Care Measures and Health Outcomes in a Pediatric Intensive Care Unit in Brazil

Introduction: In low- and middle-income countries, including Brazil, conditions that favor mortality in the PICU remain significant. Compared to developed countries, there is a shortage of skilled human resources, lower availability of technological resources, greater difficulty of access and a higher incidence of infections, including both those acquired prior to admission and those resulting from treatment and hospitalization (i.e., healthcare-associated infections (HAIs)). HAIs in the PICU include ventilator-associated pneumonia and catheter-related bloodstream infections. Actions for the prevention of HAIs can minimize the occurrence of negative outcomes. Materials and Methods: This is an epidemiological study comparing admissions at the PICU of a high-complexity hospital in South Brazil over two three-year periods: 2012-2014 (before the measures were adopted) and 2015-2017 (after the measures). The care measures were adopted mainly at the beginning of 2015 and consisted of expansion of physical therapy care, adoption of care protocols, acquisition of new materials and equipment (transparent dressings for central catheters, high-tech mechanical ventilators and multiparametric monitors) and multidisciplinary team training. The frequency of the outcomes mortality, length of PICU stay, diagnosis of catheter-related bloodstream infection, need for and duration of ventilatory support and diagnosis of ventilator-associated pneumonia were compared between the two trienniums using logistic regression with adjustment for age in months and need of vasoactive drugs. Results: A total of 1140 admissions were analyzed (470 in the first triennium and 670 in the second), representing an increase in the admission rate of 42.6% after the adoption of the measures. After adjustments, significant reductions in the frequency of mortality (adjusted OR [adjOR] = 0.54;CI 95%: 0.34 - 0.84), length of PICU stay > 7 days (adjOR = 0.75;CI 95%: 0.57 - 0.97) and duration of ventilatory support > 7 days (adjOR = 0.54;CI 95%: 0.39 - 0.74) were observed. Conclusion: The results indicate the benefits of care measures for children admitted to the PICU in terms of a reduction in adverse events and expansion of access.

Approaches to neuroprotection in pediatric neurocritical care

Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit.After primary neurologic insults,there may be cerebral brain tissue that remains at risk of secondary insults,which can lead to worsening neurologic injury and unfavorable outcomes.A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children.This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes.Here,we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.

Psychological needs of parents of children with complicated congenital heart disease after admitting to pediatric intensive care unit: A questionnaire study

BACKGROUND Parents of children with complicated congenital heart disease(CHD)have different needs after surgery.Little literature reports the impact factors for psychological needs of parents of children with complicated CHD.AIM To investigate the status quo of the needs of parents of children after surgery for complex CHD,and analyze the influencing factors,in order to provide a theoretical basis for formulating corresponding nursing countermeasures.METHODS A modified Chinese version of the Critical Care Family Needs Inventory(MCCFNI)was used to select 200 parents of children with complex CHD after surgery within 72 h after admission to the intensive care unit in our hospital to conduct an online questionnaire survey.The aim was to understand the needs of parents in relation to the following five aspects:The support from medical staff,comfort of the parents themselves,the acquisition of information,their closeness to the children,and assurance of the child’s condition.RESULTS Parents of children with complex CHD had a higher degree of demand,especially in terms of condition assurance,acquisition of information,and closeness to the children.The age,education level,and residence of the parents were related to the five dimensions of the needs of parents of children with complex CHD who had undergone surgery.CONCLUSION In practice,nurses should formulate corresponding nursing strategies based on the different cultural and social backgrounds of parents of children after complex CHD surgery to meet their different needs,and improve satisfaction.These findings provide a theoretical basis for constructing a family participatory nursing model for children in the intensive care unit in the future.

National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic

The coronavirus disease pandemic caught many pediatric hospitals unpreparedand has forced pediatric healthcare systems to scramble as they examine and planfor the optimal allocation of medical resources for the highest priority patients.There is limited data describing pediatric intensive care unit (PICU) preparednessand their health worker protections.AIMTo describe the current coronavirus disease 2019 (COVID-19) preparedness effortsamong a set of PICUs within a simulation-based network nationwide.METHODS A cross-sectional multi-center national survey of PICU medical director(s) fromchildren’s hospitals across the United States. The questionnaire was developedand reviewed by physicians with expertise in pediatric critical care, disasterreadiness, human factors, and survey development. Thirty-five children’shospitals were identified for recruitment through a long-established nationalresearch network. The questions focused on six themes: (1) PICU and medicaldirector demographics;(2) Pediatric patient flow during the pandemic;(3)Changes to the staffing models related to the pandemic;(4) Use of personalprotective equipment (PPE);(5) Changes in clinical practice and innovations;and(6) Current modalities of training including simulation.RESULTSWe report on survey responses from 22 of 35 PICUs (63%). The majority of PICUswere located within children’s hospitals (87%). All PICUs cared for pediatricpatients with COVID-19 at the time of the survey. The majority of PICUs (83.4%)witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicatedunits, and 74.6% pivoted to accept adult COVID-19 patients. All PICUsimplemented changes to their staffing models with the most common changesbeing changes in COVID-19 patient room assignment in 50% of surveyed PICUsand introducing remote patient monitoring in 36% of the PICU units. Ninety-fivepercent of PICUs conducted training for donning and doffing of enhanced PPE.Even 6 months into the pandemic, one-third of PICUs across the United Statesreported shortages in PPE. The most common training formats for PPE werehands-on training (73%) and video-based content (82%). The most commonconcerns related to COVID-19 practice were changes in clinical protocols andguidelines (50%). The majority of PICUs implemented significant changes in theirairway management (82%) and cardiac arrest management protocols in COVID-19patients (68%). Simulation-based training was the most commonly utilizedtraining modality (82%), whereas team training (73%) and team dynamics (77%)were the most common training objectives.CONCLUSIONSA substantial proportion of surveyed PICUs reported on large changes in theirpreparedness and training efforts before and during the pandemic. PICUsimplemented broad strategies including modifications to staffing, PPE usage,workflow, and clinical practice, while using simulation as the preferred trainingmodality. Further research is needed to advance the level of preparedness,support staff assuredness, and support deep learning about which preparednessactions were effective and what lessons are needed to improve PICU care andstaff protection for the next COVID-19 patient waves.

Changes in Nurses after Online Workshops Using the Pediatric Nursing Care Model

This study aimed to clarify the changes in nurses’ cognition about the rate and likelihood of implementation of daily ethical nursing items used in pediatric care before and after attending online workshops using the Pediatric Nursing Care Model (PNCM). A 1.5-hour online workshop was held twice over two weeks. A total of nine nurses participated in the program. These online workshops using PNCM helped achieve the original goals and the results revealed a positive outcome of the workshops. We should devise an educational program to arouse participants’ interest and comprehension to make the most of online competency.

Studying the Reinforcement Effect of a Seminar on Ethical Practices among Pediatric Nurses

Aim: This study aimed to examine the effect of a seminar to continuously reinforce ethical nursing practices among pediatric nurses. Methods: This seminar was based on a 24-point pediatric nursing care model (PNCM) that provided specific examples of basic ethical nursing practices for children undergoing medical procedures and their families. Participants’ knowledge level and application frequencies, regarding these practices, were assessed face-to-face in the first session and via email 2 and 5 months later, using the PNCM checklist and qualitative data about ethical practices. Results: Results revealed that 8 PNCM items about frequency remained the same as the first session after 5 months;however, 16 items reported increased application. The qualitative data collected 2 months later suggested that the nurses could have adapted better to implement ethical pediatric nursing;however, the one collected 5 months later confirmed the effect of the seminar on ethical nursing practices with children and their families. The continuous effect of the seminar became more evident from the responses received 5 months later than those received 2 months later. Conclusions: The findings confirmed a reinforced effect on ethical pediatric nursing practice with child patients and their parents after 5 months.

Ultrasound-Guided Central Venous Catheterization: A Protocol to Be Followed in Pediatrics?

Objective: To investigate the effectiveness of ultrasound-guided central venous catheterization when compared to the conventional procedure. Method: A prospective cohort study was carried out over a 9-month period from February to October 2016 involving 144 inpatients at PICU of Irmandade da Santa Casa de Sao Paulo Hospital, undergoing central venous catheterization. The patients were matched in pairs of identical patients according to the levels of potentially intervening variables (age, nutritional status, puncture site, professional experience), differing only as to the CVC technique: ultrasound-guided (USG-CVC) or conventional (C-CVC). Discarding data from non-paired patients, the remaining did forming 47 pairs, matched as two related samples: USG-CVC and C-CVC groups. Success parameters: number of puncture attempts;time spent at CVC;success rate and complications. Results: In the USG-CVC group, the number of attempts (mean = 2.04) and the time spent at catheterization (mean = 11.89 minutes) were lower (t = 2.34, df = 46, t 0.95 = 2.02, p t = 3.07, df = 46, t 0.95 = 2.02, p < 0.05), respectively, when compared to the results obtained for the control group (C-GVC), (mean = 3.21) and (mean = 28.26 minutes), respectively. As to success, there was observed a significant difference (F (1, 46) = 16.6;Q (1) = 12.5, p < 005) when considering only one trial (USG -CVC = 27/47;C-CVC = 9/47), but no significant difference (F (1, 46) = 3.76;Q (1) = 3.56, p > 0.05) when considering several attempts. Complications were found less frequently in the USG-CVC group (3/47) than in the CVC-C (13/47), (F (1, 46) = 8.24;Q (1) = 7.14, p < 0.05). Conclusion: USG-CVC was found to be more effective than the conventional technique, especially regarding success at the first puncture attempt.

Severe pediatric COVID‑19:a review from the clinical and immunopathophysiological perspectives

Background Coronavirus disease 2019(COVID-19)tends to have mild presentations in children.However,severe and critical cases do arise in the pediatric population with debilitating systemic impacts and can be fatal at times,meriting further attention from clinicians.Meanwhile,the intricate interactions between the pathogen virulence factors and host defense mechanisms are believed to play indispensable roles in severe COVID-19 pathophysiology but remain incompletely understood.Data sources A comprehensive literature review was conducted for pertinent publications by reviewers independently using the PubMed,Embase,and Wanfang databases.Searched keywords included“COVID-19 in children”,“severe pediatric COVID-19”,and“critical illness in children with COVID-19”.Results Risks of developing severe COVID-19 in children escalate with increasing numbers of co-morbidities and an unvaccinated status.Acute respiratory distress stress and necrotizing pneumonia are prominent pulmonary manifestations,while various forms of cardiovascular and neurological involvement may also be seen.Multiple immunological processes are implicated in the host response to COVID-19 including the type I interferon and inflammasome pathways,whose dysregulation in severe and critical diseases translates into adverse clinical manifestations.Multisystem inflammatory syndrome in children(MIS-C),a potentially life-threatening immune-mediated condition chronologically associated with COVID-19 exposure,denotes another scientific and clinical conundrum that exemplifies the complexity of pediatric immunity.Despite the considerable dissimilarities between the pediatric and adult immune systems,clinical trials dedicated to children are lacking and current management recommendations are largely adapted from adult guidelines.Conclusions Severe pediatric COVID-19 can affect multiple organ systems.The dysregulated immune pathways in severe COVID-19 shape the disease course,epitomize the vast functional diversity of the pediatric immune system and highlight the immunophenotypical differences between children and adults.Consequently,further research may be warranted to adequately address them in pediatric-specific clinical practice guidelines.

Severe acute respiratory syndrome coronavirus-2-related and imputable deaths in children:results from the French pediatric national registry

Background Severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)is responsible for an important mortality rate worldwide.We aimed to evaluate the actual imputability of SARS-CoV-2 on the mortality rate associated with SARS-CoV-2-related illnesses in the pediatric intensive care unit(PICU).Secondary objectives were to identify risk factors for death.Methods This national multicenter comparative study comprised all patients under 18 years old with positive SARS-CoV-2 polymerase chain reactions(PCRs)[acute corona virus disease 2019(COVID-19)or incidental SARS-CoV-2 infection]and/or pediatric inflammatory multisystem syndrome(PIMS)recorded in the French PICU registry(PICURe)between September 1,2021,and August 31,2022.Included patients were classified and compared according to their living status at the end of their PICU stay.Deceased patients were evaluated by four experts in the field of pediatric infectiology and/or pediatric intensive care.The imputability of SARS-CoV-2 as the cause of death was classified into four categories:certain,very probable,possible,or unlikely,and was defined by any of the first three categories.Results There were 948 patients included of which 43 died(4.5%).From this,26 deaths(67%)could be attributed to SARS-CoV-2 infection,with an overall mortality rate of 2.8%.The imputability of death to SARS-CoV-2 was considered certain in only one case(O.1%).Deceased patients suffered more often from comorbidities,especially heart disease,neurological disorders,hematological disease,cancer,and obesity.None of the deceased patients were admitted for pediatric inflam-matory multisystem syndrome(PIMS).Mortality risk factors were male gender,cardiac comorbidities,cancer,and acute respiratorydistress syndrome.Conclusions SARS-CoV-2 mortality in the French pediatric population was low.Even though the imputability of SARS-Cov-2 on mortality was considered in almost two-thirds of cases,this imputability was considered certain in only one case.

Cade Oil Poisoning: A Case Series

Objectives and Study: Cade oil is aromatic oil obtained from the branches and wood of Juniperus oxycedrus, common in the Mediterranean region and widely used in traditional medicine. This oil contains many chemical compounds with neurological, cardiac, renal, respiratory, hepatic, and gastrointestinal toxicity. Cade oil poisoning often requires intensive care admission due to the severity of the clinical picture. The objective of this study is to highlight the multiple manifestations found in the pediatric population due to cade oil exposure objectifying its significant toxicity. Methods: The authors report during this article a series of five cases of cade oil poisoning on pediatric patients hospitalized in the pediatric intensive care unit of El HARROUCHI hospital at the CHU Ibn Rochd in Casablanca during the period from 11/01/2022 to 12/07/2022. The patients have been exposed, a few hours before their admission, to an external cade oil application used by parents for therapeutic purposes. Main Findings: Our patients were aged from 1 month to 4 years, the average age was 1.5 years with a female predominance and a sex ratio of 1.5:1. The patients had no prior medical history, and the cade oil application was spontaneously declared by the parents of only 2 patients, 3 of them reported the use of it after the detection of the substance by the clinician. For all the cases, cade oil was applied to treat fever. All five (5) patients presented initial neurological signs. 3 of them were admitted to an acute consciousness disorder and the 2 other patients presented respectively a convulsive status epilepticus and generalized-onset seizure. We report respiratory symptoms in 4 cases ranging from a simple caught, rhinorrhea to severe respiratory distress. Three patients presented acute liver failure with very high transaminase levels associated with acute kidney failure. Two of them presented digestive symptoms such as abundant hematemesis, vomiting, and watery diarrhea. All patients received high doses of N acetylcysteine in their initial treatments. The evolution was unfavorable for 4 patients who developed a multiorgan failure, 3 of them died, with a good clinical improvement in the fifth patient after supportive and symptomatic treatment. Conclusion: Cade oil poisoning remains a very frequent situation in our context. Its toxicity is widely described in the literature. The increasing number of cases admitted, and the seriousness of the clinical picture require mass awareness among the population and the scientific community toward the use of medicinal plants.

Observation of the effects of three methods for reducing perineal swelling in children with developmental hip dislocation

BACKGROUND Developmental dysplasia of the hip is a developmental abnormality of the hip joint that results from hypoplasia during birth and continues to deteriorate after birth.AIM To observe the effects of magnesium sulfate wet compress,iodophor wet compress,and ice compress on reducing postoperative perineal swelling in children with developmental hip dislocation to provide effective nursing interventions in the clinic.METHODS A total of 120 children with hip dislocation after surgery in a third-class A hospital from January 2018 to January 2020 were randomly divided into four groups,the magnesium sulfate wet compress group,iodophor wet compress group,ice compress group and the control group.Data such as height,weight,age,duration of surgery,intraoperative blood loss,postoperative body temperature,swelling duration,pain score,and incidence of blisters were collected and analyzed.RESULTS There were no significant differences in height,weight,age,duration of surgery,intraoperative blood loss,and postoperative body temperature among the four groups of children.Statistical differences were observed between the intervention groups and the control group(P<0.05).CONCLUSION All three methods significantly reduced postoperative perineal swelling in children with developmental hip dislocation,reduced the duration of postoperative perineal swelling,reduced pain,and improved the quality of care.

Clinical application of bedside fiber-optic bronchoscopy in mechanically ventilated children in a pediatric intensive care unit

Critically ill children often require mechanical ventilation on the pediatric intensive care unit （PICU） for indications such as severe pneumonia, atelectasis, airway abnormalities, and the presence of a foreign body in the airway. The correct management of the airway is a crucial determinant of a successful outcome. We performed fiber-optic bronchoscopy （FOB） 70 times for 51 mechanically ventilated children between June 2009 and December 2011, and present our results below.

Intensive care drug therapy and its potential adverse effects on blood pressure and heart rate in critically ill children

Background Owing to complex treatment,critically ill children may experience alterations in their vital parameters.We investigated whether such hemodynamic alterations were temporally and causally related to drug therapy.Methods In a university pediatric intensive care unit,we retrospectively analyzed hemodynamic alterations defined as values exceeding the limits set for heart rate(HR)and blood pressure(BP).For causality assessment,we used the World Health Organization–Uppsala Monitoring Center(WHO–UMC)system,which categorizes the probability of causality as“certain,”“probable,”“possible,”and“unlikely.”Results Of 315 analyzed patients with 43,200 drug prescriptions,59.7%experienced at least one hemodynamic alteration;39.0%were affected by increased HR,19.0%by decreased HR,18.1%by increased BP,and 16.2%by decreased BP.According to drug information databases,83.9%of administered drugs potentially lead to hemodynamic alterations.Overall,88.3%of the observed hemodynamic alterations had a temporal relation to the administration of drugs;in 80.2%,more than one drug was involved.Based on the WHO–UMC system,a drug was rated as a“probable”causing factor for only 1.4%of hemodynamic alterations.For the remaining alterations,the probability ratings were lower because of multiple potential causes,e.g.,several drugs.Conclusions Critically ill children were frequently affected by hemodynamic alterations.The administration of drugs with potentially adverse effects on hemodynamic parameters is often temporally related to hemodynamic alterations.Hemodynamic alterations are often multifactorial,e.g.,due to administering multiple drugs in rapid succession;thus,the influence of individual drugs cannot easily be captured with the WHO–UMC system.

Veno-Venous Extra-Corporeal Membrane Oxygenation (ECMO) in a Child with Hemoptysis and Fontan Circulation

Background: Extracorporeal membrane oxygenation is a rescue life support technique used in life threatening conditions of refractory respiratory and/or cardiac distress. Indication for extracorporeal life support in children depends on age and varies from pulmonary to cardiac pathologies. In some cases, it may be used as a bridge to a therapeutic procedure. We described here the management of respiratory failure due to hemoptysis in a child with a Fontan circulation and veno-venous extracorporeal membrane oxygenation which served as a bridge to angio-embolization. Hemoptysis can be a life threatening condition which can lead to hypovolemic shock and impaired alveolar gas exchange. The latter can result in respiratory failure and consequent asphyxia. When hemoptysis occurs in a patient with a univentricular heart and a Fontan circulation, management of this clinical situation can be challenging due to the particular physiology of the latter. Total cavopulmonary connection is a palliative surgical repair which constitutes Fontan circulation as a definitive treatment in patients with a univentricular heart. Methods: Case report description of a 16 year-old boy with a univentricular heart and a Fontan circulation who presented hemoptysis managed with a veno-venous extracorporeal membrane oxygenation (ECMO) as a bridge to angio-embolization. Results: Hemoptysis due to diffuse intra-alveolar hemorrhage from collateral circulation was successfully treated in this young patient with pulmonary vascular embolization. This allowed to wean the patient from extra-corporeal membrane oxygenation. Conclusion: Veno-venous ECMO can be life-saving as a bridge to angio-embolization for severe hemoptysis in patients with Fontan circulation. The reported case allows to underline that our multidisciplinary approach in this complex pediatric patient surely participated to improve outcome.

Pediatric interfacility transport effects on mortality and length of stay

Background We aimed to evaluate the effects of interfacility pediatric critical care transport response time,physician presence during transport,and mode of transport on mortality and length of stay(LOS)among pediatric patients.We hypothesized that a shorter response time and helicopter transports,but not physician presence,are associated with lower mortality and a shorter LOS.Methods Retrospective,single-center,cohort study of 841 patients(<19 years)transported to a quaternary pediatric intensive care unit and cardiovascular intensive care unit between 2014 and 2018 utilizing patient charts and transport records.Multivariate linear and logistic regression analyses adjusted for age,diagnosis,mode of transport,response time,stabilization time,return duration,mortality risk(pediatric index of mortality-2 and pediatric risk of mortality-3),and inotrope,vasopressor,or mechanical ventilation presence on admission.Results Four hundred and twenty-eight(50.9%)patients were transported by helicopter,and 413(49.1%)were transported by ambulance.Physicians accompanied 239(28.4%)transports.The median response time was 2.0(interquartile range 1.4–2.9)hours.Although physician presence increased the median response time by 0.26 hours(P=0.020),neither physician presence nor response time significantly affected mortality,ICU length of stay(ILOS)or hospital length of stay(HLOS).Helicopter transports were not significantly associated with mortality or ILOS,but were associated with a longer HLOS(3.24 days,95%confidence interval 0.59–5.90)than ambulance transports(P=0.017).Conclusions These results suggest response time and physician presence do not significantly affect mortality or LOS.This may reflect the quality of pre-transport care and medical control communication.Helicopter transports were only associated with a longer HLOS.Our analysis provides a framework for examining transport workforce needs and associated costs.