Nirsevimab Effectiveness Against Cases of Respiratory Syncytial Virus Bronchiolitis Hospitalised in Paediatric Intensive Care Units in France, September 2023-January 2024.

In September 2023, France was one of the first countries that started a national immunisation campaign with nirsevimab, a new monoclonal antibody against respiratory syncytial virus (RSV). Using data from a network of paediatric intensive care units (PICUs), we aimed to estimate nirsevimab effectiveness against severe cases of RSV bronchiolitis in France. We conducted a case-control study based on the test-negative design and included 288 infants reported by 20 PICUs. We estimated nirsevimab effectiveness at 75.9% (48.5-88.7) in the main analysis and 80.6% (61.6-90.3) and 80.4% (61.7-89.9) in two sensitivity analyses. These real-world estimates confirmed the efficacy observed in clinical studies.

Concepts of family-centered care at the neonatal and paediatric intensive care unit: A scoping review.

BACKGROUND: Understanding family-centred care (FCC) concepts is critical for its implementation in any context. The researchers synthesised studies on FCC in neonatal and paediatric critical care units in order to present its concepts and gaps in the literature to guide further research in the area. METHOD: The study used the JBI methodology, and the PRISMA-ScR guidelines confirmed the final report. The search for material, with the use of library sources, used Medline via PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Google Scholar, and Wiley Library online for papers published in English from 2015 to 2019 and updated to 2023. RESULTS: From 904 references, 61 studies were identified for inclusion. The majority of the studies (29; 55.77%) were qualitative ethnography and phenomenology. Four themes and ten subthemes emerged from the data to support the main concepts of FCC. CONCLUSION: To guide its useful integration and implementation, more research on family-centred care in neonatal and paediatric intensive care units, involving families, staff, and managers, should be undertaken. PRACTICE IMPLICATION: Findings presented in this review may provide a guide for nurses to adjust nursing interventions for critically ill neonates and children in intensive care units.

The relationship between moral distress levels and ethical climate perceptions of PICU nurses.

BACKGROUND: The organizational climate in paediatric intensive care units is specific to the conditions of the patient, and there may be a relationship between the ethical climate perception and moral distress levels of the nurses working in this unit. AIM: The research aim was to examine the relationship between the moral distress levels and their perceptions of hospital ethical climate of paediatric intensive care unit nurses. METHODS: This research was aimed a descriptive, cross-sectional and correlational type with 239 paediatric intensive care unit nurses of public, university and training and research hospitals in Turkey. Research data were evaluated with mean, Pearson correlation and multiple linear regression analysis. RESULTS: The total score of moral distress scale was 106.36 ± 53.63, and of the hospital ethical climate scale was 100.60 ± 14.41. A moderate negative relationship was found between nurses' moral distress levels and ethical climate perceptions, ethical climate perception explained moral distress levels with a 12% variance and this significance came from the physicians sub-dimension. CONCLUSIONS: The moral distress levels of paediatric intensive care nurses were below the average, and their ethical climate perceptions were above the average. It was seen that the physicians sub-dimension was an important explanatory on the total moral distress. IMPLICATION FOR NURSING MANAGEMENT: In order to eliminate the moral distress arising from the hospital ethical climate, practices should be developed to increase the cooperation between nursing and physicians.

Stressful Experiences of Parents in the Paediatric Intensive Care Unit: Searching for the Most Intensive PICU Stressors.

Hospitalization of a child in the paediatric intensive care unit (PICU) is extremely stressful, both for the child and for his or her family. The purpose of this study was to gain deeper insight into the stressful experiences of parents of children hospitalized in the PICU. This study included 96 parents. The data were collected using a translated and standardized scale "The Parental Stressor Scale: Paediatric Intensive Care Unit (PSS: PICU)". This study confirms high exposure of parents to numerous PICU stressors. The most intense PICU stressor for parents was child's breathing depending on the ventilator (4.22 ± 1.17), and the least intense was child's demanding behaviour (1.17 ± 0.33). A significant positive correlation between the level of parents' perceived stress and the number of their children was recorded (r = 0.240, p = 0.02), while there was no significant correlation between the level of stress and other sociodemographic variables. A significantly higher level of stress was experienced by parents with primary school education (p = 0.032) and parents who are not healthcare professionals (p < 0.01). It is necessary to establish a system that will enable continuous assessment of parents' stress levels and timely prevention of stressful experiences for parents in the PICU.

Paediatric admissions to a district general hospital adult intensive care unit over a six year period: A single centre retrospective case series, with review of practitioner confidence and competence in paediatric critical care.

Background: Critically ill children presenting to district general hospitals (DGH) are admitted to adult intensive care units (AICUs) for stabilisation prior to transfer to paediatric intensive care units (PICUs). Current training in PICU for adult intensive care physicians is only three months. This single centre retrospective case series examines the case mix of children presenting to a DGH AICU and a multidisciplinary survey assesses confidence and previous experience, highlighting continued training needs for DGH AICU staff. Methods: all paediatric admissions to AICU and paediatric retrievals were reviewed over a 6-year period (2014-2019). Cases were identified from the Electronic Patient Record (EPR) and from data provided by the regional paediatric retrieval service. A questionnaire survey was sent to AICU doctors and nurses to assess confidence and competence in paediatric critical care. Results: Between 2014-2019, 284 children were managed by AICU. In total 35% of cases were <1 y, 48% of cases were <2 y and 64% of cases were <5 y, and 166/284 (58%) children were retrieved. Retrieval reduced with increasing age (OR 0.49 [0.40-0.60], p < 0.0001). The survey had an 82% response rate, and highlighted that only 13% of AICU nurses and 50% of doctors had received prior PICU training. Conclusion: At least one critically unwell child presents to the AICU each week. Assessment, stabilisation and management of critically unwell children are vital skills for DGH AICU staff, but confidence and competence are lacking. Formalised strategies are required to develop and maintain paediatric competencies for AICU doctors and nurses.

Difficult intravenous access in a paediatric intensive care unit.

INTRODUCTION: Multiple attempts during peripheral cannulation can have major consequences for patients, relatives, and healthcare professionals, therefore we set out to determine the extent of this problem in a paediatric intensive care unit (PICU). OBJECTIVES: The main aim was to describe peripheral venous catheter (PVC) and peripherally inserted central catheter (PICC) cannulation in children in the PICU. Secondary objectives were to determine the success rate of the first cannulation attempt, to quantify patients with difficult venous access (DVA), and to explore the association between DVA and sociodemographic, technique and nursing-related characteristics. METHOD: A cross-sectional descriptive study. Consecutive sampling was used to recruit patients aged 0-18 years admitted to the PICU who required peripheral venous cannulation. An ad hoc questionnaire was used for this purpose, including the presence of DVA as an independent variable. RESULTS: A total of 163 venous cannulations were reported. A total of 55.8% (91) were performed in patients under 1 year of age. Of these, 38.7% (63) were successful on the first attempt and 36.8% (60) had DVA. When there was DVA, 85% (51) of patients had complications, median time to cannulation by short CVP was 30 minutes [15-53] and 2 or more nurses were required on 80% (48) of occasions. CONCLUSIONS: We found a low success rate at first attempt and a high proportion of DVA. More nurses and time were employed during cannulation and complications increased if the patient had DVA. A statistically significant association was found between DVA and age, weight, poor perfusion, veins that were neither visible nor palpable, DIVA score ≥ 4, history of difficult intravenous access, complications, number of nurses and time spent.

Vía venosa difícil en una unidad de cuidados intensivos pediátricos / Difficult intravenous access in a paediatric intensive care unit

Introducción: Los múltiples intentos durante la canalización periférica pueden producir importantes consecuencias que afectan a pacientes, familiares y profesionales, por ello se planteó la necesidad de conocer la dimensión de este problema en una unidad de cuidados intensivos pediátricos (UCIP).Objetivos: El objetivo principal fue describir la canalización de catéter venoso periférico y catéter central de inserción periférica en niños de UCIP. Como objetivos secundarios se propuso determinar la proporción de éxito en el primer intento de canalización, cuantificar los pacientes que presentan vía venosa difícil (VVD), así como explorar la asociación entre la aparición de la VVD y las características sociodemográficas, las relativas a la técnica y a las enfermeras.Método: Estudio descriptivo transversal. Mediante muestreo consecutivo se reclutaron pacientes entre 0 y 18 años ingresados en UCIP que precisaron canalización de acceso venoso periférico. Para ello se utilizó un cuestionario ad hoc incluyendo la presencia de VVD como variable independiente.Resultados: Se recogieron 163 canalizaciones venosas. El 55,8% (91) se realizaron en pacientes menores de 1 año. El 38,7% (63) acertó en el primer intento y el 36,8% (60) presentaron VVD. Cuando aparecía VVD el 85% (51) de los pacientes tuvieron complicaciones, la mediana de tiempo para la canalización mediante catéter venoso periférico corto fue de 30minutos [15-53] y se precisaron 2 o más enfermeras en el 80% (48) de las ocasiones.Conclusiones: Se encontró un bajo porcentaje de acierto al primer intento y una proporción elevada de VVD. Aparecía un mayor número de enfermeras y de tiempo empleado durante la canalización y un aumento de las complicaciones si el paciente presentaba VVD. Se encontró asociación estadísticamente significativa entre VVD y edad, peso, mala perfusión, vena no visible ni palpable, puntuación en la escala DIVA≥4, historia de VVD, complicaciones, número de enfermeras y tiempo empleado.

Introduction: Multiple attempts during peripheral cannulation can have major consequences for patients, relatives, and healthcare professionals, therefore we set out to determine the extent of this problem in a paediatric intensive care unit (PICU).Objectives: The main aim was to describe peripheral venous catheter (PVC) and peripherally inserted central catheter (PICC) cannulation in children in the PICU. Secondary objectives were to determine the success rate of the first cannulation attempt, to quantify patients with difficult venous access (DVA), and to explore the association between DVA and sociodemographic, technique and nursing-related characteristics.Method: A cross-sectional descriptive study. Consecutive sampling was used to recruit patients aged 0-18 years admitted to the PICU who required peripheral venous cannulation. An ad hoc questionnaire was used for this purpose, including the presence of DVA as an independent variable.Results: A total of 163 venous cannulations were reported. A total of 55.8% (91) were performed in patients under 1 year of age. Of these, 38.7% (63) were successful on the first attempt and 36.8% (60) had DVA. When there was DVA, 85% (51) of patients had complications, median time to cannulation by short CVP was 30minutes [15-53] and 2 or more nurses were required on 80% (48) of occasions.Conclusions: We found a low success rate at first attempt and a high proportion of DVA. More nurses and time were employed during cannulation and complications increased if the patient had DVA. A statistically significant association was found between DVA and age, weight, poor perfusion, veins that were neither visible nor palpable, DIVA score≥4, history of difficult intravenous access, complications, number of nurses and time spent.

The care of critically ill infants and toddlers in neonatal intensive care units across Italy and Europe: our proposal for healthcare organization.

Numerous studies have shown that critically ill infants and toddlers admitted to paediatric intensive care units (PICUs) have a lower mortality than those admitted to adult ICUs. In 2014, there were only 23 registered PICUs in Italy, most of which were located in the north. For this reason, in Italy and elsewhere in Europe, some neonatal ICUs (NICUs) have begun managing critically ill infants and toddlers. Our proposal for healthcare organization is to establish "extended NICUs" in areas where paediatric intensive care beds are lacking. While some countries have opted for a strict division between neonatal and paediatric intensive care units, the model of "extended NICUs" has already been set up in Italy and in Europe. In this instance, the management of critically ill infants and toddlers undoubtedly falls upon neonatologists, who, however, must gain specific knowledge and technical skills in paediatric critical care medicine (PCCM). Postgraduate residencies in paediatrics need to include periods of specific training in neonatology and PCCM. The Italian Society of Neonatology's Early Childhood Intensive Care Study Group is supporting certified training courses for its members involving both theory and practice. CONCLUSION: Scientific societies should promote awareness of the issues involved in the intensive management of infants and toddlers in NICUs and the training of all health workers involved. These societies include the Italian Society of Neonatology, the European Society of Paediatric and Neonatal Intensive Care, and the Union of European Neonatal and Perinatal Societies. They should also act in concert with the governmental institutional bodies to establish the standards for the "extended NICUs." WHAT IS KNOWN: • The mortality of critically ill infants and toddlers admitted to PICUs is lower than that for those admitted to adult ICUs. • In Italy, there are only a handful of PICUs, located mainly in the north. WHAT IS NEW: • Critically ill infants and small toddlers can be managed in "extended NICUs" in areas with a lack of paediatric intensive care beds. • "Extended NICUs" is our proposal for healthcare organization to compensate for the paucity of paediatric intensive care beds, but neonatologists must be trained to provide them with specific knowledge and technical skills in PCCM.

Impressions of aquatic therapy treatment in children with prolonged mechanical ventilation - clinician and family perspectives: a qualitative case study.

PURPOSE: To describe the experiences of applying aquatic therapy (AT) to children with ventilation needs after discharge from the paediatric intensive care unit (PICU). MATERIAL AND METHODS: A qualitative and descriptive case study with integrated units. Purposive sampling was carried out, including the parents of the children participating in the AT programme and the healthcare professionals treating them. Fourteen participants were included: four parents, five physicians, three physiotherapists and two nurses. The study was carried out as part of a program on AT in critically ill children. Semi-structured interviews were conducted. A thematic analysis was performed. RESULTS: Three themes were identified. Theme (1) Difficulties for implementation: AT was not perceived as a viable therapeutic modality; lack of knowledge and resources. Theme (2) Risks and challenges: Perceptions of anxiety at the beginning; planning and precautions. Theme (3) AT facilitates new possibilities and benefits: The necessity of the presence of parents during the AT session; a sense of "normalcy;" outcomes of AT in relation to post-intensive care syndrome. CONCLUSIONS: Our results will help to better understand a safe and feasible way to work with children with PPMV, even though this approach is not yet widespread due to its special circumstances. These results can be used in future AT programmes in children undergoing special treatments.IMPLICATIONS FOR REHABILITATIONChildren with ventilation needs after discharge from the intensive care unit present physical, cognitive, and mental alterations that decrease functional capacity and quality of life.In a relatively small sample, positive outcomes were found for AT in relation to post-intensive care syndrome, enabling children to participate in aquatic therapy activities with the involvement of parents.This study highlighted the positive impact on the quality of life of both children and their parents.Aquatic therapy is a feasible intervention in children requiring prolonged mechanical ventilation, although certain difficulties should be addressed in terms of implementation, together with challenges regarding safety and planning.These difficulties may be overcome by promoting coordination between professionals, creating security protocols, and/or facilitating specialised education for therapists.

Outcomes for paediatric acute leukaemia patients admitted to the paediatric intensive care unit.

Children with acute leukaemia (AL) are a high-risk population for infections and life-threatening conditions requiring paediatric intensive care unit (PICU) admission, presenting an increased mortality rate. A few literature exists about PICU outcomes in this kind of patients, especially with haematopoietic stem cell transplant (HSCT) background. We investigated the clinical and epidemiological characteristics of these patients as well as their outcomes. A retrospective, single-centre analytical/observational study was conducted from January 2011 to December 2018 in the PICU of a tertiary care hospital. AL patients from 28 days to 18 years old admitted to the PICU were included, excluding those with histories of HSCT or CAR T-cell therapy. We collected epidemiological and clinical characteristics, laboratory and microbiology results and outcomes. Forty-three patients with AL required urgent admission (35 lymphoblastic and 8 myeloblastic) for 63 different episodes. The main reasons were sepsis (21, 33.3%), hyperleukocytosis (12, 19%), respiratory failure (11, 17.5%) and seizures (8, 12.7%). Nineteen (30.2%) required inotropic support, and fifteen (23.8%) required mechanical ventilation. Three patients died at the hospital (3/43, 6.9%). Sixty-day mortality was 9.3%, and 1-year mortality was 13.9%. There was no differences regarding the type of AL and 60-day mortality (log-rank 2.652, p = 0.103).Conclusion: In our study, the main cause of admission for AL patients was infection, which was associated to more severity and longer hospital admission. What is Known: • Acute leukaemia is the most common childhood cancer. Admission to a paediatric intensive care unit is required in 30% of children with acute leukaemia. • Regarding the outcomes of children with acute leukaemia that require admission to the intensive care unit data are scarce. What is New: • Mortality in acute leukaemia patients admitted to the paediatric intensive care unit is lower than that of patients with a history of stem cell therapy but higher than that of patients with solid tumours. • The main reason for admission was sepsis, which is related in literature to more severity and long length of stay.

Can calf circumference be a viable option for nutritional assessment in the PICU?

BACKGROUND: Children admitted to paediatric intensive care units (PICUs) often need specialised nutritional intervention. Nutritional assessments provide specific data to support such interventions. Body composition measures, such as mid-upper arm circumference (MUAC), can complement nutritional assessment. However, MUAC has limitations. Calf circumference (CC) is an easy and common measure of muscle loss in the elderly; however, there are still very few studies on CC in children. AIMS: To evaluate the viability of using CC for nutritional monitoring of children under intensive care, compared with MUAC and weight. METHODS: Patients aged 2-10 years admitted to the PICU between December 2018 and August 2019 were included in the study. Two MUAC, CC, and weight measurements were performed: one in the first 24 h after PICU admission and another after 7 days. As there are no reference values for CC in children, this measure was used solely to observe the patient's individual progress. The nutritional status, both according to body mass index and MUAC, was used to characterise samples. Percentage changes in these measures were compared using the Wilcoxon signed-rank test for comparison between medians and Spearman's correlation test. Information from medical records regarding hospitalisation was also collected and analysed. RESULTS: Thirty patients were included in the study. During hospitalisation week 1, CC decreased significantly (p = 0.001), whereas MUAC (p = 0.427) and weight (p = 0.315) did not change significantly. Percentage changes in CC and MUAC were statistically different (p = 0.0449), with a positive correlation between the changes in both measures (p = 0.0333; r = 0.3896); conversely, although the percentage changes in CC and weight significantly differed (p = 0.0066), no correlation was found between them (p = 0.9382; r = 0.0148). The percentage changes in MUAC and weight were not different (p = 0.1880) or correlated (p = 0.1691; r = 0.2577). No statistically significant relationship was found between percentage changes in CC and clinical outcomes (length of stay, fasting time, and mechanical ventilation time). CONCLUSIONS: CC appears to be a viable measure for use in PICUs. Although positively correlated with MUAC, a measure proven useful in critically ill children, CC decreased significantly in the first week of intensive care, whereas MUAC remained unchanged, indicating that CC may show signs of depletion earlier than MUAC in these patients. Our study reinforces the importance of alternative measures for anthropometric assessment of critically ill children.

Difficult intravenous access in a paediatric intensive care unit. / Vía venosa difícil en una unidad de cuidados intensivos pediátricos.

INTRODUCTION: Multiple attempts during peripheral cannulation can have major consequences for patients, relatives, and healthcare professionals, therefore we set out to determine the extent of this problem in a paediatric intensive care unit (PICU). OBJECTIVES: The main aim was to describe peripheral venous catheter (PVC) and peripherally inserted central catheter (PICC) cannulation in children in the PICU. Secondary objectives were to determine the success rate of the first cannulation attempt, to quantify patients with difficult venous access (DVA), and to explore the association between DVA and sociodemographic, technique and nursing-related characteristics. METHOD: A cross-sectional descriptive study. Consecutive sampling was used to recruit patients aged 0-18 years admitted to the PICU who required peripheral venous cannulation. An ad hoc questionnaire was used for this purpose, including the presence of DVA as an independent variable. RESULTS: A total of 163 venous cannulations were reported. A total of 55.8% (91) were performed in patients under 1 year of age. Of these, 38.7% (63) were successful on the first attempt and 36.8% (60) had DVA. When there was DVA, 85% (51) of patients had complications, median time to cannulation by short CVP was 30minutes [15-53] and 2 or more nurses were required on 80% (48) of occasions. CONCLUSIONS: We found a low success rate at first attempt and a high proportion of DVA. More nurses and time were employed during cannulation and complications increased if the patient had DVA. A statistically significant association was found between DVA and age, weight, poor perfusion, veins that were neither visible nor palpable, DIVA score≥4, history of difficult intravenous access, complications, number of nurses and time spent.

Fungaemia due to rare yeasts in paediatric intensive care units: A prospective study.

BACKGROUND: Considering the emergence of fungaemia due to rare yeasts at our centre, we performed a systematic epidemiologic study on fungaemia due to rare yeast. OBJECTIVES: We undertook the present prospective observational study to explore the epidemiological features and clinical characteristics of fungaemia due to rare yeasts in paediatric ICUs at our centre. METHODS: The successive yeasts isolated from blood at our PICUs during December 2017 through March 2019 were identified by molecular methods. Fungaemia due to yeasts other than C. albicans, C. tropicalis, C. glabrata, C. krusei and C. parapsilosis was categorised as rare yeasts. Antifungal susceptibility testing of the yeast isolates was performed as per clinical and laboratory standards institute (CLSI) guidelines. We also compared different clinical parameters of fungaemia due to common versus rare yeasts, and rare yeasts in neonates versus non-neonates. RESULTS: During the study period, 212 yeast isolates were obtained from 159 patients at PICUs of our hospital, and 127 isolates from 98 patients (61.6%) were categorised as rare yeasts. Neonates acquired fungaemia significantly earlier after ICU admission than non-neonates (median:4 vs 6 days; p = .005). Regarding epidemiology study of rare yeast fungaemia, Wickerhamomyces anomalus (43.8%) and Candida utilis (40.8%) were common isolates; surgical intervention and gastrointestinal disease were significantly associated; overall, azole, echinocandin and amphotericin B resistance was at 9.1%, 1.02% and 1.02%, respectively; overall mortality was 65.3%. CONCLUSIONS: The emergence of rare yeasts especially W. anomalus and C. utilis causing fungaemia in our children demands urgent attention to control the spread.

Low diagnostic yield and time to diagnostic confirmation results in prolonged use of antimicrobials in critically ill children.

Background: Broad-spectrum antimicrobial therapy is a key driver of antimicrobial resistance. Here, we aimed to review indications for antimicrobial therapy, determine the proportion of suspected bacterial infections that are confirmed by culture, and assess the time taken for microbiology test results to become available in the paediatric intensive care unit (PICU). Methods: A single-centre prospective observational cohort study of 100 consecutive general PICU admissions from 30 October 2019 to 19 February 2020. Data were collected from the hospital medical record and entered into a study database prior to statistical analysis using standard methods. Results: Of all episodes of suspected infection, 22% of lower respiratory tract infection, 43% of bloodstream and 0% of central nervous system infection were associated with growth on microbiology culture. 90% of children received antimicrobial therapy. Hospital-acquired infection occurred less commonly than primary infection, but an organism was grown in a greater proportion (64%) of cultures. Final laboratory reports for negative cultures were issued at a median of 120.3 hours for blood cultures and 55.5 hours for endotracheal tube aspirate cultures. Conclusions: Despite most critically children receiving antimicrobial therapy, infection was often not microbiologically confirmed. Novel molecular diagnostics may improve rationalisation of treatment in this population.

Persistent inflammation, immunosuppression and catabolism syndrome (PICS) in critically ill children is associated with clinical outcomes: a prospective longitudinal study.

BACKGROUND: Persistent inflammation, immunosuppression and catabolism syndrome (PICS) has been described in critically ill adults and may contribute to unfavourable outcomes. The present study aimed to describe and characterise PICS in critically ill children (PICS-ped) and to verify its association with clinical outcomes. METHODS: A prospective longitudinal study was conducted in a paediatric intensive care unit (PICU) with children aged between 3 months and 15 years. PICS-ped, based on adult definition, was described. PICS-ped was defined as PICU length of stay >14 days; C-reactive protein > 10.0 mg L-1 ; lymphocytes <25%; and any reduction of mid-upper arm circumference Z-score. Clinical, demographic, nutritional status, nutrition therapy parameters and clinical outcomes were assessed. Statistical analysis comprised Mann-Whitney and Fisher's chi-squared tests, as well as logistic and Cox regression. P < 0.05 was considered statistically significant. RESULTS: In total, 153 children were included, with a median age of 51.7 months (interquartile range 15.6-123.4 months), and 60.8% male. The mortality rate was 10.5%. The prevalence of PICS-ped was 4.6%. Days using vasoactive drugs and days using antibiotics were associated with PICS-ped. PICS-ped was associated with mortality in crude (odds ratio = 6.67; P = 0.013) and adjusted analysis (odds ratio = 7.14; P = 0.017). PICS-ped was also associated with PICU and hospital length of stay, as well as duration of mechanical ventilation. Similar results were found in a subset of critically ill children who required mechanical ventilation for more than 48 h. CONCLUSIONS: Children with PICS-ped required antibiotics or vasoactive drugs for a longer period. PICS-ped was associated with poor clinical outcomes in critically ill children. More studies are needed to properly define PICS-ped for this population.

Postoperative admission to paediatric intensive care after tonsillectomy.

OBJECTIVES: To review interventions required by children admitted for intensive care management following tonsillectomy or adenotonsillectomy either as elective or unplanned admission in a tertiary children's hospital. METHODS: A retrospective chart review over a 10-year period between April 2007 and March 2017 was performed. Charts were interrogated for treatments that were administered in the paediatric intensive care unit. Respiratory support therapies such as supplemental oxygen administration, high-flow nasal oxygen, positive pressure ventilation, continuous positive airway pressure, airway interventions and tracheal intubation were reviewed. RESULTS: There were 103 children admitted to the paediatric intensive care unit following tonsillectomy or adenotonsillectomy. The average age was 6.2 years (range 7 months-17 years). The main indications for the procedure were sleep disordered breathing or obstructive sleep apnoea syndrome. In all, 53 children had syndromes with medical comorbidities, 31 were current continuous positive airway pressure users and 5 had a tracheostomy in situ. Forty children admitted to paediatric intensive care unit did not require any high-level care. Ten children who had an unplanned admission had their respiratory interventions started in the theatre or in the post-anaesthetic care unit, before paediatric intensive care unit admission, and did not require escalation of care. CONCLUSION: Children may not require admission for intensive care after tonsillectomy if they have had an incident-free period in the post-anaesthetic care unit. Some of those who required high-flow nasal oxygen could have been managed on the ward provided with adequate training and monitoring facilities. The level of care they require in post-anaesthetic care unit reflected the level of care for the immediate postoperative period in the paediatric intensive care unit.

[What are the most reliable predictive factors of non-invasive ventilation failure in paediatric intensive care units?] / ¿Cuáles son los factores predictores de fracaso de ventilación no invasiva más fiables en una unidad de cuidados intensivos pediátricos?

INTRODUCTION: Despite there being limited evidence, non-invasive ventilation (NIV) has become a common treatment for acute respiratory failure (ARF). The aim of this study was to identify the predictive factors of NIV failure, in order to enable early detection of patients failing the treatment. PATIENTS AND METHODS: Prospective cohort study was conducted that included all ARF patients that received NIV as the initial treatment between 2005 and 2009 in a fourteen-bed Paediatric Intensive Care Unit (PICU) of a tertiary university hospital. Information was collected about the NIV, as well as clinical data prior to NIV, at 2, 8, 12, and 24hrs. The haemoglobin saturation (SpO2)/fraction of inspired oxygen (FiO2) ratio (S/F) was retrospectively calculated. NIV failure was defined as the need for intubation or requiring rescue with bi-level pressure (BLPAP). Univariate and multivariate statistical analyses were performed. RESULTS: A total of 282 patients received non-invasive support, with 71 receiving Continuous Pressure (CPAP), and 211 with BLPAP treatment. The overall success rate was 71%. Patients receiving BLPAP vs. CPAP, patients with higher S/F ratios at 2hours (odds ratio [OR] 0.991, 95% CI 0.986-0.996, P=.001], and patients older than 6 months (Hazard ratio [HZ] 0.375, 95% CI 0.171-0.820, P=.014], were also more likely to fail. Patients with higher heart rates (HR) at 2hours (OR 1.021, 95% CI [1.008-1.034], P=.001) and higher inspiratory positive airway pressure (IPAP) at 2hours were more prone to failure (HZ 1.214, 95% CI [1.046-1.408], P=.011). CONCLUSIONS: Age below 6 months, S/F ratio, HR, and IPAP at 2hours are independent predictive factors for initial NIV failure in paediatric patients with ARF admitted to the PICU.

Evaluación del uso de sedación y analgesia en niños con asistencia ventilatoria mecánica / Assessing the use of sedation and analgesia on children under mechanical ventilation / Avaliação do uso de sedação e analgesia em crianças com assistência ventilatória mecânica

Resumen: Objetivo: cuantificar el uso de sedoanalgesia en niños críticamente enfermos con asistencia ventilatoria mecánica (AVM) en la Unidad de Cuidados Intensivos (UCIN) del Centro Hospitalario Pereira Rossell (CHPR). Metodología: estudio observacional descriptivo y prospectivo realizado entre los meses de mayo a setiembre de 2017. Se incluyeron pacientes ingresados a UCIN que requirieron AVM y sedoanalgesia o mioparalización. Se registraron las siguientes variables: sexo, edad, peso, diagnóstico al ingreso. En relación con la sedación y analgesia se registraron dosis indicadas y recibidas de cada fármaco y las dosis acumulativas. Se las comparó con un estudio realizado en 2012 en UCIN. Resultados: se incluyeron 37 pacientes. El promedio de días de AVM fue de 3,7. La causa más frecuente de AVM fue patología respiratoria (n=34). Se observó discordancia entre dosis indicada y dosis recibida tanto de opiáceos, benzodiacepinas y paralizantes musculares, pero en menor medida que lo registrado en el año 2012. Las dosis acumulativas de midazolam, fentanyl y atracurio disminuyeron respecto al año 2012. Conclusión: se observó una disminución de las dosis promedio utilizadas de cada fármaco, de la duración de la AVM y una menor incidencia de síndrome de abstinencia. Las causas de esta observación pueden ser multifactoriales.

Summary: Objective: to quantify benzodiazepines and opioids dosages used in critically ill children under invasive mechanical ventilation (IMV) hospitalized in a Paediatric Intensive Care Unit (PICU). Methodology: an observational study was carried out from May to September 2017. It included children who under IMV hospitalized in a PICU and who were treated with benzodiazepines, opioids and/or neuromuscular blockers. These children key clinical features were recorded. Cumulative doses of benzodiazepines, opioids and neuromuscular blockers were recorded. Results were compared with the data obtained in a previous experience in the same PICU in 2012. Results: 37 children were included. IMV average duration of was 3.7 days. Cumulative doses and treatment duration of midazolam, fentanyl and atracurium decreased from 2012 to 2017. There were differences between the doses prescribed and the doses actually received in both periods. Conclusion: cumulative doses of benzodiazepines, opioids and neuromuscular blockers decreased in the 2012-2017 period.

Resumo: Objetivo: quantificar o uso da sedação e analgesia em crianças criticamente doentes com Assistência de Ventilação Mecânica (MAV) na Unidade de Terapia Intensiva (UTIN) do Centro Hospitalar Pediátrico Pereira Rossell (CHPR). Metodologia: estudo observacional descritivo e prospectivo realizado de maio a setembro de 2017. Incluíram-se pacientes internados em UTIN que necessitaram de MAV e sedação e analgesia e / ou bloqueadores neuromusculares. Registraram-se as seguintes variáveis: sexo, idade, peso, diagnóstico no momento da admissão. Foram registradas as doses indicadas e recebidas de cada droga de sedação e analgesia, assim como as doses cumulativas. Os resultados foram comparados com um estudo realizado em 2012 na UTIN. Resultados: incluíram-se 37 pacientes. O tempo médio de AVM foi de 3,7 dias. A causa mais frequente de MAV foi doença respiratória (n = 34). Observou-se dissonância entre a dose indicada e a dose recebida dos opiáceos, benzodiazepínicos e agentes paralisantes musculares, mas em grau menor do que o registrado em 2012. As doses cumulativas de midazolam, fentanil e atracúrio diminuíram em relação a 2012. Conclusão: observamos uma diminuição nas doses médias de cada droga utilizada, na duração da MAV e uma menor incidência de síndrome de abstinência. Esta observação pode ter causas multifatoriais.

Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study.

BACKGROUND: Hand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge. OBJECTIVES: To compare hand hygiene compliance before and after interventions to promote adherence in a paediatric intensive care unit (PICU) and to identify predictors of intention to perform the behaviour "hand hygiene during patient care in the PICU". METHODS: A before and after study was conducted in three phases. Based on the World Health Organization guideline for hand hygiene compliance monitoring, 1261 hand hygiene opportunities were directly observed during routine patient care by two observers simultaneously, in a nine-bed PICU in Brazil, before and after infrastructure and educational interventions. To identify predictors of healthcare professionals' intention to perform the behaviour hand hygiene during patient care, a data collection instrument was designed based on the Theory of Planned Behaviour. Statistical analyses were undertaken using Chi-square test or the Fisher's exact test and regression analysis. A significance level of 5% (p < 0.05) was applied to all analyses. RESULTS: The hand hygiene compliance rate increased significantly from 27.3% in the "pre-intervention phase" to 33.1% in "phase 1-post-intervention," to 37.0% in "phase 2-post-intervention" (p = .010). Perceived social pressure (p = .026) was a determinant factor of intention to perform the behaviour. CONCLUSIONS: Hand hygiene compliance raised significantly after infrastructure, educational, and performance feedback interventions. However, despite the significant effect of the implemented interventions, the overall hand hygiene compliance rate was low. Perceived social pressure characterised a determinant factor of intention to perform the behaviour "hand hygiene during patient care in the PICU", reinforcing the need for behaviour determinants analysis when designing promotional interventions.

Hyponatraemia in a Lao paediatric intensive care unit: Prevalence, associations and intravenous fluid use.

AIM: Hyponatraemia is a common and potentially deadly complication affecting hospitalised children world-wide. Hypotonic intravenous fluids can be a significant exacerbating factor. Exclusive use of isotonic fluids, coupled with rigorous blood monitoring, has proven effective in reducing hyponatraemia in developed settings. In developing countries, where hyponatraemia is often more common and severe, different factors may contribute to its incidence and detection. We aimed to determine the prevalence and disease associations of hyponatraemia and describe the intravenous maintenance fluid prescribing practices in a Lao paediatric intensive care unit. METHODS: We conducted a cross-sectional study of 164 children aged 1 month to 15 years admitted to intensive care at a tertiary centre in Lao People's Democratic Republic (PDR) and recorded their serum sodium and clinical data at admission and on two subsequent days. RESULTS: Hyponatraemia was detected in 41% (67/164, confidence interval 34-48%) of children, the majority of which was mild (34%, 56/164) and present at admission (35%, 55/158). Hyponatraemia was more common in malnourished children (odds ratio (OR) 2.3, P = 0.012) and females (OR 1.9, P = 0.045). Hyponatraemia correlated with death or expected death after discharge (OR 2.2, P = 0.015); 88% received maintenance intravenous fluids, with 67% of those receiving a hypotonic solution. Electrolyte testing was only performed in 20% (9/46) of patients outside the study protocol. CONCLUSIONS: Hyponatraemia is highly prevalent in critically ill children in Lao PDR, as is the continued use of hypotonic intravenous fluids. With financial and practical barriers to safely detecting and monitoring electrolyte disorders in this setting, this local audit can help promote testing and has already encouraged changes to fluid prescribing.