Invasive Group A Streptococcal Infections in Pediatric Critical Care: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVE: The reported rising global rates of invasive group A Streptococcus (iGAS) infection raise concern for disease related increase in critical illness and fatalities. An enhanced understanding of various presentations to health care and clinical course could improve early recognition and therapy in children with iGAS. The objective of this study was to describe the epidemiology of iGAS infections among children admitted to critical care. METHODS: A retrospective cohort study of children admitted to the PICU at The Hospital for Sick Children, in Toronto, Canada, between March 2022 and June 2023. Eligible patients were 0 to 18 years, with a diagnosis of iGAS infection. We describe the proportion of children admitted to the PICU with iGAS over the study period, their clinical characteristics, the frequency and timing of therapies, discharge versus baseline function, and PICU mortality. RESULTS: Among the 1820 children admitted to the PICU, 29 (1.6%) patients had iGAS infection. Of these 29 patients, 80% (n = 23) survived to hospital discharge. Patients who survived generally had favorable functional outcomes. Despite the high severity of illness and mortality described in this cohort, 61% returned to their baseline functional status by hospital discharge. CONCLUSIONS: This is the first report of critically ill children with iGAS in Canada during the increased incidence reported worldwide. We describe the clinical course of iGAS infection in children admitted to PICU with access to advanced extracorporeal interventions. Though there is a high mortality rate in this cohort, those who survive have favorable outcomes.

The carbon footprint of critical care: a systematic review.

PURPOSE: The provision of healthcare is a substantial global contributor to greenhouse gas (GHG) emissions. Several medical specialties and national health systems have begun evaluating their carbon emission contributions. The aim of this review is to summarise and describe the carbon footprint resulting from the provision of adult, paediatric and neonatal critical care. METHODS: A systematic search of Embase, Cochrane and Web of Science was performed in January 2023. Studies reporting any assessment of the carbon footprint of critical care were included. No language restrictions were applied. GHG emissions from life cycle assessments (LCA) were reported, in addition to waste, electricity and water use. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed. RESULTS: In total, 13 studies assessing and describing the environmental impact of 36 adult or paediatric intensive care units (ICUs) were included. Two studies described full LCAs, seven reported waste only, two provided audits of unused medical supplies, one reported electricity use, and one study described a Material Flow Analysis. The estimated carbon emissions from critical care range between 88 kg CO2e/patient/day and 178 kg CO2e/patient/day. The two predominant sources of carbon emissions in critical care originate from electricity and gas use, as well as consumables. Waste production ranged from 1.1 to 13.7 kg/patient/day in the 6 studies where mean waste could be calculated. CONCLUSION: There is a significant carbon footprint that results from intensive care provision. Consumables and waste constitute important, measurable, and modifiable components of anthropogenic emissions. There remains uncertainty due to a lack of literature, several unstudied areas of carbon emissions from critical care units, and within measured areas, measurement and reporting of carbon emissions are inconsistent.

Furosemide in pediatric intensive care: a retrospective cohort analysis.

Introduction: Furosemide is the most commonly used medication in pediatric intensive care. Growing data indicates improved hemodynamic stability and efficacy of furosemide infusions compared to intermittent injections, thereby suggesting furosemide infusions might be considered as first line therapy in critically ill, paediatric patients. The objective of this study is to examine furosemide treatment as either continuous infusions or intermittent injections and subsequent patient outcomes. Methods: This is a retrospective cohort analysis of patients treated in a pediatric intensive care unit (ICU) over a nine year period (July 31st 2006 and July 31, 2015). Eligible patients were admitted to either the general pediatric or cardiac specific ICU for a duration of at least 6 hours and who received intravenous furosemide treatment. Results: A total of 7,478 patients were identified who received a total of 118,438 furosemide administrations for a total of 113,951 (96%) intermittent doses and 4,487 (4%) infusions running for a total of 1,588,750 hours. A total of 5,996 (80%) patients received exclusively furosemide injections and 1,482 (20%) patients received at least one furosemide infusion. A total of 193 patients died during ICU admission, amounting to 87 (6%) of the 1,482 patients who received an infusion and 106 (2%) of the 5,996 who received intermittent injections. Multivariable regression analysis showed no statistically significant decrease in adjusted mortality for patients who received furosemide injections compared to furosemide infusions (aOR 1.20, CI 0.76-1.89). Discussion: This retrospective study observed similar mortality for patients who received furosemide infusions compared to furosemide injections. More research on furosemide in the ICU could provide insights on fluid management, drug effectiveness, and pharmacologic stewardship for critically ill children.

Pharmacotherapy in Critically Ill Children: A Retrospective Review of 17,199 Admissions.

OBJECTIVES: Despite the ubiquitous role of pharmacotherapy in the care of critically ill children, descriptions of the extent of pharmacotherapy in critical illness are limited. Greater understanding of drug therapy can help identify clinically important associations and assist in the prioritization of efforts to address knowledge gaps. The objectives of this study were to describe the diversity, volume, and patterns of pharmacotherapy in critically ill children. DESIGN: A retrospective cohort study was performed with patient admissions to the ICU between July 31, 2006, and July 31, 2015. SETTING: The study took place at a single, free-standing, pediatric, quaternary center. PATIENTS: Eligible patient admissions were admitted to the ICU for more than 6 hours and received one or more drug administration. There were a total 17,482 patient-admissions and after exclusion of 283 admissions (2%) with no documented enteral or parenteral drug administration, 17,199 eligible admissions were studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 17,199 eligible admissions were admitted to the ICU for 2,208,475 hours and received 515 different drugs. The 1,954,171 administrations were 894,709 (45%) enteral administrations, 998,490 (51%) IV injections and 60,972 (3%) infusions. Infusions were administered for 4,476,538 hours. Twelve-thousand two-hundred seventy-three patients (71%) were administered five or more different drugs on 80,943 of patient days (75%). The 10 most commonly administered drugs comprised of 834,441 administrations (43%). CONCLUSIONS: Drug administration in the ICU is complex, involves many medications, and the potential for drug interaction and reaction is compounded by the volume and diversity of therapies routinely provided in ICU. Further evaluation of polytherapy could be used to improve outcomes and enhance the safety of pharmacotherapy in critically ill children.

Concurrent intravenous drug administration to critically ill children: Evaluation of frequency and compatibility.

PURPOSE: To evaluate the frequency of concurrent drug administration and drug-drug incompatibility of concurrently administered drugs in critically ill children based on available references. MATERIALS AND METHODS: We retrospectively evaluated concurrent intravenous drug administration in children admitted to a single centre. Eligible patients included those admitted to the critical care unit for at least 6-hours in the ten-year period ending 30 July 2015 and received two or more IV drug administrations. Compatibilities were classified using local reference documents. RESULTS: The 16,863 eligible patients were admitted to ICU for 2,212,326h and received 3,664,667 concurrent administrations. Concurrent infusions ran for 6,263,600h. There were 2,284,066 (62%) concurrent administrations; 334,144 (9%) were compatible, 293,856 (8%) were incompatible, 293,856 (8%) required pharmacist consultation, and 752,601 (21%) had 'unknown' compatibility. Individual patients received a median (IQR) of 33 (10-132) concurrent administrations, comprised of 7 (1-30) concurrent injections 1 (0-5) concurrent infusions and 13 (0-74) concurrently administered injections and infusions. CONCLUSIONS: Concurrent IV-drug administration is frequent in critically ill children. Known incompatible concurrent administration occurs, however the compatibilities of many drug-drug pairs were unknown - adding complexity to routine bedside management and identifying information gaps for future research.