OBJECTIVES:Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We ...sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock.
DESIGN:Retrospective observational study.
SETTING:PICU at an academic medical center.
PATIENTS:One hundred thirty patients treated for severe sepsis or septic shock.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure–free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74–277 min) and to first appropriate antimicrobial was 177 minutes (90–550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27–12.06) and 3.59 (95% CI, 1.09–11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45–16.2) and 4.92 (95% CI, 1.30–18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure–free days (16 interquartile range, 1–23 vs 20 interquartile range, 6–26; p = 0.04).
CONCLUSIONS:Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.
Summary Background The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. ...We assessed the effect of CPR (conventional with rescue breathing or chest compression only) by bystanders on outcomes after out-of-hospital cardiac arrests in children. Methods In a nationwide, prospective, population-based, observational study, we enrolled 5170 children aged 17 years and younger who had an out-of-hospital cardiac arrest from Jan 1, 2005, to Dec 31, 2007. Data collected included age, cause, and presence and type of CPR by bystander. The primary endpoint was favourable neurological outcome 1 month after an out-of-hospital cardiac arrest, defined as Glasgow-Pittsburgh cerebral performance category 1 or 2. Findings 3675 (71%) children had arrests of non-cardiac causes and 1495 (29%) cardiac causes. 1551 (30%) received conventional CPR and 888 (17%) compression-only CPR. Data for type of CPR by bystander were not available for 12 children. Children who were given CPR by a bystander had a significantly higher rate of favourable neurological outcome than did those not given CPR (4·5% 110/2439 vs 1·9% 53/2719; adjusted odds ratio OR 2·59, 95% CI 1·81–3·71). In children aged 1–17 years who had arrests of non-cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (5·1% 51/1004 vs 1·5% 20/1293; OR 4·17, 2·37–7·32). However, conventional CPR produced more favourable neurological outcome than did compression-only CPR (7·2% 45/624 vs 1·6% six of 380; OR 5·54, 2·52–16·99). In children aged 1–17 years who had arrests of cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (9·5% 42/440 vs 4·1% 14/339; OR 2·21, 1·08–4·54), and did not differ between conventional and compression-only CPR (9·9% 28/282 vs 8·9% 14/158; OR 1·20, 0·55–2·66). In infants (aged <1 year), outcomes were uniformly poor (1·7% 36/2082 with favourable neurological outcome). Interpretation For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective. Funding Fire and Disaster Management Agency and the Ministry of Education, Culture, Sports, Science and Technology (Japan).
Limited data exist about the international burden of severe sepsis in critically ill children.
To characterize the global prevalence, therapies, and outcomes of severe sepsis in pediatric intensive ...care units to better inform interventional trials.
A point prevalence study was conducted on 5 days throughout 2013-2014 at 128 sites in 26 countries. Patients younger than 18 years of age with severe sepsis as defined by consensus criteria were included. Outcomes were severe sepsis point prevalence, therapies used, new or progressive multiorgan dysfunction, ventilator- and vasoactive-free days at Day 28, functional status, and mortality.
Of 6,925 patients screened, 569 had severe sepsis (prevalence, 8.2%; 95% confidence interval, 7.6-8.9%). The patients' median age was 3.0 (interquartile range IQR, 0.7-11.0) years. The most frequent sites of infection were respiratory (40%) and bloodstream (19%). Common therapies included mechanical ventilation (74% of patients), vasoactive infusions (55%), and corticosteroids (45%). Hospital mortality was 25% and did not differ by age or between developed and resource-limited countries. Median ventilator-free days were 16 (IQR, 0-25), and vasoactive-free days were 23 (IQR, 12-28). Sixty-seven percent of patients had multiorgan dysfunction at sepsis recognition, with 30% subsequently developing new or progressive multiorgan dysfunction. Among survivors, 17% developed at least moderate disability. Sample sizes needed to detect a 5-10% absolute risk reduction in outcomes within interventional trials are estimated between 165 and 1,471 corrected patients per group.
Pediatric severe sepsis remains a burdensome public health problem, with prevalence, morbidity, and mortality rates similar to those reported in critically ill adult populations. International clinical trials targeting children with severe sepsis are warranted.
Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and ...in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.
Tight glycemic control has not improved outcomes in studies involving critically ill adults or children after cardiac surgery. A controlled study involving hyperglycemic critically ill children who ...had not undergone cardiac surgery showed no benefit of tight glycemic control.
Tight glycemic control to a blood glucose level of 80 to 110 mg per deciliter (4.4 to 6.1 mmol per liter) was originally shown to reduce morbidity and mortality in a single-center, randomized clinical trial involving critically ill adult surgical patients,
1
but subsequent trials involving adults have not shown benefit.
2
–
4
Results of trials of tight glycemic control in critically ill children have been inconsistent
5
–
8
; retrospective studies have consistently shown an association between hyperglycemia and poor outcomes.
9
–
12
A single-center, randomized trial involving children, most of whom had undergone cardiac surgery, showed significantly lower mortality and infection rate . . .
Purpose
To evaluate the incidence and associated risk factors of difficult tracheal intubations (TI) in pediatric intensive care units (PICUs).
Methods
Using the National Emergency Airway Registry ...for Children (NEAR4KIDS), TI quality improvement data were prospectively collected for initial TIs in 15 PICUs from July 2010 to December 2011. Difficult pediatric TI was defined as TIs by direct laryngoscopy which failed or required more than two laryngoscopy attempts by fellow/attending-level physician providers.
Results
A total of 1,516 oral TIs were reported with a median age of 2 years. A total of 97 % of patients were intubated with direct laryngoscopy. The incidence of difficult TI was 9 %. In univariate analysis, patients with difficult TI were younger median 1 year (0–4) vs. 2 (0–8) years,
p
= 0.046, and had a reported history of difficult TI (22 vs. 8 %,
p
< 0.001). Multivariate analysis showed that history of difficult airway and signs of upper airway obstruction are significantly associated with difficult TI. The advanced airway provider was more involved as a first provider in difficult TI (81 vs. 58 %,
p
< 0.001). The presence of difficult TI was associated with higher incidence of oxygen desaturation below 80 % (48 vs. 15 %,
p
< 0.001), adverse TI associated events (53 vs. 20 %,
p
< 0.001), and severe TI associated events (13 vs. 6 %,
p
= 0.003).
Conclusions
Difficult TI was reported in 9 % of all TIs and was associated with increased adverse TI events. History of difficult airway and sign of upper airway obstruction were associated with difficult TIs.
The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of ...standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.
IMPORTANCE: Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of these children is influenced by ...the time of the event (eg, nighttime or weekends). Differences in survival could have important implications for hospital staffing, training, and resource allocation. OBJECTIVE: To determine whether outcomes after pediatric in-hospital cardiac arrests differ during nights and weekends compared with days/evenings and weekdays. DESIGN, SETTING, AND PARTICIPANTS: This study included a total of 354 hospitals participating in the American Heart Association’s Get With the Guidelines–Resuscitation registry from January 1, 2000, to December 12, 2012. Index cases (12 404 children) from all children younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using previously defined time intervals of day/evening and night, as well as weekend. Multivariable logistic regression models were used to examine the effect of independent variables on survival to hospital discharge. We used a combination of a priori variables based on previous literature (including age, first documented rhythm, location of event in hospital, extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were identified in bivariate generalized estimating equation models, and maintained significance of P ≤ .15 in the final multivariable models. MAIN OUTCOMES AND MEASURES: The primary outcome measure was survival to hospital discharge, and secondary outcomes included return of circulation lasting more than 20 minutes and 24-hour survival. RESULTS: Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488 (36.2%) survived to hospital discharge. After adjusting for potential confounders, we found that the rate of survival to hospital discharge was lower during nights than during days/evenings (adjusted odds ratio, 0.88 95% CI, 0.80-0.97; P = .007) but was not different between weekends and weekdays (adjusted odds ratio, 0.92 95% CI, 0.84-1.01; P = .09). CONCLUSIONS AND RELEVANCE: The rate of survival to hospital discharge was lower for pediatric CPR events occurring at night than for CPR events occurring during daytime and evening hours, even after adjusting for many potentially confounding patient-, event-, and hospital-related factors.
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