Initial dysnatremia and clinical outcomes in pediatric traumatic brain injury: a multicenter observational study.

PURPOSE: We aimed to investigate the association between initial dysnatremia (hyponatremia and hypernatremia) and in-hospital mortality, as well as between initial dysnatremia and functional outcomes, among children with traumatic brain injury (TBI). METHOD: We performed a multicenter observational study among 26 pediatric intensive care units from January 2014 to August 2022. We recruited children with TBI under 18 years of age who presented to participating sites within 24 h of injury. We compared demographics and clinical characteristics between children with initial hyponatremia and eu-natremia and between those with initial hypernatremia and eu-natremia. We defined poor functional outcome as a discharge Pediatric Cerebral Performance Category (PCPC) score of moderate, severe disability, coma, and death, or an increase of at least 2 categories from baseline. We performed multivariable logistic regression for mortality and poor PCPC outcome. RESULTS: Among 648 children, 84 (13.0%) and 42 (6.5%) presented with hyponatremia and hypernatremia, respectively. We observed fewer 14-day ventilation-free days between those with initial hyponatremia [7.0 (interquartile range (IQR) = 0.0-11.0)] and initial hypernatremia [0.0 (IQR = 0.0-10.0)], compared to eu-natremia [9.0 (IQR = 4.0-12.0); p = 0.006 and p < 0.001]. We observed fewer 14-day ICU-free days between those with initial hyponatremia [3.0 (IQR = 0.0-9.0)] and initial hypernatremia [0.0 (IQR = 0.0-3.0)], compared to eu-natremia [7.0 (IQR = 0.0-11.0); p = 0.006 and p < 0.001]. After adjusting for age, severity, and sex, presenting hyponatremia was associated with in-hospital mortality [adjusted odds ratio (aOR) = 2.47, 95% confidence interval (CI) = 1.31-4.66, p = 0.005] and poor outcome (aOR = 1.67, 95% CI = 1.01-2.76, p = 0.045). After adjustment, initial hypernatremia was associated with mortality (aOR = 5.91, 95% CI = 2.85-12.25, p < 0.001) and poor outcome (aOR = 3.00, 95% CI = 1.50-5.98, p = 0.002). CONCLUSION: Among children with TBI, presenting dysnatremia was associated with in-hospital mortality and poor functional outcome, particularly hypernatremia. Future research should investigate longitudinal sodium measurements in pediatric TBI and their association with clinical outcomes.

Transforming the delivery of care from "I" to "We" by developing the crisis resource management skills in pediatric interprofessional teams to handle common emergencies through simulation.

BACKGROUND: The healthcare system is highly complex, and adverse events often result from a combination of human factors and system failures, especially in crisis situations. Crisis resource management skills are crucial to optimize team performance and patient outcomes in such situations. Simulation-based training offers a promising approach to developing such skills in a controlled and realistic environment. METHODS: This study employed a mixed-methods (quantitative-qualitative) design and aimed to assess the effectiveness of a simulation-based training workshop in developing crisis resource management skills in pediatric interprofessional teams at a tertiary care hospital. The effectiveness of the intervention was evaluated using Kirkpatrick's Model, focusing on reaction and learning levels, employing the Collaboration and Satisfaction about Care Decisions scale, Clinical Teamwork Scale, and Ottawa Global Rating Scale for pre- and post-intervention assessments. Focused group discussions were conducted with the participants to explore their experiences and perceptions of the training. RESULTS: Thirty-nine participants, including medical students, nurses, and residents, participated in the study. Compared to the participants' pre-workshop performance, significant improvements were observed across all measured teamwork and performance components after the workshop, including improvement in scores in team communication (3.16 ± 1.20 to 7.61 ± 1.0, p < 0.001), decision-making (3.50 ± 1.54 to 7.16 ± 1.42, p < 0.001), leadership skills (2.50 ± 1.04 to 5.44 ± 0.6, p < 0.001), and situation awareness (2.61 ± 1.13 to 5.22 ± 0.80, p < 0.001). No significant variations were observed post-intervention among the different teams. Additionally, participants reported high levels of satisfaction, perceived the training to be highly valuable in improving their crisis resource management skills, and emphasized the importance of role allocation and debriefing. CONCLUSIONS: The study underscores the effectiveness of simulation-based training in developing crisis resource management skills in pediatric interprofessional teams. The findings suggest that such training can impact learning transfer to the workplace and ultimately improve patient outcomes. The insights from our study offer additional valuable considerations for the ongoing refinement of simulation-based training programs. There is a need to develop more comprehensive clinical skills evaluation methods to better assess the transferability of these skills in real-world settings. The potential challenges unveiled in our study, such as physical exhaustion during training, must be considered when refining and designing such interventions.

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

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

Publications in paediatric critical care medicine: Trends from Pakistan.

Objective: To analyse the characteristics of research published from Pakistan on paediatric critical care medicine. METHODS: The exploratory study was conducted at the Aga Khan University, Karachi from July 2021 to March 2022, and comprised a comprehensive search on MedLine, Google Scholar and PakMediNet databases for literature from Pakistan pertaining to paediatric critical care medicine published between January 2010 and December 2021. The search was done using appropriate key words. Conference abstracts and papers authored by paediatric intensivists with unrelated topics were excluded. Data was extracted on a structured spreadsheet, and was subjected to bibliometric analysis. Data was analysed using SPSS 20. RESULTS: Of the 7,514 studies identified, 146(1.94%) were analysed. These were published in 51 journals with a frequency of 13.3 per year. There were 107(73.3%) original articles, 96(65.8%) were published in PubMed-indexed journals, and 35(24%) were published in locally indexed journals. Further, 100(69.4%) papers were published from 5 paediatric intensive care units in Karachi, and 81(56%) were contributed by a single private-sector hospital. The total citation count was 1072, with 2(1.4%) papers receiving >50 citations. There was a linear trend with some skewing and an annual growth rate of >15%. Conclusion: Publications from Pakistan related to paediatric critical care medicine showed positive linear growth. There was a paucity of multicentre studies, randomised controlled trials, and high-impact publications.

Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan.

OBJECTIVES: To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN: Cross-sectional observational study. SETTING: Accredited pediatric training facilities in Pakistan. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

A multicenter observational study on outcomes of moderate and severe pediatric traumatic brain injuries-time to reappraise thresholds for treatment.

PURPOSE: Children with moderate traumatic brain injury (modTBI) (Glasgow Coma Scale (GCS) 9-13) may benefit from better stratification. We aimed to compare neurocritical care utilization and functional outcomes between children with high GCS modTBI (hmodTBI, GCS 11-13), low GCS modTBI (lmodTBI, GCS 9-10), and severe TBI (sTBI, GCS ≤ 8). We hypothesized that patients with lmodTBI have higher neurocritical care needs and worse outcomes than patients with hmodTBI and are similar to patients with sTBI. METHODS: Prospective observational study from June 2018 to October 2022 in 28 pediatric intensive care units (PICU) in Asia, South America, and Europe. We included children (age < 18 years) with modTBI and sTBI admitted to PICU and measured functional outcomes at 3 months using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds, scale 1-8, 1 = upper good recovery, 8 = death). RESULTS: We analyzed 409 patients: 98 (24%) and 311 (76%) with modTBI and sTBI, respectively. Patients with lmodTBI (vs. hmodTBI) were more likely to have invasive ICP monitoring (32.3% vs. 4.5%, p < 0.001), longer PICU stay (days, median [IQR]; 5.00 [4.00, 9.75] vs 4.00 [2.00, 5.00], p = 0.007), and longer hospital stay (days, median [IQR]: 13.00 [8.00, 17.00] vs. 8.00 [5.00, 12, 25], p = 0.015). Median GOS-E Peds scores were significantly different (hmodTBI (1.00 [1.00, 3.00]), lmodTBI (3.00 [IQR 2.00, 5.75]), and sTBI (5.00 [IQR 1.00, 6.00]) (p < 0.001)). After adjusting for age, sex, presence of polytrauma and cerebral edema, lmodTBI, and sTBI remained significantly associated with higher GOS-E scores (adjusted coefficient (standard error): 1.24 (0.52), p = 0.018, and 1.27 (0.33), p < 0.001, respectively) compared with hmodTBI. CONCLUSIONS: Children with lmodTBI have higher rates of neurocritical care utilization and worse functional outcomes than those with hmodTBI but better than those with sTBI. Children with lmodTBI may benefit from guideline-based management similar to what is implemented in children with sTBI. This work was performed in hospitals within the PACCMAN and LARed networks. No reprints will be ordered.

Safety huddles in paediatric intensive care unit: Implementation and staff perception in a resource limited setting.

Objective: To evaluate the perception, knowledge, empowerment and comfort level of critical care staff in relation to the implementation of safety huddles in paediatric intensive care unit of a tertiary care hospital. METHODS: The descriptive cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from September 2020 to February 2021, and comprised physicians, nurses and paramedics who were part of the safety huddle. Staff perception regarding this activity was evaluated using open-ended questions that were scored on a Likert scale. Data was analysed using STATA 15. RESULTS: Of the 50 participants, 27(54%) were females and 23(46%) were males. Overall, 26(52%) subjects were aged 20-30 years age, while 24(48%) were aged 31-50 years. Of the total, 37(74%) subjects strongly agreed that safety huddle had been routinely held in the unit since initiation; 42(84%) felt comfortable sharing their concerns about patient safety; and 37(74%) considered the huddles worthwhile. Majority 42(84%) felt more empowered through huddle participation. Moreover, 45(90%) participants strongly agreed that daily huddle helped them in becoming clearer about their responsibilities. For safety risk assessment, 41(82%) participants acknowledged that safety risks had been assessed and modified in routine huddles. Conclusion: Safety huddle was found to be a powerful tool to create a safe environment in a paediatric intensive care unit where all team members can speak up freely about patient safety.

Impact of Nutrition Support Team in Achieving Target Calories in Children Admitted in Pediatric Intensive Care Unit.

OBJECTIVE: To determine the impact of nutrition support team (NST) on achieving an early target caloric goal in mechanically ventilated children admitted in pediatric intensive care unit (PICU). METHODS: An early enteral nutrition protocol (EENP) was implemented by NST to ensure early and adequate nutrition provision to PICU patients. All children (1 month- 18 years) that were admitted in PICU for >2days and received mechanical ventilation, with no contraindications to enteral feed, were included and data was compared with those of pre-intervention. The adequacy of energy intake was defined as 70% achievement of target energy intake on the third day of admission. Chi-square/t-test was used to determine the difference between different variables pre and post intervention. RESULTS: Total 180 patients (99 and 81 in pre- and post-intervention group, respectively) were included. Overall, 115 (63.9%) received adequate calories (70%) on third day of admission. Of which 69 (85.2%) were from post intervention (P  < 0.001; odds ratio [OR] 6.6, 95% confidence interval [CI] 3.195-13.73). Moreover, NST intervention also promoted adequate protein intake in 62 (76.5%) children compared to 37 (37.4%) in pre-intervention group (P < 0.001, OR 5.468, 95% CI 2.838- 10.534). The median (interquartile range) length of PiCU stay in pre-NST group was 6 (4-9) days and in NST supported group was 4 (3-4) days (OR 0.580, CI 0.473-0.712, P < 0.001). Age, severity of illness, multiorgan dysfunction syndrome, sepsis, need of organ support had no effect in achievement of caloric target in both the groups (P > 0.05). CONCLUSION: Introduction of EENP with NST helped in the achievement of better and quicker target caloric intake.

Pediatric Critical Care Nursing Research Priorities in Asia: An eDelphi Study.

OBJECTIVES: To identify nursing research priorities in pediatric critical care in Asia. DESIGN: We conducted a modified three-round eDelphi survey with pediatric critical care nurses in Asia. The eDelphi technique has been extensively used within health research to achieve a common viewpoint from experts using questionnaires to gather research priorities. In round 1, participants were asked to list three to five research topics that they deemed important. These topics were thematically analyzed and categorized into a questionnaire. Participants rated the research topics in round 2 on a 6-point scale (1 = not important to 6 = extremely important). In round 3, the same questionnaire was used with addition of the calculated mean scores from round 2 for each topic. Research topics ranked among the top 10 were considered extremely important. SETTINGS: Twenty-two PICUs in eight Asian countries. SUBJECTS: Clinical nurses, managers, educators, and researchers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In round 1, 146 PICU nurses across eight countries provided 520 research topics. Topics from round 1 were categorized into seven domains with 52 research topics. Prioritized research topics included early recognition of patient deterioration (mean 5.58 ± 0.61), prevention of healthcare-associated infections (mean 5.47 ± 0.70), and interventions to reduce compassion fatigue (mean 5.45 ± 0.80). The top three research domains were end-of-life care (mean 5.34 ± 0.68), professionalism (mean 5.34 ± 0.69), and management of pain, sedation, and delirium (5.32 ± 0.72). CONCLUSIONS: This first PICU nursing research prioritization exercise within Asia identified key nursing research themes that should be prioritized and provide a framework for future collaborative studies.

Red blood cell transfusion in critically-ill children and its association with outcome.

OBJECTIVE: To determine the indications and threshold of haemoglobin levels for packed red blood cell transfusion and its association with outcomes in a paediatric intensive care setting. METHODS: The retrospective study was conducted in the paediatric intensive care unit of the Aga Khan University Hospital, Karachi, and comprised medical records of all inpatients with age between 1 month and 16 years who received packed red blood cell transfusions between January and December 2017. Data was retrieved from the hospital database and was analyzed using SPSS 22. RESULTS: Of the 147 subjects with a mean age of 67.89±65.8 months, 76(51.7%) were males. Mean paediatric risk of mortality score was 11.72±7.86. Major admitting diagnosis included sepsis and multiorgan dysfunction 50(34%), respiratory diseases 26(17.7%) and haematology/oncology diseases 22(15%). The indications for transfusion was low haemoglobin in 90(61.2%) patients, shock 29(19.7%) and hypoxia 28(19%). Acute transfusion reaction was observed in 1(0.7%) patient; 120(82%) required mechanical ventilation; and 94(64%) required inotropic support. Of the total, 88(59.9%) patients survived. Paediatric risk of mortality score, need for inotropic support and mechanical ventilation were associated with mortality (p<0.05). CONCLUSIONS: Packed red blood cell transfusion, which is frequently prescribed in intensive care settings, was not found to be associated with favourable outcome.

Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit.

OBJECTIVES: To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA. METHODS: Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied. RESULTS: Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay. CONCLUSION: Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA.

Relationship of Serum Procalcitonin, C-reactive Protein, and Lactic Acid to Organ Failure and Outcome in Critically Ill Pediatric Population.

OBJECTIVE: To evaluate the clinical and prognostic utility of procalcitonin (PCT), C-reactive protein (CRP), and lactic acid in children admitted to the Pediatric Intensive Care Unit (PICU) of a university teaching hospital. MATERIALS AND METHODS: Medical records of children (1 month-16 years) tested for serum PCT at the time of admission in the PICU of our hospital from July 1, 2013, to January 15, 2015, were reviewed. Within 24 h of admission, the Pediatric Risk of Mortality Score, blood cultures, white blood cell count, neutrophil counts, serum CRP, plasma lactic acid, and PCT were noted. Patient outcome was assessed at hospital discharge, and the patients were divided into nonsurvivors and survivors. RESULTS: A total of 167 children being admitted to the PICU were enrolled. The median age of the study population was 3 years (0-16 years), with 58.6% being males. Nonsurvivors had significantly higher lactic acid (4.7 mmol/L [2.07-7.6]; P < 0.05) than that of the survivors (2 mmol/L [1.3-3]; P < 0.05). In addition, nonsurvivors (94.4%; P < 0.05) had greater incidence of multiple organ dysfunction syndrome (MODS) than that of the survivors (38.05%; P < 0.05). Binary logistic regression showed age, MODS, and lactic acid to be associated with mortality. CONCLUSIONS: This study found that in comparison to PCT and CRP, high plasma lactic acid levels are associated with the development of all-cause MODS and worse outcome in critically ill children admitted in PICU. Prediction of prognosis based on the lactic acid alone may contribute to improve patient management, but further studies are required to endorse our findings.

Hyperlactetemia And Its Trends In Critically Ill Children Admitted In Pediatric Intensive Care Unit Of A Developing Country.

BACKGROUND: There is increasing evidence that in setting of critical ailments clinical signs lag biomarkers like Lactate and hyperlactetemia can be the only marker for this disorder. This study was conducted to describe the incidence of hyperlactatemia in critically ill children and its association with outcome. METHODS: Retrospective review of medical records of all children who had their lactic acid (LA) levels measured during their admission in PICU from January 2014 to December 2015 was done. Demographic and clinical variables were recorded along with PICU therapies, outcome (Survived or expired) and development of multi-organ dysfunction. Results are presented as frequency with percentages and mean with standard deviation. Appropriate statistical tests were applied and p-value of <0.05 was taken as significant. RESULTS: Total 300 patients had their LA measured and 202 were included in the study. Males were 130 (64%) and mean age was 5.7±4.6 years. Hyperlactatemia was found in 68 (33%) patients and another 75 (37%) had a second LA level >4 mmol/L. Increasing LA trend was found in 79 (39%) patients. Diagnostic categories included cardiovascular diseases (45, 22%), central nervous system diseases (40, 20%), respiratory diseases (31, 15%), sepsis (28, 14%), and gastrointestinal diseases14 (7%). 168 (83%) needed mechanical ventilation. Mean pH was 7.31±0.15 and metabolic acidosis was observed in 91 patients (45%). Mean LA levels in survivors and non survivors were 3.3±3.12 and 5.35±5.47 respectively. Hyperlactatemia was associated with death (p=0.01) and development of MODS (p=0.03) on univariate analysis. On multivariate logistic regression rising lactate and development of MODS were significantly associated with death (p=<0.05, odds ratio (OR) 9.24 (95% confidence interval 1.55-55.20). CONCLUSIONS: Hyperlactatemia and increasing LA trend in critically ill children are associated with worse outcome in PICU.

Evaluation of antibiotic use in Pediatric Intensive Care Unit of a developing country.

BACKGROUND: Pediatric Intensive Care Unit (PICU) patients are often prescribed antibiotics with a low threshold in comparison to patients elsewhere. Irrational antibiotics use can lead to rapid emergence of drug resistance, so surveillance of their use is important. OBJECTIVES: To evaluate the use of antibiotics in relation to bacteriological findings in PICU of a Tertiary Hospital. METHODS: Retrospective review of medical records of all children (age 1 month-16 years) admitted in our closed multidisciplinary-cardiothoracic PICU from January to June 2013 was performed, after approval from Ethical Review Committee. For each antibiotic, indication (prophylactic, empiric, therapeutic) and duration of use were recorded. All diagnoses of infections were recorded according to diagnostic criteria of IPSCC 2005. Results are presented as frequency and percentages and median with inter quartile range using SPSS version 19. RESULTS: All of the total 240 patients admitted in PICU during the study period received antibiotics: 43% (n = 104) prophylactically, 42% (n = 102) empirically, and 15% (n = 15) therapeutically. Median number of antibiotic use per patient in PICU was 3, with range of 1-7. 25% received 1 antibiotic, 23% received 2 antibiotics, 29% received 3 antibiotics, and rest received ≥4 antibiotics. Most commonly used antibiotics were cefazolin, meropenem, vancomycin and ceftriaxone, and most frequently used combination was meropenem and vancomycin. In majority of the cases, (70%) empiric antibiotic combinations were stopped in 72 h. CONCLUSION: This is the first report of antibiotics use in PICU from our country, which shows that antibiotics are prescribed universally in our PICU. Strategies to assess the need for antibiotic use are needed.

Burden of neurological illnesses in a pediatric intensive care unit of developing country.

OBJECTIVE: To assess the burden and spectrum of neurological illness in a pediatric intensive care unit and review the associated mortality. METHODS: Retrospective review of medical records of children (1 mo-16 years) with acute neurological diagnosis admitted in PICU in Aga Khan University hospital from January 2008 to December 2011 was done. Basic demographic, diagnosis, neuro diagnostic procedures performed, therapies and outcomes were done on a structured datasheet. RESULTS: During study period, 231 (19.3%) patients were admitted with acute neurological illnesses in PICU. The mean age was 67 ±50 months, 54% (n=125) was under-five and 138 (59.7%) were males. Out of total, 144 (62.3%) had neurological illness and 87 (37.7%) had neurosurgical diagnosis. In acute neurological illness, 51.5% (n=119) had non-traumatic-coma (NTC) and 10.8% (n=25) had neuromuscular illness. CNS infection (26%, n=60) in structural cause and status epilepticus (10%, n=23) were the most common cause of structural and metabolic type of NTC respectively. Severe traumatic brain injury (21.2%, n=49) and postoperative neurosurgical illness (16.5%, n=38) were common neurosurgical cases in our cohort. The intensive care resources were utilized as mechanical ventilation in 78% (n=180), inotropic support in 29.4% (n=67) and therapeutic hypothermia in 33% (n=76). Fifty children (21.6%) required PICU care for observation only. More than 500 neurodiagnostic tests/procedures were performed in this cohort of children with acute neurological disorders in PICU. The mortality rate in neurological cases was 18% (42/231) as compared to the overall mortality rate was 12% in PICU. CONCLUSION: Acute neurological disorders were common in PICU, and were associated with higher mortality. CNS infections, status epilepticus and severe traumatic brain injuries were the most common acute neurological illnesses in our cohort.

A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma.

INTRODUCTION: We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT. METHODS: We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT. RESULTS: 47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT. CONCLUSIONS: AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT. TYPE OF STUDY: Observational cohort study. LEVEL OF EVIDENCE: III.

Differences in clinical outcomes and resource utilization in pediatric traumatic brain injury between countries of different sociodemographic indices.

OBJECTIVE: The burden of traumatic brain injury (TBI) is disproportionately high in low- and middle-income countries (LMICs). This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe TBIs between LMICs and non-LMICs in Asia and Latin America. METHODS: The authors performed an observational multicenter study from January 2014 to February 2023 among children with moderate to severe TBIs admitted to participating pediatric intensive care units (PICUs) in the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network). They classified sites according to their 2019 sociodemographic index (SDI). Low, low-middle, and middle SDI sites were considered LMICs, while high-middle and high SDI sites were considered non-LMICs. The authors documented patient demographics and TBI management. Accounting for death, they recorded 14-day PICU-free and 28-day hospital-free days, with fewer free days indicating poorer outcome. The authors compared children who died and those who had poor functional outcomes (defined as Pediatric Cerebral Performance Category [PCPC] level of moderate disability, severe disability, or vegetative state or coma) between LMICs and non-LMICs and performed a multivariable logistic regression analysis for predicting poor functional outcomes. RESULTS: In total, 771 children with TBIs were analyzed. Mortality was comparable between LMICs and non-LMICs (9.6% vs 12.9%, p = 0.146). Children with TBIs from LMICs were more likely to have a poor PCPC outcome (31.0% vs 21.3%, p = 0.004) and had fewer ICU-free days (median [IQR] 6 [0-10] days vs 8 [0-11] days, p = 0.004) and hospital-free days (median [IQR] 9 [0-18] days vs 13 [0-20] days, p = 0.007). Poor functional outcomes were associated with LMIC status (adjusted OR [aOR] 1.53, 95% CI 1.04-2.26), a lower Glasgow Coma Scale score (aOR 0.83, 95% CI 0.78-0.88), and the presence of multiple trauma (aOR 1.49, 95% CI 1.01-2.19). Children with TBIs in LMICs required greater resource utilization in the form of early intubation and mechanical ventilation (81.6% vs 73.2%, p = 0.006), use of hyperosmolar therapy (77.7% vs 63.6%, p < 0.001), and use of antiepileptic drugs (73.9% vs 53.1%, p < 0.001). CONCLUSIONS: Within Asia and Latin America, children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. Further research should focus on investigating causal factors and developing targeted interventions to mitigate these disparities.

Clinical presentation, diagnosis and management of multisystem inflammatory syndrome in children (MIS-C): a systematic review.

BACKGROUND: Knowledge about multisystem inflammatory syndrome in children (MIS-C) is evolving, and evidence-based standardised diagnostic and management protocols are lacking. Our review aims to summarise the clinical and diagnostic features, management strategies and outcomes of MIS-C and evaluate the variances in disease parameters and outcomes between high-income countries (HIC) and middle-income countries (MIC). METHODS: We searched four databases from December 2019 to March 2023. Observational studies with a sample size of 10 or more patients were included. Mean and prevalence ratios for various variables were pooled by random effects model using R. A mixed generalised linear model was employed to account for the heterogeneity, and publication bias was assessed via funnel and Doi plots. The primary outcome was pooled mean mortality among patients with MIS-C. Subgroup analysis was conducted based on the income status of the country of study. RESULTS: A total of 120 studies (20 881 cases) were included in the review. The most common clinical presentations were fever (99%; 95% CI 99.6% to 100%), gastrointestinal symptoms (76.7%; 95% CI 73.1% to 79.9%) and dermatological symptoms (63.3%; 95% CI 58.7% to 67.7%). Laboratory investigations suggested raised inflammatory, coagulation and cardiac markers. The most common management strategies were intravenous immunoglobulins (87.5%; 95% CI 82.9% to 91%) and steroids (74.7%; 95% CI 68.7% to 79.9%). Around 53.1% (95% CI 47.3% to 58.9%) required paediatric intensive care unit admissions, and overall mortality was 3.9% (95% CI 2.7% to 5.6%). Patients in MIC were younger, had a higher frequency of respiratory distress and evidence of cardiac dysfunction, with a longer hospital and intensive care unit stay and had a higher mortality rate than patients in HIC. CONCLUSION: MIS-C is a severe multisystem disease with better mortality outcomes in HIC as compared with MIC. The findings emphasise the need for standardised protocols and further research to optimise patient care and address disparities between HIC and MIC. PROSPERO REGISTRATION NUMBER: CRD42020195823.

Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis.

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus.

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.