Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit.

PURPOSE: We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. METHODS: Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. RESULTS: This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. CONCLUSION: These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Managing liminal time in the fly-in fly-out work camp.

Fly-in fly-out (FIFO) work camps are built and organized to ensure that long-distance rotational workers are fed, housed, and mobilized in sync with the pressing yet unpredictable rhythms of resource extraction. Positioned thus 'betwixt and between' the complex relations of work and life (Johnsen and Sørensen, 2015), the work camp is a generative yet hitherto neglected example of the temporal operations of permanent liminality (Bamber et al., 2017). But what does this mean for workers? If camp does the liminal work of managing the temporal challenges of the resource-based mobility regime, how do FIFO workers experience and respond to its inevitable lived consequences? Drawing on rare qualitative fieldwork in Canada's Athabasca Oil Sands, we explain the effects of camp time-disorientation, monotony, and entrapment-and examine the temporal tactics workers deploy to manage those effects, from embracing and disrupting internal camp routines to aligning and syncing with outside and future-oriented temporalities. We argue that workers' tactics make them 'competent liminars' (Borg and Söderlund, 2015) of camp time, which is, in turn, crucial to the latter's disciplining function within the FIFO mobility regime. Our findings invite renewed attention to the temporal mediation accomplished by liminal people and places, especially in organizational contexts aimed at institutionally harnessing social time to productive imperatives.

Usefulness of implementation of a protective mechanical ventilation bundle during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome.

OBJECTIVE: Defining the best ventilatory settings under ECMO remains a challenging question. Despite a well-defined ARDS treatment before ECMO initiation, there is no recommendation on how to ventilate a patient under ECMO for P-ARDS. Only a few descriptive studies are available on ventilatory settings during respiratory ECMO. We aim at evaluating the usefulness of a protective ventilation bundle under ECMO and its capacity to reduce the ventilatory pressure in our ECMO center. METHODS: We performed a monocentric retrospective study from January 2007 to December 2018. All children aged from 1 month to 18 years old and requiring an extracorporeal membrane oxygenation for a refractory acute respiratory distress syndrome were included. A protective mechanical ventilation under ECMO bundle has been developed in 2014. We compare the period 1 (before 2014) to the period 2 (after 2014). RESULTS: Eighty-three patient had been included during the study. We reported a significant increase of PEEP and mean pressure respectively at day 3, day 7 and day 14 of ECMO during the period 2. Conversely, the driving pressure were significantly lower in the period 2 at day 3 (p: 0.009), day 7 (p:0.001) and day 14 (p: 0.001). We also shown a strong increase in the use of prone positioning during ECMO in the period 2 (p: 0.01). There was no significant effect of our bundle on the length of mechanical ventilation, of hospitalization and on the survival rate. CONCLUSIONS: The implementation of a protective mechanical ventilation bundle during ECMO is usefulness to apply for lower ventilatory pressure and higher use of prone positioning. Nonetheless, the lack of power of our study prevents us from showing its efficacy on outcome criteria.

Extracorporeal membrane oxygenation for immunocompromised children with acute respiratory distress syndrome: a French referral center cohort.

BACKGROUND: Immunocompromised children are likely to develop a refractory acute respiratory distress syndrome (ARDS). The usefulness of providing extracorporeal life support (ECLS) to these patients is a subject of debate. The aim of our study was to report the outcomes and to compare factors associated with mortality between immunocompromised and non-immunocompromised children supported with veno-venous ECMO. METHODS: We performed a retrospective monocentric study in the French pediatric ECMO center of Armand Trousseau Hospital, including all pediatric patients aged from 1 month to 18 years requiring ECLS for ARDS. RESULTS: Between 2007 and 2018, one hundred and eleven (111) patients underwent ECMO for respiratory failure; among them twenty-five (25) were immunocompromised. Survival rate at 6 months after intensive care discharge was significantly lower for immunocompromised patients compared to non-immunocompromised ones (41.7% vs. 62.8%; P=0.0.04). ARDS severity was similar between the 2 groups. Fungal pneumonias were reported only in immunocompromised patients (12.5% versus 0% in the control group; P=0.0.001). Bleeding complications were significantly more frequent in the immunocompromised group and blood product transfusions were also more frequently required in this group. CONCLUSIONS: Six months after intensive care discharge, survival rate of immunocompromised children supported with ECMO for pediatric ARDS is lower than for non-immunocompromised patients. But the expectation for a favorable outcome is real and it is worth it if their condition is likely to be compatible with a good long-term quality of life.

Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children.

BACKGROUND: A recent increase in children admitted with hypotensive shock and fever in the context of the COVID-19 outbreak requires an urgent characterization and assessment of the involvement of SARS-CoV-2 infection. This is a case series performed at 4 academic tertiary care centers in Paris of all the children admitted to the pediatric intensive care unit (PICU) with shock, fever and suspected SARS-CoV-2 infection between April 15th and April 27th, 2020. RESULTS: 20 critically ill children admitted for shock had an acute myocarditis (left ventricular ejection fraction, 35% (25-55); troponin, 269 ng/mL (31-4607)), and arterial hypotension with mainly vasoplegic clinical presentation. The first symptoms before PICU admission were intense abdominal pain and fever for 6 days (1-10). All children had highly elevated C-reactive protein (> 94 mg/L) and procalcitonin (> 1.6 ng/mL) without microbial cause. At least one feature of Kawasaki disease was found in all children (fever, n = 20, skin rash, n = 10; conjunctivitis, n = 6; cheilitis, n = 5; adenitis, n = 2), but none had the typical form. SARS-CoV-2 PCR and serology were positive for 10 and 15 children, respectively. One child had both negative SARS-CoV-2 PCR and serology, but had a typical SARS-CoV-2 chest tomography scan. All children but one needed an inotropic/vasoactive drug support (epinephrine, n = 12; milrinone, n = 10; dobutamine, n = 6, norepinephrine, n = 4) and 8 were intubated. All children received intravenous immunoglobulin (2 g per kilogram) with adjuvant corticosteroids (n = 2), IL 1 receptor antagonist (n = 1) or a monoclonal antibody against IL-6 receptor (n = 1). All children survived and were afebrile with a full left ventricular function recovery at PICU discharge. CONCLUSIONS: Acute myocarditis with intense systemic inflammation and atypical Kawasaki disease is an emerging severe pediatric disease following SARS-CoV-2 infection. Early recognition of this disease is needed and referral to an expert center is recommended. A delayed and inappropriate host immunological response is suspected. While underlying mechanisms remain unclear, further investigations are required to target an optimal treatment.

Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d'Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies.

BACKGROUND: The French Emergency Medicine Society, the French Intensive Care Society and the Pediatric Intensive Care and Emergency Medicine French-Speaking Group edited guidelines on severe asthma exacerbation (SAE) in adult and pediatric patients. RESULTS: The guidelines were related to 5 areas: diagnosis, pharmacological treatment, oxygen therapy and ventilation, patients triage, specific considerations regarding pregnant women. The literature analysis and formulation of the guidelines were conducted according to the Grade of Recommendation Assessment, Development and Evaluation methodology. An extensive literature research was conducted based on publications indexed in PubMed™ and Cochrane™ databases. Of the 21 formalized guidelines, 4 had a high level of evidence (GRADE 1+/-) and 7 a low level of evidence (GRADE 2+/-). The GRADE method was inapplicable to 10 guidelines, which resulted in expert opinions. A strong agreement was reached for all guidelines. CONCLUSION: The conjunct work of 36 experts from 3 scientific societies resulted in 21 formalized recommendations to help improving the emergency and intensive care management of adult and pediatric patients with SAE.

Nosocomial Infections in Neonates Supported by Extracorporeal Membrane Oxygenation: First French Retrospective Study.

How to cite this article: Rambaud J, Allioux C, Jean S, Guilbert J, Guellec I, Demoulin M, et al. Nosocomial Infections in Neonates Supported by Extracorporeal Membrane Oxygenation: First French Retrospective Study. Indian J Crit Care Med 2019;23(9):392-395.

Successful extracorporeal membrane oxygenation transport of a 4-month-old brain-dead infant for organ donation: A case report.

A 4-month-old infant was declared brain-dead 2 days after being initiated on venoarterial ECMO for a refractory septic shock. All brain death diagnostic criteria were fulfilled according to French law, and parental consent was given for organ donation. The hospital where ECMO was initiated had no authorization for organ procurement, and the donor was then transferred to the local referral center for child organ recovery with our mobile ECMO team to maintain organ perfusion. The kidneys were recovered and successfully transplanted to a child who is now well and alive. Although the transport elements of this case report are of limited relevance to an international audience as no other country, to our knowledge, has this particular organization, it does show excellent collaboration between teams to realize the goal of organ donation for this family. This is the first case describing a successful inter-hospital transport for organ procurement of a brain-dead infant on ECMO. Brain-dead pediatric patients undergoing ECMO can be considered as potential organ donors to expand the donor pool.

Incidence and risk factors of ventilator-associated pneumonia in neonatal intensive care unit: a first French study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a severe intensive complication and remains under estimated in neonatal intensive care unit (NICU). Center for Disease Control defined criteria for adults and pediatrics without neonatal criteria. The objective of this article was to evaluate the rate, the risks factors and the outcome of neonates suffering from ventilator-associated pneumonia in a French NICU. METHODS: We conducted a prospective observational study within a one-year period in our NICU. Three hundred and eighty-one neonates under 28 days of age were included. Data analyses were performed using Fischer exact-test, Kolgomorov analysis, Mann-Whitney test and logistic regression. RESULTS: Seventeen patients were diagnosed with ventilator-associated pneumonia. Incidence rate of VAP was 8.8 per 1000 invasive mechanical ventilator days. The median age at diagnosis was 20 days (range: 4-45). Extremely low birth weight (under than 1000 grams) were significantly associated with VAP (OR=4.31 [95% CI: 1.38-13.39]). Newborns suffering from VAP had a significantly longer duration of invasive ventilation (median: 16 days [range 4-75] versus 3 days [range 1-28], P<0.001) and hospital length of stay (median: 34 days [range 7-91] versus 7 days [range 1-56], P<0.001). Mortality rate was significantly higher in patient with VAP (P=0.028). CONCLUSIONS: We describe the first French study on VAP in a neonatal population. Amongst nosocomial infections, VAP is a complication with severe consequences for NICU patients. Larger studies are needed to better define a diagnosis strategy and prevention bundle.

Provided information and parents' comprehension at the time of admission of their child in pediatric intensive care unit.

This study evaluated the first interaction (FI) between parents and health care providers at the time of admission of a child in pediatric intensive care unit (PICU), and explored the extent to which parents understood the medical information. This prospective study took place in three French university-affiliated PICUs. Forty-two parents of 30 children were interviewed. The physician and nurse who took care of the child completed a questionnaire. We evaluated parents' comprehension (excellent, fair, or poor) by comparing parents' and physicians' responses to six items: diagnosis, affected organ, reason for hospitalization, prognosis, treatments, and further investigations. Parent-physician FI occurred within 24 h of child's admission. Two thirds of the parents were dissatisfied to wait before receiving information. Most of the parents had an excellent comprehension of the affected organ (n = 25/28, 89.3%) and prognosis (n = 26/30, 86.7%). Two thirds of the parents understood the reason for hospitalization (n = 18/28, 64.3%) and diagnosis (n = 19/30, 63.3%). Less than half the parents understood child's treatments (n = 10/30, 33.3%) and further investigations (n = 8/21, 38.1%). When a nurse delivered information on treatment, parental comprehension improved (p = 0.053). CONCLUSION: Parents complained of their wait time before receiving information. Most of them had an excellent comprehension. An improved communication between nurses and physicians is mandatory, and the active participation of nurses to give information to the parents should be encouraged. What is known: • In pediatric intensive care unit, health care providers deliver information to parents on their child's condition, which fosters the trust between them to build a partnership. • Various guidelines exist to help health care providers communicate with parents in PICU, but never mention the specific time of admission. What is new: • Even though parents could wait before entering the unit, they all received information on their child's condition within 24 hours after admission. • Parents understood the information well, and nurses improved the parental comprehension of the treatments by reformulating.

Extracorporeal Membrane Oxygenation Can Save Lives in Children With Heart or Lung Failure After Liver Transplantation.

The risk of cardiac or lung failure after liver transplantation (LT) is significant. In rare cases, the usual intensive care techniques fail to maintain organ oxygenation with a risk of multiorgan dysfunction. Although extracorporeal membrane oxygenation (ECMO) is a difficult and risky procedure, it can be proposed as life-saving. Four children with either acute pulmonary (three) or cardiac (one) failure after LT, and the criteria that decided the use of ECMO (level of ventilation and results, dosage of inotropic drugs, cardiac ultrasound, blood lactate) were retrospectively reported. These patients, 1-11 years old, were treated with either veno-arterial (three) or veno-venous (one) ECMO. Two experienced a full recovery, with 3 and 6 years of follow-up. Two died of systemic inflammatory response syndrome (SIRS) due to ECMO, and relapse of heart failure due to the underlying disease. Although our patients' survival was only 50%, we showed that ECMO can be useful in children after LT. It should be considered before the development of irreversible multiorgan failure.

Prognostic value of cerebral tissue oxygen saturation during neonatal extracorporeal membrane oxygenation.

OBJECTIVES: Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO2) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO2 and the occurrence of cerebral lesions. STUDY DESIGN: This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support. MEASUREMENTS: The assessment of cerebral perfusion was made by continuous StcO2 monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography. RESULTS: Thirty-four infants <3 months of age were included in the study over a period of 18 months. The ECMO duration was 10±7 days. The survival rate was 50% (17/34 patients), and the proportion of brain injuries was 20% (7/34 patients). The mean StcO2 during ECMO in the non-survivors was reduced in both hemispheres (p = 0.0008 right, p = 0.03 left) compared to the survivors. StcO2 was also reduced in deceased or brain-injured patients compared to the survivors without brain injury (p = 0.002). CONCLUSION: StcO2 appears to be a strong prognostic factor of survival and of the presence of cerebral lesions in young infants during ECMO.

Sexual health of adolescents in Quebec residential Youth Protection Centres.

OBJECTIVES: To document risk behaviours and prevalence of chlamydia and gonorrhoea infections among adolescents aged 14 to 17 years entering care in Quebec Youth Protection Centres (YPC). METHODS: From July 2008 to May 2009, adolescents residing in six YPCs completed a questionnaire during a face-to-face interview. Questions covered sexual and substance use behaviours prior to admission, as well as other health issues affecting respondents' mental and physical health. Urine samples were tested for Chlamydia trachomatis genital infection (CTGI) and Neisseria gonorrhoea genital infection (NGGI). RESULTS: Among 578 participants aged 14 to 17 years, 89% had had consensual sexual relations. Sexual risk behaviours included early sexual initiation (66% at <14 years); multiple partners (median lifetime number: girls 5, boys 8); 50% or more of sexual relations under the influence of drugs or alcohol (girls 43%, boys 48%); group sex (girls 38%, boys 43%); and sex in exchange for money or other goods (girls 27%, boys 8%). Only a quarter of boys and girls used double protection (condom and a contraceptive method) during the most recent vaginal relation. A history of pregnancy was reported by 28% of girls. Prevalence of CTGI was 9.3% (CI: 5.5-14.5) among girls and 1.9% (CI: 0.6-4.4) among boys. Prevalence of NGGI gonorrhoea was 1.7% (CI: 0.3-4.8) among girls and 0% (CI: 0.0-1.4) among boys.In multivariate analyses, factors significantly associated with chlamydia infection among sexually active girls were: hospitalization for alcohol intoxication; and a history of suicidal ideation with plan. CONCLUSION: Sexual risk behaviours are common among adolescents entering YPCs, resulting in high levels of chlamydia infection. Mental health issues such as substance misuse and serious depressive symptoms are associated with these high rates. A youth's stay in these facilities is an opportune time to screen not only for sexual risk behaviours but also for mental health problems; appropriate risk reduction education and referrals can then be provided as needed.