INTRODUCTION:Pediatric patients undergoing liver transplantation (LT) often require postoperative mechanical ventilation, which can increase the risk of complications such as ventilator-associated pneumonia (VAP) and higher intensive care unit (ICU) resource utilization. Advances in perioperative care have made immediate intraoperative extubation (IE) and early extubation (EE) feasible and safe; however, evidence in pediatric LT remains limited, and standardized extubation criteria are lacking. This study aimed to evaluate the incidence, outcomes, and predictors of successful IE/EE after pediatric LT at a high-volume North American center. METHOD:Perioperative data were retrospectively reviewed for patients aged ≤ 18 years who underwent isolated LT between January 1, 2013, and December 31, 2021. Patients undergoing combined liver-bowel transplantation, retransplantation, or liver autotransplantation were excluded. Recipients were categorized into three groups based on extubation timing: IE, EE (≤ 24 h), and delayed extubation (DE; > 24 h). Multivariable logistic regression was used to identify independent predictors of IE/EE. RESULTS:Of 245 patients, 33 underwent IE and 110 underwent EE, with no cases of reintubation. Over the study period, rates of IE and EE increased steadily. The IE/EE cohort had significantly shorter ICU and hospital lengths of stay compared to the DE group. Multivariable analysis identified age, preoperative care setting, and use of regional anesthesia as significant independent predictors of successful IE/EE. The predictive model demonstrated good discrimination (C-statistic 0.82; 95% CI 0.77-0.88). CONCLUSION:IE/EE after pediatric LT is increasingly common and has been associated with a high degree of safety and favorable outcomes. Recipient age, preoperative care setting, and intraoperative regional anesthesia are significant predictors of success. Over 9 years, growing experience was associated with higher IE/EE rates, reduced ICU stays, and shorter hospital length of stay, supporting earlier recovery and optimized resource utilization.

Background Delirium is a common complication of critical care admissions. In pediatrics, the introduction of antipsychotics for delirium management has not yet been established. Objectives We aimed to assess the effectiveness and short-term safety of quetiapine for delirium in critically ill patients younger than 2 years of age. Methods A single-center descriptive study included 78 patients less than 2 years old who were prescribed quetiapine in the intensive care units (ICU) from July 2018 to November 2023. Quetiapine dosing regimens, efficacy, and short-term safety parameters were assessed. Results Quetiapine use was more frequent in the cardiac critical care unit (n = 62 [79.5%]) compared to the pediatric intensive care unit (n = 16 [20.5%]). The median quetiapine course duration was 6 days (interquartile range [IQR], 2-23 days). Although Cornell Assessment of Pediatric Delirium (CAPD) scores during quetiapine use (median, 9.1 [IQR, 6-11.5]) were lower than scores before quetiapine use (median, 13.0 [IQR, 10-16]), they were still indicative of delirium (P = 0.4). Median opioid use did not differ during quetiapine use (P = 0.6), whereas benzodiazepine exposure decreased (P < 0.01). Changes in alpha-agonist use showed a transition from intravenous to oral agents (P < 0.01). Half of the patients had improvements in their mechanical ventilation requirements (P < 0.01). No adverse effects associated with quetiapine were observed. Conclusions Patients receiving quetiapine for ICU delirium had a statistically significant decrease in benzodiazepine exposure and mechanical ventilation requirements (P < 0.01). No statistically significant changes in CAPD scores (P = 0.4) or opioid exposure (P = 0.6) were observed. Quetiapine use appeared to be safe. Future research is required to standardize the duration and weaning of quetiapine in this patient population and evaluate which pediatric ICU subpopulations would most benefit from quetiapine for delirium management.

OBJECTIVE:The objective of this study was to describe barriers and facilitators to paediatric intensive care unit (PICU) therapeutic cuddling (TC) perceived by healthcare professionals (HCPs). BACKGROUND:TC is a potential intervention to prevent/manage pain, agitation, delirium, and analgosedation exposure in PICUs. However, it is not widely practiced. Given the complexity of TC in critically ill children, PICU HCPs' perspectives of barriers and facilitators are essential to inform implementation and evaluation. METHODS:A cross-sectional survey, guided by the Theoretical Domains Framework, was administered to PICU HCPs between December 2023 and July 2024. Items were asked based on age groups of patients (<1, 1-2, 3-4, 5-8, 9-12, and >12 years) and severity of illness. Nominal data were summarised using frequencies (percentage) based on the number of responses received per item. Subgroup analyses were conducted for professions with five or more respondents for items related to professional role and TC. Free-text responses were analysed utilising inductive and deductive content analysis. RESULTS:Respondents (n = 228) were predominantly women (88.6%), nurses (60.1%), physicians (17.1%), or respiratory therapists (11.8%). Most respondents (67.9%-86.4% depending on patient age group) agreed it was possible to provide TC to all PICU patients. However, respondents reported rarely (4.3%-52.6%) or never (0.5%-35.6%) observing/participating in TC, depending on child age group, with a larger proportion reporting rarely or never as age group increased. Potential determinants affecting the implementation of TC in PICUs were identified for all 14 domains of the Theoretical Domains Framework. Concerns about patient safety, staffing, and lack of supportive unit culture were identified as key barriers. Family engagement and partnership and beliefs about positive consequences were key facilitators. CONCLUSIONS:Most PICU HCPs believe that TC can be implemented for all critically ill children. Important barriers include concerns about safety, staffing, and lack of a cuddling-supportive culture. Leveraging patient and family engagement is a key facilitator to support implementation of this intervention.

Sleep is a critical neurobiological process essential for brain maturation, emotional regulation, cognitive development, and overall organ system homeostasis. In the pediatric intensive care unit (PICU), sleep architecture is frequently disrupted by environmental stimuli, sedation, and clinical interventions, resulting in sleep fragmentation. Unlike sleep deprivation, sleep fragmentation preserves sleep duration but impairs its continuity and depth, disproportionately affecting slow-wave sleep, that is essential for growth, healing, in addition to immune function and REM sleep, that is fundamental for synaptic plasticity, neurogenesis, and memory consolidation. These disruptions are particularly concerning in children, who require more sleep than adults due to ongoing neurogenesis and rapid somatic growth, rendering them uniquely vulnerable to adverse effects. Emerging evidence links fragmented sleep in the PICU to altered neurodevelopmental trajectories and increased risk of Pediatric Post-Intensive Care Syndrome (PICS-p), with delirium serving as a key mediator. Despite promising adult studies on sleep-promoting interventions and EEG-based monitoring, pediatric research remains limited. Future research should prioritize objective sleep monitoring, developmental tailoring of care protocols, and longitudinal studies to clarify the impact of sleep fragmentation on recovery and neurodevelopment. This narrative review highlights the urgent need to recognize and preserve sleep as a modifiable determinant of neurocognitive outcomes in critically ill children.

OBJECTIVES This survey aims to describe the perceived needs for follow-up, and the actual follow-up received, by caregivers of Paediatric Intensive Care Unit (PICU) survivors. It explores PICU survivors’ existing healthcare usage, primary care and specialist follow-up, and return to school and work for patients and their caregivers, respectively. METHODS A cross-sectional survey of patients surviving their PICU admission at a quaternary care children’s hospital. Patients admitted less than 24 hours or who were not expected to survive were excluded. Descriptive statistics were used to describe characteristics and responses, and Likert scale responses were summarized. RESULTS Of the 139 patients consented, 62 (45%) completed the survey. Among children who attended school/daycare, 34% had not returned within 3 months of PICU discharge and 23% of those children returning to school required a new specialized education plan. Among employed caregivers, 38% had missed more than 1 month of employment. After discharge, 39% of patients had follow-up scheduled with a hospital specialist and 53% had new allied health follow-up. Of the respondents, 59% agreed or strongly agreed that follow-up after PICU would be beneficial for their child, and 84% agreed or strongly agreed that they would attend an in-person PICU follow-up appointment. CONCLUSIONS This survey demonstrates a perceived need for follow-up among some caregivers of PICU survivors, an ongoing reliance on healthcare services, and school absenteeism following PICU admission. Further work is required to better delineate the ideal timing and format of follow-up, as well as the population most likely to benefit.

Amphotericin B and posaconazole are used in the treatment of pulmonary blastomycosis. Previous reports found inadequate treatment to both antifungals due to potential sequestration in extracorporeal membrane oxygenation (ECMO). There is a lack of evidence supporting routine use of therapeutic drug monitoring (TDM) with these agents. We report amphotericin B and posaconazole TDM in two separate cases of patients with pulmonary blastomycosis and on ECMO. Plasma concentrations were collected pre- and post-ECMO membranes and used to calculate pharmacokinetic and pharmacodynamic parameters. Drug sequestration within ECMO was not evident in our cases. As such, we speculate the drugs may have saturated the circuits over time. TDM of amphotericin B and posaconazole may be beneficial in pediatric patients on ECMO, especially near initiation of therapy or after a circuit change. Further studies are warranted to evaluate the relationship between plasma concentrations of these antifungals and efficacy and safety outcomes.

IMPORTANCE:Excessive cognitive load impairs task performance and contributes to burnout, but studies of cognitive load in pediatric critical care medicine (PCCM) settings are limited. OBJECTIVES:To better understand cognitive load in an academic PCCM setting and how cognitive load differs based on experience, role, task type, and task frequency. DESIGN, SETTINGS, AND PARTICIPANTS:Prospective two-part survey at a quaternary children's hospital PCCM department. Part 1 (February to March 2022) assessed routine role-specific tasks; part 2 (June to August 2022) evaluated acute resuscitation. Participants were registered nurses (RNs), respiratory therapists (RTs), and physicians + advanced practice providers (APPs). MAIN OUTCOMES AND MEASURES:Raw cognitive load (1-9 Paas scale), net cognitive load (Paas × task frequency), and NASA-Task Load Index (NASA-TLX) subdomain scores (0-100) for acute resuscitation. Role was the primary exposure; between-group differences were analyzed using analysis of variance with pairwise comparisons. RESULTS:There were 109-part 1 and 79-part 2 survey respondents. Across all tasks, mean raw Paas scores were highest for physicians + APPs (5.2 ± 1.1), followed by RNs (4.8 ± 1.0) and RTs (4.0 ± 1.4; p = 0.004). In the three highest-load shared tasks-acute resuscitation, rescuing a decompensating patient, and managing advanced life-support devices-RNs reported significantly higher raw load than physicians + APPs and RTs. For bedside patient assessment, RNs had higher net cognitive load (25.0 ± 8.7) than physicians + APPs (20.3 ± 7.0; p = 0.01) and RTs (18.9 ± 8.9; p = 0.01). Nursing experience correlated with overall net cognitive load (r = 0.30; p = 0.02). During resuscitation, RNs reported higher NASA-TLX scores than other providers in all but two subdomains. CONCLUSIONS AND RELEVANCE:Cognitive load in PCCM varies significantly by role and task type. Nurses experience high raw cognitive load from critical events and net cognitive load from bedside patient assessment, suggesting opportunities for role-specific workflow redesign and cognitive load reduction strategies to benefit staff and patients.

Objectives: To compare the effectiveness of cognitive aid use during resuscitation with no use of cognitive aids on cardiopulmonary resuscitation quality and performance. Methods: This systematic review followed the PICOST format. All randomised controlled trials and non-randomised studies evaluating cognitive aid use during (simulated) resuscitation were included in any setting. Unpublished studies were excluded. We did not include studies that reported cognitive aid use during training for resuscitation alone. Medline, Embase and Cochrane databases were searched from inception until July 2019 (updated August 2022, November 2023, and 23 April 2024). We did not search trial registries. Title and abstract screening, full-text screening, data extraction, risk of bias assessment (using RoB2 and ROBINS -I), and certainty of evidence (using GRADE) were performed by two researchers. PRISMA reporting standards were followed, and registration (PROSPERO CRD42020159162, version 19 July 2022) was performed. No funding has been obtained. Results: The literature search identified 5029 citations. After removing 512 duplicates, reviewing the titles and abstracts of the remaining articles yielded 103 articles for full-text review. Hand-searching identified 3 more studies for full-text review. Of these, 29 studies were included in the final analysis. No clinical studies involving patients were identified. The review was limited to indirect evidence from simulation studies only. The results are presented in five different populations: healthcare professionals managing simulated resuscitations in neonates, children, adult advanced life support, and other emergencies; as well as lay providers managing resuscitations. Main outcomes were adherence to protocol or process, adherence to protocol or process assessed by performance score, CPR performance and retention, and feasibility of chatbot guidance. The risk of bias assessment ranged from low to high. Studies in neonatal, paediatric and adult life support delivered by healthcare professionals showed benefits of using cognitive aids, however, some studies evaluating resuscitations by lay providers reported undesirable effects. The performance of a meta - analysis was not possible due to significant methodological heterogeneity. The certainty of evidence was rated as moderate to very low due to serious indirectness, (very) serious risk of bias, serious inconsistency and (very) serious imprecision. Conclusion: Because of the very low certainty evidence from simulation studies, we suggest that cognitive aids should be used by healthcare professionals during resuscitation. In contrast, we do not suggest use of cognitive aids for lay providers, based on low certainty evidence.

Objective:Antimicrobial stewardship (AS) education initiatives for multidisciplinary teams are most successful when addressing psychosocial factors driving antimicrobial prescribing (AP) and when they address the needs of the team to allow for a tailored approach to their education.Design:We conducted a mixed-methods embedded study as a needs assessment, involving quantitative analysis of AS concerns observed by pharmacists through an audit while attending clinical team rounds, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF) to identify psychosocial barriers and facilitators for antimicrobial prescribing for an inpatient general pediatric service. We analyzed the data using deductive and inductive methods by mapping the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatric inpatient health care teams.Setting:The Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU), at a tertiary care pediatric hospital in Canada.Participants:Interviews (n = 23) with staff and resident physicians, nurse practitioners, and pharmacists.Results:Psychosocial facilitators and barriers for AS practice in the PICU and CTU which were identified included: collaboration, shared decision-making, locally accessible guidelines, and an overarching goal of doing right by the patient and feeling empowered as a prescriber. Some of the barriers identified included the norm of noninterference, professional comparisons, limited resources, feeling inadequately trained in AS, emotional prescribing, and a pejorative monitoring system.Conclusions:Our findings identified barriers and facilitators to AS decisions on pediatric inpatient teams as well as actionable needs in psychosocial-based AS education.

The rate of vitamin D deficiency (VDD) in critically ill children worldwide has been estimated at 50 https://clinicaltrials.gov/study/NCT03742505

We conducted an Umbrella review of eligible studies to evaluate what patient features have been investigated in the multisystem inflammatory syndrome in children (MIS-C) population, in order to guide future investigations. We comprehensively searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from December 1, 2019 to the May 6, 2022. The time period was limited to cover the coronavirus disease-2019 (COVID-19) pandemic period. The protocol was registered in the PROSPERO registry (CRD42022340228). Eligible studies included (1) a study population of pediatric patients ≤21 years of age diagnosed with MIS-C; (2) an original Systematic review or Mata-analysis; (3) published 2020 afterward; and (4) was published in English. A total of 41 studies met inclusion criteria and underwent qualitative analysis. 28 studies reported outcome data of MIS-C. 22 studies selected clinical features of MIS-C, and 6 studies chose demographic data as a main topic. The mortality rate for children with MIS-C was 1.9

Purpose Tonsillectomy is one of the most common surgical procedures performed in children. Since most clinical practice guidelines (CPGs) are designed to support surgical decisions, none are specifically designed for the perioperative management of children undergoing tonsillectomy. We aimed to identify and analyze the existing CPGs with recommendations for the perioperative management of children undergoing tonsillectomy by conducting a systematic review. Source We searched Embase, MEDLINE, MEDLINE ePub Ahead of Print, and CINAHL for relevant articles published from inception to 3 August 2022. The inclusion criteria were: 1) CPG of perioperative recommendations for tonsillectomy under general anesthesia in children, 2) CPG that include at least one evidence-based recommendation, 3) peer-reviewed CPG published in English after 2000. We extracted data on baseline characteristics of each CPG and general recommendations for perioperative interventions or complications. Principal findings Out of five eligible CPGs, AGREE II and REX confirmed that two CPGs were high quality while only one of the two was recommended for implementation without modifications. Most of the recommendations were for pain management. Acetaminophen was the only medication recommended in all five CPG. Except for the oldest CPG, the CPG all supported of the use of nonsteroidal anti-inflammatory drugs and steroids as a pain adjunct. Conclusions Acetaminophen, nonsteroidal anti-inflammatory drugs, and steroids are recommended in the perioperative management of pediatric tonsillectomy. Future CPG should further clarify the safe use of opioids based on severity of obstructive sleep apnea and in the context of opioid-sparing techniques, such as dexmedetomidine, high-dose dexamethasone, and gabapentinoids. Study registration PROSPERO (CRD42021253374); first submitted 18 June 2021.

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

BACKGROUND:Bloodstream infections (BSIs) are associated with significant mortality and morbidity, including multiple organ dysfunction. We explored if delayed adequate antimicrobial treatment for children with BSIs is associated with change in organ dysfunction as measured by PELOD-2 scores. METHODS:We conducted a multicenter, retrospective cohort study of critically ill children <18 years old with BSIs. The primary outcome was change in PELOD-2 score between days 1 (index blood culture) and 5. The exposure variable was delayed administration of adequate antimicrobial therapy by ≥3 h from blood culture collection. We compared PELOD-2 score changes between those who received early and delayed treatment. RESULTS:Among 202 children, the median (interquartile range) time to adequate antimicrobial therapy was 7 (0.8-20.1) hours; 124 (61%) received delayed antimicrobial therapy. Patients who received early and delayed treatment had similar baseline characteristics. There was no significant difference in PELOD-2 score changes from days 1 and 5 between groups (PELOD-2 score difference -0.07, 95% CI -0.92 to 0.79, p = 0.88). CONCLUSIONS:We did not find an association between delayed adequate antimicrobial therapy and PELOD-2 score changes between days 1 and 5 from detection of BSI. PELOD-2 score was not sensitive for clinical effects of delayed antimicrobial treatment. IMPACT:In critically ill children with bloodstream infections, there was no significant change in organ dysfunction as measured by PELOD-2 scores between patients who received adequate antimicrobial therapy within 3 h of their initial positive blood culture and those who started after 3 h. Higher PELOD-2 scores on day 1 were associated with larger differences in PELOD-2 scores between days 1 and 5 from index positive blood cultures. Further study is required to determine if PELOD-2 or alternative measures of organ dysfunction could be used as primary outcome measures in trials of antimicrobial interventions in pediatric critical care research.

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Purpose To describe and review the experience of two pediatric intensive care units (PICUs) in Ontario, Canada, adapting and providing care to critically ill adults during the COVID-19 pandemic. Clinical features At a time of extreme pressure to adult intensive care unit (ICU) capacity, two PICUs provided care to critically ill adults with COVID-19 pneumonia. Substantial yet rapid planning was required to facilitate safe delivery of critical care to adult patients while maintaining PICU services, including thoughtful development of care pathways and patient selection. To prepare clinical staff, several communication strategies, knowledge translation, skill consolidation, and system-adaptation mechanisms were developed. There was iterative adaptation of operational processes, including staffing models, specialist consultation, and the pharmacy. Care provided by the interprofessional teams was reoriented as appropriate to the needs of critically ill adults in close collaboration with adult ICU teams. Forty-one adults were admitted to the two PICUs over a 12-week period. In total, 36 patients (88%) received invasive ventilation, eight patients (20%) were supported with venovenous extracorporeal membrane oxygenation, and six patients (15%) received continuous renal replacement therapy. Four died in the PICU during this period. Feedback from staff included anxiety around reorienting practice to the care of critically ill adults, physical exhaustion, and psychological distress. Importantly, staff also reported a renewed sense of purpose with participation in the program. Conclusion Though challenging, the experience has provided opportunity to enhance collaboration with partner institutions and improve the care of older children and adolescents in the PICU.