Diaphragm atrophy is associated with delayed weaning from mechanical ventilation and increased mortality in critically ill adults. We sought to test for the presence of diaphragm atrophy in children ...with acute respiratory failure.
Prospective, observational study.
Single-center tertiary noncardiac PICU in a children's hospital.
Invasively ventilated children with acute respiratory failure.
Diaphragm thickness at end-expiration and end-inspiration were serially measured by ultrasound in 56 patients (median age, 17 mo; interquartile range, 5.5-52), first within 36 hours of intubation and last preceding extubation. The median duration of mechanical ventilation was 140 hours (interquartile range, 83-201). At initial measurement, thickness at end-expiration was 2.0 mm (interquartile range, 1.8-2.5) and thickness at end-inspiration was 2.5 mm (interquartile range, 2-2.8). The change in thickness at end-expiration during mechanical ventilation between first and last measurement was -13.8% (interquartile range, -27.4% to 0%), with a -3.4% daily atrophy rate (interquartile range, -5.6 to 0%). Thickening fraction = (thickness at end-inspiration - thickness at end-expiration/thickness at end-inspiration) throughout the course of mechanical ventilation was linearly correlated with spontaneous breathing fraction (beta coefficient, 9.4; 95% CI, 4.2-14.7; p = 0.001). For children with a period of spontaneous breathing fraction less than 0.5 during mechanical ventilation, those with exposure to a continuous neuromuscular blockade infusion (n = 15) had a significantly larger decrease in thickness at end-expiration compared with children with low spontaneous breathing fraction who were not exposed to a neuromuscular blockade infusion (n = 18) (-16.4%, interquartile range, -28.4% to -7.0% vs -7.3%; interquartile range, -10.9% to -0%; p = 0.036).
Diaphragm atrophy is present in children on mechanical ventilation for acute respiratory failure. Diaphragm contractility, measured as thickening fraction, is strongly correlated with spontaneous breathing fraction. The combination of exposure to neuromuscular blockade infusion with low overall spontaneous breathing fraction is associated with a greater degree of atrophy.
Excess mortality risk imparted by acute respiratory failure in children is unknown. We determined excess mortality risk associated with mechanically ventilated acute respiratory failure in pediatric ...sepsis. Novel ICD10-based algorithms were derived and validated to identify a surrogate for acute respiratory distress syndrome to calculate excess mortality risk. Algorithm-identified ARDS was identified with specificity of 96.7% (CI 93.0 - 98.9) and sensitivity of 70.5% (CI 44.0 - 89.7). Excess risk of mortality for ARDS was 24.4% (CI 22.9 - 26.2). Development of ARDS requiring mechanical ventilation imparts modest excess risk of mortality in septic children.
Tunneled femorally inserted central catheters (FICCs) are frequently required for central access in children when upper extremity vessels cannot or should not be cannulated. A recently published ...decision tool for tunneled FICCs identifies the medial thigh as the preferred exit site. In pediatric patients, this medial exit site may remain at risk of contamination from stool due to anatomic size, and there are no tools developed for FICC exit site decisions specific to children. We present our approach for the placement of the exit site in the far lateral region of the thigh and review previous FICC literature relevant to the pediatric population. In select patients, a lateral approach has the potential to decrease the risk of exit site contamination to prolong catheter viability and reduce patient harm.
OBJECTIVES:The prevalence and importance of early right ventricular dysfunction and pulmonary hypertension in pediatric acute respiratory distress syndrome are unknown. We aimed to describe the ...prevalence of right ventricular dysfunction and pulmonary hypertension within 24 hours of pediatric acute respiratory distress syndrome diagnosis and their associations with outcomes.
DESIGN:Retrospective, single-center cohort study.
SETTING:Tertiary care, university-affiliated PICU.
PATIENTS:Children who had echocardiograms performed within 24 hours of pediatric acute respiratory distress syndrome diagnosis.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Between July 1, 2012, and June 30, 2016, 103 children met inclusion criteria. Echocardiograms were analyzed using established indices of right ventricular and left ventricular systolic function and for evidence of pulmonary hypertension. Echocardiographic abnormalities were common26% had low right ventricular fractional area change, 65% had low tricuspid annular plane systolic excursion, 30% had low left ventricular fractional shortening, and 21% had evidence of pulmonary hypertension. Abnormal right ventricular global longitudinal strain and abnormal right ventricular free wall strain were present in 35% and 40% of patients, respectively. No echocardiographic variables differed between or across pediatric acute respiratory distress syndrome severity. In multivariable analyses, right ventricular global longitudinal strain was independently associated with PICU mortality (odds ratio, 3.57 1.33–9.60; p = 0.01), whereas right ventricular global longitudinal strain, right ventricular free wall strain, and the presence of pulmonary hypertension were independently associated with lower probability of extubation (subdistribution hazard ratio, 0.46 0.26–0.83, p = 0.01; subdistribution hazard ratio, 0.58 0.35–0.98, p = 0.04; and subdistribution hazard ratio, 0.49 0.26–0.92, p = 0.03, respectively).
CONCLUSIONS:Early ventricular dysfunction and pulmonary hypertension were detectable, prevalent, and independent of lung injury severity in children with pediatric acute respiratory distress syndrome. Right ventricular dysfunction was associated with PICU mortality, whereas right ventricular dysfunction and pulmonary hypertension were associated with lower probability of extubation.
To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure.
...Prospective, cross-sectional study.
Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022.
Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease.
None.
Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio OR 0.18 95% CI, 0.06-0.56, p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 95% CI, 0.29-0.68, p < 0.0001).
In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.
Femorally inserted central catheters (FICCs) are frequently required for central access in children. Ultrasound can accurately locate the catheter tip in most cases and its use is increasing in ...clinical vascular access practice. In patients with poor acoustic windows, intracavitary electrocardiogram (IC-ECG) is an alternative to ultrasound-guidance for FICC positioning. A case series of three patients demonstrate methods of FICC positioning in children. The first patient had excellent acoustic windows and ultrasound-guided FICC positioning is described in conjunction with IC-ECG measurements. The following two patients had poor acoustic windows, thus IC-ECG guided FICC tip position. The use of FICCs in children has increased in recent years. Ultrasound has emerged as a reliable method of assessing FICC tip location. IC-ECG is an accurate and complementary method of assessing FICC tip location, but can be a primary method when ultrasound is not available or cannot directly visualize the catheter. IC-ECG P-wave characteristics identify optimal tip position at the inferior cavoatrial junction and are different from characteristics at the superior cavoatrial junction.
BACKGROUNDPediatric patients requiring extracorporeal life support (ECLS) often need central venous access for extended periods of time. In this population, the placement of an upper extremity ...peripherally inserted central catheter (PICC) can be challenging due to the location and size of the venous ECLS cannula. Bedside placement of a tunneled femorally inserted central catheters (T-FICC) can be a viable alternative to a traditional PICC. METHODSIn this case series we present five children who were on ECLS and had a T-FICC placed at the bedside. RESULTSIn this series of five patients we successfully placed T-FICCs while the patients were on ECLS. The T-FICCs dwelled from 15 to 182 days. There were no events of central line associated blood stream infections or deep vein thrombosis. There was only one unintentional line dislodgement noted. CONCLUSIONThe use of T-FICCs placed at the bedside is a safe and reliable alternative for secure long-term venous access in children who are on ECLS.
Background: Pediatric brain injury is accompanied by hemodynamic perturbations complicating the optimization of cerebral physiology. Point-of-care ultrasound (POCUS) uses dynamic real-time imaging to ...complement the physical examination and identify hemodynamic abnormalities in preload, contractility, and afterload conditions, but the contribution of cardiac POCUS in the context of pediatric brain injury is unclear. Methods: We reviewed cardiac POCUS images integrated in clinical care to examine those with neurological injury and hemodynamic abnormalities. Results: We discuss three children with acute brain injury and myocardial dysfunction identified using cardiac POCUS by bedside clinicians. Conclusions: Cardiac POCUS may have an important role in caring for children with neurologic injury. These patients received personalized care informed by POCUS data in attempts to stabilize hemodynamics and optimize clinical outcomes.
The trajectory and importance of right ventricular systolic function and pulmonary hypertension during the course of pediatric acute respiratory distress syndrome are unknown. We hypothesized that ...new or persistent right ventricular systolic dysfunction and pulmonary hypertension would be associated with worse patient outcomes.
Retrospective, single-center cohort study.
Tertiary care, university-affiliated PICU.
Children who had at least two echocardiograms less than 8 days following pediatric acute respiratory distress syndrome diagnosis.
None.
Between July 1, 2012, and April 30, 2018, 74 children met inclusion criteria. The first echocardiogram was performed a median of 0.61 days (interquartile range, 0.36-0.94 d) and the second echocardiogram was performed a median of 2.57 days (interquartile range, 1.67-3.63 d) after pediatric acute respiratory distress syndrome diagnosis. Univariate analyses showed that new or persistent right ventricular systolic dysfunction as defined by global longitudinal strain or free wall strain was associated with a greater number of ICU days in survivors (global longitudinal strain p = 0.04, free wall strain p = 0.04), lower ventilator-free days at 28 days (global longitudinal strain p = 0.03, free wall strain p = 0.01), and higher rate of PICU death (global longitudinal strain p = 0.046, free wall strain p = 0.01). Mixed-effects multivariate modeling showed that right ventricular global longitudinal strain and right ventricular fractional area change stayed relatively constant over the course of the first 8 days in nonsurvivors and that there was a linear improvement in global longitudinal strain (p = 0.037) and fractional area change (p = 0.05) in survivors. Worsening right ventricular dysfunction at the time of repeat echocardiogram as defined by global longitudinal strain and free wall strain were independently associated with decreased probability of extubation (subdistribution hazard ratio, 0.30 0.14-0.67; p = 0.003 and subdistribution hazard ratio, 0.47 0.23-0.98; p = 0.043, respectively). In univariate and multivariate analyses, pulmonary hypertension had no significant associations with outcomes in his cohort.
New or persistent right ventricular systolic dysfunction over the first week following pediatric acute respiratory distress syndrome onset is associated with worse patient outcomes, including decreased probability of extubation and higher PICU mortality.
Whether functional status is associated with survival to pediatric lung transplant is unknown. We hypothesized that completely dependent functional status at waitlist registration, defined using ...Lansky Play Performance Scale (LPPS), would be associated with worse outcomes.
Retrospective cohort study of pediatric lung transplant registrants utilizing United Network for Organ Sharing's Standard Transplant Analysis and Research files (2005-2020). Primary exposure was completely dependent functional status, defined as LPPS score of 10-40. Primary outcome was waitlist removal for death/deterioration with cause-specific hazard ratio (CSHR) regression. Subdistribution hazard regression (SHR, Fine and Gray) was used for the secondary outcome of waitlist removal due to transplant/improvement with a competing risk of death/deterioration. Confounders included: sex, age, race, diagnosis, ventilator dependence, extracorporeal membrane oxygenation, year, and listing center volume.
A total of 964 patients were included (63.5% ≥ 12 years, 50.2% cystic fibrosis CF). Median waitlist days were 95; 20.1% were removed for death/deterioration and 68.2% for transplant/improvement. Completely dependent functional status was associated with removal due to death/deterioration (adjusted CSHR 5.30 95% CI 2.86-9.80). This association was modified by age (interaction p = 0.0102), with a larger effect for age ≥12 years, and particularly strong for CF. In the Fine and Gray model, completely dependent functional status did not affect the risk of removal due to transplant/improvement with a competing risk of death/deterioration (adjusted SHR 1.08 95% CI 0.77-1.49).
Pediatric lung transplant registrants with the worst functional status had worse pretransplant outcomes, especially for adolescents and CF patients. Functional status at waitlist registration may be a modifiable risk factor to improve survival to lung transplant.
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