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1.
BMC Health Serv Res ; 24(1): 595, 2024 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-38714998

RESUMO

BACKGROUND: Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. METHODS: A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. RESULTS: The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. CONCLUSION: Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.


Assuntos
Cuidadores , Estado Terminal , Pessoal de Saúde , Pesquisa Qualitativa , Centros de Atenção Terciária , Humanos , Malaui , Estado Terminal/terapia , Cuidadores/psicologia , Masculino , Feminino , Criança , Pessoal de Saúde/psicologia , Monitorização Fisiológica/métodos , Entrevistas como Assunto , Pré-Escolar , Lactente , Unidades de Terapia Intensiva Pediátrica , Adulto
2.
BMC Palliat Care ; 23(1): 125, 2024 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-38769557

RESUMO

BACKGROUND: Few studies have evaluated the perceptions of healthcare providers in China regarding pediatric palliative care, particularly in critical care units (PICUs), where many children receive palliative care. To evaluate the knowledge, attitudes and practices of PICU personnel in China regarding pediatric palliative care. METHODS: This cross-sectional study was conducted in five cities in China (Shanghai, Suzhou, Chongqing, Chengdu and Yunnan) between November 2022 and December 2022. RESULTS: The analysis included 204 participants (122 females), with 158 nurses and 46 physicians. The average knowledge, attitude and practice scores were 9.75 ± 2.90 points (possible range, 0-13 points), 38.30 ± 3.80 points (possible range, 12-60 points) and 35.48 ± 5.72 points (possible range, 9-45 points), respectively. Knowledge score was higher for physicians than for nurses (P < 0.001) and for personnel with previous training in pediatric palliative care (P = 0.005). According to structural equation modelling knowledge had a direct positive effect on attitude (ß = 0.69 [0.28-1.10], p = 0.001), and indirect on practice (ß = 0.82 [0.36-1.28], p < 0.001); attitude had significant effect on practice as well (ß = 1.18 [0.81-1.56], p < 0.001). CONCLUSIONS: There is room for improvement in the knowledge, attitudes and practices of PICU personnel in China regarding pediatric palliative care. The findings of this study may facilitate the design and implementation of targeted education/training programs to better inform physicians and nurses in China about pediatric palliative care.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Cuidados Paliativos , Humanos , Estudos Transversais , Feminino , Masculino , Cuidados Paliativos/métodos , Cuidados Paliativos/normas , Cuidados Paliativos/psicologia , China , Adulto , Inquéritos e Questionários , Pessoa de Meia-Idade , Pessoal de Saúde/psicologia , Pessoal de Saúde/estatística & dados numéricos , Atitude do Pessoal de Saúde , Unidades de Terapia Intensiva Pediátrica/organização & administração , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Unidades de Terapia Intensiva/organização & administração , Pediatria/métodos , Pediatria/normas
3.
JAMA Netw Open ; 7(5): e2410746, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38728028

RESUMO

Importance: Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. Objective: To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. Design, Setting, and Participants: This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). Main Outcomes and Measures: The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Results: Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Conclusions and Relevance: Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.


Assuntos
Bronquiolite , Unidades de Terapia Intensiva Pediátrica , Humanos , Bronquiolite/terapia , Bronquiolite/epidemiologia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Lactente , Masculino , Estudos Transversais , Feminino , Ventilação não Invasiva/estatística & dados numéricos , Ventilação não Invasiva/métodos , Respiração Artificial/estatística & dados numéricos , Respiração Artificial/métodos , Recém-Nascido , Oxigenoterapia/estatística & dados numéricos , Oxigenoterapia/métodos , Hospitalização/estatística & dados numéricos
4.
Crit Care Explor ; 6(5): e1088, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38747691

RESUMO

IMPORTANCE: A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis. OBJECTIVES: We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database. MAIN OUTCOMES AND MEASURES: The primary exposure was NIPPV and the primary outcome was IHCA. MEASUREMENTS AND MAIN RESULTS: Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]). CONCLUSIONS AND RELEVANCE: Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.


Assuntos
Bronquiolite , Parada Cardíaca , Humanos , Bronquiolite/terapia , Bronquiolite/epidemiologia , Bronquiolite/complicações , Estudos Retrospectivos , Lactente , Feminino , Masculino , Parada Cardíaca/terapia , Parada Cardíaca/mortalidade , Parada Cardíaca/epidemiologia , Parada Cardíaca/etiologia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Ventilação não Invasiva , Pré-Escolar , Respiração com Pressão Positiva/métodos , Respiração com Pressão Positiva/estatística & dados numéricos , Estudos de Coortes
5.
JAMA Netw Open ; 7(5): e2411375, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38748423

RESUMO

Importance: While disparities in consent rates for research have been reported in multiple adult and pediatric settings, limited data informing enrollment in pediatric intensive care unit (PICU) research are available. Acute care settings such as the PICU present unique challenges for study enrollment, given the highly stressful and emotional environment for caregivers and the time-sensitive nature of the studies. Objective: To determine whether race and ethnicity, language, religion, and Social Deprivation Index (SDI) were associated with disparate approach and consent rates in PICU research. Design, Setting, and Participants: This retrospective cohort study was performed at the Children's Hospital of Philadelphia PICU between July 1, 2011, and December 31, 2021. Participants included patients eligible for studies requiring prospective consent. Data were analyzed from February 2 to July 26, 2022. Exposure: Exposures included race and ethnicity (Black, Hispanic, White, and other), language (Arabic, English, Spanish, and other), religion (Christian, Jewish, Muslim, none, and other), and SDI (composite of multiple socioeconomic indicators). Main Outcomes and Measures: Multivariable regressions separately tested associations between the 4 exposures (race and ethnicity, language, religion, and SDI) and 3 outcomes (rates of approach among eligible patients, consent among eligible patients, and consent among those approached). The degree to which reduced rates of approach mediated the association between lower consent in Black children was also assessed. Results: Of 3154 children included in the study (median age, 6 [IQR, 1.9-12.5] years; 1691 [53.6%] male), rates of approach and consent were lower for Black and Hispanic families and those of other races, speakers of Arabic and other languages, Muslim families, and those with worse SDI. Among children approached for research, lower consent odds persisted for those of Black race (unadjusted odds ratio [OR], 0.73 [95% CI, 0.55-0.97]; adjusted OR, 0.68 [95% CI, 0.49-0.93]) relative to White race. Mediation analysis revealed that 51.0% (95% CI, 11.8%-90.2%) of the reduced odds of consent for Black individuals was mediated by lower probability of approach. Conclusions and Relevance: In this cohort study of consent rates for PICU research, multiple sociodemographic factors were associated with lower rates of consent, partly attributable to disparate rates of approach. These findings suggest opportunities for reducing disparities in PICU research participation.


Assuntos
Unidades de Terapia Intensiva Pediátrica , Humanos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Masculino , Feminino , Estudos Retrospectivos , Criança , Pré-Escolar , Lactente , Etnicidade/estatística & dados numéricos , Philadelphia , Pesquisa Biomédica , Fatores Socioeconômicos , Hispânico ou Latino/estatística & dados numéricos , Seleção de Pacientes , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos
6.
BMC Pediatr ; 24(1): 345, 2024 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-38760748

RESUMO

BACKGROUND: Sepsis is an infection-related systemic inflammatory response that often leads to elevated lactate levels. Monitoring lactate levels during severe sepsis is vital for influencing clinical outcomes. The aim of this study was to assess the association between plasma lactate levels and mortality in children with severe sepsis or septic shock. METHODS: The current prospective study was conducted in the PICU of University Children's Hospital. The International Paediatric Sepsis Consensus Conference criteria for Definitions of Sepsis and Organ Failure in 2005 were used to diagnose patients with sepsis. We measured plasma lactate levels upon admission (Lac H0) and 6 h later (Lac H6). The static indices included the absolute lactate values (Lac H0 and Lac H6), while the dynamic indices included the delta-lactate level (ΔLac) and the 6-hour lactate clearance. The 6-hour lactate clearance was calculated using the following formula: [(Lac H0-Lac H6)100/Lac H0]. ΔLac was calculated as the difference between the Lac H0 and Lac H6 levels. Patient survival or death after a PICU stay was the primary outcome. RESULTS: A total of 46 patients were included in this study: 25 had septic shock, and 21 had severe sepsis. The mortality rate was 54.3%. The Lac H0 did not significantly differ between survivors and nonsurvivors. In contrast, the survivors had significantly lower Lac H6 levels, higher ΔLac levels, and higher 6-hour lactate clearance rates than nonsurvivors. Lactate clearance rates below 10%, 20%, and 30% were significantly associated with mortality. The best cut-off values for the lactate clearance rate and Lac H6 for the prediction of mortality in the PICU were < 10% and ≥ 4 mmol/L, respectively. Patients with higher Lac H6 levels and lower lactate clearance rates had significantly higher PICU mortality based on Kaplan-Meier survival curve analysis. CONCLUSIONS: This study highlights the significance of lactate level trends over time for the prediction of mortality in the PICU in patients with severe sepsis or septic shock. Elevated lactate levels and decreased lactate clearance six hours after hospitalisation are associated with a higher mortality rate.


Assuntos
Ácido Láctico , Sepse , Choque Séptico , Humanos , Estudos Prospectivos , Masculino , Feminino , Ácido Láctico/sangue , Sepse/sangue , Sepse/mortalidade , Sepse/diagnóstico , Pré-Escolar , Lactente , Choque Séptico/sangue , Choque Séptico/mortalidade , Criança , Unidades de Terapia Intensiva Pediátrica , Biomarcadores/sangue , Adolescente
7.
BMC Pulm Med ; 24(1): 216, 2024 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-38698400

RESUMO

BACKGROUND: High-flow nasal cannula (HFNC) is often used in pediatric populations with respiratory distress. In adults, the respiratory-rate oxygenation (ROX) index is used as a predictor of HFNC therapy; however, children have age-associated differences in respiratory rate, thus may not be applicable to children. This study aims to find the reliability of ROX index and modified P-ROX index as predictors of HFNC therapy failure in pediatric patients. METHODS: Subjects in this analytical cross-sectional study were taken from January 2023 until November 2023 in Cipto Mangunkusumo Hospital. Inclusion criteria are children aged 1 month to 18 years with respiratory distress and got HFNC therapy. Receiver operating characteristics (ROC) analysis was used to find mP-ROX index cutoff value as a predictor of HFNC failure. The area under curve (AUC) score of mP-ROX index was assessed at different time point. RESULTS: A total of 102 patients, with 70% of the population with pneumonia, were included in this study. There are significant differences in the ROX index between the successful and failed HFNC group therapy (p < 0.05). This study suggests that mP-ROX index is not useful as predictor of HFNC therapy in pediatrics. While ROX index < 5.52 at 60 min and < 5.68 at 90 min after HFNC initiation have a sensitivity of 90% and specificity of 71%, sensitivity of 78% and specificity of 76%, respectively. CONCLUSION: mP-ROX index is not useful as a predictor of HFNC therapy in pediatrics. Meanwhile, ROX index at 60 min and 90 min after initiation of HFNC is useful as a predictor of HFNC failure.


Assuntos
Cânula , Unidades de Terapia Intensiva Pediátrica , Oxigenoterapia , Taxa Respiratória , Humanos , Criança , Estudos Transversais , Masculino , Lactente , Pré-Escolar , Feminino , Oxigenoterapia/métodos , Adolescente , Curva ROC , Reprodutibilidade dos Testes , Falha de Tratamento , Insuficiência Respiratória/terapia
8.
Pediatr Crit Care Med ; 25(5): 434-442, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38695692

RESUMO

OBJECTIVES: The pediatric Sequential Organ Failure Assessment (pSOFA) score summarizes severity of organ dysfunction and can be used to predict in-hospital mortality. Manual calculation of the pSOFA score is time-consuming and prone to human error. An automated method that is open-source, flexible, and scalable for calculating the pSOFA score directly from electronic health record data is desirable. DESIGN: Single-center, retrospective cohort study. SETTING: Quaternary 40-bed PICU. PATIENTS: All patients admitted to the PICU between 2015 and 2021 with ICU stay of at least 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used 77 records to evaluate the automated score. The automated algorithm had an overall accuracy of 97%. The algorithm calculated the respiratory component of two cases incorrectly. An expert human annotator had an initial accuracy of 75% at the patient level and 95% at the component level. An untrained human annotator with general clinical research experience had an overall accuracy of 16% and component-wise accuracy of 67%. Weighted kappa for agreement between the automated method and the expert annotator's initial score was 0.92 (95% CI, 0.88-0.95), and between the untrained human annotator and the automated score was 0.50 (95% CI, 0.36-0.61). Data from 9146 patients (in-hospital mortality 3.6%) were included to validate externally the discriminability of the automated pSOFA score. The admission-day pSOFA score had an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.77-0.82). CONCLUSIONS: The developed automated algorithm calculates pSOFA score with high accuracy and is more accurate than a trained expert rater and nontrained data abstracter. pSOFA's performance for predicting in-hospital mortality was lower in our cohort than it was for the originally derived score.


Assuntos
Algoritmos , Mortalidade Hospitalar , Unidades de Terapia Intensiva Pediátrica , Escores de Disfunção Orgânica , Humanos , Estudos Retrospectivos , Masculino , Feminino , Criança , Pré-Escolar , Lactente , Adolescente , Registros Eletrônicos de Saúde , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/mortalidade , Reprodutibilidade dos Testes
10.
Pediatr Crit Care Med ; 25(5): 443-451, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38695693

RESUMO

OBJECTIVES: The pediatric Sequential Organ Failure Assessment (pSOFA) score was designed to track illness severity and predict mortality in critically ill children. Most commonly, pSOFA at a point in time is used to assess a static patient condition. However, this approach has a significant drawback because it fails to consider any changes in a patients' condition during their PICU stay and, especially, their response to initial critical care treatment. We aimed to evaluate the performance of longitudinal pSOFA scores for predicting mortality. DESIGN: Single-center, retrospective cohort study. SETTING: Quaternary 40-bed PICU. PATIENTS: All patients admitted to the PICU between 2015 and 2021 with at least 24 hours of ICU stay. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated daily pSOFA scores up to 30 days, or until death or discharge from the PICU, if earlier. We used the joint longitudinal and time-to-event data model for the dynamic prediction of 30-day in-hospital mortality. The dataset, which included 9146 patients with a 30-day in-hospital mortality of 2.6%, was divided randomly into training (75%) and validation (25%) subsets, and subjected to 40 repeated stratified cross-validations. We used dynamic area under the curve (AUC) to evaluate the discriminative performance of the model. Compared with the admission-day pSOFA score, AUC for predicting mortality between days 5 and 30 was improved on average by 6.4% (95% CI, 6.3-6.6%) using longitudinal pSOFA scores from the first 3 days and 9.2% (95% CI, 9.0-9.5%) using scores from the first 5 days. CONCLUSIONS: Compared with admission-day pSOFA score, longitudinal pSOFA scores improved the accuracy of mortality prediction in PICU patients at a single center. The pSOFA score has the potential to be used dynamically for the evaluation of patient conditions.


Assuntos
Estado Terminal , Mortalidade Hospitalar , Unidades de Terapia Intensiva Pediátrica , Escores de Disfunção Orgânica , Humanos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Estudos Retrospectivos , Masculino , Feminino , Criança , Pré-Escolar , Lactente , Estado Terminal/mortalidade , Adolescente , Estudos Longitudinais , Curva ROC , Prognóstico
11.
Pediatr Crit Care Med ; 25(5): e232-e238, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38695702

RESUMO

OBJECTIVES: Ethanol lock therapy (ELT) is a potential method of central catheter salvage following central line-associated bloodstream infection (CLABSI) although there is potential risk of catheter damage in polyurethane catheters. Further, there is limited efficacy data across the spectrum of common pediatric catheters, and published ELT protocols describe dwell times that are not feasible for critically ill children. We sought to evaluate the safety and efficacy of ELT in polyurethane catheters using brief (30 min to 2 hr) dwell times in our PICU. DESIGN: Investigational pilot study using historical control data. SETTING: PICU in quaternary care, free-standing children's hospital. INTERVENTIONS: ELT in polyurethane central venous catheters for catheter salvage. RESULTS: ELT with brief dwell times was used in 25 patients, 22 of whom were bacteremic. Ultimately 11 patients, comprising 14 catheters, were diagnosed with a primary CLABSI. The catheter salvage rate in primary CLABSI patients receiving ELT was 92% (13/14) and significantly higher than the salvage rate in patients receiving antibiotics alone (non-ELT) (62%, 39/64; mean difference 0.32, 95% CI [0.14-0.50], p = 0.03). The rate of catheter fracture in all patients receiving ELT was 8% (2/25) while the rate of fracture in the non-ELT group was 13% (8/64; mean difference -0.05, 95% CI [-0.18 to 0.09], p = 0.72). The rate of tissue plasminogen activator (tPA) use in the ELT group was 8% (2/25), whereas the rate of tPA use in the non-ELT group was significantly higher at 42% (26/64; mean difference -0.34, 95% CI [-0.49 to -0.17], p = 0.002). CONCLUSIONS: The use of ELT for catheter salvage and prophylaxis in the PICU is safe in a variety of polyurethane catheters. Dwell times ranging from 30 minutes to 2 hours were effective in sterilizing the catheters while allowing other therapies to continue. This approach may decrease the need for frequent line changes in a medically fragile pediatric population.


Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateteres Venosos Centrais , Etanol , Unidades de Terapia Intensiva Pediátrica , Poliuretanos , Humanos , Infecções Relacionadas a Cateter/prevenção & controle , Criança , Projetos Piloto , Etanol/administração & dosagem , Masculino , Pré-Escolar , Feminino , Lactente , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/instrumentação , Cateteres Venosos Centrais/efeitos adversos , Cateteres de Demora/efeitos adversos , Adolescente , Bacteriemia/prevenção & controle , Bacteriemia/etiologia , Anti-Infecciosos Locais/administração & dosagem , Anti-Infecciosos Locais/uso terapêutico
12.
Pediatr Crit Care Med ; 25(5): e239-e245, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38695703

RESUMO

OBJECTIVES: To adapt and develop a reliable and easily administered outcome measure of physical and respiratory function in critically ill children in the PICU. DESIGN: Modified Delphi study to adapt the Chelsea Critical Care Physical Assessment (CPAx) tool for use in children 2-18 years old, with subsequent prospective testing in a single-center cohort. SETTING: Single-center tertiary PICU. SUBJECTS: Delphi process in 27 panelists (including physiotherapists, occupational therapists, and pediatric intensivists from seven countries from January 2018 to March 2018). Cohort study in 54 patients admitted to PICU for greater than 24 hours over a 3-month period (April 2018 to June 2018), with median age 5.5 years (interquartile range [IQR], 3-12.75 yr), 33 of 54 male, and 38 of 54 invasively ventilated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three Delphi iterations were required to reach greater than or equal to 80% consensus in all the children's CPAx (cCPAx) items. In the subsequent cohort study, six physiotherapists used the cCPAx tool and scored 54 participants, with a total 106 observations. The median cCPAx tool score was 14.50 (IQR, 3-25) out of a possible total of 50. Inter-rater reliability for 30 randomly selected participants was excellent (intraclass correlation coefficient, 0.998). Completion rate of cCPAx in the 54 patients occurred in 78 of 106 occasions (74%). CONCLUSIONS: The cCPAx tool content that was developed using Delphi methodology provided a feasible and clinically relevant tool for use in assessing physical morbidity in PICU patients 2-18 years old. Overall, the cCPAx scores were low, demonstrating low levels of physical function and high levels of immobility during PICU care.


Assuntos
Cuidados Críticos , Técnica Delphi , Unidades de Terapia Intensiva Pediátrica , Humanos , Pré-Escolar , Masculino , Adolescente , Criança , Feminino , Cuidados Críticos/métodos , Estudos Prospectivos , Estado Terminal/terapia , Reprodutibilidade dos Testes , Exame Físico/métodos , Desempenho Físico Funcional
13.
Pediatr Crit Care Med ; 25(5): e263-e272, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38695705

RESUMO

OBJECTIVES: To inform workforce planning for pediatric critical care (PCC) physicians, it is important to understand current staffing models and the spectrum of clinical responsibilities of physicians. Our objective was to describe the expected workload associated with a clinical full-time equivalent (cFTE) in PICUs across the U.S. Pediatric Critical Care Chiefs Network (PC3N). DESIGN: Cross-sectional survey. SETTING: PICUs participating in the PC3N. SUBJECTS: PICU division chiefs or designees participating in the PC3N from 2020 to 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A series of three surveys were used to capture unit characteristics and clinical responsibilities for an estimated 1.0 cFTE intensivist. Out of a total of 156 PICUs in the PC3N, the response rate was 46 (30%) to all three distributed surveys. Respondents used one of four models to describe the construction of a cFTE-total clinical hours, total clinical shifts, total weeks of service, or % full-time equivalent. Results were stratified by unit size. The model used for construction of a cFTE did not vary significantly by the total number of faculty nor the total number of beds. The median (interquartile range) of clinical responsibilities annually for a 1.0 cFTE were: total clinical hours 1750 (1483-1858), total clinical shifts 142 (129-177); total weeks of service 13.0 (11.3-16.0); and total night shifts 52 (36-60). When stratified by unit size, larger units had fewer nights or overnight hours, but covered more beds per shift. CONCLUSIONS: This survey of the PC3N (2020-2022) provides the most contemporary description of clinical responsibilities associated with a cFTE physician in PCC. A 1.0 cFTE varies depending on unit size. There is no correlation between the model used to construct a cFTE and the associated clinical responsibilities.


Assuntos
Cuidados Críticos , Unidades de Terapia Intensiva Pediátrica , Admissão e Escalonamento de Pessoal , Carga de Trabalho , Humanos , Estudos Transversais , Estados Unidos , Unidades de Terapia Intensiva Pediátrica/organização & administração , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Cuidados Críticos/organização & administração , Cuidados Críticos/estatística & dados numéricos , Criança , Inquéritos e Questionários
15.
Pediatr Crit Care Med ; 25(5): e258-e262, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38695704

RESUMO

Caring for children and their families at the end-of-life is an essential but challenging aspect of care in the PICU. During and following a child's death, families often report a simultaneous need for protected privacy and ongoing supportive presence from staff. Balancing these seemingly paradoxical needs can be difficult for PICU staff and can often lead to the family feeling intruded upon or abandoned during their end-of-life experience. In this "Pediatric Critical Care Medicine Perspectives" piece, we reframe provision of privacy at the end-of-life in the PICU and describe an essential principle that aims to help the interprofessional PICU team simultaneously meet these two opposing family needs: "Supported Privacy." In addition, we offer concrete recommendations to actualize "Supported Privacy" in the PICU, focusing on environmental considerations, practical needs, and emotional responses. By incorporating the principles of "Supported Privacy" into end-of-life care practices, clinicians can support the delivery of high-quality care that meets the needs of children and families navigating the challenges and supports of end-of-life in the PICU.


Assuntos
Unidades de Terapia Intensiva Pediátrica , Privacidade , Assistência Terminal , Humanos , Assistência Terminal/ética , Assistência Terminal/psicologia , Unidades de Terapia Intensiva Pediátrica/organização & administração , Criança , Relações Profissional-Família , Família/psicologia
16.
BMJ Paediatr Open ; 8(1)2024 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-38754894

RESUMO

BACKGROUND AND OBJECTIVES: This study aimed to identify predictors of sepsis-associated in-hospital mortality from readily available laboratory biomarkers at onset of illness that include haematological, coagulation, liver and kidney function, blood lipid, cardiac enzymes and arterial blood gas. METHODS: Children with sepsis were enrolled consecutively in a prospective observational study involving paediatric intensive care units (PICUs) of two hospitals in Beijing, between November 2016 and January 2020. The data on demographics, laboratory examinations during the first 24 hours after PICU admission, complications and outcomes were collected. We screened baseline laboratory indicators using the Least Absolute Shrinkage and Selection Operator (LASSO) analysis, then we constructed a mortality risk model using Cox proportional hazards regression analysis. The ability of risk factors to predict in-hospital mortality was evaluated by receiver operating characteristic (ROC) curves. RESULTS: A total of 266 subjects were enrolled including 44 (16.5%) deaths and 222 (83.5%) survivors. Those who died showed a shorter length of hospitalisation, and a higher proportion of mechanical ventilation, complications and organ failure (p<0.05). LASSO analysis identified 13 clinical parameters related to prognosis, which were included in the final Cox model. An elevated triglyceride (TG) remained the most significant risk factor of death (HR=1.469, 95% CI: 1.010 to 2.136, p=0.044), followed by base excess (BE) (HR=1.131, 95% CI: 1.046 to 1.223, p=0.002) and pH (HR=0.95, 95% CI: 0.93 to 0.97, p<0.001). The results of the ROC curve showed that combined diagnosis of the three indicators-TG+BE+pH-has the best area under the curve (AUC) (AUC=0.77, 95% CI: 0.69 to 0.85, p<0.001), with a 68% sensitivity and 80% specificity. CONCLUSION: Laboratory factors of TG, BE and pH during the first 24 hours after intensive care unit admission are associated with in-hospital mortality in PICU patients with sepsis. The combination of the three indices has high diagnostic value.


Assuntos
Biomarcadores , Mortalidade Hospitalar , Unidades de Terapia Intensiva Pediátrica , Sepse , Humanos , Masculino , Estudos Prospectivos , Feminino , Sepse/mortalidade , Sepse/sangue , Sepse/diagnóstico , Pré-Escolar , Lactente , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Biomarcadores/sangue , Valor Preditivo dos Testes , Criança , Fatores de Risco , Infecções Comunitárias Adquiridas/mortalidade , Infecções Comunitárias Adquiridas/sangue , Infecções Comunitárias Adquiridas/diagnóstico , Curva ROC , Prognóstico
17.
PLoS One ; 19(5): e0299884, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38691554

RESUMO

Bloodstream infection (BSI) is associated with increased morbidity and mortality in the pediatric intensive care unit (PICU) and high healthcare costs. Early detection and appropriate treatment of BSI may improve patient's outcome. Data on machine-learning models to predict BSI in pediatric patients are limited and neither study included time series data. We aimed to develop a machine learning model to predict an early diagnosis of BSI in patients admitted to the PICU. This was a retrospective cohort study of patients who had at least one positive blood culture result during stay at a PICU of a tertiary-care university hospital, from January 1st to December 31st 2019. Patients with positive blood culture results with growth of contaminants and those with incomplete data were excluded. Models were developed using demographic, clinical and laboratory data collected from the electronic medical record. Laboratory data (complete blood cell counts with differential and C-reactive protein) and vital signs (heart rate, respiratory rate, blood pressure, temperature, oxygen saturation) were obtained 72 hours before and on the day of blood culture collection. A total of 8816 data from 76 patients were processed by the models. The machine committee was the best-performing model, showing accuracy of 99.33%, precision of 98.89%, sensitivity of 100% and specificity of 98.46%. Hence, we developed a model using demographic, clinical and laboratory data collected on a routine basis that was able to detect BSI with excellent accuracy and precision, and high sensitivity and specificity. The inclusion of vital signs and laboratory data variation over time allowed the model to identify temporal changes that could be suggestive of the diagnosis of BSI. Our model might help the medical team in clinical-decision making by creating an alert in the electronic medical record, which may allow early antimicrobial initiation and better outcomes.


Assuntos
Diagnóstico Precoce , Unidades de Terapia Intensiva Pediátrica , Aprendizado de Máquina , Humanos , Masculino , Feminino , Lactente , Estudos Retrospectivos , Pré-Escolar , Criança , Sepse/diagnóstico , Sepse/sangue , Bacteriemia/diagnóstico , Recém-Nascido , Adolescente
18.
Ann Med ; 56(1): 2337714, 2024 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38590177

RESUMO

The purpose was to investigate how well age-adjusted modified quick Sequential Organ Failure Assessment (qSOFA) scores paired with blood glucose and lactate levels predict the outcomes of septicemic children in the pediatric intensive care unit (PICU). One hundred children who were diagnosed with sepsis and septic shock in the PICU of Henan Children's Hospital were eligible, and other 20 patients in the same hospital at different times were selected as a validation set. Respiratory rate (RR), heart rate (HR), capillary refill time (CRT), and Alert, Voice, Pain, Unresponsive (AVPU) scale were included in the age-adjusted modified qSOFA scoring criteria for scoring. The primary outcome was 28-day all-cause mortality. The predictive values were evaluated by the ROC curve. In the sepsis group, 50 patients were male, and 50 patients were female. The 28-day all-cause mortality rate was 52%. Fifty-one patients with age-adjusted modified qSOFA scores >1. The serum lactate level was 2.4 mmol/L, and the blood glucose level was 9.3 mmol/L. The AUCs for the age-adjusted modified qSOFA score, serum lactate and blood glucose levels for the prediction of 28-day all-cause mortality in children with sepsis were 0.719, 0.719 and 0.737, respectively. The cut-off values were one point, 3.8 mmol/L and 10 mmol/L, respectively. The AUC of the age-adjusted modified qSOFA score for the validation set of was 0.925. When the three indices were combined, the AUC was 0.817, the Hosmer-Lemeshow goodness-of-fit test showed χ2 = 2.428 and p = .965. When children with sepsis are admitted to the ICU, we recommend performing rapid scoring and rapid bedside lactate and glucose testing to determine the early prognosis.


Assuntos
Escores de Disfunção Orgânica , Sepse , Criança , Humanos , Masculino , Feminino , Ácido Láctico , Glucose , Glicemia , Estudos Retrospectivos , Prognóstico , Unidades de Terapia Intensiva Pediátrica , Curva ROC , Sepse/diagnóstico , Mortalidade Hospitalar
19.
BMJ Open ; 14(4): e081314, 2024 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-38688666

RESUMO

INTRODUCTION: In children, respiratory distress due to upper airway obstruction (UAO) is a common complication of extubation. The quantitative cuff-leak test (qtCLT) is a simple, rapid and non-invasive test that has not been extensively studied in children. The objective of the ongoing study whose protocol is reported here is to investigate how well the qtCLT predicts UAO-related postextubation respiratory distress in paediatric intensive care unit (PICU) patients. METHODS AND ANALYSIS: Air Leak Test in the Paediatric Intensive Care Unit is a multicentre, prospective, observational study that will recruit 900 patients who are aged 2 days post-term to 17 years and ventilated through a cuffed endotracheal tube for at least 24 hours in any of 19 French PICUs. Within an hour of planned extubation, the qtCLT will be performed as a sequence of six measurements of the tidal volume with the cuff inflated then deflated. The primary outcome is the occurrence within 48 hours after extubation of severe UAO defined as combining a requirement for intravenous corticosteroid therapy and/or ventilator support by high-flow nasal cannula and/or by non-invasive ventilation or repeat invasive mechanical ventilation with a Westley score ≥4 with at least one point for stridor at each initiation. The results of the study are expected to identify risk factors for UAO-related postextubation respiratory distress and extubation failure, thereby identifying patient subgroups most likely to require preventive interventions. It will also determine whether qtCLT appears to be a reliable method to predict an increased risk for postextubation adverse events as severe UAO. ETHICS AND DISSEMINATION: The study was approved by the Robert Debré University Hospital institutional review board (IRB) on September 2021 (approval #2021578). The report of Robert Debré University Hospital IRB is valid for all sites, given the nature of the study with respect to the French law. The results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05328206.


Assuntos
Extubação , Unidades de Terapia Intensiva Pediátrica , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Extubação/efeitos adversos , Obstrução das Vias Respiratórias/etiologia , França , Intubação Intratraqueal/efeitos adversos , Estudos Multicêntricos como Assunto , Estudos Observacionais como Assunto , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Volume de Ventilação Pulmonar
20.
Comput Methods Programs Biomed ; 250: 108166, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38614026

RESUMO

BACKGROUND AND OBJECTIVE: Critically ill children may suffer from impaired neurocognitive functions years after ICU (intensive care unit) discharge. To assess neurocognitive functions, these children are subjected to a fixed sequence of tests. Undergoing all tests is, however, arduous for former pediatric ICU patients, resulting in interrupted evaluations where several neurocognitive deficiencies remain undetected. As a solution, we propose using machine learning to predict the optimal order of tests for each child, reducing the number of tests required to identify the most severe neurocognitive deficiencies. METHODS: We have compared the current clinical approach against several machine learning methods, mainly multi-target regression and label ranking methods. We have also proposed a new method that builds several multi-target predictive models and combines the outputs into a ranking that prioritizes the worse neurocognitive outcomes. We used data available at discharge, from children who participated in the PEPaNIC-RCT trial (ClinicalTrials.gov-NCT01536275), as well as data from a 2-year follow-up study. The institutional review boards at each participating site have also approved this follow-up study (ML8052; NL49708.078; Pro00038098). RESULTS: Our proposed method managed to outperform other machine learning methods and also the current clinical practice. Precisely, our method reaches approximately 80% precision when considering top-4 outcomes, in comparison to 65% and 78% obtained by the current clinical practice and the state-of-the-art method in label ranking, respectively. CONCLUSIONS: Our experiments demonstrated that machine learning can be competitive or even superior to the current testing order employed in clinical practice, suggesting that our model can be used to severely reduce the number of tests necessary for each child. Moreover, the results indicate that possible long-term adverse outcomes are already predictable as early as at ICU discharge. Thus, our work can be seen as the first step to allow more personalized follow-up after ICU discharge leading to preventive care rather than curative.


Assuntos
Unidades de Terapia Intensiva Pediátrica , Aprendizado de Máquina , Humanos , Criança , Masculino , Feminino , Pré-Escolar , Estado Terminal , Seguimentos , Alta do Paciente
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