Essentials of Paediatric Intensive Care

ObjectiveTo identify the neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil that use cuffed tracheal tubes in clinical practice and to describe the characteristics related to the use of protocols and monitoring.MethodsTo identify the intensive care units in Brazil, the Ministry of Health’s National Registry of Health Facilities was accessed, and information was collected on 693 registered intensive care units. This was an analytical cross-sectional survey conducted through electronic questionnaires sent to 298 neonatal, pediatric and mixed intensive care units in Brazil.ResultsThis study analyzed 146 questionnaires (49.3% from neonatal intensive care units, 35.6% from pediatric intensive care units and 15.1% from mixed pediatric intensive care units). Most of the participating units (78/146) used cuffed tracheal tubes, with a predominance of use in pediatric intensive care units (52/78). Most of the units that used cuffed tracheal tubes applied a cuff pressure monitoring protocol (45/78). The use of cuff monitoring protocols was observed in intensive care units with a physical therapy service exclusive to the unit (38/61) and in those with a physical therapist present 24 hours/day (25/45). The most frequent cause of extubation failure related to the use of cuffed tracheal tubes in pediatric intensive care units was upper airway obstruction.ConclusionIn this survey, the use of cuffed tracheal tubes and the application of a cuff pressure monitoring protocol was predominant in pediatric intensive care units. The use of a monitoring protocol was more common in intensive care units that had a physical therapist who was exclusive to the unit and was present 24 hours/day.

Important Outcomes for Parents of Critically Ill Children.

Objective: Elevated intra-abdominal pressure (IAP) is associated with organ dysfunction in critically ill children. Thus far, the predictive value of IAP for mortality remains unknown. Moreover, only few studies determined normal IAP values in pediatric intensive care unit (PICU) children. This study aimed to determine the predictive value of IAP for mortality and calculate normal IAP values in PICU patients.Methods: This prospective observational study was conducted in two PICUs of two tertiary care university teaching hospitals. Patients admitted to the PICU between December 2013 and November 2015 were included. IAP was determined by bladder pressure measurements performed every 8 h until 48 h or until PICU discharge. All patients (except neonatal patients) aged ≤ 14 years who were admitted to the PICUs and had no history of chemical neuromuscular blockade use, neurogenic bladder, or bladder surgery were enrolled. Binary logistic regression was used to analyze the predictive value of IAP for 28-day mortality. Receiver operating characteristic curves were generated to evaluate the prediction effect of IAP.Results: Overall, 229 patients were enrolled. IAP (hazard ratio 1.09, 95% confidence interval [CI] 1.029–1.161, P = 0.004) and lactic acid (hazard ratio 3.04, 95% CI 1.769–5.21, P < 0.001) were independent predictors of 28-day mortality. Additionally, IAP had good predictive power for 28-day mortality, with an area under the curve of 0.74. The optimal cutoff point was 12.13 mmHg (sensitivity 0.58, specificity 0.80). The Youden index was 0.38.Furthermore, 111 (48.47%) patients without high-risk factors or clinical manifestations of IAH were analyzed to determine normal IAP values, which were 7.57 ± 2.85 mmHg (range, 1.98–13.16 mmHg). There were no significant differences in normal IAP values according to different diseases, sex, age, weight, or body mass index (BMI).Conclusions: IAP has good predictive power for 28-day mortality. The optimal IAP cutoff point is 12.13 mmHg. The IAP reference range is 2.0–13.2 mmHg, which was not associated with factors such as sex, age, weight, and BMI in PICU children. We recommend that IAP be included in critical illness scoring systems in the future. IAP >12.13 mmHg may be more suitable for IAH definition in PICU patients.

Background: Pediatric intensive care unit (PICU) is a highly stressful environment to most parents. Knowledge of stress allows us to plan counselling strategies for the suffering parents. The objectives were to identify common parental stressors during their child’s critical illness and to examine the relationship of demographic variables with their stress.Methods: It was a prospective observational study done in PICU of a tertiary care medical college hospital in Mangalore. One hundred parents of children (1 month to 15 years) admitted to PICU for at least 24 hours were interviewed using the Parental Stress Scale (PSS: PICU), which rates 22 factors on a scale from 1 (not stressful) to 5 (extremely stressful). The demographic and clinical characteristics of children were also recorded and analysed statistically.Results: The average parental stress score was 3.5. The main causes of extremely stressful situations were the sight of their child being unresponsive, sight of monitors &amp; equipment in PICU, other sick children in PICU, crises in other children in the PICU. Parents of children who got admitted in PICU for the first time were more stressed. Younger parents were more stressed than older parents, irrespective of the illness and clinical status. Age of the child, sex, socioeconomic status, urban/rural, father/mother did not vary stress levels, all had similar stress level (score&gt;3). Among the procedures, majority (52%) parents felt intravenous cannulation as more stressful followed by blood sampling (43%).Conclusions: Young parents and first PICU admission were more stressful. Socioeconomic status, residential area and age of children did not affect level of stress. Many of these stress factors can be looked into and remedial steps can be taken to relieve some of these stressors.

Les clowns en réanimation pédiatrique : état des lieux en France

Aims: This study aimed to investigate the impact of the presence or absence of verbal communication skills in pediatric intensive care unit (PICU) patients who are unable to eat orally and are fed via enteral or parenteral methods, on the stress levels perceived by their parents. Methods: The study included 49 children hospitalized in the PICU with dysphagia and feeding difficulties. The participants’ information regarding tracheostomy, intubation, ability/inability to engage in verbal communication, and type of enteral feeding was recorded. Patients were retrospectively assessed using PRISM (pediatric risk of mortality) scores, and the Turkish version of the Parental Stress Scale was administered to one parent per patient. The participants were grouped based on their child’s verbal communication ability and feeding method (enteral vs. parenteral), and statistical comparisons were made using the Mann-Whitney U test. ROC (receiver operating characteristic) analysis was conducted to identify which of the recorded clinical variables had the most significant effect on parental stress. Results: The mean age of the children was 7.69 years, with 59.2% being male. Of the 49 children included, 31 (63.3%) were classified as non-verbal and 18 (36.7%) as verbal, according to their ability to communicate. While 81.6% were non-intubated, 42.9% had tracheostomies. Feeding methods included nasogastric tube (46.9%), total parenteral nutrition (38.8%), and percutaneous endoscopic gastrostomy (10.2%). The mean PRISM score was 4.0, and the average parental stress score was 69.1. Parents of non-verbal children reported significantly higher stress levels than those of verbal children (p=0.002). Although parental stress appeared higher in the parenteral nutrition group, the difference was not statistically significant (p=0.077). PRISM scores showed no significant differences between groups based on communication or feeding method. According to the ROC analysis [area under the curve (AUC)=0.728], the most significant indicator of parenteral stress was found to be the inability to engage in verbal communication. Conclusion: The findings demonstrate that the inability of children in PICU to verbally communicate significantly increases parental stress levels, independent of illness severity. Although feeding method did not significantly impact parental stress, a trend toward higher stress in parents of parenterally fed children was observed. These results emphasize the importance of preserving or supporting communication abilities in PICU patients. Implementing augmentative and alternative communication strategies (e.g., speaking valves, communication boards) and integrating psychosocial support for caregivers may contribute to improved family-centered care in pediatric critical care settings.

BackgroundThe use of long-term life-sustaining technology for children improves survival rates in paediatric intensive care units (PICUs), but it may also increase long-term morbidity. One example of this is children who are dependent on invasive long-term ventilation. Clinicians caring for these children navigate an increasing array of ethical complexities. This study looks at the meaning clinicians give to the bioethical considerations associated with the availability of increasingly sophisticated technology.MethodsA hermeneutic phenomenological exploration of the experiences of clinicians in deciding whether to initiate invasive long-term ventilation in children took place, via unstructured interviews. Data were analysed to gain insight into the lived experiences of clinicians. Participants were from PICUs, or closely allied to the care of children in PICUs, in four countries.ResultsThree themes developed from the data that portray the experiences of the clinicians: forming and managing relationships with parents and other clinicians considering, or using, life sustaining technology; the responsibility for moral and professional integrity in the use of technology; and keeping up with technological developments, and the resulting ethical and moral considerations.DiscussionThere are many benefits of the availability of long-term life-sustaining technology for a child, however, clinicians must also consider increasingly complex ethical dilemmas. Bioethical norms are adapting to aid clinicians, but challenges remain.ConclusionDuring a time of technological solutionism, more needs to be understood about the influences on the initiation of invasive long-term ventilation for a child. Further research to better understand how clinicians, and bioethics services, support care delivery may positively impact this arena of health care.

PurposeSerratia marcescens is a well-recognized hospital-acquired pathogen frequently implicated in outbreaks in neonatal and pediatric intensive care units. We compared clinical characteristics of infants with Serratia bloodstream infections (BSI) to those with non-Serratia gram-negative BSI.MethodsA retrospective case-control study comparing infants (0-2 y/o) hospitalized at our referral pediatric cardiac intensive care unit (PCICU), who acquired gram-negative blood cultures, during 2012-2022. Patients were categorized into two groups: S. marcescens BSI versus non-Serratia gram-negative BSI. Demographic and clinical data were extracted from our medical databases.ResultsOf 112 patients meeting inclusion criteria, 40 (36%) had Serratia BSI and 72 (64%) non-Serratia gram-negative BSI. Blood stream infection with Serratia occurred later postoperatively (median 15 vs 7 days, p < .01), were associated with less pre-infection inotropic support (median VIS 0 vs 5, p < .01) and higher rates of multisite involvement (35% vs 18%, p = .04). Duration of indwelling vascular catheters at time of infection was longer in the Serratia group (median 10 vs 7 days, p = .03). No associated mortality was attributed to Serratia BSI, as compared to a 5.6% mortality rate in the non-Serratia group.ConclusionsSerratia BSI in the PCICU tends to develop later during hospitalization, involves more multiple infection sites, and is associated with longer vascular catheters dwell durations at the time of infection. Serratia infections appeared sporadically throughout the year without seasonal clustering. This supports the importance of stringent infection control practices and warrants prospective studies on prevention strategies.

Computed radiography in neonatal and pediatric intensive care units: A comparison of 2.5 K × 2 H soft copy images vs digital hard-copy film

ObjectiveTo quantify the characteristics of children admitted to neonatal units (NNUs) and paediatric intensive care units (PICUs) before the age of 2 years.DesignA data linkage study of routinely collected data.SettingNational...

Comparison of severity and diagnosis-adjusted mortality rates from pediatric intensive care units (ICUs) staffed by physicians training in pediatric critical care, as well as pediatric residents, with mortality rates from pediatric ICUs staffed with only pediatric residents. Cohort study. Sixteen volunteer pediatric ICUs, eight with critical care fellowships, and eight without such programs. Consecutive admissions until at least 14 deaths occurred at each site. None. Descriptive data and Pediatric Risk of Mortality scores were collected. Severity and diagnosis-adjusted mortality risk for each patient was computed by a predictor developed in an independent sample. The effect of fellowship programs was analyzed at the institution level by ranking the pediatric ICUs in terms of observed/predicted mortality rates, and, at the patient level, by including a training factor into the predictor model. The use of monitoring and therapeutic modalities was compared in the two types of pediatric ICUs by severity-adjusted odds ratios. There were 2,744 admissions (145 deaths) to the eight fellowship pediatric ICUs and 3,006 admissions (150 deaths) to the eight nonfellowship pediatric ICUs. Institutional characteristics were not different between the two pediatric ICU sets. The raw mortality rates were similar (fellowship 5.28%; nonfellowship 4.99%, p = .714). Institution-level analyses indicated that fellowship pediatric ICUs performed better than nonfellowship pediatric ICUs; fellowship pediatric ICUs ranked better than pediatric ICUs without such programs (Wilcoxon rank-sum test, p = .020). However, both the best and the worst ranked pediatric ICUs had fellowships. Patient-level analyses also indicated that outcome was significantly influenced by the fellowship status of the pediatric ICU. Using two different patient-level analytic approaches, the odds of dying in a fellowship pediatric ICU vs. a nonfellowship pediatric ICU were 0.592 (95% confidence interval 0.468 to 0.749, p = .0001) and 0.714 (95% confidence interval 0.529 to 0.964, p = .028). Pediatric ICUs with fellowship programs performed more (p < .05) invasive monitoring, including intra-arterial catheters and central venous pressure catheters, and more technological therapies such as mechanical ventilation. Pediatric ICUs with critical care fellowship programs are generally associated with better risk-adjusted mortality rates than pediatric ICUs without such fellowship training programs. The cause for this effect requires a more in-depth study. The presence or absence of such training programs does not guarantee superior or inferior performance.

BackgroundResearch on pediatric intensive care unit (PICU) readmission is lacking in China. This study was conducted to describe the risk factors associated with PICU readmission within 1 year after PICU discharge.MethodsThis retrospective case-control study included patients aged from 1 month to 16 years who were discharged between January 2018 and May 2020. The case group included readmitted patients with two or more PICU admissions within 1 year during the study period. The control group included survivors with only one PICU admission during the same study period, and the controls were matched on age and sex. Demographic and clinical variables were collected from the electronic administrative database. Risk factors were analyzed by univariate and multivariate analyses.ResultsFrom January 2018 to May 2020, 2,529 patients were discharged from the PICU, and 103 (4.07%) were readmitted within 1 year. In the univariate analysis, PICU readmission within 1 year was associated with lower weight, the presence of chronic conditions, a higher StrongKids score on admission, length of PICU stay of more than 2 weeks, the presence of dysfunction at discharge, sedation medications use, vasopressor use, and invasive mechanical ventilation in the first PICU stay. Patients had a higher StrongKids score as a surrogate for increased risk of malnutrition. In the multivariate analysis, the factors most significantly associated with PICU readmission within 1 year were the presence of chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks in the first PICU stay. In the subgroup analysis, compared with the control group, the factors most significantly associated with readmission within 48 h of discharge were the presence of chronic conditions, a higher StrongKids score on admission, and vasopressor use during the first PICU stay. The mortality rate was 8.74% (9/103) in patients with PICU readmission. The overall PICU mortality rate was 7.39% (201/2,721) during the study period.ConclusionsPatients with chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks were at much higher risk for PICU readmission within 1 year. Patients with vasopressor use during the first PICU hospitalization were more likely to be readmitted within 48 h of discharge.

Mycoses are diseases caused by fungi that involve different parts of the body and can generate dangerous treatment complications. This study aims to analyze fungal infection epidemiology in intensive care units (Pediatric and Cardiac Surgery Intensive Care Units—PCICU) and the Neonatal Intensive Care Unit (NICU) in one large pediatric center in the period 2015–2020 compared with 2005. The year 2005 was randomly selected as a historical time reference to notice possible changes. In 2005 and 2015–2020, 23,334 mycological tests were performed in intensive care units. A total of 4628 tests (19.8%) were performed in the intensive care units. Microbiological diagnostics involved mycological and serological testing. Of the 458 children hospitalized in the NICU, positive results in the mycological tests in the studied years were found in 21–27% of the children and out of 1056 PCICU patients, positive results were noticed in 18–29%. In both departments, the main detected pathogen was Candida albicans which is comparable with data published in other centers. Our experience indicates that blood cultures as well as the detection of antifungal antibodies do not add important information to mycological diagnostics. For the years of observation, only a few positive results were detected, even in patients with invasive fungal diseases. To our knowledge, this is one of a few similar studies over recent years and it provides contemporary reports of mycoses in pediatric ICU patients.

Successful Integration of Advanced Practice Providers Into a Pediatric Academic Community Intensive Care Unit

Kobayashi Pediatric Clinic, Fujieda 426-0067, JapanCommunicated by Takaji Wakita(Accepted August 26, 2013)In 2011, a large outbreak of hand-foot-and-mouthdisease (HFMD) caused by coxsackievirus A6 (CV-A6)occurred in Japan and other countries. The cutaneousmanifestations of CV-A6-associated HFMD (CV-A6-HFMD) are more extensive and variable than those ofclassic HFMD (1–3). Differential diagnosis of HFMDfrom chickenpox is occasionally challenging because ofits unusual clinical characteristics. For example, thespread of rashes in CV-A6-HFMD is more toward theextremities and body trunk, a manner different fromthat in typical HFMD in which the rashes are mostly lo-calized to the hands and soles of the feet (1,2).A 24-month-old girl was hospitalized in the pediatricintensive care unit (PICU) on May 16, 2013 (23 days be-fore day 0) due to hypoxemia. The patient had an un-derlying diagnosis of Down syndrome with a ventricularseptal defect and pulmonary hypertension but no histo-ry of varicella infection or vaccination against varicella.Before discharge on June 8, 2013 (day 0), she devel-oped a reddish papular rash with some vesicles on herhip, which rapidly spread throughout her entire bodyand face; she was afebrile.On June 10, 2013 (day 2), the Infection Control Team(ICT) of the Saiseikai Nakatsu Hospital (Osaka, Japan)was notified of this patient as a suspected case of chick-enpox in PICU. Assessment of this case was complicat-ed because the rash spread to her upper and lower ex-tremities; however, it was also observed to a lesserextent on her body trunk but not on the head. Althoughthe papules were comparable to varicella in terms oftheir size (approximately 5 mm), HFMD was consideredto be more likely because there were fewer vesicles thanthat expected for varicella, and the rash was neithercrusted nor pigmented.Infection control policies and measures for varicella-zoster virus (VZV) and enterovirus are different. VZV istransmitted via droplet nuclei, whereas enterovirus istransmitted from person to person via direct contactwith the virus shed from the gastrointestinal or upperrespiratory tract. To prevent enteroviral transmission,hand hygiene is particularly important (4). Althoughthere was no other case of suspected chickenpox inPICU, the Department of Pediatrics was concernedabout the high transmissibility of varicella, which is air-borne. ICT in collaboration with the pediatric staff im-mediately initiated varicella infection control in thepediatric ward and performed laboratory diagnosis fortreatment of the present case. ICT decided to implementthe following responses: (i) immediate isolation of theinfected patient from other children in PICU from June10, 2013; (ii) immediate restriction on PICU use fromJune 10, 2013; and (iii) drafting a plan of broadprophylactic administration of antivirals against VZVfor children who were housed in the same room depend-ing on the laboratory result for VZV.In addition to a specific laboratory examination forVZV, specimens of pharyngeal swabs, vesicular fluid,and feces were collected during the course of medicalcare, and laboratory tests were performed for diagnosisand treatment. Informed consent for this study was ob-tained from the patient’s guardian, and the clinicalsamples were tested to device a treatment plan and in-fection control measures.On June 12, 2013 (day 4), the results of VZV tests in-cluding analysis of IgM, IgG, and specific viral antigen,were negative. On the same day, specimens (vesiclefluid, nasopharyngeal swabs, and feces) were collected,and reverse transcription (RT)-hyper PCR (5) was per-formed to screen for enterovirus in all samples (day 4).RT-hyper PCR was employed because it is faster thanpreviously available PCR methods (5,6).Based on the results obtained by RT-hyper PCR, ICTimmediately terminated varicella surveillance and dis-continued the restriction on PICU use and antiviraltherapy to the patient. The team also withdrew thebroader prophylactic antiviral administration through-out the unit and instead endorsed precautions againstcontact infections.On June 14, 2013 (day 6), RT-PCR was performed todetermine the partial nucleotide sequence of the capsidprotein VP1 cording region. Primer pairs were designed