Characteristics, management and changing incidence of children with empyema in a paediatric intensive care unit.

AIM: Paediatric intensive care unit (PICU) admissions for empyema increased following the 13-valent pneumococcal conjugate vaccine (PCV13). We describe the clinical characteristics, management and outcomes for children with empyema and compare incidence before and after PCV13. METHODS: Retrospective study of patients <18 years admitted to The Royal Children's Hospital Melbourne PICU with empyema between January 2016 and July 2019. We investigated the incidence of empyema during two time periods: 2007-2010 (pre-PCV13) and 2016-2019 (post-PCV13). RESULTS: Seventy-one children (1.9% of all PICU admissions) were admitted to PICU with empyema between 2016 and 2019. Sixty-one (86%) had unilateral disease, 11 (16%) presented with shock and 44 (62%) were ventilated. Streptococcus pneumoniae and group A Streptococcus were the most commonly identified pathogens. Forty-five (63%) were managed with video-assisted thoracoscopic surgery (VATS). There was a 31% reduction in empyema hospitalisations as a proportion of all hospitalisations (IRR 0.69, 95% CI 0.59-0.8), but a 2.8-fold increase in empyema PICU admissions as a proportion of all PICU admissions (95% CI 2.2-3.5, P < 0.001). For the PICU cohort, this was accompanied by reduction in PIM2 probability of death (median 1% vs. 1.9%, P = 0.02) and duration of intubation (median 69 h vs. 126.5 h, P = 0.045). CONCLUSIONS: In children with empyema in PICU 62% required ventilation, 16% had features of shock and 63% received VATS. Empyema admissions, as a proportion of all PICU admissions, increased in the era post-PCV13 compared to pre-PCV13 despite no increase in illness severity at admission.

Successful Treatment of a Severe Vision-Threatening Paradoxical Tuberculous Reaction with Infliximab: First Pediatric Use.

A 7-year-old girl with tuberculous (TB) meningitis developed optochiasmatic arachnoiditis, a vision-threatening paradoxical reaction, after starting TB treatment including adjunctive steroid therapy. She was treated with infliximab with complete recovery. This is the first report of the use of a tissue necrosis factor α inhibitor for the treatment of a severe paradoxical TB reaction in a child.

Antecedents to cardiac arrests in a teaching hospital intensive care unit.

BACKGROUND: In hospital cardiac arrests (CA) treated with cardio-pulmonary resuscitation (CPR) outside of the intensive care unit (ICU) have poor outcomes. Most are preceded by deranged vital signs. There are, however, limited studies assessing antecedents to CAs inside the ICU. OBJECTIVES: To study the antecedents to, and characteristics of CAs in ICU. STUDY POPULATION: We prospectively identified CA cases that occurred inside our ICU between January 2010 and July 2012. Controls were obtained by sequentially matching ICU patients based on APACHE III diagnosis, APACHE III score, age, gender and length of stay in ICU. RESULTS: Thirty-six patients had a CA during the study period (6.28/1000 admissions). In the 12h prior to CA, index patients had higher maximum (22 breaths/min vs. 18 breaths/min, p=0.001) and minimum respiratory rates (16 breaths/min vs. 12 breaths/min, p=0.031), a lower median mean arterial pressure (65 mmHg vs. 70 mmHg, p=0.029) and systolic blood pressure (97 mmHg vs. 106 mmHg, p=0.033), a higher central venous pressure (14 cm H2O vs. 11 cm H2O, p=0.008) and a lower bicarbonate level (20.5 mmol vs. 26 mmol, p=0.018) compared to controls. CA patients also had a higher maximum dose of noradrenaline (norepinephrine) (17.5 mcg/min vs. 8.0 mcg/min, p=0.052) but there was no difference in any other levels of intensive care support. Two-thirds of CA's occurred within the first 48 h of ICU admission. The initial monitored rhythm was non-shock responsive (pulseless electrical activity, bradycardia or asystole) in 26/36 (72%). Return of spontaneous circulation was achieved in 29/36 (80.6%) patients, with 16/36 (44.4%) surviving to hospital discharge. CONCLUSIONS: In the period leading up to the CA inside ICU, there were signs of physiological instability and the need for higher doses of noradrenaline. Return of spontaneous circulation was achieved in 80%. However, in-hospital mortality was greater than 50%.