Factors to be Considered in Advancing Pediatric Critical Care Across the World.

This article reviews the many factors that have to be taken into account as we consider the advancement of pediatric critical care (PCC) in multiple settings across the world. The extent of PCC and the range of patients who are cared for in this environment are considered. Along with a review of the ongoing treatment and technology advances in the PCC setting, the structures and systems required to support these services are also considered. Finally the question of how PCC can be made sustainable in a volatile world with the impacts of global crises such as climate change is addressed.

The Need for Specialized Pediatric Cardiac Critical Care Training Program in Limited Resource Settings.

Congenital heart disease (CHD) is one of the major global health problems with the highest birth prevalence in low- and middle-income countries. In these populous countries, basic health services for the children with CHD, including surgery, are lacking. Even though surgery is performed, outcome after cardiac surgery is influenced by the quality of the postoperative management with a reported high morbidity and mortality. Henceforth, there is an urgent need for comprehensive interventions to provide high quality cardiac intensive care programs to improve the quality of pediatric cardiac surgery services in order to address high morbidity and mortality after cardiac surgery. The development and training of the health workers in the field of pediatric cardiac intensive care program is required. It is imperative to conduct this training prior to actual implementation of the program in limited resources settings.

The global burden of paediatric heart disease.

An estimated 15 million children die or are crippled annually by treatable or preventable heart disease in low- and middle-income countries. Global efforts to reduce under-5 mortality have focused on reducing death from communicable diseases in low- and middle-income countries with little to no attention focusing on paediatric CHD and acquired heart disease. Lack of awareness of CHD and acquired heart disease, access to care, poor healthcare infrastructure, competing health priorities, and a critical shortage of specialists are important reasons why paediatric heart disease has not been addressed in low resourced settings. Non-governmental organisations have taken the lead to address these challenges. This review describes the global burden of paediatric heart disease and strategies to improve the quality of care for paediatric heart disease. These strategies would improve outcomes for children with heart disease.

Pediatric Respiratory Support Technology and Practices: A Global Survey.

OBJECTIVE: This global survey aimed to assess the current respiratory support capabilities for children with hypoxemia and respiratory failure in different economic settings. METHODS: An online, anonymous survey of medical providers with experience in managing pediatric acute respiratory illness was distributed electronically to members of the World Federation of Pediatric Intensive and Critical Care Society, and other critical care websites for 3 months. RESULTS: The survey was completed by 295 participants from 64 countries, including 28 High-Income (HIC) and 36 Low- and Middle-Income Countries (LMIC). Most respondents (≥84%) worked in urban tertiary care centers. For managing acute respiratory failure, endotracheal intubation with mechanical ventilation was the most commonly reported form of respiratory support (≥94% in LMIC and HIC). Continuous Positive Airway Pressure (CPAP) was the most commonly reported form of non-invasive positive pressure support (≥86% in LMIC and HIC). Bubble-CPAP was used by 36% HIC and 39% LMIC participants. ECMO for acute respiratory failure was reported by 45% of HIC participants, compared to 34% of LMIC. Oxygen, air, gas humidifiers, breathing circuits, patient interfaces, and oxygen saturation monitoring appear widely available. Reported ICU patient to health care provider ratios were higher in LMIC compared to HIC. The frequency of respiratory assessments was hourly in HIC, compared to every 2-4 h in LMIC. CONCLUSIONS: This survey indicates many apparent similarities in the presence of respiratory support systems in urban care centers globally, but system quality, quantity, and functionality were not established by this survey. LMIC ICUs appear to have higher patient to medical staff ratios, with decreased patient monitoring frequencies, suggesting patient safety should be a focus during the introduction of new respiratory support devices and practices.

Challenges and Priorities for Pediatric Critical Care Clinician-Researchers in Low- and Middle-Income Countries.

INTRODUCTION: There is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high. MATERIALS AND METHODS: To inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis. RESULTS: The majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation. CONCLUSION: LMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success.

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions.

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.

Global paediatric advanced life support: improving child survival in limited-resource settings.

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

Mixed venous oxygen saturation monitoring after stage 1 palliation for hypoplastic left heart syndrome.

BACKGROUND: Staged palliation for hypoplastic left heart syndrome has been marked by high early mortality due to the limited cardiac output of the postischemic single right ventricle combined with the inefficiency and volatility of parallel circulation. METHODS: Since July 1996, we have performed stage 1 palliation (S1P) in 178 patients. Within this group is a consecutive cohort of 116 patients with true hypoplastic left heart syndrome that underwent S1P with a modified Blalock-Taussig shunt. A prospective database containing postoperative hemodynamic data was maintained on all patients. Studied were the incidence of organ failure, extracorporeal membrane oxygenation (ECMO), and mortality, as well as the relationship between these outcomes and postoperative hemodynamics. RESULTS: Hospital survival for this cohort was 93% (108/116). Patients who died after S1P had a lower superior vena cava oxygen saturation (SVO2) level compared with survivors (53.1% +/-10.6% versus 59.3% +/-9.2%, p = 0.034). Renal failure developed in 2 (1.7%) of the 116 patients, necrotizing enterocolitis developed in 1 (0.9%), and 5 (4.3%) had clinical seizures. ECMO support was instituted in 12 patients (10.3%). The SVO2 level was lower in patients requiring ECMO (54.0% +/- 9.7% versus 59.9% +/- 9.2%, p = 0.031). CONCLUSIONS: Goal-directed therapy with SVO2 as an indicator of systemic oxygen delivery is associated with excellent early survival and a low incidence of organ failure after S1P. Inability to optimize SVO2 in the early postoperative period is associated with an increased risk of organ failure, ECMO, and death.