Severe multiple organ failure as a consequence of diabetic ketoacidosis in an adolescent with new-onset type 1 diabetes: A case report.

The initial presentation of pediatric diabetes is variable, making prompt diagnosis and treatment challenging. The overlap between type 1 and type 2 diabetes and presence of developmental delays can complicate diagnosis, resulting in delays and severe illness at presentation. Here we describe a case of a 13-year-old male with autism and attention deficit hyperactivity disorder who presented with severe diabetic ketoacidosis, multiple organ failure, and shock. Within 2 weeks of this initial presentation, he had further clinical decompensation due to an intestinal perforation. Cultures from resected gastrointestinal tissue grew mucormycosis, protracting his hospital stay and recovery. He was able to go home several months later with remarkable improvement. This case highlights the necessity of careful history taking and early testing, and how investigation for rare complications of diabetes is vital when patients do not improve as expected.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility.

RATIONALE: A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE: To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN: The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS: Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS: The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS: The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Self-care Strategies to Combat Burnout Among Pediatric Critical Care Nurses and Physicians.

BACKGROUND: Professional burnout is a widespread phenomenon in health care. The health of patients and organizations begins with the well-being of health care professionals. Identifying and understanding self-care strategies that professionals perceive to be helpful is crucial to combat burnout. OBJECTIVE: To determine perceptions of self-care strategies to combat professional burnout among nurses and physicians in pediatric critical care settings. METHODS: This was a qualitative descriptive study with a phenomenological overtone. The study was conducted in a 20-bed pediatric intensive care unit and an 8-bed intermediate care unit of a children's hospital in the United States. Information flyers and emails were used to introduce the study. A combination of convenience and purposive sampling methods was used to recruit participants who were full-time nurses and physicians in the 2 units. Information saturation was used to regulate sample sizes, resulting in 20 participants. Data were collected through a onetime face-to-face interview with each participant. A qualitative descriptive approach was used to analyze the data. The first author was the primary coder and discussed the codes with the coauthors throughout the coding process. RESULTS: Six major self-care strategies were identified: finding meaning in work, connecting with an energy source, nurturing interpersonal connections, developing an attitude of positivity, performing emotional hygiene, and recognizing one's uniqueness and contributions at work. CONCLUSIONS: Developing effective self-care strategies helps promote health care professionals' physical and psychological well-being and reduce burnout. It is vital for health care professionals to care for themselves so that they can best care for others.

Multi-modal Educational Curriculum to Improve Richmond Agitation-sedation Scale Inter-rater Reliability in Pediatric Patients.

INTRODUCTION: The Richmond Agitation-sedation Scale (RASS) is a reliable and valid scale for assessing sedation in critically ill pediatric patients. This investigation evaluates the inter-rater reliability of the RASS in mechanically ventilated pediatric patients before and after an educational intervention. METHODS: This prospective, interventional quality improvement study was completed in a 20-bed pediatric intensive care unit from July 2013 to July 2014. Children 0-18 years of age requiring mechanical ventilation and receiving sedative or analgesic medications were eligible. Staff completed simultaneous paired RASS assessments in 3 phases: baseline, after educational intervention, and maintenance. RESULTS: Staff completed 347 paired assessments on 45 pediatric intensive care unit patients: 49 in the baseline phase, 228 in the postintervention phase, and 70 in the maintenance phase. There was a significant increase in the weighted κ after the intervention, from 0.56 (95% CI, 0.39-0.72) to 0.86 (95% CI, 0.77-0.95; P < 0.001). The improvement was maintained months later with weighted κ 0.78 (95% CI, 0.61-0.94). In subgroup analysis, there was an increase in weighted κ in patients less than 1 year of age (0.41-0.87) and those with developmental delay (0.49-0.84). CONCLUSIONS: The RASS is a reliable tool for sedation assessment in mechanically ventilated, sedated pediatric patients after implementation of an educational intervention. It is also reliable in patients less than 12 months of age and patients with developmental delay. The ability to easily educate providers to utilize a valid, reliable sedation tool is an important step toward using it to provide consistent care to optimize sedation.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

OBJECTIVE: To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. DESIGN AND SETTING: A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. PATIENTS: A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. INTERVENTIONS: None. MEASUREMENTS: Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. RESULTS: A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0). CONCLUSIONS: The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Fertility and pregnancy outcomes in men and women with cystic fibrosis in the United Kingdom.

BACKGROUND: The survival of patients with cystic fibrosis (CF) now occurs into the fourth decade of life. Our aim was to evaluate the fertility and pregnancy outcomes of men and women with cystic fibrosis within a large British cohort. METHODS: A population based cohort study of 4659 males and females registered with the UK Cystic Fibrosis Database in 2001. RESULTS: Poor respiratory health (forced expiratory volume in 1 s FEV1 <50%) and CF-related diabetes increased significantly post-puberty compared with childhood. Few individuals with CF sought fertility treatment (1% men, 0.5% women) or achieved pregnancies (1.3% of partners of men, 5.7% women). However, the majority of pregnancies had a good outcome (67% live term birth among male partners, 74% among women). Women who achieved a pregnancy were less likely to suffer from poor respiratory health (FEV1 <50%), age adjusted Odds Ratio 0.6 (95% CI 0.3-0.9), less likely to be homozygous for the DF508 genotype OR 0.5 (95% CI 0.3-0.9) and had a significantly earlier median age at diagnosis (0 years vs 2 years, P=0.001). CONCLUSIONS: Increasing numbers of males and females with cystic fibrosis are reaching reproductive age but currently very few have a child. Optimal adult health should improve the reproductive prognosis for both men and women.