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Background and aims: Acute kidney injury (AKI) is common in critically ill children, but current biomarkers are suboptimal. Proenkephalin A 119-159 (PENK) is a promising new AKI biomarker in adults, but pediatric data is lacking. We determined PENK reference intervals for healthy children, crucial for clinical implementation, and explored concentrations in critically ill infants aged under 1 year.

Subjects and methods: Observational cohort study in healthy infants and critically ill children aged 0-1 years. Reference values were determined using generalized additive models. Plasma PENK concentrations were compared between healthy children and critically ill children with and without AKI, using linear mixed modelling. The performance of PENK as AKI biomarker was compared to cystatin C (CysC) and β-trace protein (BTP) using receiver-operating-characteristic (ROC) analysis.

Results: PENK concentrations in 100 healthy infants were stable during the first year of life (median 517.3 pmol/L). Median PENK concentrations in 91 critically ill children, were significantly higher in those with AKI (n=40)(KDIGO Stage 1 507.9 pmol/L, Stage 2 704.0 pmol/L, Stage 3 930.5 pmol/L) than non-AKI patients (n=51, 432.2 pmol/L)(p<0.001). PENK appeared to relate better to AKI diagnosis than CysC and BTP (AUROC PENK 0.858, CysC 0.770, BTP 0.711) in the first 24 hours after recruitment.

Conclusions: PENK reference values are much higher in young infants than adults, but clearly discriminate between children with and without AKI, with comparable or better performance than CysC and BTP. Our results illustrate the importance of establishing age-normalized reference values and indicate PENK as a promising pediatric AKI biomarker.

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Background: Status epilepticus (SE) is the most frequent pediatric neurologic emergency. Appropriate and timely management of seizures is mandatory in order to avoid intensive care admission.

Purpose: to describe the population admitted to our PICU for SE and to analyze the management before-PICU admission.

Methods: A prospective observational study was conducted in a tertiary PICU of Padua (Italy) from January 2013 to March 2020.

Results: 118 children were enrolled; mean age 4.4 years. Most frequent etiology was acute symptomatic in 48 (40.7%). Thirty-one patients were epileptic (26.3%). In 24% patients first treatment was given out-of-hospital and administered AEDs were exclusively benzodiazepines. As first-line in-hospital treatment, most frequently administered drugs were benzodiazepines (77,7%). Among children that received at least one dose of benzodiazepines, 23 had an iatrogenic respiratory failure (23.2%). In secondary-care hospitals, propofol, thiopentone or ketamine were administered as either first- or second-line drug in 28/74 (37,8%) of patients and intubation performed more frequently than in tertiary referral center (86.4% vs 41.4%, p=<0,001). Mean length of stay and duration of mechanical ventilation were short, not associated either with the antiepileptic drug, the illness severity at PICU admission (PIM score) or the neurological morbidity at discharge.

Conclusions: Our results disclose a poor adherence to treatment protocols before PICU admission. Drugs indicated for refractory SE are used as first or second treatment. The shortness of stay in the PICU and the low PIM score at admission support the hypothesis that there was not a real need for intensive care unit admission.

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Background: Paediatric oncology patients on intensive care can be the sickest and those requiring continuous renal replacement therapy (CRRT) on intensive care units have poorer outcomes compared with all other admissions.

Method: We conducted a retrospective study to review the paediatric oncology patients requiring CRRT and establish the need for CRRT, clinical response and survival outcomes.

Results: There were a total of 131 patients who needed CRRT on paediatric intensive care units in the East Midlands over the last 5years (2015-2019). Amongst them, 12 were patients with a cancer diagnosis (9%). Indications for CRRT were tumour lysis (3 patients), fluid overload and acid base imbalance (1 patient), AKI with sepsis (4 patients) associated with multi-organ failure and AKI related to disease or chemotherapy (4 patients). The median time for CRRT was 67 hours.

The mortality rate for these patients was high with 75% of all children dying within 6 months of discharge from intensive care unit. 5 patients (41%) died during their acute admission to intensive care unit. 3 patients are currently well; 1 patient is in remission on maintenance chemotherapy, 1 patient is on post bone marrow transplant follow-up and the last one is continuing with acute chemotherapy.

Conclusions: CRRT may be needed in oncology patients for many reasons. Outcome in these patients is poor. While most of the mortality is not in the acute phase, the need for CRRT may signify a worse outcome.

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Background: Pericardiocentesis is the most useful procedure for the early management of large and/or symptomatic pericardial effusions (PE). Aim: characterize patients submitted to pericardiocentesis with pericardial drain insertion (PDI) and their outcomes.
Methods: Restrospective study of PICU patients submitted to pericardiocentesis with PDI over an 11-year period. Iatrogenic PE were excluded. Variables analysed: demographic, clinical and laboratory parameters, management and outcomes. Poor outcome indices were: length of stay > 5 days, pericardial drain removal time > 48 hours or PE recurrence.
Results: Twenty-three patients were submitted to pericardiocentesis with PDI (median age: 5.5 years). Main causes of PE were malignancy (7; 30%), post-pericardiotomy syndrome (6; 26%) and idiopathic (4; 17%). Dyspnoea (12; 52%), fatigue (10; 43%) and chest pain (9; 39%) were the main symptoms. Tachycardia (16; 70%) was the main sign. Seven (30%) presented with hypotension and 3 (13%) with cardiac arrest. ECG was performed in 12 (52%) showing typical changes in 8 (67%). Echocardiography found diastolic collapse of the right cavities in all patients and large PE in 11 (48%). Procedure complications occurred in 3 patients (13%) and PE recurred in 5 (22%). Median time of pericardial drain removal was 3 days. Drain removal time was > 48h in 80% of those with an exudate and in 17% of patients with a transudate (p=0,014). Nineteen (83%) had at least one poor outcome index.
Conclusions: Most patients were diagnosed before signs of tamponade occur. Post-pericardiotomy syndrome was a frequent underlying cause for pericardiocentesis. Pericardial fluid characteristics may influence pericardial drain removal time.

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BACKGROUND AND AIM
The Airway, Breathing, Circulation, Disability and Exposure (ABCDE) approach is a universally applied approach for the assessment and treatment of critically ill patients. However, adherence in practice appears to be suboptimal. This study aims to identify factors influencing healthcare professionals’ adherence to the ABCDE approach.

METHODS
An explorative, mixed-method study was performed, using a questionnaire and semi-structured focus group interviews. The questionnaire was sent to all healthcare professionals from six departments of the Radboudumc in Nijmegen, the Netherlands: Anaesthesiology, Paediatrics, Emergency Department and the Neonatal- (NICU), Paediatric- (PICU) and Adult Intensive Care Units (ICU). Results of the questionnaire were analysed descriptively and used for the interviews. The interviews were transcribed and analysed following template analysis. Primary outcomes were barriers and facilitators influencing the adherence to the ABCDE approach. Results were discussed, leading to identification of additional themes.

RESULTS
A total of 236 of the 954 eligible participants filled out the questionnaire and 21 participants were selected for five focus group interviews. Barriers and facilitators concerning the guideline itself, professional factors, patient factors, team factors, and incentives and resources were identified. Situational dependency, language and personal value were identified as additional themes.

CONCLUSIONS
This study provides factors influencing healthcare professionals’ adherence to the ABCDE approach. Not only factors related to implementation seem to be important, but also additional factors such as personal value of the ABCDE approach. These findings will facilitate the development of tailored interventions in education and practice to improve the adherence to the ABCDE approach.