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

Pediatric Neck Vessel Repair Following Extracorporeal Membrane Oxygenation Decannulation: Assessing Stroke Risk, Long-Term Neurologic Outcomes, and Vessel Patency. [1] Cain-Trivette et al. ASAIO J. 2025 Oct 15. PMID 41088517 AND Follow-Up Brain MRI After Carotid Reconstruction or Ligation in Neonatal Venoarterial Extracorporeal Membrane Oxygenation: Single-Center Retrospective Cohort, 2009 – 2022. [2] Okochi et al. Pediatr Crit Care Med. 2026 Feb 1;27(2):126-136. PMID 41307464

There is no consensus about the management of cervical vessels at the time of decannulation among children on VA-ECMO. While pediatric surgeons routinely ligate both the carotid artery and internal jugular vein, congenital cardiac surgeons typically reconstruct one or both vessels. Reconstruction is more time-consuming, technically difficult, and can theoretically increase the risk of hemorrhage and/or reperfusion injury to the brain. However, it allows for future re-cannulation if needed. Several studies have attempted to compare short-term risks and long-term outcomes between the two approaches, but controversy still exists.

Both authors conducted single-center retrospective cohort studies of children cannulated via cervical approach onto VA-ECMO. Cain-Trivette et al included all children under the age of 18 and stratified indications for cannulation broadly into cardiac, respiratory, and ECPR. The primary outcome was radiographic signs of neurologic injury post-decannulation on CT or MRI. Okochi at el focused on neonates and excluded congenital cardiac diseases and durations longer than 10 days because they did not offer reconstruction after that time. The primary outcome was brain injury identified only on MRI. Both studies reported no association between radiographic brain injury and decannulation strategy and concluded that it was safe to ligate the carotid artery at the time of decannulation.

Favorable Vessel Patency Following Carotid Artery Reconstruction During Extracorporeal Membrane Oxygenation Decannulation in Children with Congenital Heart Disease. [3] Chau et al. World J Pediatr Congenit Heart Surg. 2025 Nov;16(6):810-816. PMID 40405763

There is no consensus about the management of cervical vessels at the time of decannulation among children on VA-ECMO. While pediatric surgeons routinely ligate both the carotid artery and internal jugular vein, congenital cardiac surgeons typically reconstruct one or both vessels. Reconstruction is more time-consuming, technically difficult, and can theoretically increase the risk of hemorrhage and/or reperfusion injury to the brain. However, it allows for future re-cannulation if needed. Several studies have attempted to compare short-term risks and long-term outcomes between the two approaches, but controversy still exists.

The authors conducted a single-center retrospective review of children with congenital cardiac disease under the age of 21 who were cannulated for VA-ECMO via cervical approach from 2015 to 2022. Children were included if they had their carotid artery reconstructed and survived to discharge. The primary outcome was carotid artery patency on follow-up ultrasound or CT. The authors reported an 84% patency rate and concluded that reconstruction demonstrated favorable early patency rates although long-term neurologic outcomes when compared to carotid artery ligation remained unclear.

Percutaneous Pigtail Catheter versus Chest Tube for the Treatment of Pediatric Traumatic Hemothorax: An Eastern Association for the Surgery of Trauma Multicenter Study. [4] Goodman LF et al., J Trauma Acute Care Surg. 2025 Dec 1;99(6):850-858. Epub 2025 Sep 15. PMID: 40956282.

Current recommendations in pediatrics direct providers to large bore chest tubes (CT) for the evacuation of traumatic hemothorax in children. These recommendations have changed in adults where small percutaneously placed pigtail catheters (PC) are now considered safe and effective when compared to CT. This change in practice recommendation by the Eastern Association for the Surgery of Trauma was directed by both retrospective and randomized control data. Prior to this study there have not been studies published comparing these treatments in the pediatric trauma population.

The authors conducted a retrospective cohort study of hemodynamically stable pediatric trauma patients (age less than 18) with hemothorax or hemopneumothorax. The study included 41 trauma centers from 2010 to 2022 with 548 patients after exclusion criteria were applied (CT n=477 and PC n=71). They defined failure of the catheter by requirement for surgery, additional tube placement, or thrombolytics. They report that the “failure rate was similar between CT versus PC (17.6% vs. 12.6%, p = 0.38).” They concluded there was no difference in the risk of failure between PC and CT and found no difference in complications after adjustment for confounders.

Risk factors for deep venous thrombosis in pediatric trauma patients: A review of the National Trauma Data Bank from 2017 to 2022. [5] Griffard J et al., J Trauma Acute Care Surg. 2025 Oct 1;99(4):533-540. Epub 2025 Jul 3. PMID: 40604362.

Pediatric trauma patients often do not receive venous thromboembolism (VTE) prophylaxis. The risk of VTE may be higher in certain subgroups including lower extremity orthopedic injuries, traumatic brain injuries, and those with more severe injury. There have been multiple studies of deep vein thrombosis (DVT) after trauma in pediatric populations and the “Eastern Association for the Surgery of Trauma conditionally recommends pharmacologic and mechanical VTE prophylaxis in patients older than 15 years and post pubertal patients with ISS greater than 25.”

The authors conducted a retrospective cohort study of the National Trauma Data Bank from 2017 to 2022 on patients less than 17 years old. Patients with DVT were compared to those in the cohort without DVT. The cohort included 693,729 patients total and 786 (0.11%) had a DVT. Based on the adjusted analysis the authors recommend “expanding the current guidelines to include age 13 years or older, higher AIS (Abbreviated Injury Scale) scores for head and lower extremities, pRBC transfusion within 4 hours of admission, and ISS (Injury Severity Score) of >15.” These recommendations could lead to a broadening of current EAST guidelines for pediatric VTE prophylaxis.

Epinephrine vs Norepinephrine as Initial Treatment in Children with Septic Shock. [6] Eisenberg MA et al., JAMA Netw Open. 2025 Apr 1;8(4):e254720. PMID: 40214988.

Sepsis remains a leading cause of morbidity and mortality among children worldwide, with refractory septic shock contributing significantly to pediatric sepsis deaths. Once fluid resuscitation fails to reverse shock, vasoactive agents are required to restore blood pressure and perfusion. Historically, dopamine was recommended as the initial vasoactive agent in pediatric septic shock until studies showed epinephrine was superior to dopamine. Revised guidelines subsequently endorsed either epinephrine or norepinephrine as first-line agents, but no direct head-to-head comparisons of epinephrine versus norepinephrine had been conducted in children. As a result, there has been wide variation in clinical practice, with some clinicians favoring epinephrine and others norepinephrine, while adult guidelines recommend norepinephrine as the first-line agent. This lack of pediatric-specific comparative data has left uncertainty about which agent is more effective or safer for initial treatment in pediatric septic shock without cardiac dysfunction.

This retrospective, propensity-matched cohort study used data from 231 children with septic shock without known cardiac dysfunction treated at a large quaternary pediatric hospital. It directly compared outcomes in patients who received epinephrine (n=147) versus norepinephrine (n=84) as the first vasoactive agent. The study found no significant difference in the primary outcome of major adverse kidney events within 30 days between the two groups. There was also no difference in the 3-day mortality or the need for extracorporeal membrane oxygenation; however, the 30-day mortality was higher in the epinephrine group (3.7% vs. 0%), suggesting norepinephrine may be associated with improved survival. These findings challenge current practice patterns and suggest that norepinephrine may offer a mortality benefit compared to epinephrine as the initial vasoactive therapy in pediatric septic shock, underscoring the need for prospective trials to confirm these results and inform future guidelines.

Prospective Randomized Pilot Study Comparing Bivalirudin Versus Heparin in Neonatal and Pediatric Extracorporeal Membrane Oxygenation. [7] McMichael A et al., Pediatr Crit Care Med. 2025 Jan 1;26(1):e86-e94. Epub 2024 Nov 25. PMID: 39585174

Unfractionated heparin has historically been the standard anticoagulant used in neonatal and pediatric extracorporeal membrane oxygenation (ECMO) due to familiarity and availability. However, heparin use is associated with limitations including variable pharmacokinetics in children, dependence on antithrombin for effectiveness, risk of heparin resistance, and complications such as bleeding or thrombosis, which contribute significantly to morbidity and mortality in pediatric ECMO. Bivalirudin, a direct thrombin inhibitor, has emerged as a potential alternative with theoretical advantages such as more predictable pharmacokinetics, direct inhibition of both free and clot-bound thrombin, and lower immunogenicity. Retrospective and observational studies suggested possible benefits of bivalirudin in reducing bleeding complications, but no prospective randomized trials had compared bivalirudin to heparin in children on ECMO, leaving uncertainty about the feasibility and safety of bivalirudin as a primary anticoagulant in this setting.

This single-center, open-label, prospective randomized pilot trial enrolled 30 pediatric patients supported with ECMO between 2018 and 2021 to evaluate the feasibility of using bivalirudin compared to heparin for anticoagulation. Patients were randomized to receive either bivalirudin (n=16) or unfractionated heparin (n=14). More anticoagulant dosing changes were needed in the bivalirudin group compared to heparin, however the study found no significant difference in the primary outcome of time spent at goal anticoagulation between groups. However, thrombotic complications requiring ECMO circuit changes occurred more frequently in the bivalirudin group (37.5% vs. 0%, p=0.02), while patients receiving bivalirudin required fewer red blood cell transfusions compared to those on heparin. Bleeding complications were similar between groups. These results of this pilot study demonstrate that a randomized trial of bivalirudin vs. heparin in pediatric ECMO is feasible. Notably, two patients randomized to the bivalirudin group during this study period were positive for COVID-19, and it is unclear if the prothrombotic effect of COVID-19 affected these results. Larger multicenter studies are needed to clarify safety and efficacy, especially regarding the risk of circuit thrombosis when using bivalirudin.

Central or Peripheral Venoarterial Extracorporeal Membrane Oxygenation for Pediatric Sepsis: Outcomes Comparison in the Extracorporeal Life Support Organization Dataset, 2000-2021. [8] Totapally A et al., Pediatr Crit Care Med. 2025 Apr 1;26(4):e463-e472. Epub 2025 Jan 23. PMID: 39846796.

Refractory septic shock (RSS) is a leading cause of death in pediatric sepsis, and venoarterial extracorporeal membrane oxygenation (ECMO) is used as a rescue therapy for children unresponsive to conventional treatments. Small, single-center retrospective studies from over a decade ago suggested that central cannulation during ECMO for RSS may result in higher flows (likely meeting oxygen demands sooner) and improved survival compared with peripheral cannulation, although these findings were limited by small sample sizes. Additionally, earlier data indicated that high ECMO flow rates (≥150 mL/kg/min) might be associated with better outcomes. However, more recent reports offered conflicting evidence, suggesting peripheral cannulation could be a viable alternative and highlighting potential complications of central cannulation—such as increased bleeding risk and nosocomial infection—versus risks of cerebrovascular injury with peripheral cannulation. Further, the decision for central versus peripheral cannulation may be logistically challenging, as central cannulation requires cardiothoracic surgical capability and comes with the challenges associated with managing an open chest, while peripheral cannulation lacks these barriers. Large-scale data comparing the outcomes of central versus peripheral cannulation strategies and ECMO flow rates in pediatric sepsis has been lacking, leaving clinicians uncertain about the optimal approach to cannulation and flow targets during ECMO support for RSS.

This retrospective analysis of 1,242 pediatric patients without congenital heart disease who underwent venoarterial ECMO for sepsis between 2000 and 2021, using the international Extracorporeal Life Support Organization (ELSO) dataset, represents the largest study to date addressing this question. The study found that higher ECMO flow rates at 4 hours after initiation were independently associated with lower odds of mortality, but this relationship was not seen at 24 hours. Importantly, central cannulation, compared with peripheral cannulation, was independently associated with significantly lower odds of mortality (adjusted odds ratio 1.7 favoring central cannulation). Peripheral cannulation was associated with shorter hospital stays but higher risks of complications like cannula problems. These findings suggest that early maximization of ECMO flow and the use of central cannulation may improve survival in pediatric patients with refractory septic shock, providing new insights that could inform future guidelines and prompting further research to balance the risks and benefits of cannulation strategies in this vulnerable population.

Update on ventilation management in the Pediatric Intensive Care Unit. [9] Egbuta C, Easley RB. Paediatr Anaesth. 2022 Feb;32(2):354-362. Epub 2021 Dec 15. PMID: 34882910.

Mechanical ventilation is widely used in pediatric intensive care, but standardized protocols for initiation, weaning, and extubation are lacking. Noninvasive ventilation (NIV), including HFNC, CPAP, and BiPAP, has become a primary strategy for respiratory support, but failure often leads to invasive mechanical ventilation. Lung-protective strategies, such as low tidal volume and higher PEEP, help mitigate ventilator-induced lung injury (VILI). Alternative approaches, including HFOV and ECMO, provide rescue options when conventional ventilation fails. Challenges remain in determining the optimal timing for tracheostomy, reducing sedation-related complications, and preventing ventilator-associated events.

A comprehensive review of recent advancements in pediatric ventilation, including the growing role of esophageal pressure monitoring, volumetric capnography, and NAVA in optimizing ventilator settings. Insights into nonconventional ventilation strategies and their role in specific clinical scenarios where conventional approaches fall short. A discussion on evolving practices in ECMO and extracorporeal carbon dioxide removal (ECCO2R) as emerging technologies in pediatric respiratory failure. · Knowledge gaps in pediatric extubation readiness trials, tracheostomy indications, and sedation management are identified, highlighting areas for future research and clinical improvement.

Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study. [10] Wollny K et al., Pediatr Crit Care Med. 2023 Apr 1;24(4):311-321. Epub 2023 Apr 6. PMID: 37026721.

Unplanned extubations (UEs) in pediatric intensive care units (PICUs) are rare but serious events that require immediate clinical intervention. Reintubation following a UE is associated with significant risks, including airway trauma, prolonged mechanical ventilation, and increased mortality. A recent large-scale study by Wollny et al. analyzed 5,703 pediatric UEs across 149 PICUs between 2012 and 2020. The study found that 29.1% of these cases required reintubation within 24 hours. Several factors increased the likelihood of reintubation, including age under two years, a primary respiratory diagnosis, and unscheduled admissions. In contrast, patients admitted on a scheduled basis were less likely to require reintubation. The researchers developed a predictive model using LASSO regression, which confirmed these risk factors with limited accuracy (AUROC ~0.59). The study suggests that incorporating additional clinical variables, such as oxygenation status and ventilatory support at the time of extubation, could improve predictive capability.

Current PICU protocols focus on preventing unplanned extubations (UEs) through key strategies: Properly securing endotracheal tubes (ETTs). Maintaining appropriate sedation and nursing ratios to prevent accidental extubation. Conducting extubation readiness assessments before planned removals. While these measures help reduce UE rates, they do not provide precise risk stratification for reintubation after extubation.

Using a large, multicenter dataset, this study validates known risk factors for reintubation in pediatric critical care. Key predictors of reintubation risk include: Younger age. Respiratory conditions. Unscheduled admissions. Findings emphasize the need for proactive management of high-risk patients. As the most extensive study on this topic, it provides strong evidence to guide targeted interventions. It lays the foundation for predictive models that could improve clinical preparedness and enhance patient safety.

Early Versus Late Enteral Nutrition in the Pediatric Critically-Ill Trauma Patient: A Retrospective Cohort Study. [11] Fastag E et al., J Pediatr Surg. 2025 Jan 23;60(4):162189. Epub ahead of print. PMID: 39893842.

This retrospective cohort study examined the impact of early versus late enteral nutrition (EN) in critically ill pediatric trauma patients. It aimed to determine its effects on PICU and hospital length of stay (LOS) while identifying barriers to early initiation. The study was conducted at a Level 1 pediatric trauma center, which analyzed 238 patients under 18 years of age, categorizing them into early EN (within 48 hours of admission) and late EN groups. Findings revealed that early EN was significantly associated with shorter PICU and hospital LOS, with adjusted incidence rates of 1.26 (p = 0.030) and 1.36 (p = 0.005), respectively. However, the groups showed no significant difference in the days spent on mechanical ventilation. Barriers to early EN included higher opioid use, administration of vasoactive medications, greater severity of illness, and abdominal trauma. Despite these challenges, the study highlights the benefits of early EN in reducing hospital stays and underscores the need for standardized enteral nutrition protocols in critically ill pediatric trauma patients.

As ASPEN and SCCM guidelines recommended, enteral nutrition (EN) is the preferred method of nutritional support in critically ill pediatric patients with a functioning gastrointestinal (GI) tract. Early EN (within 48 hours of admission) has been associated with improved outcomes in specific pediatric populations, such as those with traumatic brain injury and burn injuries. Delayed EN has been linked to increased complications, including infections, hyperglycemia, and prolonged mechanical ventilation. Despite guidelines supporting early EN, clinical practice remains variable, especially in pediatric trauma patients, due to concerns about feeding intolerance, gut ischemia, use of vasoactive medications, and injury severity.

This study provides specific evidence that early EN in a general pediatric trauma population (not limited to particular injuries like TBI or burns) is associated with significantly shorter PICU and hospital length of stay without increasing mechanical ventilation days. It identifies common barriers to early EN, including higher opioid use, administration of vasoactive medications, and abdominal trauma, which may contribute to delays in feeding. It challenges the perception that early EN should be avoided in more severely injured patients, suggesting that it can be implemented safely with appropriate monitoring and clinical decision-making. The study supports a need for standardized enteral nutrition protocols in pediatric trauma patients to ensure timely initiation and optimize patient outcomes. This study reinforces the benefits of early EN and identifies practical barriers. It provides a foundation for improving adherence to existing guidelines and enhancing pediatric trauma nutrition strategies.

Impact of the Magnitude and Timing of Fluid Overload on Outcomes in Critically Ill Children: A Report From the Multicenter International Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) Study. [12] Selewski DT et al., Crit Care Med. 2023 May 1;51(5):606-618. Epub 2023 Feb 17. PMID: 36821787

Fluid overload is associated with adverse outcomes in critically ill children, including mortality, AKI, and ICU-free days.

This study specifically sought to define clinically meaningful measures of fluid overload. This is a planned secondary analysis of the AWARE study, which prospectively observed AKI in 32 pediatric intensive care units in 9 countries. Over 5,000 patients were included. Fluid overload was defined as the cumulative intake/output balance over the patient’s weight, expressed as a percentage. The investigators found that fluid overload >10% on Day 1 or Day 2 was associated with higher mortality, fewer ICU-free days, and fewer ventilator-free days. Peak fluid overload was also associated with higher mortality, fewer ICU-free days, and fewer ventilator-free days. Fluid overload also occurred frequently, with one quarter of the cohort experiencing fluid overload >10% on Day 2 of ICU admission.

Management Changes After Echocardiography Are Associated With Improved Outcomes in Critically Ill Children. [13] Ip PYF et al., Pediatr Crit Care Med. 2024 Aug 1;25(8):689-698. Epub 2024 Apr 9. PMID: 38591948.

In children with sepsis, myocardial dysfunction is a significant contributor to shock. Vascular tone and hypovolemia co-exist with myocardial dysfunction, and tailoring treatment to the dominant pathophysiology may improve outcomes.

This is a single-center retrospective study of 249 children admitted to the PICU requiring both vasoactive infusions and mechanical ventilation, who underwent formal echocardiography within 72 hours. The cohort was divided into two groups: patients with depressed cardiac function, and those with near-normal cardiac function. In patients with depressed cardiac function, use of vasoconstrictors was associated with increased fluid overload, increased lung water, worse p/f ratio, worse lactate clearance, and worse oxygen extraction. However, patients with depressed cardiac function on echo were likely to be switched to a management strategy favoring inotropes and conservative fluid administration. This was associated with an increased likelihood of extubation and ability to wean off vasoactive support. In short, this study shows that in children with myocardial dysfunction, echo-guided changes in management strategy are associated with faster recovery.

Anticoagulation-Free Pediatric Extracorporeal Membrane Oxygenation: Single-Center Retrospective Study [14] Rabinowitz EJ et al., Pediatr Crit Care Med. 2023 Jun 1;24(6):499-509. Epub 2023 Mar 8. PMID: 36883843

With improvements in ECLS circuit technology, there is increasing optimism in adult literature around anticoagulation-free periods on ECMO or anticoagulation-free runs altogether.

This is a single-center retrospective study of 35 pediatric patients (NICU patients excluded) cannulated for ECMO 2018 – 2021 who had anticoagulation-free periods of at least 6 hours, immediately following cannulation (i.e., the first 6 hours of ECMO support). Median time off anticoagulation was 18 hours (IQR 13 – 26 hours). Only 8% of patients experienced a thrombotic event while off anticoagulation.

ECMO in trauma care: What you need to know[15] Flatley M et al, J Trauma Acute Care Surg. 2024 Feb 1;96(2):186-194. Epub 2023 Oct 16. PMID: 37843631

This is an adult review article but does have a pediatric section. It is definitely still applicable. It discusses physiology, importance of early consult to the ECLS team, indications in trauma, cannulation strategies, managing bleeding vs. anticoagulation in the trauma population

Resuscitation With Early Adrenaline Infusion for Children With Septic Shock: A Randomized Pilot[16]Harley A et al, Pediatr Crit Care Med. 2024 Feb 1;25(2):106-117. Epub 2024 Jan 19. PMID: 38240535.

This is a multicenter randomized control trial in Australia (only 40 patients) for patients presenting in septic shock to the emergency department. It aims to reduce fluid overload in pediatric septic shock by evaluating earlier administration of IV adrenaline in the course of resuscitation. The patients were either assigned to receive IV adrenaline infusions after 20ml/kg bolus or 40-60ml/kg fluid bolus. The patients were randomized 1:1 but the study was not blinded, and was designed as a feasibility study with a small sample size. They found that the intervention group (20ml/kg) had a shorter hospital length of stay and trended toward earlier reversal of shock physiology with more pressors and less overall fluid given. We are realizing that fluid overload is a big problem, this is a step toward further studies like this, such as the one currently being conducted by Vince Duron at Columbia.

Impact of hypocalcemia on mortality in pediatric trauma patients who require transfusion [17] Abou Khalil E et al, J Trauma Acute Care Surg. 2024 Aug 1;97(2):242-247. Epub 2024 Apr 8. PMID: 38587878

This is a retrospective single-institution trauma database study over 9 years. They looked at 331 patients in their pediatric level-1 trauma center who received blood products within 24 hours of injury. They compared ionized calcium (iCa) levels on admission and considered those with iCa < 1.00mmol/L hypocalcemic. The hypocalcemic group had higher injury severity score and shock index compared to those who were normocalcemic. They also had increased mortality, both at 24 hours and overall, in logistic regression adjusting for ISS, GCS, and shock index. This suggests that future studies are necessary to evaluate the role of calcium supplementation or replacement in pediatric trauma patients, and that current protocols suggesting empiric calcium be given are likely appropriate. Limitations: This is a single center study with relatively small numbers, and does not include any demonstration or even suggestion of biologic plausibility.

Damage-control resuscitation in pediatric trauma: What you need to know[18] Russell RT et al, J Trauma Acute Care Surg. 2023 Oct 1;95(4):472-480. Epub 2023 Jun 12. PMID: 37314396

This is a review paper that is about one year old. Their recommendations are as follows: In pediatric patients in hemorrhagic shock, give blood and limit crystalloid. There is increased mortality with < 1:1 ratio plasma/RBC. Low titer o negative whole blood (LTOWB) has a mortality benefit in massively transfused children. Tranexamic acid (TXA) should be given within 3 hours of injury. Massive transfusion protocols (MTP) are very important, but implementation challenges can be hard to overcome. A whole blood in pediatric trauma RCT, MATIC-2, is coming, so it is important and helpful to remind everyone of these principles.

Neurologic Outcomes and Quality of Life in Children After Extracorporeal Membrane Oxygenation[19]. Michel A, et al. Pediatr Crit Care Med. 2024 Mar 1;25(3):e158-e167. Epub 2023 Dec 13. PMID: 38088764.

Extracorporeal membrane oxygenation (ECMO) is a form of life support used in children with severe cardiopulmonary failure. One of the main risk factors of ECMO is neurologic injury. In several recent studies, nearly half of the neonates and children supported on ECMO had radiographic evidence of brain injury on post-ECMO MRI. However, the neurodevelopmental manifestations of these radiographic findings are not fully elucidated. With an increasing number of children being successfully supported on ECMO to decannulation and hospital discharge, there is a growing interest in the long-term developmental outcomes of these children.

This is a single-institution observational study conducted on a cohort of forty patients less than 18 years old that underwent venoarterial or venovenous ECMO between October 2014 and January 2020 and were still alive as of May 2021. These patients underwent a brain MRI within a week of ECMO decannulation, which was retrospectively reviewed for the purposes of this study by a pediatric radiologist blinded to the patient’s mode of ECMO and clinical outcome. To assess short term outcome, patients were divided into “good” and “poor” neurologic outcome at the time of PICU discharge. Poor neurologic outcome was defined by motor deficit, cognitive functional impairment, pyramidal, extrapyramidal, and/or cerebellar symptoms; seizures, or sensory impairment consistent with finding on brain imaging. Pediatric Overall/Cerebral Performance Category (POPC/PCPC) scores were also used for functional evaluation of patients before PICU and at PICU discharge. There were 40 patients total. Thirty- five children (88%) underwent venoarterial ECMO. 38% of the 40 patients had neurologic injuries noted at PICU discharge. Brain MR images of the 15 patients with poor neurologic outcome showed eight of 15 with strokes and eight of 15 with white matter or cortical injuries related to low flow. However, all patients had POPC/PCPC scores below 4 at the time, indicating that they did not have severe neurologic disability at that time. To assess long term neurologic outcome, all children were assessed with POPC/PCPC. Additionally, some sub-groups of patients underwent testing with a Denver II test (DTII) and had healthcare related quality of life (HRQoL) assessments with the Pediatric Quality of Life Inventory scale. In the long-term data, HRQoL scores were lower than healthy peers (70/100 vs 80/100), but similar to other children with chronic diseases. Also, 36 of 40 patients had a POPC/PCPC score less than or equal to 3 at the time of long term follow up in May 2021. These results highlight the remarkable neuroplasticity of pediatric brains after severe injury and the difficulty in making prognostic assessments based solely on brain imaging after ECMO decannulation. The authors state that this is further evidence that these patients should be supported with appropriate rehabilitation programs after hospital discharge and be followed in ECMO-specific multidisciplinary programs.

Similar rate of venous thromboembolism (VTE) and failure of non‐operative management for early versus delayed VTE chemoprophylaxis in adolescent blunt solid organ injuries: a propensity‐matched analysis[20]. Grigorian A, et al. Eur J Trauma Emerg Surg. 2024 Jan 9. Epub ahead of print. PMID: 38194094.

Non-operative management is now the standard of care in stable pediatric patients with blunt solid organ injury (BSOI). The primary cause of failure of non-operative management (NOM) is bleeding. In adult patients, the risk of venous thromboembolism (VTE) can reach up to 60% in trauma patients with BSOI. Therefore, this considerable risk of VTE outweighs the risk of bleeding with VTE chemoprophylaxis and thus early VTE chemoprophylaxis is initiated in stable patients without evidence of bleeding with BSOI. Hospitalized children under the age of 12 have a much lower risk of VTE and therefore most providers do not initiate VTE chemoprophylaxis in this cohort. What remains unknown is the VTE risk in adolescents with BSOI and the need for VTE chemoprophylaxis in that group of patients.

This is a retrospective review of the Trauma Quality Improvement Program (TQIP) database of 1022 adolescents aged 12-17 with traumatic blunt kidney, liver or spleen injury who underwent non-operative management between 2017 and 2019. Patients were divided into early (≤ 48 h of arrival, n=417, 40.8%) or delayed (>48 h of arrival, n=605, 59.2%) VTE chemoprophylaxis groups. Propensity score matching was employed to match children for age, comorbidities, angiography use, solid organ injury, BSOI grade, pelvic fracture, long bone fracture, injury severity score (ISS), hypotension on arrival and blood transfusion necessity. The primary outcome was the composite VTE rate, comprising deep vein thrombosis (DVT) and pulmonary embolism (PE). The secondary outcome was the rate of NOM failure. In this study, 52.7% of the patients had a grade 4 or 5 solid organ injury. In the matched cohorts, there were 2 patients that developed a VTE in the early VTE chemoprophylaxis cohort (0.6%) and 6 patients that developed a VTE in the delayed chemoprophylaxis cohort (1.7%), rates which are consistent with the incidence of VTE in similar studies of pediatric BSOI. The difference between groups was not significant (p=0.155). Additionally, NOM failure rates were comparable between the two groups and there was no difference in hospital length of stay. Therefore, the authors of this study concluded that early vs. late initiation of chemoprophylaxis does not appear to change the risk of VTE in adolescents and VTE chemoprophylaxis did not increase the failure rate of non-operative management. This is important data for those patients with multisystem injuries including BSOI with high risk or significant consequences of bleeding where VTE chemoprophylaxis is being considered.

Early Cardiac Arrest Hemodynamics, End-Tidal Co2, and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016–2021)[21]. Yates AR, et al. Pediatr Crit Care Med. 2023 Dec 13. Epub ahead of print. PMID: 38088765

Extracorporeal membrane oxygenation (ECMO) is a form of life support used in children with cardiopulmonary failure. ECMO during cardiopulmonary resuscitation (ECPR) is an increasingly utilized form of extracorporeal support for children who are refractory to all conventional methods of resuscitation. In children that undergo ECPR, overall survival is 30-50% in the current literature. In the prospective Pediatric Intensive Care Quality of CPR (PICqCPR) study, achieving diastolic blood pressures greater than or equal to 25 mm Hg for patients younger than 1 year old or greater than or equal to 30 mm Hg for patients 1 year old or older was associated with survival to hospital discharge. This study aimed to associate early arrest hemodynamics and end-tidal CO2 measurements with survival to hospital discharge after ECPR with favorable neurologic outcome.

This is a secondary analysis of the ICU-RESUS study which evaluated patients 37 weeks post-conceptual age to 18 years old who underwent CPR in one of the 18 PICUs designated in the original study design. The final cohort for this study consisted of 97 patients who were rescued from conventional CPR by ECPR cannulation to veno-arterial ECMO and had invasive arterial line data for analysis. The primary outcome was favorable neurologic outcome, defined as no greater than moderate disability as defined by Pediatric Cerebral Performance Category (PCPC) score ≤ 3, or an unchanged PCPC score in patients that had a pre-existing score that was 4 or 5. 64% of patients in this study were surgical cardiac patients, including 85% with some form of congenital cardiac disease. 73% of the patients were younger than 1 year old. Patients who survived with favorable neurologic outcome had a shorter duration of CPR (36.5 vs 47 minutes, p-0.015). Of the patients who required CPR less than 30 minutes, 57% survived to discharge with favorable neurologic outcome. This was in comparison to 42% survival with favorable neurologic outcome in patients that underwent CPR for 30-60 minutes and 16% in patients that required greater than 60 minutes of CPR. Survival with favorable neurologic outcome was also associated with lower peak arterial lactate levels in the initial 6 hours after resuscitation (9.6 vs 15.2 mmoL/dL, p=0.010) and lower peak arterial lactate levels between 6 to 24 hours after resuscitation (3.2 vs 5.9 mmoL/dL, p< 0.001) compared to those with poor neurologic outcome. End-tidal CO2 data was available in 35 patients and it was notable that 4 of 17 patients with recorded EtCO2 less than 10mmHg survived with favorable neurologic outcome. The authors did not find an association between CPR hemodynamics and favorable neurologic outcome. In summary, they noted that rapid cannulation onto ECMO during CPR likely minimizes organ ischemia time as evidenced by lower levels of lactic acidosis and provides the best chances for survival post-ECPR with favorable neurologic outcome.

Phototherapy: a new risk factor for necrotizing enterocolitis in very low birth weight preterm infants? a retrospective case-control study[22]. Li J. et al. J Perinatol. 2023 Nov;43(11):1363-1367. doi: 10.1038/s41372-023-01744-y. Epub 2023 Aug 7.

Phototherapy (PT) is a standard treatment for neonatal jaundice and is considered generally safe. However, concerns have arisen about the long-term safety of PT, especially in very low birth weight (VLBW) infants. Some studies have suggested that PT can affect intestinal flora and increase proinflammatory cytokines, which are associated with Necrotizing Enterocolitis (NEC).

This retrospective case control study explores the association between PT and NEC development in VLBW infants (born before 35 weeks of gestation). Authors found that VLBW infants with increased PT exposure appeared to have a higher risk of developing NEC. Specifically, it was found that exposure to >120 hours and >4 sessions of PT are significantly associated with NEC. The study emphasizes caution in the use of PT in VLBW infants due to the potential risks of NEC.

Efficacy and safety of dexmedetomidine for analgesia and sedation in neonates: a systematic review[23]. Portelli K, et al. J Perinatol. 2024 Feb;44(2):164-172. Epub 2023 Oct 16.

As Pediatric Surgeons, we understand the need for adequate analgesia and sedation for neonates. Opioids and benzodiazepines have been traditionally used for neonatal pain relief, but they come with potential long-term neurodevelopmental risks. Dexmedetomidine, an alpha-2-adrenoreceptor agonist, has emerged as a potential alternative due to its analgesic and neuroprotective properties.

In this systematic review article, authors evaluate the efficacy and safety of dexmedetomidine in neonates. The article provides evidence that dexmedetomidine may effectively provide sedation and analgesia. Dexmedetomidine might reduce the need for additional sedation or analgesia, decrease the time to extubation, increase time to achieve full enteral feeds, and shorten the duration of mechanical ventilation. The drug’s safety profile was found to be consistent with findings in adult populations, with no significant episodes of bradycardia or hypotension. The potential anti-inflammatory effects of dexmedetomidine might contribute to reduced mechanical ventilation duration and lower incidences of culture-positive sepsis and NEC. This article suggests that dexmedetomidine might offer a promising alternative to traditional sedatives in the NICU setting. Below is a visual summary of the findings:

Dexmedetomidine in Neonates

Comparison of conventional mechanical ventilation and high-frequency oscillatory ventilation in congenital diaphragmatic hernias: a systematic review and meta-analysis[24]. Yang HB, et al. Sci Rep. 2023 Sep 26;13(1):16136

Pediatric Surgeons are well aware of the main causes of mortality in CDH being pulmonary hypoplasia and pulmonary hypertension. High-frequency oscillatory ventilation (HFOV) has been suggested as an elective rescue mode of ventilation however, there’s a lack of evidence comparing the outcomes of conventional mechanical ventilation (CMV) and HFOV in CDH patients. The VICI-trial had aimed to determine the optimal initial ventilation mode in CDH. Yet, there’s a gap in evidence regarding the comparison of incidence and mortality for chronic lung disease (CLD) between CMV and HFOV in CDH patients. The APSA Critical Care Committee wanted to highlight this recently published article in the Journal of Perinatology comparing outcomes of CMV and HFOV in CDH patients.

This systematic review and meta-analysis compared the outcomes of CMV and HFOV in children with CDH. In this article, authors use mortality and incidence of chronic lung disease as the outcome measures and subgroup analyses were performed according to the strategy for applying HFOV in CDH patients. Group A: CMV was initially applied in all CDH patients, and HFOV was applied in unstable patients. Group B: chronologically analyzed (CMV and HFOV era) Group C: CMV or HFOV was used as the initial MV. Regarding mortality, 16.7% (365/2180) and 32.8% (456/1389) patients died in CMV and HFOV, respectively. Subgroup analyses showed significantly worse, better, and equivalent mortality for HFOV than that for CMV in group A, B, and C, respectively. CLD occurred in 32.4% (399/1230) and 49.3% (369/749) patients in CMV and HFOV, respectively. The authors conclude that within limitations of study, mortality and the incidence of CLD appeared worse after HFOV in children with CDH. Authors however urged cautious interpretation due to the heterogeneity of studies included in review and lack of randomized prospective data.

Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents with COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs[25]. Bembea MM, et al. Pediatr Crit Care Med. 2023 May 1;24(5):356-371. Epub 2023 Mar 30.

Children with COVID-19 or multi-inflammatory syndrome in children (MIS-C) may develop life threatening acute respiratory distress syndrome or shock and may be placed on ECMO support. Although several small case series in children have described outcomes, the characteristics and clinical outcomes of these populations remain unclear.

The Overcoming COVID-19 Network performed active surveillance of SARS-CoV-2-related illness in 63 US hospitals from 2020-2021. Seventy-one of 1203 COVID-19 (5.9%) and 37 of 1530 (2.4%) MIS-C patients received ECMO. Of note, there were no differences in demographics, social vulnerability index, or insurance status between those receiving and not receiving ECMO. Patients with MIS-C had ECMO initiated earlier (median 1 day vs. 5 days) in the hospital course primarily for cardiogenic shock indications (87% vs 23%) and had shorter (median 3.9 vs 14 days), mostly venoarterial (92% vs 41%) ECMO courses with lower in hospital mortality (27% vs 37%) compared to COVID-19 patients. Surviving MIS-C patients had less major morbidity at discharge (oxygen or mechanical ventilation requirement, tracheostomy, or neurologic deficit). Interestingly, BMI-based obesity was present in 63% of COVID-19 patients receiving ECMO support and suggest that obesity may be an important risk factor for severe disease. Overall survival to discharge and need for rehabilitation among ECMO survivors were similar or compared favorably with historical, pre-pandemic pediatric ECMO cohorts. This study provides important outcomes data on two related but pathophysiologically distinct disease processes and suggests that children with SARS-CoV-2-realted illness are excellent ECMO candidates.

Fluid Overload Precedes and Masks Cryptic Kidney Injury in Pediatric Acute Respiratory Distress Syndrome[26]. Dixon CG, et al. Crit Care Med. 2023 Jun 1;51(6):765-774. Epub 2023 Mar 20.

Increasing fluid overload (FO – relative increase in total body water) is associated with worse outcomes in pediatric acute respiratory distress syndrome (PARDS) including fewer ventilator-free days, longer ICU length of stay, and increased mortality. Similarly, acute kidney injury (AKI – typically defined in stages by urine output and measured creatinine) has also been shown to be associated with worse outcomes in this population. FO and AKI are interrelated, and FO may allow for the underestimation of AKI in critically ill children.

This single-institution study sought to shed light on the relationship of FO and AKI in PARS. The authors assessed fluid overload adjusted creatinine and collected granular fluid and AKI metrics. This was a retrospective analysis of a prospective cohort representing 720 children. There were 75 children (10%) with early, 21 (3%) with late, and 96 (13%) with persistent AKI. Patients with early and persistent AKI were more critically ill. Patients with AKI had an increased mortality (38% vs 12%) and was associated with worse outcomes regardless of timing of onset. Adjusting creatinine for FO allowed detection of children (33 or 6% of the no AKI population) who did not meet AKI criteria but who had worse outcomes (mortality: 24% vs 11%; ventilator-free days: median 11 vs 18; ventilator days in survival: median 12 vs 9) than those without AKI. This study confirms the known direct relationship between AKI and poor outcomes in patients with PARDS and confirms the presence of a subset of patients with AKI masked by FO - aka “cryptic AKI”. Although distinct patient populations, pediatric surgeons should be aware of the possibility of “cryptic AKI” in their critically ill postoperative and resuscitated trauma patients and the potential implications for poor outcomes.

Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding [27]. 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 [28]. 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 [29]. 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[30]. 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 [31]. 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) [32]. 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 [33]. 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 [34]. 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 [35]. 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 [36]. 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 [37], 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 [38], 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 [39], 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 [40], 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 [41], Prout et al Crit Care Med 2019 Nov 27

Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity [42], 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 [43], 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 [44], 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 [45], Meert et al Crit Care Med 2019 Mar;47(3):393-402.

Neurologic Outcomes After Extracorporeal Membrane Oxygenation: A Systematic Review [46], 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 [47], Miyata J Pediatr Surg 2018 Aug;53(8):1499-1503.

Cardiac Index Changes With Fluid Bolus Therapy in Children With Sepsis – An Observational Study [48], 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 [49], 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 [50], Meinert et al. Pediatr Crit Care Med 2018 Apr;19(4):345-352.

Renal Replacement Therapy in the Critically Ill Child [51], Westrope et al Pediatr Crit Care Med 2018 Mar;19(3):210-217.

Vascular Access in Critically Ill Pediatric Patients With Obesity [52], 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 [53], 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 [54], 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 [55], 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 [56], 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 [57], Mehta et al Pediatr Crit Care Med 2017 Jul;18(7):675-715.

Neurodevelopmental outcomes in infants undergoing general anesthesia [58], 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 [59], 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 [60], 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 [61], Unegbu et al Pediatrics 2017 Mar;139(3).

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children [62], 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 [63], Gupta et al Crit Care Med 2016 Oct; 44(10): 1901-9.

Epidemiology of Acute Kidney Injury in Critically Ill Children and Young Adults [64], Kaddourah et al N Engl J Med. 2017 Jan;376(1):11-20.

New Medical and Surgical Insights into Neonatal Necrotizing Enterocolitis: A Review [65], Frost et al JAMA Pediatr 2017 Jan; 171(1): 83-88.

Impact of Weight Extremes on Clinical Outcomes in Pediatric Acute Respiratory Distress Syndrome [66], Ward et al Crit Care Med 2016 Nov;44(11):2052-2059.

Prediction of Catheter-Associated Thrombosis in Critically Ill Children [67], Marquez et al Pediatr Crit Care Med 2016 Sep 22.

Persistent Challenges in Pediatric Pulmonary Hypertension [68], Hopper et al Chest 2016 Jul;150(1):226-36.

High-Dose Erythropoietin and Hypothermia for Hypoxic-Ischemic Encephalopathy: A Phase II Trial [69], Wu et al Pediatrics. 2016 Jun;137(6).

Evaluation of the “Early” Use of Albumin in Children with Extensive Burns: A Randomized Controlled Trial [70], 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 [71], Kinsella et al J Pediatr 2016 Mar;170:312-4.

New Modes in Non-invasive Ventilation [72], Rabec C, et al Paediatr Respir Rev 2016 Mar;18:73-84.

Obesity and Mortality Risk in Critically Ill Children [73], Ross et al Pediatrics 2016 Mar;137(3):1-8.

Mortality Among Injured Children Treated at Different Trauma Center Types [74], Sathya et al JAMA Surg 2015 Sep;150(9):874-81.

Maintenance Intravenous Fluids in Acutely Ill Patients [75], 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 [76], Rimensberger et al Pediatr Crit Care Med 2015 Jun;16(5 Suppl 1):S51-60.

References