Outcomes of Cardiopulmonary Resuscitation in the Pediatric Intensive Care of a Tertiary Center.

Understanding the factors affecting survival and modifying the preventable factors may improve patient outcomes following cardiopulmonary resuscitation (CPR). The aim of this study was to assess the prevalence and outcomes of cardiac arrest and CPR events in a tertiary pediatric intensive care unit (PICU). Outcomes of interest were the return of spontaneous circulation (ROSC) lasting more than 20 minutes, survival for 24 hours post-CPR, and survival to hospital discharge. We analyzed data from the PICU CPR registry from January 1, 2011 to January 1, 2018. All patients who underwent at least 2 minutes of CPR in the PICU were included. CPR was administered in 65 PICU instances, with a prevalence of 1.85%. The mean patient age was 32.7 months. ROSC occurred in 38 (58.5%) patients, 30 (46.2%) achieved 24-hour survival, and 21 (32.3%) survived to hospital discharge. Younger age ( p < 0.018), respiratory cause ( p < 0.001), bradycardia ( p < 0.018), and short duration of CPR ( p < 0.001) were associated with better outcomes, while sodium bicarbonate, norepinephrine, and vasopressin were associated with worse outcome ( p < 0.009). The off-hour CPR had no impact on the outcome. The patients' cumulative predicted survival declined by an average of 8.7% for an additional 1 minute duration of CPR ( p = 0.001). The study concludes that the duration of CPR, therefore, remains one of the crucial factors determining CPR outcomes and needs to be considered in parallel with the guideline emphasis on CPR quality. The lower survival rate post-ROSC needs careful consideration during parental counseling. Better anticipation and prevention of CPR remain ongoing challenges.

Enhancing Expert Panel Discussions in Pediatric Palliative Care: Innovative Scenario Development and Summarization With ChatGPT-4.

This study presents a novel approach to enhance expert panel discussions in a medical conference through the use of ChatGPT-4 (Generative Pre-trained Transformer version 4), a recently launched powerful artificial intelligence (AI) language model. We report on ChatGPT-4's ability to optimize and summarize the medical conference panel recommendations of the first Pan-Arab Pediatric Palliative Critical Care Hybrid Conference, held in Riyadh, Saudi Arabia. ChatGPT-4 was incorporated into the discussions in two sequential phases: first, scenarios were optimized by the AI model to stimulate in-depth conversations; second, the model identified, summarized, and contrasted key themes from the panel and audience discussions. The results suggest that ChatGPT-4 effectively facilitated complex do-not-resuscitate (DNR) conflict resolution by summarizing key themes such as effective communication, collaboration, patient and family-centered care, trust, and ethical considerations. The inclusion of ChatGPT-4 in pediatric palliative care panel discussions demonstrated potential benefits for enhancing critical thinking among medical professionals. Further research is warranted to validate and broaden these insights across various settings and cultures.

The burden of viral infections in pediatric intensive care unit between endemic and pandemic coronavirus infections: A tertiary care center experience.

OBJECTIVES: To measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country. METHODS: A retrospective chart review of children 0-14 years old admitted to PICU with a viral infection. RESULTS: Of 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001). CONCLUSION: Viral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations.

Enhancing parental knowledge of childhood and adolescence safety: An interventional educational campaign.

BACKGROUND: Safeguarding children and adolescents from unintentional injuries is a significant concern for parents and caregivers. With them staying more at home during the coronavirus disease 2019 pandemic, more educational tools and valid educational programs are warranted to improve parental knowledge and awareness about childhood and adolescences' safety. This study aims to explore the effectiveness of childhood and adolescence safety campaigns on parents' knowledge and attitude toward preventable injuries. METHODS: This was a pre-post experimental study, in which the predesigned assessments were used as an evaluation tool before and after attending a childhood and adolescence safety campaign. The pre-post assessment question included questions to evaluate the socio-demographic status, followed by knowledge questions in line with the current childhood and adolescence safety campaign. The outcomes of interest were assessed before and after attending the campaign's stations. RESULTS: Three hundred eight parents volunteered to participate in this study. Their knowledge score improved from 36.2 [standard deviation (SD) 17.7] to 79.3 (SD 15.6) after attending the Campaign (t value = 34.6, P < .001). Both, perceptions on the preventability of accidents and the parents' perceived usefulness of educational campaigns showed improvements, with (t value = 6.3, P < .001) and (t value = 3.097, P < .001), respectively. CONCLUSION: The educational childhood and adolescence safety campaign for caregivers in Saudi Arabia resulted in a significant increase in the overall knowledge and attitudes toward childhood and adolescence's safety. As children and adolescents are currently staying at home more, additional educational tools and programs are warranted to promote safe practices among parents and caregivers.

Initial Fluid Balance Associated Outcomes in Children With Severe Sepsis and Septic Shock.

INTRODUCTION: Net fluid balance and its role in sepsis-related mortality is not clear; studies suggest that aggressive fluid resuscitation can help in treatment, whereas others consider it is associated with poor outcomes. This study aimed to clarify the possible association of initial 24 hours' fluid balance with poor outcomes in pediatric patients with sepsis. METHODS: Retrospective data analysis included pediatric patients admitted with suspected or proven sepsis or septic shock to pediatric intensive care unit (PICU) of a tertiary care teaching hospital in Saudi Arabia. RESULTS: The study included 47 patients; 13 (28%) died, and mortality rate was significant in children with neurologic failure (P < 0.02), mechanical ventilation within 24 hours of admission (P < 0.03), leukopenia (P < 0.02), abnormal international normalized ratio (P < 0.02), initial blood lactate levels higher than 5 mmol/L (P < 0.02), or positive fluid balance at 24 hours of admission to the PICU (P < 0.001). CONCLUSION: Among children with sepsis and/or septic shock, there is significant association between mortality and initial high blood lactate levels and positive fluid balance at 24 hours from admission to the PICU.

Causes, timing, and modes of death in a tertiary pediatric intensive care unit: Five years' experience.

OBJECTIVES: To identify the causes, modes, and timing of death in a tertiary pediatric intensive care unit (PICU). METHODS: This is a retrospective data analysis of patients older than 48 hours and younger than 15 years who died in the PICU over a 5-year period from January 2012 until December 2016 at a tertiary hospital in Riyadh, Saudi Arabia. RESULTS: There were 101 deaths out of 2295 admissions, representing average crude mortality rate of 4.4%. Sepsis was the most common cause of death in 31 patients (30.7%), followed by lower respiratory tract infections in 19 (18.8%), and cardiac diseases in 12 (11.9%). Failed cardiopulmonary resuscitation was the most common mode of death in 51 patients (50.5%), followed by withholding life-sustaining treatment in 43 (42.6%), and brain death in 7 (6.9%). Although more deaths occurred during after hours (n=70; 69.3%), there was no significant correlation between mode of death and working hours vs. after hours (p>0.05). Among the cohort, 63 patients (62.4%) had an infection-attributed mortality, of which 43 (68.3%) were bacterial, 14 (22.2%) were viral, and 10 (15.9%) were fungal. CONCLUSION: Infections remain a significant cause of death in the PICU. Further improvement of prevention programs and early therapy of severe infections could lower pediatric mortality. This report highlights the need for enhancing palliative care programs. The low rate of brain death diagnoses warrants further investigation.

Pediatric Intensive Care Hybrid-Style Clinical Round During COVID-19 Pandemic: A Pilot Study.

Objectives: With the evolving COVID-19 pandemic and the emphasis on social distancing to decrease the spread of SARS-CoV-2 among healthcare workers (HCWs), our pediatric intensive care unit (PICU) piloted the integration of Zoom meetings into clinical rounds. We aimed to explore the feasibility of these hybrid virtual and physical clinical rounds for PICU patients. Design: Mixed quantitative and qualitative deductive thematic content analysis of narrative responses. Setting: PICU, single tertiary-care academic center. Participants: Multidisciplinary PICU HCWs. Interventions: Integration of Zoom meeting into clinical daily PICU rounds. Measurements: For the quantitative part, we gathered the details of daily PICU hybrid rounds in terms of times, number of HCWs, and type of files shared through Zoom. For the qualitative part, open-ended questions were used. Main Results: The physical round took statistically significantly less time (34.68 ± 14.842 min) as compared with the Zoom round (72.45 ± 22.59 min), p < 0.001. The most shared component in the virtual round was chest X-rays (93.5%). Thirty-one HCWs participated in focus group discussions and were included in the analysis. Some of the HCWs' perceived advantages of the hybrid rounds were enabling multidisciplinary discussions, fewer round interruptions, and practicality of virtual discussions. The perceived challenges were the difficulty of the bedside nurse attending the virtual round, decreased teaching opportunities for the trainees, and decreased interactions among the team members, especially if video streaming was not utilized. Conclusions: Multidisciplinary hybrid virtual and physical clinical rounds in the PICU were perceived as feasible by HCWs. The virtual rounds decreased the physical contact between the HCWs, which could decrease the possibility of SARS-CoV-2 spread among the treating team. Still, several components of the hybrid round should be optimized to facilitate the virtual team-members' interactions and enhance the teaching experience.

Virtual Handover of Patients in the Pediatric Intensive Care Unit During the Covid-19 Crisis.

OBJECTIVE: A key measure to mitigate coronavirus disease 2019 (COVID-19) has been social distancing. Incorporating video-conferencing applications in the patient handover process between healthcare workers can enhance social distancing while maintaining handover elements. This study describes pediatric intensive care unit (PICU) physicians' experience using an online video-conferencing application for handover during the COVID-19 pandemic. DESIGN: Qualitative content analysis. SETTING: PICU at a university hospital in Riyadh, Saudi Arabia. SUBJECTS: PICU Physicians. INTERVENTIONS: Due to the pandemic, the hospital's PICU used Zoom® as a remote conferencing application instead of a face-to-face handover. Following institutional review board approval, data were collected over two weeks (1 Jul 2020 to 14 Jul 2020). MEASUREMENTS: An online survey was conducted using open-ended questions to capture demographic data and the perceived efficacy of remote handovers. Thematic framework analysis process included open coding, creating categories, and abstraction. MAIN RESULTS: All 37 PICU physicians who participated in the handover completed the survey. The participants comprised six attendings, nine specialists, and 22 residents. While 20 (54.1%) physicians reported attending 1-5 Zoom handovers by the time of the study, some (n. 6, 16.2%) had more than ten virtual handovers. They had variable previous teleconferencing experiences. Most physicians (78.4%) were comfortable conducting a remote handover. Most found that Situation-Background-Assessment-Recommendation handover elements were properly achieved through this remote handover process. The perceived advantages of online handover included fewer interruptions, time efficiency, and facilitation of social distancing. The perceived disadvantages were the paucity of nonverbal communication and teaching during virtual meetings. CONCLUSION: Video-conferencing applications for online handovers could supplement traditional face-to-face intensive care unit patient handover during outbreaks of infectious diseases. The use of video streaming and more emphasis on teaching should be encouraged to optimize the users' experience.

Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study.

BACKGROUND: Several factors influence patients' length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs). METHODS: This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units' leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days. RESULTS: Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million). CONCLUSION: If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.

Long-stay patients in pediatric intensive care units. Five-years, 2-points, cross-sectional study.

OBJECTIVES: To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources. METHODS: This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included. RESULTS: Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%). CONCLUSION: A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.

JAK Inhibitor Therapy in a Child with Inherited USP18 Deficiency.

Deficiency of ubiquitin-specific peptidase 18 (USP18) is a severe type I interferonopathy. USP18 down-regulates type I interferon signaling by blocking the access of Janus-associated kinase 1 (JAK1) to the type I interferon receptor. The absence of USP18 results in unmitigated interferon-mediated inflammation and is lethal during the perinatal period. We describe a neonate who presented with hydrocephalus, necrotizing cellulitis, systemic inflammation, and respiratory failure. Exome sequencing identified a homozygous mutation at an essential splice site on USP18. The encoded protein was expressed but devoid of negative regulatory ability. Treatment with ruxolitinib was followed by a prompt and sustained recovery. (Funded by King Saud University and others.).

Satisfaction and perceived usefulness with newly-implemented Electronic Health Records System among pediatricians at a university hospital.

BACKGROUND: Apposite implementation of Electronic Health Records (EHR) is anchoring standards of care in healthcare settings by reducing long-run operational costs, improving healthcare quality, and enhancing patient safety. OBJECTIVE: This study aims to explore factors that might influence Pediatricians' satisfaction with an implemented EHR system and its perceived usefulness at a tertiary-care teaching hospital, Riyadh, Saudi Arabia. METHODS: A cross-sectional survey distributed to all physicians working in the pediatric department of King Saud University Medical City (KSUMC) in the period from June to November 2015, two months after the launch of the EHR system, internally branded as electronic system for integrated health information (eSiHi). Bivariate and multivariate regression were analyzed to examine factors associated with physicians' satisfaction. RESULTS: Of the 112 physicians who completed the survey, 97 (86.6%) attended training courses before the implementation of new EHR. On average, the participants rated the perceived usefulness of the new system at 6.4/10 for patient care and physicians' satisfaction levels were 5.2/10. The top indicator of EHR usefulness was the system's ability to reduce errors and improve the quality of care [mean 3.31, SD 0.9, RII 82.8%]; the lowest-ranking indicator was the physicians' perceived familiarity with functions and benefits [mean 2.68, SD 0.7, RII 67%]. The top indicator of satisfaction with the EHR system was enhanced "individual performance" [mean 3.04, SD 1, RII 60.9%]; the lowest-ranking perceived indicator was the limited availability of workplace computers [mean 1.91, SD 1.2, RII 38.2%]. CONCLUSIONS: Limited data regarding EHR implementation and end-users satisfaction in the Middle East region necessitates further work on factors affecting levels of satisfaction with the EHR system among different health institutes. Lack of information technology (IT) support, hardware, and time-consuming data entry process are challenging barriers for proper utilization of EHR for pediatric health care services.

Advanced coats-like retinopathy as the initial presentation of Familial Retinal Arterial Macroaneurysms.

PURPOSE: To describe two young Saudi brothers with bilateral progressive retinal arterial aneurysms and a subtotal exudative retinal detachment with Coats-like presentation in the older sibling as the initial presentation of Familial Retinal Arterial Macroaneurysms (FRAM). OBSERVATIONS: Two young Saudi brothers with a family history of consanguinity presented with the classic clinical presentation and genetic identification of FRAM. In this report, we describe the presence of prominent peripheral retinal capillary changes mimicking Coats' disease. CONCLUSIONS AND IMPORTANCE: FRAM can present similar to bilateral Coats' disease and should be considered in the differential diagnosis of Coats-like retinopathy. The diagnosis of FRAM may have a significant implication because of the associated cardiac abnormality, such as supravalvular pulmonary stenosis, which should be evaluated by echocardiography and managed accordingly.

Cytomegalovirus associated severe pneumonia, multi-organ failure and Ganciclovir associated arrhythmia in immunocompetent child.

Cytomegalovirus (CMV) can rarely cause severe manifestations in immunocompetent individuals. Hereby, we report a twelve-year-old boy who presented with tachycardia, tachypnea, fever and leukocytosis, which progressed to hypoxemic respiratory failure and severe acute respiratory distress syndrome (ARDS). Subsequently, he developed multi-organ failure despite the ongoing full supportive care and empiric broad spectrum antibiotics. Cytomegalovirus infection was diagnosed by Polymerase Chain Reaction (PCR) in blood and histopathological examination of lung biopsy. Immunological work up for the child was unremarkable. Ganciclovir therapy was introduced and showed significant improvement until full recovery. However, our patient developed transient heart block as a rare complication for Ganciclovir therapy throughout his course. We present this case with literature review for the CMV infection associated morbidity and mortality among immunocompetent children.