From bronchiolitis guideline to practice: A critical care perspective

Acute viral bronchiolitis is a leading cause of admission to pediatric intensive care units, but research on the care of these critically ill infants has been limited. Pathology of viral bronchiolitis revealed respiratory obstruction due to intraluminal debris and edema of the airways and vasculature. This and clinical evidence suggest that airway clearance interventions such as hypertonic saline nebulizers and pulmonary toilet devices may be of benefit, particularly in situations of atelectasis associated with bronchiolitis. Research to distinguish an underlying asthma predisposition in wheezing infants with viral bronchiolitis may one day lead to guidance on when to trial bronchodilator therapy. Considering the paucity of critical care research in pediatric viral bronchiolitis, intensive care practitioners must substantially rely on individualization of therapies based on bedside clinical assessments. However, with the introduction of new diagnostic and respiratory technologies, our ability to support critically ill infants with acute viral bronchiolitis will continue to advance.

Validation of a pediatric bedside tool to predict time to death after withdrawal of life support

AIM: To evaluate the accuracy of a tool developed to predict timing of death following withdrawal of life support in children. METHODS: Pertinent variables for all pediatric deaths(age ≤ 21 years) from 1/2009 to 6/2014 in our pediatric intensive care unit(PICU) were extracted through a detailed review of the medical records. As originally described, a recently developed tool that predicts timing of death in children following withdrawal of life support(dallas predictor tool [DPT]) was used to calculate individual scores for each patient. Individual scores were calculated for prediction of death within 30 min(DPT30) and within 60 min(DPT60). For various resulting DPT30 and DPT60 scores, sensitivity, specificity and area under the receiver operating characteristic curve were calculated.RESULTS: There were 8829 PICU admissions resulting in 132(1.5%) deaths. Death followed withdrawal of life support in 70 patients(53%). After excluding subjects with insufficient data to calculate DPT scores, 62 subjects were analyzed. Average age of patients was 5.3 years(SD: 6.9), median time to death after withdrawal oflife support was 25 min(range; 7 min to 16 h 54 min). Respiratory failure, shock and sepsis were the most common diagnoses. Thirty-seven patients(59.6%) died within 30 min of withdrawal of life support and 52(83.8%) died within 60 min. DPT30 scores ranged from-17 to 16. A DPT30 score ≥-3 was most predictive of death within that time period, with sensitivity = 0.76, specificity = 0.52, AUC = 0.69 and an overall classification accuracy = 66.1%. DPT60 scores ranged from-21 to 28. A DPT60 score ≥-9 was most predictive of death within that time period, with sensitivity = 0.75, specificity = 0.80, AUC = 0.85 and an overall classification accuracy = 75.8%.CONCLUSION: In this external cohort, the DPT is clinically relevant in predicting time from withdrawal of life support to death. In our patients, the DPT is more useful in predicting death within 60 min of withdrawal of life support than within 30 min. Furthermore, our analysis suggests optimal cut-off scores. Additional calibration and modifications of this important tool could help guide the intensive care team and families considering DCD.

Late immune consequences of combat trauma: A review of trauma-related immune dysfunction and potential therapies

With improvements in personnel and vehicular body armor,robust casualty evacuation capabilities,and damage control resuscitation strategies,more combat casualties are surviving to reach higher levels of care throughout the casualty evacuation system.As such,medical centers are becoming more accustomed to managing the deleterious late consequences of combat trauma related to the dysregulation of the immune system.In this review,we aim to highlight these late consequences and identify areas for future research and therapeutic strategies.Trauma leads to the dysregulation of both the innate and adaptive immune responses,which places the injured at risk for several late consequences,including delayed wound healing,late onset sepsis and infection,multi-organ dysfunction syndrome,and acute respiratory distress syndrome,which are significant for their association with the increased morbidity and mortality of wounded personnel.The mechanisms by which these consequences develop are complex but include an imbalance of the immune system leading to robust inflammatory responses,triggered by the presence of damage associated molecules and other immune-modifying agents following trauma.Treatment strategies to improve outcomes have been difficult to develop as the immunophenotype of injured personnel following trauma is variable,fluid and difficult to determine.As more information regarding the triggers that lead to immune dysfunction following trauma is elucidated,it may be possible to identify the immunophenotype of injured personnel and provide targeted treatments to reduce the late consequences of trauma,which are known to lead to significant morbidity and mortality.

Predicting early outcomes of liver transplantation in young children: The EARLY study

AIM To determine potentially modifiable predictors of early outcomes after liver transplantation in children of age < 3 years.METHODS This study was a retrospective chart review including all consecutive children of age less than 3-years-old having had a liver transplant done at the Western Canadian referral center from June 2005 to June 2015.Pre-specified potential predictor variables and primary and secondary outcomes were recorded using standard definitions and a case report form. Associations between potential predictor variables and outcomes were determined using univariate and multiple logistic [odds ratio(OR); 95%CI] or linear(effect size, ES; 95%CI) regressions. RESULTS There were 65 children, of mean age 11.9(SD 7.1) mo and weight 8.5(2.1) kg, with biliary-atresia in 40(62%), who had a living related donor [LRD; 29(45%)], split/reduced [21(32%)] or whole liver graft [15(23%)]. Outcomes after liver transplant included: ventilator-days of 12.5(14.1); pediatric intensive care unit mortality of 5(8%); re-operation in 33(51%), hepatic artery thrombosis(HAT) in 12(19%), portal vein thrombosis(PVT) in 11(17%), and any severe complication(HAT, PVT, bile leak, bowel perforation, intraabdominal infection, retransplant, or death) in 32(49%) patients. Predictors of the prespecified primary outcomes on multiple regression were:(1) HAT: split/reduced(OR 0.06; 0.01, 0.76; P = 0.030) or LRD(OR 0.16; 0.03, 0.95; P = 0.044) vs whole liver graft; and(2) ventilator-days: surgeon(P < 0.05), lowest antithrombin(AT) postoperative day 2-5(ES-0.24;-0.47,-0.02; P = 0.034), and split/reduced(ES-12.5;-21.8,-3.2; P = 0.009) vs whole-liver graft. Predictors of the pre-specified secondary outcomes on multiple regression were:(1) any thrombosis: LRD(OR 0.10; 0.01, 0.71; P = 0.021) or split/reduced(OR 0.10; 0.01, 0.85; P = 0.034) vs whole liver graft, and lowest AT postoperative day 2-5(OR 0.93; 0.87, 0.99; P = 0.038); and(2) any severe complication: surgeon(P < 0.05), lowest AT postoperative day 2-5(OR 0.92; 0.86-0.98; P = 0.016), and split/reduced(OR 0.06; 0.01, 0.78; P = 0.032) vs whole-liver graft. CONCLUSION In young children, whole liver graft and surgeon was associated with more complications, and higher AT postoperative day 2-5 was associated with fewer complications early after liver transplantation.

Neurologic complications and neurodevelopmental outcome with extracorporeal life support

Extracorporeal life support is used to support patients of all ages with refractory cardiac and/or respiratory failure. Extracorporeal membrane oxygenation(ECMO)has been used to rescue patients whose predicted mortality would have otherwise been high. It is associated with acute central nervous system(CNS) complications and with long- term neurologic morbidity. Many patients treated with ECMO have acute neurologic complications, including seizures, hemorrhage, infarction, and brain death. Various pre-ECMO and ECMO factors have been found to be associated with neurologic injury, including acidosis, renal failure, cardiopulmonary resuscitation, and modality of ECMO used. The risk of neurologic complication appears to vary by age of the patient, with neonates appearing to have the highest risk of acute central nervous system complications. Acute CNS injuries are associated with increased risk of death in a patient who has received ECMO support. ECMO is increasingly used during cardiopulmonary resuscitation when return of spontaneous circulation is not achieved rapidly and outcomes may be good in select populations. Economic analyses have shown that neonatal and adult respiratory ECMO are cost effective. There have been several intriguing reports of active physical rehabilitation of patients duringECMO support that is well tolerated and may improve recovery. Although there is evidence that some patients supported with ECMO appear to have very good outcomes, there is limited understanding of the longterm impact of ECMO on quality of life and long-term cognitive and physical functioning for many groups, especially the cardiac and pediatric populations. This deserves further study.