Intensive care unit admission in children with malignant or nonmalignant disease: incidence, outcome, and prognostic factors: a single-center experience.

OBJECTIVE: To investigate pediatric intensive care unit (PICU) admission in children with malignant and nonmalignant diseases who developed life-threatening complications. PATIENTS AND METHODS: Between 1999 and 2010, of the 1278 eligible pediatric patients treated for a malignant or nonmalignant disease, 54 were admitted to the PICU for respiratory distress (40.7%), neurological events (33.3%), severe sepsis (14.8%), and organ failure (11.2%). RESULTS: Rate of PICU admission was 4.2%, with a 2-year cumulative incidence of 4.5%. Risk factors associated with higher cumulative incidence of PICU admission were older age at study entry (P=0.003), nonmalignant underlying disease (P=0.015), and hematopoietic stem cell transplantation (P<0.001). Patients with leukemia/lymphoma were more likely to be admitted to the PICU compared with patients with solid tumors (P<0.001). Patients admitted because of organ failure had the highest frequency of death within 90 days. Factors significantly associated with survival at 90 days from PICU admission included: no mechanical ventilation (P<0.001), nonmalignant underlying disease (P=0.030), and year of PICU admission after 2005 (P=0.038). CONCLUSIONS: Nonmalignant disease and use of alternative hematopoietic stem cell transplantation were associated with higher risk of PICU admission. Close cooperation between hematologists and intensivists and definition of criteria for PICU admission and discharge contributed to increase in survival of these patients.

Spinal muscular atrophy type 1: avoidance of hospitalization by respiratory muscle support.

OBJECTIVE: The aim of this study was to report the outcomes of an oximetry protocol using up to continuous full ventilator-setting noninvasive ventilation (NIV) and mechanically assisted coughing (MAC) to avoid episodes of acute respiratory failure and hospitalizations for children with spinal muscular atrophy type 1 under 3 yrs of age. DESIGN: This study was a retrospective chart review of 16 patients with spinal muscular atrophy type 1 under 3 yrs of age consecutively referred for respiratory decompensations resulting in continuous NIV dependence and oxyhemoglobin desaturation. An avoided hospitalization was defined by the need for continuous NIV using high span bilevel positive airway pressure and reversal of desaturations by MAC in the home setting. The protocol included training and equipping parents to use NIV, MAC, and basic life support. RESULTS: There were 49 acute episodes (1.20/patient per year), of which 43 met the criteria for an avoided hospitalization. Therefore, only six episodes (0.15/patient per year) required hospitalization, and four required endotracheal intubation (0.1/patient per year). Three of the four were extubated after 4, 9, and 15 days, respectively, to full NIV support and aggressive MAC. The fourth patient, for whom NIV could not be provided, underwent an emergency intubation at home and died at the age of 40 mos. CONCLUSIONS: A protocol including high span bilevel positive airway pressure along with MAC to expel airway secretions and normalize oxyhemoglobin saturation can be used by trained caregivers to avoid episodes of acute respiratory failure and hospitalization for children with spinal muscular atrophy type 1 under 3 yrs of age.

Pediatric Intensive Care Unit admission criteria for haemato-oncological patients: a basis for clinical guidelines implementation.

Recent advances in supportive care and progress in the development and use of chemotherapy have considerably improved the prognosis of many children with malignancy, thus the need for intensive care admission and management is increasing, reaching about 40% of patients throughout the disease course. Cancer remains a major death cause in children, though outcomes have considerably improved over the past decades. Prediction of outcome for children with cancer in Pediatric Intensive Care Unit (PICU) obviously requires clinical guidelines, and these are not well defined, as well as admission criteria. Major determinants of negative outcomes remain severe sepsis/septic shock association and respiratory failure, deserving specific approach in children with cancer, particularly those receiving a bone marrow transplantation. A nationwide consensus should be achieved among pediatric intensivists and oncologists regarding the threshold clinical conditions requiring Intensive Care Unit (ICU) admission as well as specific critical care protocols. As demonstrated for the critically ill non-oncologic child, it appears unreasonable that pediatric patients with malignancy can be admitted to an adult Intensive Care Unit ICU. On a national basis a pool of refecence institutions should be identified and early referral to an oncologic PICU is warranted.

Invasive mould infections in newborns and children.

Invasive mould infections represent important complications of different pediatric conditions. Epidemiology and clinical features vary according to the type of underlying conditions that determine the risk of invasive mycosis. No pediatric study has specifically evaluated the efficacy of prophylaxis or therapy invasive moulds infections, while pediatric dosages for the treatment of invasive aspergillosis are available for drugs that produced positive results in clinical trials undertaken in adults.

High Levels of beta-D-glucan in immunocompromised children with proven invasive fungal disease.

The plasmatic levels of 1,3-beta-d-glucan (BDG) were >523 pg/ml in 4 children, 2 low-birth-weight neonates and 2 stem cell transplant recipients, with the following invasive fungal diseases (IFD) proven apart from this BDG test: 3 cases of Candida parapsilosis candidemias and 1 case of disseminated aspergillosis. The BDG test may be useful for identification of IFD in pediatrics.