PICU Admission Rates in Pediatric Cancer and Hematopoietic Stem Cell Transplant Patients Receiving High-flow Nasal Cannula Oxygen Therapy on the General Ward.

The use of high-flow nasal cannula (HFNC) oxygen therapy is growing as an alternative to standard oxygen. However, its use in patients treated for malignancies, including hematopoietic stem cell transplantation (HSCT) patients, is controversial. In this retrospective cohort study, we assessed outcomes of pediatric cancer and HSCT patients (including nonmalignant indications) with acute hypoxemic respiratory failure treated with HFNC on the ward. Among 39 patients included in the study, 53 episodes of HFNC treatment were analyzed. Of these episodes, 18 (34%) failed and patients required subsequently pediatric intensive care unit (PICU) admission. A significant median higher C reactive protein (175 [range, 72 to 308] vs. 80 [13.5 to 187.8] mg/dL; P=0.006) and higher Bedside Pediatric Early Warning Score (PEWS) 1 to 4 hours after initiation of HFNC (10.1±0.8 vs. 7.1±0.4; P=0.001) was found in the failure group compared with the nonfailure group. Among the 18 patients admitted to PICU, 14 (78%) needed intubation. Five (28%) patients died during their PICU admission. In summary, one third of the pediatric cancer and HSCT patients receiving HFNC on the ward eventually required PICU admission of which 78% were intubated. C reactive protein and BedsidePEWS 1 to 4 hours after initiation of HFNC were significantly associated with the need for PICU admission. However, no firm conclusion can be drawn whether HFNC treatment should actually be initiated in the ward in this vulnerable patient population. Larger, prospective studies are needed to evaluate the most appropriate treatment and setting (PICU or general ward) for these patients.

PICU mortality of children with cancer admitted to pediatric intensive care unit a systematic review and meta-analysis.

BACKGROUND: Outcomes for children diagnosed with cancer have improved dramatically over the past 20 years. However, although 40% of pediatric cancer patients require at least one intensive care admission throughout their disease course, PICU outcomes and resource utilization by this population have not been rigorously studied in this specific group. METHODS: Using a systematic strategy, we searched Medline, Embase, and CINAHL databases for articles describing PICU mortality of pediatric cancer patients admitted to PICU. Two investigators independently applied eligibility criteria, assessed data quality, and extracted data. We pooled PICU mortality estimates using random-effects models and examined mortality trends over time using meta-regression models. RESULTS: Out of 1218 identified manuscripts, 31 studies were included covering 16,853 PICU admissions with the majority being retrospective in nature. Overall pooled weighted mortality was 27.8% (95% confidence interval (CI), 23.7-31.9%). Mortality decreased slightly over time when post-operative patients were excluded. The use of mechanical ventilation (odds ratio (OR): 18.49 [95% CI 13.79-24.78], p < 0.001), inotropic support (OR: 14.05 [95% CI 9.16-21.57], p < 0.001), or continuous renal replacement therapy (OR: 3.24 [95% CI 1.31-8.04], p = 0.01) was significantly associated with PICU mortality. CONCLUSIONS: PICU mortality rates of pediatric cancer patients are far higher when compared to current mortality rates of the general PICU population. PICU mortality has remained relatively unchanged over the past decades, a slight decrease was only seen when post-operative patients were excluded. This compared infavorably with the improved mortality seen in adults with cancer admitted to ICU, where research-led improvements have led to the paradigm of unlimited, aggressive ICU management without any limitations on resuscitations status, for a time-limited trial.

Citrate versus heparin anticoagulation in continuous renal replacement therapy in small children.

BACKGROUND: Citrate is preferred over heparin as an anticoagulant in adult continuous renal replacement therapy (CRRT). However, its potential adverse effects and data on use in CRRT in infants and toddlers is limited. We conducted a prospective study on using citrate in CRRT in critically ill small children. METHODS: Children who underwent CRRT with the smallest filter in our PICU between November 2011 and November 2016 were included. Both heparin and citrate were applied according to a strict protocol. Our primary outcome was circuit survival time. Secondary outcomes were alkalosis, citrate toxicity, and number of red blood cell transfusions. RESULTS: Heparin was used in six patients (121 circuits, total CRRT time 3723 h). Citrate was used in 14 patients (105 circuits, total CRRT time 4530 h). Median circuit survival time with heparin was 21 h (IQR 14.5-27.5) compared to 45.2 h (IQR 37.5-52.8) with citrate (p < 0.001). Actual administered effluent dose compared to prescribed dose was 85% (IQR 69-98%) with heparin compared to 92% (IQR 88-98%) with citrate (p = 0.31). No patient treated with citrate developed citrate toxicity. No other differences in electrolytes were found between the two CRRT regimes. In the heparin group, a median of 6.5 units of red blood cells (IQR 1.5-23.8) were given during CRRT, compared to three in the citrate group (IQR 2.0-5.0, p = 0.12). CONCLUSIONS: Use of regional citrate significantly prolongs circuit survival time and thereby should increase CRRT efficiency when compared to heparin. In addition, citrate appears safe for CRRT in critically ill small children.

Are central line bundles and ventilator bundles effective in critically ill neonates and children?

Central line-associated bloodstream infections (CLABSI) and ventilator-associated pneumonia (VAP) are common problems in adult, pediatric (PICU) and neonatal (NICU) intensive care unit patients. Care bundles have been developed to prevent these hospital-acquired infections and to provide best possible care. Studies in adults have proven that care bundles contribute to a decrease in CLABSI and VAP rates. The purpose of this literature review was to critically appraise the known evidence of the effectiveness of central line bundles and ventilator bundles in PICU and NICU patients. The number of publications of central line bundles and ventilator bundles in PICU and NICU patients is limited compared to adults. Ten studies in PICU patients demonstrated a significant decrease in the CLABSI or VAP rate after implementation of the bundle. Two studies in neonates demonstrated a reduction in the CLABSI rate after implementation of the central line bundle. No studies on the effectiveness of the ventilator bundle in neonates were found. Bundle elements differed between studies, and their scientific basis was not as robust as in adults. Monitoring of compliance to bundle elements seems required for optimal reduction of CLABSI and VAP. Bundle components that focus on maintenance of a central line probably are important to prevent CLABSI in children.

Thirty years of home mechanical ventilation in children: escalating need for pediatric intensive care beds.

PURPOSE: To describe trends in pediatric home mechanical ventilation (HMV) and their impact on the use of pediatric intensive care unit (PICU) beds. METHODS: Review of all children who had started HMV in a single center for HMV. RESULTS: Between 1979 and 2009, HMV was started in 197 patients [100 (51%) with invasive and 97 with noninvasive ventilation], with a median age of 14.7 (range 0.5-17.9) years. Most patients (77%) were males with a neuromuscular disorder (66%). The number of children receiving HMV increased from 8 in the 1979-1988 period to 122 in the 1999-2008 period. This increase occurred foremost in patients aged 0-5 years and was accompanied by a sharp rise in the use of PICU beds. In 150 patients (76%), HMV was initiated on an ICU with a total of 12,440 admission days, of which 10,385 days (83%) could be attributed to 67 patients who started non-electively with invasive HMV. Of the latter, 52 patients had been admitted to a PICU with a total of 9,335 admission days. At the end of the study, 134 patients (68%) were still being ventilated, 43 patients (22%) had died, 11 patients (6%) were weaned from HMV, 4 patients (2%) did not want to continue HMV and 5 patients (3%) were lost to follow-up. CONCLUSIONS: Over time, there was an impressive increase in the application of HMV in children. This increase was most obvious in the youngest age group with invasive HMV, and these children had very long stays in the PICU.

Mechanical ventilation for respiratory failure in children with severe neurological impairment: is it futile medical treatment?

AIM: To assess outcome for children with severe neurological impairment receiving invasive mechanical ventilation for respiratory failure. METHOD: Medical charts for all such children treated in our intensive care unit (ICU) between January 2003 and July 2008 were reviewed. Outcomes were compared with those for children with moderate neurological impairment. RESULTS: Twenty-two children with severe neurological impairment were included (nine females, 13 males; median age 7y 10mo; range 4mo-17y). The median duration of mechanical ventilation was 16 days. Six children had an uneventful 1-year survival, the others required reintubation or readmission to the ICU, or died. Eleven children were still alive 1 year after discharge from the ICU. Nine patients died of respiratory failure. None of the children in the severe group died of a heart defect. Eleven children with moderate neurological impairment were included (eight females, three males; median age 1y 1mo, range 4mo-13y). Four children had an uneventful 1-year survival. Eight children were still alive 1 year after discharge from the ICU. Two of the three non-survivors died of their heart defects. INTERPRETATION: Mechanical ventilation for respiratory failure in children with severe neurological impairment is complex and associated with limited survival. However, it cannot be regarded as futile medical treatment. Further studies are urgently needed for the rational guidance of clinical decision-making.

Monitoring biochemical parameters as an early sign of propofol infusion syndrome: false feeling of security.

OBJECTIVE: The aim of this report is to describe a fatal case of propofol infusion syndrome (PRIS), despite regular screening for this syndrome and immediate discontinuation of the infusion after the first signs of biochemical derangement. DESIGN: Case report. SETTING: Pediatric intensive care unit. PATIENT: A 17-year-old patient admitted after sustaining a traumatic brain injury. INTERVENTIONS: Treatment for traumatic brain injury was given with mechanical ventilation, inotropic support, mannitol, and sedation with propofol. Blood gases and serum levels of lactate and creatine kinase were monitored frequently to screen for PRIS. MEASUREMENTS AND MAIN RESULTS: Propofol infusion was stopped immediately after the first signs of biochemical derangement. The patient died despite supportive treatment with intra-aortic balloon pump and cardiopulmonary resuscitation. CONCLUSIONS: This case report demonstrates that frequent monitoring of biochemical parameters, as suggested in literature, cannot always prevent death due to PRIS.

Survival in a recent cohort of mechanically ventilated pediatric allogeneic hematopoietic stem cell transplantation recipients.

There is ongoing discussion whether survival improved for children requiring mechanical ventilation after hematopoietic stem cell transplantation (HSCT). We reviewed the outcomes of 150 children who received an allogeneic HSCT between January 1999 and April 2007, in a pediatric university hospital in The Netherlands. Thirty-five of the 150 patients received mechanical ventilation on 38 occasions. None of the recorded risk factors was significantly associated with the requirement of mechanical ventilation. Sixteen admissions resulted in death in the intensive care unit (ICU), giving a case fatality rate of 42% (95% confidence interval 26%-58%). ICU mortality was associated with multiorgan failure on the second day of admission and with the use of high frequency oscillatory ventilation. Patients had higher pediatric risk of mortality scores than in previous studies, reflecting higher acuity of illness on admission to the ICU. Six-month survival in patients discharged from the ICU was 82%. Compared to previous studies, we found an improvement in ICU survival and survival 6 months after ICU discharge in a recent cohort of ventilated children after allogeneic HSCT, even though our patients were more severely ill. Our results are promising, but they need to be confirmed in larger, preferably multicenter, studies.

Intensive care unit mortality trends in children after hematopoietic stem cell transplantation: a meta-regression analysis.

BACKGROUND: There is ongoing discussion whether intensive care unit mortality has decreased over time for children after hematopoietic stem cell transplantation. OBJECTIVE: To analyze intensive care unit mortality trends in children after hematopoietic stem cell transplantation. DATA SOURCES: Search of MEDLINE, EMBASE, and Cochrane databases, and a manual review of reference lists. STUDY SELECTION: Prospective and retrospective cohort studies containing intensive care unit mortality data of children after hematopoietic stem cell transplantation. DATA EXTRACTION: Mortality statistics and features associated with mortality were abstracted from studies of interest. To assess mortality over time, the median years of inclusion in original studies were included as risk factor. A multiple random-effects meta-regression analysis was conducted to assess the independent contribution of prognostic factors on mortality. DATA SYNTHESIS: Twenty-three studies were included, reporting on 1101 intensive care unit admissions. Overall intensive care unit mortality was 60% (range, 25%-91%). Once mechanical ventilation was necessary (n = 822), mean intensive care unit mortality was 71% (range, 25%-91%). Over the years, significantly fewer intensive care unit admitted patients received mechanical ventilation (p < 0.001). Univariable analysis in all intensive care unit admitted patients showed a significant decrease in mortality associated with year of inclusion. Mechanical ventilation and pulmonary disease were associated with increased mortality. In the multiple meta-regression analysis, only pulmonary disease remained significantly associated with mortality (odds ratio = 1.21, 95% confidence interval 1.01-1.46 per 10% increase in the number of patients with pulmonary disease in studies). The association between year of inclusion and intensive care unit mortality was less pronounced (odds ratio = 0.92, 95% confidence interval 0.84-1.01). CONCLUSION: There is a widely held impression that intensive care unit mortality clearly decreased in children after hematopoietic stem cell transplantation. However, characteristics of intensive care unit admitted patients significantly changed over time. After correcting for this, an improvement in intensive care unit survival was less evident. More studies are needed before a true improvement in intensive care unit survival can be confirmed.

Outcome of assisted ventilation for acute respiratory failure in cystic fibrosis.

OBJECTIVES: To assess outcome of assisted ventilation in cystic fibrosis (CF) patients with acute respiratory failure (ARF), to identify risk factors associated with poor outcome and to compare long-term outcome of CF children who were mechanically ventilated for ARF with unventilated CF controls. DESIGN: Retrospective cohort study. SETTING: Two large CF centres in the Netherlands. PATIENTS: CF patients who required assisted ventilation for ARF and unventilated CF controls. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Thirty-one CF patients required assisted ventilation for ARF between January 1990 and March 2005. All five children (under 2 years of age) and seven adults (27%) survived. In the total population, age was a statistically significant risk factor for poor outcome (p=0.02). In adult CF patients who required invasive mechanical ventilation, acute on chronic respiratory failure was associated with poor outcome. In children who required mechanical ventilation for ARF, lung function and CF related complications 5 years later were not significantly different compared with controls matched for age, gender and genotype. CONCLUSIONS: CF patients younger than 2 years old, who are ventilated because of ARF, have a good prognosis and their long-term outcome seems identical to unventilated CF controls. ARF in adult CF patients still is associated with high mortality, especially among patients with acute on chronic respiratory failure.