Long-Term Pediatric Outcomes of Decompressive Craniectomy after Severe Traumatic Brain Injury.

OBJECTIVE: There is no consensus on the use of decompressive craniectomy (DC) to manage severe traumatic brain injury (sTBI). We evaluated the profile of pediatric patients admitted with sTBI and assessed functional outcomes, 6 months posttrauma, in patients who had a DC and in those who had not, and the functional outcomes of early versus late DCs. PATIENTS AND METHODS: This case-control observational study evaluated pediatric patients admitted for sTBI in Puerto Rico (June 2016-October 2018); we included patients admitted within 24 hours of injury and had a Glasgow Coma Scale (GCS) of 8 or lower. 6-month post trauma outcomes were measured with the Glasgow Outcome Scale Extended Pediatric (GOS-E Peds). RESULTS: 20 patients were included; 15 underwent a DC and 5 comprised the control group. We found no differences in terms of sex, age, GCS score, Pediatric Risk of Mortality score, or Pediatric Trauma Score. However, in the DC group, a higher percentage of patients presented significant cerebral herniation in the initial computed tomography scan (CT) (DC: 73%; control: 0%; P = .005). No differences were found regarding intracranial pressure (ICP), cerebral perfusion pressure, mean arterial pressure, PaCO2, or temperature. Patients in the DC group had longer hospital stay (DC: 41; control: 17 days; P = .0005). All patients with DC survived, with an early procedure being associated with favorable outcomes. CONCLUSION: As determined 6 months post-trauma, this study showed that early DC increased survival and improved functionality.

The psychological impact of the COVID-19 pandemic on physicians in Puerto Rico: a cross-sectional study after the second wave in 2021.

Introduction: Health care providers faced a challenge with the emergence of COVID-19 and its rapid spread. Early studies measuring the psychological impact of COVID-19 on the general population found high levels of anxiety and sleep disorders. The primary goal of this project was to assess the psychological impact of COVID-19 on physicians in Puerto Rico. Materials and methods: A cross-sectional study of physicians in Puerto Rico was conducted anonymously and electronically from February 2021 through April 2021. The electronic survey included socio-demographic data and 4 self-administered assessment tools (Generalized Anxiety Disorder-7, Perceived Stress Scale-10, Pittsburgh Sleep Quality Index and COVID-19 Organizational Support) for anxiety, perceived stress, sleep disturbances, and organizational support during the COVID-19 pandemic. Results: A total of 145 physicians completed the survey, with a female predominance of 53.5% and a majority practicing in the San Juan metropolitan area (50.3%). Mild anxiety symptoms were reported in 26.9% of physicians, and 33.8% had moderate to severe anxiety symptoms. Moderate to high perceived stress was found in 69.9% of participants, and women reported statistically significantly higher levels of anxiety symptoms (8.84 ± 5.99; p = 0.037) and stress (19.0 ± 6.94, p = 0.001). The Pittsburgh Sleep Quality Index reported 67.9% of physicians with global scores associated with poor sleep quality. Assessment of perceived organizational support found a high perception of work support (65.7%) but low perception of personal support (43.4%) and risk support (30.3%). A correlation analysis found a negative correlation for work and personal support, but a positive correlation for risk support, all statistically significant. Conclusion: COVID-19 had a lasting psychological impact in health care providers in Puerto Rico a year after the beginning of the pandemic. Our data supports the importance of organizational support and its correlation with the development of anxiety. It is thus essential to develop strategies to identify individuals at risk of experiencing psychological disturbances and to provide effective support for medical professionals during medical emergencies for their well-being and optimal delivery of patient care.

Pediatric Risk, Injury, Failure, Loss, End-Stage renal disease score identifies acute kidney injury and predicts mortality in critically ill children: a prospective study.

OBJECTIVES: To determine whether Pediatric Risk, Injury, Failure, Loss, End-Stage renal disease (pRIFLE) criteria serve to characterize the pattern of acute kidney injury in critically ill pediatric patients. To identify if pRIFLE score will predict morbidity and mortality in our patient's cohort. DESIGN: Prospective cohort. SETTING: Multidisciplinary, tertiary care, ten-bed PICU. PATIENTS: A total of 266 patients admitted to PICU from November 2009 to November 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The incidence of acute kidney injury in the PICU was 27.4%, of which 83.5% presented within 72 hours of admission to the PICU. Patients with acute kidney injury were younger; weighed less; were more likely to be on fluid overload greater than or equal to 10%; and were more likely to be on inotropic support, diuretics, or aminoglycosides. No difference in gender, use of other nephrotoxins, or mechanical ventilation was observed. Fluid overload greater than or equal to 10% was an independent predictor of morbidity and mortality. In multivariate analysis, acute kidney injury and failure categories, as defined by pRIFLE, predicted mortality, hospital length of stay, and PICU length of stay. CONCLUSIONS: In this cohort of critically ill pediatric patients, acute kidney injury identified by pRIFLE and fluid overload greater than or equal to 10% predicted increased morbidity and mortality. Implementation of pRIFLE scoring and close monitoring of fluid overload upon admission may help develop early interventions to prevent and treat acute kidney injury in critically ill children.

Efficacy, safety and cost-efficiency of using an alternative technique for automated exchange transfusion in pediatric patients with sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) patients suffer complications requiring simple and/or exchange transfusion. In 1999 we developed an automated exchange technique using infusion pumps and vascular catheters (IV Pump Method). OBJECTIVE: To prove that IV Pump Method is cost-efficient, and as safe and effective as automated cell separators. METHODS: Retrospective chart review of SCD patients requiring exchange transfusion admitted to PICU from 2003-2009. Evaluated method used, complications, costs, and Hemoglobin S% (HgS%) change, excluding patients not requiring exchange transfusion. RESULTS: Cost-reduction with IV Pump Method is around $1000. Average HgS% reduction using IV Pump Method was 30.3 vs. 28.8 in Blood Cell Separator group (p = 0.84). We had no complications or mortalities, with the majority of patients being male (p = 0.03) and on the oldest age group (11-19 y/o) for both methods. CONCLUSION: The IV Pump Method is a safe, effective, and cost-efficient alternative to perform exchange transfusion.

Diabetic ketoacidosis in pediatrics: management update.

The management of diabetic ketoacidosis has remained unchanged for several years. Lately, as more evidence has been available, practice has been modified to simplify the management and avoid complications. For the last twenty years patients admitted to the Pediatric Intensive Care Unit (PICU) at the University Pediatric Hospital, were managed following a protocol where the patient's volume deficit was calculated based on the degree of dehydration (mild, moderate, and severe) and then administered accordingly over 36 hours. Also, we administered an insulin IV bolus (0.1 u/kg) prior to starting the insulin drip. Our experience employing this approach in the pediatric population had been successful having no morbidity or mortality due to cerebral edema. Nevertheless, new evidence, based on studies and international consensus, suggest changes should be made in the management of DKA. It is the new consensus that patients should be rehydrated over 48 hour period, and that the initial insulin bolus should be avoided. Of course, it needs to be pointed out, that the clinical status of each patient is the barometer by which therapy should be tailored. The following information is the new suggested guideline in the management of DKA.