Epidemiology and clinical characteristics of severe acute respiratory infections among hospitalized children under 5 years of age in a tertiary care center in Bangkok, Thailand, 2019-2020.

Background: Acute respiratory infections (ARIs) are common in children and can range in severity from mild self-limiting illnesses to more severe conditions such as pneumonia and respiratory failure. Data on the epidemiology of viral and bacterial pathogens causing ARIs in children are scarce in this region. This study aimed to investigate the epidemiology and clinical manifestations of pathogens in children aged ≤5 years presenting with severe acute respiratory infection (SARI) in Bangkok, Thailand. The impact of rapid multiplex PCR-based testing on clinical management is also explored. Methods: This cross-sectional study enrolled consecutive children aged ≤5 years presenting with SARI at a tertiary care centre in Bangkok, Thailand, between 2019 and 2020. Nasopharyngeal swabs were collected once at admission, and viral and bacterial pathogens were tested using the QIAstat-Dx respiratory panel. Results: A total of 169 children were enrolled in this study. At least one pathogenic virus was detected in 91.7 % of participants. Based on the final diagnoses made upon discharge, 30.2 % had upper respiratory tract infection, whereas 66.3 % had lower respiratory tract infection. Pneumonia was the most common diagnosis (59.2 %). The most common pathogen identified was rhino/enterovirus (45.2 %), followed by respiratory syncytial virus (31.6 %) and parainfluenza virus (14.2 %). Co-infection was found in 15.4 % and was not associated with increased disease severity. Conclusions: This study provides additional insights into the pathogen profiles, clinical diagnosis, and co-infection combinations of ARIs in hospitalized children. This information is useful for diagnosis and treatment of ARIs, as well as implementation of appropriate infection control measures and guidance for future vaccine policy development.

Using an experiment among clinical experts to determine the cost and clinical impact of rapid whole exome sequencing in acute pediatric settings.

Objective: Evaluate the cost and clinical impacts of rapid whole-exome sequencing (rWES) for managing pediatric patients with unknown etiologies of critical illnesses through an expert elicitation experiment. Method: Physicians in the intervention group (n = 10) could order rWES to complete three real-world case studies, while physicians in the control group (n = 8) could not. Costs and health outcomes between and within groups were compared. Results: The cost incurred in the intervention group was consistently higher than the control by 60,000-70,000 THB. Fewer other investigation costs were incurred when rWES could provide a diagnosis. Less cost was incurred when an rWES that could lead to a change in management was ordered earlier. Diagnostic accuracy and the quality of non-pharmaceutical interventions were superior when rWES was available. Conclusion: In acute pediatric settings, rWES offered clinical benefits at the average cost of 60,000-70,000 THB. Whether this test is cost-effective warrants further investigations. Several challenges, including cost and ethical concerns for assessing high-cost technology for rare diseases in resource-limited settings, were potentially overcome by our study design using expert elicitation methods.

Autoresuscitation after circulatory arrest: an updated systematic review.

PURPOSE: Current practice in organ donation after death determination by circulatory criteria (DCD) advises a five-minute observation period following circulatory arrest, monitoring for unassisted resumption of spontaneous circulation (i.e., autoresuscitation). In light of newer data, the objective of this updated systematic review was to determine whether a five-minute observation time was still adequate for death determination by circulatory criteria. SOURCE: We searched four electronic databases from inception to 28 August 2021, for studies evaluating or describing autoresuscitation events after circulatory arrest. Citation screening and data abstraction were conducted independently and in duplicate. We assessed certainty in evidence using the GRADE framework. PRINCIPAL FINDINGS: Eighteen new studies on autoresuscitation were identified, consisting of 14 case reports and four observational studies. Most studies evaluated adults (n = 15, 83%) and patients with unsuccessful resuscitation following cardiac arrest (n = 11, 61%). Overall, autoresuscitation was reported to occur between one and 20 min after circulatory arrest. Among all eligible studies identified by our reviews (n = 73), seven observational studies were identified. In observational studies of controlled withdrawal of life-sustaining measures with or without DCD (n = 6), 19 autoresuscitation events were reported in 1,049 patients (incidence 1.8%; 95% confidence interval, 1.1 to 2.8). All resumptions occurred within five minutes of circulatory arrest and all patients with autoresuscitation died. CONCLUSION: A five-minute observation time is sufficient for controlled DCD (moderate certainty). An observation time greater than five minutes may be needed for uncontrolled DCD (low certainty). The findings of this systematic review will be incorporated into a Canadian guideline on death determination. STUDY REGISTRATION: PROSPERO (CRD42021257827); registered 9 July 2021.

RéSUMé: OBJECTIF: La pratique actuelle en matière de don d'organes après une détermination du décès par critères circulatoires (DCC) préconise une période d'observation de cinq minutes après l'arrêt circulatoire et le monitorage de la reprise non assistée de la circulation spontanée (c.-à-d. l'auto-réanimation). À la lumière de données plus récentes, l'objectif de cette revue systématique mise à jour était de déterminer si un temps d'observation de cinq minutes était toujours suffisant pour une détermination de décès selon des critères circulatoires (DCC). SOURCES: Nous avons effectué des recherches dans quatre bases de données électroniques depuis leur création jusqu'au 28 août 2021 pour en tirer les études évaluant ou décrivant des événements d'autoréanimation après un arrêt circulatoire. L'examen des citations et l'extraction des données ont été réalisés de manière indépendante et en double. Nous avons évalué la certitude des données probantes à l'aide de la méthodologie GRADE. CONSTATATIONS PRINCIPALES: Dix-huit nouvelles études sur l'autoréanimation ont été identifiées, comprenant 14 présentations de cas et quatre études observationnelles. La plupart des études ont évalué des adultes (n = 15, 83 %) et les patients dont la réanimation avait échoué à la suite d'un arrêt cardiaque (n = 11, 61 %). Dans l'ensemble, l'autoréanimation a été signalée entre une et 20 minutes après l'arrêt circulatoire. Parmi toutes les études admissibles identifiées par nos comptes rendus (n = 73), sept études observationnelles ont été identifiées. Dans les études observationnelles sur l'interruption contrôlée des thérapies de maintien des fonctions vitales avec ou sans DCC (n = 6), 19 événements d'autoréanimation ont été rapportés chez 1049 patients (incidence 1,8 % ; intervalle de confiance à 95 %, 1,1 à 2,8). Toutes les reprises ont eu lieu dans les cinq minutes suivant l'arrêt circulatoire et tous les patients en autoréanimation sont décédés. CONCLUSION: Un temps d'observation de cinq minutes est suffisant pour un DCC contrôlé (certitude modérée). Un temps d'observation supérieur à cinq minutes peut être nécessaire en cas de DDC non contrôlé (faible certitude). Les résultats de cette revue systématique seront intégrés à des lignes directrices canadienne de pratique clinique sur la détermination du décès. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021257827); enregistrée le 9 juillet 2021.

Factors Influencing Prolonged Intensive Care Unit Length of Stay after Craniotomy for Intracranial Tumor in Children: A 10-year Analysis from a University Hospital.

Background: Postoperative intensive care unit (ICU) admission is routinely practiced in pediatric and adult craniotomy. This study aims to identify the factors associated with an ICU stay of more than one day (prolonged ICU stay, PIS) after pediatric brain tumor surgery. Methods: Medical records of children who underwent craniotomy for brain tumor during a 10-year period were reviewed and analyzed. Perioperative variables were examined and compared between the one-day ICU stay (ODIS) and PIS groups. Results: A total of 314 craniotomies performed on 302 patients was included. Patients requiring postoperative ICU care for more than a day represented 37.9% of the sample. Significant factors found in the multivariate analysis affecting prolonged ICU length of stay included operative time ≥360 minutes (adjusted odds ratio [AOR], 2.438; 95% confidence interval [CI]: 1.223-4.861; p = 0.011), presence of an endotracheal (ET) tube (AOR, 7.469; 95% CI: 3.779-14.762; p < 0.001), and external ventricular drain (EVD) at ICU admission (AOR, 2.512; 95% CI: 1.458-4.330; p = 0.001). Conclusion: While most children undergoing a craniotomy for brain tumor need a postoperative ICU care of ≤1 day, slightly more than a one-third in our study stayed longer. The prediction of a PIS can be beneficial for optimal resource utilization, increasing ICU bed turnover rate, reduction of operation cancellation, and improved preparation for parent expectations. How to cite this article: Sangtongjaraskul S, Lerdsirisopon S, Sae-phua V, Kanta S, Kongkiattikul L. Factors Influencing Prolonged Intensive Care Unit Length of Stay after Craniotomy for Intracranial Tumor in Children: A 10-year Analysis from a University Hospital. Indian J Crit Care Med 2023;27(3):205-211.

Achievement of nutritional goals after a pediatric intensive care unit nutrition support guideline implementation.

BACKGROUND AND AIMS: A nutrition support guideline was developed and implemented in a pediatric intensive care unit (PICU) to improve the nutritional management of patients. This study aimed to evaluate the impact of this guideline on achieving energy and protein delivery goals. METHODS: Medical records of the patients admitted in the PICU from August 2015 to April 2017 were retrospectively reviewed. Patients who stayed in the PICU for less than 24 h or had an inborn error of metabolism were excluded. Achievement of nutritional goals was compared between the patients during the pre-implementation period (August to October 2015) and post-implementation period (November 2015 to April 2017) of the guideline. Subgroup analysis by protocol compliance was conducted in the post-implementation group. RESULTS: A total of 215 patients were included in the study (53 pre-implementation, 162 post-implementation). There were no differences between the two groups in patient characteristics, time to start enteral nutrition, time to reach the energy delivery goal, time to reach the protein delivery goal, and proportion of the patients who reached each goal. In the post-implementation group, parenteral nutrition was delayed to three days compared with one day in pre-implementation (p = 0.027) and the proportion of patients who did not receive nutrition support was lower (3.1% vs 9.4% pre-implementation, p = 0.043). Subgroup analysis in the post-implementation group showed that 69.7% of the patients were protocol compliant, of which the time to reach the energy delivery goal (59 vs 103 h, p < 0.001) and protein delivery goal (64 vs 135 h, p = 0.02) were significantly shorter compared with the non-compliant group. Moreover, the proportion of the patients who reached the energy delivery goal (75.2% vs 24.5%, p < 0.001) and protein delivery goal (56.6% vs 12.2%, p < 0.001) were higher in the compliant group. CONCLUSIONS: Compliance with the nutrition support guideline significantly improved the achievements in delivering energy and protein to patients in PICU. Increasing compliance with the guideline may improve clinical outcomes in PICU patients.

Optimal Enteral Nutrition Support Preserved Muscle Mass in Critically Ill Children.

BACKGROUND: Inflammation and immobility are the most relevant mechanisms that alter protein synthesis and increase protein breakdown. Protein catabolism is associated with morbidity and mortality in critically ill children. OBJECTIVE: To demonstrate the effectiveness of the routinely used enteral nutrition support guideline in preventing muscle breakdown in critically ill children. METHODS: A prospective cohort study was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital. Critically ill children (aged 1 month to 15 years) admitted to the PICU were enrolled. All patients were assessed for nutritional status and nutritional requirement. Enteral nutrition support following the guideline was initiated within the first 24 hours if no contraindication. The calorie target was defined either by direct measurement from indirect calorimetry or estimated from Schofield equation with protein target at least 1.5 g/kg/day. Anthropometric assessments and body composition measurements by bioelectrical impedance analysis (BIA) were examined at baseline and on the seventh day of the PICU admission. RESULTS: Sixty-three patients were enrolled in the study. The most common age group was 1-5 years old (38.1%). The length of PICU stay was 9.1 (SD = 12.7) days. Respiratory problems were the major cause of PICU admission (50.8%). Mechanical ventilation was required in 55.6% of the patients with the average duration of 6.3 (SD = 12.4) days. Undernutrition was found in 36.5% of the patients. Enteral feeding was the major route of nutrition support (95.2%). After the first week of admission, muscle mass was significantly preserved (p < 0.01). All patients received the nutrition support at their target energy and protein goal within the first week. The enteral feeding-related complication was reported in 1.6% of the patients. CONCLUSION: Protein catabolism during critically ill period can be minimized by optimal nutrition support. Nutrition practice using the enteral nutrition support guideline was effective in helping critically ill children reach their target caloric and protein intake.

Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand.

AIM AND OBJECTIVE: Pediatric acute liver failure (PALF) is a life-threatening condition. Extracorporeal support has been applied for toxic metabolite clearance and serves as a bridging therapy to liver transplantation (LT) or to the regeneration of the liver, but evidence for treatment approaches is still lacking in the pediatric population. We aim to report our experience on therapeutic plasma exchange with high-volume continuous renal replacement therapy (TPE + HV-CRRT) as a promising supportive treatment for PALF. MATERIALS AND METHODS: A total of eight PALF cases aged 9 months to 14 years, weighing 10-50 kg., who were admitted to PICU King Chulalongkorn Memorial Hospital, Thailand and treated with TPE + HV-CRRT from January 2016 to September 2019 were reviewed. Patient demographic data, indications, technical aspects, and clinical outcomes were recorded. RESULTS: All patients who underwent TPE + HV-CRRT showed clinical improvement regarding serum bilirubin levels and coagulation studies after the therapy. Complications from the therapy were hemodynamic instability, symptomatic fluid overload, and bleeding from catheter sites. Among these, 6 (75%) patients survived with 4 (50%) successful LTs and 2 (25%) spontaneous recovery. Two children (25%) died while on the transplantation list. CONCLUSION: TPE + HV-CRRT can be used safely as a bridging therapy in children with PALF. As opposed to the adult population, higher volume of TPE or higher blood flow rate in pediatric patients might associate with hemodynamic instability during the procedure. HOW TO CITE THIS ARTICLE: Trepatchayakorn S, Chaijitraruch N, Chongsrisawat V, Chanakul A, Kongkiattikul L, Samransamruajkit R. Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand. Indian J Crit Care Med 2021;25(7):812-816.

Pediatric Severe Sepsis and Shock in Three Asian Countries: A Retrospective Study of Outcomes in Nine PICUs.

OBJECTIVES: Pediatric sepsis remains a major health problem and is a leading cause of death and long-term disability worldwide. This study aims to characterize epidemiologic, therapeutic, and outcome features of pediatric severe sepsis and septic shock in three Asian countries. DESIGN: A multicenter retrospective study with longitudinal clinical data over 1, 6, 24, 48, and 72 hours of PICU admission. The primary outcome was PICU mortality. Multivariable logistic regression analysis was used to identify factors at PICU admission that were associated with mortality. SETTING: Nine multidisciplinary PICUs in three Asian countries. PATIENTS: Children with severe sepsis or septic shock admitted to the PICU from January to December 2017. INTERVENTION: None. MEASUREMENT AND MAIN RESULTS: A total of 271 children were included in this study. Median (interquartile range) age was 4.2 years (1.3-10.8 yr). Pneumonia (77/271 [28.4%]) was the most common source of infection. Majority of patients (243/271 [90%]) were resuscitated within the first hour, with fluid bolus (199/271 [73.4%]) or vasopressors (162/271 [59.8%]). Fluid resuscitation commonly took the form of normal saline (147/199 [74.2%]) (20 mL/kg [10-20 mL/kg] over 20 min [15-30 min]). The most common inotrope used was norepinephrine 81 of 162 (50.0%). Overall PICU mortality was 52 of 271 (19.2%). Improved hemodynamic variables (e.g., heart rate, blood pressure, and arterial lactate) were seen in survivors within 6 hours of admission as compared to nonsurvivors. In the multivariable model, admission severity score was associated with PICU mortality. CONCLUSIONS: Mortality from pediatric severe sepsis and septic shock remains high in Asia. Consistent with current guidelines, most of the children admitted to these PICUs received fluid therapy and inotropic support as recommended.

International Survey on Determinants of Antibiotic Duration and Discontinuation in Pediatric Critically Ill Patients.

OBJECTIVES: We hypothesized that antibiotic use in PICUs is based on criteria not always supported by evidence. We aimed to describe determinants of empiric antibiotic use in PICUs in eight different countries. DESIGN: Cross-sectional survey. SETTING: PICUs in Canada, the United States, France, Italy, Saudi Arabia, Japan, Thailand, and Brazil. SUBJECTS: Pediatric intensivists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used literature review and focus groups to develop the survey and its clinical scenarios (pneumonia, septic shock, meningitis, and intra-abdominal infections) in which cultures were unreliable due to antibiotic pretreatment. Data analyses included descriptive statistics and linear regression with bootstrapped SEs. Overall response rate was 39% (482/1,251), with individual country response rates ranging from 25% to 76%. Respondents in all countries prolonged antibiotic duration based on patient characteristics, disease severity, pathogens, and radiologic findings (from a median increase of 1.8 d [95% CI, 0.5-4.0 d] to 9.5 d [95% CI, 8.5-10.5 d]). Younger age, severe disease, and ventilator-associated pneumonia prolonged antibiotic treatment duration despite a lack of evidence for such practices. No variables were reported to shorten treatment duration for all countries. Importantly, more than 39% of respondents would use greater than or equal to 7 days of antibiotics for patients with a positive viral polymerase chain reaction test in all scenarios, except in France for pneumonia (29%), septic shock (13%), and meningitis (6%). The use of elevated levels of inflammatory markers to prolong antibiotic treatment duration varied among different countries. CONCLUSIONS: Antibiotic-related decisions are complex and may be influenced by cultural and contextual factors. Evidence-based criteria are necessary to guide antibiotic duration and ensure the rational use of antibiotics in PICUs.

The impact of a quality improvement project to standardize pain, agitation, and withdrawal assessments on the use of morphine and midazolam in the Pediatric Intensive Care Unit.

BACKGROUND: This study aims to assess the impact of a quality improvement initiative to increase assessments of pain, agitation, and iatrogenic withdrawal syndrome, on the use of sedative and analgesic medication in a pediatric intensive care unit. METHODS: This is a retrospective pre and post, observational, quality improvement study conducted in an 18-bed medical-surgical-cardiac, tertiary intensive care unit. We included patients consecutively admitted from October 1 to March 31 (pre-period 2015-2016, post-period 2016-2017) who were mechanically ventilated beyond 48 hours. A multidisciplinary team, including a family advisor, implemented the following interventions using rapid "Plan-Do-Study-Act cycles:" (a) standardized pain and sedation assessments, (b) standardized sedation goal setting, and (c) non-pharmacological strategies to manage pain and agitation. We did not implement any specific sedation protocol. We used audit and feedback to reinforce change. RESULTS: The post-intervention phase started once sedation scores were documented q12h for >60% of patients. The groups (n = 45 per group) were similar regarding demographics, severity of illness, and mechanical ventilation duration, but different in length of intensive care stay. The cumulative dose of midazolam equivalent was significantly lower in the post-intervention period (3.71 vs 2.65 mg/kg/mechanical ventilation day, P = 0.009, 95% CI: -1.12 (-1.89, -0.31)). Morphine equivalent usage went from 3.51 to 2.57 mg/kg/mechanical ventilation day (P = 0.066, 95% CI: -0.67 [-1.44, 0.05]). There were no significant pre-post-differences in the use of other sedative agents, rates of iatrogenic withdrawal syndrome or severe pain, nor medication cost. CONCLUSION: Implementation of a multifaceted QI project was successful at increasing standardized assessments of pain and agitation, and was associated with a significant reduction in midazolam use. We also observed a decrease in morphine use without increasing rates of severe pain. Incidence of iatrogenic withdrawal syndrome and cost were unchanged.

Relationship between Obesity Indices and Pulmonary Function Parameters in Obese Thai Children and Adolescents.

OBJECTIVE: To determine the correlation between various obesity indices and pulmonary function parameters in obese Thai children and adolescents. METHODS: Obese children and adolescents aged from 8 to 18 y and diagnosed under the criteria of International Obesity Task Force (IOTF) were enrolled. Anthropometric and body composition measurements (bioelectrical impedance analysis) of all eligible participants were recorded. Pulmonary function studies (spirometry and body plethysmography) were also performed on the same day. RESULTS: Forty-five children and adolescents [84 % boys; mean age 11.9 ± 2.4 y; mean BMI 31.8 ± 5.1 kg/m(2); and, mean body mass index (BMI) z-score 3.2 ± 0.5] were studied. Mean body fat percentage, mean fat mass index (FMI), mean fat free mass index, and mean truncal fat percentage were 47.4 ± 10.2 %, 15.2 ± 5.2 kg/m(2), 16.3 ± 3.1 kg/m(2), and 47.7 ± 11.5 %, respectively. Abnormal lung functions were found in 73.2 % of subjects; the most common was decreased functional residual capacity (FRC) (29 cases; 64.4 %). There was a negative correlation between FRC and BMI z-score (r = -0.32; p 0.03), waist-height ratio (r = -0.32; p 0.02), body fat percentage (r = -0.32; p 0.03), FMI (r = -0.36; p 0.02), and truncal fat percentage (r = -0.32; p 0.04). Obese individuals who had FMI > 17 kg/m(2) were 5.7 times more likely to have decreased FRC than those who had lower FMI (95 % CI 1.1-29.7; p 0.016). CONCLUSIONS: Decreased FRC was the most common pulmonary function abnormality in obese children and adolescents. BMI z-score, waist-height ratio, body fat percentage, FMI, and truncal fat percentage were all negatively correlated with FRC. FMI had the highest negative correlation. Obese individuals with FMI > 17 kg/m(2) had a 5.7 times increased risk of low FRC. Appropriate planning for respiratory care and follow-up may be required in this population.