Neurologic and Functional Morbidity in Critically Ill Children With Bronchiolitis. (Carroll)

Shein SL, et al. Neurologic and Functional Morbidity in Critically Ill Children With Bronchiolitis. Pediatr Crit Care Med. 2017 Dec;18(12): 1106-1113.

OBJECTIVES: Neurologic and functional morbidity occurs in ~30% of PICU survivors, and young children may be at particular risk. Bronchiolitis is a common indication for PICU admission among children less than 2 years old. Two single-center studies suggest that greater than 10-25% of critical bronchiolitis survivors have neurologic and functional morbidity but those estimates are 20 years old. We aimed to estimate the burden of neurologic and functional morbidity among more recent bronchiolitis patients using two large, multicenter databases.

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The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study. (Carroll)

Selewski DT, Askenazi DJ, Bridges BC, Cooper DS, Fleming GM, Paden ML, Verway M, Sahay R, King E, Zappitelli M. The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study. Pediatr Crit Care Med. 2017 Dec;18(12):1126-1135.

OBJECTIVE: To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation in children treated with extracorporeal membrane oxygenation.

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Critical Care Resource Utilization and Outcomes of Children With Moderate Traumatic Brain Injury. (Carroll)

Chandee T, et al. Critical Care Resource Utilization and Outcomes of Children With Moderate Traumatic Brain Injury. Pediatr Crit Care Med. 2017 Dec;18(12):1166-1174.

OBJECTIVES: To characterize admission patterns, critical care resource utilization, and outcomes in moderate pediatric traumatic brain injury. Continue reading

The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die. (Dodd)

Weiss SL, et al. The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die. Pediatr Crit Care Med. 2017 Sep;18(9):823-830.

OBJECTIVE: The epidemiology of in-hospital death after pediatric sepsis has not been well characterized. We investigated the timing, cause, mode, and attribution of death in children with severe sepsis, hypothesizing that refractory shock leading to early death is rare in the current era.

DESIGN: Retrospective observational study.

SETTING: Emergency departments and ICUs at two academic children’s hospitals.

PATIENTS: Seventy-nine patients less than 18 years old treated for severe sepsis/septic shock in 2012-2013 who died prior to hospital discharge.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Time to death from sepsis recognition, cause and mode of death, and attribution of death to sepsis were determined from medical records. Organ dysfunction was assessed via daily Pediatric Logistic Organ Dysfunction-2 scores for 7 days preceding death with an increase greater than or equal to 5 defined as worsening organ dysfunction. The median time to death was 8 days (interquartile range, 1-12 d) with 25%, 35%, and 49% of cumulative deaths within 1, 3, and 7 days of sepsis recognition, respectively. The most common cause of death was refractory shock (34%), then multiple organ dysfunction syndrome after shock recovery (27%), neurologic injury (19%), single-organ respiratory failure (9%), and nonseptic comorbidity (6%). Early deaths (≤ 3 d) were mostly due to refractory shock in young, previously healthy patients while multiple organ dysfunction syndrome predominated after 3 days. Mode of death was withdrawal in 72%, unsuccessful cardiopulmonary resuscitation in 22%, and irreversible loss of neurologic function in 6%. Ninety percent of deaths were attributable to acute or chronic manifestations of sepsis. Only 23% had a rise in Pediatric Logistic Organ Dysfunction-2 that indicated worsening organ dysfunction.

CONCLUSIONS: Refractory shock remains a common cause of death in pediatric sepsis, especially for early deaths. Later deaths were mostly attributable to multiple organ dysfunction syndrome, neurologic, and respiratory failure after life-sustaining therapies were limited. A pattern of persistent, rather than worsening, organ dysfunction preceded most deaths.

Dexmedetomidine for Sedation During Noninvasive Ventilation in Pediatric Patients. (Dodd)

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

OBJECTIVES: To describe the use of dexmedetomidine for sedation in a large cohort of nonintubated children with acute respiratory insufficiency receiving noninvasive ventilatory support.

DESIGN: Single-center, retrospective, observational cohort study.

SETTING: A large quaternary-care PICU.

PATIENTS: The study cohort included 202 children receiving noninvasive ventilatory and a dexmedetomidine infusion within 48 hours of PICU admission over a 6-month period.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The primary respiratory diagnoses in the cohort (median age, 2 yr) included status asthmaticus (60%) and bronchiolitis (29%). Dexmedetomidine was infused for a median of 35 hours with a median hourly dose across the patient cohort of 0.61 μg/kg/hr (range, 0.4-0.8 μg/kg/hr). The target sedation level was achieved in 168 patients (83%) in the cohort for greater than or equal to 80% of the recorded values over the entire noninvasive ventilatory course, with dexmedetomidine as the only continuously administered sedative agent. While vital signs were frequently abnormal relative to age-based norms, clinical interventions were needed rarely to treat bradycardia (13%), hypotension (20%), and hypopnea (5%). The most frequently used of these interventions was a dexmedetomidine dose reduction, fluid bolus, and titration of noninvasive ventilatory support. Five patients (2.5%) required endotracheal intubation: three due to progression of their respiratory illness, one with septic shock, and one with apnea requiring resuscitation. In 194 of 202 patients (96%), the outcome of the noninvasive ventilatory course was successful with the patient being weaned from noninvasive respiratory support to nasal cannula or room air.

CONCLUSIONS: Dexmedetomidine was often effective as a single continuous sedative infusion during pediatric noninvasive ventilatory. Cardiorespiratory events associated with its use were typically mild and/or reversible with dose reduction, fluid administration, and/or noninvasive ventilatory titration. Prospective studies comparing dexmedetomidine with other agents in this setting are warranted.