Pharmacist Metrics in the Pediatric Intensive Care Unit: an Exploration of the Medication Regimen Complexity-Intensive Care Unit (MRC-ICU) Score.

INTRODUCTION: The medication regimen complexity-intensive care unit (MRC-ICU) score has been developed and validated as an objective predictive metric for patient outcomes and pharmacist workload in the adult critically ill population. The purpose of this study was to explore the MRC-ICU and other workload metrics in the pediatric ICU (PICU). METHODS: This study was a retrospective cohort of pediatric ICU patients admitted to a single institution -between February 2, 2022 - August 2, 2022. Two scores were calculated, including the MRC-ICU and the pediatric Daily Monitoring System (pDMS). Data were extracted from the electronic health record. The primary outcome was the correlation of the MRC-ICU to mortality, as measured by Pearson -correlation -coefficient. Additionally, the correlation of MRC-ICU to number of orders was evaluated. Secondary -analyses explored the correlation of the MRC-ICU with pDMS and with hospital and ICU length of stay. RESULTS: A total of 2,232 patients were included comprising 2,405 encounters. The average age was 6.9 years (standard deviation [SD] 6.3 years). The average MRC-ICU score was 3.0 (SD 3.8). For the primary outcome, MRC-ICU was significantly positively correlated to mortality (0.22 95% confidence interval [CI 0.18 - 0.26]), p<0.05. Additionally, MRC-ICU was significantly positively correlated to ICU length of stay (0.38 [CI 0.34 - 0.41]), p<0.05. The correlation between the MRC-ICU and pDMS was (0.72 [CI 0.70 - 0.73]), p<0.05. CONCLUSION: In this pilot study, MRC-ICU demonstrated an association with existing prioritization metrics and with mortality and length of ICU stay in PICU population. Further, larger scale studies are required.

Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children.

Importance: Optimal agents and duration of primary treatment for multisystem inflammatory syndrome in children (MIS-C) remain unclear. Objective: To compare short-term patient outcomes based on initial treatment with corticosteroids, intravenous immunoglobulin (IVIG), or both. Design, Setting, and Participants: This retrospective cohort study included patients in a tertiary-care pediatric hospital system who had MIS-C per the Centers for Disease Control and Prevention case definition during the period March 2020 to February 2021. Exposures: Immunomodulatory therapy within the first 24 hours (patients in the intensive care unit [ICU]) or 48 hours (non-ICU patients): corticosteroids alone, IVIG alone, and IVIG plus corticosteroids. Main Outcomes and Measures: Primary outcome was failure of initial therapy, defined as therapy escalation due to fever or worsening or lack of improvement of laboratory, cardiac, or noncardiac clinical factors after 24 hours (ICU patients) or 48 hours (non-ICU patients) from time of therapy initiation, per clinician assessment. Secondary outcomes included presence of complications, cardiovascular outcomes, fever duration, length of hospital and ICU stays, corticosteroid use duration, and need for readmission. Results: Among 228 eligible patients, 215 patients were included in the univariate analysis; median age was 8 years, and 135 (62.8%) were boys. There were 69 patients in the corticosteroids group, 31 patients in the IVIG group, and 115 patients in the IVIG plus corticosteroids group. Patients in the corticosteroids group had milder disease at presentation. After propensity score weighting including 179 patients (68 in the corticosteroids group and 111 in the IVIG plus corticosteroids group), rates of initial treatment failure were similar between groups. Among patients whose initial treatment failed, treatment failure in the IVIG plus corticosteroids group was more likely to be based on laboratory parameters (odds ratio [OR], 1.96; 95% CI, 1.07-3.60) and less likely to be based on cardiovascular markers (OR, 0.39; 95% CI, 0.2-0.76), per clinician assessment. Patients in the IVIG plus corticosteroids group had a longer median inpatient stay (6 vs 5 days; P = .001) and longer median corticosteroid course duration (10 vs 5 days; P = .04) compared with the corticosteroids group. Forty-nine patients (71% of 69 in the corticosteroids group) recovered after receiving corticosteroid monotherapy for 10 days or less. Conclusions and Relevance: Corticosteroid monotherapy is a reasonable management option for a subset of patients with MIS-C, particularly those with mild disease.

Severe acute respiratory syndrome coronavirus 2 infection and critically ill children.

PURPOSE OF REVIEW: Amidst an ongoing pandemic, the delineation of the pediatric consequence of infection from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus is emerging. This review summarizes available pediatric data and covers the aspects of epidemiology, critical illness with acute infection [coronavirus disease 2019 (COVID-19)], the discovered multi-inflammatory syndrome in children (MIS-C), and management options. RECENT FINDINGS: The available data from the source of the initial viral transmission and then through Europe, Africa, and the Western Hemisphere identifies important aspects of the SARS-CoV2 pandemic: 1) Pediatric infection occurs commonly, is likely underestimated, and transmission patterns remain incompletely described, 2) Pediatric patients suffer multiple end-organ injuries but COVID-19 is not the same prevalence in terms of severity as in adults, 3) MIS-C is a novel and life-threatening manifestation of exposure to the virus, 4) Management using a combination of supportive care, standard practice intensive care management, and anti-inflammatory agents is associated with recovery, 5) Long-term sequelae of viral exposure is unknown at this time. SUMMARY: Emerging evidence suggests pediatric patients are at risk for severe and life-threatening effects of exposure to SARS-CoV2. As the pandemic continues, further research is warranted - particularly as a vaccine is not yet available for use in children.

"Difficult to Sedate": Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children.

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08-0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

Genome Sequences of Gordonia Phages BaxterFox, Kita, Nymphadora, and Yeezy.

Gordonia phages BaxterFox, Kita, Nymphadora, and Yeezy are newly characterized phages of Gordonia terrae, isolated from soil samples in Pittsburgh, Pennsylvania. These phages have genome lengths between 50,346 and 53,717 bp, and encode on average 84 predicted proteins. All have G+C content of 66.6%.

The intermediate filament network in cultured human keratinocytes is remarkably extensible and resilient.

The prevailing model of the mechanical function of intermediate filaments in cells assumes that these 10 nm diameter filaments make up networks that behave as entropic gels, with individual intermediate filaments never experiencing direct loading in tension. However, recent work has shown that single intermediate filaments and bundles are remarkably extensible and elastic in vitro, and therefore well-suited to bearing tensional loads. Here we tested the hypothesis that the intermediate filament network in keratinocytes is extensible and elastic as predicted by the available in vitro data. To do this, we monitored the morphology of fluorescently-tagged intermediate filament networks in cultured human keratinocytes as they were subjected to uniaxial cell strains as high as 133%. We found that keratinocytes not only survived these high strains, but their intermediate filament networks sustained only minor damage at cell strains as high as 100%. Electron microscopy of stretched cells suggests that intermediate filaments are straightened at high cell strains, and therefore likely to be loaded in tension. Furthermore, the buckling behavior of intermediate filament bundles in cells after stretching is consistent with the emerging view that intermediate filaments are far less stiff than the two other major cytoskeletal components F-actin and microtubules. These insights into the mechanical behavior of keratinocytes and the cytokeratin network provide important baseline information for current attempts to understand the biophysical basis of genetic diseases caused by mutations in intermediate filament genes.