Introduction

The APSA Surgical Critical Care Committee has identified the following articles to help identify best practices and appropriate standards for clinical management of pediatric surgical disease.

Articles

Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding [1]. Spinella PC, et al. Pediatr Crit Care Med. 2022 Apr 1;23(4):235-244. Epub 2022 Feb 28.

Blood product transfusion ratios have been a topic of research in adult and pediatric trauma as part of the concept of hemostatic resuscitation. Along with avoidance of crystalloids, hypothermia, hypocalcemia, and acidosis, balanced transfusion ratios of products has become a core tenet of caring for the bleeding patient. More recently, specific ratios of transfusion have been investigated with adult data suggesting higher plasma to RBC ratios yield improved survival. Little is known about transfusion ratios in children. Similarly, the concept of plasma or platelet deficits, defined as the volume of each component subtracted from the RBC volume, is understudied and may provide more insight into the quality of resuscitation.

This study raises important questions about both ratios and product deficits, as well as providing a common framework for future studies focusing on survival at early time points in life threatening hemorrhage. The Massive Transfusion in Children (MATIC), published in 2021, was a 24 center, international prospective, observational trial of pediatric patients with life threatening bleeding. Patients received at least 40 ml/kg in blood products over 6 hours with no more than 30 minutes between transfusions or were under massive transfusion protocol. This planned secondary analysis evaluated the impact of transfusion ratios and product deficits in traumatically injured patients. A high plasma:RBC ratio, defined as >1:2, was associated with greater 6 hour survival compared to low plasma:RBC ratio, but did not impact 24 hour and 28 day survival. Platelet:RBC ratio did not impact survival. Regarding deficits, both 6 and 24 hour mortality were increased in children with greater plasma deficits, while 24 hour mortality was increased with greater platelet deficits. Importantly, there was substantial overlap between high transfusion ratio groups, making it difficult to independently assess the impact. Additionally, the high plasma ratio group also had significantly higher rates of cryoprecipitate, factor VIIa, and tranexamic acid infusion.

Early Peritoneal Dialysis and Postoperative Outcomes in Infants After Pediatric Cardiac Surgery: A Systematic Review and Meta-Analysis [2]. Namachivayam SP, et al. Meta-Analysis. Pediatr Crit Care Med. 2022 Oct 1;23(10):793-800. Epub 2022 Jul 15.

Management of fluid overload in critically ill patients improves outcomes and is a central tenet in the care of post-operative patients. High-risk pediatric cardiac surgery has utilized early post-operative peritoneal dialysis to this end with promising results, with observational studies noting reductions in mechanical ventilator days, ICU days, and mortality. Proposed mechanisms include reduction in fluid overload, mitigation of acute kidney injury, and attenuation of inflammatory cascades by reducing cytokine burden.

In the systematic review, 5 studies were deemed suitable for meta-analysis for a total of 589 patients. Early initiation of peritoneal was associated with a mortality reduction, with an odds ratio of 0.43 (95% CI 0.23 – 0.80). All five studies showed that early peritoneal dialysis shortened the duration of mechanical ventilation, with a pooled mean difference of one day (95% CI –1.86 to –0.33). The pooled median difference in ICU length of stay was 2.46 fewer days (95% CI –3.57 to –1.35). The authors urge caution in broadly applying the studies given the small number and underlying heterogeneity of the studies, as well as the tendency of the studies to select high risk cardiac surgery patients with the bias that introduces.

The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the Age of Blood in Children in the PICU Trial [3]. Steffen KM, et al. Pediatr Crit Care Med. 2023 Feb 1;24(2):84-92. Epub 2023 Jan 20.

Restrictive transfusion practices have demonstrated safety in adult and pediatric populations. The Transfusion Requirements in the PICU (TRIPICU) study, published in 2007, showed a 44% reduction in transfusion without any difference in new or progressive multiple organ system dysfunction when using a restrictive transfusion threshold of a hemoglobin of 7 g/dL compared to a liberal strategy with a threshold of 9.5 g/dL or greater in hemodynamically stable children. Released in 2018, the Transfusion and Anemia Expertise Initiative (TAXI) summarized available evidence, recommending against transfusion above a hemoglobin of 7g/dL in hemodynamically normal children without cardiac disease.

The Age of Blood in Children in the PICU (ABC-PICU) trial was an international, blinded randomized controlled trial across 50 institutions primarily designed to analyze the impact of red blood cell age on the development of new or progressive multiple organ system dysfunction in critically ill children. In this secondary analysis, the authors analyze the impact of adhering to the TAXI guidelines. Noncompliant transfusions were common, occurring in 49% of patients. Groups were balanced for confounding variables, and there was no difference between them in new or progressive multiple organ system dysfunction, ICU mortality, or 28 day mortality. Patients receiving compliant transfusions had 1.7 more ICU-free days and $38,845 less in ICU costs per patient.

Health-Related Quality of Life Following Delirium in the PICU[4]. Dervan LA, et al. Pediatr Crit Care Med. 2022 Feb 1;23(2):118-128.

Delirium during the ICU stay is associated with decline in health-related quality of life from baseline to post-discharge follow-up among children assessed by the Pediatric Quality of Life Inventory, who were generally characterized by normal baseline cognitive function and less medical comorbidity. This association was not present among children assessed by the Functional Status II-R, potentially due to their higher overall risk of health-related quality of life decline, or other clinical differences that modify the effects of delirium in this group.

The authors of this studied the impact of delirium during pediatric critical illness and association with post-discharge health-related quality of life (HRQL). They performed a retrospective cohort study at an academic tertiary center of 534 patients aged 1 to 18. The Cornell Assessment of Pediatric Delirium was performed twice daily and a score >9 indicated delirium. Pre-admission and post- discharge HRQL were assessed by the Pediatric Quality of Life Inventory or the Functional Status II- R (for children with developmental disability). They found delirium was frequent, present in 44% of the study population as was clinically significant decrease in HRQL at greater than 6 weeks post discharge. The study found that ICU delirium is independently associated with a decline in HRQL among children without baseline cognitive impairment or medical complexity. The study found a greater decline in the psychosocial subscore than the physical sub-score of the Pediatric Quality of Life Inventory. The author’s recommendation is that patients and families of older children should be counseled about possible long term effects and considered for screening and referral to support services.

Delirium in Pediatric Critical Care [5]. Patel AK, et al. Pediatr Clin North Am. 2017 Oct;64(5):1117-1132.

Delirium is defined as acute cognitive dysfunction characterized by disturbance in attention, awareness, and cognition over a brief period that is frequently encountered in critically ill patients. It is found in the majority of adult ICU patients, and although temporary, it is associated with poor outcomes. The presence and associated morbidity in pediatric patients are less well understood but it is found in 20-25% of PICU patients and 50% of mechanically ventilated children. Pediatric delirium is also associated with increased morbidity, longer mechanical ventilation, and increased lengths of stay. Benzodiazepine use is associated with risk for development of pediatric delirium.

Delirium occurs frequently in the critically ill child. It is a syndrome characterized by an acute onset and fluctuating course, with behaviors that reflect a disturbance in awareness and cognition. Delirium represents global cerebral dysfunction due to the direct physiologic effects of an underlying medical illness or its treatment. Pediatric delirium is strongly associated with poor outcomes, including increased mortality, prolonged intensive care unit length of stay, longer time on mechanical ventilation, and increased cost of care. With heightened awareness, the pediatric intensivist can detect, treat, and prevent delirium in at-risk children.

Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia Expertise Initiative – Control/Avoidance of Bleeding (TAXI-CAB) [6]. Nellis ME, et al. Pediatr Crit Care Med. 2022 Jan 1;23(1):34-51.

Plasma and platelet transfusion are frequently administered to critically ill children. They are commonly employed for the management of bleeding or as prophylaxis to decrease the risk of bleeding in the setting of coagulopathy or altered hemostasis. In general, practice patterns for plasma and platelet transfusions vary widely across institutions and are associated with adverse outcomes. The purpose of the TAXI-CAB initiative is to develop evidence-based best practice recommendations for plasma and platelet transfusions with the goals of decreasing variability.

The TAXI-CAB collaborative included experts from intensive care, cardiac intensive care, pediatric surgery, congenital heart surgery, anesthesia, emergency medicine, hematology/oncology, neurosurgery, and transfusion medicine. A systematic literature review using GRADE methodology was used to develop evidence-based practice recommendations; good practice and expert consensus recommendations were also developed when needed to address clinical questions where evidence was lacking or of poor quality. Recommendations are provided for subpopulations including 1) severe trauma, intracranial hemorrhage, and traumatic brain injury 2) cardiac surgery 3) extracorporeal life support (ECLS) 4) oncology and stem cell transplant 5) acute liver failure and liver transplantation 6) noncardiac surgery 7) invasive procedures 8) sepsis. Pediatric surgeons are frequently involved in the care of these critically ill children and this manuscript may serve as a succinct reference that facilitate discussion with the critical care team regarding indications, risks, and benefits of plasma and platelet transfusions. With regards to pediatric trauma patients, the recommendations favor a balanced hemostatic resuscitation potentially augmented with a goal directed hemostatic resuscitation strategy using viscoelastic monitoring. With regards to children receiving ECLS, prophylactic platelet transfusion in the absence of clinically significant bleeding is unlikely to be beneficial if the platelet count if over 100k/mm3. Recommendation highlights for transfusion following noncardiac surgery include: not obtaining routine coagulation tests in the absence of bleeding, avoiding routine prophylactic transfusions based solely on abnormal coagulation studies without further evaluation, and considering transfusion when the platelet count is less than 20k/mm3 in the setting of mild or no bleeding and less than 50k/mm3 in the setting of moderate bleeding.

Life-Threatening Bleeding in Children: A Prospective Observational Study [7]. Leonard JC, et al. CCM Journal. 2021 Nov 1; 49(11):1943-1954.

Damage control resuscitation strategies have evolved over the past decade. Implementation of massive transfusion protocols (MTP) have helped bring the knowledge gained in military and civilian trauma to the management of hemorrhage in children. In pediatrics, physician discretion appears to be the main driving force behind MTP initiation. Unfortunately, high quality, prospective data in children regarding the etiology of hemorrhage, use of MTP, and patient outcomes is lacking.

This is a prospective, observational study across 24 tertiary children’s hospitals over 4 years. Patients were enrolled if they received more than 40mL per kg of total blood products over 6 hours or if MTP was activated. Patient demographics, injury/illness factors including etiology of bleeding, and mortality were collected on each patient. There were several important findings that leave room for further improvement and future study. Despite MTP activation, there was a significant delay in receiving plasma and platelets, and many children did not receive them at all. In trauma patients especially, high volume crystalloid administration was noted, despite evidence that this is suboptimal in this population. Children who died from hemorrhage typically did so within the first 6-24 hours. While trauma was the most common cause of bleeding, medical bleeding and surgical bleeding was included in this cohort as well. Patients with medical bleeding had more severe comorbidities, and those with surgical bleeding tended to be younger. Future studies from this group plan to correlate these variations with outcomes, but causality will be difficult to ascertain based on the current data.

A Communication Guide for Pediatric Extracorporeal Membrane Oxygenation [8]. Moynihan, KM, et al. Pediatric Critical Care Medicine, 2021-05-17, Vol.22 (9), p.832-841.

It is challenging to communicate with families and multidisciplinary teams regarding extracorporeal life support (ECLS) initiation and decannulation, especially in situations where a patient is unlikely to survive or may have a poor neurodevelopmental outcome. Ethical dilemmas are common during an ECLS and navigating these with families can be challenging. Structured communication guides can be helpful in standardizing these discussions.

This article proposes a framework for discussing the nuanced complexities regarding the indications, risks, benefits of ECLS. It emphasizes ECLS as a bridge and temporary support in the path toward specific goals and not a treatment for any specific condition. On Day 0, the initial discussion focuses on the delivery of “serious news,” conveying the severity of the child’s condition and the possibility of death. Treatment goals are established, and when time allows, members of the team and function of the circuit are introduced. On day 1, the clinician expands on the cannulation day discussion and each day or every few days after that, iterative conversations take place which continue to help families comprehend the situation. At the decannulation point, there is a branch point into one of three discussions – (1) decannulation when death is anticipated, (2) decannulation where survival is possible, and (3) decannulation where survival is anticipated. In the situations in which end-of-life is anticipated or possible, it is helpful to reiterate the temporary support aspect of ECLS and give families a predefined time to say goodbye. Decisions should be made collaboratively, and communication should remain transparent throughout. Defining ECLS, providing anticipatory guidance and evaluating family’s goals are core concepts in this helpful review.

Use of Antifibrinolytics in Pediatric Life-Threatening Hemorrhage: A Prospective Observational Multicenter Study [9]. Spinella PC, et al. Crit Care Med 2021 Oct 18;epub.

There is a lack of high-quality outcomes data in pediatric patients with life-threatening bleeding. As a result, the majority of pediatric resuscitation guidelines are derived from adult data despite pediatric differences in coagulation and physiologic response to bleeding. Recently, adult data has shown reduced mortality in bleeding patients who receive antifibrinolytics such as tranexamic acid or epsilon aminocaproic acid. These medications work by inhibiting the conversion of plasminogen to plasmin and can also directly inhibit plasmin. The potential benefit in the pediatric life-threatening bleeding population is unknown.

This study is a secondary analysis of the Massive Transfusion epidemiology and outcomes In Children study, a prospective, observational study of children with life-threatening bleeding (traumatic, operative or medical) at 24 medical centers in the U.S., Canada and Italy. Outcomes were compared based on receipt or not of antifibrinolytic medication. In the adjusted analysis, the anti-fibrinolytic group had significantly lower 6-hour and 24-hour mortality compared to the non-fibrinolytic group. There was no difference between the groups regarding 28-day survival. Thus, early administration of anti-fibrinolytics, within 1-2 hours from the initiation of life-threatening hemorrhage, should be considered in pediatric bleeding resuscitation.

Optimal Timing of Tracheostomy in Injured Adolescents [10]. Butler EK, et al. Pediatr Crit Care Med 2021 July;22(7):629-41.

In adults, early tracheostomy after trauma is associated with reduced ventilator time, ICU days, and hospital days as well as a lower incidence of ventilator-associated pneumonia. On the other hand, in injured children, there is a paucity of data regarding the optimal timing of tracheostomy and its effect on outcomes. The pediatric literature also does not answer the question of whether a tracheostomy has more beneficial outcomes compared to prolonged intubation.

This study used the ACS National Trauma Data Bank to evaluate adolescents between 2007-2016 who were intubated for at least 24 hours. Traumatic brain injury (TBI) vs. non-TBI populations were compared. In regards to optimal timing of tracheostomy, TBI patients who had a tracheostomy placed prior to 3 days vs. after had 7.5 fewer ICU days and 8.7 fewer hospital days. They also had a significantly lower risk of pneumonia. Compared to intubated patients, TBI patients with a tracheostomy placed between 3-7 days had fewer ICU days and hospital days, though no difference in risk of pneumonia. In non-TBI patients, a tracheostomy placed prior to 3 days vs. after had even fewer ICU and hospital days (13.8 and 13.5 days, accordingly) and continued to have a significantly lower risk of pneumonia. Compared to intubated patients, non-TBI patients with a tracheostomy placed earlier, at less than 3 days, had barely fewer ICU days, but not hospital days, as well as a significantly lower risk of pneumonia. In conclusion, pediatric trauma patients with or without TBI may benefit from a tracheostomy if the need for mechanical ventilation is anticipated beyond 7 days. Prospective studies are needed to further validate this.

Switching to Centrifugal Pumps May Decrease Hemolysis Rates Among Pediatric ECMO Patients [11], Johnson et al, Perfusion 2021 Jan 18.

Most pediatric extracorporeal life support (ECLS) centers have transitioned to centrifugal pumps. However, a number of studies have shown increased rates of hemolysis with centrifugal pumps compared to roller pumps for the neonatal and pediatric age groups. Johnson et al. compared rates of hemolysis between centrifugal and roller pumps. From 2005 to 2017 they treated 590 neonates and pediatric patients with ECLS. The overall hemolysis rate was 27% as defined by a plasma-free hemoglobin of greater than 50mg/dL. They identified the use of roller pumps (OR 2.24, 95% CI 1.53-3.27), neonatal age (1.60, 95% 1.10-1.32), and duration of ECLS (1.002, 95% CI 1.00-1.01) as risk factors for hemolysis. In addition, in-hospital mortality was greater in patients that had hemolysis (OR 3.11, 95% 2.13-4.54). Lastly, the authors observed that after 2011, when the transition occurred from roller to centrifugal pumps, hemolysis rates progressively decreased at their center. They also noted that during the study periods their anticoagulation methods were consistent. These data, therefore, suggest that transitioning to centrifugal pumps can be done safely in the pediatric population.

Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation [12], Hamzah et al Pediatr Crit Care Med 2020 Sept; 21(9): 827-834.

Heparin is the universal anticoagulant for patients supported on extracorporeal life support. Heparin has some advantages but also has inherent limitations. These limitations include that heparin requires the cofactor antithrombin III for efficacy, causes platelet activation and dysfunction, inhibits free thrombin only, and does not affect clot-bound thrombin. In addition, heparin is highly antigenic and may trigger an immune-mediated response, HIT. Bivalirudin binds directly to thrombin (no need for antithrombin III) and inhibits both free-and clot-bound thrombin. Bivalirudin is being used by more ECMO centers for anticoagulation.
The study demonstrates that both heparin and bivalirudin systemic anticoagulation results in similar recovery and ECMO decannulation results. But the study demonstrates several advantages to bivalirudin anticoagulation. These include a shorter time to reach therapeutic anticoagulation levels, fewer bleeding events, and fewer blood product transfusions. They also demonstrated no difference in thrombotic events between both heparin and bivalirudin. Bivalirudin is known to be more expensive than heparin but when reviewing the comprehensive cost analysis of the medication, blood draws, transfusions, and all related costs, bivalirudin anticoagulation therapy is significantly less than heparin. Bivalirudin is a safe and potentially superior alternative to heparin anticoagulation therapy in pediatric ECMO.

Lung ultrasound completely replaced chest X-ray for diagnosing neonatal lung diseases: a 3-year clinical practice report from a neonatal intensive care unit in China [13], Gao et al J Matern Fetal Neonatal Med 2020 Oct;1–9.

The current use of lung ultrasound to diagnosis of neonatal lung disease is becoming more common. Lung ultrasound has been shown to have higher accuracy and reliability than traditional chest radiograph (CXR) in diagnosing neonatal lung disease.

This study demonstrates that lung ultrasound could completely replace CXR for the diagnosis and differential diagnosis of neonatal lung disease. This single institution completely replaced CXRs in their neonatal intensive care unit with lung ultrasound and reported their three-year clinical practice experience. In the study, the authors demonstrated that CXRs often lead to misdiagnosis (greater than 20%) and missed diagnosis (greater than five percent). The authors also note that up to 36% of bronchopulmonary dysplasia cases diagnosed by traditional criteria are incorrect and lung ultrasound more accurately diagnoses the presence of other lung pathological changes. These include atelectasis, pneumonia, severe pulmonary edema and pulmonary edema with focal lung consolidation. With the improved accuracy of neonatal lung disease, their NICU was able more accurately treat the neonates and thereby minimize or completely resolve their oxygen needs. The authors report no bronchopulmonary dysplasia in 931 preterm infants treated in their NICU. Lung ultrasound should be considered in our management of neonates and has the potential to decrease radiation exposure while improving our diagnosis of neonatal lung diseases.

Dexmedetomidine Sedation in Mechanically Ventilated Critically Ill Children: A Pilot Randomized Controlled Trial [14], Erickson et al Pediatr Crit Care Med 2020 Sept; 21(9): e731-e739.

Optimal sedation is an integral component in treating critically ill children and provides anxiolysis, amnesia and facilitates mechanical ventilation. However, there is no universally accepted approach (lack of quality evidence) to the sedation of mechanically ventilated children. Over sedation may result in prolonged mechanical ventilation, delirium and drug tolerance and withdrawal; while under sedation may lead to loss or displacement of intravenous access and drains, unplanned extubation and emotional distress. Midazolam is still widely used as a primary sedative in children but has been linked to neurotoxicity, delirium and significant drug withdrawal. Dexmedetomidine, a selective α2-adrenoreceptor agonist, provides sedation, anxiolysis and analgesia and has not been linked to neurotoxicity.

The Baby SPICE Investigators and the Australian and New Zealand Intensive Care Society Paediatric Study Group (ANZICS-PSG) demonstrate that a sedation protocol using dexmedetomidine as the primary sedative was feasible, appeared safe, achieved early, light sedation and reduced midazolam requirements. The dexmetomidine group achieved the goal of light sedation quicker in the first 24 hours and maintained that goal over the first 48 hours significantly more often than usual care arm. Cumulative midazolam dosage was significantly reduced in the dexmedetomidine arm. There were more episodes of hypotension and bradycardia with dexmedetomidine but no difference in vasopressor requirements. In light of growing concerns with long term effects of our usual sedation practices this study demonstrates the safety of the alternative sedation strategies with dexmedetomidine.

Bacterial and Fungal Etiology of Sepsis in Children in the United States: Reconsidering Empiric Therapy [15], Prout et al Crit Care Med 2019 Nov 27

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity [16], Nellis et al Crit Care Med 2019 Dec;47(12)1766-1772

Effect of Gastric Residual Evaluation on Enteral Intake in Extremely Preterm Infants: A Randomized Clinical Trial [17], Parker et al JAMA Pediatr 2019 Jun 1;173(6):534-543.

This was a single center randomized clinical trial comparing the omission of gastric residual evaluation with prefeed gastric residual evaluation. The authors found that among extremely preterm infants, the omission of gastric residual evaluation increased the delivery of enteral nutrition as well as improved weight gain, especially at week five and six after birth and led to earlier hospital discharge. When controlled for gestational age, infants in the no residual group were discharged on average eight days earlier. In addition, the no residual group was not found to have an increased incidence of necrotizing enterocolitis or ventilator associated pneumonia.

gastric residuals

Visual abstract courtesy of David Darcy

Mortality of Critically Ill Children Requiring Continuous Renal Replacement Therapy: Effect of Fluid Overload, Underlying Disease, and Timing of Initiation [18], Cortina et al Pediatr Crit Care Med 2019 Apr;20(4):314-322.

Extracorporeal Cardiopulmonary Resuscitation: One-Year Survival and Neurobehavioral Outcome Among Infants and Children With In-Hospital Cardiac Arrest [19], Meert et al Crit Care Med 2019 Mar;47(3):393-402.

Neurologic Outcomes After Extracorporeal Membrane Oxygenation: A Systematic Review [20], Boyle et al Pediatr Crit Care Med 2018 Aug;19(8):760-766.

A wide range of disabilities were identified on a systematic review of neurologic outcomes after extracorporeal life support in children including behavior problems (16 to 46%) and severe motor impairment (12%). The quality of life, evaluated at school age or adolescence, was more than one standard deviation below the population mean at their respective groups. The study highlights a need for consistent, long term follow-up in pediatric patients after ECMO and counseling of expectations for parents and families.

neurologic outcome after ECMO

Visual abstract courtesy of Francois Luks

The Rate of PD Catheter Complication does not Increase with Simultaneous Abdominal Surgery [21], Miyata J Pediatr Surg 2018 Aug;53(8):1499-1503.

Cardiac Index Changes With Fluid Bolus Therapy in Children With Sepsis – An Observational Study [22], Long Pediatr Crit Care Med. 2018 Jun;19(6):513-518.

Short-term Neurodevelopmental Outcome in Congenital Diaphragmatic Hernia: The Impact of Extracorporeal Membrane Oxygenation and Timing of Repair [23], Danzer et al Pediatr Crit Care Med 2018 Jan;19(1):64-74.

This retrospective study assessed neurodevelopmental outcomes at a median age of 22 months. The authors found that the need for extracorporeal membrane oxygenation in patients with congenital diaphragmatic hernias is associated with worse neurocognitive and neuromotor outcomes. They also found that the need for congenital diaphragmatic hernia repair while on extracorporeal support is associated with worse cognitive and motor scores. Twenty percent of congenital diaphragmatic hernia survivors repaired on extracorporeal membrane oxygenation (ECMO) support scored within the average range for all composite domains. Based on this analysis it may be that children who can be successfully weaned off ECMO support and undergo a delayed CDH repair have improved outcomes with decreased mortality and neurodevelopmental sequelae.

Initiating Nutritional Support Before 72 Hours is Associated with Favorable Outcome After Severe Traumatic Brain Injury in Children: A Secondary Analysis of a Randomized, Controlled Trial of Therapeutic Hypothermia [24], Meinert et al. Pediatr Crit Care Med 2018 Apr;19(4):345-352.

Renal Replacement Therapy in the Critically Ill Child [25], Westrope et al Pediatr Crit Care Med 2018 Mar;19(3):210-217.

Vascular Access in Critically Ill Pediatric Patients With Obesity [26], Halvorson et al Pediatr Crit Care Med 2018 Jan;19(1):1-8.

Are children with obesity more likely to require vascular device insertion and do they develop more complications associated with that access?
120,272 patients were admitted to the pediatric intensive care unit (PICU) in 94 United States hospitals. 73,964 vascular devices were placed in 45,409 patients (38% of total cohort). Placement of vascular access devices decreased with increasing body mass index (BMI). Overall, there were more device complications associated with class 3 obesity and more mechanical and bleeding complications associated with all classes of obesity.
Vascular access devices may be more difficult to place in obese patients and may be one of the contributing factors to the reduced number of devices. Patients with obesity, especially those in increased BMI categories, although less likely to have a more permanent device placed, were more likely to keep those devices in place upon discharge. This may be due to concerns about being able to regain access should the patient return to the PICU. Obese patients may also have had increased complications because their total device time was also longer.

Cannulating the contraindicated: effect of low birth weight on mortality in neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation [27], Delaplain et al J Pediatr Surg. 2017 Dec;52(12):2018-2025.

Do infants with CDH requiring ECMO with either a birth weight (BW) of less than 2 kg or a gestational age at birth of less than 34 weeks have an increased risk of death?
In the ELSO registry between 1988 and 2015, 7564 neonates with CDH were treated with ECMO, 100 of which had a BW less than 2 kg. Patients with birth weight less than 2 kg had an increased risk of death but did not have an increased risk of neurologic complications. However, those patients with gestational age at birth of less than 34 weeks did have an increased risk of neurologic complications.
Birth weight of less than 2 kg and a gestational age of less than 34 weeks are typically listed as cutoffs for use of ECMO in the management of CDH. This study suggests that given improved strategies for anticoagulation and ventilator management, ECMO may be safe to offer in this population, however it may lead to increased neurologic complications. Additionally, long term neurodevelopmental outcomes were not evaluated.

Dexmedetomidine for Sedation During Noninvasive Ventilation in Pediatric Patients [28], Venkatraman et al Pediatr Crit Care Med 2017 Sep;18(9):831-837.

Over the past 10 years the use of dexmedetomidine has become progressively more widespread. In many centers it is now routinely used as the first line agent for sedation in the pediatric intensive care unit. In addition, because of its safety profile when it comes to hypotension and respiratory depression, many have begun to use dexmedetomidine with weaning protocols, postextubation and with noninvasive ventilation. However, very little data has been collected and published in children for these uses.

This study is a single center retrospective report collecting data on the use of dexmedetomidine, specifically in children while receiving noninvasive ventilation. The results demonstrate a reasonable safety profile and to some extent validates a practice that is an evolving trend in many institutions.

The American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock: Executive Summary [29], Davis et al Pediatr Crit Care Med 2017; Sep;18(9):884-890.

Guidelines for the care of septic shock in pediatrics were developed in 2002, updated in 2007 and have become standards throughout the country. The American College of Critical Care Medicine has now finalized the next update and provided an executive summary of the key points of these guidelines. The new recommendations advocate hospital specific guidelines that address three key issues: recognition of sepsis, resuscitation and stabilization and performance. Practical examples of potential bundles to address each of these issues are provided in the summary.

Functional Outcome After Intracranial Pressure Monitoring for Children With Severe Traumatic Brain Injury [30], Bennett et al JAMA Pediatr 2017 Oct 1;171(10):965-971.

The widespread use of intracranial pressure (ICP) monitors for severe traumatic brain injury in children has been a passionately debated topic over the past several years with conflicting expert opinion and low likelihood of a true randomized controlled trial to settle the questions. This study collected data from two large national databases and used sophisticated statistical analysis on cohorts of patients to look at outcome measures with and without the use of ICP monitoring. They concluded there was no association between ICP monitor use and functional survival.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition [31], Mehta et al Pediatr Crit Care Med 2017 Jul;18(7):675-715.

Neurodevelopmental outcomes in infants undergoing general anesthesia [32], Nestor et al J Pediatr Surg. 2017 Jun;52(6):895-900.

Centrifugal pumps and hemolysis in pediatric extracorporeal membrane oxygenation (ECMO) patients: An analysis of Extracorporeal Life Support Organization (ELSO) registry data [33], O’Brien et al
J Pediatr Surg 2017 Jun;52(6):975-978.

Comparative Effectiveness of Nonsteroidal Anti-inflammatory Drug Treatment vs No Treatment for Patent Ductus Arteriosus in Preterm Infants [34], Slaughter et al JAMA Pediatr 2017 Mar 6;171(3):e164354.

Pulmonary Hypertension Therapy and a Systematic Review of Efficacy and Safety of PDE-5 Inhibitors [35], Unegbu et al Pediatrics 2017 Mar;139(3).

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children [36], Moler et al N Engl J Med 2017 Jan 26;376(4):318-329.

Effect of Inhaled Nitric Oxide on Outcomes in Children with Acute Lung Injury: Propensity Matched Analysis From a Linked Database [37], Gupta et al Crit Care Med 2016 Oct; 44(10): 1901-9.

Epidemiology of Acute Kidney Injury in Critically Ill Children and Young Adults [38], Kaddourah et al N Engl J Med. 2017 Jan;376(1):11-20.

New Medical and Surgical Insights into Neonatal Necrotizing Enterocolitis: A Review [39], Frost et al JAMA Pediatr 2017 Jan; 171(1): 83-88.

Impact of Weight Extremes on Clinical Outcomes in Pediatric Acute Respiratory Distress Syndrome [40], Ward et al Crit Care Med 2016 Nov;44(11):2052-2059.

Prediction of Catheter-Associated Thrombosis in Critically Ill Children [41], Marquez et al Pediatr Crit Care Med 2016 Sep 22.

Persistent Challenges in Pediatric Pulmonary Hypertension [42], Hopper et al Chest 2016 Jul;150(1):226-36.

High-Dose Erythropoietin and Hypothermia for Hypoxic-Ischemic Encephalopathy: A Phase II Trial [43], Wu et al Pediatrics. 2016 Jun;137(6).

Evaluation of the “Early” Use of Albumin in Children with Extensive Burns: A Randomized Controlled Trial [44], Müller Dittrich et al Pediatr Crit Care Med 2016 Jun;17(6):e280-6.

Recommendations for the Use of Inhaled Nitric Oxide Therapy in Premature Newborns with Severe Pulmonary Hypertension [45], Kinsella et al J Pediatr 2016 Mar;170:312-4.

New Modes in Non-invasive Ventilation [46], Rabec C, et al Paediatr Respir Rev 2016 Mar;18:73-84.

Obesity and Mortality Risk in Critically Ill Children [47], Ross et al Pediatrics 2016 Mar;137(3):1-8.

Mortality Among Injured Children Treated at Different Trauma Center Types [48], Sathya et al JAMA Surg 2015 Sep;150(9):874-81.

Maintenance Intravenous Fluids in Acutely Ill Patients [49], Moritz et al N Engl J Med. 2016 Jan 21;374(3):290-1.

Ventilatory support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference [50], Rimensberger et al Pediatr Crit Care Med 2015 Jun;16(5 Suppl 1):S51-60.

References