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Background and Aims

Retinopathy of prematurity is a major cause of morbidity in preterm infants but population-based studies to evaluate recent trends in incidence in the United States (US) are lacking. Moreover, previous studies did not include the use of anti-Vascular Endothelial Growth Factor medications. The objective of the study was to examine the recent secular trends in the incidence and treatment of severe retinopathy of prematurity (sROP) in the United States (US) from 2009 to 2018.

Methods

This was a population-based, serial cross-sectional study that utilized data from the National Inpatient Sample. The inclusion criteria were preterm infants with gestational age (GA) ≤30 weeks and length of stay >28 weeks. The primary outcomes were trends in ROP surgery (photocoagulation, sclerotherapy, scleral buckling, vitrectomy) and intravitreal injection of therapeutic (anti-VEGF) medications. The Cochran-Armitage test was used to evaluate trends and P-value <0.05 was considered significant.

Results

Out of 256,932 hospitalizations that met the inclusion criteria, 11,216 (4.4%) had sROP. Those with sROP were more likely to have severe intraventricular hemorrhage (12.5% vs 6.1%), bronchopulmonary dysplasia (48.2% vs 25.9%), and pulmonary hypertension (10.7% vs 4.7%). From 2009-2018, sROP significantly increased from 3.3% to 4.9% (P<0.001), ROP surgery decreased from 35.6% to 10.8% (P<0.001) while intra-vitreal administration of therapeutic drugs increased from 1% to 7.4% (P<0.001).

Conclusions

Surgery for sROP decreased while intra-vitreal administration of therapeutic drugs increased in the setting of increasing incidence of sROP in the US. Taken together, these findings suggest a gradual practice change and the long-term outcomes of intra-vitreal agents warrants future study

Background and Aims

Background:

The British Society for Paediatric Endocrinology and Diabetes (BSPED) guidelines recommend early referral of unwell patients with diabetic ketoacidosis (DKA) to the paediatric critical care team. In our region, DKA patients are referred from district general hospitals to our paediatric critical care retrieval team, the North West and North Wales Paediatric Transport Service (NWTS).

Aim:

To review and compare the DKA patient population referred to NWTS pre-Covid-19 and during Covid-19.

Methods

Data was extracted from an audit of patients referred August 2016-September 2018, and compared to data from an audit of patients referred January-December 2020.

Results

Conclusions

There was a statistically significant increase in the proportion of DKA patients, and the proportion of newly diagnosed T1D patients with DKA referred to NWTS in 2020, compared to pre-Covid-19. A reduction in the utilisation of healthcare services likely contributed to late presentation of illness^[1]. This result corresponds to the UK survey which also showed increased proportion of new onset T1D paediatric patients presenting in DKA during this period^[2]. Further research is warranted to determine any other relationship between Covid-19 and T1D.

1. Roland D, et al. https://doi.org/10.1016/S2352-4642(20)30206-6

2. Ng SM, et al. https://doi.org/10.1136/bmjpo-2020-000884

Background and Aims

Capnography in addition to clinical monitoring (CM: visual assessment of spontaneous breathing and pulse oximetry) is recommended to monitor ventilation of patients during procedural sedations (PS). However, the benefits of capnography in addition to CM in children undergoing PS have not been shown, especially in children under 3 years. We aimed to determine the rate of respiratory adverse events (RAE: episodes of desaturations <90% for >5 seconds or EtCO₂ > 50 mmHg) in children undergoing PS with and without the use of capnography.

Methods

We compared CM (G1) and CM+Capnography (G2) in a two-phases prospective cohort study of patients aged 0 to 18 years undergoing PS by our PICU team. Occurrence of RAE were compared. Children under 3 years were analyzed as a predetermined subgroup.

Results

566 PS were studied (G1, n=224 and G2, n=342). 115 patients in G2 were excluded (capnography impossible for technical reasons). Main indications for PS were gastrointestinal (41,1%) and oncologic (30,0%) procedures. Ketamine/midazolam were used in 91,8% of patients. 23 RAE were observed, requiring flow-by oxygen supplementation in 14/23 (60,8%). The rate of RAE between groups was not different (G1:5,4% VS G2:4,9%, p = 0,697). Subgroup analysis of 66 patients under 3 years showed a lower RAE trend in G2 (G1: 18,8% vs G2:2,9%, p = 0,082).

Conclusions

No difference in the incidence of RAE with the addition of capnography to CM of pediatric patients receiving PS was observed. Further study is required to determine clinical circumstances where capnography may benefit patients undergoing PS.

Background and Aims

During the spring of 2020 early indicators suggested that demand for Adult Intensive Care Unit (AICU) beds during the first wave of the COVID-19 pandemic in England was likely to rapidly outstrip bed capacity. We set out to describe the planning and experience of PICUs that repurposed their units, equipment and staff to care for critically ill adults during the first wave of COVID-19.

Methods

Contemporaneously, the UK Paediatric Critical Care Society (PCCS) used routine audit data from the Paediatric Intensive Care Audit Network database to estimate the demand for PICU beds, both nationally and regionally, in England from March through to June 2020, using historical data.

Subsequently, PICUs that repurposed their units gathered retrospective data on their management of space, staff, equipment, clinical care, communication, governance systems and learning gained. In addition, the characteristics, interventions and outcomes of adults cared for in PICUs were also gathered.

Results

Seven English PICUs accommodated critically ill adults. Neighbouring PICUs increased bed capacity to maintain bed numbers for children; historical modelling suggested 280–307 beds would be required between March and June. A total of 145 adult patients were cared for in PICUs. Of these, 75% had COVID-19, 85% required invasive ventilation, 29% underwent a tracheostomy, 14% required renal replacement therapy, and 20 patients (14%) died.

Conclusions

During the first wave of the COVID-19 pandemic, seven English PICUs were repurposed to care for adult patients. The success of this effort was secured through extensive local preparation, collaboration with Adult Intensivists and national planning to safeguard Paediatric capacity.

Background and Aims

Acute Kidney Injury (AKI) after surgery for congenital heart disease (CHD) has been associated with prolonged ICU length-of-stay (LOS)¹. Our aim was to evaluate for possible differences between patients with and without AKI paying particular attention on post-operative ICU LOS.

Methods

Records of children who underwent surgery for CHD from April 2020 to January 2021 were reviewed. AKI was defined according to KDIGO criteria. An absolute post-operative serum creatinine level of >0.5 mg/dl was necessary to diagnose AKI². Differences between groups (AKI vs non-AKI) were estimated using chi-square test of homogeneity, Fisher’s exact test and Mann-Whitney U test, depending on the group sample size and the type of the dependent variables.

Results

112 children (ages between 1 day and 18 years old) were included in the analysis. AKI occurred in 18 patients (16%). Age and weight were statistically significantly lower for children with AKI than for children without AKI. Post-operative ICU LOS and mortality were statistically significantly higher for children with AKI than for children without AKI.

Conclusions

AKI development in children undergoing cardiac surgery for CHD was associated with prolonged post-operative ICU LOS. Focus should be paid in preventing AKI by improving CPB techniques, optimising haemodynamics and careful fluid balance monitoring amongst others.

Background and Aims

Recent population-based studies suggest that tracheostomy placement in bronchopulmonary dysplasia (BPD) in the United States (US) is increasing but it is unknown if this trend differs by gestational age (GA). We examined the GA-specific rates and trends of tracheostomy in preterm infants with BPD in the US from 2008 to 2017

Methods

This was a population-based, repeated cross-sectional analysis of the National Inpatient Sample. Preterm infants with gestational age (GA) ≤30 weeks with BPD who had tracheostomy from 2008 to 2017 categorized by GA into 4 groups: </=24, 25-26, 27-28, and 29-30 weeks. The incidence rate of tracheostomy in preterm infants with BPD was expressed as per 1,000 livebirths </=30 weeks GA. The primary outcomes were the GA-specific rates and trends of tracheostomy in BPD. Linear regression was used to evaluate trends and P-value <0.05 was considered significant

Results

Among 384,233 neonatal hospitalizations</=30 weeks GA from 2008-2017, 68,953 had BPD of which 987 received tracheostomy, an overall incidence rate of 2.5 per 1000 livebirths. The tracheostomy rate per 1,000 livebirths differed by GA: </= 24 weeks: 3.5; 25-26 weeks: 5.8; 27-28 weeks: 2.1; 29-30: 0.7. Between 2008 and 2017, the tracheostomy rate significantly increased from 0.65 to 4.8 for those </=24 weeks (P=0.025). No significant change was observed for the other GA groups (25-26 weeks: 7.57 to 7.34, P=0.84; 27-28 weeks: 3.71 to 2.41, P=0.39; 29-30: 0.37 to 0.65, P=0.87).

Conclusions

In this population-based study, the rate of tracheostomy in BPD was low but there was a significant increase in preterm infants </=24 weeks GA.

Background and Aims

There is no consensus on what constitutes extubation failure (EF) in pediatric critical care studies. The aim of this systemic review is to describe the various definitions used for EF in the medical literature and compare clinical outcomes based on the definitions used in pediatric intensive care unit(PICU).

Methods

A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed to May 2020. Randomized controlled trials (RCTs) or observational studies that studied the association between pre-extubation characteristics and EF in a PICU were included. Different EF definitions were identified and categorised, and EF rates were analysed as our outcome.

Results

56 studies (7 RCTs, 49 observational studies) were included. 33(59%) and 17(30%) studies examined EF in general PICU and cardiac patients, respectively. The most common definitions used for EF were reintubation alone [42 (75%)] and re-intubation or need for non-invasive ventilation (NIV) [14 (25%)] with corresponding EF rates 12.2% (8.2%-17%) and 13.3% (10.8%-22.6%), respectively. Duration of defined EF were also variable: within 24, 48 and >72 hours [11(20%), 28(50%) and 17(30%)], respectively. Studies that defined EF>72 hours post-extubation had highest EF rate [16.7% (8.4%-25.6%)] compared to studies that utilized a shorter duration. EF rate was higher in studies involving cardiac patients compared to general PICU cohort [13.8% (10%-17.5%) vs. 11.2% (8%-17.4%)].

Conclusions

There is a wide variation of definitions and duration used in EF studies in critically ill children. Consensus among practitioners and researchers are required to standardize this definition to aid comparison among studies.

Background and Aims

BACKGROUND AND AIMS:

The medical treatment in bronchiolitis is based in respiratory support. There has been an increase in the use of high flow nasal cannula (HFNC), despite the lack of evidence on its advantages over conventional oxygen therapy and non-invasive ventilation (NIV). The objective is to perform a systematic review on the efficacy of HFNC in bronchiolitis.

Methods

METHODS:

A search was carried out of clinical trials in which HFNC was compared with conventional oxygen therapy (LFOT) and/or NIV in bronchiolitis. Paired meta-analyses and network meta-analyses were performed, with subgroup analyses according to study setting. The main outcome was invasive mechanical ventilation (IMV).

Results

RESULTS:

In the paired meta-analyses, there were no differences in the risk of IMV between HFNC and LFOT (Odds Ratio [OR] 1.79, 95% confidence interval [CI] 0.59 to 5.41) nor between HFNC and NIV (OR 1.77, 95% CI 0.67 to 4.69). HFNC was more effective than LFOT in reducing treatment failure and oxygen days. In the network meta-analyses, NIV was the most effective intervention to avoid IMV (SUCRA 86.55%), as well as to avoid treatment failure (SUCRA 95.31%) and to reduce days under oxygen therapy (SUCRA 81.84%); HFNC only was superior to LFOT for treatment failure outcome.

Conclusions

CONCLUSIONS:

HFNC appears to be more effective than LFOT in reducing treatment failure and days under oxygen therapy, but not in preventing IMV or admission to pediatric intensive care unit (PICU). NIV is the most effective treatment to prevent IMV and reduce days under oxygen therapy.

Background and Aims

Neonatal sepsis is major cause of neonatal morbidity and mortality in developing countries. Blood culture and sepsis screen tests are currently used methods for diagnosis but procedure is time taking and cost limit their utility. Platelet indices are parameters are low cost and readily available at even small health center.

This study was undertaken to evaluate the significance of platelet indices and with it's comparison to other sepsis screen test for Early diagnosis of neonatal sepsis.

Methods

As per calculated sample size 250 neonates admitted in NICU of hospital showing sign and symptoms of sepsis were included in study.All these neonates has-been evaluated included blood culture,sepsis screen test(CRP, micro-ESR, I T ratio,ANC)and platelet indices on day 1,3 and 7(PLT,PCT,PDW,MPV).

Results

In present study, Mean PLT on day 3,7 were significantly lower in proven(1.34+-0.98,1.34+-1.00) and probable sepsis(1.55+-1.09,1.64+-1.15)as compared to clinical sepsis (1.98+-1.49,2.14+-1.46),(p<0.001).Similar trend was shown with PCT which was lower in proven (0.13+-0.09,0.13+-0.10)probable sepsis (0.15+-0.11,0.15+-0.10)as compared to clinical sepsis (0.19+-0.14,0.21+-0.15),(p<0.001).PDW on day 3 was higher in proven(14.76+-3.28) probable(14.79+-9.38) as compared to clinical sepsis(13.31+-2.83),(p=0.019).If the mean cutoff value of day 7 PLT(1.34+-1.00)and PCT(0.13+-0.10) is considered as diagnostic test of sepsis,these exhibit a fairly good performance with sensitivity and specificity (67.08%,64.55% and 53.08,56.72% respectively) quite similar to I T ratio and micro-ESR which has sensitivity and specificity(65.82%,44.30%,77.19%,78.36%) respectively.

Conclusions

Lower mean PLT, PCT on day 3and 7 and higher PDW on day 3 were significantly associated with neonatal sepsis.Therefore, PLT on day7<1.34 lacs/microL and PCT <0.13% could be used as one of the sepsis screen tests.