A Need for a Novel Survival Risk Scoring System for Intensive Care Admissions Due to Sepsis in Pediatric Hematology/Oncology Patients.

Background: Children with hemato-oncological diseases or following stem cell transplantation (SCT) are at high risk for life-threatening infections; sepsis in this population constitutes a substantial proportion of pediatric intensive care unit (PICU) admissions. The current pediatric prognostic scoring tools to evaluate illness severity and mortality risk are designed for the general pediatric population and may not be adequate for this vulnerable subpopulation. Methods: Retrospective analysis was performed on all PICU admissions for sepsis in children with hemato-oncological diseases or post-SCT, in a single tertiary pediatric hospital between 2008 and 2021 (n = 233). We collected and analyzed demographic, clinical, and laboratory data and outcomes for all patients, and evaluated the accuracy of two major prognostic scoring tools, the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and the Pediatric Risk of Mortality III (PRISM III). Furthermore, we created a new risk-assessment model that contains additional parameters uniquely relevant to this population. Results: The survival rate for the cohort was 83%. The predictive accuracies of PELOD-2 and PRISM III, as determined by the area under the curve (AUC), were 83% and 78%, respectively. Nine new parameters were identified as clinically significant: age, SCT, viral infection, fungal infection, central venous line removal, vasoactive inotropic score, bilirubin level, C-reactive protein level, and prolonged neutropenia. Unique scoring systems were established by the integration of these new parameters into the algorithm; the new systems significantly improved their predictive accuracy to 91% (p = 0.01) and 89% (p < 0.001), respectively. Conclusions: The predictive accuracies (AUC) of the PELOD-2 and PRISM III scores are limited in children with hemato-oncological diseases admitted to PICU with sepsis. These results highlight the need to develop a risk-assessment tool adjusted to this special population. Such new scoring should represent their unique characteristics including their degree of immunosuppression and be validated in a large multi-center prospective study.

Therapeutic plasma exchange for neonatal hepatic failure.

We report a case of therapeutic plasma exchange in a neonate with fulminant liver failure. A six-day old, 2800-gram baby was referred to our medical center for evaluation and treatment of fulminant hepatic failure. The working diagnosis at admission was gestational alloimmune liver disease, and therapeutic plasma exchange was proposed. A double volume plasma exchange was successfully performed, using the Spectra Optia apheresis system, primed with packed red blood cells. Access was obtained via a radial artery catheter and a peripheral intravenous line. On hospital D-14 a diagnosis of E3 deficiency was confirmed, and disease-specific therapy was started. Automated TPE using peripheral arterial and venous catheters may be safely performed in neonates, and should be considered in the treatment of a variety of disorders including neonatal fulminant hepatic failure.

Acute kidney injury in pediatric toxic shock syndrome is associated with worse clinical course in the intensive care unit.

To explore the prevalence, severity, nature, and significance of acute kidney injury (AKI) among children admitted to the pediatric intensive care unit (PICU) with toxic shock syndrome (TSS). Bi-center, retrospective observational study. Children admitted for TSS to two intensive care units from 2009-2022 were included. We identified 41 children (median age 5 years, 46% females) who met the Centers for Disease Control and Prevention (CDC) definitions of TSS. Staphylococcal TSS accounted for 63% of the patients and Streptococcal TSS accounted for the remaining 37%. AKI was diagnosed in 24 (59%) (stage 1: n = 6 [15% of total], stage 2: n = 10 [24%], and stage 3: n = 8 [20%]). The worst creatinine level was measured during the first day of admission in 34 (83%) patients. The median duration of AKI was 2 days. Creatinine normalized by hospital discharge in all cases. Patients with AKI had a longer intensive care unit stay than those without AKI (6 vs. 3 days, respectively, p = 0.01), needed more respiratory support (87% vs. 47%, p = 0.002), had fewer 28 ventilation-free days (25 vs. 28, p = 0.01), fewer vasopressor-free days (25 vs. 28, p = 0.001), and received more blood products (p = 0.03).    Conclusion: Children admitted to the PICU with TSS, show a high prevalence of AKI at presentation. Creatinine levels and clearance normalize by hospital discharge in most cases. AKI in the setting of TSS could be used as an early marker for illness severity and a predictor of a more complex course. What is Known: • TSS is characterized according to the CDC by specific sets of clinical signs and symptoms in conjunction with specific laboratory findings one of which is AKI. • AKI is associated with worse outcomes in critically ill patients in general and in septic patients in particular. What is New: • AKI is found in about 60% of all patients admitted to the PICU with a diagnosis of TSS and hence is an important defining criteria. • AKI in the setting of TSS is associated with a more complex illness course and can serve as an early marker predicting such a course.

Blood pressure monitoring following kidney transplantation in children: a comparison of invasive and noninvasive measurements using Doppler as a benchmark technique.

BACKGROUND: Blood pressure (BP) monitoring following pediatric kidney transplantation is essential for optimizing graft perfusion. Differences between invasive BP and noninvasive BP (NIBP) measurements are sometimes considerable. We aimed to assess agreement between invasive BP and NIBP in pediatric patients after kidney transplantation and compare with measurements obtained by systolic Doppler with manual sphygmomanometer as a reference technique. METHODS: A prospective, observational cohort study, of children aged 18 years or younger, admitted immediately following kidney transplantation to the pediatric intensive care unit of a tertiary, university-affiliated medical center, between May 2019 and June 2021. RESULTS: Eighty-two paired simultaneous measurements of invasive BP, NIBP, and Doppler BP in 18 patients were compared. Patients were significantly hypertensive, with mean systolic NIBP above the 95th percentile (96 ± 6%). Systolic invasive BP measurements were significantly higher than NIBP (149 ± 20 vs. 136 ± 15 mmHg, p < 0.001). Substantial differences (≥ 20 mmHg) were found in 23% (95% CI 15-34%). Similar disagreement was found between systolic invasive and Doppler BP (150 ± 23 and 137 ± 17 mmHg, respectively, p < 0.001). In contrast, systolic NIBP was in good agreement with Doppler BP (135 ± 17 and 138 ± 18, respectively, p = 0.27). A moderate to strong correlation was found between higher systolic invasive BP and the difference to systolic Doppler BP (Spearman's ρ = 0.63, p < 0.001). CONCLUSIONS: In children immediately following kidney transplantation, clinically significant disagreement was found between invasive and noninvasive BP measurements. Invasive BP values were significantly higher than those obtained by Doppler. Better agreement was found between NIBP and Doppler. These issues should be considered when interpreting BP measurements in this sensitive patient population. A higher resolution version of the Graphical abstract is available as Supplementary information.

Early post-liver transplant thrombocytopenia in children: Clinical characteristics and significance.

BACKGROUND: Post-liver transplant thrombocytopenia is common and associated with worse outcome in adults. In children, however, the prevalence, course, and significance of post-liver transplantation thrombocytopenia are not described. Therefore, we aimed to assess this phenomenon in children. METHODS: A retrospective chart review of children who underwent liver transplantation at a single tertiary center between 2004 and 2021. RESULTS: Overall, 130 pediatric liver transplantations were reviewed. During the first 28 POD, thrombocytopenia was evident in 116 (89%, 95% CI 83%-94%). The median nadir platelet count was 54 K/µl (IQR: 37-99). Nadir platelet count was reached in half the patients by the third POD (IQR: 1-6). In multivariate analysis, preoperative platelet count (p = .024), volume of intraoperative packed cell transfusion (p = .045), and hypersplenism (p = .007) were associated with lower postoperative platelet counts. Patients with platelet count lower than the 50th centile on the first POD suffered from a more complicated course leading to a longer PICU admission (p = .039). CONCLUSIONS: Early post-liver transplant thrombocytopenia appears to be common in children and associated with preoperative thrombocytopenia, hypersplenism, and higher intraoperative blood transfusion volumes. A low first POD platelet count (<86 K/µl) was found to be independently associated with a more complicated postoperative course, suggesting the need for heightened surveillance.

Intranasal dexmedetomidine vs oral triclofos sodium for sedation of children with autism undergoing electroencephalograms.

BACKGROUND: Sedation may be necessary for performing electroencephalograms in children with autistic spectrum disorder, however, our sedation success rate using triclofos sodium (TFS) is limited. Intra-nasal dexmedetomidine (IN-DEX) may be a superior sedative for these children. OBJECTIVE: Compare IN-DEX with TFS for sedation efficacy, resistance to drug delivery and adverse events in children with autism undergoing an electroencephalogram. STUDY DESIGN: A single center, prospective observational study of children with autism sedated for electroencephalograms using IN-DEX compared to an age matched, historic group of children with autism, sedated for electroencephalograms using TFS. RESULTS: Characteristics of 41 IN-DEX sedations were compared to 41 TFS sedations in 82 ASD children. Epileptiform discharges were demonstrated in 23/82 (28%) of children in the cohort. Sedation depth by UMSS was significantly deeper in the IN-DEX group (2.49 ± 0.78 vs. 1.41 ± 0.89, p < 0.001). Electroencephalogram quality demonstrated less motion artifact in the IN-DEX group (1.75 ± 0.76 vs. 2.18 ± 0.88, p < 0.001). The rate of very poor or sedation failure was significantly lower in the IN-DEX group (17% vs 56.1%, p < 0.001), RR = 0.3 (95% CI 0.15 to 0.63, p < 0.001). No major adverse events were documented in either group. Bradycardia occurred in 8/41(19.5%) of children in IN-DEX group and none in TFS group (p = 0.003). Hypotension or poor perfusion were not demonstrated in either group. CONCLUSION: In children with autism undergoing electroencephalograms, IN-DEX was more tolerable than TFS, induced deeper sedation with a greater success rate, and improved electroencephalogram quality. Both sedatives were equally safe in this population.

Hyperlactatemia in children following brain tumor resection: prevalence, associated factors, and clinical significance.

PURPOSE: Hyperlactatemia is associated with worse outcome among critically ill patients. The prevalence of hyperlactatemia in children following craniotomy for intracranial tumor resection is unknown. This study was designed to assess the prevalence, associated factors, and significance of postoperative hyperlactatemia in this context. METHODS: A retrospective study was conducted at an intensive care unit of a tertiary, pediatric medical center. Children younger than 18 years admitted following craniotomy for brain tumor resection between October 2004 and November 2019 were included. RESULTS: Overall, 222 elective craniotomies performed in 178 patients were analyzed. The mean age ± SD was 8.5 ± 5.5 years. All but two patients survived to discharge. All were hemodynamically stable. Early hyperlactatemia, defined as at least one blood lactate level ≥ 2.0 mmol/L during the first 24 h into admission, presented following 74% of the craniotomies; lactate normalized within a mean ± SD of 11 ± 6.1 h. The fluid balance per body weight at 12 h and 24 h into the intensive care unit admission was similar in children with and without hyperlactatemia [7.0 ± 17.6 vs 3.5 ± 16.4 ml/kg, p = 0.23 and 4.0 ± 27.2 vs 4.6 ± 29.4 ml/kg, p = 0.96; respectively]. Hyperlactatemia was associated with higher maximal blood glucose, older age, and a pathological diagnosis of glioma. Intensive care unit length of stay was similar following craniotomies with and without hyperlactatemia (p = 0.57). CONCLUSIONS: Hyperlactatemia was common in children following craniotomy for brain tumor resection. It was not associated with hemodynamic impairment or with a longer length of stay.

Fetal Sacral Ratio: A Novel Method for Prenatal Sonographic Assessment of Sacral Abnormalities.

OBJECTIVES: The sacral ratio (SR) was described as a postnatal X-ray-based method to detect sacral abnormalities and predict functional prognosis for fecal continence in children with anorectal malformations (ARMs). The present study aimed to describe a novel method of assessing sonographic fetal sacral ratio (f-SR) in a normal population of fetuses. METHODS: Sixty three-dimensional (3D) ultrasound reconstruction images of the sacrum obtained from routine low-risk scans performed between 21 and 26 weeks of gestation served for measurement. The f-SR was calculated in a coronal view as the ratio between lines drawn at the upper and lower levels of the iliac bone and the 5th sacral vertebra. Bland-Altman plots assessed the inter- and intrareader variabilities of measurements. RESULTS: The f-SR in the normal population of fetuses was 0.913 (±0.094). During the study period, three cases with ARM were examined and had a mean f-SR of 0.55. There was good repeatability of measurements and between readers' agreement. CONCLUSIONS: The present study introduces a novel prenatal sonographic f-SR that can be reliably calculated on prenatal 3D ultrasound with good reliability and reproducibility. Future research will identify the clinical significance of f-SR abnormalities in ARM and their long-term impact on continence.

Transient Cardiac Injury in Adolescents Receiving the BNT162b2 mRNA COVID-19 Vaccine.

BACKGROUND: Vaccines are paramount in the effort to end the coronavirus disease 2019 global epidemic. BNT162b2 is approved for the vaccination of adolescents over 16 years of age. Systemic adverse events were scarce though the pretested cohort of this age group was relatively small. The aim of the current study is to raise awareness for potential adverse reactions. METHODS: This is a case series of patients diagnosed with perimyocarditis following vaccination. Patients were compiled from 3 pediatric medical centers in Israel through a network of pediatricians and data regarding those cases was collected. In addition, incidence of perimyocarditis during the vaccination period was compared with previous years. RESULTS: All patients were males 16-18 years old, of Jewish descent, who presented with chest pain that began 1-3 days following vaccination (mean, 2.1 days). In 6 of the 7 patients, symptoms began following the 2nd dose and in 1 patient following the 1st dose. All cases were mild and none required cardiovascular or respiratory support. The incidence of perimyocarditis during the vaccination period was elevated in comparison to previous years. CONCLUSIONS: This case series describes a time association between coronavirus disease 2019 vaccine and perimyocarditis in adolescents. All cases were mild, although only long-term follow-up can reveal the true impact of this cardiac injury. While it seems that the incidence of perimyocarditis during the vaccination campaign period is increased, a more comprehensive data collection on a wider scale should be done. We hope this report will serve as a reminder to report events and allow for analysis of potential adverse reactions.

Persistent pulmonary air leak in the pediatric intensive care unit: Characteristics and outcomes.

BACKGROUND: Persistent air leak (PAL) complicates various lung pathologies in children. The clinical characteristics and outcomes of children hospitalized in the pediatric intensive care unit (PICU) with PAL are not well described. We aimed to elucidate the course of disease among PICU hospitalized children with PAL. METHODS: A retrospective cohort study of all PICU-admitted children aged 0-18 years diagnosed with pneumothorax complicated by PAL, between January 2005 and February 2020 was conducted at a tertiary center. PAL was defined as a continuous air leak of more than 48 h. RESULTS: PAL complicated the course of 4.8% (38/788) of children hospitalized in the PICU with pneumothorax. Two were excluded due to missing data. Of 36 children included, PAL was secondary to bacterial pneumonia in 56%, acute respiratory distress syndrome (ARDS) in 31%, lung surgery in 11%, and spontaneous pneumothorax in 3%. Compared to non-ARDS causes, children with ARDS required more drains (median, range: 4, 3-11 vs. 2, 1-7; p < .001) and mechanical ventilation (100% vs. 12%; p < .001), and had a higher mortality (64% vs. 0%; p < .001). All children with bacterial pneumonia survived to discharge, with a median air leak duration of 14 days (range 3-72 days). Most of which (90%) were managed conservatively, by continuous chest drainage. CONCLUSION: Bacterial pneumonia was the leading cause of PAL in this cohort. PAL secondary to ARDS was associated with a worse outcome. In contrast, non-ARDS PAL was successfully managed conservatively, in most cases.

Fluid overload and renal function in children after living-donor renal transplantation: a single-center retrospective analysis.

BACKGROUND: We aimed to compare renal function after kidney transplantation in children who were treated with higher vs. lower fluid volumes. METHODS: A retrospective analysis of 81 living-donor renal transplantation pediatric patients was performed between the years 2007 and 2018. We analyzed associations of the decrease in serum creatinine (delta creatinine) with fluid balance, central venous pressure (CVP), pulmonary congestion, mean arterial pressure (MAP), and MAP-CVP percentiles in the first 3 postoperative days. After correcting creatinine for fluid overload, we also assessed associations of these variables with the above parameters. Finally, we evaluated the association between delta creatinine and estimated glomerular filtration rate (eGFR) at 3 months follow-up. RESULTS: Both delta creatinine and delta-corrected creatinine were found to be associated with pulmonary congestion on the second and third postoperative days (p < 0.02). In addition, trends for positive correlations were found of delta creatinine with fluid balance/kg (p = 0.07), and of delta-corrected creatinine with fluid balance/kg and CVP (p = 0.06-0.07) on the second postoperative day. An association was also demonstrated between the accumulated fluid balance of the first 2 days and eGFR at 3 months after transplantation (p = 0.03). CONCLUSIONS: An association was demonstrated between indices of fluid overload, >80 ml/kg, and greater improvement in renal function. IMPACT: There is no consensus regarding the optimal fluid treatment after pediatric renal transplantation. In our cohort, indices of fluid overload were associated with better renal function immediately after the transplantation and 3 months thereafter. Fluid overload after living-donor renal transplantation in children may have short- and long-term benefits on renal function.

Ultrasound Cardiac Output Monitor (USCOM™) Measurements Prove Unreliable Compared to Cardiac Magnetic Resonance Imaging in Adolescents with Cardiac Disease.

The purpose of this stuy is to prospectively assess the reliability of the ultrasound cardiac output monitor (USCOM™) for measuring stroke volume index and predicting left ventricular outflow tract diameter in adolescents with heart disease. Sixty consecutive adolescents with heart disease attending a tertiary medical center underwent USCOM™ assessment immediately after cardiac magnetic resonance imaging. USCOM™ measured stroke volume index and predicted left ventricular outflow tract diameter were compared to cardiac magnetic resonance imaging-derived values using Bland-Altman analysis. Ten patients with an abnormal left ventricular outflow tract were excluded from the analysis. An adequate USCOM™ signal was obtained in 49/50 patients. Mean stroke volume index was 46.1 ml/m2 by the USCOM™ (range 22-66.9 ml/m2) and 42.9 ml/m2 by cardiac magnetic resonance imaging (range 24.7-59.9 ml/m2). The bias (mean difference) was 3.2 ml/m2; precision (± 2SD of differences), 17 ml/m2; and mean percentage error, 38%. The mean (± 2SD) left ventricular outflow tract diameter was 0.445 ± 0.536 cm smaller by the USCOM™ algorithm prediction than by cardiac magnetic resonance imaging. Attempted adjustment of USCOM™ stroke volume index using cardiac magnetic resonance imaging left ventricular outflow tract diameter failed to improve agreement between the two modalities (bias 28.4 ml/m2, precision 44.1 ml/m2, percentage error 77.3%). Our study raises concerns regarding the reliability of USCOM™ for stroke volume index measurement in adolescents with cardiac disease, which did not improve even after adjusting for its inaccurate left ventricular outflow tract diameter prediction.

Routine chest X-ray following ultrasound-guided internal jugular vein catheterization in critically ill children: A prospective observational Study.

BACKGROUND: Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications. AIMS: To assess the usefulness of routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular veins in critically ill children. METHODS: A prospective observational study was conducted at a pediatric intensive care unit of a tertiary, university-affiliated pediatric medical center. All children under the age of 18 who underwent ultrasound-guided central venous catheter insertion through the right or left internal jugular vein between May 2018 and November 2019 were evaluated for eligibility. Procedures were prospectively documented, and chest X-ray was screened for pneumothorax, hemothorax, central venous catheter tip position, and resultant corrective interventions. RESULTS: Of 105 central venous catheter insertion attempts, 99 central venous catheters (94.3%) were inserted. All were located within the venous system. None were diagnosed with pneumo/hemothorax on chest X-ray. Twenty (20.2%; 95% CI 12.8%-29.5%) were defined as malpositioned by strict criteria; however, only one (1%) was judged significantly misplaced by the clinical team leading to its repositioning. CONCLUSIONS: In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.

Hemodynamic effects of intravenous paracetamol in critically ill children with septic shock on inotropic support.

BACKGROUND: Treatment with intravenous paracetamol may impair hemodynamics in critically ill adults. Few data are available in children. The aim of this study was to investigate the frequency, extent, and risk factors of hypotension following intravenous paracetamol administration in children with septic shock on inotropic support. METHODS: We retrospectively reviewed the electronic medical charts of all children aged 1 month to 18 years with septic shock who were treated with intravenous paracetamol while on inotropic support at the critical care unit of a tertiary pediatric medical center in 2013-2018. Data were collected on patient demographics, underlying disease, Pediatric Logistic Organ Dysfunction (PELOD) score, hemodynamic parameters before and up to 120 min after paracetamol administration, and need for inotropic support or intravenous fluid bolus. The main outcome measures were a change in blood pressure, hypotension, and hypotension requiring intervention. RESULTS: The cohort included 45 children of mean age 8.9 ± 5.1 years. The mean inotropic support score was 12.1 ± 9.5. A total of 105 doses of paracetamol were administered. The lowest mean systolic pressure (108 ± 15 mmHg) was recorded at 60 min (p = 0.002). Systolic blood pressure decreased at 30, 60, 90, and 120 min after delivery of 50, 67, 61, and 59 drug doses, respectively. There were 5 events of systolic hypotension (decrease of 1 to 16 mmHg below systolic blood pressure hypotensive value). Mean arterial pressure decreased by ≥ 15% in 8 drug doses at 30 min (7.6%, mean - 19 ± 4 mmHg), 18 doses at 60 min (17.1%, mean - 20 ± 7 mmHg), 16 doses at 90 min (15.2%, mean - 20 ± 5 mmHg), and 17 doses at 120 min (16.2%, mean - 19 ± 5 mmHg). Mean arterial hypotension occurred at the respective time points in 2, 13, 10, and 9 drug doses. After 12 drug doses (11.4%), patients required an inotropic dose increment or fluid bolus. CONCLUSIONS: Hypotensive events are not uncommon in critically ill children on inotropic support treated with intravenous paracetamol, and physicians should be alert to their occurrence and the need for intervention.

Triclofos Sodium for Pediatric Sedation in Non-Painful Neurodiagnostic Studies.

AIM: Triclofos sodium (TFS) has been used for many years in children as a sedative for painless medical procedures. It is physiologically and pharmacologically similar to chloral hydrate, which has been censured for use in children with neurocognitive disorders. The aim of this study was to investigate the safety and efficacy of TFS sedation in a pediatric population with a high rate of neurocognitive disability. METHODS: The database of the neurodiagnostic institute of a tertiary academic pediatric medical center was retrospectively reviewed for all children who underwent sedation with TFS in 2014. Data were collected on demographics, comorbidities, neurologic symptoms, sedation-related variables, and outcome. RESULTS: The study population consisted of 869 children (58.2% male) of median age 25 months (range 5-200 months); 364 (41.2%) had neurocognitive diagnoses, mainly seizures/epilepsy, hypotonia, or developmental delay. TFS was used for routine electroencephalography in 486 (53.8%) patients and audiometry in 401 (46.2%). Mean (± SD) dose of TFS was 50.2 ± 4.9 mg/kg. Median time to sedation was 45 min (range 5-245), and median duration of sedation was 35 min (range 5-190). Adequate sedation depth was achieved in 769 cases (88.5%). Rates of sedation-related adverse events were low: apnea, 0; desaturation ≤ 90%, 0.2% (two patients); and emesis, 0.35% (three patients). None of the children had hemodynamic instability or signs of poor perfusion. There was no association between desaturations and the presence of hypotonia or developmental delay. CONCLUSION: TFS, when administered in a controlled and monitored environment, may be safe for use in children, including those with underlying neurocognitive disorders.

The Hemodynamic Effect of Intravenous Paracetamol in Children: A Retrospective Chart Review.

AIM: Studies in adults have reported frequent episodes of blood pressure drops following intravenous paracetamol administration. We aimed to investigate the hemodynamic effects of intravenous paracetamol in critically ill children. METHODS: The charts of 100 pediatric intensive care patients (age range 0.1-18 years) who were treated with intravenous paracetamol between March and September 2017 were retrospectively reviewed. A hemodynamic event was defined as a drop of > 15% in systolic or mean arterial blood pressure within 120 min after drug administration. Hypotension was defined as either a drop in systolic blood pressure (SBP) below the 5th percentile for age or a hemodynamic event associated with tachycardia, increased lactate level, or treatment with a fluid bolus or vasopressors. RESULTS: A hemodynamic event was observed in 39 patients (39%). In these patients, SBP was in the pre-hypertension or hypertension values in 36/39 patients before paracetamol administration, median (IQR) SBP decreased from the 99th (95-99) percentile for age before to the 50th (50-95) percentile after paracetamol (p < 0.001) and mean heart rate was 137 bpm before treatment and 115 bpm after (p = 0.002). SBP values did not drop below the 5th percentile in any patient. In 15 patients diagnosed with shock on admission, paracetamol treatment did not cause an increase in vasopressor treatment after drug administration. CONCLUSIONS: In the present study of critically ill pediatric patients, intravenous paracetamol administration was associated with a drop in SBP from high to normal values for age, possibly due to pain relief, with no evidence for a negative hemodynamic event.