Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial.

OBJECTIVES: Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN: Multicenter prospective before-and-after comparison design study. SETTING: Twenty-one PICUs. PATIENTS: Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS: The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS: There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS: Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.

Postoperative hypoalbuminemia and outcomes of pediatric liver transplantation.

BACKGROUND: Hypoalbuminemia after liver transplantation (LT) is associated with acute kidney injury (AKI) and poor outcomes in adult LT recipients. This study was performed to examine the association between the postoperative serum albumin level and early postoperative outcomes of LT in children. METHODS: This single-center retrospective review involved pediatric LT recipients (0-18 years old) treated from January 2013 to June 2020. All patients were admitted to PICU and received standard post-LT care protocol. We divided patients into low (< 30 g/L) and normal (> 30 g/L) groups based on postoperative albumin day 1 to 3. RESULTS: Among 108 LT recipients, most had biliary atresia. The median age at the time of LT was 1.8 years [interquartile range (IQR), 1.5-5.7]. There were 18 patients in low albumin group [median albumin level, 27.9 g/L (IQR, 25.8-29.6) and 90 patients in normal albumin group [median albumin level, 34.5 g/L (IQR, 32.4-36.9). The low albumin group had significantly higher incidence of AKI, occurring in 20% of patients with a median onset of 2.5 days following LT (IQR, 1-5). Postoperative hypoalbuminemia (OR, 4.94; 95% CI, 1.32-18.47; p = 0.01) and a longer operative time (OR, 1.37; 95% CI, 1.01-1.47; p = 0.02) were independent risk factors for AKI by multivariable analysis. No significant differences between the two groups were found in other early postoperative outcomes. CONCLUSION: Postoperative hypoalbuminemia was associated with early postoperative AKI following LT in children but not with other worsening outcomes.

Handshake stewardship reduces carbapenem prescription in a pediatric critical care setting.

BACKGROUND: Intensive care unit (ICU) settings typically have a high-volume prescription of carbapenems. Antimicrobial stewardship programs (ASPs) aim to promote appropriate antibiotic use. Handshake stewardship (HS) is adapted from ASPs but focuses on direct feedback to physicians who prescribed antibiotics regarding the appropriateness of antibiotic prescription. This study aimed to evaluate the impact and acceptability of HS on carbapenem consumption in pediatric critical care settings. METHODS: This study was conducted over 18 months spanning pre-and post-implementation of HS. Carbapenem prescriptions were automatically discontinued during the pre-implementation period after 72 h if no indications existed. During the post-implementation, HS was performed by direct feedback to ICU physicians regarding the appropriateness of carbapenem prescriptions within 24 h. The primary outcome was the carbapenem consumption rate, defined as days of therapy (DOT)/1,000 patient-ICU days. Secondary outcomes were the acceptability of HS, length of critical care stay (LOCS), 30-day infection-related mortality rate, and the rate of carbapenem-resistant Enterobacteriaceae (CRE). RESULTS: There were 212 carbapenem prescriptions (163 patients) and 174 carbapenem prescriptions (110 patients) in the pre-and post-implementation periods, respectively. Carbapenem consumption decreased significantly from 667 to 369 DOT/1,000 patient-ICU days, with a median difference of 292 DOT/1,000 patient-ICU days (P < 0.001; 95% confidence interval: 175-408) after HS implementation. The acceptability of the HS was 95.4%. The LOCS, 30-day infection-related mortality, and CRE rate were not significantly different between pre-and post-implementation periods. CONCLUSIONS: Handshake stewardship significantly reduced carbapenem prescription in critically ill pediatric patients without negatively affecting patient outcomes.

Pediatric Severe Sepsis and Shock in Three Asian Countries: A Retrospective Study of Outcomes in Nine PICUs.

OBJECTIVES: Pediatric sepsis remains a major health problem and is a leading cause of death and long-term disability worldwide. This study aims to characterize epidemiologic, therapeutic, and outcome features of pediatric severe sepsis and septic shock in three Asian countries. DESIGN: A multicenter retrospective study with longitudinal clinical data over 1, 6, 24, 48, and 72 hours of PICU admission. The primary outcome was PICU mortality. Multivariable logistic regression analysis was used to identify factors at PICU admission that were associated with mortality. SETTING: Nine multidisciplinary PICUs in three Asian countries. PATIENTS: Children with severe sepsis or septic shock admitted to the PICU from January to December 2017. INTERVENTION: None. MEASUREMENT AND MAIN RESULTS: A total of 271 children were included in this study. Median (interquartile range) age was 4.2 years (1.3-10.8 yr). Pneumonia (77/271 [28.4%]) was the most common source of infection. Majority of patients (243/271 [90%]) were resuscitated within the first hour, with fluid bolus (199/271 [73.4%]) or vasopressors (162/271 [59.8%]). Fluid resuscitation commonly took the form of normal saline (147/199 [74.2%]) (20 mL/kg [10-20 mL/kg] over 20 min [15-30 min]). The most common inotrope used was norepinephrine 81 of 162 (50.0%). Overall PICU mortality was 52 of 271 (19.2%). Improved hemodynamic variables (e.g., heart rate, blood pressure, and arterial lactate) were seen in survivors within 6 hours of admission as compared to nonsurvivors. In the multivariable model, admission severity score was associated with PICU mortality. CONCLUSIONS: Mortality from pediatric severe sepsis and septic shock remains high in Asia. Consistent with current guidelines, most of the children admitted to these PICUs received fluid therapy and inotropic support as recommended.

The impact of high frequency oscillatory ventilation on mortality in paediatric acute respiratory distress syndrome.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS. METHODS: Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect. RESULTS: A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS. CONCLUSION: The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.

Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial.

AIMS: The prolonged use of benzodiazepines and opioids can lead to an increase in the incidence of withdrawal syndrome. One of the known risk factors is the lack of a sedative-weaning protocol. This study established a sedative-weaning protocol and compared this protocol with the usual care of weaning in high-risk critically ill children. MATERIALS AND METHODS: This was an open-label, randomized controlled trial in a tertiary-care hospital. We recruited children aged 1 month to 18 years who had received intravenous sedative or analgesic drugs for at least 5 days. The exclusion criteria were patients who had already experienced the withdrawal syndrome. We established a weaning protocol. Eligible patients were randomly divided into the protocolized (intervention) and usual care (control) groups. The primary objective was to determine the prevalence of the withdrawal syndrome compared between two groups. RESULTS: Thirty eligible patients were enrolled (19 in the intervention and 11 in the control group). Baseline characteristics were not significantly different between both the groups. The prevalence of the withdrawal syndrome was 84% and 81% of patients in the intervention and control group, respectively. The duration of the initial weaning phase was shorter in the intervention group than in the control group (p value = 0.026). The cumulative dose of morphine solution for rescue therapy in the intervention group was statistically lower than that in the control group (p value = 0.016). CONCLUSION: The implementation of the sedative-weaning protocol led to a significant reduction in the percentage of withdrawal days and length of intensive care unit stay without any adverse drug reactions. External validation would be needed to validate this protocol. CLINICALTRIALSGOV IDENTIFIER: NCT03018977. HOW TO CITE THIS ARTICLE: Tiacharoen D, Lertbunrian R, Veawpanich J, Suppalarkbunlue N, Anantasit N. Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial. Indian J Crit Care Med 2020;24(6):451-458.

Differences Between Pulmonary and Extrapulmonary Pediatric Acute Respiratory Distress Syndrome: A Multicenter Analysis.

OBJECTIVES: Extrapulmonary pediatric acute respiratory distress syndrome and pulmonary pediatric acute respiratory distress syndrome are poorly described in the literature. We aimed to describe and compare the epidemiology, risk factors for mortality, and outcomes in extrapulmonary pediatric acute respiratory distress syndrome and pulmonary pediatric acute respiratory distress syndrome. DESIGN: This is a secondary analysis of a multicenter, retrospective, cohort study. Data on epidemiology, ventilation, therapies, and outcomes were collected and analyzed. Patients were classified into two mutually exclusive groups (extrapulmonary pediatric acute respiratory distress syndrome and pulmonary pediatric acute respiratory distress syndrome) based on etiologies. Primary outcome was PICU mortality. Cox proportional hazard regression was used to identify risk factors for mortality. SETTING: Ten multidisciplinary PICUs in Asia. PATIENTS: Mechanically ventilated children meeting the Pediatric Acute Lung Injury Consensus Conference criteria for pediatric acute respiratory distress syndrome between 2009 and 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-one of 307 patients (13.4%) and 266 of 307 patients (86.6%) were classified into extrapulmonary pediatric acute respiratory distress syndrome and pulmonary pediatric acute respiratory distress syndrome groups, respectively. The most common causes for extrapulmonary pediatric acute respiratory distress syndrome and pulmonary pediatric acute respiratory distress syndrome were sepsis (82.9%) and pneumonia (91.7%), respectively. Children with extrapulmonary pediatric acute respiratory distress syndrome were older, had higher admission severity scores, and had a greater proportion of organ dysfunction compared with pulmonary pediatric acute respiratory distress syndrome group. Patients in the extrapulmonary pediatric acute respiratory distress syndrome group had higher mortality (48.8% vs 24.8%; p = 0.002) and reduced ventilator-free days (median 2.0 d [interquartile range 0.0-18.0 d] vs 19.0 d [0.5-24.0 d]; p = 0.001) compared with the pulmonary pediatric acute respiratory distress syndrome group. After adjusting for site, severity of illness, comorbidities, multiple organ dysfunction, and severity of acute respiratory distress syndrome, extrapulmonary pediatric acute respiratory distress syndrome etiology was not associated with mortality (adjusted hazard ratio, 1.56 [95% CI, 0.90-2.71]). CONCLUSIONS: Patients with extrapulmonary pediatric acute respiratory distress syndrome were sicker and had poorer clinical outcomes. However, after adjusting for confounders, it was not an independent risk factor for mortality.

Risk Stratification in Pediatric Acute Respiratory Distress Syndrome: A Multicenter Observational Study.

OBJECTIVES: The Pediatric Acute Lung Injury Consensus Conference developed a pediatric specific definition for acute respiratory distress syndrome (PARDS). In this definition, severity of lung disease is stratified into mild, moderate, and severe groups. We aim to describe the epidemiology of patients with PARDS across Asia and evaluate whether the Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS. DESIGN: A multicenter, retrospective, descriptive cohort study. SETTING: Ten multidisciplinary PICUs in Asia. PATIENTS: All mechanically ventilated children meeting the Pediatric Acute Lung Injury Consensus Conference criteria for PARDS between 2009 and 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data on epidemiology, ventilation, adjunct therapies, and clinical outcomes were collected. Patients were followed for 100 days post diagnosis of PARDS. A total of 373 patients were included. There were 89 (23.9%), 149 (39.9%), and 135 (36.2%) patients with mild, moderate, and severe PARDS, respectively. The most common risk factor for PARDS was pneumonia/lower respiratory tract infection (309 [82.8%]). Higher category of severity of PARDS was associated with lower ventilator-free days (22 [17-25], 16 [0-23], 6 [0-19]; p < 0.001 for mild, moderate, and severe, respectively) and PICU free days (19 [11-24], 15 [0-22], 5 [0-20]; p < 0.001 for mild, moderate, and severe, respectively). Overall PICU mortality for PARDS was 113 of 373 (30.3%), and 100-day mortality was 126 of 317 (39.7%). After adjusting for site, presence of comorbidities and severity of illness in the multivariate Cox proportional hazard regression model, patients with moderate (hazard ratio, 1.88 [95% CI, 1.03-3.45]; p = 0.039) and severe PARDS (hazard ratio, 3.18 [95% CI, 1.68, 6.02]; p < 0.001) had higher risk of mortality compared with those with mild PARDS. CONCLUSIONS: Mortality from PARDS is high in Asia. The Pediatric Acute Lung Injury Consensus Conference definition of PARDS is a useful tool for risk stratification.

Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial.

OBJECTIVES: To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children. DESIGN: Double-blind, placebo-controlled randomized clinical trial. SETTING: PICU in a tertiary referral center. PATIENTS: Children 1 month to 15 years old who underwent mechanical ventilation. INTERVENTIONS: Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor. MEASUREMENTS AND MAIN RESULTS: One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90-585] vs 60 [42-116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively). CONCLUSIONS: The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.

Ultrasound Versus Traditional Palpation to Guide Radial Artery Cannulation in Critically Ill Children: A Randomized Trial.

OBJECTIVES: To identify success rates for radial artery cannulation in a pediatric critical care unit using either palpation or ultrasound guidance to cannulate the radial artery. METHODS: A prospective randomized comparative study of critically ill children who required invasive monitoring in a tertiary referral center was conducted. All patients were randomized by a stratified block of 4 to either ultrasound-guided or traditional palpation radial artery cannulation. The primary outcomes were the first attempt and total success rates. RESULTS: Eighty-four children were enrolled, with 43 randomized to the palpation technique and 41 to the ultrasound-guided technique. Demographic data between the groups were not significantly different. The total success and first attempt rates for the ultrasound-guided group were significantly higher than those for the palpation group (success ratio, 2.03; 95% confidence interval, 1.13-3.64; P = .018; and success ratio, 4.18; 95% confidence interval, 1.57-11.14; P = .004, respectively). The median time to success for the ultrasound-guided group was significantly shorter than that for the palpation group (3.3 versus 10.4 minutes; P < .001). Cannulation complications were lower in the ultrasound-guided group than the palpation group (12.5% versus 53.3%; P < .001). CONCLUSIONS: The ultrasound-guided technique could improve the success rate and allow for faster cannulation of radial artery catheterization in critically ill children.

Accuracy of bedside glucometry in critically ill children with peripheral hypoperfusion.

The accuracy of glucose test strip in critically care has been questioned. We investigated the accuracy of glucose test strip in critically ill children. Patients, aged from 1 month to 18 years admitted in pediatric intensive care unit. Demographic data, hemodynamic parameters, and perfusion index (PI) were recorded. Glucose test strips were performed from finger stick blood [capillary blood glucose (CBG)] and from whole blood [whole blood glucose (WBG)] along with laboratory plasma blood glucose (PBG) from either arterial or venous blood samples. The accuracy of glucose test strips was defined according to ISO 15197 and Clarke error grid (CEG). One hundred and eighty one blood samplings including 117 arterial blood (CBG, WBGa, PBGa) and 64 venous blood (CBG, WBGv, PBGv) were obtained. The accuracy of WBGa was 98.3 and 95.2% when compared to the accuracy of CBG (88.7 and 83.3%. The accuracy of WBGv was 92.2% and 87.0 when compared to the accuracy of CBG which was 79.7 and 72.9% (ISO 15197: 2003 and 2013, respectively). Bland-Altman plot demonstrated bias and precision of 7.4±17.7 mg/dL in acceptable PI group compared to 30.2±23.4 mg/dL in low PI group (PI≤0.3). The CBG test strip must be interpreted carefully in critically ill children. A low PI was associated with poor CBG strip accuracy. WBG test strip from arterial blood was more appropriate for glucose monitoring in children with peripheral hypoperfusion.

Serious adverse events associated with vasopressin and norepinephrine infusion in septic shock.

OBJECTIVE: The frequency, risk factors, and mortality rates of serious adverse events associated with the use of vasopressin and norepinephrine are not clear. The objectives of this study were to determine frequency, risk factors (including candidate gene polymorphisms), and outcomes of serious adverse events in septic shock patients. DESIGN: Retrospective cohort study using multicenter discovery and single-center validation cohorts. SETTING: ICUs at academic teaching centers. PATIENTS: Five hundred ninety-seven patients with septic shock in discovery (Vasopressin and Septic Shock trial) and 533 patients in validation (St. Paul's Hospital) cohorts. INTERVENTION: Vasopressin and norepinephrine for septic shock. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was 90-day mortality rates of patients with and without serious adverse events. Secondary outcome variables were the association between vasopressor genotype pathway polymorphisms, plasma vasopressin levels, and serious adverse events. Plasma vasopressin concentrations were measured at baseline, 6 hours, 24 hours, 72 hours, and 7 days after vasopressor infusion. Patients with septic shock were genotyped for 268 vasopressor pathway tag single-nucleotide polymorphisms. Serious adverse events occurred in 10.5% and 9.7% of patients in Vasopressin and Septic Shock trial and St. Paul's Hospital cohorts, respectively. Patients who had serious adverse events had higher mortality (p < 0.01) than patients without serious adverse events (adjusted for age, serum lactate, Acute Physiology and Chronic Health Evaluation II, and maximum dose of norepinephrine day 1) (hazard ratio, 2.97; 95% CI, 2.20-4.00; p < 0.001 and hazard ratio, 1.89; 95% CI, 1.26-2.85; p = 0.002 in Vasopressin and Septic Shock trial and St. Paul's Hospital, respectively). There was no difference in the area under the plasma vasopressin concentration curve between patients with and without serious adverse events (p = 0.1). The AA genotype of rs28418396 single-nucleotide polymorphism (near the arginine vasopressin receptor 1b gene) was significantly associated with serious adverse events in discovery and validation cohorts (p = 0.001 and p = 0.04, respectively). CONCLUSION: Serious adverse events associated with vasopressin and norepinephrine in patients who have septic shock are associated with increased mortality and morbidity. AA genotype of rs28418396 single-nucleotide polymorphism near the arginine vasopressin receptor 1b gene is associated with serious adverse events. The mechanism of this association requires investigation.

Sepsis-related pediatric acute respiratory distress syndrome: A multicenter prospective cohort study.

OBJECTIVES: This study aimed to compare the risk factors and outcomes for organ dysfunction between sepsis-related Pediatric acute respiratory distress syndrome (PARDS) and nonsepsis PARDS. METHODS: We prospective cohort recruited intubated patients with PARDS at four tertiary care centers in Thailand. The baseline characteristics, mechanical ventilation, fluid balance, and clinical outcomes were collected. The primary outcome was organ dysfunction. RESULTS: One hundred and thirty-two mechanically ventilated children with PARDS were included in the study. The median age was 29 months and 53.8% were male. The mortality rate was 22.7% and organ dysfunction was 45.4%. There were 26 (19.7%) and 106 (80.3%) patients who were classified into sepsis-related PARDS and nonsepsis PARDS, respectively. Sepsis-related PARDS patients had a significantly higher incidence of acute kidney injury (30.8% vs. 13.2%, P = 0.041), septic shock (88.5% vs. 32.1%, P < 0.001), organ dysfunction (84.6% vs. 35.8%, P < 0.001), and death (42.3% vs. 17.9%, P = 0.016) than nonsepsis PARDS group. Multivariate analysis adjusted for clinical variables showed that sepsis-related PARDS and percentage of fluid overload were significantly associated with organ dysfunction (odds ratio [OR] 11.414; 95% confidence interval [CI] 1.40892.557, P = 0.023 and OR 1.169; 95% CI 1.0121.352, P = 0.034). CONCLUSIONS: Sepsis-related PARDS patients had more severe illness, organ dysfunction, and mortality than nonsepsis PARDS patients. The higher percentage of fluid overload and presentation of sepsis was the independent risk factor of organ dysfunction in PARDS patients.

Modified high-flow nasal cannula for children with respiratory distress.

BACKGROUND: High-flow nasal cannula (HFNC) is a noninvasive respiratory support that provides the optimum flow of an air-oxygen mixture. Several studies demonstrated its usefulness and good safety profile for treating pediatric respiratory distress patients. However, the cost of the commercial HFNC is high; therefore, the modified high-flow nasal cannula was developed. PURPOSE: This study aimed to compare the effectiveness, safety, and nurses' satisfaction of the modified system versus the standard commercial HFNC. METHODS: This prospective comparative study was performed in a tertiary care hospital. We recruited children aged 1 month to 5 years who developed acute respiratory distress and were admitted to the pediatric intensive care unit. Patients were assigned to 2 groups (modified vs. commercial). The effectiveness and safety assessments included vital signs, respiratory scores, intubation rate, adverse events, and nurses' satisfaction. RESULTS: A total of 74 patients were treated with HFNC. Thirty- nine patients were assigned to the modified group, while the remaining 35 patients were in the commercial group. Intubation rate and adverse events did not differ significantly between the 2 groups. However, the commercial group had higher nurses' satisfaction scores than the modified group. CONCLUSION: Our findings suggest that our low-cost modified HFNC could be a useful respiratory support option for younger children with acute respiratory distress, especially in hospital settings with financial constraints.

Effect of the COVID-19 Pandemic on Lower Respiratory Tract Infection Determinants in Thai Hospitalized Children: National Data Analysis 2015-2020.

Background: The COVID-19 outbreak emerged in January 2020 and remains present in 2022. During this period, nonpharmaceutical interventions (NPIs) have been used to reduce the spread of COVID-19 infection. Nationwide data analysis should be pushed as the new standard to demonstrate the impact of COVID-19 infection on other respiratory illnesses and the reliability of NPIs during treatment. Objective: This study aims to identify and compare the incidence of lower respiratory tract infections (LRTIs) among children in Thailand before and after the emergence of COVID-19. Methods: A retrospective study was carried out in hospitalized children under the age of 18 in Thailand from October 2015 to September 2020. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Thai Modification, was used to identify patient diagnoses (ICD-10-TM). The data were extracted from the Universal Coverage Health Security Scheme Database. Results: A total of 1,610,160 admissions were attributed to LRTIs. The most common diagnosis was pneumonia (61.9%). Compared to the 2019 fiscal year, the number of hospitalizations due to LRTIs decreased by 33.9% in the 2020 fiscal year (COVID-19 period) (282,590 vs. 186,651). The incidence of all three diagnostic groupings was substantially lower in the pre- and post-COVID-19 eras, with a decrease of 28% in the pneumonia group (incidence rate ratio (IRR) = 0.72; 95% confidence interval (CI): 0.71 to 0.72), 44% in the bronchiolitis group (IRR = 0.56; 95% CI: 0.55 to 0.57), and 34% in the bronchitis group (IRR = 0.66; 95% CI: 0.65 to 0.67). Between fiscal years 2019 and 2020, the overall monthly cost of all hospitalizations for LRTIs decreased considerably (p value < 0.001). Conclusions: NPIs may decrease the number of pediatric hospitalizations related to LRTIs. All policies designed to prevent the spread of COVID-19 must be continually utilized to maintain the prevention of LRTIs.

Correlation and prediction of arterial partial pressure of carbon dioxide from venous umbilical blood gases.

BACKGROUND: Arterial partial pressure of carbon dioxide (pCO < sub > 2 < /sub > ) samples are lower in children and higher in fetuses when compared with venous samples. The correlation and prediction of pCO < sub > 2 < /sub > from umbilical venous (UVBG) to umbilical arterial blood gas (UABG) dyad in neonates are identified. METHODS: A prospective study was performed from July 2018 to December 2019. Two dependent tests and a multivariate regression model were used to analyze the comparison and correlation tests. RESULTS: A total of 116 paired UABG and UVBG samples were obtained. The medians (interquartile ranges, IQR) were as follows: gestational age of 34 (29-37) weeks, birth weight of 2122 (1146-2839) g, and postnatal age of 2.3 (1.4-10.8) h. The median (IQR) pCO < sub > 2(UABG) < /sub > and pCO < sub > 2(UVBG) < /sub > measurements were 40.2 (33.5-45.8) and 40.4 (34.7-46.8) mmHg, respectively (rho = 0.75, p < 0.001). The median of the differences (IQR) in pCO < sub > 2(UABG) < /sub > and pCO < sub > 2(UVBG) < /sub > was -0.9 (-4.7 to 2.3) mmHg, (p = 0.06). The equation to predict pCO < sub > 2(UABG) < /sub > was 0.9 × pCO < sub > 2(UVBG) < /sub > + 4, as derived from simple linear regression. The best model for predicting pCO < sub > 2(UABG) < /sub > was 0.9 x pCO < sub > 2(UVBG) < /sub > - 0.7 × venous base excess + 0.6 × 5-min Apgar score + 6.1 × meconium aspiration syndrome - 7.7 × patent ductus arteriosus - 6.5 (adjusted r < sup > 2 < /sup > = 0.74). CONCLUSIONS: pCO < sub > 2(UVBG) < /sub > correlates with and can predict pCO < sub > 2(UABG) < /sub > . Therefore, pCO < sub > 2(UVBG) < /sub > can be applied to pCO < sub > 2(UABG) < /sub > in neonates for whom UAC insertion is unsuccessful or to avoid an arterial puncture.