treatments, and outcomes in the United States for children hospitalized with acute myocarditis. Methods: This retrospective study was conducted using data collected from the Pediatric Health Information System (PHIS) database for the years 2014-2020. We included patients 21 years or younger with acute myocarditis. The statistical analysis was performed using Chi-squared and continuous variables using Mann-Whitney U-test for continuous data comparisons. Results: We found 1199 patients with acute myocarditis. About 60% of patients required admission to the intensive care unit (ICU). The median hospital length of stay was four days for all patients and six days for ICU patients. Two hundred sixty-five (22.1%) patients required invasive mechanical ventilation, 127 (10.6%) required Extracorporeal membrane oxygenation, 33 (2.8%) required Ventricular assist device and 22 (1.8%) required cardiac transplantations. Milrinone was the most used vasoactive agent. The overall hospital mortality was 2.3%. IVIG infusion use decreased during the study period. On multivariate analysis, vasoactive medication use, (p< 0.01) and arrhythmia (p = 0.02) were independently associated with increased odds of mortality. IVIG use (p=0.01) was associated with decreased odds of mortality. Conclusions: Despite high morbidity and frequent need for advanced life support measures, the survival outcomes of acute myocarditis in children are favorable. Vasoactive medication support and occurrence of arrythmia were independently associated with mortality, most likely due to disease severity. Administration of IVIG was independently associated with reduced mortality.
Abstract Pediatric chronic critical illness (PCCI) is characterized by prolonged and recurrent hospitalizations, multiorgan conditions, and use of medical technology. Our prior work explored the mismatch between intensive care unit (ICU) acute care models and the chronic needs of patients with PCCI. The objective of this study was to examine whether the number and frequency of treatment weans in ICU care were associated with clinical setbacks and/or length of stay for patients with PCCI. A retrospective chart review of the electronic medical record for 300 pediatric patients with PCCI was performed at the neonatal intensive care unit, pediatric intensive care unit, and cardiac intensive care unit of two urban children's hospitals. Daily patient care data related to weans and setbacks were collected for each ICU day. Data were analyzed using multilevel mixed multiple logistic regression analysis and a multilevel mixed Poisson regression. The patient-week level adjusted regression analysis revealed a strong correlation between weans and setbacks: three or more weekly weans yielded an odds ratio of 3.35 (95% confidence interval [CI] = 2.06–5.44) of having one or more weekly setback. There was also a correlation between weans and length of stay, three or more weekly weans were associated with an incidence rate ratio of 1.09 (95% CI = 1.06–1.12). Long-stay pediatric ICU patients had more clinical setbacks and longer hospitalizations if they had more than two treatment weans per week. This suggests that patients with PCCI may benefit from a slower pace of care than is traditionally used in the ICU. Future research to explore the causative nature of the correlation is needed to improve the care of such challenging patients.
The purpose of this study was to describe the care of intubated patients in pediatric critical care. Acknowledging there are several perceived factors that contribute to unplanned extubations, a secondary objective was to describe how practice variation may relate to observed differences in unplanned extubation rates. A survey about practices related to the care of intubated patients was distributed to all pediatric intensive care units (PICUs) participating in the Virtual Pediatric Systems (VPS, LLC). Unplanned extubation rates for 2019 to 2020 were obtained from VPS. Univariate and bivariate analyses were performed to describe the responses, with unplanned extubation rates calculated as means. The text responses about perceived causes of unplanned extubation in participants' sites were explored using thematic content analysis. A total of 44 PICUs were included in this study (response rate 37.0%). The mean unplanned extubation rate for the sample was 0.41 (95% confidence interval: 0.31–0.50) per 100 intubation days. Variability was found across several aspects that impact care, including staffing, the frequency of procedures (e.g., chest radiography), and treatment-related goals (e.g., sedation and mobilization). The perceived causes of unplanned extubations in the sample included patient-, staff-, and equipment-related factors. We found practice variability in pediatric critical care units related to the care of intubated patients, which may contribute to the frequency of adverse events. As evidence emerges and professional associations and organizations recommend the best practices, knowledge translation will be required for the implementation and deimplementation of practices to improve the quality of care in PICUs.
Objective: To evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. Methods: A retrospective cross-sectional analysis of electronic health record-derived data spanning ten 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 median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Results: Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/hr (range: 0.1-1.8), median daily dose of 6.8 mcg/kg/day (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 ((3: 1.9; 95% CI: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/day) ((3: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/day) ((3: 0.2; 95% CI: 0.1, 0.3), male sex ((3:-1.1; 95% CI:-2.0,-0.2), and non-Black reported race ((3:-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. Conclusions: Readily obtainable information such as demographics, concomitant medications, and duration of infusion account 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.
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.
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.
Objectives This article evaluates correlation and agreement between oxygen saturation (SpO(2))/fraction of inspired oxygen (FiO(2)) (SF) ratio and partial pressure of oxygen (PaO2)/FiO(2) (PF) ratio. It also derives and validates predictive PF ratio from noninvasive SF ratio measurements for clinically relevant PF ratios and derives SF ratio equivalent of PF ratio cutoffs used to define acute lung injury (ALI, PF < 300) and acute respiratory distress syndrome (ARDS, PF < 200). Methods Retrospective cohort study including neonates with respiratory failure over a 6-year study period. Correlation and agreement between PF ratio with SF ratio was analyzed by Pearson's correlation coefficient and Bland-Altman analysis. Generalized estimating equation was used to derive PF ratio from measured PF ratio and derive corresponding SF ratio for PF ratio cutoffs for ALI and ARDS. Results A total of 1,019 paired measurements from 196 neonates with mean 28 (+/- 4.7) weeks' gestational age and 925 (+/- 1111) g birth weight were analyzed. Strong correlation was noted between SF ratio and PF ratio (r = 0.90). Derived PF ratios from regression (1/PF = -0.0004304 + 2.0897987/SF) showed strong accuracy measures for PF ratio cutoffs < 200 (area under the curve [AUC]: 0.85) and < 100 (AUC: 0.92) with good agreement. Equivalent SF ratio to define ALI was < 450, moderate ARDS was < 355, and severe ARDS was < 220 with strong accuracy measures (AUC > 0.81, 0.84, and 0.93, respectively). Conclusion SF ratio correlated strongly with PF ratio with good agreement between derived PF ratio from noninvasive SpO(2) source and measure PF ratio. Derived PF ratio may be useful to reliably assess severity of respiratory failure in neonates. Further studies are needed to validate SF ratio with clinical illness severity and outcomes.
Catecholamine-resistant shock, also known as vasoplegia, is a challenging entity with a significant risk of mortality. We seek to provide further data on the safety and effectiveness of methylene blue (MB) for vasoplegic shock in the pediatric population. We conducted a retrospective observational study of pediatric patients admitted to the pediatric intensive care unit or pediatric cardiac intensive care unit at Mount Sinai Kravis Children's Hospital from 2011 to 2021 who received MB for refractory shock. A list of patients was obtained by performing a pharmaceutical query from 2011 to 2021 for “MB.” Chart review was performed to determine indication for use and to collect demographic and clinical data. There were 33 MB administrations: 18 administrations (16 unique patients) for vasoplegic shock, 11 for surgical dye, and 4 for methemoglobinemia. The median age was 5 years (interquartile range [IQR]: 0.08, 13). Ten patients required MB following congenital cardiac repair (62.5%); one administration for myocarditis, septic shock, postcardiac arrest, high output chylothorax, scoliosis repair, and one multisystem inflammatory syndrome in children. No patients experienced hemolytic anemia or serotonin syndrome following administration. The median dose of MB was 1 mg/kg. Vasoactive-inotrope score (VIS) improved in 4 out of 18 administrations at 1 hour. Mean arterial pressure (MAP) improved in 10 out of 18 administrations at 1 hour. Systolic blood pressure (SBP) improved in 8 out of 18 administrations at 1 hour. VIS, MAP, and SBP improved in 8 out of 18 administrations at 6 hours. MB may be safely considered as rescue therapy in catecholamine-resistant shock in pediatrics.
Objective This article compares patient outcomes before and after implementation of a risk stratified pediatric sedation weaning protocol. Methods This observational cohort study, in a 30-bed tertiary care pediatric intensive care unit (PICU), included patients requiring opioid, benzodiazepine, and/or dexmedetomidine infusions. Outcomes (duration of wean, PICU length of stay [LOS], and Withdrawal Assessment Tool [WAT-1] scores) were collected by retrospective chart review for 12 months before and after protocol implementation. The influence of the protocol was assessed using an interrupted time series (ITS) analysis. Results There were 49 patients before and 47 patients after protocol implementation. Median opioid wean duration preprotocol was 10.5 days (interquartile range [IQR]: 4.25, 20.75) versus 9.0 days (IQR: 5.0, 16.75) postprotocol (p = 0.66). Median benzodiazepine wean duration was 11.5 days (IQR: 3.0, 19.8) preprotocol versus 5.0 days (IQR: 2.0, 13.5) postprotocol (p = 0.31). Median alpha-agonist wean duration was 7.0 days (IQR: 3.5, 17.0) preprotocol versus 3 days (IQR: 1.0, 14.0) postprotocol (p = 0.03). The ITS indicated a reduction in opioid wean by 6.7 days (p = 0.35), a reduction in benzodiazepine wean by 13.4 days (p = 0.12), and a reduction in alpha-agonist wean by 12.9 days (p = 0.06). WAT-1 scores > 3 (12.6% preprotocol vs. 9.9% postprotocol, p = 0.569) and PICU LOS (16.0 days [IQR: 11.0, 26.0] vs. 17.0 days [IQR: 11.0, 26.5], p = 0.796) did not differ between groups. Conclusion Implementation of a risk stratified sedation weaning protocol in the PICU was associated with a significant reduction in alpha-agonist wean duration without a significant increase in withdrawal symptoms.
Introduction: The purpose of this retrospective study was to investigate the effects of a single dose of aminophylline on urine output and fluid balance in children admitted to the cardiac intensive care unit. Methods: A retrospective study was done to compare variables of interest before and 24 hours after aminophylline administration in children under the age of 18 years who were admitted to the cardiac intensive care unit at our institution from January 2011 onwards. Variables of interest included age, weight, aminophylline dose, concurrently administered diuretics, specific hemodynamic parameters, and blood urea nitrogen and creatinine levels. Variables such as urine output and fluid balance were measured through a binary endpoint. Data were compared in a paired fashion and continuous variables were compared through paired t-tests. Analyses were conducted using SPSS Version 23.0. Results: A total of 14 patients were included in the study. There was no significant change in hemodynamic parameters or creatinine levels before and after intravenous aminophylline administration of 5mg/kg. There was a significant difference in urine output, fluid balance, and blood urea nitrogen levels from the baseline value. Concurrent usage of diuretics did not show significant association with a difference in urine output or fluid balance from baseline. No significant adverse reactions were noted 24 hours after the administration of aminophylline. Conclusion: Use of aminophylline dosed at 5 mg/kg is safe and leads to improvement in urine output and fluid balance without negatively impacting systemic oxygen delivery or renal filtration function.
Objectives: To observe the mean daily dose of fentanyl required for adequate sedation in critically ill, mechanically ventilated children randomized to receive dexmedetomidine or placebo. Methods: We conducted Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multicenter, double-blind, randomized, placebo-controlled, dose-escalating trial. We enrolled children aged 35 weeks post-menstrual to 17 years (inclusive) admitted across 13 pediatric multidisciplinary and cardiac intensive care units. Adequate sedation was based on a State Behavioral Score and Richmond Agitation-Sedation Scale of-1 or lower. Only the first two dexmedetomidine dosing cohorts opened for enrollment, due to early trial closure during the coronavirus 2019 pandemic. Thirty children were randomized over 13 months and included in the analyses. Results: Demographic and baseline characteristics were not different between dexmedetomidine and placebo cohorts. Similarly, mean daily fentanyl use was not different, using an unadjusted mixed regression model that considered treatment, time, and a treatment-by-time interaction. Adverse events and safety events of special interest were not different between cohorts. Conclusions: The DOSE trial revealed that dexmedetomidine added to fentanyl does not impact safety and may not spare fentanyl use in critically ill children, although the trial did not meet its recruitment goals, due to early closure during the coronavirus 2019 pandemic. More rigorous inpatient pediatric trials like DOSE that study critically ill, mechanically ventilated children are needed. Despite the many obstacles faced, the DOSE trial presents challenges from which the greater research community can learn and use to optimize future therapeutic trials in children.
Objectives: Data regarding a terminal withdrawal of mechanical ventilation in pediatric patients, in particular the time-to-death, would be helpful to family and hospital staff. Methods: This retrospective case series will review the terminal withdrawal of mechanical ventilation in PICU patients at our hospital between 2015 and 2020. Results: There were 222 PICU deaths and 53 of these patients died following a terminal withdrawal of mechanical ventilation. 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 terminal withdrawal of mechanical ventilation was associated with time-to-death. Terminal withdrawal of mechanical ventilation 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 one 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. Conclusions: Time-to-death following a terminal withdrawal of mechanical ventilation 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 one in ten survived a terminal withdrawal of mechanical ventilation 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.
