Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce.

OBJECTIVE: To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. DATA SOURCES: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. STUDY SELECTION: Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract. DATA EXTRACTION: Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. DATA SYNTHESIS: One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001). CONCLUSIONS: Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

OBJECTIVES: To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN: Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children. SETTING: Not applicable. INTERVENTION: None. SUBJECTS: Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion. METHODS: A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. MEASUREMENTS AND RESULTS: The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations. CONCLUSIONS: The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.

Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries.

Poor growth with underweight for age, decreased length/height for age, and underweight-for-height are all relatively common in children with CHD. The underlying causes of this failure to thrive may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilisation of absorbed nutrition. These factors are particularly common and severe in low- and middle-income countries. Although nutrition should be carefully assessed in all patients, failure of growth is not a contraindication to surgical repair, and patients should receive surgical repair where indicated as soon as possible. Close attention should be paid to nutritional support - primarily enteral feeding, with particular use of breast milk in infancy - in the perioperative period and in the paediatric ICU. This nutritional support requires specific attention and allocation of resources, including appropriately skilled personnel. Thereafter, it is essential to monitor growth and development and to identify causes for failure to catch-up or grow appropriately.

Paediatric tracheostomy and ventilation home care with challenging socio-economic circumstances in South Africa.

BACKGROUND: Children discharged home with a tracheostomy need a safe home environment and access to health care. We described the indications, clinical characteristics, socio-economic circumstances and outcomes of children enroled in a tracheostomy home care programme in South Africa. METHODS: We performed a retrospective chart review of children receiving a tracheostomy and enroled in the Breatheasy programme at the Red Cross War Memorial Children's Hospital, Cape Town. Medical and background characteristics were recorded. Influences of socio-economic variables and underlying medical conditions on length of hospital stay, unplanned readmissions and mortality in the first year after discharge were evaluated. RESULTS: In the period 2008-2012, 157 patients were discharged home with a tracheostomy. Median hospital stay after tracheostomy insertion was significantly longer when parents had incomplete schooling compared to completed secondary school or higher education; 30 days (IQR 21-53) versus 23 days (IQR 16-33), respectively. Unplanned readmissions in the first year were documented for 72 patients (45.9%). The risk for unplanned readmission was 2.6 times higher in families with substance abuse the risk of respiratory infections was two-fold in case of household cigarette smoke exposure (OR 2.3.) Tracheostomy-related mortality was low (1.2%). An underlying medical condition was the only independent significant risk factor for mortality (OR 5.1, 95% CI 1.8-14.3). CONCLUSION: This study demonstrates that despite difficult socio-economic circumstances, home ventilation of children with a tracheostomy is safe, provided caregivers are adequately trained and supported.

Continuous flow peritoneal dialysis (CFPD) improves ultrafiltration in children with acute kidney injury on conventional PD using a 4.25 % dextrose solution.

BACKGROUND: Criticism against the use of acute peritoneal dialysis (PD) has been its low clearance and low ultrafiltration (UF) volumes compared to extracorporeal techniques. The aim of our study was to determine whether continuous flow peritoneal dialysis (CFPD) would improve UF in children with acute kidney injury (AKI) in cases where UF on conventional PD was inadequate using 4.25 % glucose concentrations. METHODS: Five infants were prospectively studied. All had AKI with fluid overload. The median age of the patients was 6 (range 0.43-9) months; the median weight was 6.5 (range 2.7-8.4) kg. Each patient served as his or her own control, undergoing both CFPD and conventional PD. CFPD was performed with two bedside-placed catheters using a 2.5 % glucose concentration. After initial filling, a dialysate flow rate of 100 ml/min/1.73 m(2) was maintained with an adapted continuous venovenous haemofiltration machine. The UF flow rate was set at 2.5 ml/min/1.73 m(2) and adapted as necessary. UF and clearance rates were measured for both PD and CFPD. RESULTS: The median UF rate achieved was 1.7 (range 0.01-5.30) mg/kg/h with conventional PD versus 6.7 (range 2.17-15.7) mg/kg/h with CFPD (p = 0.042). The clearances of urea and creatinine were 6.89 (range 4.50-7.55) and 7.46 (range 4.79-10.50) mL/min/1.73 m(2), respectively, with conventional PD and 19 (17.0-30.0) and 41 (standard deviation17.4, range 12.0-52.0) mL/min/1.73 m(2), respectively, with CFPD (both p = 0.043). CONCLUSION: Continuous flow peritoneal dialysis improves UF in fluid overloaded infants who are not achieving adequate UF on conventional PD.

Pediatric intensive care in South Africa: an account of making optimum use of limited resources at the Red Cross War Memorial Children's Hospital*.

OBJECTIVE: To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources. SETTING: Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa. DESIGN: Retrospective description of policy development and implementation PATIENTS: All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children's Hospital. INTERVENTIONS: Development and application of admission policy. MEASUREMENTS AND MAIN RESULTS: In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain "buy-in" from all potential stakeholders in the process and also to implement such policies under conditions of high stress. CONCLUSION: Development and implementation of explicit policies for utilization of PICU resources provide a "reasonable" process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services.

Measles in a South African paediatric intensive care unit: again!

AIM: The aim of this study is to evaluate the outcomes of children with measles-related disease (MRD) admitted to a paediatric intensive care unit (PICU) and the effect on PICU resources and elective surgery of a recent measles epidemic. METHODS: This was a retrospective observational study of all patients admitted to the PICU of Red Cross War Memorial Children's Hospital, Cape Town, South Africa, with MRD from January to December 2010. Patient admission characteristics, duration of PICU admission and mortality were recorded. Costs were calculated using bed days utilised and estimated daily PICU admission cost. RESULTS: A total of 1274 children were admitted over the study period, 58 (4.6%) with MRD (median (interquartile range) age 7 (5-9) months). Pneumonia was the most common reason for admission (81%) and the main cause of mortality. Non-MRD mortality was 8.8% compared with MRD mortality of 31% (P < 0.0001). Standardised mortality for non-MRD was 0.7 versus 1.7 in MRD (P = 0.002). HIV comorbidity and being underweight for age were associated with increased mortality. Patients with MRD occupied 379 bed days with a median (interquartile range) duration of stay of 5.5 (3.0-9.0) days at an estimated overall cost of R4,813,300 (approximately $543,900). During the study period, 67 children booked for elective surgery, and 87 other referrals were refused PICU admission. CONCLUSIONS: MRD was associated with significant morbidity and mortality, and substantial strain on scarce PICU resources.

North-South divide: distribution and outcome of respiratory viral infections in paediatric intensive care units in Cape Town (South Africa) and Nottingham (United Kingdom).

AIM: This study aims to describe and compare the spectrum, course, seasonality and outcome of children with virus-associated respiratory symptoms (VARS) admitted to two paediatric intensive care units (PICUs) in the United Kingdom (UK) and South Africa (SA). METHODS: Cross-sectional study of routinely collected data on subjects admitted to PICU with respiratory symptoms and positive respiratory viral polymerase chain reaction between July 2009 and July 2011. RESULTS: Six hundred forty-six samples yielding 765 viral isolates (74% from SA) from 599 patients (53% male; median (interquartile range) age 6.0 (2.3-16.5) months) were included. Rhinovirus, respiratory syncytial virus and adenovirus were most commonly isolated. Adenovirus was more prevalent in SA (24.3% vs. 16.8%, P = 0.03). Possible or likely nosocomial viral acquisition occurred in 78% of isolates in SA versus 48% in the UK (P < 0.0001).Total mortality was 13.5%; 17% in SA versus 4% in the UK (P < 0.0001). Mortality for community acquired VARS was 8.4% versus 16.1% in those with possible nosocomial viral acquisition (P = 0.009). Factors independently associated with mortality were: SA study site (adjusted odds ratio (OR) 3.4, 95% confidence interval (CI) 1.4-8.5; P = 0.008); age (months) (OR 1.0, 95% CI 1.0-1.02; P = 0.001); Paediatric Index of Mortality 2 score (%) (OR 1.0, 95% CI 1.01-1.03; P = 0.0002) and isolation of adenovirus (OR 3.0, 95% CI 1.8-5.0; P < 0.0001). CONCLUSIONS: The outcome of children with VARS was worse in SA compared with the UK PICU. Nosocomial VARS was highlighted as an important concern and requires further investigation.

An investigation into the prevalence and outcome of patients admitted to a pediatric intensive care unit with viral respiratory tract infections in Cape Town, South Africa.

OBJECTIVES: To describe the prevalence and outcome of patients admitted to a pediatric intensive care unit with viral respiratory tract infections. DESIGN: Retrospective descriptive study. SETTING: Pediatric intensive care unit in a tertiary pediatric hospital situated in Cape Town, South Africa. PATIENTS: All children (n = 195; 20% pediatric intensive care unit admissions) with positive respiratory viral isolates between April 1 and December 31, 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, clinical, laboratory, and outcome data were recorded from medical folders. Complete data were available for 175 patients (median age [interquartile range] 4.7 months [2.3-12.9 months]; 49% male). One hundred four (59.4%) patients had comorbid conditions; 30 (17%) were HIV-infected. Rhinovirus (n = 76 [39%]), respiratory syncytial virus (n = 54 [27.7%]), adenovirus (n = 30 [15.4%]), influenza A (n = 26 [13.3%]), parainfluenza (n = 23 [11.8%]), and human metapneumovirus (n = 12 [6.2%]) were most commonly isolated. Ninety-five infections (51.4%) were isolated >48 hrs after admission. Seasonal patterns were identified for respiratory syncytial virus, human metapneumovirus, and influenza A, whereas others occurred throughout the year. Twenty-five patients (14.3%) had more than one viral isolate. Presumed bacterial coinfection, which occurred in 68 (39%) patients (18 [26.5%] HIV-infected), was associated with significantly longer pediatric intensive care unit and hospital stays but not with mortality. Twenty patients died (11%, standardized mortality ratio 0.64). High Pediatric Index of Mortality scores, HIV exposure and infection, nosocomial infection, and influenza A infection were associated with mortality. CONCLUSIONS: Viral respiratory tract infection is common in this pediatric intensive care unit associated with significant morbidity and mortality, which may relate to the high burden of comorbidity and HIV.

Improvements in lung function of a pediatric cystic fibrosis population in a developing country.

OBJECTIVE: To document the change in pulmonary function of a pediatric cystic fibrosis population managed at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa, between January 1999 and December 2006. METHODS: Retrospective review of the medical records and best spirometry results within 3-monthly intervals. RESULTS: A total of 1,139 pulmonary function tests from 79 patients showed a significant improvement over the 8 years studied. When comparing the first quarter of 1999 with the last quarter of 2006, 78 pulmonary function tests were performed on 65 patients with equal patient numbers in both groups and similar in terms of gender, age, age at diagnosis, ethnicity, cystic fibrosis genotype and number of patients colonized with either Staphylococcus aureus or Pseudomonas aeruginosa. In 2006, 15 patients (38.5%) were on azithromycin treatment compared to one (2.6%) patient in 1999 (p = 0.0003). Median (interquartile range) forced expiratory volume in 1 second, forced vital capacity, and average expiratory flow between 25 and 75% of forced vital capacity increased from 61% (51-73), 63% (52-89), and 40% (27-57), predicted in the first quarter of 1999, to 81% (69-100, p = 0.004), 82% (70-98, p = 0.007), and 62% (41-87, p = 0.01), predicted during the last quarter of 2006, respectively. CONCLUSIONS: Pulmonary function tests increased by 20% over 8 years in comparable patient groups. This likely reflects improved care of South African children with cystic fibrosis.

Melhoras na função pulmonar de uma população com fibrose cística em um país em desenvolvimento / Improvements in lung function of a pediatric cystic fibrosis population in a developing country

OBJETIVO: Documentar a alteração em função pulmonar de uma população pediátrica com fibrose cística tratada no Red Cross War Memorial Children's Hospital, Cidade do Cabo, África do Sul, entre janeiro de 1999 e dezembro de 2006. MÉTODOS: Revisão retrospectiva dos prontuários médicos e melhores resultados de espirometria em intervalos de 3 meses. RESULTADOS: Um total de 1.139 testes de função pulmonar de 79 pacientes mostrou melhora significativa ao longo dos 8 anos estudados. Ao comparar o primeiro trimestre de 1999 com o último trimestre de 2006, 78 testes de função pulmonar foram realizados em 65 pacientes com números iguais de pacientes em ambos os grupos e semelhante em termos de gênero, idade, idade ao diagnóstico, etnia, genótipo da fibrose cística e número de pacientes colonizados com Staphylococcus aureus ou Pseudomonas aeruginosa.Em 2006, 15 pacientes (38,5 por cento) estavam em tratamento com azitromicina, comparados com um (2,6 por cento) paciente em 1999 (p = 0,0003). Volume expiratório forçado no primeiro segundo mediano (intervalo interquartil), capacidade vital forçada e fluxo expiratório médio entre 25 e 75 por cento da capacidade vital forçada aumentaram de 61 por cento (51-73), 63 por cento (52-89) e 40 por cento (27-57) previstos no primeiro trimestre de 1999 para 81 por cento (69-100, p = 0,004), 82 por cento (70-98, p = 0,007) e 62 por cento (41-87, p = 0,01) previstos durante o último trimestre de 2006, respectivamente. CONCLUSÕES: Testes de função pulmonar aumentaram em 20 por cento ao longo de 8 anos em grupos comparáveis de pacientes. Isso provavelmente reflete a melhora na prestação de cuidados a crianças sul-africanas com fibrose cística.

OBJECTIVE: To document the change in pulmonary function of a pediatric cystic fibrosis population managed at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa, between January 1999 and December 2006. METHODS: Retrospective review of the medical records and best spirometry results within 3-monthly intervals. RESULTS: A total of 1,139 pulmonary function tests from 79 patients showed a significant improvement over the 8 years studied. When comparing the first quarter of 1999 with the last quarter of 2006, 78 pulmonary function tests were performed on 65 patients with equal patient numbers in both groups and similar in terms of gender, age, age at diagnosis, ethnicity, cystic fibrosis genotype and number of patients colonized with either Staphylococcus aureus or Pseudomonas aeruginosa. In 2006, 15 patients (38.5 percent) were on azithromycin treatment compared to one (2.6 percent) patient in 1999 (p = 0.0003). Median (interquartile range) forced expiratory volume in 1 second, forced vital capacity, and average expiratory flow between 25 and 75 percent of forced vital capacity increased from 61 percent (51-73), 63 percent (52-89), and 40 percent (27-57), predicted in the first quarter of 1999, to 81 percent (69-100, p = 0.004), 82 percent (70-98, p = 0.007), and 62 percent (41-87, p = 0.01), predicted during the last quarter of 2006, respectively. CONCLUSIONS: Pulmonary function tests increased by 20 percent over 8 years in comparable patient groups. This likely reflects improved care of South African children with cystic fibrosis.

The lactate:pyruvate ratio following open cardiac surgery in children.

OBJECTIVE: To explore the relationship between lactate:pyruvate ratio, hyperlactataemia, metabolic acidosis, and morbidity. DESIGN AND SETTING: Prospective observational study in the paediatric intensive care unit (PICU) of a university hospital. PATIENTS: Ninety-seven children after open cardiac surgery. Most children (94%) fell into low-moderate operative risk categories; observed PICU mortality was 1%. INTERVENTIONS: Blood was sampled on admission for acid-base analysis, lactate, and pyruvate. Metabolic acidosis was defined as standard bicarbonate lower than 22 mmol/l, raised lactate as higher than 2 mmol/l, and raised lactate:pyruvate ratio as higher than 20. MEASUREMENTS AND RESULTS: Median cardiopulmonary bypass and aortic cross-clamp times were 80 and 46 min. Metabolic acidosis occurred in 74%, hyperlactataemia in 42%, and raised lactate:pyruvate ratio in 45% of children. In multivariate analysis lactate:pyruvate ratio increased by 6.4 in children receiving epinephrine infusion and by 0.4 per 10 min of aortic cross-clamp. Duration of inotropic support increased by 0.29 days, ventilatory support by 0.27 days, and PICU stay by 0.42 days, for each 1 mmol/l increase in lactate. Neither standard bicarbonate nor lactate:pyruvate ratio were independently associated with prolongation of PICU support. CONCLUSIONS: Elevated lactate:pyruvate ratio was common in children with mild metabolic acidosis and low PICU mortality. Hyperlactataemia, but not elevated lactate:pyruvate ratio or metabolic acidosis, was associated with prolongation of PICU support. Routine measurement of lactate:pyruvate ratio is not warranted for children in low-moderate operative risk categories.