Pediatric Critical Care Medicine最新文献

{"title":"Severe Neonatal Respiratory Failure and Transfer for Higher Level Intensive Care: Early Factors Associated With Mortality and Other Outcomes in a Retrospective Cohort, 2018-2020.","authors":"Livia Procopiuc, Geoffrey E Burnhill, Nandiran Ratnavel, Thomas J Brick, Rebecca Smith, Aida Lopez de Pedro, Nadia Baasher, Jon Lillie","doi":"10.1097/PCC.0000000000003821","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003821","url":null,"abstract":"<p><strong>Objectives: </strong>To identify factors associated with death, requirement for extracorporeal membrane oxygenation (ECMO), or cardiac intervention in neonates referred for higher level neonatal ICU (NICU) due to respiratory failure.</p><p><strong>Design: </strong>Retrospective cohort study, 2018-2020.</p><p><strong>Setting: </strong>Referrals for transport to tertiary-level NICUs using the London Neonatal Transfer Service in the United Kingdom.</p><p><strong>Patients: </strong>Neonates with a diagnosis of severe respiratory failure who were intubated and receiving Fio2 greater than 60% at referral. We excluded neonates younger than 34 weeks corrected gestational age, less than 2 kg, or with a known cardiac diagnosis.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We identified 170 neonates with a median (interquartile range [IQR]) age of 4 hours (2-11 hr) at referral and 9 hours (IQR, 7-16 hr) at time of departure from the referring NICU. Overall, 21 of 170 babies required immediate transfer to a center providing ECMO, of whom two of 21 died and two of 21 received ECMO support. Of the 149 transferred to NICUs that do not provide ECMO, 11 of 149 died (7%) and a further 16 of 149 (11%) required secondary transfers to an ECMO center where one of 16 died and three of 16 required ECMO. In total, there were 23 of 170 neonates with outcome of death, need for ECMO, or cardiac intervention. A composite score of Vasoactive-Inotropic Score (VIS) greater than or equal to 18 and oxygenation index (OI) greater than 24 after patient stabilization was associated with death, a need for ECMO or a previously undiagnosed cardiac lesion, with a sensitivity of 83% and a specificity of 73%.</p><p><strong>Conclusions: </strong>This 2018-2020 cohort of neonates with severe respiratory failure managed in London, United Kingdom, shows that VIS greater than or equal to 18 and OI greater than 24 after stabilization were associated with death, need for ECMO, or cardiac intervention. These parameters may have the potential to trigger discussion with ECMO centers for early consideration of transfer but needs validation in a wider neonatal population.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":4.5,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145016103","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Tale of Two Subphenotypes in Pediatric Sepsis-Associated Acute Kidney Injury.","authors":"James D Fortenberry","doi":"10.1097/PCC.0000000000003800","DOIUrl":"10.1097/PCC.0000000000003800","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1165-e1167"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144789636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Derivation and Validation of Pediatric Sepsis-Associated Acute Kidney Injury Subphenotypes With Prognostic Relevance.","authors":"Natalja L Stanski, Bin Zhang, Jiarong Ouyang, L Nelson Sanchez-Pinto, E Vincent S Faustino, Colin M Rogerson, Mark W Hall, Scott L Weiss, Tellen D Bennett, Stephen W Standage, Stuart L Goldstein, Kathleen D Liu","doi":"10.1097/PCC.0000000000003789","DOIUrl":"10.1097/PCC.0000000000003789","url":null,"abstract":"<p><strong>Objectives: </strong>Sepsis-associated acute kidney injury (SAKI) is a heterogeneous syndrome associated with poor outcomes. Subphenotypes of SAKI with prognostic and therapeutic relevance have been identified in adults, but not in children. We sought to identify reproducible and clinically relevant pediatric SAKI (pSAKI) subphenotypes using readily available clinical and laboratory data.</p><p><strong>Design: </strong>Secondary analysis of a retrospective observational study of pediatric sepsis.</p><p><strong>Setting: </strong>Thirteen PICUs in the United States from January 2012 to January 2018.</p><p><strong>Patients: </strong>Patients aged 0-18 years with septic shock (sepsis and requiring vasoactive medications) and day 1-2 SAKI (≥ Kidney Disease Improving Global Outcomes stage 1 by serum creatinine).</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Fourteen hundred fifty-five patients were included after inclusion and exclusion criteria were applied: 873 (60%) in the derivation cohort and 582 (40%) in the external validation cohort. A two-subphenotype latent class analysis model had the best fit in both cohorts: pSAKI subphenotype 1 (pSAKI-1) and pSAKI subphenotype 2 (pSAKI-2). pSAKI-2 was characterized by younger age, more organ support, greater fluid accumulation, and laboratory evidence of inflammation, acid-base derangement, thrombocytopenia, and coagulopathy. pSAKI-2 had uniformly worse outcomes, including higher rates of severe and persistent AKI at days 3-4 (54% vs. 23%, p < 0.001) and day 7 (31% vs. 12%, p < 0.001), increased use of continuous renal replacement therapy (21% vs. 6%, p < 0.001), and independently increased odds of mortality after adjustment for potential confounders (adjusted odds ratio 1.59; 95% CI, 1.04-2.41; p = 0.03). A parsimonious classification model accurately identified pSAKI-2 membership (C-statistic 0.94 [95% CI, 0.92-0.95] and 0.85 [95% CI, 0.82-0.88], respectively, in the derivation and internal validation cohorts).</p><p><strong>Conclusions: </strong>We identified two distinct early pSAKI subphenotypes using readily available data that exhibit differential risk for poor outcomes and can be identified from a parsimonious set of variables. Pending external validation, operationalization of pSAKI subphenotypes may allow for prognostic enrichment to guide clinical care and inform clinical trial enrollment.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1084-e1095"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12252218/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144601123","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acute Bronchiolitis in Infants on Invasive Mechanical Ventilation: Physiology Study of Airway Closure.","authors":"Javier Varela, Nadine Aranis, Francisca Varas, Martina Vallejos, Alejandro Bruhn","doi":"10.1097/PCC.0000000000003790","DOIUrl":"10.1097/PCC.0000000000003790","url":null,"abstract":"<p><strong>Objectives: </strong>This study aimed to explore whether airway closure can be detected in patients with severe acute bronchiolitis on invasive mechanical ventilation.</p><p><strong>Design: </strong>Single-center prospective physiologic study carried out in 2023-2024.</p><p><strong>Setting: </strong>PICU in a tertiary-care general hospital.</p><p><strong>Patients: </strong>Infants with acute bronchiolitis undergoing invasive mechanical ventilation.</p><p><strong>Interventions: </strong>Under deep sedation and neuromuscular blockade, the mechanical ventilator, in a volume-controlled mode, was transiently set with a respiratory rate of five breaths/min, a tidal volume of 6 mL/kg of ideal body weight, positive end-expiratory pressure 0 cm H 2 O, a flow rate of 2 L/min, an inspiratory-expiratory ratio of 1:1, and a F io2 of 1.0. After recording three breath cycles, the patient was returned to baseline ventilatory settings.</p><p><strong>Measurements and main results: </strong>We identified the presence of airway closure through the low-flow pressure-volume curve obtained from a pneumotachometer with a flow sensor placed at the Y-piece and simultaneously from the pressure-impedance curve and ventilation maps acquired using electrical impedance tomography. We included 12 patients, and airway closure was detected in seven of them. The median (interquartile range [IQR]) airway opening pressure was 14 cm H 2 O (IQR, 11-17 cm H 2 O). Patients with airway closure exhibited high levels of driving pressure, with a median of 16 cm H 2 O (IQR, 11-17 cm H 2 O), and low levels of respiratory system compliance, with a median of 0.41 mL/cm H 2 O/kg (IQR, 0.38-0.59 mL/cm H 2 O/kg). When these parameters were corrected for airway opening pressure, there was a significant decrease in driving pressure to 9 cm H 2 O (IQR, 8-12 cm H 2 O; p = 0.018) and a significant increase in respiratory system compliance to 0.70 mL/cm H 2 O/kg (IQR, 0.53-0.81 mL/cm H 2 O/kg; p = 0.018).</p><p><strong>Conclusions: </strong>Airway closure requiring high opening pressures can be detected in ventilated infants with acute bronchiolitis, and this phenomenon may impact respiratory mechanics.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1096-e1104"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144541817","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gone Today.","authors":"Zhaohui Su","doi":"10.1097/PCC.0000000000003783","DOIUrl":"10.1097/PCC.0000000000003783","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1187-e1188"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144485476","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Inconceivable Complexity of Lung Mechanics in Critical Bronchiolitis.","authors":"Alexandre T Rotta, Tobias L Straube","doi":"10.1097/PCC.0000000000003797","DOIUrl":"10.1097/PCC.0000000000003797","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1168-e1171"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144643064","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical and Risk Analytics Associations With Extubation Failure in Children Following Congenital Cardiac Surgery: A Multicenter Retrospective Cohort Study, 2017-2020.","authors":"Daniel L Hames, Qalab Abbas, Ahmed Asfari, Santiago Borasino, J Wesley Diddle, Yuanyuan Fu, Avihu Z Gazit, Stuart Lipsitz, Amanda M Marshall, Katherine Reise, Luciana Rodriguez Guerineau, Joshua S Wolovits, Joshua W Salvin","doi":"10.1097/PCC.0000000000003793","DOIUrl":"10.1097/PCC.0000000000003793","url":null,"abstract":"<p><strong>Objectives: </strong>The use of risk analytics indices alongside clinical factors has potential to assist clinicians in identifying children at high risk for extubation failure (EF). We investigated the association of two physiologic risk analytics indices with EF in children receiving mechanical ventilation (MV) after cardiac surgery: the probability of inadequate oxygen delivery (ID o2 ) and inadequate ventilation of carbon dioxide index (IV co2 ). A secondary aim was to evaluate clinical factors associated with EF.</p><p><strong>Design: </strong>Multicenter retrospective cohort study.</p><p><strong>Setting: </strong>Eight international pediatric cardiac ICUs.</p><p><strong>Patients: </strong>Children between 1 month and 12 years old receiving MV for greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2020.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Nine hundred twenty-two children were analyzed with 79 (8.6%) having EF (defined as reintubation within 48 hr). In multivariable analysis of clinical variables, preoperative MV (adjusted odds ratio [aOR], 1.78; 95% CI, 1.08-2.96; p = 0.03), receiving inhaled nitric oxide (iNO) at extubation (aOR, 2.22; 95% CI, 1.13-4.35; p = 0.02), and duration of postoperative MV (aOR, 1.03; 95% CI, 1.00-1.06; p = 0.03) were independently associated with EF. Seven hundred ninety-two patients (86%) had pre-extubation ID o2 data, 602 (65%) had pre-extubation IV co2 data, and 600 (65%) had both pre-extubation ID o2 and IV co2 data available. In multivariable analysis including these risk analytics algorithms, patients with either ID o2 greater than or equal to 5 or IV co2 greater than or equal to 50 before extubation had higher odds of EF (aOR, 2.06; 95% CI, 1.08-3.94; p = 0.03).</p><p><strong>Conclusions: </strong>The addition of risk analytics algorithms evaluating the probability of inadequate systemic oxygen delivery or inadequate ventilation to clinical factors (duration of ventilation or iNO delivery at extubation) is useful in assessing the risk for EF in children recovering from cardiac surgery.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1105-e1114"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144743965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Proposed Component of an Extubation Readiness Bundle: Science or Marketing?","authors":"Ira M Cheifetz","doi":"10.1097/PCC.0000000000003802","DOIUrl":"10.1097/PCC.0000000000003802","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1172-e1174"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144760754","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"End-of-Life Course and Subspecialty Palliative Care Involvement for Children on Mechanical Circulatory Support: Five-Center Retrospective Cohort Study from the United States, 2015-2020.","authors":"Zasha Vazquez Colon, Lorelei Robinson, Dalia Lopez-Colon, Anna Joong, Elisha Waldman, Claudia Delgado-Corcoran, Lindsay J May, Melissa K Cousino, David M Peng, Stevan Lukich, Elizabeth D Blume, Desiree S Machado, Katie M Moynihan","doi":"10.1097/PCC.0000000000003792","DOIUrl":"10.1097/PCC.0000000000003792","url":null,"abstract":"<p><strong>Objectives: </strong>To characterize end-of-life (EOL) care and subspecialty palliative care (SPC) involvement in children with heart disease supported on mechanical circulatory support (MCS), including ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO).</p><p><strong>Design: </strong>A multicenter retrospective study describing clinical characteristics, SPC involvement and timing, and EOL circumstances.</p><p><strong>Setting: </strong>Five U.S. centers.</p><p><strong>Patients: </strong>Children (< 18 yr old) with heart disease who received MCS from January 1, 2015, to July 1, 2020.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Overall, 169 deaths occurred in 838 patients receiving MCS, including 23 VAD and 146 ECMO decedents. VAD patients were more likely to die after initial improvement than deterioration, whereas ECMO deaths were more likely to occur early post-cannulation or following persistent decline without improvement. Most patients died the day of MCS discontinuation (22/23 VAD and 92% of ECMO deaths). Overall, 87%, 33%, and 13% had ventilation, inotropes, or dialysis discontinued as part of the EOL process, respectively. SPC followed 72 patients (43%; 11/23 VAD and 42% of ECMO decedents). Early consult (either preimplantation or > 30 d before death) occurred in 36 patients (21%), including all VAD decedents with SPC involved. Accounting for clustering by institution, SPC involvement was associated with two times greater odds of advance care planning (ACP; 95% CI, 1.05-4.26) and lower odds of cardiopulmonary resuscitation (CPR; 0.35; 95% CI, 0.12-0.99).</p><p><strong>Conclusions: </strong>Most pediatric deaths after MCS occur soon after discontinuation of devices while receiving invasive therapies in ICUs. SPC teams were involved in less than half of the cases, with only 21% being consulted early. SPC was associated with more ACP and less CPR at EOL. Further research is needed to better understand the barriers to, and advantages of, SPC involvement in children receiving MCS, as well as how to better identify patients who will benefit from early consultation to promote goal-concordant care.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1115-e1125"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144691183","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Parent and Provider Perspectives on Short-Term Outcomes of Critically Ill Ventilated Children.","authors":"Megan M Shannon, Garrett Keim, Michael O Harhay, Nadir Yehya","doi":"10.1097/PCC.0000000000003794","DOIUrl":"10.1097/PCC.0000000000003794","url":null,"abstract":"<p><strong>Objectives: </strong>As mortality is rare in pediatrics, alternative composite outcomes such as ventilator-free days (VFDs), PICU-free days, or hospital-free days, are often used in pediatric critical care research. However, it is unclear which of these nonmortality components of composite outcomes are prioritized by families, and thus reflect true patient-centered outcomes. We therefore aimed to determine and compare families' and PICU providers' priorities regarding outcomes for ventilated patients in the PICU. We hypothesized that families and providers would prioritize different nonmortality outcomes.</p><p><strong>Design: </strong>This is a single-center, prospective cross-sectional survey of immediate caregivers of children experiencing both invasive and noninvasive ventilation and asynchronously of PICU attending providers. Subjects were asked to rank, in order of priority, five nonmortality outcomes: duration of invasive ventilation, duration of invasive and noninvasive ventilation, duration of any oxygen support, PICU length of stay (LOS), and hospital LOS.</p><p><strong>Setting: </strong>Quaternary, academic PICU in urban setting.</p><p><strong>Subjects: </strong>We surveyed 50 adult caregivers and 30 PICU faculty.</p><p><strong>Interventions: </strong>Survey administration at a single timepoint.</p><p><strong>Measurements and main results: </strong>While both families (kappa = 0.11) and providers (kappa = 0.15) demonstrated poor overall intra-group agreement of rankings, most families and providers ranked duration of invasive ventilation highest, and duration of invasive and noninvasive ventilation second highest. However, families ranked their subsequent priorities (in order) as the duration of all oxygen support, PICU LOS, and then hospital LOS. In contrast, providers ranked PICU LOS, then hospital LOS, and lastly, duration of all oxygen support.</p><p><strong>Conclusions: </strong>In a study that directly assessed family and provider preferences of nonmortality outcomes, we found that duration of invasive ventilation is indeed a patient- and family-centered outcome measure, while LOS is less prioritized in intubated PICU patients. This suggests that composites based on ventilator duration, such as VFDs, are indeed patient-centered.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":" ","pages":"e1149-e1153"},"PeriodicalIF":4.5,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12313130/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144691184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}