The author replies.

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

Important Outcomes for Parents of Critically Ill Children.

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.

Pediatric AnesthesiaVolume 31, Issue 2 p. 249-250 CORRESPONDENCE Intrathecal nusinersen administration: Is anesthesia really needed? Anna Camporesi, Corresponding Author Anna Camporesi anna.camporesi@asst-fbf-sacco.it orcid.org/0000-0002-1160-1456 Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, Italy Correspondence Anna Camporesi, Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, Italy. Email: anna.camporesi@asst-fbf-sacco.itSearch for more papers by this authorAnna Mandelli, Anna Mandelli Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, ItalySearch for more papers by this authorElisa Melloni, Elisa Melloni Psychiatry and Psychobiology Unit, Division of Neuroscience, Scientific Institute Ospedale San Raffaele, Milano, ItalySearch for more papers by this author Anna Camporesi, Corresponding Author Anna Camporesi anna.camporesi@asst-fbf-sacco.it orcid.org/0000-0002-1160-1456 Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, Italy Correspondence Anna Camporesi, Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, Italy. Email: anna.camporesi@asst-fbf-sacco.itSearch for more papers by this authorAnna Mandelli, Anna Mandelli Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, ItalySearch for more papers by this authorElisa Melloni, Elisa Melloni Psychiatry and Psychobiology Unit, Division of Neuroscience, Scientific Institute Ospedale San Raffaele, Milano, ItalySearch for more papers by this author First published: 04 February 2021 https://doi.org/10.1111/pan.14048Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume31, Issue2February 2021Pages 249-250 RelatedInformation

Paediatric Intensive Care Unit, Department of Pediatrics, Sidra Medicine, Doha, Qatar *See also p. e130. Dr. Branco has disclosed that he does not have any potential conflicts of interest.

Les clowns en réanimation pédiatrique : état des lieux en France

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.

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.

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

Essentials of Paediatric Intensive Care

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

The prevalence of delirium in intensive care units (ICUs) is high and has a major impact on patient outcomes. To describe delirium assessment instruments, prevalence, interventions and barriers in delirium management in adult and paediatric ICUs; and to explore the association between delirium prevalence and reported interventions and barriers at unit level. A secondary analysis of the cross-sectional World Delirium Awareness Day Delirium Survey on 15 March 2023. This was a prospective study to assess the one-day point delirium prevalence, practices and quality improvement efforts across healthcare systems. Data was analysed descriptively and using multiple linear regression. Data of 1612 assessments in 123 ICUs from three German-speaking countries were analysed. The most frequently used delirium assessment instrument was the Intensive Care Delirium Screening Checklist (43.9%, n = 54). The prevalence of delirium at 8 AM was 18.6% and at 8 PM 20.4% from the 94 ICUs included in the regression analyses. Prevalence for adult and paediatric and mixed ICUs are comparable. Main reported over all unit-level interventions were 'pain management' (95.9%, n = 118), 'mobilization' (94.3%, n = 116) and 'verbal re-orientation' (84.6%, n = 104). Main reported over all unit-level barriers were 'shortage of staff' (53.7%, n = 66) and 'patients who are difficult to assess' (44.7%, n = 55). Interventions such as 'avoidance of bladder tubes/catheters' in all ICUs, 'use of ear plugs and/or sleep glasses' in adult ICUs and 'mobilization' in paediatric and mixed ICUs were associated with reduced delirium prevalence. Across all ICUs, as well as in both adult and paediatric ICUs, 'lack of appropriate scores for delirium assessment' was identified as a significant barrier. One fifth of assessed ICU patients suffer from delirium. Several reported unit-level interventions and barriers may have an impact on delirium prevalence, suggesting an approach for future studies and clinical practice. In clinical practice, unit-level 'avoidance of bladder tubes/catheters', 'use of ear plugs and/or sleep glasses' and 'mobilization' may be used as delirium prevention and treatment interventions.

AimTo optimise smart-pump functionality as part of an ongoing multi-phase project to develop a national smart-pump drug library of standard concentration infusions (SCIs) suitable for paediatric and neonatal patients in...