Two months outcomes following delirium in the pediatric intensive care unit.

The lasting consequences of delirium in children are not well characterized. This study aimed to compare the two-month outcomes in pediatric intensive care unit (PICU) survivors according to the presence of delirium. Post-hoc analysis of a single-center prospective study of mechanically ventilated (invasive ventilation or non-invasive ventilation) children followed at the CHU Sainte-Justine PICU follow-up clinic two months after PICU discharge, between October 2018 and August 2022. Delirium was defined as one or more Cornell Assessment of Pediatric Delirium (CAPD) scores ≥ 9. Primary outcome was survivors' quality of life and secondary outcomes were sleep and posttraumatic stress and anxiety and depression in parents. Multivariable linear and logistic regression models assessed the independent associations between delirium and outcomes while adjusting for age, sex, comorbidity, diagnosis, severity of illness, PICU length of stay, and invasive mechanical ventilation. Of the 179 children included over a 47 month-period, 117 (65.4%) had delirium. Children with delirium were more commonly intubated (91.5% vs. 30.7%, p < 0.001) and had higher PELOD-2 scores (10 vs. 4, p < 0.001). On multivariable analysis, delirium was associated with a decreased quality of life at 2.3 months post discharge (p = 0.03). The severity of the delirium episode (higher scores of CAPD) was associated with a higher likelihood of sleep disturbances (OR 1.13, p = 0.01) and parental anxiety (OR 1.16, p = 0.01), in addition to lower quality of life (p = 0.03).Conclusions: Two months following their PICU stay, children with delirium had a lower quality of life, suggesting a lasting effect of delirium on children and their families.

PICU Follow-Up Clinic: Patient and Family Outcomes 2 Months After Discharge.

OBJECTIVES: Hospitalization in a PICU is a life-altering experience for children and their families. Yet, little is known about the well-being of these children after their discharge. We are describing the outcome of PICU survivors at a PICU clinic 2 months after discharge. DESIGN: Prospective cohort study. SETTING: PICU and PICU clinic of CHU Sainte-Justine. PATIENTS: Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, odds ratio greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine. PATIENTS: Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, or greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were evaluated by a pediatric intensivist 2 months after discharge at the follow-up clinic. They were asked to fill out validated questionnaires. One hundred thirty-two patients were followed from October 2018 to September 2020. The PICU diagnoses were respiratory illness (40.9%), head trauma, and septic shock (7.6%). Average length of PICU stay was 28.5 ± 84.2 days (median 7 d). Sixty-one percent were intubated. Symptoms reported by families were as follows: fatigue (9.9%), sleep disturbances (20.5%), feeding difficulties (12.1%), and voice change and/or stridor (9.8%). Twenty-one percent of school-aged children reported school delays. Twenty-seven children demonstrated communication delays, 45% gross motor function delays, 41% fine motor delays, 37% delays in problem-solving, and 49% delays in personal-social functioning. Quality of Life scores were 78.1 ± 20.5 and 80.0 ± 17.5 for physical and psychosocial aspects, respectively. Fourteen percent of parents reported financial difficulties, 42% reported symptoms of anxiety, 29% symptoms of depression. CONCLUSIONS: PICU survivors and their families experience significant physical and psychosocial morbidities after their critical illness. PICU follow-up is crucial to determine the outcome of these children and develop interventions.

The implementation of a synchronous telemedicine platform linking off-site pediatric intensivists and on-site fellows in a pediatric intensive care unit: A feasibility study.

OBJECTIVE: The aim of this study was to assess the feasibility of implementing a synchronous telemedicine platform in a pediatric intensive care unit (STEP-PICU). METHOD: A prospective mixed study was conducted. Two sources of data were mobilised: a survey with structured questionnaires and direct non-intrusive observation. The study site was the PICU of a university hospital. Users' perceptions of six aspects of the STEP-PICU were studied: telemedicine system quality, data quality, quality of technical support, use of the new system, overall satisfaction and system benefits. RESULTS: During the 6-month experimentation period, use of the telemedicine platform was rather limited and fell short of the promoter's expectations.The mean scores for the six user perception dimensions were low, with no differences between the two groups of users. A Mann-Whitney test showed that being an off-site pediatric intensivist or on-site fellow did not make a statistically significant difference in responses on system quality (p = .518), data quality (p = 1.00), quality of technical support (p = 1.00), system use (p = .556), overall satisfaction (p = .482), or benefits (p = .365). The low use of the STEP-PICU was attributed to three root causes: human factors, the platform's functionalities, and technical problems. DISCUSSION: The synchronous telemedicine service for PICU was feasible but would need good pre-implementation preparation to be truly helpful. Its usefulness during the night shift and holiday on-call periods was scored as low by the off-site pediatric intensivists and the on-site fellows. It would appear that such a service could be more beneficial for communications with other remote healthcare facilities, where there is a greater need for the expertise of a pediatric critical care intensivist.

Impact of Synchronous Telemedicine Models on Clinical Outcomes in Pediatric Acute Care Settings: A Systematic Review.

OBJECTIVES: To evaluate the impact of synchronous telemedicine models on the clinical outcomes in pediatric acute care settings. DATA SOURCES: Citations from EBM Reviews, MEDLINE, EMBASE, Global Health, PubMed, and CINAHL. STUDY SELECTION: We identified studies that evaluated the impact of synchronous telemedicine on clinical outcomes between January 2000 and April 2018. All studies involving acutely ill children in PICUs, pediatric cardiac ICUs, neonatal ICUs, and pediatric emergency departments were included. Publication inclusion criteria were study design, participants characteristics, technology type, interventions, settings, outcome measures, and languages. DATA EXTRACTION: Two authors independently screened each article for inclusion and extracted information, including telecommunication method, intervention characteristics, sample characteristics and size, outcomes, and settings. DATA SYNTHESIS: Out of the 789 studies initially identified, 24 were included. The six main outcomes of interest published were quality of care, hospital and standardized mortality rate, transfer rate, complications and illness severity, change in medical management, and length of stay. The use of synchronous telemedicine results improved quality of care and resulted in a decrease in the transfer rate (31-87.5%) (four studies), a shorter length of stay (8.2 vs 15.1 d) (six studies), a change or reinforcement of the medical care plan, a reduction in complications and illness severity, and a low hospital and standardized mortality rate. Overall, the quality of the included studies was weak. CONCLUSIONS: Despite the broad recommendations found for using telemedicine in pediatric acute care settings, high-quality evidence of its impacts is still lacking. Further robust studies are needed to better determine the clinical effectiveness and the associated impacts of telemedicine in pediatric acute care settings.

Neurally Adjusted Ventilatory Assist After Pediatric Cardiac Surgery: Clinical Experience and Impact on Ventilation Pressures.

BACKGROUND: After pediatric cardiac surgery, ventilation with high airway pressures can be detrimental to right ventricular function and pulmonary blood flow. Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator interactions, helping maintain spontaneous ventilation. This study reports our experience with the use of NAVA in children after a cardiac surgery. We hypothesize that using NAVA in this population is feasible and allows for lower ventilation pressures. METHODS: We retrospectively studied all children ventilated with NAVA (invasively or noninvasively) after undergoing cardiac surgery between January 2013 and May 2015 in our pediatric intensive care unit. The number and duration of NAVA episodes were described. For the first period of invasive NAVA in each subject, detailed clinical and ventilator data in the 4 h before and after the start of NAVA were extracted. RESULTS: 33 postoperative courses were included in 28 subjects with a median age of 3 [interquartile range (IQR) 1-12] months. NAVA was used invasively in 27 courses for a total duration of 87 (IQR 15-334) h per course. Peak inspiratory pressures and mean airway pressures decreased significantly after the start of NAVA (mean differences of 5.8 cm H2O (95% CI 4.1-7.5) and 2.0 cm H2O (95% CI 1.2-2.8), respectively, P < .001 for both). There was no significant difference in vital signs or blood gas values. NAVA was used noninvasively in 14 subjects, over 79 (IQR 25-137) h. CONCLUSIONS: NAVA could be used in pediatric subjects after cardiac surgery. The significant decrease in airway pressures observed after transition to NAVA could have a beneficial impact in this specific population, which should be investigated in future interventional studies.

An Order Protocol for Respiratory Distress/Acute Pain Crisis in Pediatric Palliative Care Patients: Medical and Nursing Staff Perceptions.

BACKGROUND: An order protocol for distress (OPD), including respiratory distress and acute pain crisis, has been established for pediatric palliative care patients at Sainte-Justine Hospital (SJH). After discussion with the patient/his or her family, the OPD is prescribed by the attending physician whenever judged appropriate. The OPD can then be initiated by the bedside nurse when necessary; the physician is notified after the first dose is administered. OBJECTIVES: The study objectives were to evaluate the perceptions and experience of the medical/nursing staff towards the use of the OPD. METHODS: A survey was distributed to all physicians/nurses working on wards with pediatric palliative care patients. Answers to the survey were anonymous, done on a voluntary basis, and after consent of the participant. RESULTS: Surveys (258/548) were answered corresponding to a response rate of 47%. According to the respondents, the most important motivations in using the OPD were the desire to relieve patient's distress and the speed of relief of distress by the OPD; the most important obstacles were going against the patient's/his or her family's wishes and fear of hastening death. The respondents reported that the OPD was frequently (56%) or always (36%) effective in relieving the patient's distress. The respondents felt sometimes (16%), frequently (34%), or always (41%) comfortable in giving the OPD. They thought the OPD could never (12%), rarely (32%), sometimes (46%), frequently (8%), or always (1%) hasten death. Physicians were less favorable than nurses with the autonomy of bedside nurses to initiate the OPD before notifying the physician (p = 0.04). Overall, 95% of respondents considered that they would use the OPD in the future. CONCLUSIONS: Data from this survey shows that respondents are in favor of using the OPD at SJH and find it effective. Further training as well as support for health care professionals are mandatory in such palliative care settings.

Electronic Medical Record in Pediatric Intensive Care: Implementation Process Assessment.

The implementation of an electronic medical record (EMR) is a high-priority project in a majority of industrialized countries. The Healthcare Information and Management Systems Society (HIMSS) Analytics established an eight-stage EMR Adoption Model (EMRAM) to track progress against health care organizations across a country. In Canada, 36.5% of the hospitals are at the stage 3 or higher, whereas 0.2% have reached the seventh stage. To assess the impact on the safety and caregivers' satisfaction of a stage 7 EMR in a Quebec Pediatric Hospital initially at the EMRAM stage 3, a pilot customized implementation of paperless pediatric intensive care EMR was performed and evaluated. Six months after implementation, there was a nonsignificant decrease in severe medical incidents in comparison to the same period of time, the previous year. Most pediatric intensive care unit (PICU) staff were very or completely comfortable with the EMR, but the EMR satisfied 33.9% of all staff (everyday users [internal staff] and occasional user [external staff]) and 41.9% of internal staff only. The information gathered with this pilot EMR implementation using a 20-month preparation period and a continuous monitoring including change management ("living lab approach") after the "go live" helped in the success of the implementation but did not improve significantly caregivers' satisfaction, in the first 6 months of this dramatic change in practice.

Length of storage and in vitro immunomodulation induced by prestorage leukoreduced red blood cells.

BACKGROUND: The relationship between length of storage of red blood cell (RBC) units and biochemical changes has been well studied, but little is known about the progression of cellular immunomodulative properties in blood recipients. This study aims to quantify in vitro T-cell activation and cytokine release by white blood cells, after incubation with supernatants from leukoreduced RBCs. STUDY DESIGN AND METHODS: Whole blood cultures were incubated with supernatant from five leukoreduced RBC units stored for 1, 6, 10, 15, 24, and 42 days. Supernatant-induced T-cell activation was evaluated by quantifying CD25 expression. Supernatant-induced cytokine production was determined by measuring interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha levels. RESULTS: No cytokines were detected in RBC supernatants even after 42 days of storage. However, IL-6 levels in whole blood culture increased significantly when incubated with supernatant from RBC units stored for 1, 6, and 15 days, by factors of 1.7 +/- 0.3, 1.7 +/- 0.3, and 1.4 +/- 0.3, respectively. TNF-alpha levels were significantly decreased on Days 24 and 42 of storage by factors of 0.50 +/- 0.42 and 0.33 +/- 0.21, respectively. IL-10 levels were significantly increased on Days 1 and 42 of storage by factors of 2.3 +/- 1.3 and 3.2 +/- 2.8, respectively. After an initial increase in IL-6 and TNF-alpha production, there was a significant linear decrease in their levels measured from units stored for longer times. No significant changes in CD25 expression were observed over time. CONCLUSION: Although no cytokines were measured in the supernatants from leukoreduced RBCs, these supernatants exhibited variable immunomodulatory effects related to their length of storage.

Transfusion strategies for patients in pediatric intensive care units.

BACKGROUND: The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as judged by the outcome of multiple-organ dysfunction. METHODS: In this noninferiority trial, we enrolled 637 stable, critically ill children who had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients to a threshold of 9.5 g per deciliter (liberal-strategy group). RESULTS: Hemoglobin concentrations were maintained at a mean (+/-SD) level that was 2.1+/-0.2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7+/-0.4 and 10.8+/-0.5 g per deciliter, respectively; P<0.001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, -4.6 to 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other outcomes, including adverse events. CONCLUSIONS: In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes. (Controlled-trials.com number, ISRCTN37246456 [controlled-trials.com].).

Induction of apoptosis by herpes simplex virus-1 in neonatal, but not adult, neutrophils.

We report a study on the effect of herpes simplex virus 1 (HSV-1) infection on apoptosis of neutrophils from both adults and neonates and present evidence showing that HSV-1 enhances apoptosis in neonatal, but not adult, neutrophils. HSV-1 enhanced the expression of both Fas and Fas ligand on the surface of neonatal neutrophils. Treatments with anti-Fas antibody and a Fas ligand inhibitor significantly reduced the induction of apoptosis by HSV-1. Using an ELISA assay, it was found that HSV-1 infection also leads to increased release of soluble FasL from HSV-1-infected neonatal neutrophils. Increased neonatal neutrophil apoptosis following HSV-1 infection may represent an important mechanism by which HSV-1 may diminish the antiviral response of neonatal neutrophils and might explain, at least in part, the severity of infections that are caused in newborns by this herpesvirus.

Platelet-activating factor antagonists decrease follicular dendritic-cell stimulation of human B lymphocytes.

Both B-lymphoblastoid cell lines and tonsillar B lymphocytes express receptors for platelet-activating factor (PAF). In lymph node germinal centres, B lymphocytes interact with follicular dendritic cells (FDCs), which present antigen-containing immune complexes to B lymphocytes. FDCs have phenotypic features that are similar to those of stromal cells and monocytes and may therefore be a source of lipid mediators. In this study, we evaluated the effects of the PAF antagonist WEB 2170 on the activation of tonsillar B lymphocytes by FDCs. FDCs were isolated from tonsils by Bovine Serum Albumin (BSA) gradient centrifugation. After being cultured for 6 to 10 days, they were incubated with freshly isolated B cells in the presence or absence of the specific PAF receptor antagonist WEB 2170. B-lymphocyte proliferation was assessed by [3H]-thymidine incorporation, and immunoglobulin (Ig) G and IgM secretion was assessed by enzyme-linked immunosorbent assay (ELISA). WEB 2170 (10-6 to 10-8 M) inhibited [3H]-thymidine incorporation by up to 35% +/- 3%. Moreover, the secretion of IgG and IgM was inhibited by up to 50% by WEB 2170 concentrations ranging from 10-6 to 10-8 M. There was no evidence of toxicity by trypan blue staining, and the addition of WEB 2170 to B cells in the absence of FDCs did not inhibit the spontaneous production of IgG or IgM. The effect of the PAF antagonist is primarily on B lymphocytes, as reverse transcription polymerase chain reaction detected little PAF receptor messenger ribonucleic acid (mRNA) from FDCs. These data suggest that endogenous production of PAF may be important in the interaction of B lymphocytes with FDCs.

Airway eicosanoids in acute severe respiratory syncytial virus bronchiolitis.

We prospectively studied the levels of eicosanoids in intubated patients with severe bronchiolitis and compared them to electively intubated non-infected infants. LeukotrieneE(4) (LTE(4)), leukotrieneB(4) (LTB(4)), and prostaglandinE(2) (PGE(2)) levels were significantly increased (P <.01) from endotracheal (ET) aspirates of infants with bronchiolitis compared with controls, as were urinary LTE(4) levels (P <.001). We conclude that eicosanoids are increased in the tracheal aspirates and urine of children with bronchiolitis.

The management of anterior dislocation of the shoulder with proximal humerus fracture, bony Bankart lesion, and associated glenoid labrum avulsion: a report of 2 cases.

Proximal humerus fractures are common in the older population. These fractures can be associated with dislocation of the shoulder. Four-part fracture-dislocations and head-splitting 3-part fractures are generally indicated for shoulder hemiarthroplasty in the older population. When such surgery is warranted, inspection of the glenoid during the procedure is indicated, as loss of evaluation may lead to postoperative shoulder instability. There is value in alerting orthopedic surgeons to the possibility of anterior glenoid rim fracture in association with proximal shoulder fracture-dislocation. We focus on this issue and advise that the lesion can be visualized and confirmed at open reconstruction and does not need multiple radiographic views.

Circulating granulocyte colony-stimulating factor, C-X-C, and C-C chemokines in children with Escherichia coli O157:H7 associated hemolytic uremic syndrome.

Leukocytes are implicated in the pathogenesis of diarrhea-associated hemolytic uremic syndrome (D(+) HUS). We hypothesized that increased circulating levels of granulocyte colony-stimulating factor (G-CSF), and the chemokines epithelial cell-derived neutrophil-activating protein-78 (ENA-78), growth related oncogen-alpha (GRO-alpha), macrophage inflammatory protein-1beta (MIP-1beta), and monocyte chemotactic protein-1 (MCP-1) are related to the severity of illness in Escherichia coli O157:H7 infections. We compared the circulating concentrations of these mediators in the course of E. coli O157:H7 enteritis, hemorrhagic colitis, and HUS. Our data show that, on admission, children with HUS presented 10-fold abnormally increased levels of G-CSF (p < 0.007), 3-fold increased MIP-1beta concentrations (p < 0.001), and 2-fold lower values of ENA-78 (p < 0.0001). One week later, a further 4-fold decrease in ENA-78 concentration was noted (p < 0.0001) whereas MIP-1beta levels returned to normal. HUS patients requiring peritoneal dialysis showed 6-fold increased G-CSF (p < 0.001) and 5-fold decreased ENA-78 (p < 0.001) levels. On admission, children with uncomplicated O157:H7 hemorrhagic colitis (HC) presented 3-fold abnormally increased concentrations of G-CSF (p < 0.001) and MIP-1beta (p < 0.0001). Those with O157:H7 enteritis but no bloody stools showed higher rates of abnormal GRO-alpha, MIP-1beta, and MCP-1 measurements than children with O157:H7 HC or HUS: GRO-alpha (50% enteritis, 36% HC, 17% HUS; p < 0.06), MIP-1beta (40% enteritis, 22% HC, 11% HUS; p < 0.02), MCP-1 (77% enteritis, 20% HC, 18% HUS; p < 0.0001). The data indicates that GRO-alpha, MIP-1beta, and MCP-1 are produced during E. coli O157:H7 enteritis, whether or not HC or HUS develops. Our data suggest that children with O157:H7 associated HUS may present abnormally increased circulating levels of G-CSF and decreased ENA-78 concentrations. The mechanisms responsible for leukocytes recruitment in O157:H7 infections are unclear and await further studies.

Survey on transfusion practices of pediatric intensivists.

OBJECTIVE: To describe the red blood cell transfusion practices of pediatric intensivists. DESIGN: Cross-sectional self-administered survey. SETTING: Pediatric intensive care units. PATIENTS: Academic pediatric intensivists. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Scenario-based survey among English- or French-speaking intensivists from Canada, France, Belgium, or Switzerland, working in tertiary-care pediatric intensive care units. Respondents were asked to report their decisions regarding transfusion practice with respect to four scenarios: cases of bronchiolitis, septic shock, trauma, and the postoperative care of a patient with Fallot's tetrad. The response rate was 71% (163 of 230). The overall baseline hemoglobin transfusion threshold that would have prompted intensivists to transfuse a patient ranged from 7 to 13 g/dL (70-130 g/L) within almost all scenarios. There was a significant difference between scenarios of the average baseline hemoglobin transfusion thresholds (p < .0001). A low Pao2, a high blood lactate concentration, a high Pediatric Risk of Mortality score, active gastric bleeding, emergency surgery, and age (2 wks) were important determinants of red blood cell transfusion, whereas none of the respondents' personal characteristics were. The average volume of packed red blood cells transfused in the four scenarios did not differ significantly. CONCLUSIONS: This survey documented a significant variation in transfusion practice patterns among pediatric critical care practitioners with respect to the threshold hemoglobin concentration for red blood cell transfusion. The volume of packed red blood cells given was not adjusted to the hemoglobin concentration.