Prehospitalization Trauma and Physiologic Factors Associated with the Presence of Post-traumatic Stress 3 Months After PICU Discharge.

BACKGROUND: Children admitted to the pediatric intensive care unit (PICU) have post-traumatic stress (PTS) rates up to 64%, and up to 28% of them meet criteria for PTS disorder (PTSD). We aim to examine whether a prior trauma history and increased physiologic parameters due to a heightened sympathetic response are associated with later PTS. Our hypothesis was children with history of prehospitalization trauma, higher heart rates, blood pressures, cortisol, and extrinsic catecholamine administration during PICU admission are more likely to have PTS after discharge. METHODS: This is a prospective, observational study of children admitted to the PICU at an urban, quaternary, academic children's hospital. Children aged 8 to 17 years old without developmental delay, severe psychiatric disorder, or traumatic brain injury were included. Children's prehospitalization trauma history was assessed with a semistructured interview. All in-hospital variables were from the electronic medical record. PTS was present if children had 4 of the Diagnostic and Statistical Manual of Mental Disorders IV criteria for PTSD. Student's t- and chi-squared tests were used to compare the presence or absence of prior trauma and all of the PICU-associated variables. RESULTS: Of the 110 children at baseline, 67 had 3-month follow-up. In the latter group, 46% met the criteria for PTS, mean age of 13 years (SD 3), 57% male, a mean PRISM III score of 4.9 (SD 4.3), and intensive care unit length of stay 6.5 days (SD 7.8). There were no statistically significant differences in the demographics of the children with and without PTS. The only variable to show significance was trauma history; children with prehospitalization trauma were more likely to have PTS at 3-month follow-up (P = .02). CONCLUSIONS: Prehospitalization trauma history was associated with the presence of PTS after admission to the PICU. This study suggests future studies should shift to the potential predictive benefit of screening children for trauma history upon PICU admission.

Noninvasive Surrogate for Physiologic Dead Space Using the Carbon Dioxide Ventilatory Equivalent: Testing in a Single-Center Cohort, 2017-2023.

OBJECTIVES: We sought to evaluate the association between the carbon dioxide (co2) ventilatory equivalent (VEqco2 = minute ventilation/volume of co2 produced per min), a marker of dead space that does not require a blood gas measurement, and mortality risk. We compared the strength of this association to that of physiologic dead space fraction (VD/Vt = [Paco2-mixed-expired Pco2]/Paco2) as well as to other commonly used markers of dead space (i.e., the end-tidal alveolar dead space fraction [AVDSf = (Paco2-end-tidal Pco2)/Paco2], and ventilatory ratio [VR = (minute ventilation × Paco2)/(age-adjusted predicted minute ventilation × 37.5)]). DESIGN: Retrospective cohort data, 2017-2023. SETTING: Quaternary PICU. PATIENTS: One hundred thirty-one children with acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All dead space markers were calculated at the same 1-minute timepoint for each patient within the first 72 hours of using invasive mechanical ventilation. The 131 children had a median (interquartile range, IQR) age of 5.8 (IQR 1.4, 12.6) years, oxygenation index (OI) of 7.5 (IQR 4.6, 14.3), VD/Vt of 0.47 (IQR 0.38, 0.61), and mortality was 17.6% (23/131). Higher VEqco2 (p = 0.003), VD/Vt (p = 0.002), and VR (p = 0.013) were all associated with greater odds of mortality in multivariable models adjusting for OI, immunosuppressive comorbidity, and overall severity of illness. We failed to identify an association between AVDSf and mortality in the multivariable modeling. Similarly, we also failed to identify an association between OI and mortality after controlling for any dead space marker in the modeling. For the 28-day ventilator-free days outcome, we failed to identify an association between VD/Vt and the dead space markers in multivariable modeling, although OI was significant. CONCLUSIONS: VEqco2 performs similarly to VD/Vt and other surrogate dead space markers, is independently associated with mortality risk, and may be a reasonable noninvasive surrogate for VD/Vt.