Defining Pediatric Chronic Critical Illness: A Scoping Review.

OBJECTIVES: Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions. DATA SOURCES: Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021. STUDY SELECTION: We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening. DATA EXTRACTION: We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed. DATA SYNTHESIS: Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18). CONCLUSIONS: Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Assessing comfort level of organ donation competencies among pediatric intensivists in Saudi Arabia: a national survey.

BACKGROUND: As increasing the number of organ donations presents a global challenge, Saudi Arabia is no different. Intensivists can play a major role in maximizing the organ donation process and minimize the challenges. The purpose of this study was to investigate Saudi pediatric intensivists' comfort and importance levels of organ donation competencies. METHODS: We conducted a cross-sectional survey whose sampling frame included 100 pediatric intensivists. The pediatrician intensivists were identified through an updated list provided by the Saudi Critical Care Society. We assessed 14 competencies categorized into four domains: the general donation, donation after brain death (DBD), neurological determination of death, and medicolegal, religious, and ethical domains. Then we investigated the association between these competencies and physicians' characteristics. RESULTS: With a response rate of 76%, we found that 40-60% of the surveyed pediatric intensivists rated their comfort in 6 out of 14 competencies as high or very high. There was a statistically significant gap in the intensivists' rating of 10 competencies (i.e., high importance but low comfort levels). Ordinal regression showed that comfort levels with the general donation, neurological determination of death, and medicolegal, religious, and ethical domains were higher in intensivists who were frequently involved with DBD than those who had never been exposed. CONCLUSIONS: Pediatric intensivists expressed low comfort levels to organ donation competencies that are essential for maximizing donation rates. Adapting mandatory comprehensive donation education programs and dedicated physician specialists may be beneficial in critical care units aiming to increase donation rates.

Evaluation of antibiotic treatment decisions in pediatric intensive care units in Saudi Arabia: A national survey.

OBJECTIVE: To describe variables used by Saudi pediatric intensivists to make antibiotic-related decisions for children with suspected severe bacterial infections. METHODS: We conducted a cross-sectional survey, which was developed using a multi-step methodological approach. The survey included 4 clinical scenarios of the most relevant bacterial infections in pediatric critical care (pneumonia, sepsis, meningitis and intra-abdominal infection). The potential determinants of antibiotic treatment duration addressed in all scenarios included clinical variables (patient characteristics, disease severity), laboratory infection markers, radiologic findings, and pathogens. RESULTS: The response rate was 65% (55/85). Eight variables (immunodeficiency, 3 months of age, 2 or more organ dysfunctions, Pediatric Risk of Mortality III score >10, leukocytosis, elevated C-reactive protein [CRP], elevated erythrocyte sedimentation rate [ESR], and elevated procalcitonin [PCT]) were associated with prolonging antibiotic treatment duration for all 4 clinical scenarios, with a median increase ranging from 3.0 days (95% confidence interval [CI] 0.5, 3.5, leukocytosis) to 8.8 days (95% CI 5.5, 10.5, immunodeficiency). There were no variables that were consistently associated with shortening antibiotic duration across all scenarios. Lastly, the proportion of physicians who would continue antibiotics for ≥5 days despite a positive viral polymerase chain reaction test result was 67% for pneumonia, 85% for sepsis, 63% for meningitis, and 95% for intra-abdominal infections. CONCLUSION: Antibiotic-related decisions for critically ill patients are complex and depend on several factors. Saudi pediatric intensivists will use prolonged courses of antibiotics for younger patients, patients with severe clinical picture, and patients with persistently elevated laboratory markers and hospital acquired infections, even when current literature and guidelines do not suggest such practices. Antimicrobial stewardship programs should include interventions to address these misconceptions to ensure the rational use of antibiotics in pediatric intensive care units.

SARS-CoV-2 infection in children, clinical characteristics, diagnostic findings and therapeutic interventions at a tertiary care center in Riyadh, Saudi Arabia.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 was first identified in Wuhan, China. All ages are susceptible to SARS-CoV-2 infection. Few studies had reported milder course in children however, severe course of illness has been reported. We aimed to describe the clinical features of COVID-19 in pediatric patients including diagnostic findings and therapeutic interventions in sever disease manifestation. METHODS: We retrospectively reviewed 742 patients with SARS-CoV-2 proven infection at King Abdullah Specialist Children's Hospital, from April 2020 and July 2020. Inpatients, outpatient, including those with sever manifestation treated at the Intensive Care Unit (ICU) were included. We collected data including demographic data, comorbidities, symptoms, imaging data, laboratory findings, treatments and clinical outcomes of patients with COVID-19. RESULTS: Among of 742 patients, 71 (9.6%) were hospitalized. The median age of patients was 75 months old and 53.6 were male. A total of 461 (62.1%) had close contact with confirmed cases, 45 (6.1%) had no contact history, and 236 (31.8%) with unknown exposure risk. The most common symptoms at the onset of illness were fever (32.5%), respiratory symptoms (21%) and gastrointestinal symptoms (10.3%). Among the entire cohort, 7 patients were admitted to PICU with COVID-19 related symptoms, five patients diagnosed with MIS-C, one patient with Kawasaki, and one patient with pneumonia. All patients received supportive therapy, no antiviral treatment had been used however, in MIS-C patients IVIG had been given to all patients, five patients received Anakinra; and one patient received tocilizumab. CONCLUSIONS: In this study, children infected with SARS-CoV-2 are less likely to develop symptomatic or serious diseases. Among symptomatic children, the most common clinical features were fever and respiratory symptoms followed by gastrointestinal manifestations. The majority of infected children have reported contact with an infected individual. MIS-C associated with COVID-19 is a severe presentation of SARS-CoV-2 infection and of a major concern as an overlapping features with other diseases could happen, making the diagnosis challenging.

Association between platelet count and multiorgan dysfunction and outcomes in patients with sepsis in the pediatric intensive care unit in Saudi Arabia.

BACKGROUND: Sepsis is one of the leading causes of morbidity and mortality in the pediatric population worldwide. This study aimed to establish a correlation between platelet count and outcomes of severe sepsis/septic shock in pediatric patients. METHODS: This retrospective cohort study was conducted in the pediatric intensive care unit (PICU) in a pediatric tertiary care medical hospital. Pediatric patients from newborns to 14-year-olds with a diagnosis of sepsis or septic shock who were admitted to the PICU between April 2015 and February 2018 were enrolled. Patients were classified into two groups based on the presence of thrombocytopenia: thrombocytopenia group (TG) with a platelet count <150,000/µL during the first seven days after admission, and non-thrombocytopenia group (NTG) with a platelet count >150,000/µL. RESULTS: Overall, 206 children were enrolled, including 82 (39.8%) in the TG and 124 (60.2%) in the NTG. Thrombocytopenia was more common in patients with a negative bacterial blood culture (93.9%, P = 0.007). NTG was associated with a higher mortality rate (29%) than the TG (12.2%, P = 0.005). Multiorgan dysfunction syndrome (MODS) at the onset of sepsis (time zero) was found to be more prevalent in NTG than in TG (P = 0.001), while the progression of MODS over the three days remained the same in both groups. CONCLUSION: Thrombocytopenia was more associated with non-bacterial sepsis/septic shock, and it may indicate a better outcome of sepsis in pediatric patients.

Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study.

BACKGROUND: Inappropriate antibiotic utilization is associated with the emergence of antimicrobial resistance (AMR) and a decline in antibiotic susceptibility in many pathogenic organisms isolated in intensive care units. Antibiotic stewardship programs (ASPs) have been recommended as a strategy to reduce and delay the impact of AMR. A crucial step in ASPs is understanding antibiotic utilization practices and quantifying the problem of inappropriate antibiotic use to support a targeted solution. We aim to characterize antibiotic utilization and determine the appropriateness of antibiotic prescription in a tertiary care pediatric intensive care unit. METHODS: A retrospective cohort study was conducted at King Abdullah Specialized Children's Hospital, Riyadh, Saudi Arabia, over a 6-month period. Days of therapy (DOT) and DOT per 1000 patient-days were used as measures of antibiotic consumption. The appropriateness of antibiotic use was assessed by two independent pediatric infectious disease physicians based on the Centers for Disease Control and Prevention 12-step Campaign to prevent antimicrobial resistance among hospitalized children. RESULTS: During the study period, 497 patients were admitted to the PICU, accounting for 3009 patient-days. A total of 274 antibiotic courses were administered over 2553 antibiotic days. Forty-eight percent of antibiotic courses were found to be nonadherent to at least 1 CDC step. The top reasons were inappropriate antibiotic choice (empirical or definitive) and inappropriate prophylaxis durations. Cefazolin and vancomycin contributed to the highest percentage of inappropriate DOTs. CONCLUSIONS: Antibiotic consumption was high with significant inappropriate utilization. These data could inform decision-making in antimicrobial stewardship programs and strategies. The CDC steps provide a more objective tool and limit biases when assessing antibiotic appropriateness.

Association of Antibiotics Administration Timing With Mortality in Children With Sepsis in a Tertiary Care Hospital of a Developing Country.

Objective: To investigate the association between antibiotics administration timing with morbidity and mortality in children with severe sepsis and septic shock, presenting to a tertiary care center in a developing country. Methods: This is a retrospective study of children aged 14 years or younger diagnosed with severe sepsis or septic shock at a free-standing tertiary children's hospital in Saudi Arabia between April 2015 and February 2018. We investigated the association between antibiotic administration timing and pediatric intensive care unit (PICU) mortality, PICU length of stay (LOS), hospital LOS, and ventilation-free days after adjusting for confounders. Results: Among the 189 admissions, 77 patients were admitted with septic shock and 112 with severe sepsis. Overall, the mortality rate was 16.9%. The overall median time from sepsis recognition to antibiotic administration was 105 min (IQR: 65-185.5 min); for septic shock patients, it was 85 min (IQR: 55-148 min), and for severe sepsis, 130 min (IQR: 75.5-199 min). Delayed antibiotic administration (> 3 h) was associated with 3.85 times higher PICU mortality (95% confidence intervals 1.032-14.374) in children with septic shock than in children who receive antibiotics within 3 h, after controlling for severity of illness, age, comorbidities, and volume resuscitation. However, delayed antibiotics administration was not significantly associated with higher PICU mortality in children diagnosed with severe sepsis. Conclusions: Delayed antibiotics administration in children with septic shock admitted to a free-standing children's hospital in a developing country was associated with PICU mortality.

Association Between Culture-Negative Versus Culture-Positive Sepsis and Outcomes of Patients Admitted to the Pediatric Intensive Care Unit.

Background Sepsis remains a major cause of death, with high mortality and morbidity rates in children. The cause of mortality may be associated with several factors, including differences in cultures and the type of organism. This study was aimed at evaluating the characteristics and outcomes of negative bacterial blood culture compared to those of positive bacterial blood culture in children with severe sepsis/septic shock. Methods A retrospective cohort study was conducted at a pediatric intensive care unit (PICU) of a tertiary care medical center. All pediatric patients, from newborn to 14 years of age, admitted between April 2015 and January 2018 were included in the study if they fulfilled the criteria for severe sepsis/septic shock. Results Of the 209 patients, 30 (14.3%) had a positive bacterial blood culture whereas 179 (86.6%) had a negative bacterial blood culture. Mortality was more in positive bacterial blood culture 13 (43%) vs 35 (20%) in negative bacterial blood culture (P = 0.004). Respiratory tract infections were extremely common, present in 108 of 179 (60%) patients, and tended to result in a negative culture. The rate of organ dysfunction was higher in the positive bacterial blood culture group at admission (P = 0.01). However, the results did not reveal a significant finding related to multiorgan dysfunction syndrome (MODS) progression over three days of PICU admission (P = 0.06). Conclusion The negative bacterial blood culture constitutes a substantial proportion of pediatric patients with severe sepsis/septic shock. Furthermore, these pediatric patients have a lower mortality rate compared to positive bacterial blood cultures. The culture-negative sepsis group also had less organ dysfunction.

Hospital preparedness and management of pediatric population during COVID-19 outbreak.

With the recent pandemic of Coronavirus disease-2019 (COVID-19), there has been a higher number of reported cases in children more than to the prior Corona Virus-related diseases, namely, severe acute respiratory syndrome and the Middle East respiratory syndrome. The rate of COVID-19 in children is lower than adults; however, due to high transmission rate, the number of reported cases in children has been increasing. With the rising numbers among children, it is imperative to develop preparedness plans for the pediatric population at the hospital level, departmental level, and patient care areas. This paper summarizes important considerations for pediatric hospital preparedness at the hospital level that includes workforce, equipment, supply; capacity planning, and infection prevention strategies, it also span over the management of COVID-19 pediatric patients in high-risk areas such as critical care areas, Emergency Department and operative rooms.

The epidemiology of domestic violence in Saudi Arabia: a systematic review.

OBJECTIVES: The aim of this study is to review the prevalence, risk factors, and outcomes of domestic violence (DV) in Saudi Arabia. METHODS: Systematic review utilizing PRISMA guidelines conducted on articles focusing on research related to the epidemiology of domestic violence in Saudi Arabia between 2009 and 2017 were identified through electronic databases (PubMed and Embase) and supplemented by cross-referencing and local journal searches. RESULTS: Eleven studies were conducted in six cities (Riyadh, Jeddah, Madina, Taif, Arar, and Al-Ahsa). Several screening questionnaires were utilized; four studies used the WHO multi-country study questionnaire and found that the lifetime prevalence of DV ranged between 39.3 and 44.5%. The most frequently reported risk factors for DV were the level of education of both the victim and the spouse and alcohol or drug addiction of the spouse. CONCLUSIONS: One in every three women in Saudi Arabia is a victim of domestic violence. Strategies to reduce risk factors, prevent DV, care for victims, and mitigate the effects of DV must be adopted by health care agencies in Saudi Arabia.