Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view.

In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field.    Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.

Nurse perspectives on supporting children and youth who use augmentative and alternative communication (AAC) in the pediatric intensive care unit.

Many children who require hospitalization in the pediatric intensive care unit (ICU) are unable to or have difficulty communicating through speech, whether because of preexisting or acute conditions. Children who are unable to be heard and understood using only speech benefit from aided augmentative and alternative communication (AAC), including in hospital settings. This qualitative interview study sought to understand the perspectives of nurses on care and support for children who use or would benefit from aided AAC in the pediatric ICU. Participants were six nurses who worked in pediatric intensive care at a tertiary care unit of a children's hospital in the United States. Three main themes were identified related to nurses' views about supporting children's communication: (a) Caring for the Whole Child, (b) Needing Support from Others and Moving between Roles, and (c) Working with Available Resources and Demands. Nurses emphasized the importance of a holistic approach to care, the impact of others' support and knowledge, and a desire for building greater capacity for promoting children's access to effective communication. Findings offer insight that could improve patient-centered care for children with complex communication needs and support for nurses themselves, particularly within the broader context of ICU liberation.

Neutrophil CD64 index for diagnosis of infectious disease in the pediatric ICU: a single-center prospective study.

BACKGROUND: Infection is a major cause of death in children, and it is particularly important to identify biological indicators of early infection. Previous studies showed that the neutrophil CD64 (nCD64) index may be a useful biomarker for infection. The purpose of this study was to investigate use of the nCD64 index to identify infection in children from a pediatric ICU (PICU) in China. METHODS: This prospective observational study enrolled 201 children who were admitted to our PICU and were divided into an infection group and a non-infection group. In each patient, C-reactive protein (CRP), nCD64 index, procalcitonin (PCT), and white blood cell count were measured during the first 24 h after admission. Receiver operating characteristic (ROC) analyses were used to determine the sensitivity, specificity, and diagnostic value of the nCD64 index for infection. RESULTS: Among all 201 children, the infection group had greater levels of CRP, nCD64 index, and PCT (all p < 0.05). ROC analysis indicated the nCD64 index had a sensitivity of 68.8%, specificity of 90.7%, accuracy of 80.5%, and an optimal cut-off value of 0.14, which had better diagnostic value than CRP or PCT. For children with postoperative fever, the nCD64 index also distinguished systemic inflammatory response syndrome (SIRS) from infection with accuracy of 79%. CONCLUSIONS: The nCD64 index is a useful biomarker for the diagnosis of early infection in children admitted to the PICU.

Expanding the genotypes and phenotypes for 19 rare diseases by exome sequencing performed in pediatric intensive care unit.

Phenotypes of some rare genetic diseases are atypical and it is a challenge for pediatric intensive care units (PICUs) to diagnose and manage such patients in an emergency. In this study, we investigated 58 PICU patients (39 deceased and 19 surviving) in critical ill status or died shortly without a clear etiology. Whole exome sequencing was performed of 103 DNA samples from their families. Disease-causing single-nucleotide variants (SNVs) and copy number variants (CNVs) were identified to do genotype-phenotypes analysis. In total, 27 (46.6%) patients received a genetic diagnosis. We identified 34 pathogenic or likely pathogenic SNVs from 26 genes, which are related to at least 19 rare diseases. Each rare disease involved an isolated patient except two patients caused by the same gene ACAT1. The genotypic spectrum was expanded by 23 novel SNVs from gene MARS1, PRRT2, TBCK, TOR1A, ECE1, ARX, ZEB2, ACAT1, CPS1, VWF, NBAS, COG4, and INVS. We also identified two novel pathogenic CNVs. Phenotypes associated with respiratory, multiple congenital anomalies, neuromuscular, or metabolic disorders were the most common. Twenty patients (74.1%) accompanied severe infection, 19 patients (70.1%) died. In summary, our findings expanded the genotypes and phenotypes of 19 rare diseases from PICU with complex characteristics.

A Comparative Study of Children with MIS-C between Admitted to the Pediatric Intensive Care Unit and Pediatric Ward: A One-Year Retrospective Study.

OBJECTIVES: This descriptive study aimed to compare the clinical and laboratory features of the children with the multisystem inflammatory syndrome in children (MIS-C), requiring pediatric intensive care unit (PICU), admission with the MIS-C patients who did not require PICU admission. PATIENTS AND METHODS: This study was conducted between March 2020 and February 2021 at the University of Health Sciences Dr. Behçet Uz Children's Hospital, a referral center for pediatric infectious diseases in the Aegean Region of Turkey. All hospitalized patients aged 18 years old or less with MIS-C according to the definition of the universal guidelines were included in the study. Data of the patients with the diagnosis of MIS-C were recorded and collected from the electronic medical records of the hospital. The data included demographic characteristics, presenting signs and symptoms, laboratory findings and clinical data. RESULTS: A total of 58 patients with MIS-C were included in this study. Thirty-eight (65.5%) patients were male. The median age was 6 years (2 months-16 years). The patients admitted to PICU were 15 (25.9%). The rate of pulmonary involvement was 81.3% (n = 13) in the PICU group. The median procalcitonin, C-reactive protein, erythrocyte sedimentation rate, D-Dimer and ferritin values were significantly higher in the PICU group compared to non-PICU group (p < 0.001, p = 0.02, p < 0.001, p = 0.006 and p = 0.031). CONCLUSIONS: Besides the depressing cardiac functions reported before, the pulmonary involvement and signs of shock are important factors for PICU admission in children with MIS-C.

A case series of children with adenovirus pneumonia: three-year experiences in a tertiary PICU.

BACKGROUND: Describe the outcome of adenovirus pneumonia in a pediatric intensive care unit (PICU) over a 3-year period, to identify the risk factors that may be associated with worse outcome. METHODS: A retrospective observational study was performed in the PICU of children's hospital in Shanghai from July 2016 to June 2019. Sixty-seven children over 29 days to 14 years old with adenovirus pneumonia who were admitted to PICU with acute hypoxemic respiratory failure were included in this study. The primary outcome was hospital mortality, and secondary outcomes were hospital and PICU length of stay (LOS), and risk factors of worse outcome. RESULTS: Of 67 children with severe adenovirus pneumonia, the hospital mortality was 16.42% (11/67) and 28-day mortality was 14.93% (10/67). Median Pediatric Risk of Mortality III (PRISM III) score at admission was 13 (interquartile range [IQR], 10-15). Median PICU LOS stay was 11 days (8-18d) and hospital LOS was 22 days (16-31d). Among children with extracorporeal membrane oxygenation (n = 9), 6 cases survived and 3 cases died. The patients who need renal replacement therapy, neuromuscular blockade, parenteral nutrition, and packed red blood cell perfusion had higher hospital mortality (p < 0.001, p = 0.041, p = < 0.001, p = 0.012, respectively). Multivariate logistic analysis indicated that liver dysfunction and nosocomial infection were associated with high risk of mortality. CONCLUSIONS: The hospital mortality of adenovirus pneumonia in our PICU was 16.42%. Patients complicated liver dysfunction and co-infection & nosocomial infection were associated with poor outcome.

Zwischen Himmel und Hölle: Erfahrungen von Eltern mit einem kritisch kranken Kind mit extrakorporaler Membranoxygenierung (ECMO) - Eine qualitative-explorative Studie mit Paarinterviews.

Between Heaven and Hell: Experiences of parents with a critically ill child with extracorporeal membrane oxygenation (ECMO) - A qualitative-explorative study with couple interviews Abstract. Background: It is a traumatic experience for parents when their child's severe illness necessitates a period of intensive care. This situation becomes even more challenging for parents if a highly technical therapy such as extracorporeal membrane oxygenation (ECMO) in the Pediatric Intensive Care Unit is required. Aim: The study explores the experiences of parents of critically ill children undergoing ECMO therapy with the aim of better understanding their needs and identifying courses of action for healthcare professionals. Method: The qualitative-explorative study was based on interviews with six couples whose critically ill child is or has been receiving ECMO during the last year, which were used to examine their experiences. The analysis of six such interviews was performed using intensive paraphrasing and inductive coding. Results: The parents' situation can be best characterised as ambivalent with simultaneous feelings of hope and fear. They recognize the danger to their child's life, leading to intense feelings of helplessness with strong emotional reactions. It becomes apparent that there is too little fit between the emotional world of the parents and the action patterns of the health care professionals. Conclusions: The health care professionals thinking logic is based on professional criteria, such as the life threat and risks of ECMO, which ignores the emotional needs of the parents. For this reason, it is important to be more sensitive to the parents and to share positive little signs about their child' s state of health and ability to suffer with them.

Spectrum and Immediate Outcome of Acute Kidney Injury in a Pediatric Intensive Care Unit: A Snapshot Study from Indian Subcontinent.

BACKGROUND AND AIMS: Acute kidney injury (AKI) became an important cause of mortality and morbidity in critically ill children, despite advancement in its management. In developing countries etiology of AKI are different from that of developed countries. MATERIALS AND METHODS: This observational study was carried out in pediatric intensive care unit (PICU) in 2 months to18 years of critically ill children. Kidney injury was defined and categorized by the pRIFLE criteria. RESULTS: Out of 361children, 86 children (23.8%) developed AKI at some point during admission, 275 children (age and sex matched) who did not develop kidney injury during hospitalization served as non-AKI children. Maximum cases of AKI were seen in 1-5 years of age. Maximum children of AKI were of viral encephalitis (n = 43, 50.0%) followed by scrub typhus (n = 14, 16.3%). Risk factors for the development of AKI were shock, PRISM score and longer hospital stay. In our study the mortality in AKI children (n = 30, 34.8%) was significantly higher (p = 0.005) as compared to non-AKI children (n = 56, 20.3%)). Duration on mechanical ventilation, PICU stay and hospital stay were also significantly (p = 0.001) higher in AKI children. CONCLUSION: AKI is common in critically ill children and associated with high mortality and morbidity. HOW TO CITE THIS ARTICLE: Bharat A, Mehta A, Tiwari HC, Sharma B, Singh A, Singh V. Spectrum and Immediate Outcome of Acute Kidney Injury in a Pediatric Intensive Care Unit: A Snapshot Study from Indian Subcontinent. Indian J Crit Care Med 2019;23(8):352-355.

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource-limited hospitals.

Pediatric oncology patients hospitalized in resource-limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost-effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource-limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care.

The Influence of Context on Utilizing Research Evidence for Pain Management in Jordanian Pediatric Intensive Care Units (PICU).

PURPOSE: The purpose of this study was to gain a beginning understanding of the contextual factors that influence the use of research for pain management in Jordanian Pediatric Intensive Care Units (PICUs). DESIGN AND METHODS: A paper or online questionnaire was used to collect data on instrumental research use (IRU) and conceptual research use (CRU) and ten contextual variables from 73 registered nurses working in four Jordanian PICUs. The Pearson product-moment correlation coefficient was used to test the relationship between continuous (demographic and contextual) factors and IRU and CRU. One way ANOVA and independent t-test were used to examine the differences between sociodemographic variables and IRU and CRU. Generalized Estimating Equations (GEE) was used to determine the demographic and contextual factors that influenced research use. We modeled the significant variables identified by bivariate correlation, t-test, and ANOVA at (p≤0.10). RESULTS: Nine of the contextual factors significantly and positively correlated with the IRU for pain assessment, eight with the IRU for pain treatment, and six with the CRU for pain management (including assessment and treatment). Hospital type (public) predicted the IRU for pain assessment. Social capital, structural, and electronic resources predicted the IRU for pain treatment. Social capital predicted the CRU for pain management. CONCLUSION: Context influences Jordanian PICU nurses' use of research for pain management. PRACTICE IMPLICATIONS: Concentrating on modifiable contextual factors may positively influence Jordanian PICU nurses' use of research for pain management. This influence may extend to reduce children's pain in Jordanian PICUs.

The potential influence of human parainfluenza viruses detected during hospitalization among critically ill patients in Kuwait, 2013-2015.

BACKGROUND: The four types of human parainfluenza viruses (PIV) are important causes of community-acquired pneumonia, particularly in children; however, limited information exists about the incidence of PIV in critically ill patients. The aim of this study is to describe the spectrum, incidence and clinical features of PIV-associated infections diagnosed during the hospital stay of patients admitted to pediatric intensive care unit (PICU) and intensive care unit (ICU) of 5 medical centers across Kuwait. METHODS: This was a population-based, retrospective study from 2013 to 2015. Specimens were analyzed by molecular methods. This analysis was performed using the database of Virology Unit, Mubarak Al-Kabeer Hospital. Data from 1510 admitted patients with suspected respiratory viral infections was extracted. RESULTS: The database contained a total of 39 (2.6%) patients infected with PIV (53.8% male and 46.2% females) and 20 (51.3%) were under 1 year of age. The most frequently isolated type was type 3 (28, 71.8%) followed by type 1 (9, 23.1%). At admission the most common clinical diagnosis was pneumonia in 12 patients (30.8%, p < 0.05) followed by bronchiolitis in 10 patients (25.6%). CONCLUSION: PIV plays an important yet unrecognized role in the outcomes of PIUC and ICU patients. Our results contribute to the limited epidemiologic data of PIV in PIUC and ICU in this region.

Comparison of diagnostic criteria for sepsis-associated acute kidney injury in the pediatric intensive care unit: a retrospective cohort study.

Background: pRIFLE (Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease), KDIGO (Kidney Disease Improving Global Outcomes) and pROCK (Pediatric Reference Change Value Optimized for AKI) are diagnostic criteria used for acute kidney injury (AKI) incidence evaluation. The aim of this study was to explore the diagnostic consistency, incidence and mortality rate, clinical signs, and influencing factors of renal injury related to sepsis in children diagnosed by three different AKI diagnostic criteria, and then evaluate which one was more valuable. Methods: A retrospective analysis was performed on the clinical data of children with severe sepsis. The patients were diagnosed and staged according to the 2007 pRIFLE standard, the 2012 KDIGO standard, and the 2018 pROCK standard. The clinical characteristics and prognosis of children with different stages of sepsis were compared between the three diagnostic standards. Results: A total of 62 patients with sepsis were included. Blood stream infection is common (11 cases, 17.74%). According to pRIFLE, KDIGO, and pROCK standards, the incidence of sepsis-associated AKI (SA-AKI) was 74.2%, 67.7%, and 56.5%, respectively. The pRIFLE had the highest diagnostic rate of early detection of SA-AKI. There was no statistical difference in SA-AKI incidence or staging consistency between the pRIFLE and KDIGO groups (κ=0.0671; κ>0.60); the consistency of SA-AKI diagnoses across the three standards was good (all P values <0.05), and pROCK demonstrated a higher specificity. A high Pediatric Risk of Mortality (PRISM) score and high procalcitonin level were independent risk factors. Shock and renal replacement therapy were independent risk factors for SA-AKI death. Death from admission to 28 days after admission was used as an endpoint to draw a survival graph, which revealed that the AKI group had a significantly higher risk of death than did the non-AKI group. Conclusions: The consistency of diagnosing SA-AKI across the three classification criteria was similar, and mortality rate increased with increased SA-AKI staging. The pRIFLE criteria were more sensitive in the early detection of SA-AKI, while the pROCK had higher specificity. There was no significant difference between the pRIFLE and KDIGO in terms of incidence, diagnosis, or staging of SA-AKI.

The association between nutritional status measured by body mass index and outcomes in the pediatric intensive care unit.

Aim/Introduction: The relationship between nutritional status upon admission to a pediatric intensive care unit (PICU) and clinical outcomes remains unclear. We examined the relationship between nutrition status, as indicated by body mass index-for-age (BMI-for-age), and clinical outcomes in the PICU. Method: In this retrospective study at a tertiary care center, records of 1,015 critically ill children and adolescents aged one month to 18 years old with available anthropometric parameters were included. The nutritional status upon admission was determined by calculating the BMI-for-age z-score using the WHO growth charts as the reference. The participants were categorized as underweight (BMI-for-age z-score < -2), normal weight (-2 ≤ BMI-for-age z-score ≤ +1), and overweight/obese (BMI-for-age z-score > +1). Multi-variate odds ratios (OR) with 95% confidence intervals (CI) were used to investigate the association between malnutrition (being underweight and overweight/obese) and odds of Prolonged PICU stay (≥7 days) and PICU mortality after controlling for descriptive characteristics, Glasgow Coma Scale score status, fluctuations in serum sodium, and acute kidney injury confounders. Results: The proportions of patients in underweight, normal weight, and overweight/obese categories were 34.2%, 45.8%, and 20%, respectively. During the study period, 21.5% of patients had prolonged PICU stay, and 5.6% of patients in PICU died. Compared to normal-weight patients, underweight patients had higher odds of prolonged PICU stay (OR: 1.52; 95% CI: 1.05-2.22) and PICU mortality (OR: 2.12; 95% CI: 1.22-4.01). Age- and gender-stratified full-adjusted analysis showed that the increased odds of prolonged PICU stay remained significant among underweight boys and underweight individuals aged 5-19 years old. Furthermore, the increased odds of PICU mortality remained significant among underweight individuals aged 2-5 years old. However, being overweight or obese during PICU admission did not demonstrate a significant association with our outcomes in the total sample or subgroup analysis. Conclusion: Our findings showed that PICU patients who were underweight had higher odds of prolonged PICU stay and PICU mortality than their normal-weight counterparts. This underscores the importance of closely monitoring underweight patients in the PICU upon admission in order to improve clinical outcomes.

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room.

OBJECTIVE: This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario. BACKGROUND: The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy. METHODOLOGY: During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD. RESULTS: Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone. CONCLUSION: Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

Bioelectrical impedance phase angle and the mortality in critically ill children.

Background: Phase angle (PhA) is a variable obtained from bioelectrical impedance analysis (BIA). It is highly sensitive and specific and is commonly used in clinical nutrition assessment. Recently, PhA has shown promise in predicting clinical outcomes, especially as a new indicator of mortality, but its use in pediatric research is limited. This study aims to investigate the association between PhA measured at admission using BIA and PICU length of stay (LOS) and 60-day mortality in critically ill children and adolescents. Methods: A consecutive series of pediatric patients in the PICU underwent BIA measurements within 72 h of admission. All patients met the inclusion and exclusion criteria. Patient demographics, anthropometric measurements, pediatric index of mortality 2 score (PIM-2), and laboratory exams were recorded. Kaplan-Meier (K-M) survival curves were constructed based on the critical PhA value to assess differences in survival status within the 60-day window. Multivariate cox regression model was employed to illustrate the relationship between PhA and 60-day mortality rates. The Youden's index method was used to identify the critical cut-off value for PhA in relation to mortality rates. ROC curves provided the area under the curve (AUC) and a 95% confidence interval (CI). Results: A total of 205 pediatric patients (118 boys) were included, with a mean age of 9.2 years (±6.0). Survival curves indicated a cutoff value of 3.1°, with higher survival in patients with PhA ≥3.1° compared to those with PhA <3.1° (F = 10.51, p < 0.0001). The area under the ROC curve was 0.70, with a sensitivity of 0.65 and specificity of 0.72. Total hospital LOS was longer in the PhA <3.1° group compared to the PhA ≥3.1° group (p = 0.000). The PhA <3.1° group had a longer PICU LOS (adjusted for age and sex, HR 1.871, p = 0.000, log-rank test, p = 0.000). PhA and PIM-2 were two independently significant correlated variables (p < 0.05) for the 60-day mortality rate in this study. Conclusion: Low PhA in patients is associated with longer PICU LOS and an increased risk of PICU patient mortality. PhA not only serves as an indicator for monitoring pediatric nutrition but also as a prognostic indicator for PICU patients.

Clinical and Etiological Profile of Children With Acute Viral Encephalitis in a Tertiary Care Hospital: A Cross-Sectional Study.

BACKGROUND:  Acute encephalitis refers to the clinical diagnosis of children who have a sudden onset of symptoms and show evidence of inflammatory lesions in the brain. Timely diagnosis is crucial for both lifesaving measures and the preservation of brain functions. OBJECTIVE:  The objective of the study was to determine the clinical and etiological profile of acute viral encephalitis in children within a tertiary care hospital. METHODS:  This hospital-based cross-sectional study was conducted in the Pediatric Intensive Care Unit (PICU) at Dr. D. Y. Patil Medical College, Hospital, and Research Centre in Pune. The study included children aged one month to 12 years diagnosed with suspected viral encephalitis. Over 22 months, from August 2022 to June 2024, 35 children who met the inclusion criteria were enrolled. Data collection involved clinical examinations, laboratory investigations, and imaging studies, following informed consent from the parents or guardians. RESULTS: The study examined 35 patients with suspected acute encephalitis syndrome (AES) and found a male-to-female ratio of 3.4:1. Among the patients, 22 (62.85%) had a confirmed viral etiology, while 13 (37.17%) had an unknown etiology. The most common virus isolated was mumps, with school-age children most affected. The cases were concentrated in the Chikhali, Bhosari, Nigdi, and Chinchwad regions. Symptoms included fever, seizures, vomiting, and altered mental status. Low vaccination rates were observed, and the Glasgow Coma Scale (GCS) scores, shock incidence, and ventilation showed an association with mortality. Most patients required intensive care, antiedema measures, antibiotics, and antivirals. The mortality rate was 11.4%, with 17% of patients discharged with neurological sequelae. CONCLUSION: Causative agents such as mumps, herpes simplex virus (HSV), dengue, and many other viruses are now more prevalent than the Japanese encephalitis (JE) virus. Bad clinical course and fatal outcomes are observed in patients affected with rabies, HSV, and H1N1 influenza virus. Factors such as GCS scores, shock, and need for ventilation play a significant role in determining patient prognosis. Early detection and prompt treatment may aid in better outcomes for patients.

Recurrent Subglottic Stenosis in a 16-Month-Old Male in the Setting of Influenza A, Intubation, and Honey Consumption.

Recurrent episodes of subglottic stenosis are rare in the literature, and the etiologic causes are misunderstood but can be congenital, idiopathic, or iatrogenic in nature. Complications of intubation can result in subsequent inflammation and reactive processes. This case involves a 16-month-old male who suffered from a recurrent episode of subglottic stenosis in the setting of croup, influenza, and honey consumption. He had presented to the emergency department in respiratory distress after ingesting a home remedy of onion juice and honey. He had been discharged one day prior from the pediatric intensive care unit after four days of intubation and a seven-day hospital course with evidence of croup on imaging. He was readmitted, and subglottic edema and narrowing were confirmed via endoscopy, which prompted antibiotic treatment and close monitoring. After three days of monitoring and re-evaluation by bronchoscopy, the patient's condition began to improve, and no intubation was necessary. It is unclear what the cause of recurrent subglottic stenosis is due to the patient's clinical picture being clouded by a potential allergic reaction to honey versus an inflammatory reactive process post-intubation from the previous admission days prior. This case emphasizes the need for further research on the prevalence and etiology of recurrent subglottic stenosis and a deeper understanding of how to optimize diagnosis and treatment.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs.

BACKGROUND: The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals. OBJECTIVE: The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU. MATERIALS AND METHODS: It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors. RESULTS:  Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality. CONCLUSIONS: Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Methicillin-Sensitive Staphylococcus aureus Co-infection in Adolescent Patients With Delta-Variant SARS-CoV-2 Acute Respiratory Failure.

We report a series of five pediatric patients admitted with acute respiratory failure due to delta-variant SARS-CoV-2, found to have a methicillin-sensitive Staphylococcus aureus (MSSA) co-infection. All five patients required escalation of their respiratory support within 24 hours of discovering the MSSA infections. Four out of the five patients received immune-modulating therapies. Four patients required extracorporeal membrane oxygenation support. One patient died, and the other four survived until hospital discharge. Clinicians should consider secondary bacterial infections in patients with COVID-19 treated with immune modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with COVID-19.

Risk factors predicting need for the pediatric intensive care unit (PICU) post-hematopoietic cell transplant, PICU utilization, and outcomes following HCT: a single center retrospective analysis.

Hematopoietic cell transplant (HCT) is a curative treatment for multiple malignant and non-malignant disorders. While morbidity and mortality have decreased significantly over the years, some patients still require management in the pediatric intensive care unit (PICU) during their HCT course for additional respiratory, cardiovascular, and/or renal support. We retrospectively reviewed pediatric patients (0-18 years) who underwent HCT from January 2015-December 2020 at our institution to determine risk factors for PICU care and evaluate PICU utilization and outcomes. We also assessed pulmonary function testing (PFT) data to determine if differences were noted between PICU and non-PICU patients as well as potential evolution of pulmonary dysfunction over time. Risk factors of needing PICU care were lower age, lower weight, having an underlying inborn error of metabolism, and receiving busulfan-based conditioning. Nearly half of PICU encounters involved use of each of respiratory support types including high-flow nasal cannula, non-invasive positive pressure ventilation, and mechanical ventilation. Approximately one-fifth of PICU encounters involved renal replacement therapy. Pulmonary function test results largely did not differ between PICU and non-PICU patients at any timepoint aside from individuals who required PICU care having lower DLCO scores at one-year post-HCT. Future directions include consideration of combining our data with other centers for a multi-center retrospective analysis with the goal of gathering and reporting additional multi-center data to work toward continuing to decrease morbidity and mortality for patients undergoing HCT.