Morbidity Associated with Deviation from Pediatric Status Epilepticus Guidelines.

Treatment guidelines for the management of pediatric status epilepticus (PSE) are often institution-specific. We aim to characterize deviation from our hospital-based PSE treatment guidelines, the total dosage of benzodiazepines administered, and the need for intubation. The study population included all patients with an ICD -10 code for PSE who required admission to the Pediatric Intensive Care Unit (PICU) from April 2019 to April 2022. There were 66 PICU admissions. All patients with concern for PSE and altered mental status are admitted to the PICU. The cohort was divided between those treated according to the PSE protocol (benzodiazepine dose (0.05 mg/kg- 0.2 mg/kg) versus those who had low dose (≤0.05 mg/kg) and high-dose benzodiazepine (> 0.2 mg/kg) totals. The dosage was calculated as the total dose of benzodiazepines received pre-hospital and in the ED before intubation or transport. Forty-one (62 %) of patients received high-dose benzodiazepines (median 0.34 mg/kg [IQR 0.29-0.56], 19 (29 %) received recommended-dose benzodiazepines (median 0.13 mg/kg [IQR 0.09,0.15] and 6 (9 %) received low-dose (median 0.05 mg/kg [IQR 0.03,0.05]. The high-dose group was 15.9 (95 % CI = 3.7, 99.9) times more likely to be intubated controlling for the location of care (tertiary versus community hospital), and the age of the patient. The recommended-dose and low-dose groups required intubation with much less frequency.

Characterizing Sleep Disruption and Delirium in Children After Cardiac Surgery: A Feasibility Study.

OBJECTIVES: Patients in the pediatric cardiac ICU are frequently exposed to pharmacologic and environmental factors that predispose them to sleep disturbances and may increase the risk of delirium. In this pilot study, we sought to demonstrate the feasibility of actigraphy monitoring in pediatric cardiac ICU patients to investigate the association between sleep characteristics and delirium development. DESIGN: Prospective observational pilot study. SETTING: Pediatric cardiac ICU in an academic children's hospital in the United States. PATIENTS: Children admitted to the pediatric cardiac ICU after cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nineteen enrolled patients wore actigraphy watches that provided data for a total of 63 pediatric cardiac ICU days. The median pediatric cardiac ICU length of stay was 2 days (interquartile range, 1-3 d). The median sleep episode among all patients was 37 minutes in duration (interquartile range, 18-46 min), and the longest sleep episode was a median of 117 minutes (interquartile range, 69-144 min). Sixty-one percent of patients (95% CI, 36-83%) screened positive for delirium at least once during admission, and the median number of delirious days among those who were positive was 2 days (interquartile range, 1-3 d). The median percent sleep time was 43% for delirious patients and 49% for those with no delirium, with similar median sleep and longest sleep episodes. The median ratio of daytime activity/24-hr activity was 54% (interquartile range, 49-59%) in both groups. CONCLUSIONS: Actigraphy monitoring in conjunction with delirium screening is feasible in infants and children admitted to the pediatric cardiac ICU after cardiac surgery. Our data suggest that most children in the pediatric cardiac ICU experience severe sleep disruption and delirium is common. These pilot data provide important insights for the design of a large-scale observational study to investigate potential causal relationships between sleep disruption and delirium in the pediatric cardiac ICU.

Outcomes Analysis of Children Diagnosed With Hemophagocytic Lymphohistiocytosis in the PICU.

OBJECTIVES: Describe a single center experience of hemophagocytic lymphohistiocytosis in a PICU over a 10-year period, to identify clinical features that may be associated with worse outcomes, including mortality, hospital and ICU length of stay, and functional and cognitive impairments on discharge. DESIGN: Retrospective electronic medical record review, 2007-2017. SETTING: PICU located in a large urban academic quaternary care children's hospital. PATIENTS: All children admitted with hemophagocytic lymphohistiocytosis to our PICU from 2007 to 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were identified utilizing International Classification of Diseases, 9th Revision and International Classification of Diseases, 10th Revision codes. Each chart was reviewed for demographic information, hemophagocytic lymphohistiocytosis diagnostic criteria, laboratory data, Pediatric Risk of Mortality Score III, clinical features and events of ICU stay, and PICU and hospital (length of stay). Mortality at 1 year and change in Functional Status Scale from admission to discharge were recorded. There were 42 admissions with 33 unique patients. Median Pediatric Risk of Mortality score at admission was 9 (interquartile range, 7-16). Median PICU length of stay was 7 days (interquartile range, 2-21 d) and hospital length of stay was 24 days (interquartile range, 14-37 d). During their ICU stay, 56% of patients received mechanical ventilation, 43% required vasoactives, 18% required continuous renal replacement therapy, and 5% received extracorporeal life support. Clinical factors related to increased PICU length of stay included Pediatric Risk of Mortality III score (p = 0.019), maximum lactate dehydrogenase (p = 0.017), maximum total bilirubin (p = 0.042), need for mechanical ventilation (p = 0.002), vasoactive use (p = 0.02), and secondary infection (p = 0.007). The most common therapies for hemophagocytic lymphohistiocytosis included steroids (93%), etoposide (55%), and anakinra (48%). Of the 26 patients who survived to hospital discharge, 19% had newly acquired morbidities. Overall 1-year mortality was 42%. CONCLUSIONS: Hemophagocytic lymphohistiocytosis diagnosed in the PICU is a disease with high mortality. Patients who survive to discharge had relatively little morbidity, however, the mortality risk in the year following discharge continued to remain high.

Diabetic ketoacidosis, hyperuricemia and encephalopathy intractable to regular-dose insulin.

BACKGROUND: Diabetic ketoacidosis (DKA) in children less than 1 year of age is a rare occurrence. Typical presentation includes a prodrome of weight loss and polyuria with subsequent presentation to medical care when acidosis becomes symptomatic. CASE PRESENTATION: We describe an unusual case of a previously healthy infant with a 3 days' history of constipation, presenting acutely with abdominal pain, lethargy, and dehydration. On initial evaluation, our patient had profound encephalopathy, with marked tachypnea and work of breathing. Arterial blood gas revealed a pH of 6.9, pCO2 of 20 and a bicarbonate level of <5. There was profound leukocytosis (WBC 77 K/µL), hyperuricemia (uric acid 15.9 mg/dL), and evidence of pre-renal azotemia [blood urea nitrogen (BUN) 54, Cr 0.82]. Blood glucose was >700 mg/dL. Despite fluid resuscitation and insulin infusion of 0.1 unit/kg/h, which are the mainstays of therapy for DKA, her severe metabolic acidosis and altered mental status did not improve. Differential diagnosis for her metabolic derangements included inborn errors of metabolism, insulin receptor defects, toxic ingestions, and septic shock secondary to an underlying oncologic or intra-abdominal process. The patient was treated with broad spectrum antibiotics and rasburicase. She continued to have significant shock for the first 30 h of her hospital stay, requiring moderate vasoactive support. Due to her refractory acidosis and persistent hyperglycemia, insulin infusion was increased to 0.15 units/kg/h. A hemoglobin A1C obtained on the second hospital day revealed a level of 7.4 and helped to solidify the diagnosis. CONCLUSIONS: Metabolic acidosis in an infant requires a broad differential. Rasburicase should be considered in hyperuricemia and DKA.