Characteristics and Outcomes of Critically Ill Pediatric Patients with Posterior Reversible Encephalopathy Syndrome.

BACKGROUND/OBJECTIVE: Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity, typically manifesting as reversible neurological symptoms and signs of white matter edema on magnetic resonance imaging. PRES has been widely described in adults. Studies of PRES in children are mostly limited to case series and case controls. METHODS: Retrospective chart review of patients under 21 years with PRES admitted at a tertiary children's hospital from 2011 to 2016. They were compared to controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score. RESULTS: Sixteen cases of PRES were identified in 13 patients (ages 5-17 years, 46% male). PRES presented with altered mental status (75%), seizures (77%), headache (31%), and vision changes (23%). In patients who recovered (n = 11), median days to symptom resolution was three (range 1-8). PRES patients had a higher mortality rate (15% vs. 5%, p < 0.05) and higher mean length of stay (13.1 vs. 4.6 days) and were more likely to have autoimmune disease (p < 0.05), immunosuppression (p < 0.05), and anemia (p < 0.05). No PRES patients were diagnosed with epilepsy by last known follow-up, and all of whom had been started on an antiepileptic drug were discontinued within 13 months. Sepsis was suspected in 53% of PRES patients and 59% of controls (p = 1.00). All PRES patients had stage II hypertension, versus 41% of controls (p < 0.05). Average creatinine in PRES was 2.35 mg/dL compared to 0.90 mg/dL in controls (p < 0.05). PRES patients had lower serum calcium (p < 0.05). After correcting for albumin, no association between PRES and hypocalcemia remained. PRES patients had a higher length of stay (13.1 vs. 4.6 days, p < 0.05) and mortality rate (15% vs. 3%, p < 0.05). CONCLUSIONS: Immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES after controlling for mortality risk in critically ill children. There was no association between corrected serum calcium and sepsis with PRES.

An Updated Therapeutic Intervention Scoring System for Critically Ill Children Enables Nursing Workload Assessment With Insight Into Potential Untoward Events.

BACKGROUND: To introduce an updated version of the original Therapeutic Intervention Scoring System (TISS) applicable to critically ill children (TISS-C). This version was designed to assess patient acuity and nursing workload (NW) and to determine a relationship between such assessment and the incidence of adverse events. METHODS: Reviewing previous versions of TISS, an updated TISS-C was developed. Items inapplicable to pediatric critical care were eliminated; items current to critical care were added; and items still valid were edited. The point system accounts for the wide range of care provided. Random patients from a predetermined period had TISS-C scores calculated. The TISS-C scores were also calculated on patients with documented adverse events. Baseline scores were compared with scores of patients in whom adverse events had occurred. We determined the pediatric intensive care unit (PICU) NW to be the product of the TISS-C score and the patient-nurse ratio (PNR). RESULTS: One hundred twenty-five random patients had a mean TISS-C of 14.6 ± 11.8. Patients with any adverse event (98) had a TISS-C of 19.9 ± 11.6 (P < .05). Using our PICU mean PNR of 1.4 (20 patients/14 nurses), the NW for patients with more severe events was 33.6 ± 15.9. CONCLUSIONS: Critically ill pediatric patients are more vulnerable to experience adverse events when their derived NW values are high. It is postulated that a critical NW exists, where adverse events are more likely to occur.

What are we missing? Arrhythmia detection in the pediatric intensive care unit.

OBJECTIVES: To test the hypothesis that instituting a process of routine daily review of rhythm alarms in non-cardiac patients in the pediatric intensive care unit would yield clinically important disturbances that would otherwise go undetected. STUDY DESIGN: A prospective observational study was performed over a consecutive 28-day period. Total bedside monitor alarms, rhythm alarms, and heart rate (HR) trends were recorded. Rhythm alarm recordings were reviewed independently by two study team members. Medical records for patients with critical arrhythmias were reviewed to evaluate for prior knowledge of the event and to correlate with clinical data. RESULTS: We evaluated 86 patients (343 patient-days). There were 54,656 total monitor alarms (159.3 alarms/patient-day), of which 19,970 (37%) were rhythm alarms, including 4032 (20%) critical arrhythmias. Fifty-six percent of the critical alarms were artifactual. Seventeen of the 1786 ventricular tachycardia alarms represented true episodes that occurred in 5 patients. Two patients' care were altered as a result of detection of the arrhythmia in the review process. Eight hundred sixty-five (98%) of the 883 true critical alarms reviewed were for extreme HR. Eighty-three percent (5172) of the 6239 true non-critical alarms reviewed were HR alarms. CONCLUSIONS: Daily review of rhythm alarms improves detection of clinically relevant arrhythmias in non-cardiac pediatric intensive care unit patients.

Concomitant assessment of depth of sedation by changes in bispectral index and changes in autonomic variables (heart rate and/or BP) in pediatric critically ill patients receiving neuromuscular blockade.

OBJECTIVE: We evaluated whether or not changes in bispectral index (BIS) are associated with concomitant changes in autonomic variables that are in agreement with the different level of sedation that the changes in BIS indicate. DESIGN: A retrospective chart review. SETTING: A pediatric ICU of a children's hospital. METHODS AND MAIN RESULTS: Charts of patients who were receiving mechanical ventilation and IV sedation, neuromuscular blockade, and continuous BIS monitoring were enrolled in the study. Changes in BIS values > or = 30% from previous readings were evaluated to determine whether or not concomitant changes of > or = 10% in autonomic variables, in the same direction, coexisted. Forty-seven patients (35 male and 12 female) were enrolled in our study; ages ranged from 10 days to 18 years (mean, 4.2 +/- 6.2 years [+/- SD]). Twenty-five patients were < 1 year of age (53%). All patients were sedated and pharmacologically paralyzed. Overall, 387 BIS readings (15%) showed a > or = 30% change from the previously documented BIS number. These BIS changes were in agreement with heart rate (HR) changes, mean arterial pressure (MAP) changes, and both HR and MAP changes in 10.6%, 23.8%, and 5.7% of the time, respectively. The same analysis of agreement was done for patients < or = 1 year old, and results were no different from those of older patients. Among 21 patients who were not receiving any vasoactive drugs (alpha- and/or beta-adrenergic agonists) during the study period, 157 BIS recordings (15%) showed a > or = 30% change from the previously documented BIS number. The percents of agreement with HR, MAP, and HR and MAP for these patients were 14.6%, 17.2%, and 7.6%, respectively. In 26 patients who were receiving vasoactive medications during the study, 230 BIS recordings (15%) showed a > or = 30% change from the previously documented BIS number. For these patients, the percentages of agreement were 7.8%, 28.3%, and 4.3%, respectively. Agreement with MAP was significantly better than with HR for this group of patients (p < 0.05; Fisher Exact Test). SUMMARY: While significant changes in BIS are thought to reflect significant changes in depth of sedation, they have a very low rate of agreement with changes in vital signs. In the absence of BIS, the level of sedation of chemically paralyzed pediatric patients can be better guided by changes in MAP than in HR, particularly in patients receiving vasoactive drug treatment.