Impact of Inherited Genetic Variants on Critically Ill Septic Children

Sepsis remains an important source of morbidity and mortality in children, despite the development of standardized care. In the last decades, there has been an increased interest in genetic and genomic approaches to early recognition and development of treatments to manipulate the host inflammatory response. This review will present a summary of the normal host response to infection and progression to sepsis, followed by highlighting studies with a focus on gene association studies, epigenetics, and genome-wide expression profiling. The susceptibility (or outcome) of sepsis in children has been associated with several polymorphisms of genes broadly involved in inflammation, immunity, and coagulation. More recently, gene expression profiling has been focused on identifying novel biomarkers, pathways and therapeutic targets, and gene expression-based subclassification. Knowledge of a patient’s individual genotype may, in the not-too-remote future, be used to guide tailored treatment for sepsis. However, at present, the impact of genomics remains far from the bedside of critically ill children.

Effect of Early Nutritional Assessment and Nutritional Support on Immune Function and Clinical Prognosis of Critically Ill Children

The aim of this study was to study the effect of early nutritional assessment and nutritional support on immune function and clinical prognosis of critically ill children. 90 critically ill children at the same level of severity admitted to the pediatric intensive care unit (PICU) of our hospital (June 2019–June 2020) were chosen as the research objects and were equally separated into the experimental group and the control group by the random number table method. The children in the control group were admitted to the PICU according to the routine process, and the nutritional support was provided to the malnourished ones. After admission to the PICU, the children in the experimental group were given nutritional assessment, nutritional risk screening, and nutritional support according to the screening results. The PICU stay time and total hospitalization time of the experimental group were obviously shorter than those of the control group ( P < 0.05 ), the hospitalization expenses of the experimental group were obviously lower than those of the control group ( P < 0.05 ), the clinical outcomes and immune function of the experimental group were obviously better than those of the control group ( P < 0.05 ), and the nutrition indicators of the experimental group were obviously higher than those of the control group ( P < 0.05 ). Early nutritional assessment and nutritional support can effectively improve the immune function and reduce the incidence of adverse clinical outcomes of critically ill children, which are worthy of clinical application and promotion.

Peritoneal Dialysis with Rigid Catheters in Children with Acute Kidney Injury: A Single-Centre Experience

Peritoneal dialysis (PD) is a simple and preferred modality of dialysis for children with acute kidney injury (AKI) in resource poor countries. The aim of the study is to evaluate the utility and safety of acute PD using rigid catheter in critically ill children admitted to pediatric intensive care unit (PICU) with emphasis on short-term patient and renal outcome and complications. In this retrospective study, outcome and complications of PD using rigid catheter were evaluated in 113 critically ill children admitted in PICU of a tertiary care hospital from 2014 to 2019. The most common causes for AKI were sepsis (39.8%), dengue infection (16.8%), and hemolytic uremic syndrome (13.2%). In 113 patients, 122 PD catheters were inserted, and the median duration of PD was 60 (IQR: 36–89) hours. At the initiation of PD, 64 (56.6%) patients were critically ill requiring mechanical ventilation and inotropes, 26 (23%) had disseminated intravascular coagulation, and 42 (37%) had multiorgan dysfunction syndrome. PD was effective and there was a significant improvement in urea and creatinine, and one-third patients (n = 38; 33.6%) had complete renal recovery at the end of PD. Total complications were seen in 67% children but majority of them were metabolic (39.8%). Total catheter related complications were seen in 21.2% and peritonitis was seen in 4.4%. Catheter removal due to complications was required in 8.8% children. Overall, among children on PD, 53.7% survived. Acute PD with rigid catheters can be performed bedside in absence of soft catheters and significant clearance can be obtained without major life-threatening complications.

Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study

Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children.Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels.Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7–7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93–0.96; p &lt; 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p &lt; 0.001) and NRS, rho = 0.958 (p &lt; 0.001) was excellent. The RASS scores were significantly different (p &lt; 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789–0.865; p &lt; 0.001), κ 0.762 (95% CI, 0.713–0.811, p &lt; 0.001). A significant change in RASS scores (p &lt; 0.001) was recorded with the variance of sedative doses.Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.

Gastrointestinal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Prior criteria to define pediatric multiple organ dysfunction syndrome (MODS) did not include gastrointestinal dysfunction. OBJECTIVES Our objective was to evaluate current evidence and to develop consensus criteria for gastrointestinal dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and EMBASE were conducted from January 1992 to January 2020, using medical subject heading terms and text words to define gastrointestinal dysfunction, pediatric critical illness, and outcomes. STUDY SELECTION Studies were included if they evaluated critically ill children with gastrointestinal dysfunction, performance characteristics of assessment/scoring tools to screen for gastrointestinal dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, case series with sample size ≤10, and non-English language studies with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS The systematic review supports the following criteria for severe gastrointestinal dysfunction: 1a) bowel perforation, 1b) pneumatosis intestinalis, or 1c) bowel ischemia, present on plain abdominal radiograph, computed tomography (CT) scan, magnetic resonance imaging (MRI), or gross surgical inspection, or 2) rectal sloughing of gut mucosa. LIMITATIONS The validity of the consensus criteria for gastrointestinal dysfunction are limited by the quantity and quality of current evidence. CONCLUSIONS Understanding the role of gastrointestinal dysfunction in the pathophysiology and outcomes of MODS is important in pediatric critical illness.

Acute Neurologic Dysfunction in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Acute neurologic dysfunction is common in critically ill children and contributes to outcomes and end of life decision-making. OBJECTIVE To develop consensus criteria for neurologic dysfunction in critically ill children by evaluating the evidence supporting such criteria and their association with outcomes. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020, by using a combination of medical subject heading terms and text words to define concepts of neurologic dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if the researchers evaluated critically ill children with neurologic injury, evaluated the performance characteristics of assessment and scoring tools to screen for neurologic dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies with an adult population or premature infants (≤36 weeks' gestational age), animal studies, reviews or commentaries, case series with sample size ≤10, and studies not published in English with an inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each study meeting inclusion criteria into a standard data extraction form by task force members. DATA SYNTHESIS The systematic review supported the following criteria for neurologic dysfunction as any 1 of the following: (1) Glasgow Coma Scale score ≤8; (2) Glasgow Coma Scale motor score ≤4; (3) Cornell Assessment of Pediatric Delirium score ≥9; or (4) electroencephalography revealing attenuation, suppression, or electrographic seizures. CONCLUSIONS We present consensus criteria for neurologic dysfunction in critically ill children.

Endocrine Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Endocrine dysfunction is common in critically ill children and is manifested by abnormalities in glucose, thyroid hormone, and cortisol metabolism. OBJECTIVE To develop consensus criteria for endocrine dysfunction in critically ill children by assessing the association of various biomarkers with clinical and functional outcomes. DATA SOURCES PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION We included studies in which researchers evaluated critically ill children with abnormalities in glucose homeostasis, thyroid function and adrenal function, performance characteristics of assessment and/or scoring tools to screen for endocrine dysfunction, and outcomes related to mortality, organ-specific status, and patient-centered outcomes. Studies of adults, premature infants or animals, reviews and/or commentaries, case series with sample size ≤10, and non–English-language studies were excluded. DATA EXTRACTION Data extraction and risk-of-bias assessment for each eligible study were performed by 2 independent reviewers. RESULTS The systematic review supports the following criteria for abnormal glucose homeostasis (blood glucose [BG] concentrations &gt;150 mg/dL [&gt;8.3 mmol/L] and BG concentrations &lt;50 mg/dL [&lt;2.8 mmol/L]), abnormal thyroid function (serum total thyroxine [T4] &lt;4.2 μg/dL [&lt;54 nmol/L]), and abnormal adrenal function (peak serum cortisol concentration &lt;18 μg/dL [500 nmol/L]) and/or an increment in serum cortisol concentration of &lt;9 μg/dL (250 nmol/L) after adrenocorticotropic hormone stimulation. LIMITATIONS These included variable sampling for BG measurements, limited reporting of free T4 levels, and inconsistent interpretation of adrenal axis testing. CONCLUSIONS We present consensus criteria for endocrine dysfunction in critically ill children that include specific measures of BG, T4, and adrenal axis testing.