Vasopressors and Enteral Nutrition in the Survival Rate of Children During Extracorporeal Membrane Oxygenation.

OBJECTIVES: Nutrition support is essential in improving outcome and survival in children on extra corporal membranous support (ECMO). We aim to evaluate the association between the timing of enteral nutrition (EN) initiation and its impact on outcome. METHODS: We retrospectively reviewed the electronic health records of children (≤18 years) from November 2014 to November 2019 who were on veno-arterial ECMO for ≥48 hours. Abstracted data included demographics, ECMO indication and duration, timing of EN initiation, change in weight-for-age z score (WAZ), and survival rate. The vasoactive-inotropic score (VIS) was calculated to assess illness acuity. RESULTS: We identified 76 children with median age (interquartile range [IQR]) of 0.3 years (0-2.6), 46 of which were infants (59%) who required ECMO for a median (IQR) of 10 days (6-22). Thirty-six (47%) survived to hospital discharge. EN was initiated in 55 (72%) of patients while on ECMO. EN initiation by day 3 of ECMO was positively associated with survival ( P = 0.0438). VIS at the time of EN initiation was lower in surviving infants ( P = 0.022). Children who achieved enteral autonomy were more likely to survive ( P = 0.0024). Survivors had greater WAZs at ECMO completion ( P = 0.0004). CONCLUSIONS: Initiation of EN by day 3 of ECMO and at a lower VIS is associated with greater likelihood of survival.

Utility of medical record diagnostic codes to ascertain attention-deficit/hyperactivity disorder and learning disabilities in populations of children.

BACKGROUND: To develop and evaluate machine learning algorithms to ascertain attention-deficit/hyperactivity (ADHD) and learning disability (LD) using diagnostic codes in the medical record. METHOD: Diagnoses of ADHD and LD were confirmed in cohorts of children in Olmsted County of Minnesota based on validated research criteria. Models to predict ADHD and LD were developed using ICD-9 codes in a derivation cohort of 1057 children before evaluated in a validation cohort of 536 children. RESULTS: The ENET-MIN model using selected ICD-9 codes at prior probability of 0.25 has a sensitivity of 0.76, PPV of 0.85, specificity of 0.98, and NPV of 0.97 in the validation cohort. However, it does not offer significant advantage over a model using a single ICD-9 code of 314.X, which shows sensitivity of 0.81, PPV of 0.83, specificity of 0.98, and NPV of 0.97. None of the models developed for LD performed well in the validation cohort. CONCLUSIONS: It is feasible to utilize diagnostic codes to ascertain cases of ADHD in a population of children. Machine learning approaches do not have advantage compared with simply using a single family of diagnostic codes for ADHD. The use of medical record diagnostic codes is not feasible to ascertain LD.

Epidemiology and Outcomes of Pediatric Multiple Organ Dysfunction Syndrome.

OBJECTIVE: To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015). DATA SOURCES: Literature review, research data, and expert opinion. STUDY SELECTION: Not applicable. DATA EXTRACTION: Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS: Summary of presentations and discussion supported and supplemented by the relevant literature. CONCLUSIONS: A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

Epidemiology of Pediatric Critical Illness in a Population-Based Birth Cohort in Olmsted County, MN.

OBJECTIVES: Investigations of pediatric critical illness typically focus on inpatient cohorts drawn from wide referral areas and diverse healthcare systems. Cohorts amenable to investigating the full spectrum of critical illness as it develops within a community have yet to be studied in the United States. Our objective was to provide the first epidemiologic report of the incidence and presentation of pediatric critical illness within a U.S. population-based birth cohort. DESIGN: Retrospective cohort study. SETTING: A geographically defined community (Olmsted, MN) with medical record linkage across all health systems. All ICU services are provided within a single children's hospital. PATIENTS: A birth cohort of children (n =9,441) born 2003-2007 in Olmsted County, MN. MEASUREMENTS AND MAIN RESULTS: During the study period, there were a total of 15,277 ICU admissions to Mayo Clinic Children's Hospital. A total of 577 birth cohort children accounted for 824 of these admissions during the 61,770 person-years of follow-up accumulated. Incidence of first-time ICU admission was 9.3 admits per 1,000 person-years. Admission rates were highest in the first year of life and then declined steadily. Respiratory problems were among the most common reasons for admission at any age and diagnoses reflect changes in health risk factors as children grow and develop over time. After 1 year old, a majority of children admitted have preexisting chronic comorbidities and/or prior ICU stays. In-hospital mortality occurred exclusively in children admitted prior to 5 days of age (n = 4). Seven children died after hospital discharge. CONCLUSIONS: This is the first report characterizing critical illness within a population-based birth cohort of U.S. children. The results demonstrate the changing incidence, presentation, and healthcare requirements associated with critical illness across the developmental spectrum as a population of children ages.

Risk of Cardiac Reoperation: An Analysis of The STS Congenital Heart Surgery Database.

BACKGROUND: The increasing number of congenital heart disease patients undergoing reoperative cardiac surgery presents critical and growing challenges. Our objective was to evaluate the association between number of prior cardiopulmonary bypass operations and operative mortality and morbidity in a national cohort. METHODS: The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was reviewed for index cardiac operations on cardiopulmonary bypass during 2016-2021. Infants and patients with functionally univentricular physiology were excluded. Multivariable logistic regression adjusted for covariates in the STS-CHSD Mortality Risk Model, STAT Mortality Category, and institutional volume. RESULTS: Of 50,625 eligible operations, 22,100 (44%) were performed on patients with ≥1 prior cardiopulmonary bypass operation. Most common diagnoses were Tetralogy of Fallot (4,340/22,100 [19.6%]), pulmonary atresia/ventricular septal defect (1,334/22,100 [6.0%]), and aortic stenosis (966/22,100 [4.4%]). Operative mortality correlated with number of prior cardiopulmonary bypass operations, 157/28,525 (0.6%) for zero, 127/13,488 (0.9%) for one, 81/5,664 (1.4%) for two, 61/2,039 (3.0%) for three, 35/623 (5.6%) for four, 10/207 (4.8%) for five, and 5/79 (6.3%) for ≥6 (p<0.001). On multivariable analysis, patients with ≥3 prior cardiopulmonary bypass operations had higher risk of operative mortality (OR 2.31, p<0.001) and major morbidity (OR 1.60, p<0.001). Annual institutional volume and age were not associated with either outcome. CONCLUSIONS: Three or more prior cardiopulmonary bypass operations was an independent risk factor for operative mortality/morbidity, even after controlling for risk factors and institutional volume. Future research is needed to identify modifiable factors to optimize outcomes, particularly for those with ≥3 prior cardiopulmonary bypass operations.

End organ perfusion and pediatric microcirculation assessment.

Cardiovascular instability and reduced oxygenation are regular perioperative critical events associated with anesthesia requiring intervention in neonates and young infants. This review article addresses the current modalities of assessing this population's adequate end-organ perfusion in the perioperative period. Assuring adequate tissue oxygenation in critically ill infants is based on parameters that measure acceptable macrocirculatory hemodynamic parameters such as vital signs (mean arterial blood pressure, heart rate, urinary output) and chemical parameters (lactic acidosis, mixed venous oxygen saturation, base deficit). Microcirculation assessment represents a promising candidate for assessing and improving hemodynamic management strategies in perioperative and critically ill populations. Evaluation of the functional state of the microcirculation can parallel improvement in tissue perfusion, a term coined as "hemodynamic coherence". Less information is available to assess microcirculatory disturbances related to higher mortality risk in critically ill adults and pediatric patients with septic shock. Techniques for measuring microcirculation have substantially improved in the past decade and have evolved from methods that are limited in scope, such as velocity-based laser Doppler and near-infrared spectroscopy, to handheld vital microscopy (HVM), also referred to as videomicroscopy. Available technologies to assess microcirculation include sublingual incident dark field (IDF) and sublingual sidestream dark field (SDF) devices. This chapter addresses (1) the physiological basis of microcirculation and its relevance to the neonatal and pediatric populations, (2) the pathophysiology associated with altered microcirculation and endothelium, and (3) the current literature reviewing modalities to detect and quantify the presence of microcirculatory alterations.

Outcomes of Biventricular and Single Ventricle Heterotaxy Patients: A Single Center Five-Decade Experience.

BACKGROUND: Surgical palliation of patients with heterotaxy syndrome has proven challenging. Long-term outcomes have historically been poor. Factors contributing to these outcomes are not completely understood. METHODS: The institutional databases were queried for patients with heterotaxy syndrome from 1973 to 2021. Comparisons were made between patients managed with single ventricle physiology and biventricular physiology. RESULTS: Heterotaxy syndrome was identified in 230 patients (polysplenia, 47%; asplenia, 53%). In all, 199 patients had single ventricle physiology; 180 (78%) had undergone Fontan palliation. Thirty-one patients had biventricular physiology, including 20 (9%) with surgical intervention and 11 (5%) without surgical intervention. Median age at Fontan was 7.5 years (interquartile range, 8.8). Median follow-up was 20 years (interquartile range, 21). Kaplan-Meier analysis showed decreased survival with single ventricle physiology (53% ± 4%, vs biventricular 93% ± 5% at 30 years; P = .001), as well as asplenia compared with polysplenia (49% ± 5% vs 68% ± 5% at 30 years; P < .001). Polysplenia patients with biventricular physiology demonstrated the best survival (100% alive, vs 53% ± 25% of asplenia biventricular at 30 years; P < .001). Overall, 8 patients (3.5%) underwent cardiac transplantation at a median age of 17 years. On multivariable analysis, risk factors associated with mortality included single ventricle physiology (odds ratio [OR] 7.2; 95% CI, 2.4-21.7), no prior Glenn (OR 3.6; 95% CI, 1.9-6.7), need for permanent pacemaker (OR 2.3; 95% CI, 1.2-4.6), and asplenia (OR 2.7; 95% CI, 1.5-5.0). CONCLUSIONS: Overall, patients with asplenia demonstrated decreased survival compared with patients with polysplenia; and single ventricle physiology had decreased survival compared with biventricular. Patients with biventricular physiology and polysplenia had the best survival.

Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives.

Since the first successful application of extracorporeal membrane oxygenation (ECMO) in 1972, ECMO's role in the management of respiratory and circulatory collapse continues to be refined and debated. Randomized clinical trials aimed at establishing efficacy and patient selection criteria have been fraught with ethical challenges. Growing concerns over rising health care costs require that careful evaluations of cost, utilization, and ethical issues surrounding heroic life-saving interventions such as ECMO are undertaken. Continued analyses of ECMO's place in the medical management of respiratory and circulatory failure will help ensure that ECMO is used for not only prolonging life but also for providing a chance for "quality of life" following recovery from near-fatal illnesses.

Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community.

OBJECTIVES: Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited. METHODS: In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population. RESULTS: Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background. CONCLUSIONS: Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.

Socioeconomic Status, Race/Ethnicity, and Health Disparities in Children and Adolescents in a Mixed Rural-Urban Community-Olmsted County, Minnesota.

OBJECTIVE: To characterize disparities in childhood health outcomes by socioeconomic status (SES) and race/ethnicity in a mixed rural-urban US community. METHODS: This was a retrospective population-based study of children 18 years and younger residing in Olmsted County, Minnesota, in 2009. The prevalence rates of childhood health outcomes were determined using International Classification of Diseases, Ninth Revision codes. Socioeconomic status was measured using the HOUsing-based SocioEconomic Status index (HOUSES), derived from real property data. Adjusting for age and sex, logistic regression models were used to examine the relationships among HOUSES, race/ethnicity, and prevalence of childhood health outcomes considering an interaction between HOUSES and race/ethnicity. Odds ratios were calculated using the lowest SES quartile and non-Hispanic white participants as the reference groups. RESULTS: Of 31,523 eligible children, 51% were male and 86% were of non-Hispanic white race/ethnicity. Overall, lower SES was associated with higher prevalence of bronchiolitis, urinary tract infection, asthma, mood disorder, and accidents/adverse childhood experiences (physical and sexual abuse) in a dose-response manner (P<.04). Prevalence rates of all childhood conditions considered except for epilepsy were significantly different across races/ethnicities (P<.002). Racial/ethnic disparities for asthma and mood disorder were greater with higher SES. CONCLUSION: Significant health disparities are present in a predominantly affluent, non-Hispanic white, mixed rural-urban community. Socioeconomic status modifies disparities by race/ethnicity in clinically less overt conditions. Interpretation of future health disparity research should account for the nature of disease.

Vasopressor magnitude predicts poor outcome in adults with congenital heart disease after cardiac surgery.

BACKGROUND: High levels of vasoactive inotrope support (VIS) after congenital heart surgery are predictive of morbidity in pediatric patients. We sought to discern if this relationship applies to adults with congenital heart disease (ACHD). METHODS: We retrospectively studied adult patients (≥18 years old) admitted to the intensive care unit after cardiac surgery for congenital heart disease from 2002 to 2013 at Mayo Clinic. Vasoactive medication dose values within 96 hours of admission were examined to determine the relationship between VIS score and poor outcome of early mortality, early morbidity, or complication related morbidity. RESULTS: Overall, 1040 ACHD patients had cardiac surgery during the study time frame; 243 (23.4%) met study inclusion criteria. Sixty-two patients (25%), experienced composite poor outcome [including eight deaths within 90 days of hospital discharge (3%)]. Thirty-eight patients (15%) endured complication related early morbidity. The maximum VIS (maxVIS) score area under the curve was 0.92 (95% CI: 0.86-0.98) for in-hospital mortality; and 0.82 (95% CI: 0.76-0.89) for combined poor clinical outcome. On univariate analysis, maxVIS score ≥3 was predictive of composite adverse outcome (OR: 14.2, 95% CI: 7.2-28.2; P < 0.001), prolonged ICU LOS ICU LOS (OR: 19.2; 95% CI: 8.7-42.1; P < 0.0001), prolonged mechanical ventilation (OR: 13.6; 95% CI: 4.4-41.8; P < 0.0001) and complication related morbidity (OR: 7.3; 95% CI: 3.4-15.5; P < 0.0001). CONCLUSIONS: MaxVIS score strongly predicted adverse outcomes and can be used as a risk prediction tool to facilitate early intervention that may improve outcome and assist with clinical decision making for ACHD patients after cardiac surgery.

A "Fundamentals" Train-the-Trainer Approach to Building Pediatric Critical Care Expertise in the Developing World.

Pediatric Fundamental Critical Care Support (PFCCS) is an educational tool for training non-intensivists, nurses, and critical care practitioners in diverse health-care settings to deal with the acute deterioration of pediatric patients. Our objective was to evaluate the PFCCS course as a tool for developing a uniform, reproducible, and sustainable model for educating local health-care workers in the optimal management of critically ill children in the Republic of Georgia. Over a period of 18 months and four visits to the country, we worked with Georgian pediatric critical care leadership to complete the following tasks: (1) survey health-care needs within the Republic of Georgia, (2) present representative PFCCS lectures and simulation scenarios to evaluate interest and obtain "buy-in" from key stakeholders throughout the Georgian educational infrastructure, and (3) identify PFCCS instructor candidates. Georgian PFCCS instructor training included the following steps: (1) US PFCCS consultant and content experts presented PFCCS course to Georgian instructor candidates. (2) Simulation learning principles were taught and basic equipment was acquired. (3) Instructor candidates presented PFCCS to Georgian learners, mentored by PFCCS course consultants. Objective evaluation and debriefing with instructor candidates concluded each visit. Between training visits Georgian instructors translated PFCCS slides to the Georgian language. Six candidates were identified and completed PFCCS instructor training. These Georgian instructors independently presented the PFCCS course to 15 Georgian medical students. Student test scores improved significantly from pretest results (n = 14) (pretest: 38.7 ± 7 vs. posttest 62.7 ± 6, p < 0.05). A Likert-type scale of 1 to 5 (1 = not useful or effective, 5 = extremely useful or effective) was used to evaluate each student's perception regarding (1) relevance of course content to clinical work students rated as median (IQR): (a) relevance of PFCCS content to clinical work, 5 (4-5); (b) effectiveness of lecture delivery, 4 (3-4); and (c) value of skill stations for clinical practice, 5 (4-5). Additionally, the mean (±SD) responses were 4.6 (±0.5), 3.7 (±0.6), and 4.5 (±0.6), respectively. Training local PFCCS instructors within an international environment is an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care. Future collaborations will evaluate the clinical impact of PFCCS throughout the Georgian health-care system.

Total and free cortisol responses and their relation to outcomes after cardiopulmonary bypass in infants.

BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery. METHODS: We enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-µg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness. RESULTS: Sixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (<9 µg/dL) at TP2 had greater fluid requirements (P < .001) and greater chest tube output (P < .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3. CONCLUSIONS: We observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ <9 µg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.

Assessing health disparities in children using a modified housing-related socioeconomic status measure: a cross-sectional study.

OBJECTIVES: Socioeconomic status (SES) is a well-established risk factor for many health outcomes. Recently, we developed an SES measure based on 4 housing-related characteristics (termed HOUSES) and demonstrated its ability to assess health disparities. In this study, we aimed to evaluate whether fewer housing-related characteristics could be used to provide a similar representation of SES. STUDY SETTING AND PARTICIPANTS: We performed a cross-sectional study using parents/guardians of children aged 1-17 years from 2 US Midwestern counties (n=728 in Olmsted County, Minnesota, and n=701 in Jackson County, Missouri). PRIMARY AND SECONDARY OUTCOME MEASURES: For each participant, housing-related characteristics used in the formulation of HOUSES (assessed housing value, square footage, number of bedrooms and number of bathrooms) were obtained from the local government assessor's offices, and additional SES measures and health outcomes with known associations to SES (obesity, low birth weight and smoking exposure) were collected from a telephone survey. Housing characteristics with the greatest contribution for predicting the health outcomes were added to formulate a modified HOUSES index. RESULTS: Among the 4 housing characteristics used in the original HOUSES, the strongest contributions for predicting health outcomes were observed from assessed housing value and square footage (combined contribution ranged between 89% and 96%). Based on this observation, these 2 were used to calculate a modified HOUSES index. Correlation between modified HOUSES and other SES measures was comparable to the original HOUSES for both locations. Consistent with the original HOUSES formula, the strongest association with modified HOUSES was observed with smoking exposure (OR=0.24 with 95% CI 0.11 to 0.49 for comparing participants in highest HOUSES vs lowest group; overall p<0.001). CONCLUSIONS: The modified HOUSES requires only 2 readily available housing characteristics thereby improving the feasibility of using this index as a proxy for SES in multiple communities, especially in the US Midwestern region.

Duration and magnitude of vasopressor support predicts poor outcome after infant cardiac operations.

BACKGROUND: The vasoactive inotrope score (VIS) is a sum of the total vasopressor dose at a single point in time. Incorporating duration and magnitude of vasopressor requirements during the postcardiac surgical period could improve VIS sensitivity for predicting poor outcome. METHODS: This is a retrospective review of 244 infants (aged ≤365 days) who underwent cardiopulmonary bypass during congenital cardiac operations from 2002 to 2011. The VIS was calculated hourly for the first 72 hours. Poor outcome was defined as prolonged mechanical ventilation (≥6 days) or intensive care length of stay (≥12 days). First, the association between the maximum VIS (maxVIS) in the first 48 postoperative hours and poor outcome was confirmed for our study population. Next, postoperative intervals and VIS values that were significantly associated with poor outcome were identified and incorporated into a formula, termed the VISindex, which was compared with the traditional maxVIS. RESULTS: The VISindex demonstrated improved sensitivity for predicting prolonged mechanical ventilation (VISindex: area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.79 to 0.90; maxVIS: AUC, 0.80; 95% CI, 0.75 to 0.86) and intensive care unit length of stay (VISindex: AUC, 0.84; 95% CI, 0.79 to 0.89; maxVIS: AUC, 0.77; 95% CI, 0.71 to 0.83) after cardiac operations in infants. CONCLUSIONS: Incorporating magnitude and duration of postoperative vasopressor support into the VIS improves its sensitivity for predicting poor outcome.

Dexamethasone levels predict cortisol response after infant cardiopulmonary bypass.

OBJECTIVES: We sought to evaluate whether there is variability in blood dexamethasone levels after a standard 1 mg/kg dose of dexamethasone administered before infant cardiopulmonary bypass. We hypothesized that postoperative dexamethasone drug levels are highly variable, and that the infant stress response is related inversely to the amount of dexamethasone measured in the blood. METHODS: Thirty-two infants (age, ≤365 days) received 1 mg/kg of dexamethasone before cardiopulmonary bypass (CPB) initiation. Blood was analyzed for cortisol, adrenocorticotropin, and interleukin (IL)-6, IL-8, and IL-10 levels after anesthesia induction, after CPB, after intensive care unit (ICU) arrival, and 4, 8, 12, and 24 hours after surgery. Patients were grouped as high dexamethasone (≥15 µg/dL) or low dexamethasone (<15 µg/dL) based on their level at ICU arrival. RESULTS: Dexamethasone levels varied significantly between the high (n = 22) and low (n = 10) dexamethasone groups throughout the entire postoperative course and were correlated highly with cortisol response. Patients with high dexamethasone levels had postoperative cortisol levels that were lower than their pre-CPB baseline cortisol levels. Cortisol levels remained low throughout the first 24 postoperative hours even after dexamethasone levels neared zero. There were no significant differences between groups in the duration of mechanical ventilation or ICU length of stay. CONCLUSIONS: Dexamethasone levels are highly variable at ICU arrival, despite standardized 1 mg/kg dosing before CPB initiation.

Existing data analysis in pediatric critical care research.

Our objectives were to review and categorize the existing data sources that are important to pediatric critical care medicine (PCCM) investigators and the types of questions that have been or could be studied with each data source. We conducted a narrative review of the medical literature, categorized the data sources available to PCCM investigators, and created an online data source registry. We found that many data sources are available for research in PCCM. To date, PCCM investigators have most often relied on pediatric critical care registries and treatment- or disease-specific registries. The available data sources vary widely in the level of clinical detail and the types of questions they can reliably answer. Linkage of data sources can expand the types of questions that a data source can be used to study. Careful matching of the scientific question to the best available data source or linked data sources is necessary. In addition, rigorous application of the best available analysis techniques and reporting consistent with observational research standards will maximize the quality of research using existing data in PCCM.