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Objective:To investigate the status of cognition and clinical management of prolonged mechanical ventilation(PMV) among medical staffs in pediatric intensive care unit(PICU) in China, and in order to improve the awareness of PICU medical staffs on PMV and standardize the management of PMV.Methods:The cross-sectional study was conducted with doctors and nurses in PICUs of the collaborative group as the survey objects from July 12 to September 12, 2020.The questionnaire was issued, collected and checked by the Children′s Hospital of Fudan University.Results:(1) PMV related settings: Nine out of eleven hospitals had established PMV multidisciplinary teams, respiratory techniques such as diaphragm ultrasound and airway peak flow monitoring could be respectively executed in 72.7% and 36.4% of PICU.Pulmonary rehabilitation techniques such as airway clearance techniques, induced spirometer exercise, external diaphragm pacemaker stimulation, transfer bed exercise, balloon blowing, hyperbaric oxygen therapy could be respectively executed in 100.0%, 9.1%, 9.1%, 9.1%, 27.3% and 27.3% of PICU, respectively.(2) The cognitive status quo of children′s PMV: The most medical staffs agreed with the view that PMV referred to the children′s continuous mechanical ventilation for more than two weeks.Sixty percent of medical staffs believed that children with PMV had basic central nervous system diseases, and 62.7% of medical staffs believed that the most common causes of difficulty in PMV weaning was abnormal brain function.(3) The cognitive status quo of the children′s PMV management in PICU: Respondents believed that the most commonly used mechanical ventilation mode was synchronized intermittent mandatory ventilation+ pressure support ventilation in children′s PMV during stable disease.Ninety-two percent of medical staffs performed the spontaneous breathing test when weaning.And 58.7% of the respondents agreed to perform tracheotomy for the children during 3 to 4 weeks of mechanical ventilation.More than half of medical staffs would execute diaphragm function assessment, bedside rehabilitation training, nutritional assessment, analgesia and sedation assessment for children with PMV.(4) The cognitive status quo of the children′s PMV management of transition from hospital to family: 54.5% of PICU provided family care training to the family members before the children were discharged from the hospital.One center established the PMV specialized outpatient clinic.45.5% of PICU would follow up these discharged children one month later.Conclusion:At present, PICU medical staffs have different awareness of children′s PMV related problems in China.And children′s PMV lacks a systematic plan regarding diagnosis, treatment and management.
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The number of children receiving prolonged mechanical ventilation has increased significantly in recent years.Nutritional support is very important to improve the prognosis of children on prolonged mechanical ventilation.But there is a lack of research, expert consensus or guidelines on nutritional support for children on prolonged mechanical ventilation now.This review summarized the process and strategy of nutrition support for children with prolonged mechanical ventilation based on the current research results.Multidisciplinary collaboration helps improve nutritional support outcomes.A large number of high-quality studies are needed to provide evidences to develop more rational and standardized nutritional support strategies.
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Antipyretic-analgesics are currently one of the most prescribed drugs in children.The clinical application of antipyretic-analgesics for children in our country still have irrational phenomenon, which affects the therapeutic effect and even poses hidden dangers to the safety of children.In this paper, suggestions were put forward from the indications, dosage form/route, dosage suitability, pathophysiological characteristics of children with individual differences and drug interactions in the symptomatic treatment of febrile children, so as to provide reference for the general pharmacists when conducting prescription review.
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Objective:To investigate the clinical features and prognosis of septic shock(SS) children with different basic diseases in pediatric intensive care unit (PICU).Methods:The medical records of SS children admitted to PICU at Beijing Children′s Hospital from January 1, 2017 to December 31, 2019 were collected retrospectively.They were grouped according to the presence or absence of basic diseases and types of basic diseases.The clinical characteristics, prognosis and pathogens of SS under different basic diseases were summarized.Results:A total of 218 children with SS were included during the study period, and the overall case fatality rate was 21.6%(47/218). There were 141 cases with basic diseases, accounting for 64.7%(141/218) and 24.1%(34/141) case fatality rate.The mortality rate was highest(37.5%, 17/45) in the malignant hematologic diseases and tumors patients with post-chemotherapy bone marrow suppression, and lowest(16.9%, 13/77) in patients with no underlying diseases.Gram-negative bacterial infection was more common in SS children with underlying diseases(63.1%, 41/65), and was highest in the malignant hematologic diseases and tumors patients with post-chemotherapy bone marrow suppression(80.0%, 20/25). Gram-positive bacteria accounted for the highest proportion in the group without underlying disease(52.1%, 25/48). The incidence of multiple organ dysfunction syndrome(MODS) was the highest(95.6%, 43/45) in the malignant hematologic diseases and tumors patients with post-chemotherapy bone marrow suppression, and the lowest(59.7%, 46/77) in the group without underlying disease.Conclusion:Gram-negative bacteria is the most common pathogen in SS children with underlying diseases, especially in malignant hematologic diseases and tumors patients with post-chemotherapy bone marrow suppression, and with high mortality and incidence of MODS.Gram-positive bacteria is the most common pathogen for those without underlying diseases, with a relatively low mortality and incidence of MODS.
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Mycoplasma pneumoniae (MP) is the most common pathogens of community-acquired pneumonia in children.Macrolides are the first-line antibiotics for mycoplasma pneumoniae pneumonia (MPP) treatment.However, in recent years, with macrolide resistant MP (MRMP) becoming prevalent, refractory MPP (RMPP) and fulminant MPP (FMPP) increased significantly.It has become a hot issue for clinicians.This paper reviewed the recent studies on MRMP, RMPP and FMPP, discussed the diagnosis and treatment options for MRMP, RMPP and FMPP in detail.Prioritizing the selection of sensitive antibiotics and early initiation of effective antibiotic therapy, appropriate use of immunoregulatory and anti-inflammatory therapies, and aggressive treatment of complications and co-infections are the keys to RMPP and FMPP therapy.
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Objective:To evaluate the efficacy and safety of nasal continuous positive airway pressure(NCPAP) in the treatment of congenital airway stenosis with severe pneumonia.Methods:A single-center retrospective clinical study was used to select children with congenital airway stenosis and pneumonia who were admitted to PICU of Beijing Children′s Hospital of Capital Medical University during 5 years and treated with NCPAP within 48 hours after admission.The baseline data, clinical manifestations, vital signs, arterial blood gas, clinical outcomes, NCPAP use time and adverse reactions were collected.Results:A total of 64 children were included in this study, with 58 cases in the effective group and six cases in the ineffective group.The total effective rate of NCPAP was 90.6% (58/64) during 5 years.In the effective group, 63.8% patients were weaned in three to seven days, with an average weaning time of 6.09 days.In the effective group, the heart rate and PaCO 2 after NCPAP treatment were significantly lower than that before treatment, and pH and PaO 2 were significantly higher than that before treatment, and the difference was statistically significant (all P<0.05). A total of six patients in the ineffective group were finally changed to tracheal intubation and invasive ventilation.The survival rate of both groups was 100%.All cases had no adverse reactions or complications. Conclusion:NCPAP can effectively improve the oxygenation in children with congenital airway stenosis and severe pneumonia, with high efficiency and good safety.
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Objective:To explore the vasculopathy of central nervous system (CNS) infections in critically ill children.Methods:The clinical data of 43 children with CNS infections requiring mechanical ventilation admitted to the Intensive Care Unit of Beijing Children′s Hospital from July 2017 to October 2018 were analyzed retrospectively.The peak systolic velocity and the pulsatility index of the bilateral middle cerebral artery in each child were detected by Transcranial Doppler (TCD), and the vasculopathy was explored by combining with the imaging manifestations such as computed tomography or magnetic resonance imaging.Results:TCD results were normal in 11 cases and abnormal in 32 cases.In the abnormal group, the cerebral blood flow velocity increased in 27 cases and decreased in 5 cases.Of the 27 cases with increased velocity, 15 cases met the criteria of vasospasm, and 4 of the 5 cases with decreased velocity showed shock waves.Among all patients, 21 cases (48.9%) had cerebral hypoxic-ischemic manifestations, 6 cases (13.9%) had cerebral hemorrhage (5 cases were accompanied with cerebral ischemia), and 2 cases (4.7%) were complicated with cerebral malacia during hospitalization.Twenty cases in all of them had completed magnetic resonance angiography, which was abnormal in 14 cases (70%). There were 32 cases (74.4%) with poor prognosis at discharge, including 10 cases of death or brain death (23.3%, 10/32 cases).Conclusions:Cerebral hemodynamic abnormalities and ischemic changes are more common in children with severe encephalitis.Patients with vasospasm or decreased flow velocity have the worst prognosis.
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Objective:To investigate the clinical characteristics and prognosis of children with septic shock caused by invasive pneumococcal diseases (IPDs) in pediatric intensive care unit (PICU).Methods:The clinical data of children diagnosed as septic shock caused by IPDs and hospitalized in the intensive care unit (ICU) of Beijing Children′s Hospital, Capital Medical University and the PICU of Henan Children′s Hospital from January 2013 to August 2019 were retrospectively collected, and the clinical characteristics and prognosis of these patients were analyzed.Results:Twenty-one children were included, with a median age of 1.2 (0.75, 3.90) years old.The pediatric index of mortality 2 (PIM-2) at admitting was (23.3±29.6)%, and 6 cases had underlying diseases.Main sites of infection included blood flow (20 cases) and suppurative meningitis (15 cases). The drug sensitivity test was performed on 18 children, among who 9 cases were sensitive to Penicillin, 10 cases to Cefepime, 11 cases to Cefotaxime and 10 cases to Meropenem.All 18 patients were sensitive to Vancomycin and Linezolid.Seven cases and 13 cases were treated with sensitive antibiotics at the disease onset and before septic shock, respectively.In 21 cases whose lactic acid level was (6.1±4.6) mmol/L, the shock redress time of 10 cases was (10.9±10.1)h, and 13 cases (61.9%) died (14.6±12.2) hours after septic shock, among who 10 died of transforamed magna herniation.The PIM-2 score at admitting into PICU and the rate of intracranial hypertension crisis in the death group were significantly higher than those in the survival group [(37.1±30.3)% vs.(0.9±1.3)%, 69.9% (9/13 cases) vs.25.0% (2/8 cases)](all P<0.05). There was no significant difference in age and the utilization rate of effective antibiotics before septic shock between the two groups (all P<0.05). Four of the surviving 8 children had severe cerebral functional disability. Conclusions:Septic shock caused by IPD is more common in children under 5 years old, and the most common sites are blood flow and intracranial infection.It has high resistance rate against Cephalosporins and Carbopenem.Patients with purulent meningitis are easy to develop intracranial hypertension crisis, which has an extremely high mortality and morbidity, so it needs to be identified and treated early.
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Objective@#To evaluate the effect of prophylactic nimodipine in vasospasm prevention and outcome improvement in children with subarachnoid hemorrhage (SAH).@*Methods@#A prospective, randomized controlled clinical trial which enrolled children with SAH who were admitted to pediatric intensive care unit (PICU) of Beijing Children′s Hospital from January 2015 to October 2018 was conducted. A total of 43 patients were randomly divided into nimodipine group (24 patients) and control group (19 patients) according to random number table. Transcranial Doppler (TCD) was used to dynamically monitor blood flow velocity and spectrum monography of bilateral middle cerebral artery (MCA) for vasospasm evaluation. Pediatric cerebral performance category (PCPC) scale was used to evaluate patients′ brain function on 28th day after discharge. Data were analyzed by t test, Mann-Whitney U test, χ2 test.@*Results@#Except heart rate ((157±26) vs. (137±34) beats/min, t=2.079, P=0.045), no significant differences existed between the two groups in basic demographic characteristics, primary diseases, and clinical manifestations (all P>0.05). The peak velocities of bilateral MCA on the 5th day after admission were significantly lower in nimodipine group (left MCA (136±34) vs. (158±23) cm/s, t=-2.890, P=0.006; right MCA (129±34) vs. (176±27) cm/s, t=-3.717, P=0.001). Likewise, a lower peak velocity of left MCA was observed on the 7th day after admission in nimodipine group ((127±45) vs. (152±13) cm/s, t=-2.903, P=0.007), but no significant difference existed in that of right MCA ((131±48) vs. (150±22) cm/s, t=-1.760, P=0.090). Eleven patients suffered from vasospasm, 25% (6/24) in nimodipine group and 26% (5/19) in control group (χ2=0.010, P=1.000), within whom 8 patients had complete remission after continuing nimodipine treatment, one died in hospital and the other two′s vasospasm still existed at the time of discharge. No significant differences were found between the two groups in mean length of hospitalization, proportion of mechanical ventilation, Glasgow coma scale at discharge, survival rate at discharge or survival rate on 28th day after discharge (all P>0.05). However, nimodipine group had a higher proportion of favorable PCPC brain function (92% (22/24) vs. 63% (12/19), χ2=5.208, P=0.030). No side effects such as hypotension, rash or injection site erythema were observed.@*Conclusion@#Prophylactic nimodipine cannot reduce vasospasm incidence in children with SAH but may improve short-term brain function, without any significant safety issues.
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Objective To analyze the clinical characteristics of fatal cases with confirmed influenza A ( H1N1) in children in order to improve the diagnosis and treatment. Methods The fatal cases of influenza A (H1N1) admitted to Pediatric Intensive Care Unit of Beijing Children′s Hospital from December 2017 to March 2018 were collected,whose clinical features,diagnosis,treatment,and the causes of death were ana-lyzed retrospectively. Results A total of eight children were enrolled. The age ranged from 3 months to 9 years,and six cases were less than 5 years old. Four cases had underlying diseases. All patients had fever, cough,dyspnea,cyanosis,flaring nares and three depressions sign. Four cases had coma. On admission,the average score of pediatric index of mortality was 58. 8％. Blood routine test showed that lymphocyte predomi-nance in six cases, three cases had leukopenia. C-reactive protein elevated in five patients. Procalcitonin increased in all cases. P/F ratio (PaO2/FiO2) were less than 100 mmHg(1 mmHg =0. 133 kPa) in four cases who were diagnosed as severe acute respiratory distress syndrome. The pulmonary imaging showed mul-tiple parenchymal or mixed lesions. Three cases had air leakage syndrome,and one had pleural effusion. Bac-terial culture was performed on the day of admission. Four cases were complicated with bacterial infection. Three cases had Gram-positive cocci infection,and multidrug-resistant bacteria were predominant. The aver-age time from onset to definitive diagnosis was 8 days. Neuraminidase inhibitors were used in all patients,and the average time from onset to the first dose was 8 days. Mechanical ventilation were performed in all patients in this group. Extracorporeal membrane oxygenation was applied in one case. Four cases in this group died of severe acute respiratory distress syndrome. Three cases died of influenza associated encephalopathy,and one died of septic shock with multiple organ failure. Conclusion Fatal influenza A (H1N1) mostly appeares in children under 5 years old or with underlying diseases. Acute respiratory distress syndrome and influenza associ-ated encephalopathy are the main causes of death. Delayed diagnosis and delayed use of anti-influenza drugs may be an important factors leading to death,and bacteria infection may be another important cause of death.
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Thrombotic thrombocytopenic purpura (TTP) is a rare but fatal entity of thrombotic microangiopathies(TMAs).The pathophysiology of the disease is based on a severe functional deficiency of a disintegrin and metalloprotease with thrombospondin type 1 repeats,member 13 (ADAMTS-13),the specific von Willebrand factor (VWF)-cleavage protease.This deficiency may be either acquired or congenital.The clinical manifestations of TTP include microangiopathic hemolytic anemia,thrombocytopenia and dysfunction of involved organs,which are similar to other TMAs.The differential diagnosis with other TMAs may be challenging.The activity of plasma ADAMTS-13 ＜ 10％ is the only definitive method for diagnosis of TTP.The first-line treatment of the acute phase of TTP is based on plasmatherapy.In congenital TTP,patients benefit from a prophylactic plasmatherapy.In acquired TTP,steroids and B-cells depleting therapies are increasingly used together with plasma exchange.Long-term follow-up including the monitoring of ADAMTS-13 activity is mandatory.A severe decrease in ADAMTS-13 activity (＜ 10％) may predict relapses and preemptive B-cell depletion with rituximab can be used to prevent relapses of acquired TTP.
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Traumatic injuries are the most common cause of children death and disability in the world. Trauma resuscitation is a complex and dynamic process that is best managed by experienced,highly trained teams. Advanced trauma life support(ATLS) course is the most broadly disseminated and recognized training program for the initial assessment,stabilization and management of the injured patient worldwide. Pe-diatric trauma life support(PTLS) is the section of ATLS on emergency management of childhood trauma. ATLS course provided a standardized approach to the care of critically injured patients. It introduced the air-way(A)-breathing(B)-circulation(C)-disability(D)-exposure(E) sequence of initial evaluation to trauma care and highlighting the importance of a team approach. When resuscitation efforts are well established,and the vital signs are normalizing or improving,the secondary survey can be conducted. The secondary survey is a head-to-toe evaluation of the trauma patient,including a complete history,physical examination,and the reassessment of all vital signs. The ATLS and PTLS systematic evaluation is designed to help clinicians focus on life-threatening problems and minimize the risk of missed injuries.
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Objective To analyze the cause of fatal cases in children with confirmed influenza virus infection,and in order to improve the level of diagnosis and treatment.Methods Deaths in critical illness of influenza were collected from November 2017 to April 2018 in Pediatric Intensive Care Unit of Beijing Children's Hospital,Capital Medical University.The clinical characteristics and causes of death were retrospectively analyzed according to the different virus types.Results A total of 19 cases were included.Fifteen cases (78.95％) were less than 5 years old and 9 cases (47.37％) were less than 2 years old.On admission,the median score of pediatric index of mortality 2 was 72.7％.There were 11 cases of influenza H1N1 and 8 cases of influenza B.Six cases had underlying diseases.All patients had fever,cough and dyspnea.Thirteen patients had coma.Seventeen cases had pneumonia,11 cases had severe acute respiratory distress syndrome(ARDS),3 cases had air leakage syndrome and 8 cases had influenza-related encephalopathy(IAE).Ten cases (52.63％) died of severe ARDS,7 cases (36.84％) died of IAE,1 case(5.26％) died of multiple organ dysfunction,and 1 case(5.26％)died of severe myocarditis and cardiogenic shock.There was statistical difference in the time from onset to death between the ARDS group and IAE group[15(4,22) d vs.3(2,8) d] (Z =-2.063,P =0.039).Among the children who died of severe ARDS,most patients in influenza H1 N1 group ＜ 2 years old,while those influenza B group ≥ 2 years old.All children who died of IAE were all ≥ 1 years old.Six cases (31.58％) had bacterial infection,mainly gram-positive cocci.All patients were treated with neuraminidase inhibitors.The average time from onset to the first time of medication was 5 days.Conclusions Severe ARDS and IAE are the main causes of death in children with influenza virus infection.Compared with ARDS,the condition of children with IAE worsened more rapidly.
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A working knowledge about the management of poisoning in children is essential for all pediatricians and nurses involved in acute pediatric care. Having an organized,efficient and consistent approach to the diagnosis and management of poisoned or potentially poisoned patients is paramount.When presented with a poisoned or potentially poisoned patient,considerations for both diagnosis and treatment may occur sequentially or simultaneously,depending on the clinical situation and severity of illness.The diagnostic arm consists of taking detailed toxicologic history,performing physical examination with attention to toxidrome recognition and carrying through certain diagnostic test that may provide useful information.The treatment arm involves emergency stabilizing the airway, breathing and circulation, deciding the decontamination method by clinical scenario, choosing the enhancing elimination procedure according to certain xenobiotics,and using specific antidote carefully when indicated.
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Objective To investigate the prognostic factors of pediatric acute respiratory distress syndrome(pARDS),according to pARDS criteria from the 2015 Pediatric Acute Lung Injury Consensus Con-ference.Methods Clinical data of 69 cases with pARDS in PICU of Beijing Children′s Hospital affiliated to Capital Medical University from January 2009 to December 2015 were retrospectively analyzed. Results Among the 69 cases of pARDS,there were 13 cases with mild ARDS,19 cases with moderate ARDS and 37 cases with severe ARDS. Seventeen pARDS were dead in PICU,including 2 mild pARDS,3 moderate pARDS and 12 severe pARDS,and 14 pARDS of them were female,3 pARDS were male.Gender and chron-ic complication were related to the outcomes of pARDS,and the difference was significant(P<0.05).The mortality of pARDS with chronic complication was up to 69.23%.Duration of mechanical ventilation was related to PICU hospital stay and total length of hospital stay(correlation:0.324,0.181,P<0.01).Duration of mechanical ventilation was also related to weight(correlation 0.491,P<0.01),and weight was a protec-tive factor.Conclusion pARDS is one of the most critical diseases in PICU with low morbidity and high mortality,the mortality of pARDS in this study is 24.64%.Female or chronic co-morbidities pARDS may have poor prognosis.Duration of mechanical ventilation determines the PICU length of stay and total hospital length of stay,and weight is the protective factor of the duration of mechanical ventilation.
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Fatal arrhythmias are much less common in children than adults and the symptoms presented may be nonspecific.The critical rescue measures for these patients are to identify and appropriately manage the arrhythmias,since when left untreated,arrhythmias may lead to cardiopulmonary compromise and arrest.Most children with a fatal arrhythmia present to a emergency physician before being referred to a pediatric cardiologist for assessment and management.Thus,the emergency pediatricians have to be able to recognize the fatal arrhythmia and to provide the acute treatment.This article was intended to provide diagnostic and acute management measures of the common types of fatal arrhythmias seen in children.
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Nutrition practice in burn injury requires a multifaceted approach aimed at providing meta-bolic support during a heightened inflammatory state,while accommodating surgical and medical needs of the patient. Nutritional assessment and determination of nutrient requirements are difficult,particularly given the metabolic disarray that frequently accompanies inflammation. Nutritional therapy requires careful decision making,regarding the safe use of enteral or parenteral nutrition and the aggressiveness of nutrient delivery given the severity of the patient′s illness and response to treatment.
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Objective To assess the effect of scene simulation-based teaching on pediatric advanced life support(PALS)skills in medical students.Methods The students of two grades of Department of Pedi-atrics in Capital Medical University participated in the PALS training.All of them had the examination of the-ory and skills of critical illness management and cardiopulmonary resuscitation in children before and after the scene simulation-based teaching on PALS.The questionnaire was filled out and the data was analyzed after the training.Results Fifty-one students completed the training.The average score after the training was sig-nificantly higher than that before the training(86.51 ±7.16 vs.53.85 ±14.24,P ﹤0.05).After the training, the error rate of ECG recognition,etiological identification and treatment of the disease,and the dosage as well as usage of medicine was significantly decreased (64.7% vs.15.7%,71.0% vs.10.5%,73.2%vs.25.9%).All of the students could use the defibrillator correctly and the students'satisfaction rate was more than 94%.Conclusion Scene simulation-based teaching on PALS skills can improve the theory and skills of critical illness management and cardiopulmonary resuscitation of children in medical students.
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Objective To analyze the epidemiologic characteristics and risk factors for mortality in non-(human immunodeficiency virus,HIV) infected children with pneumocystis carinii pneumonia(PCP). Methods The data of non-HIV infected children with PCP diagnosed in Beijing Children′s Hospital from January 1,2006 to December 31,2012 were collected. They were divided into survival and non-survival group according to the prognosis. The epidemiologic characteristics and risk factors for mortality were analyzed. Results Sixteen patients were enrolled in this study. Ten of them survived and 6 of them were non-survived. The basic diseases included malignant tumor in 5 patients and non-malignancy diseases in 11 of them. Com-pared with the survival group,the non-survival group had a higher average age [(12. 00 ± 2. 00) years vs. (6. 65 ± 4. 32)years,P=0. 01],higher ratio to need mechanical ventilation (6/6 vs. 4/10,P=0. 04),lower PaO2/FiO2[(73. 88 ±26. 95) mmHg vs. (167. 50 ± 97. 17) mmHg,1 mmHg=0. 133 kPa,P=0. 01] and lower pediatric critical illness score(75. 67 ± 5. 72 vs. 86. 40 ± 8. 88,P=0. 02). There were no differences on sex ratio,kinds of basic diseases,whether with co-infections,the time of immunosuppressant administration, the time from onset to diagnosis,the time from onset to beginning trimethoprim-sulfamethoxazole therapy, PaCO2 ,white blood cell counts,lymphocyte counts,CD4+ cell counts,C-reactive protein,and hemoglobin con-centrations between the survival and non-survival group. Conclusion A higher age, need for mechanical ventilation,lower PaO2/FiO2 and lower pediatric critical illness score were risk factors for mortality in non-HIV infected children with PCP.