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Background and Aims

Observational studies in children reported pressure support(PS) to underestimate post-extubation work of breathing and overestimate extubation readiness in comparison to continuous positive airway pressure(CPAP) and T-piece. We aimed to compare the effect of extubation readiness test(ERT) using PS vs CPAP on rates of successful liberation from invasive ventilation.

Methods

Open label randomized non-inferiority trial was conducted [Dec-2019 to Aug-2021] in PICU among children ready for weaning after at least 48-hours of invasive ventilation. Children were randomized to undergo 2-hour ERT with PS (8cmH₂O above PEEP) or CPAP (5–6cmH₂O). Primary outcome was successful liberation (free from invasive ventilation for 72-hours) after first ERT. Secondary outcomes include first ERT success rate, need for post-extubation non-invasive ventilation (HFNC/BiPAP) and PICU length-of-stay.

Results

247 children were randomized and 244 completed the trial (121 in PS and 123 in CPAP group). Median(IQR) age was 24(9–84) months. Median(IQR) duration of ventilation before randomization was 108(72–156) hours. Successful liberation from invasive ventilation after first ERT occurred in 97(80.2%) children in PS group and 93(75.6%) children in CPAP group [difference 4.6%; 95%CI(-5.8%,15%); p=0.39]. Secondary outcomes including first ERT success rate [111(91.7%) vs 105(85.4%); difference 6.3%; 95%CI(-1.6%, 14.3%); p=0.12], need for post-extubation NIV [52(43%) vs 49(40%)], reintubation within 72-hours [14(12.6%) vs 12(11.4%)] and median(IQR) PICU length-of-stay [9(6–15) vs 8(5.5–13)days; p=0.48] were comparable. Four (1.6%) children had unfavourable outcome (1 died, 3 discontinued care; all in CPAP group).

Conclusions

In children receiving mechanical ventilation, a 2-hour ERT with pressure support was non-inferior to CPAP in predicting successful liberation from invasive ventilation.

Background and Aims

We aimed to evaluate Ketamine efficacy in ensuring comfort and sparing conventional drugs when used as an adjuvant for analgesia and sedation in the PICU as a continuous infusion (≥12 hours), as well as its safety profile.

Methods

Design: Observational prospective study. Setting: tertiary-care PICU. Patients: Patients <18years who received ketamine for ≥12 hours between January 2019, and July 2021. Interventions: None.

Results

Seventy-seven patients (median age 16 months, IQR 7-43) were enrolled. Twenty-six percent of patients (n=20) were paralyzed. The median dosages of ketamine were between 15 (IQR 15-20) and 30 mcg/kg/min (IQR 20-50). At 24h of ketamine infusion, values of CBS were significantly lower compared with values pre-ketamine (p<0.001). Simultaneously, dosages/kg/h of opioids and benzodiazepines significantly decreased at 24 h (p<0.001 and p=0.002, respectively), while dosages/kg/h of propofol and dexmedetomidine did not significantly change. Among paralyzed patients, 13 (65%) did not require an increase of concomitant analgosedation within 24h hours after ketamine introduction. Overall, 55/77 (71%) of patients responded to ketamine. The mean and maximum ketamine infusion dosages were significantly higher in the non-responders (p=0.021 and 0.028, respectively). Eleven patients had AEs potentially related to ketamine (hypersalivation, systemic hypertension, dystonia/dyskinesia, tachycardia, agitation), and 6 patients required intervention (dose reduction, suspension, or pharmacologic therapy). None of the patients developed delirium during ketamine infusion.

Conclusions

Ketamine used as a continuous infusion in the PICU is able to ensure comfort and spares the use of opioids and benzodiazepines. AEs are relatively rare, minor, and easily reversible.

Background and Aims

Septic shock is a life-threatening condition that has been reported as one of the most common pathologies specific to intensive care. The main purpose of this paper is to predict the evolution of sepsis in septic shock using complete blood count and echocardiography at the admission of children in intensive care.

Methods

This prospective, observational study includes children hospitalized in the Pediatric Intensive Care Unit of “Grigore Alexandrescu” Emergency Clinical Hospital for Children who met the criteria for sepsis. In addition to demographic data, values of serum lactate, base excess, procalcitonin (PCT), C-reactive protein (PCR) and complete blood count, the following ratios were taken into account: neutrophils/lymphocytes(NLR), platelets/lymphocytes(PLR), monocytes/lymphocytes (MLR), hemoglobin/lymphocytes(HLR), hemoglobin/platelets(HPR) and systemic inflammatory index(SII). From the ultrasound data the values of cardiac index(CI) and systemic vascular resistance index(SVRI) were derived. Principal component analysis was performed using the BioVinci 2.0 program.

Results

Out of 72 children with sepsis (mean age=7.4±5.85 years), 20 developed septic shock in the first 48 hours after admission to intensive care. To principal component 1 (eigenvalue=7.19,variance=23.97%) contributed significantly: NLR (loading= 0.922), SII(loading= 0.833), PLR(loading= 0.748) and SVRI(loading=-0.709). To principal component 2(eigenvalue=4.02,variance=13.42) contributed significantly: RDW (loading=0.621), HPR(loading=-0.506), HLR(loading=-0.249). The algorithm generated from the decision tree of Biovinci has an area under curve(AUC) of 0.96. This algorithm outperformed the human-based scoring methods such as qSOFA, pSOFA(pediatric), SOFA, MEWS and SIRS.

Conclusions

The evolutionary trend of sepsis in septic shock can be very accurately predicted using the algorithm based on novel inflammatory biomarkers and echocardiography.

Background and Aims

In Sub-Saharan Africa, infection/inflammation are risk factors for neonatal encephalopathy (NE) (Tann 2018). Findings from the HELIX trial suggests therapeutic hypothermia (HT) is ineffective in this setting (Thayyil 2021). Following inflammation-amplified hypoxia-ischaemia (AS-HI) in newborn piglets, where white matter (WM) injury predominates as seen in LMICs, we observed no neuroprotection with HT (Martinello 2020), highlighting the need for alternative therapies. Preclinical studies demonstrate melatonin has robust protection following HI, therefore we aimed to assess its safety and efficacy after IA-HI.

Methods

Piglets underwent IA-HI injury by E. coli lipopolysaccharide pre-sensitisation, carotid artery occlusion and FiO₂ reduction. After 1h, piglets were randomised to vehicle (n=10) or melatonin (ethanol-free) (n=8), repeated at 24h and 48h. Continuous electroencephalogram (aEEG) and ¹H Magnetic Resonance Spectroscopy Lactate/N-acetylaspartate (Lac/NAA) peak ratio were acquired at 60h. Piglets were euthanised at 65h and brain assessed by immunohistochemistry.

Results

There were no differences in insult severity between groups. Therapeutic levels (15-30mg/L) were achieved within 3h with no systemic hypotension. Melatonin reduced mean Lac/NAA by -0.35 (95%CI, -0.86-0.15) Log₁₀ units in the WM and -0.05 (95%CI,-0.33-0.43) in the BGT voxel (Figure). Bayesian analysis using non-informative priors indicated a 90.8% and 40.2% probability of treatment superiority in the WM and BGT regions respectively. Melatonin significantly suppressed microglial activation (IBA-1) in 2 cortical regions (Figure). No significant improvement in aEEG activity was observed.

Conclusions

Melatonin reduced WM injury, the predominant region of injury seen in LMICs. Ethanol-containing formulations show improved protection and require further assessment in this model.

Study was funded by Wellbeing of Women (RG2222).

Background and Aims

Interruptions occur frequently in clinical environments increasing the risk of errors and adding cognitive burden to Registered Nurses (RNs). There is sparse evidence and understanding of behaviour management strategies used by RNs to manage medication interruptions.

Aim: To observe and assess the behaviour management strategies used to manage medication interruptions on PICU

Methods

An observational study of the medication process on a 31 bedded UK PICU was conducted 11/11/21 to 26/11/21. A data collection tool was developed, piloted and used by trained observers. Types of interruption observed (Figure 1) and the management strategy utilised by nurses; engaging (abandoning medication), multi-tasking (simultaneous completion and dealing with interruption), mediating (partial completion of medication) or blocking (interruption ignored), (Figure 2), were collected. Qualitative data was collected by the observers to allow the authors to analyse the appropriateness of the strategies retrospectively.

Results

32 medication episodes were observed with 58 interruptions. The most frequent reason for interruptions was communication (74%, n=43), with nursing communication accounting for 47% (n=27) of episodes. 62% (n=36) of observed interruptions were assessed as being managed inappropriately. Nurses found managing communication interruptions (e.g. nursing, parental and health care professionals) challenging (Figure 3). They mainly adopted a multi-tasking approach (49%, n=22) and only 21% (n=9) of these episodes were managed appropriately.

Conclusions

PICU RNs managed 21% of episodes appropriately when independently assessed. Education about appropriate behaviour management strategies is required, particularly focused on communication-based interruptions with further research to evaluate the effectiveness of training.