Resuscitating the macro- vs. microcirculation in septic shock.

PURPOSE OF REVIEW: This review summarizes current literature about the relationships between macro and microcirculation and their practical clinical implications in children with septic shock. RECENT FINDINGS: Current evidence from experimental and clinical observational studies in children and adults with septic shock reveals that the response to treatment and resuscitation is widely variable. Furthermore, there is a loss of hemodynamic coherence, as resuscitation-induced improvement in macrocirculation (systemic hemodynamic parameters) does not necessarily result in a parallel improvement in the microcirculation. Therefore, patient-tailored monitoring is essential in order to adjust treatment requirements during resuscitation in septic shock. Optimal monitoring must integrate macrocirculation (heart rate, blood pressure, cardiac output, and ultrasound images), microcirculation (videomicroscopy parameters and capillary refill time) and cellular metabolism (lactic acid, central venous blood oxygen saturation, and difference of central venous to arterial carbon dioxide partial pressure). SUMMARY: There is a dire need for high-quality studies to assess the relationships between macrocirculation, microcirculation and tissue metabolism in children with septic shock. The development of reliable and readily available microcirculation and tissue perfusion biomarkers (other than lactic acid) is also necessary to improve monitoring and treatment adjustment in such patients.

Early detection of ocular lesions in critically ill children: Testing an ocular assessment scale.

OBJECTIVE: There is scarcity of data on the incidence and factors associated with the occurrence of ocular lesions in critically ill children. The objective was to test the applicability and utility of an ocular assessment scale and to identify risk factors of ocular lesions. DESIGN: Prospective observational study. SETTING: A tertiary care medical-surgical Paediatric Intensive Care Unit. SAMPLE: 194 children without previous ocular disease who stayed in the Paediatric Intensive Care Unit for more than 48 h. INTERVENTIONS: An ocular lesions risk scale was designed including risk factors lagophthalmos, eye dryness, conjunctival hyperemia, slow blinking, intubation, sedation, relaxation, face mask and hemodynamic instability. Patients were classified as high-, medium-, and low-risk patients. Corneal lesions were examined by fluorescein staining according to their risk and were confirmed by an ophthalmologist. RESULTS: 76 patients were examined with fluorescein staining. Thirty-two ocular lesions were detected by nursing staff, 26 confirmed by the ophthalmologist. 53.6% of the high-risk patients developed a corneal lesion. Univariate analysis revealed an association between ocular damage and all factors included in the scale, except for face mask. In the multivariate analysis, ocular lesions were associated with lagophthalmos, hyperemia, invasive mechanical ventilation and inotropic support. CONCLUSIONS: The scale was useful to detect corneal lesions in critically ill children. The identification of risk factors will enable the development of measures to reduce the incidence of ocular lesions. RELEVANCE FOR CLINICAL PRACTICE: A new, non-validated scale allowed staff to detect eye injuries, study this problem and improve future prevention.

Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children.

INTRODUCTION AND OBJECTIVES: No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350 + E) for constipation in critically ill children. METHODS: We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72 h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350 + E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances). RESULTS: The sample included 56 patients with a mean age of 48.2 ±â€¯11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350 + E and 12 (21.4%) with rectal enemas. The proportion of patients that responded well to treatment was greater in the PEG 3350 + E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P = .151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350 + E was more effective in children aged less than 2 years (100%) compared to older children (100% vs 65.4%; P < .01), with no significant differences in the development of adverse events. CONCLUSIONS: The PEG 3350 + E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years.

Volumetric capnography and return of spontaneous circulation in an experimental model of pediatric asphyxial cardiac arrest.

A secondary analysis of a randomized study was performed to study the relationship between volumetric capnography (VCAP) and arterial CO2 partial pressure (PCO2) during cardiopulmonary resuscitation (CPR) and to analyze the ability of these parameters to predict the return of spontaneous circulation (ROSC) in a pediatric animal model of asphyxial cardiac arrest (CA). Asphyxial CA was induced by sedation, muscle relaxation and extubation. CPR was started 2 min after CA occurred. Airway management was performed with early endotracheal intubation or bag-mask ventilation, according to randomization group. CPR was continued until ROSC or 24 min of resuscitation. End-tidal carbon dioxide (EtCO2), CO2 production (VCO2), and EtCO2/VCO2/kg ratio were continuously recorded. Seventy-nine piglets were included, 26 (32.9%) of whom achieved ROSC. EtCO2 was the best predictor of ROSC (AUC 0.72, p < 0.01 and optimal cutoff point of 21.6 mmHg). No statistical differences were obtained regarding VCO2, VCO2/kg and EtCO2/VCO2/kg ratios. VCO2 and VCO2/kg showed an inverse correlation with PCO2, with a higher correlation coefficient as resuscitation progressed. EtCO2 also had an inverse correlation with PCO2 from minute 18 to 24 of resuscitation. Our findings suggest that EtCO2 is the best VCAP-derived parameter for predicting ROSC. EtCO2 and VCO2 showed an inverse correlation with PCO2. Therefore, these parameters are not adequate to measure ventilation during CPR.

Evaluation of tracheal intubations in a paediatric intensive care unit.

INTRODUCTION: Tracheal intubation is a frequent procedure in paediatric intensive care units (PICUs) that carries a risk of complications that can increase morbidity and mortality. PATIENTS AND METHODS: Prospective, longitudinal, observational study in patients intubated in a level III PICU between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events. RESULTS: The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5% vs 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including 1 case of cardiac arrest, 2 cases of severe hypotension and 1 of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events. CONCLUSIONS: In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children.

Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.

Early vs late enteral nutrition in pediatric intensive care unit: Barriers, benefits, and complications.

BACKGROUND: This study aimed to define the existing barriers for early enteral nutrition (EEN) in critically ill children and to analyze the differences in nutrient supply, complications, and outcomes between EEN and late EN (LEN). METHODS: This is a secondary analysis of a multicenter observational, prospective study including critically ill children receiving EN. Variables analyzed included demographic and anthropometric features, caloric and nutrient supply, outcomes, and complications according to the EN onset. Patients were classified into two groups according to the start of EN: 24-EEN vs EN started after 24 h (24-LEN) and 48-EEN vs EN started after 48 h (48-LEN). RESULTS: Sixty-eight children were enrolled; 22.1% received 24-EEN, and 67.6% received 48-EEN. EN was most frequently delayed in patients older than 12 months, in patients with cardiac disease, and in those requiring mechanical ventilation (MV). Children in the 24-EEN group had shorter duration of MV compared with those in the 24-LEN group (P = 0.04). The 48-EEN group received a higher caloric intake (P = 0.04), reached the caloric target earlier (P < 0.01), and had lower incidence of constipation (P = 0.01) than the 48-LEN group. There was a positive correlation between the time required to reach the maximum caloric intake and the length of pediatric intensive care stay (r = 0.46; P < 0.01). CONCLUSION: EEN may improve nutrient delivery, reduce time on MV, and prevent constipation in critically ill children. No relevant differences between 24-EEN and 48-EEN were found. Cardiac disease, MV, and age older than 12 months were risk factors associated with LEN.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children.

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis.

PURPOSE: Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. METHODS: A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. RESULTS: 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations. CONCLUSIONS: Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance.

Doppler ultrasound in the assessment of renal perfusion before and during continuous kidney replacement therapy in the pediatric intensive care unit.

BACKGROUND: This study aimed to assess observer variability and describe renal resistive index (RRI) and pulsatility index (PI) before and after onset of continuous kidney replacement therapy (CKRT). A secondary objective was to correlate Doppler ultrasound findings with those from direct measurement of renal blood flow (RBF). METHODS: This is a prospective observational study in hemodynamically stable Maryland piglets with and without acute kidney injury (AKI) and in hemodynamically unstable critically ill children requiring CKRT. Doppler-based RRI and PI were assessed for each subject. Measurements were made by two different operators (pediatric intensivists) before and after CKRT onset. RESULTS: Observer variability assessment in the measurement of RRI and PI rendered a moderate correlation for both RRI (ICC 0.65, IQR 0.51-0.76) and PI (ICC 0.63, IQR 0.47-0.75). RRI and PI showed no correlation with RBF or urine output. Baseline RRI and PI were normal in control piglets [RRI 0.68 (SD 0.02), PI 1.25 (SD 0.09)] and those with AKI [RRI 0.68 (SD 0.03), PI 1.20 (SD 0.13)]. Baseline RRI and PI were elevated in critically ill children (RRI 0.85, PI 2.0). PI and RRI did not change with CKRT in any study group. CONCLUSIONS: Observer variability between inexperienced pediatric intensivists was comparable with that between senior and junior operators. Doppler-based calculations did not correlate with invasive measurements of RBF. RRI and PI were normal in hemodynamically stable piglets with and without AKI. RRI and PI were high in hemodynamically unstable patients requiring CKRT. RRI and PI did not change after CKRT onset, despite changes in hemodynamic status. A higher resolution version of the Graphical abstract is available as Supplementary information.

Novelties in the pediatric cardiopulmonary resuscitation recommendations and lines of development in Spain.

OBJECTIVES: To analyse the 2020 international and European recommendations for Paediatric cardiopulmonary resuscitation (CPR), highlighting the most important changes and propose lines of development in Spain. METHODS: Critical analysis of the paediatric cardiopulmonary resuscitation recommendations of the European Resuscitation Council. RESULTS: The most relevant changes in the CPR recommendations for 2020 are in basic CPR the possibility of activating the emergency system after performing the five rescue ventilations with the mobile phone on loudspeaker, and in advanced CPR, bag ventilation between two rescuers if possible, the administration of epinephrine as soon as a vascular access is obtained, the increase in the respiratory rate in intubated children between 10 and 25 bpm according to their age and the importance of controlling the quality and coordination of CPR. In CPR training, the importance of training non-technical skills such as teamwork, leadership and communication and frequent training to reinforce and maintain competencies is highlighted. CONCLUSIONS: It is essential that training in Paediatric CPR in Spain follows the same recommendations and is carried out with a common methodology, adapted to the characteristics of health care and the needs of the students. The Spanish Paediatric and Neonatal Cardiopulmonary Resuscitation Group should coordinate this process, but the active participation of all paediatricians and health professionals who care for children is also essential.

Evaluation of Pediatric Immediate Life Support Courses by the Students.

A retrospective analysis was performed of 1637 questionnaires among students of immediate pediatric life support (IPLS) courses. All theory and practice classes and organization and methods received an average score higher than 8.5 except for the schedule and time devoted to developing contents. All parameters evaluating instructors' skills received a score higher than 9. Participants requested more time to practice and for course adaptation to their specific professionals needs. IPLS courses are highly valued by students. The duration of IPLS practice sessions should be increased and the course should be adapted to the specific professional needs of participants.

Continuous Incisional Lidocaine in Pediatric Patients following Open Heart Surgery.

Continuous incisional lidocaine infusion has been proposed as an adjunctive therapy in the management of postoperative pain in adult patients. The aim of this study was to determine the efficacy and safety of a continuous subcutaneous lidocaine infusion in pediatric patients following open heart surgery. All patients receiving a subcutaneous lidocaine infusion in median sternotomy incisions after open heart surgery during 2 consecutive years were included in the study. A historical cohort of patients was used as a control group. Demographic variables (age, size, and surgical procedure), variables related to sedation and analgesia (COMFORT and analgesia scales, drug doses, and duration), and complications were registered. 106 patients in the lidocaine infusion group and 79 patients in the control group were included. Incisional analgesia was effective for the treatment of pain as it reduced the dose and duration of intravenous fentanyl (odds ratio (OR) 6.26, confidence interval (CI) 95%: 2.48-15.97, p = 0.001; OR 4.30, CI 95%: 2.09-8.84, p = 0.001, respectively). The reduction in fentanyl use was more important in children over two years of age. Adverse effects were seen in three children (2.8%): they all had decreased level of consciousness, and one of them presented seizures as well. Two of these three patients had lidocaine levels over 2 mcg/ml. A continuous lidocaine incisional infusion is effective for the treatment of pain after open heart surgery. This procedure reduced intravenous analgesic drug requirements in pediatric patients undergoing a median sternotomy incision. Although the incidence of secondary effects is low, monitoring of neurologic status and lidocaine blood levels are recommended in all patients.

[Novelties in the paediatric cardiopulmonary resuscitation recommendations and lines of development in Spain]. / Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica y líneas de desarrollo en España.

OBJECTIVES: To analyse the 2020 international and European recommendations for paediatric cardiopulmonary resuscitation (CPR), highlight the most important changes and propose lines of development in Spain. METHODS: Critical analysis of the paediatric cardiopulmonary resuscitation recommendations of the European Resuscitation Council. RESULTS: The most relevant changes in the CPR recommendations for 2020 are in basic CPR the possibility of activating the emergency system after performing the five rescue ventilations with the mobile phone on loudspeaker, and in advanced CPR, bag ventilation between two rescuers if possible, the administration of epinephrine as soon as a vascular access is obtained, the increase in the respiratory rate in intubated children between 10 and 25bpm according to their age and the importance of controlling the quality and coordination of CPR. In CPR training, the importance of training non-technical skills such as teamwork, leadership and communication and frequent training to reinforce and maintain competencies is highlighted. CONCLUSIONS: It is essential that training in paediatric CPR in Spain follows the same recommendations and is carried out with a common methodology, adapted to the characteristics of health care and the needs of the students. The Spanish Paediatric and Neonatal Cardiopulmonary Resuscitation Group should coordinate this process, but the active participation of all paediatricians and health professionals who care for children is also essential.

Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary.

Objective: The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.

MONISEDA Project: Improving Analgosedation Monitoring in Spanish Pediatric Intensive Care Units.

Background: Analgosedation (AS) assessment using clinical scales is crucial to follow the international recommendations about analgosedation. The Analgosedation workgroup of the Spanish Society of Pediatric Intensive Care (SECIP) carried out two surveys in 2008 and 2015, which verified the gap in analgosedation assessment in Spanish pediatric intensive care unit (PICUs). The objective of the study was to analyze how analgosedation assessment by clinical scales changed after a multicenter intervention program. Methods: This is a multicenter pre-post study comparing the use of sedation, analgesia, withdrawal, and delirium scales before and after the MONISEDA project. Results were also compared with a control group formed by non-participating units. A survey about analgosedation management and monitoring was filled out before (year 2015) and after (year 2020) the implementation of the MONISEDA project in 2016. Results were compared not only between those periods of time but also between participant and non-participant PICUs in the MONISEDA project (M-group and non-M group, respectively). Data related to analgosedation of all patients admitted to a MONISEDA-participant PICU were also collected for 2 months. Results: Fifteen Spanish PICUs were enrolled in the MONISEDA project and another 15 non-participant PICUs formed the control group. In the M-group, the number of PICUs with a written analgosedation protocol increased from 53 to 100% (p = 0.003) and withdrawal protocol from 53 to 100% (p = 0.003), whereas in the non-M group, the written AS protocol increased from 80 to 87% and the withdrawal protocol stayed on 80%. The number of PICUs with an analgosedation team increased from 7 to 47% in the M-group (p = 0.01) and from 13 to 33% in the non-M group (p = 0.25). In the M-group, routine use of analgosedation clinical scales increased from 7 to 100% (p < 0.001), withdrawal scales from 7% to 86% (p = 0.001), and delirium scales from 7 to 33% (p = 0.125). In the non-M group, the number of PICUs using AS scales increased from 13 to 100% (p < 0.001), withdrawal scales from 7 to 27% (p = 0.125), and delirium scales from 0 to 7% (p = 1). Conclusions: The development of a specific training program improves monitoring and management of analgosedation in PICUs.