Objectives: To describe regional differences and change over time in the degree of centralization of pediatric intensive care in Australia and New Zealand (ANZ) and to compare the characteristics and ICU mortality of children admitted to specialist PICUs and general ICUs (GICUs). Design: A retrospective cohort study using registry data for two epochs of ICU admissions, 2003-2005 and 2016-2018. Setting: Population-based study in ANZ. Patients: A total of 43,256 admissions of children aged younger than 16 years admitted to an ICU in ANZ were included. Infants aged younger than 28 days without cardiac conditions were excluded. Interventions: None. Measurements and Main Results: The primary outcome was risk-adjusted ICU mortality. Logistic regression was used to investigate the association of mortality with the exposure to ICU type, epoch, and their interaction. Compared with children admitted to GICUs, children admitted to PICUs were younger (median 25 vs 47 mo; p < 0.01) and stayed longer in ICU (median 1.6 vs 1.0 d; p < 0.01). For the study overall, 93% of admissions in Australia were to PICUs whereas in New Zealand only 63% of admissions were to PICUs. The adjusted odds of death in epoch 2 relative to epoch 1 decreased (adjusted odds ratio [AOR], 0.50; 95% CI, 0.42-0.59). There was an interaction between unit type and epoch with increased odds of death associated with care in a GICU in epoch 2 (AOR, 1.63; 95% CI, 1.05-2.53 for all admissions; 1.73, CI, 1.002-3.00 for high-risk admissions). Conclusions: Risk-adjusted mortality of children admitted to specialist PICUs decreased over a study period of 14 years; however, a similar association between time and outcome was not observed in high-risk children admitted to GICUs. The results support the continued use of a centralized model of delivering intensive care for critically ill children.

Hospital readmissions within 28 days are an important performance measurement of quality and safety of health care. The aims of this study were to examine the rates, trends and characteristics of paediatric intensive care unit admissions, and factors associated with readmissions to hospital within 28 days of discharge. This retrospective, population-based record linkage study included all children ≥28 days and <16 years old admitted to an intensive care unit (ICU) in a New South Wales (NSW) public hospital from 2004 to 2013. Data were sourced from the NSW Admitted Patients Data Collection and the NSW Registry of Births, Deaths and Marriages, Death Registration. We identified 21 200 ICU admissions involving 17 130 children. Admissions increased by 24% over the study period with the greatest increase attributed to respiratory and musculoskeletal conditions. A higher proportion of children were <5 years, male, lived in major cities, were publicly insured and had chronic conditions. The median length of ICU stay was 42 h and overall hospital stay was 7 days. There were 905 deaths, two-thirds during the index admission with the leading causes being injuries, cancer and infections. Twenty-three per cent of ICU admissions were readmitted to hospital within 28 days of discharge. Associated independent factors were younger age, longer index hospital stay and emergency index admission. Children with chronic conditions of cancer and genitourinary disorders were more likely to be readmitted. Identification of complex chronic conditions, consideration of long-term health planning and interventions intended to reduce readmission is warranted in order to reduce the burden to families and the health-care system.

OBJECTIVES:To investigate if the performance of Pediatric Index of Mortality 3 is improved by including imputed values for the PaO2/FIO2 ratio where measurements of PaO2 or FIO2 are missing. DESIGN:A prospective observational study. SETTING:A bi-national pediatric intensive care registry. PATIENTS:The records of 37,983 admissions of children less than 16 years old admitted to 19 ICUs. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Seven published equations describing an association between PaO2/FIO2 and oxygen saturation measured by pulse oximetry (SpO2)/FIO2 were used to derive an alternative variable d100 × FIO2/PaO2 for the Pediatric Index of Mortality 3 variable 100 × FIO2/PaO2. Six equations exclude SpO2/FIO2 values if SpO2 is greater than 96-98%. 100 × FIO2/PaO2 was missing in 72% of patient records primarily due to missing PaO2, d100 × FIO2/PaO2 was missing in 71% of patient records if values of SpO2greater than 97% were excluded or in 17% of patient records if all measurements of SpO2 were included. Univariable analysis supported the inclusion of SpO2 values greater than 97%. Compared to the standard Pediatric Index of Mortality 3 model, two alternative models imputing 100 × FIO2/PaO2 from d100 × FIO2/PaO2 only if 100 × FIO2/PaO2 was missing, or using d100 × FIO2/PaO2 values exclusively, resulted in a small but statistically significant improvements in discrimination of Pediatric Index of Mortality 3 (area under the receiver operator curve 0.9068 [0. 8965-0. 9171]; 0.9083 [0.8981-0.9184]; 0.9087 [0.8987-0.9188], respectively). CONCLUSIONS:Imputation of the PaO2/FIO2 ratio in cases where arterial sampling was not performed resulted in a large reduction in the rate of missing data if all values of SpO2 were included. The imputation technique improved the discrimination of Pediatric Index of Mortality 3; however, the magnitude of the increment in overall model performance was small. A possible benefit of the approach is reducing the potential for bias resulting from variation in practice for invasive monitoring of oxygenation.

AimTo describe the changes to paediatric intensive care unit (PICU) admission patterns and ventilation requirements for children with bronchiolitis following the introduction of humidified high‐flow nasal cannula oxygen outside the PICU.MethodsRetrospective study comparing patients <24 months of age with a discharge diagnosis of bronchiolitis admitted to the PICU. A comparison was made between those before humidified high‐flow nasal cannula oxygen use (year 2008) to those immediately following the introduction of humidified high‐flow nasal cannula oxygen use (year 2011) and those following further consolidation of humidified high‐flow nasal cannula oxygen use outside the PICU (year 2013).ResultsHumidified high‐flow nasal cannula oxygen use up to 1 L/kg/min in the hospital did not reduce PICU admission. Intubation rates were reduced from 22.2% in 2008 to 7.8% in 2013. There was a non‐significant trend towards decreased length of stay in the PICU while hospital length of stay showed a significant decrease following the introduction of humidified high‐flow nasal cannula oxygen. Age <6 months and respiratory syncytial virus bronchiolitis were associated with an increased chance of failing humidified high‐flow nasal cannula oxygen therapy.ConclusionHumidified high‐flow nasal cannula oxygen utilised outside of the PICU in our institution for children with bronchiolitis did not reduce admission rates or length of stay to the PICU but was associated with a decreasing need for invasive ventilation and reduced hospital length of stay.

Introduction: Critically ill children are at an increased risk of malnutrition. Variability in feeding practices has been highlighted as a barrier to optimising nutrition during Paediatric Intensive Care Unit (PICU) admission. Introduction of a feeding algorithm has been shown to improve nutritional outcomes in this population.

Expertise is typically associated with high levels of experience in a domain. However, high levels of experience do not necessarily mean that operators are capable of performing at the level of expertise. Based on evidence that pattern-recognition is the foundation of expert diagnostic performance, two studies investigated the utility of distinguishing competent from expert practitioners using measures of the component tasks of pattern-recognition. In two dissimilar domains, performance across the tasks clustered into two levels, reflecting competence and expertise. Performance on the tasks was only weakly correlated with years of experience in the domain. The significance of these results is discussed in relation to assessment and training evaluation.

OBJECTIVES:To determine the incidence, risk factors and impact of ventilator-associated pneumonia (VAP) in a mixed tertiary paediatric intensive care unit.DESIGN:Prospective observational study.METHODS:Patients in the intensive care unit who were mechanically ventilated for more than 48 hours were assessed daily, according to criteria for a diagnosis of VAP. Potential risk factors for VAP, if present, were documented.RESULTS:Of 692 invasively ventilated patients, 269 (38.9%) were ventilated for > 48 hours and met no exclusion criteria. Eighteen (6.7%) patients had episodes of VAP, and the VAP incidence density was 7.02 per 1000 intubation days. The mean admission Paediatric Index of Mortality 2 risk of death was similar in patients with and without VAP (0.084 v 0.056; P =0.8). Patients with VAP (compared with patients without VAP) had a longer median duration of ICU stay, (19.35 v 7.35 days; P < 0.001), duration of ventilation (11.99 v 4.92 days; P=0.024) and duration of hospital stay (35.5 v 20 days; P < 0.001). Univariate analysis showed that reintubation, absence of tube feeding and absence of stress ulcer prophylaxis were risk factors for VAP. While backward selection removed reintubation as a positive predictor during multivariate analysis, tube feeds (hazard ratio (HR), 0.27; 95% CI, 0.09-0.85; P = 0.02) and stress ulcer prophylaxis (HR, 0.29; 95% CI, 0.11-0.76; P = 0.01) were independently associated with reduced VAP incidence.CONCLUSIONS:VAP in children is associated with significant morbidity and increased length of hospital stay. Enteral feeding and stress ulcer prophylaxis while intubated are associated with lower VAP hazards.

Medical expertise is typically denoted on the basis of experience, but this approach appears to lack validity and reliability. The present study investigated an innovative assessment of diagnostic expertise in medicine. This approach was developed from evidence that expert performance develops following the acquisition of cue associations in memory, which facilitates diagnostic pattern-recognition. Four distinct tasks were developed, for which the judicious extraction and selection of environmental cues may be advantageous. Across the tasks, performance clustered into two levels, reflecting competent and expert performance. These clusters were only weakly correlated with traditional methods of identifying domain experts, such as years of experience. The significance of this outcome is discussed in relation to training, evaluation and

Objective: The authors describe the development of a new, more objective method of distinguishing experienced competent nonexpert from expert practitioners within pediatric intensive care.Background: Expert performance involves the acquisition and use of refined feature-event associations (cues) in the operational environment. Competent nonexperts, although experienced, possess rudimentary cue associations in memory. Thus, they cannot respond as efficiently or as reliably as their expert counterparts, particularly when key diagnostic information is unavailable, such as that provided by dynamic cues.Method: This study involved the application of four distinct tasks in which the use of relevant cues could be expected to increase both the accuracy and the efficiency of diagnostic performance. These tasks included both static and dynamic stimuli that were varied systematically. A total of 50 experienced pediatric intensive staff took part in the study.Results: The sample clustered into two levels across the tasks: Participants who performed at a consistently high level throughout the four tasks were labeled experts, and participants who performed at a lower level throughout the tasks were labeled competent nonexperts. The groups differed in their responses to the diagnostic scenarios presented in two of the tasks and their ability to maintain performance in the absence of dynamic features.Conclusion: Experienced pediatricians can be decomposed into two groups on the basis of their capacity to acquire and use cues; these groups differ in their diagnostic accuracy and in their ability to maintain performance in the absence of dynamic features.Application: The tasks may be used to identify practitioners who are failing to acquire expertise at a rate consistent with their experience, position, or training. This information may be used to guide targeted training efforts.

We report 36 week gestation twins born following a traumatic delivery. Twin 2 had profuse haemorrhage where haemostasis was achieved with recombinant Factor VIIa (rFVIIa - NovoSeven;Novo Nordisk A/S, Bagsvaerd, Denmark).

Children requiring cardiac surgery present particular challenges in peri-operative respiratory management. The wide variety of conditions and operations and their varied impact on respiratory function makes dialogue with related medical staff essential. In most circumstances, cardiac performance is the main determinant of respiratory outcomes. Changing cardiologic and surgical approaches have combined to diminish the severity and frequency of pulmonary hypertensive issues and new treatment modalities are simplifying the intensive care approach. Patients with Down's syndrome and 22q11 deletion syndrome present particular issues related to anatomy, physiology and respiratory function. Certain conditions, including tetralogy of Fallot and cavopulmonary connections, present unique circumstances where respiratory management, sometimes including extubation, may assist in optimisation of cardiac performance. These and other conditions highlight the complexities of cardiopulmonary interactions. Cardiac performance remains the principal determinant of outcome after paediatric cardiac surgery and has the biggest impact on respiratory function.

To review the use of recombinant activated factor VII in paediatric cardiac surgery.

OBJECTIVES To develop indirect calorimetry to enable measurement of energy expenditure in mechanically ventilated children and to assess the effect of endotracheal tube leak on the accuracy of indirect calorimetry measurements. DESIGN Prospective, observational study, using a convenience sample. SETTING Tertiary pediatric intensive care unit in a university-associated children's hospital. PATIENTS Eighteen patients, 3 months to 10 yrs of age, with various diagnoses, and requiring mechanical ventilation. INTERVENTIONS Patients were intubated and received routine intensive care treatment. MEASUREMENTS AND MAIN RESULTS Energy expenditure and respiratory quotient were measured using a new modification to the technique of indirect calorimetry, which includes an assessment of any expired gas lost around the endotracheal tube. Mean energy expenditure was 97% of predicted energy expenditure, but there was great variability between patients, and energy expenditure could not be estimated reliably from predictive equations. The amount of expired gas lost because of gas leak around the endotracheal tube was often a clinically important proportion of total expired gas, and this lost gas could not be predicted by audible endotracheal tube leak. CONCLUSIONS Measurement of energy expenditure by indirect calorimetry may be useful in the nutritional management of critically ill children. Results may be inaccurate if the gas lost because of leak around uncuffed endotracheal tubes is not taken into account.

The accumulation of toxic metabolites in children with inborn errors of metabolism may cause acute metabolic crises and result in long-term neurological dysfunction or death. Peritoneal dialysis often provides insufficient clearance to protect against these complications, while intermittent haemodialysis cannot prevent reaccumulation of metabolites between dialysis sessions. We describe the use of continuous venovenous haemofiltration (CVVH) or haemodiafiltration (CVVHD) in three infants with maple syrup urine disease (MSUD) and one child with carbamyl phosphate synthetase (CPS) deficiency. All children with MSUD had a satisfactory reduction in branchedchain amino acids within 24 h of onset of haemofiltration, and are now neurologically normal. The child with CPS deficiency had an ammonia level of <100 μmol/l within 24 h of onset of therapy, but died 3 days later from unrelated cardiovascular complications. Complications of the therapy included the clotting of one haemofilter and the replacement of two vascular access catheters per patient on average per therapy. Two patients required blood transfusion. We report the successful use of CVVH and CVVHD in the acute management of metabolic crises associated with inborn errors of metabolism, and believe that these may be the optimal techniques for the acute clearance of toxic metabolites.