Background

Significant differences in processes of care in septic shock exist between the developed and developing region. Despite advances in the understanding of septic shock, mortality is 20% in developed and 50% in the resource limited setting.

Objectives

The primary endpoint is 28-day all-cause mortality. Secondary endpoints are therapeutic endpoint achieved, new onset organ failure and length of PICU and hospital stay.

Methods

TThe open-labeled randomized controlled trial enrolled the 120 children aged one-month to 12-year with septic shock. Patients were randomized to EGDT with intermittent ScvO2 monitoring (n=59) and standard care with no ScvO2 monitoring (n=61) group. EGDT group patient was managed by modified Rivers et al. protocol (intermittent ScvO2 instead of continuous monitoring). Standard care group patient managed by protocol adapted from adapted from Rivers et al.

Results

EGDT-group had lower mortality (35.6%) as compared to standard care-group (60.6%; RR=0.61, 95%CI 0.42–0.88, p=0.006). Dobutamine need in first six-hour (61.1% vs. 33.9%; p=0.004) and PRBC need (59% vs. 23%; p=0.056) was higher in the EGDT-group. There was no difference in therapeutic endpoint achieved at six-hour (61.1% vs. 57.1%; p=0.672), at 72-hour median (IQR) SOFA-score (4, 1–9 vs. 6, 2–11), PeLOD-score (6, 1–14 vs. 10, 2–17) and median stay in PICU (5, 3–9 vs. 5, 2–10 days) and in hospital (8, 5–13 vs. 7, 5–13 days).

Conclusion

EGDT with intermittent ScvO2 monitoring was associated with lower all-cause 28-day mortality in pediatric septic shock in resource limited setting as compared to standard care.

Background

CLABSIs are conditions with great morbidity and costs. Hospitals that performed in-depth review of CLABSI events to improve processes reduced CLABSI rates. At Children’s Hospital of Eastern Ontario (CHEO) the high CLABSI rates led to a quality improvement initiative that included apparent cause analysis of all CLABSI events.

Objectives

To identify contributing factors to CLABSIs at CHEO PICU, NICU and inpatient units to guide process improvement.

Methods

A team constituted of a physician, the local nurse educator, a vascular access expert, and an infection control professional systematically reviewed all inpatient CLABSI events for a period of 14 months. The team interviewed providers and reviewed charts to identify standard of care deviation and unusual circumstances related to central line care.

Results

Between November 2017 and December 2018, CHEO inpatient units had a total of 10269 line-days. NICU had 10 CLABSI events, PICU 5, Hematology and Oncology Unit 14, and other inpatient units 5. Line care documentation was incomplete in 9 cases. Gaps in care were identified in 6 events and 2 were deemed as serious safety events. Skin breakdown at the line site, frequent visits to the operating room, active resuscitation utilizing PICC line were some of the contributing factors identified

Conclusion

Processes for documentation, management of skin breakdown at the site, line repair and others were reviewed and disseminated. Central line access and care training was offered for the operating room providers. These changes contributed to a downward trend in the CLABSI rate from 3.62, before intervention, to 2.85, in its last 6 months.

Background

Objectives

Methods

Results

Conclusion

Background

UNDER5 pneumonia is a common childhood illness attributing to mortality in LMIC countries. Early appropriate respiratory support likely to improve the outcome

Objectives

To study the clinical effectiveness of HHFNC compared to simple low flow nasal cannula oxygen as a first contact respiratory support measure in UNDER5 children hospitalized with severe pneumonia

Methods

All UNDER5 children presenting with acute respiratory symptoms were screened for eligibility. Those with “Severe Pneumonia requiring oxygen therapy” were enrolled after informed consent and randomized to ‘High Flow therapy’ (HFNC) and ‘Standard Flow therapy’ (SFNC) groups. Pre-enrolment therapy was standardized and similar in both groups. ‘Failure of therapy’ was considered as primary outcome and was defined as ‘Need to intubate or to escalate to next level of respiratory support as per pre-defined criteria’.

Results

Of 240 children enrolled 124 received SFNC and 116 received HFNC therapy as per randomization. 31 children failed first contact respiratory support measure, of which 10/31 were in HFNC group and 21/31 were in SFNC group. Baseline variables like, age, sex and RDS score at admission, RDS score categories were comparable among groups. ‘Failure of therapy’ was significantly higher (p 0.02) in the SFNC group with relative risk of 2.24 (1.10 - 4.56). There was no significant difference in time to clinical stability, time to respiratory stability, FO% at 24 hours and 48 hours among the study groups.

Conclusion

HFNC as first contact respiratory support in UNDER5 children with severe pneumonia admitted to emergency room is more effective than SFNC evidenced by significantly lesser failure incidences.

Background

More than half of all cases of AKI in critically ill children are sepsis or sepsis-related. Understanding of the renal histopathological changes will give a better insight into the pathogenesis of pediatric septic AKI. No prospective study of the histopathological features of septic AKI in critically ill children has been performed.

Objectives

To study the histopathological changes in septic AKI.

Methods

A prospective observational study involving children aged less than 12-year died with septic AKI screened for percutaneous renal biopsy from January-2015 to February-2019. Three core of kidney tissue were taken for histopathological evaluation by light and immunofluorescence examination. Sepsis and AKI were defined using international pediatric sepsis consensus conference and AKIN criteria respectively.

Results

A total of 2249 patients were admitted to the PICU with a mortality of 25 % (n = 562) and 39 complete data of post-mortem renal histopathological reports were included. The median (IQR) age was 22.5 (5–75) months and PRISM-III was 17 (13–23). Normal histology was the most common change 46% (n=18) followed by acute tubular necrosis (ATN) 33% (n=13). A combination of changes involving tubules, glomeruli, interstitium, and blood vessels was noted in 23% (n=9) of the specimens. Three percentage (n=1) of the specimens had features consistent with thrombotic microangiopathy. Normal histology was noted in 11% (n = 2/18), 72.2 % (n = 13/18), and 16.7 % (n = 3/18) of AKI stage I, II, and III respectively.

Conclusion

The most common renal histopathological change in septic AKI in critically ill children was normal histology followed by ATN.

Background

Most children who die in UK Paediatric Intensive Care Units (PICUs) are infants. Male infants have higher mortality compared to female infants globally. Specific reasons that drive the UK gender disparity have not been studied.

Objectives

To study gender differences in UK PICU mortality and investigate factors that may explain these differences

Methods

We extracted data from UK PICUs from 01/2005 to 12/2015 and included all infants aged 0-12 months admitted to PICU. To investigate potential aetiological causes for differences in mortality, we used a parametric cause-specific hazard ratio (CSHR) with restricted cubic splines, time varying coefficients, and cluster robust standard errors. Variables used for risk adjustment were a recalibrated version of PIM2, age at admission, elective or emergency admission, infection, year and month of admission, inotropic and renal support.

Results

We analysed records of 71,242 infants from 35 PICUs. More female than male infants died (1809/41723, 4.3% versus 1411/29519, 4.8% for males/females respectively). The adjusted CSHR for males versus females was 0.88 (95% CI 0.82 to 0.95, p=0.001). Higher PIM2 score, infection, inotropic and renal support were all strongly associated with an increased CSHR for mortality. Older age and later years were strongly associated with deccreased mortality. None of the factors investigated altered the CSHR. The CSHR of gender was at its lowest during the first three days of admission, suggesting that whatever drives higher female mortality occurs early after admission.

Conclusion

UK female infants have higher PICU mortality than male infants. The reason behind this finding is unclear and needs further investigation.

Background

The co-presence of persistent pulmonary hypertension (PPHN) in preterm infants with respiratory distress syndrome (RDS) can result in signficant morbidity and even mortality. Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator and data regarding its use in preterm infants with RDS and PPHN are both scant and controversial.

Objectives

To test the hypothesis that the effects on survival of early treatment with iNO in preterm infants aged 22–29 weeks' gestational age (GA) who required mechanical ventilation for treatment of RDS and PPHN would vary according to birth size and GA.

Methods

iNO was not randomly prescribed to neonates in this cohort so propensity score-matching was utilized to pair a neonate who received iNO at a chronological age of ≤7 days with an unexposed (control) neonate possessing similar baseline characteristics. The primary outcome was in-hospital mortality which was evaluated using a Cox proportional hazards regression model separately according to stratification by GA and birth size.

Results

Of the 92,635 preterm neonates initially meeting inclusion criteria, a cohort consisting of 615 pairs of neonates (iNO-exposed and unexposed) was created using propensity score matching. Compared to unexposed infants, large-for-gestational-age preterms exposed to iNO experienced a significant decrease in the risk of in-hospital mortality (hazard ratio, 0.45; 95% confidence interval, 0.23-0.88). There were no other effects of iNO on survival on any other strata.

Conclusion

When stratified according to birth size and GA, most extremely preterm neonates with RDS and PPHN do not experience a survival benefit from early treatment with iNO.

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Conclusion