Pathogen kinetics and detection by next-generation sequencing in pediatric complicated pneumonia.

Pediatric pneumonia can be severe and result in empyema. Next-generation sequencing (NGS) may broadly detect pathogens though, optimal timing and impact of sample type on diagnostic yield is unknown. This is a prospective, single-center pilot study of children aged 3 months through 17 years admitted to the PICU with a primary diagnosis of complicated pneumonia. Plasma, endotracheal, nasopharyngeal, and pleural fluid samples were collected at three time points during hospitalization. After nucleic acid extraction, combined libraries were enriched with an NGS enrichment panel kit (RPIP, Illumina), sequenced and quantitative organism detections were analyzed. NGS identified the same bacterial pathogen as traditional testing in all samples, regardless of antibiotic pre-treatment or time collected. Conventional culture methods only identified the pathogen reliably in invasively obtained pleural fluid or endotracheal aspirates. Future application of NGS may allow for non-invasive pathogen detection at a broader range of time points and more targeted antibiotic coverage.

High Flow Nasal Cannula Versus Conventional Oxygen Therapy and Incidence of Post-Extubation Airway Obstruction in PICU: An Open-Label Randomized Controlled Trial (HiFloCOT-PICU Trial).

OBJECTIVES: To study the impact of high flow nasal cannula (HFNC) vs. conventional oxygen therapy (COT) (by simple nasal cannula) as respiratory support after extubation on the rates of post-extubation airway obstruction (PEAO) among mechanically ventilated critically ill children. METHODS: This open-label randomized controlled trial was conducted in pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India over a period of 7 mo (11 August 2021 to 10 March 2022). Children aged 3 mo to 12 y who required invasive mechanical ventilation for > 72 h and had passed spontaneous breathing trial (ready for extubation) were enrolled and randomized by computer generated block randomization to receive HFNC or COT after extubation. Primary outcome was rate of PEAO (assessed by modified Westley croup score, mWCS) within 48 h of extubation; and secondary outcomes were rate and number of adrenaline nebulization, treatment failure (requiring escalation of respiratory support), extubation failure, adverse events, and length of PICU stay in two groups. RESULTS: During the study period, 116 children were enrolled (58 each in HFNC and COT groups). There was no difference in rate of PEAO (55% vs. 51.7%, respectively), need of adrenaline nebulization, extubation failure, adverse events, and duration of PICU stay in two groups. However, the HFNC group had significantly lower rates of treatment failure (27.6% vs. 48.3%, p = 0.02). CONCLUSIONS: The rate of PEAO was similar in HFNC and COT groups. However, HFNC group had significantly lower rate of treatment failure requiring escalation of respiratory support.

A simple nomogram for predicting the mortality of PICU patients with sepsis-associated encephalopathy: a multicenter retrospective study.

Background: As one of the serious complications of sepsis in children, sepsis-associated encephalopathy (SAE) is associated with significantly poor prognosis and increased mortality. However, predictors of outcomes for pediatric SAE patients have yet to be identified. The aim of this study was to develop nomograms to predict the 14-day and 90-day mortality of children with SAE, providing early warning to take effective measures to improve prognosis and reduce mortality. Methods: In this multicenter, retrospective study, we screened 291 patients with SAE admitted to the PICU between January 2017 and September 2022 in Shandong Province. A least absolute shrinkage and selector operation (LASSO) method was used to identify the optimal prognostic factors predicting the outcomes in pediatric patients with SAE. Then, multivariable logistic regression analysis was performed based on these variables, and two nomograms were built for visualization. We used the area under the curve (AUC), calibration curves and decision curves to test the accuracy and discrimination of the nomograms in predicting outcomes. Results: There were 129 patients with SAE in the training cohort, and there were 103 and 59 patients in the two independent validation cohorts, respectively. Vasopressor use, procalcitonin (PCT), lactate and pediatric critical illness score (PCIS) were independent predictive factors for 14-day mortality, and vasopressor use, PCT, lactate, PCIS and albumin were independent predictive factors for 90-day mortality. Based on the variables, we generated two nomograms for the early identification of 14-day mortality (AUC 0.853, 95% CI 0.787-0.919, sensitivity 72.4%, specificity 84.5%) and 90-day mortality (AUC 0.857, 95% CI 0.792-0.923, sensitivity 72.3%, specificity 90.6%), respectively. The calibration plots for nomograms showed excellent agreement of mortality probabilities between the observed and predicted values in both training and validation cohorts. Decision curve analyses (DCA) indicated that nomograms conferred high clinical net benefit. Conclusion: The nomograms in this study revealed optimal prognostic factors for the mortality of pediatric patients with SAE, and individualized quantitative risk evaluation by the models would be practical for treatment management.

Oncological pediatric early warning score: a dedicated tool to predict patient's clinical deterioration and need for pediatric intensive care treatment.

Pediatric oncohematological patients frequently require PICU admission during their clinical history. The O-PEWS is a specific score developed to predict the need for PICU admission of oncohematological children. This study aimed at i) describing the trend of the O-PEWS in a cohort of patients hospitalized in the Pediatric Oncohematology ward and transferred to the PICU of Padua University Hospital, measured at different time-points in the 24 hours before PICU admission and to evaluate its association with mortality and presence of organ failure; ii) investigating the association between the recorded O-PEWS, and PIM3, number of organ failure and the need for ventilation, dialysis and inotropes.This retrospective single-center study enrolled oncohematological children admitted to the PICU between 2017 and 2021. The O-PEWS, ranging between 0 and 15, was calculated on the available medical records and the TIPNet-Network database at 24 (T-24), 12 (T-12), 6 (T-6) and 0 (T0) hours before PICU admission.RESULTS: 101 PICU admissions, related to 80 children, were registered. During the 24 hours prior to PICU admission, the O-PEWS progressively increased in all the patients. At T-24 the median O-PEWS was 3 (IQR 1-5), increasing to a median value of 6 (IQR 4-8) at T0. The O-PEWS was positively associated with mortality, organ failure and the need for ventilation at all the analyzed time-points and with the need for dialysis at T-6.The O-PEWS appears as a useful tool for predicting early clinical deterioration in oncohematological patients and for anticipating the initiation of life-support treatments.

Uses of infrared thermography in acute illness: a systematic review.

Introduction: Infrared thermography (IRT) is a non-contact, non-ionising imaging modality, providing a visual representation of temperature distribution across a surface. Methods: We conducted a systematic search of indexed and grey literature for studies investigating IRT applications involving patients in acute care settings. Studies were categorised and described along themes identified iteratively using narrative synthesis. Quality appraisal of included studies was performed using the Quality Assessment tool for Diagnostic Accuracy Studies. Results: Of 1,060 unique records, 30 studies were included. These were conducted in emergency departments and intensive care units involving adult, paediatric and neonatal patients. IRT was studied for the diagnosis, monitoring or risk stratification of a wide range of individual conditions. IRT was predominantly used to display thermal change associated with localised inflammation or microcirculatory dysfunction. Existing research is largely at an early developmental stage. Discussion: We recommend that high quality diagnostic validation studies are now required for some clinical applications. IRT has the potential to be a valuable tool in the acute care setting and represents an important area for future research particularly when combined with advances in machine learning technology. Systematic review registration: CRD 42022327619 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327619).

Early Impressions and Adoption of the AtriAmp for Managing Arrhythmias Following Congenital Heart Surgery.

AtriAmp is a new medical device that displays a continuous real-time atrial electrogram on telemetry using temporary atrial pacing leads. Our objective was to evaluate early adoption of this device into patient care within our pediatric intensive care unit (PICU). This is a qualitative study using inductive analysis of semi-structured interviews to identify dominant themes. The study was conducted in a single-center, tertiary, academic 21-bed mixed PICU. The subjects were PICU multidisciplinary team members (Pediatric Cardiac Intensivists, PICU Nurse Practitioners, PICU nurses and Pediatric Cardiologists) who were early adopters of the AtriAmp (n = 14). Three prominent themes emerged: (1) Accelerated time from arrhythmia event to diagnosis and treatment; (2) Increased confidence in the accuracy of providers' arrhythmia diagnosis; and (3) Improvement in the ability to educate providers about post-operative arrhythmias. Providers also noted some learning curves, but none compromised medical care or clinical workflow. Insights from early adopters of AtriAmp signal the need for simplicity and fidelity in new PICU technologies. Our research suggests that such technologies can be pivotal to the support and growth of multi-disciplinary teams, even among those who do not participate in early implementation. Further research is needed to understand when and why novel technology adoption becomes widespread in high-stakes settings.

Pediatric Sequential Organ Assessment Score: A Comprehensive Review of the Prognostic Marker in the Pediatric Intensive Care Unit.

Critically ill children admitted to the pediatric intensive care unit (PICU) face a substantial risk of morbidity and mortality, regardless of whether they are in developed or developing countries. To aid in treatment planning, various prognostic scoring systems have been developed to predict the likelihood of morbidity and death in these young patients. While the sequential organ failure assessment (SOFA) score has been validated as an independent risk predictor for adult mortality in cases of confirmed or suspected sepsis, it is not suitable for use in children due to its lack of age normalization. Children in critical condition often exhibit significant deviations from the normal physiological balance of their bodies. These deviations from the typical range of physiological variables can be leveraged to estimate the extent of these variations and create scoring systems. In this context, the pediatric SOFA (pSOFA) score was developed by modifying the original SOFA score and incorporating age-adjusted cutoffs for various bodily systems. The objective of this review is to assess the effectiveness of the pSOFA score in predicting sepsis-related mortality in pediatric patients within the PICU setting.

Comparison of invasive blood pressure monitoring vs. non-invasive blood pressure monitoring in critically ill children receiving vasoactive agents-a prospective observational study.

Objective: The primary aim of this study was to compare non-invasive blood pressure (NIBP) measurement using the automated oscillometric method with invasive blood pressure (IBP) measurement using peripheral arterial line insertion in critically ill children receiving vasoactive agents. Design: Single-centre, prospective cohort study. Setting: Tertiary care 15 bedded Pediatric ICU in Urban Indian city. Subjects: All critically ill children between the ages of 1 month to 16 years with shock on vasoactive medications and with IBP monitoring. Results: Forty children with 1,072 paired BP measurements were incorporated in the final analysis. Among all normotensive children (Total number of paired measurements = 623) receiving vasoactive agents, Bland-Altman analysis revealed an acceptable agreement between Invasive mean blood pressure (MBP) and non-invasive MBP with a bias of -2.10 mmHg (SD 11.35). The 95% limits of agreement were from -24.34 to 20.14 mmHg. In children with hypotension (Total number of paired measurements = 449), Bland-Altman analysis showed disagreement between Invasive MBP and non-invasive MBP i.e., a bias of -8.44 mmHg (SD 9.62). The 95% limits of agreement were from -27.29 to 10.41 mmHg. Conclusion: A limited agreement exists between invasive blood pressure (IBP) and non-invasive blood pressure (NIBP) measurements in critically ill children requiring vasoactive agents. This discrepancy can lead to either an underestimation or an overestimation of blood pressure. While NIBP can serve as a screening tool for hemodynamically stable children, those who are hemodynamically unstable and necessitate the initiation of vasoactive agents should undergo IBP monitoring.

Ventilator-Associated Pneumonia Bundle of Care Training of Nursing Officers Using Simulation and Its Impact on Their Knowledge and Incidence of Ventilator-Associated Pneumonia: A Quasi-Experimental Study.

The objective of this study was to assess the effectiveness of simulation-based training (SBT) of a ventilator-associated pneumonia (VAP) bundle of care on the knowledge and practice of nursing officers working in the pediatric intensive care unit (PICU) and its impact on the incidence of VAP. This study was a single-center, pre- and postsimulation-based educational interventional tool conducted in a six-bed PICU located in Western Rajasthan, India. Thirty nursing officers working in the PICU participated in the study. Baseline knowledge and practice regarding VAP bundle of care were assessed using a questionnaire and practice checklist. It was followed by 1:1 SBT of the VAP bundle of care following which all participants were immediately reassessed and then again at 3 months postintervention. The incidence of VAP (events/1,000 ventilation days) was subsequently compared both at 6 months pre- and postintervention. Thirty nursing officers participated in the study of which 63% were male. Baseline knowledge and practice increased significantly immediately after the VAP bundle of care training and then again at 3 months in comparison to preintervention testing (baseline 20.27 ± 4.51, immediate postintervention 26.0 ± 3.67, 3 months postintervention 23.97 ± 4.69). The incidence of VAP showed a declining trend from 46.1 to 36.5/1,000 ventilation days; however, this finding was not statistically significant ( p = 0.22). The simulation-based teaching program significantly enhanced nursing officers' knowledge and practice toward utilization of a preventive VAP bundle of care. There was decay in knowledge with time indicating that repetitive sessions are required at regular intervals to sustain this effect.

Plasma Ascorbic Acid Levels in Critically Ill Pediatric Patients.

Ascorbic acid, or vitamin C, is a physiological antioxidant that has been found to be deficient in critically ill adults with sepsis and acute respiratory distress system. In adults, ascorbic acid supplementation has been shown to reduce the need for vasopressors and mechanical ventilation. This study aimed to describe the prevalence of ascorbic acid deficiency in critically ill pediatric patients. This prospective, single-centered study analyzed 34 patients aged 1 month to 18 years old with septic shock and/or acute respiratory failure requiring mechanical ventilation in a quaternary, urban, pediatric intensive care unit. Plasma ascorbic acid levels were measured by high-performance liquid chromatography within 24 hours of meeting eligibility criteria. The median level was 23.34 µM (IQR [11.45, 39.14]). Twenty-three patients had repeat samples that were collected 3 to 5 days later. The median for repeat samples was higher at 42.41 µM (IQR [13.08, 62.43]). Patients who were enterally fed had significantly higher levels than those who were not (62.4 ± 7.7 µM vs. 32.4 ± 7.1 µM; p = 0.03). Ascorbic acid levels vary widely among critically ill children with septic shock and/or respiratory failure requiring mechanical ventilation, but one-half of our patients had deficient levels that are typically seen in scurvy. Further studies are warranted to investigate the significance of low levels as well as the impact of normalizing levels through nutritional support.

Adapting the Cornell assessment of pediatric delirium for Swedish context: translation, cultural validation and inter-rater reliability.

BACKGROUND: Pediatric delirium causes prolonged hospital stays, increased costs, and distress for children and caregivers. Currently, there is no delirium screening tool available in Sweden that has been translated, culturally validated, and tested for reliability. This study aimed to translate, culturally adapt, and assess the suitability of the Cornell Assessment of Pediatric Delirium (CAPD) for implementation in Swedish healthcare settings. METHODS: The CAPD was translated and culturally adapted to Swedish context following the ten-step process recommended by the International Society for Pharmacoeconomics and Outcomes Task Force for Translation and Cultural Adaptation. The Swedish CAPD was tested in the pediatric intensive care unit of Uppsala University Hospital, a tertiary hospital in Sweden. Inter-rater reliability was tested using intraclass correlation coefficient (ICC), with both Registered Nurses (RNs) and Assistant Nurses (ANs) conducting parallel measurements using the Swedish CAPD. A reliability score of ICC > 0.75 was considered indicative of good reliability. RESULTS: After translation of the CAPD into Swedish, 10 RNs participated in the cultural adaptation process. Issues related to word choice, education, and instructions were addressed. Wording improvements were made to ensure accurate interpretation. Supplementary training sessions were organized to strengthen users' proficiency with the Swedish CAPD. Additional instructions were provided to enhance clarity and usability. Inter-rater reliability testing resulted in an ICC of 0.857 (95% CI: 0.708-0.930), indicating good reliability. CONCLUSION: This study successfully translated and culturally adapted the CAPD to align with Swedish contextual parameters. The resulting Swedish CAPD demonstrated good inter-rater reliability, establishing its viability as a tool for measuring delirium among pediatric patients in Swedish pediatric intensive care units. TRAIL REGISTRATION: Not applicable.

Nutritional status and clinical outcomes of brain tumor surgery in pediatric intensive care unit: A prospective cohort study.

BACKGROUND: To determine whether nutritional status affects mortality and length of stay in the pediatric intensive care unit (PICU) after brain tumor surgery. METHODS: Subjects aged 2 months to 13 years with brain tumor surgery were included in the study. Z-scores of BMI for age, weight for age, and weight for length were calculated at admission. Undernutrition was defined as Z-score < -2. Nutritional intake was measured daily by a clinical nutritionist. Outcomes to be measured included duration of hospitalization and mortality. Regression analyses was used to investigate the relationship between nutritional variables and outcomes. RESULTS: A total of 63 patients met the inclusion criteria. Undernutrition at admission was found in 33% of subjects based on Z-scores of BMI and weight for length. The mortality rate was 17.5%. Calorie and protein intake was <50% of the target in 50.7% and 42.8 % of children, respectively. Undernutrition by weight for age Z-score, BMI for age and weight for length Z-scores, and low protein intake increased mortality risk by 5, 5.9 and 4.7 times, respectively. The risk of shorter PICU-free days was independently 80% and 90% lower in those receiving <50% of protein and calorie requirements. CONCLUSION: Undernutrition at admission is prevalent in children undergoing brain tumor surgery and is associated with a higher risk of mortality. Caloric and protein intake during hospitalization is generally low, leading to longer PICU stay.

Risk factors predicting need for the pediatric intensive care unit (PICU) post-hematopoietic cell transplant, PICU utilization, and outcomes following HCT: a single center retrospective analysis.

Hematopoietic cell transplant (HCT) is a curative treatment for multiple malignant and non-malignant disorders. While morbidity and mortality have decreased significantly over the years, some patients still require management in the pediatric intensive care unit (PICU) during their HCT course for additional respiratory, cardiovascular, and/or renal support. We retrospectively reviewed pediatric patients (0-18 years) who underwent HCT from January 2015-December 2020 at our institution to determine risk factors for PICU care and evaluate PICU utilization and outcomes. We also assessed pulmonary function testing (PFT) data to determine if differences were noted between PICU and non-PICU patients as well as potential evolution of pulmonary dysfunction over time. Risk factors of needing PICU care were lower age, lower weight, having an underlying inborn error of metabolism, and receiving busulfan-based conditioning. Nearly half of PICU encounters involved use of each of respiratory support types including high-flow nasal cannula, non-invasive positive pressure ventilation, and mechanical ventilation. Approximately one-fifth of PICU encounters involved renal replacement therapy. Pulmonary function test results largely did not differ between PICU and non-PICU patients at any timepoint aside from individuals who required PICU care having lower DLCO scores at one-year post-HCT. Future directions include consideration of combining our data with other centers for a multi-center retrospective analysis with the goal of gathering and reporting additional multi-center data to work toward continuing to decrease morbidity and mortality for patients undergoing HCT.

Novel data visualization and risk analytic algorithm in a low-middle income country.

To discuss the use of T3™, a data aggregation, visualization, and risk analytic platform in a single centre and its framework for implementation of such a tool in clinical care. We share experience of a tool implemented in a tertiary care Intensive Care Unit (ICU) with limited resources. Superusers were identified and trained. Implementation involved monitoring, evaluation, and user engagement data for continuous emphasis on the use of this tool. Persistent display of T3 data enhanced nursing operational efficiency. Its use was expanded to use in nurses rounds and handover, mortality and morbidity meetings, clinical team teaching through selected teaching cases and analysis of stored data with different research questions. However, lack of infrastructure and technological comprehension, paucity of multidisciplinary teams makes it a challenge in its implementation. Clear framework of implantation and pre-designed studies to determine the clinical usage and effectiveness are important for wide-spread use of such tools.

The death risk of pediatric patients with cancer-related sepsis requiring continuous renal replacement therapy: a retrospective cohort study.

OBJECTIVE: To assess the outcome of patients with cancer-related sepsis requiring continuous renal replacement therapy (CRRT) in a single-center pediatric intensive care unit (PICU). METHOD: Children with sepsis who necessitate CRRT from January 2017 to December 2021 were enrolled. The patients with leukemia/lymphoma or solid tumors were defined as underlying cancer. Multivariate logistic regression analysis was performed to identify the death risk factors in patients with cancer-related sepsis. RESULTS: A total of 146 patients were qualified for inclusion. Forty-six (31.5%) patients with cancer-related sepsis and 100 (68.5%) non-cancer-related sepsis. The overall PICU mortality was 28.1% (41/146), and mortality was significantly higher in cancer-related sepsis patients compared with non-cancer patients (41.3% vs. 22.0%, p = 0.016). Need mechanical ventilation, p-SOFA, acute liver failure, higher fluid overload at CRRT initiation, hypoalbuminemia, and high inotropic support were associated with PICU mortality in cancer-related sepsis patients. Moreover, levels of IL-6, total bilirubin, creatinine, blood urea nitrogen, and international normalized ratio were significantly higher in non-survivors than survivors. In multivariate logistic regression analysis, pediatric sequential organ failure assessment (p-SOFA) score (OR:1.805 [95%CI: 1.047-3.113]) and serum albumin level (OR: 0.758 [95%CI: 0.581 -0.988]) were death risk factors in cancer-related sepsis receiving CRRT, and the AUC of combined index of p-SOFA and albumin was 0.852 (95% CI: 0.730-0.974). CONCLUSION: The overall PICU mortality is high in cancer-related sepsis necessitating CRRT. Higher p-SOFA and lower albumin were independent risk factors for PICU mortality.

Characteristics and spectrum changes of PICU cases during the COVID-19 pandemic: a retrospective analysis.

Objective: This study aims to compare the changes in the disease spectrum of children admitted to the Pediatric Intensive Care Units (PICU) during the COVID-19 pandemic with the three years prior to the pandemic, exploring the impact of the COVID-19 pandemic on the disease spectrum of PICU patients. Methods: A retrospective analysis was conducted on critically ill children admitted to the PICU of Hunan Children's Hospital from January 2020 to December 2022, and the results were compared with cases from the same period between January 2017 and December 2019. The cases were divided into pre-pandemic period (January 2017-December 2019) with 8,218 cases, and pandemic period (January 2020-December 2022) with 5,619 cases. General characteristics, age, and gender were compared between the two groups. Results: Compared to the pre-pandemic period, there was a 31.62% decrease in the number of admitted children during the pandemic period, and a 52.78% reduction in the proportion of respiratory system diseases. The overall mortality rate decreased by 87.81%. There were differences in age and gender distribution between the two periods. The length of hospital stay during the pandemic showed no statistical significance, whereas hospitalization costs exhibited statistical significance. Conclusion: The COVID-19 pandemic has exerted a certain influence on the disease spectrum of PICU admissions. Implementing relevant measures during the pandemic can help reduce the occurrence of respiratory system diseases in children. Considering the changes in the disease spectrum of critically ill PICU children, future clinical prevention and treatment in PICUs should continue to prioritize the respiratory, neurological, and hematological oncology systems.

Renal resistive index by point of care ultrasound to predict sepsis associated acute kidney injury in critically ill children.

BACKGROUND: Sepsis associated acute kidney injury (AKI) is linked with adverse outcomes in the PICU. Doppler-based renal resistive index (RRI) has shown promising results in adults for prediction of AKI. We aimed to explore the performance of RRI in children with sepsis. METHODS: This prospective observational study (March - November 2022) included children aged 1-12 years with sepsis admitted to the PICU. RRI and urine neutrophil gelatinase associated lipocalin (NGAL) were measured within 12 h of admission. Children were followed up for 3 days. AKI (new and persistent) was defined as any child with KDIGO stage 2 or 3 AKI on day 3. RESULTS: We enrolled 90 children but included 79 in final analysis. Two thirds (n = 53, 67%) had septic shock. Median (IQR) age was 6.2 years (4.1-9.2). RRI decreased with increasing age. Twenty-six (33%) children had AKI on day 3. Mean (SD) RRI was higher in the AKI group [0.72 (0.08) vs. 0.65 (0.07), p < 0.001].The area under ROC curve for RRI to detect AKI among the 1-4 year old group was 0.75 (95% CI:0.51, 0.98; p = 0.05) and among the 5-12 year old group was 0.76 (0.62, 0.89; p = 0.001). An RRI 0.71 predicted AKI with 100% sensitivity and 46.2% specificity among the 1-4-year-old group and RRI 0.69 predicted it with 70% sensitivity and 77.5% specificity in the 5-12-year-old group. RRI and eGFR at admission were independent predictors of AKI on multivariable analysis. Urine NGAL 94.8 ng/ml predicted AKI with 76.9% sensitivity and 77.4% specificity and AUROC was 0.74 (0.62, 0.86) among the 1-12-year-old group. CONCLUSIONS: RRI values varied with age. RRI showed good diagnostic accuracy to detect new/persistent AKI on day 3 in children with sepsis; however, it was less precise as an independent predictor.

Before Diagnosing Paroxysmal Sympathetic Hyperactivity in PICU Patients Alternative Conditions must be Considered.

How to cite this article: Finsterer J. Before Diagnosing Paroxysmal Sympathetic Hyperactivity in PICU Patients, Alternative Conditions must be Considered. Indian J Crit Care Med 2024;28(5):516-517.

Total face mask with neurally adjusted ventilatory assist as a rescue therapy in infants with severe bronchiolitis.

Severe bronchiolitis patients are often supported with non-invasive ventilation (NIV). In case of NIV failure, we recently started to use non-invasive neurally adjusted ventilatory assist ventilation (NIV-NAVA) with a total face mask interface (TFM) and report now our experience with this modality of respiratory support. Retrospective study was made from October 2022 to May 2023 at the Geneva University Hospital Paediatric Intensive Care Unit. Inclusion criteria were children, aged from 0 to 6 months, with severe bronchiolitis with initial NIV failure and switch to NIV-NAVA-TFM. From 49 children with respiratory syncytial virus (RSV)-induced bronchiolitis requiring any form of respiratory support, 10 (median age 61 days (IQR 44-73) failing CPAP or NIV underwent rescue treatment with NIV-NAVA using a TFM. Patients were switched to TFM-NIV-NAVA 8 h (IQR 3-22) after admission for 24.5 h (IQR 13-60). After initiation of TFM-NIV-NAVA, oxygenation improved significantly as early as 1 h after initiation, whereas transcutaneous CO2 values remained stable. None of the patients needed to be intubated and there was no episode of TFM discontinuation due to interface discomfort or other unwanted side effects. Sedation was used in all patients with high proportion of intravenous dexmedetomidine. Median ventilatory assistance duration was 2.5 days (IQR 2-4) and median PICU stay was 4.5 (IQR 3-6).   Conclusion: In infants with severe RSV-induced bronchiolitis, respiratory support with TFM-NIV-NAVA seems to be feasible as a rescue therapy and might be considered in selected patients. What is Known: • Bronchiolitic patients with NIV support failure may require invasive mechanical ventilation. • Interface related complications, especially facial sores, can be a cause of NIV failure. What is New: • Total face mask with non-invasive neurally adjusted ventilatory assist (TFM-NIV-NAVA) seems feasible as a rescue therapy in deteriorating patients with CPAP or NIV failure. • TFM-NIV-NAVA can improve oxygenation rapidly in patients with aggravating hypoxemia and seems to be well tolerated.

Early Impressions and Adoption of the AtriAmp for Managing Arrhythmias Following Congenital Heart Surgery.

Objective: AtriAmp is a new medical device that displays a continuous real-time atrial electrogram on telemetry using temporary atrial pacing leads. Our objective was to evaluate early adoption of this device into patient care, understand how it affected clinical workflow, and identify unforeseen benefits or limitations. Design: Qualitative study using inductive analysis of semi-structured interviews to identify dominant themes. Setting: Single center, tertiary, academic 21-bed mixed pediatric intensive care unit (PICU). Subjects: PICU multidisciplinary team members (Pediatric intensivists, PICU Nurse Practitioners, PICU nurses and Pediatric Cardiologists) who were early adopters of the AtriAmp (n=14). Results: Three prominent themes emerged from qualitative analysis of the early adopters' experiences. (1) Accelerated time from arrhythmia event to diagnosis, treatment, and determination of treatment effectiveness; (2) Increased confidence and security in the accuracy of providers' arrhythmia diagnosis; and (3) Improvement in the ability to educate providers about post-operative arrythmias where reliance on time consuming consultation is a default. Providers also noted some learning curves with the device; none of which compromised medical care or clinical workflow. Conclusions: Insights from early adopters of AtriAmp signal the need for simplicity and fidelity in new technologies within the PICU. Further research in the qualitative and observational sphere is needed to understand how technologies, such as AtriAmp, find expanded use in the PICU environment. Our research suggests that such technologies can be pivotal to the support and growth of multi-disciplinary teams, even among those who do not participate in early implementation.