Background

Cerebrovascular incidents are rare in paediatric patients and are usually due to vascular malformation or underlying disease.

Objectives

Retrospective study of epidemiology, etiology, frequent clinical manifestations, predisposing factors and outcome of cerebrovascular incidents in paediatric patients in Greece.

Methods

Patients with non-traumatic cerebrovascular incidents, hospitalized in our PICU from 1/1/1998 to 31/12/2018, were included in the study.

Results

During the last 21 years, 26 patients with cerebrovascular incidents were hospitalized (median age: 5 ^3/12years). Nine patients (36%) were younger than one year of age. The most frequent clinical symptoms were headache (70%), drowsiness (65%), acute neurological signs (53%), convulsions (31%). 42% of the patients were intubated at the emergency department due to low GCS. 88% of them suffered from cerebral hemorrhage whereas, only 12% were diagnosed with cerebrovascular occlusion. 30% of patients were diagnosed with arteriovenous malformation and underwent embolism and 42% had surgical intervention (hematoma drainage, hydrocephalus drainage or craniectomy). In 3 of 26 patients predisposing factors were identified (hemophilia, Noonan syndrome, aneurysm). Median length of stay was 5 days (2-51 days). Outcome: 23% of patients died in PICU, 42% had no neurological symptoms at discharge, 20% suffered from mild neurological symptoms whereas, 15% of patients depicted severe neurological disability.

Conclusion

The most frequent symptom of cerebrovascular incidents in paediatric patients is severe headache. Approximately 50% of these incidents are due to arteriovenous malformations that may be treated with embolism or, an underlying disease. General prognosis of cerebrovascular incidents in children is better than that of adults.

Background

Dysregulated cerebral blood flow (CBF) may be a key component for secondary neurologic injury in HIE. The load of fluids to increase intravascular volume is the point of care in infants, but the choice of fluids is still debatable.

Objectives

To determine the impact of 6% HES 130/0.42 in a balanced crystalloid solution on brain perfusion in term neonates with HIE.

Methods

Prospective single-center randomized clinical study in 205 term neonates with HIE was performed in NICU Level III in 2009-2019. All infants were randomly divided into HES and control groups. In HES group 45 term infants were treated at the 1^st DOL with 6% HES 130/0.42 in a balanced crystalloid solution at a dose of 10 ml/kg. The control group included 160 term neonates undergoing routine intensive care with normal saline 20 ml/kg as the loading volume if needed. To assess the efficacy of 6% HES we compared mean blood pressure (MBP) and transfontanel Doppler Resistant Index (RI).

Results

There was slight but statistically significant difference in MBP between control (56 [48-65] mm Hg) and HES (55 [49-65] mm Hg) groups (p=0.007).

The ANOVA test showed the significant difference between RI measured on the Day 1 and Day 2 (p=0.020) inside the groups of patients who received and did not receive 6% HES at Day 1. RI level was significantly higher in 6% HES group comparing to control (p=0.025).

Conclusion

6% HES 130/0.42 at the dose of 10 ml/kg could be an effective for volume resuscitation in term newborns with HIE.

Background

Head injury is the leading cause of death and disability for children in Latvia. Timely neurosurgical intervention (<4 hours) can improve neurological outcome.

Objectives

The purpose of this audit was to determine the time from injury to neurosurgical decompression for children with acute head injury (AHI) in Latvia.

Methods

Children <18 with AHI who required admission to the PICU in the Children’s Clinical University Hospital (CCUH) from 2014 –2018 and underwent neurosurgery within 24 hours were included. Data were tested for normality and expressed as mean and standard deviation (SD) or median and interquartile range (IQR), as appropriate.

Results

A total of 22 patients were included – 9 (41%) girls and 13 (59%) boys; the median age was 88.3 months (IQR 17.0–127.1). Eight (36%) patients had mild, three (14%) moderate and elven (50%) severe head trauma. Eleven (50%) patients were directly admitted to CCUH with median transfer time 57.0 min (IQR 46.2–73.8) and eleven (50%) were taken to the regional hospitals with median primary and secondary transfer times of 39.5 min (IQR 27.3–78.3) and 372.1 (IQR 289.3–455.5), respectively. The mean of total time from the accident to neurosurgical decompression was 316.5 min (SD 221.2) for direct admissions and 610.5 min (SD 240.4) for secondary transfers (difference of means 294.0 min, CI 95%: 88.5–499.4; p = 0.007).

Conclusion

Children with AHI in Latvia did not meet the recommended time to neurosurgical intervention even when admitted to CCUH directly. This audit warrants a revision of care for children with time-critical head injuries.

Background

Abusive head trauma (AHT) is the number one cause of death in children who are suffering from physical violence. It still remains a challenge for physicians to diagnose.

Objectives

To determine, which clinical signs are relevant in distinguishing AHT from non-abusive head trauma (nAHT).

Methods

This is a retrospective descriptive study. Patients from age 0-3 years old who were hospitalized in the Children’s Clinical University Hospital in the Pediatric Intensive Care Unit (PICU) with intracranial injury (ICI) were included between 2007 – 2018. Chi-square test, pvalue for calculation was used in SPSS software.

Results

69 patients were included and were separated into the following 3 groups: 1. conformed AHT with 14 patients (20.29%), 2. nAHT with 37 patients (53.62%) and 3. unclarified head injury (UHI) with 18 patients (26.09%). Between groups there were significant differences (p<0.05) in following clinical signs (see figure 1). No significant differences (p>0.05) between groups with head and/or neck bruising and with rib fractures were found.

Conclusion

There were significant differences in the frequency between nAHT and the other two groups in the following clinical signs: retinal hemorrhages, apneas, seizures, skull fractures and also between subdural and epidural hematomas. Several similarities were found between AHT and UHI groups. Due to the above mentioned points there is a possibility that the patients with UHI had suffered from physical abuse. However additional cases and other factors such as detailed patient history, need to be evaluated.

Background

Continuous electroencephalography (cEEG) is the gold standard for brain monitoring in PICU. Seizure detection rates range from 7-43% across published studies. This may be attributable to differences in indications, duration of monitoring and patient cohort. Given the finite availability of cEEG in Europe, routine EEG studies (rEEG) are more commonly utilised to answer seizure-related clinical questions in PICU.

Objectives

Aims and Objectives: To investigate the rate of seizure detection within PICU using available rEEG resources.

To examine how the indication for, duration of, and delays to access of EEG influence seizure detection rates.

To place our findings in the context of international published literature.

Methods

Methodology: A retrospective observational study in an Irish tertiary-level PICU. All consecutive EEGs carried out in the PICU over a 2.5 year period were included.

Results

Results: 196 EEGs were carried out in 108 patients. Fifty seven percent of patients were aged 12 months or younger. Seizures were recorded in 28% of EEGs and 17% of patients

Seizure detection was more common among patients with an established history of seizures (26.3% vs 11%) and for whom seizures were the primary reason for ICU admission (55% vs 23%).

Patients with seizures had a mortality rate of 17% compared with general ICU mortality rate of 4.5%. The presence of seizures did not affect duration of ICU stay

Conclusion

Conclusion: Levels of seizure detection were lower than many studies described in the literature. This shortfall may be attributable to the reduced duration of EEG, pointing to a need for greater EEG accessibility in our PICU.

Background

Traumatic brain injury (TBI) remains a signifcant health burden worldwide. The management, the demographic data and the outcomes vary center to center depending on the regions and pre-ıcu resources.

Objectives

Aim: To analyse the outcomes and the factors affecting the outcomes of children with severe traumatic brain injury admitted to our hospital in Turkey.

Methods

Medical records of children with severe traumatic brain injury admitted to our Pediatric Intensive Care Unit over a 7-year period were retrospectively reviewed. Patients were divided in to three categories according to Glasgow outcome scale performed at PICU discharge, GOS of 1: the children who died, GOS of 2-3: poor neurological outcome, GOS of 4-5: good neurological outcome and compared according to demographic, clinical and radiological data.

Results

A total of 62 patients were analyzed (median age:56 months; 35 boys). Most common mechanisms of injury was fall from a height (n=24, 38.7%). Twenty-four patients died (38.7%). Seven patients were discharged with poor neurological outcome,half of the patients (n=31) were discharged with good neurological outcome. Presence of CPR before admission, GCS of 3-5 at admission, hypotension at admission, metabolic acidosis during the first 24 hours, effacement of basal cisterns on first Cranial CT , PTS , ISS , blood sodium level of first day, INR level at admission was statistically significant between patients who died and patients with poor and good neurological outcome.

Conclusion

To evalute the factors affecting the outcomes of children with severe traumatic brain injury.may improve the outcomes in regions that have limited resources with poor pre-ıcu management.

Background

Lung-protective mechanical ventilation (MV) strategies are associated with survival benefits in adults.

Objectives

We aim to determine if a greater degree of adherence to the Pediatric Acute Lung Injury Consensus Conference (PALICC) ventilation recommendations would result in improved survival in pediatric acute respiratory distress syndrome (PARDS).

Methods

Patients with PARDS were included in this prospective cohort study. Adherent days were defined as days where at least three out of five of the following conventional MV (CMV) strategies were adhered to on the first seven days of PARDS: (1) peak inspiratory pressures <28cmH₂O, (2) tidal volumes <6ml/kg, (3) positive end expiratory pressure to fraction of inspired oxygen table, (4) permissive hypercapnia (pH 7.20-7.30) and (5) permissive hypoxia (93-97% for mild, 88-92% for moderate/severe PARDS). Logistic regression was used to evaluate the impact of “adherence” on pediatric intensive care unit (PICU) mortality, adjusting for PARDS severity.

Results

Forty-seven patients were recruited over a year. Overall median (interquartile range) age and Pediatric Index of Mortality 2 score were 2.3(0.4, 6.6) years and 9.3(3.2, 27.6) %. The median oxygenation index was 6.5 (4.9, 10.9) and there were 8/47(19.5%) patients with severe PARDS. PICU mortality was 7/47(14.9%). There was a total of 192/253(75.9%) CMV days. The median number of adherent days was 1 (0, 3). The number of days adherent to ventilatory recommendations was not associated with PICU mortality [adjusted odds ratio 1.1 (95%confidence interval 0.9, 1.3); p=0.459].

Conclusion

In PARDS, a greater degree of adherence to the PALICC CMV recommendations was not associated with improved PICU mortality.

Background

Pretreatment with multidose steroid regime prevents post extubation airway obstruction (PEAO) in children. There is lack of information on its optimal dose for prevention of PEAO.

Objectives

Compare the effect of 24 hour pretreatment of low dose versus high dose of dexamethasone in preventing the occurrence of PEAO and reintubation in children at a tertiary care hospital as a randomized open-labeled control trial

Methods

One hundred and sixty six children (3 months to 12 years) who were intubated for ≥48 hours and planned for first extubation were randomized to receive low dose (0.25mg/kg/dose; n=83) or high dose (0.5mg/kg/dose; n=83) dexamethasone injections 6 hourly for a total of 6 doses. Extubation was performed 24 hours after the last injection. PEAO was recorded for 24 hours of extubation.Patients with preexistent upper airway conditions, chronic respiratory diseases, steroid therapy in last 7 days, gastrointestinal bleeding were excluded

Results

Two groups were similar in their baseline characteristics. The study protocol could be implemented in 147 patients only. On per protocol analysis, 45 (28.5%) patients developed PEAO; lesser patients (17/71, 23.9%) in high dose group compared to low dose group (28/76, 36.8%) (p=0.09). Reintubation was needed by lesser patients in high dose group compared to low dose group (4/71, 5.6% vs 7/76, 9.2%) (p=0.41). Univariate analysis revealed duration of intubation as the only risk factor of PEAO (p=0.016).

Conclusion

24 hour pre-treatment with high dose (0.50mg/kg/dose) dexamethasone led to lesser patients developing PEAO and requiring reintubation, though it could not reach statistical significance probably due to small sample size

Background

Background: Studies in adult ARDS have shown an association between fluid overload (FO) and worse outcome. Data in pediatric acute respiratory distress syndrome (PARDS) is limited, although few studies have demonstrated worsening oxygenation and lesser ventilator free days.

Objectives

To study the effects of FO in children with PARDS

Methods

Prospective observational study between August 2017–August 2018, in a tertiary level PICU of a teaching hospital in India, including 48 children aged 31 days to 12 years, mechanically ventilated for PARDS (PALICC definition)

Results

The median(IQR) P/F ratio was 164(122,213), while oxygenation index(OI) was 7.21(4.7,13.9). Thirty five children (72.9%) had severe, 9(18.8%) had moderate and 4(8.3%) had mild PARDS. Thirty two(66.6%) children had FO% >10; more in severe than in mild-moderate ARDS (80% vs. 30.8%; P<0.001). The odds of severe ARDS increased by nearly 9 times in children with FO(OR 9; 95% CI 6.13-13.22; P<0.0001). On linear mixed modelling regression analysis, peak FO%(PFO) was a significant predictor of worst OI(F-value 23.47; P<0.001); for every 1% increase in PFO, worst OI increased by 0.67(95% CI 0.40-0.94;P<0.001).Similarly for every 1% increase in daily FO%(DFO), mean OI increased by 0.9[95% CI:0.82-0.96; P<0.001].Twenty five (83.3%) non-survivors as against 7(38.8%) survivors had FO(P= 0.002). FO was seen in 23(74.2%) out of 31 with progressive MODS, 22(73.2%) out of 30 with AKI, and 14(73.7%) out of 19 with myocardial dysfunction.

Conclusion

Fluid overload is a significant contributor to severity of ARDS; unit change in daily or peak FO% leads to significant increases in OI and mortality.

Background

Limited adult data suggests that ΔP (P_PLAT—PEEP), might better reflect the lung injury than tidal volume in ARDS.

Objectives

This study aimed to evaluate the effect of ΔP on morbidity and mortality of children with AHRF.

Methods

This retrospective study at tertiary care PICU in developing country was done on children who received invasive mechanical ventilation for AHRF (PaO₂/FiO₂ <300 within 24 hours after intubation), in a 2-year period. Cohort was divided to two groups based on the highest ΔP in first 24 hours.

Results

101 case out of 380 ventilated children were enrolled. In comparison to high ΔP (≥15 cm H₂O) group, children in low ΔP group had significantly lower duration of ventilation [median (IQR) 5 (4-6) vs 8(6-11) days, p< 0.001] , length of PICU stay [6 (5-8) vs 12(8-15) days, p< 0.001] and higher ventilator free days at day 28 [23(20-24) vs 17(0-22) days, p<0.001]. However, there was no statistically significant difference in mortality between two groups (17% in low ΔP v/s 24% in high ΔP, p=0.38). Logistic regression model also suggested ΔP as an independent predictor of morbidity. ΔP >19 cm H₂O was associated with significant mortality.. Subgroup analysis of 65 patients with ARDS, yielded similar results with respect to mortality and morbidity. The independent early mortality predictors (at 24 hours) found by multivariate analysis were Oxygenation Index >8 and cumulative fluid balance >5%.

Conclusion

ΔP <15cm H₂O might be beneficial in AHRF children with significantly decreased morbidity.

Background

Mild head injury is a common cause for paediatric emergency department visits. Cranial computer tomography (CCT) is the diagnostic standard for radiologic investigations, though the risk of radiation. Paediatric Emergency care applied research network (PECARN) clinical prediction rules have been invented to reduce CCT scans. They provide a guideline for outpatient care, or short-term observation for patients with moderate risk.

Objectives

To evaluate the impact of the implementation of PECARN rules in children with mild head injury on hospitalisation and CCT rate, patient management before and after rule implementation was recorded

Methods

In this retrospective study, children with mild head injury presenting in the paediatric emergency department between 2012 and 2016 were examined. We compared two groups, before and after implementation of PECARN criteria in clinical routine and the second group afterwards. Changes in hospitalisation rates and CT rates were calculated using Chi² test.

Results

Of 742 included patients (age ± 5.6 years; 317 female and 425 male), 388 were seen prior to the implementation of PECARN rules, compared to 354 patients afterwards. The amount of admissions to the ward decreased significantly from 325/388 (84%) to 254/354 (71%), whereas the number of discharges rose (p<0.05). Based on all paediatric admissions, the rate of patients with mild head injury fell from 5.9% to 4.2%.

The baseline CCT rate was low in the first group 64/388 (16%), with no significant reduction in the second group 51/363 (14%)(p<0.44).

Conclusion

PECARN rules help to reduce hospitalisation rates. Hospitals with low CCT rates do not experience significant reduction.