Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

OBJECTIVES: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.

An evaluation of vancomycin dosing for complicated infections in pediatric patients.

OBJECTIVE: To determine the incidence with which a vancomycin dosing regimen of 15 mg/kg per dose every 6 hours achieves steady-state trough concentrations of 15 to 20 mg/L in pediatric patients with complicated infections. METHODS: We performed a retrospective chart review for patients admitted to our children's hospital between July 1, 2009, and June 30, 2011. Patients were included if they were between 1 month and 18 years of age, had at least 1 steady-state vancomycin trough obtained, received an initial vancomycin dose of 15 mg/kg per dose every 6 hours, and were being treated for a diagnosis of meningitis, pneumonia, osteomyelitis, bacteremia/sepsis, or endocarditis. RESULTS: Seventy-four patients were enrolled, mean age of 4.2±3.9 years and weight of 17.0±11.2 kg. Five (6.8%) patients obtained an initial trough of 15 to 20 mg/L. Patients between 1.0 and 5.9 years of age were significantly less likely to achieve an initial trough of 15 to 20 mg/L compared with other age groups evaluated (P=.041). Thirty-four patients with initial subtherapeutic troughs received a dose adjustment and a follow-up vancomycin trough. Of these patients, 15 (44.1%) achieved a trough between 15 and 20 mg/L. The median dose for patients achieving a therapeutic trough at any point during the study was 80 mg/kg per day. CONCLUSIONS: A vancomycin dosing regimen of 15 mg/kg per dose every 6 hours is not likely to achieve a trough concentration of 15 to 20 mg/L in pediatric patients with complicated infections. An initial regimen of 80 mg/kg per day for these patients may be more likely to result in therapeutic steady-state concentrations of vancomycin.

Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support.

BACKGROUND/PURPOSE: Children receiving extracorporeal membrane oxygenation (ECMO) for respiratory failure can have significant fluid overload and renal insufficiency. Addition of inline continuous venovenous hemofiltration (CVVH) could provide additional benefits in fluid management compared to use of standard medical therapies with ECMO. METHODS: Patients with pediatric respiratory failure receiving ECMO with CVVH were case-matched to similar patients receiving ECMO without CVVH to compare fluid balance, medication use, and clinical outcomes. RESULTS: Twenty-six of eighty-six patients with pediatric respiratory failure on ECMO (30%) received CVVH for >24 h (median 7.5 days on CVVH). Survival was not significantly different between patients receiving CVVH and those who did not receive CVVH (P = 0.51). For ECMO survivors receiving CVVH, overall fluid balance was less than that in non-CVVH survivors (median 25.1 ml kg(-1) day(-1); range -40.2 to 71.2 vs. 40.2, 1.1 to 134.9; P = 0.028). Time to desired caloric intake was faster in patients receiving CVVH (1 day, 1-5) than in patients who did not receive CVVH (5 days; 1-11; P < 0.001). Patients receiving CVVH-ECMO also received less furosemide (0.67 vs. 2.11 mg kg(-1) day(-1); P = 0.009). CONCLUSIONS: Use of CVVH in ECMO was associated with improved fluid balance and caloric intake and less diuretics than in case-matched ECMO controls.

Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis.

OBJECTIVE: Continuous venovenous hemofiltration (CVVH) is used for renal replacement and fluid management in critically ill children. A previous small study suggested that survival was associated with less percent fluid overload (%FO) in the intensive care unit (ICU) before hemofiltration. We reviewed our experience with a large series of pediatric CVVH patients to evaluate factors associated with outcome. DESIGN: Retrospective chart review. SETTING: Tertiary children's hospital. PATIENTS: CVVH pediatric ICU patients from November 1997 to January 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: %FO was defined as total fluid input minus output (up to 7 days before CVVH for both hospital stay and ICU stay) divided by body weight. One hundred thirteen patients received CVVH; 69 survived (61%). Multiple organ dysfunction syndrome (MODS) was present in 103 patients; 59 survived (57%). Median patient age was 9.6 yrs (25th, 75th percentile: 2.5, 14.3). Median %FO was significantly lower in survivors vs. nonsurvivors for all patients (7.8% [2.0, 16.7] vs. 15.1% [4.9, 25.9]; p =.02] and in patients with > or =3-organ MODS (9.2% [5.1,16.7] vs. 15.5% [8.3, 28.6]; p =.01). The Pediatric Risk of Mortality Score III at CVVH initiation also was associated with survival in these groups, but by multivariate analysis, %FO was independently associated with survival in patients with > or =3-organ MODS (p =.01). CONCLUSIONS: Survival in critically ill children receiving CVVH in this large series was higher than in previous reports. CVVH survival may be associated with less %FO in patients with > or =3-organ MODS. Prospective studies are necessary to determine whether earlier use of CVVH to control fluid overload in critically ill children can improve survival.

The use of the air leak test and corticosteroids in intubated children: a survey of pediatric critical care fellowship directors.

INTRODUCTION: Uncertainties exist regarding the value of the air leak test or use of steroids for preventing post-extubation stridor and extubation failure in children. OBJECTIVE: Determine the practice preferences of pediatric critical care physicians regarding the air leak test and administration of glucocorticosteroids to prevent airway edema. METHODS: A 14-question survey regarding the value of the air leak test, use of glucocorticosteroids, and management of airway edema in intubated children was sent to all North American pediatric critical care fellowship directors affiliated with medical school teaching hospitals. RESULTS: The response rate was 85% (58/68). Seventy-six percent (44/58) routinely check for air leak prior to extubation. The physicians who check for air leak were more likely to delay extubation in order to administer glucocorticosteroids (60% [26/43] vs 15% [2/13], p = 0.01). An air leak of >or= 30 cm H(2)O was more likely (than >or= 20 cm H(2)O) to result in delaying extubation (95% [35/37] vs 51% [19/37], p <0.001). Of the respondents who use steroids for airway edema prophylaxis, 73% (24/33) give steroids based on the air leak test. CONCLUSIONS: The majority of surveyed pediatric critical care fellowship program directors rely on the air leak test and use corticosteroids to prevent post-extubation stridor and extubation failure. At an air leak of >or= 30 cm H(2)O most of the surveyed physicians would delay extubation and initiate glucocorticosteroids.