Publications by authors named "Guillaume Emeriaud"

94 Publications

Inhaled Antibiotics for the Prevention of Respiratory Tract Infections in Children With a Tracheostomy.

Front Pediatr 2021 5;9:633039. Epub 2021 Feb 5.

Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada.

To describe the use of prophylactic inhaled antibiotics in children with a tracheostomy and assess if its use is associated with a reduction in exposition to broad-spectrum antibiotics and a lower risk of acquired respiratory tract infections. A case series study was performed in a tertiary care university affiliated hospital. All consecutive children (<18 years old) with a tracheostomy, hospitalized between January 2004 and November 2016, and treated with prophylactic inhaled antibiotics were identified. We analyzed the 3 month- period before and after initiation of prophylactic inhaled antibiotics and described exposure to broad spectrum antibiotics, the number of respiratory tract infections and the associated adverse events. Six children (median age: 11 months, range: 8-100) were included. One received colimycin, 3 received tobramycin and 2 were treated with both antibiotics in alternance. The median duration of treatment was 74 days (22-173) with one patient still being treated at the end of the study. Patients were exposed to systemic antibiotics for 18 days (2-49) in the 3 months preceding the treatment vs. 2 days (0-15) in the 3 months following the treatment initiation ( = 0.115). The number of respiratory tract infections went from median of 2 (0-3) to 1 (0-1) during the same periods ( = 0.07). Adverse events most commonly reported were cough ( = 2) and increased respiratory secretions post-inhalation ( = 4). Only one new bacterial resistance was observed. This series of consecutive cases underlines the need for future studies evaluating the potential benefit of prophylactic inhaled antibiotics in children with a tracheostomy.
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http://dx.doi.org/10.3389/fped.2021.633039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893104PMC
February 2021

An Automated Scoring of Clinical Asthma Score: Proof of Concept and the Future Possibility.

Crit Care Explor 2021 Jan 8;3(1):e0319. Epub 2021 Jan 8.

Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC.

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http://dx.doi.org/10.1097/CCE.0000000000000319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803746PMC
January 2021

Positive End-Expiratory Pressure in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: Higher May Be Too High.

Crit Care Med 2020 12;48(12):1925-1927

Division of Pediatric Intensive Care, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.

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http://dx.doi.org/10.1097/CCM.0000000000004648DOI Listing
December 2020

Incremental effect of non-invasive oscillating device on chest physiotherapy in critically ill children: a cross-over randomised trial.

BMJ Open 2020 10 5;10(10):e038648. Epub 2020 Oct 5.

Pediatrics, University of Montreal, Montreal, Quebec, Canada

Introduction: Chest physiotherapy (CPT) and intrathoracic percussion ventilation have been recognised as to encourage dislodging the secretions; nonetheless, the tolerance to the procedure and its efficiency have not been proven to be sufficient.

Method And Analyses: This study aims to examine the tolerance, feasibility and physiological effects in airway clearance by using a novel extrathoracic non-invasive oscillating transducer device (NIOD) in critically ill children. A two-stage cross-over randomised controlled study in a paediatric intensive care unit in a Canadian Academic Children's Hospital will be applied. Children under 24 months old, for whom CPT is prescribed for airway clearance, will be included. The study consists of two stages; (1) Stage 1 'Frequency Level': we will apply two different frequencies of the NIOD (40 Hz vs 60 Hz) for 12 min each, on each patient 3 hours apart, and (2) Stage 2 'NIOD versus CPT': we will implement NIOD and CPT alternatingly for 3 hours apart. The order of the procedures will be randomly allocated for each case. We will compare the average Δchanges of tidal lung volume measured by a 3D imaging system and regional lung functions using electrical impedance tomography, between the two different frequencies and between the NIOD periods and the CPT periods. We will also examine tolerance by seeing COMFORT Scales and related complications during the procedures. We estimate necessary sample size as 6 for each arm (Total 12 cases) for stage 1 and 48 cases for Stage 2, with power of 0.8 and alpha of 0.05.

Ethics And Dissemination: This study has been approved by the Health Research Ethics Board of University of Montreal, Canada (REB number: 2020-2471). We will disseminate our findings through peer-reviewed publications and conference presentations in paediatric or/and critical care fields.

Trial Registration Number: ClinicalTrials.gov Registry (NCT03821389).
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http://dx.doi.org/10.1136/bmjopen-2020-038648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537431PMC
October 2020

The New Trainee Effect in Tracheal Intubation Procedural Safety Across PICUs in North America: A Report From National Emergency Airway Registry for Children.

Pediatr Crit Care Med 2020 12;21(12):1042-1050

Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship.

Design: Retrospective cohort study.

Setting: Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children.

Patients: All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017.

Interventions: None.

Measurements And Main Results: The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14).

Conclusions: The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.
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http://dx.doi.org/10.1097/PCC.0000000000002480DOI Listing
December 2020

Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation.

Crit Care Med 2020 Oct;48(10):1503-1512

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation.

Design: Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry.

Setting: Thirteen PICUs (in 12 institutions) in the United States and Canada.

Patients: All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation.

Interventions: None.

Measurements And Main Results: Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events.

Conclusions: Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.
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http://dx.doi.org/10.1097/CCM.0000000000004500DOI Listing
October 2020

Validation process of a high-resolution database in a paediatric intensive care unit-Describing the perpetual patient's validation.

J Eval Clin Pract 2020 May 5. Epub 2020 May 5.

Pediatric Intensive Care Unit, CHU Sainte Justine, University of Montreal, Montreal, Quebec, Canada.

Rationale: High data quality is essential to ensure the validity of clinical and research inferences based on it. However, these data quality assessments are often missing even though these data are used in daily practice and research.

Aims And Objectives: Our objective was to evaluate the data quality of our high-resolution electronic database (HRDB) implemented in our paediatric intensive care unit (PICU).

Methods: We conducted a prospective validation study of a HRDB in a 32-bed paediatric medical, surgical, and cardiac PICU in a tertiary care freestanding maternal-child health centre in Canada. All patients admitted to the PICU with at least one vital sign monitored using a cardiorespiratory monitor connected to the central monitoring station.

Results: Between June 2017 and August 2018, data from 295 patient days were recorded from medical devices and 4645 data points were video recorded and compared to the corresponding data collected in the HRDB. Statistical analysis showed an excellent overall correlation (R = 1), accuracy (100%), agreement (bias = 0, limits of agreement = 0), completeness (2% missing data), and reliability (ICC = 1) between recorded and collected data within clinically significant pre-defined limits of agreement. Divergent points could all be explained.

Conclusions: This prospective validation of a representative sample showed an excellent overall data quality.
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http://dx.doi.org/10.1111/jep.13411DOI Listing
May 2020

Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events.

Crit Care Med 2020 Jun;48(6):e489-e497

Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events.

Design: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017.

Setting: Forty international PICUs participating in the National Emergency Airway Registry for Children.

Patients: Critically ill children 0-17 years old who underwent tracheal intubation in a PICU.

Interventions: None.

Measurements And Main Results: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock.

Conclusions: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.
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http://dx.doi.org/10.1097/CCM.0000000000004314DOI Listing
June 2020

Complexity of Pediatric Tracheostomy Practice and Its Understanding.

Crit Care Med 2020 May;48(5):e429

Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada, and Department of Pediatrics, Children's Hospital Eastern Ontario, University of Ottawa, Ottawa, ON, Canada Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Montreal, Montreal, QC, Canada.

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http://dx.doi.org/10.1097/CCM.0000000000004241DOI Listing
May 2020

Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Crit Care Med 2020 06;48(6):e514-e522

Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, PA.

Objectives: Pediatric acute respiratory distress syndrome is heterogeneous, with a paucity of risk stratification tools to assist with trial design. We aimed to develop and validate mortality prediction models for patients with pediatric acute respiratory distress syndrome.

Design: Leveraging additional data collection from a preplanned ancillary study (Version 1) of the multinational Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study, we identified predictors of mortality. Separate models were built for the entire Version 1 cohort, for the cohort excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths. Models were externally validated in a cohort of intubated pediatric acute respiratory distress syndrome patients from the Children's Hospital of Philadelphia.

Setting: The derivation cohort represented 100 centers worldwide; the validation cohort was from Children's Hospital of Philadelphia.

Patients: There were 624 and 640 subjects in the derivation and validation cohorts, respectively.

Interventions: None.

Measurements And Main Results: The model for the full cohort included immunocompromised status, Pediatric Logistic Organ Dysfunction 2 score, day 0 vasopressor-inotrope score and fluid balance, and PaO2/FIO2 6 hours after pediatric acute respiratory distress syndrome onset. This model had good discrimination (area under the receiver operating characteristic curve 0.82), calibration, and internal validation. Models excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths also demonstrated good discrimination (all area under the receiver operating characteristic curve ≥ 0.84) and calibration. In the validation cohort, models for intubated pediatric acute respiratory distress syndrome (including and excluding neurologic deaths) had excellent discrimination (both area under the receiver operating characteristic curve ≥ 0.85), but poor calibration. After revision, the model for all intubated subjects remained miscalibrated, whereas the model excluding neurologic deaths showed perfect calibration. Mortality models also stratified ventilator-free days at 28 days in both derivation and validation cohorts.

Conclusions: We describe predictive models for mortality in pediatric acute respiratory distress syndrome using readily available variables from day 0 of pediatric acute respiratory distress syndrome which outperform severity of illness scores and which demonstrate utility for composite outcomes such as ventilator-free days. Models can assist with risk stratification for clinical trials.
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http://dx.doi.org/10.1097/CCM.0000000000004345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237024PMC
June 2020

Continuous neurally adjusted ventilation: a feasibility study in preterm infants.

Arch Dis Child Fetal Neonatal Ed 2020 Nov 8;105(6):640-645. Epub 2020 Apr 8.

Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada

Objectives: To assess the feasibility and tolerance of NeuroPAP, a new non-invasive ventilation mode which continuously adjusts (during both inspiration and expiration) the pressure support proportionally to the diaphragm electrical activity (Edi), in preterm infants and to evaluate the impact on ventilation pressure and Edi.

Design: Prospective cross-over single-centre feasibility study.

Setting: One level 3 neonatal intensive care unit in Canada.

Patients: Stable preterm infants ventilated with non-invasive positive pressure ventilation (NIPPV).

Interventions: Subjects were successively ventilated in NIPPV with prestudy settings (30 min), in NeuroPAP with minimal pressure similar to NIPPV PEEP (positive end-expiratory pressure) (60 min), in NeuroPAP with minimal pressure reduced by 2 cmH0 (60 min), in continuous positive airway pressure (15 min) and again in NIPPV (30 min). Main outcome measures included tolerance, ventilation pressure, Edi and patient-ventilator synchrony.

Results: Twenty infants born at 28.0±1.0 weeks were included. NeuroPAP was well tolerated and could be delivered during 100% of planned period. During NeuroPAP, the PEEP was continuously adjusted proportionally to tonic diaphragm Edi, although the average PEEP value was similar to the set minimal pressure. During NeuroPAP, 83 (78-86)% breaths were well synchronised vs 9 (6-12)% breaths during NIPPV (p<0.001).

Conclusions: NeuroPAP is feasible and well tolerated in stable preterm infants, and it allows transient adaptation in PEEP in response to tonic diaphragm electrical activity changes. Further studies are warranted to determine the impact of these findings on clinical outcomes.

Trial Registration Number: NCT02480205.
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http://dx.doi.org/10.1136/archdischild-2019-318660DOI Listing
November 2020

Early Use of Adjunctive Therapies for Pediatric Acute Respiratory Distress Syndrome: A PARDIE Study.

Am J Respir Crit Care Med 2020 06;201(11):1389-1397

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania.

Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS). To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations. This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks. We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use. The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.
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http://dx.doi.org/10.1164/rccm.201909-1807OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7258654PMC
June 2020

Comparison of the Automated Pediatric Logistic Organ Dysfunction-2 Versus Manual Pediatric Logistic Organ Dysfunction-2 Score for Critically Ill Children.

Pediatr Crit Care Med 2020 04;21(4):e160-e169

Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Montreal, QC, Canada.

Objectives: The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2).

Design: Retrospective cohort study.

Setting: Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada).

Patients: Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected.

Interventions: None.

Measurements And Main Results: The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01).

Conclusions: We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.
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http://dx.doi.org/10.1097/PCC.0000000000002235DOI Listing
April 2020

Monitoring of Respiratory Muscle Function in Critically Ill Children.

Pediatr Crit Care Med 2020 05;21(5):e282-e290

Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, QC, Canada.

Objectives: This review discusses the different techniques used at the bedside to assess respiratory muscle function in critically ill children and their clinical applications.

Data Sources: A scoping review of the medical literature on respiratory muscle function assessment in critically ill children was conducted using the PubMed search engine.

Study Selection: We included all scientific, peer-reviewed studies about respiratory muscle function assessment in critically ill children, as well as some key adult studies.

Data Extraction: Data extracted included findings or comments about techniques used to assess respiratory muscle function.

Data Synthesis: Various promising physiologic techniques are available to assess respiratory muscle function at the bedside of critically ill children throughout the disease process. During the acute phase, this assessment allows a better understanding of the pathophysiological mechanisms of the disease and an optimization of the ventilatory support to increase its effectiveness and limit its potential complications. During the weaning process, these physiologic techniques may help predict extubation success and therefore optimize ventilator weaning.

Conclusions: Physiologic techniques are useful to precisely assess respiratory muscle function and to individualize and optimize the management of mechanical ventilation in children. Among all the available techniques, the measurements of esophageal pressure and electrical activity of the diaphragm appear particularly helpful in the era of individualized ventilatory management.
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http://dx.doi.org/10.1097/PCC.0000000000002254DOI Listing
May 2020

Post-discharge respiratory outcomes of children with acute respiratory distress syndrome.

Pediatr Pulmonol 2020 02 25;55(2):468-473. Epub 2019 Nov 25.

Department of Pediatrics, University of Montréal, Montréal, Canada.

Objectives: While long-term sequelae of acute respiratory distress syndrome (ARDS) are well-documented in adults, few studies reported post-discharge respiratory complications in pediatric ARDS (PARDS) and none used the recent Pediatric Acute Lung Injury Consensus Conference (PALICC) diagnostic criteria. This study describes the respiratory symptoms, pulmonary function, and health resource use of PARDS survivors at 3 months post-discharge.

Design: Retrospective study.

Patient Selection: Children less than 18 years admitted to the intensive care unit of Sainte-Justine University Health Center from 1st September 2015 to 1st July 2017, and meeting PALICC diagnostic criteria for PARDS.

Methods: We evaluated 38 of the 44 children with PARDS in the follow-up clinic at a mean (SD) of 3.4 (2.0) months post-discharge for respiratory symptoms, age-appropriate pulmonary function tests (spirometry or oscillometry, maximal respiratory pressures), and all-cause emergency department (ED) visits or rehospitalizations since discharge.

Results: Fourteen (36.8%) had abnormal respiratory symptoms (most commonly cough between respiratory infections and wheezing), 7 of whom (18.4%) presented new respiratory symptoms since PARDS diagnosis. A mild-to-moderate restrictive pattern was observed in 3 of 10 patients who performed spirometry and mildly decreased maximal inspiratory pressures were noted in 2 of 8 patients who performed these maneuvers. Nine (23.7%) patients consulted in the ED and 4 (10.5%) were rehospitalized post-discharge.

Conclusions: Despite our cohort's limited sample size, our findings suggest that a significant proportion of PARDS survivors experience abnormal respiratory symptoms, pulmonary function deficits, and recurrent problems requiring medical attention. Larger, multicenter studies are required to identify risk factors associated with poor post-discharge outcomes among PARDS survivors.
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http://dx.doi.org/10.1002/ppul.24581DOI Listing
February 2020

Cerebral oxygenation in children with sleep-disordered breathing.

Paediatr Respir Rev 2020 Apr 23;34:18-23. Epub 2019 Oct 23.

Université de Paris, VIFASOM, F-75004 Paris, France; Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, F-75015 Paris, France. Electronic address:

Sleep-disordered breathing (SDB) is associated with neurocognitive and behavioral dysfunction, and structural brain abnormalities. Near infrared spectroscopy allows a continuous and non-invasive monitoring of brain tissue oxygenation, giving insight in some pathophysiological mechanisms potentially associated with SDB-related neurocognitive dysfunction. The present review summarizes the finding of studies describing brain tissue oxygenation in adults and children with SDB. Contrary to adults, mean nocturnal tissue oxygenation index (TOI) during sleep does not seem to be different in children with SDB as compared to healthy controls. During respiratory events such as apnoeas and hypopnoeas, the decrease in TOI precedes the peripheral, systemic desaturation. The decrease in TOI has been shown to be greater during apnoeas as compared to hypopnoeas, during rapid-eye movement sleep as compared to other sleep stages, in younger children as compared to their older counterparts, and in those with a high apnoea-hypopnoea index as compared with a low apnoea-hypopnoea index. Studies analyzing the association between repetitive changes in TOI and neurocognitive and behavioral dysfunction may help to decipher the pathophysiology of neurocognitive dysfunction associated with SDB in children.
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http://dx.doi.org/10.1016/j.prrv.2019.10.002DOI Listing
April 2020

Transfusion in children with acute respiratory distress syndrome.

Ann Transl Med 2019 Oct;7(19):511

Department of Pediatrics, Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.

Transfusion is a frequent treatment in pediatric patients with acute respiratory distress syndrome (PARDS) although evidence to support transfusion decision-making is lacking. The purpose of this review is to review the current state of knowledge on the issue of transfusion in children with PARDS and to detail the possible beneficial effects and potential deleterious impacts of transfusion in this patient population. Based on the current literature and recent guidelines, a restrictive red blood cell (RBC) transfusion strategy (avoidance of transfusion when the haemoglobin level is above 7 g/dL) is indicated in stable patients without severe PARDS, as these were excluded from the large trials. In children with severe PARDS, further research is needed to determine if factors other than the haemoglobin level might guide RBC transfusion decision-making by better characterizing the presence of low oxygen delivery (DO). Additionally, appropriate indications for prophylactic transfusion of hemostatic products (plasma or platelets) in children with PARDS are lacking.
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http://dx.doi.org/10.21037/atm.2019.08.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6828792PMC
October 2019

Neural feedback is effective in preterm infants during neurally adjusted ventilatory assist, when using clinically relevant settings.

Pediatr Pulmonol 2019 12 16;54(12):1878-1879. Epub 2019 Aug 16.

Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.

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http://dx.doi.org/10.1002/ppul.24478DOI Listing
December 2019

Qualitative subjective assessment of a high-resolution database in a paediatric intensive care unit-Elaborating the perpetual patient's ID card.

J Eval Clin Pract 2020 Feb 17;26(1):86-91. Epub 2019 Jun 17.

Pediatric Intensive Care Unit, CHU Sainte Justine, University of Montreal, Montreal, Québec, Canada.

Objective: The main purpose of our study was to subjectively assess the quality of a paediatric intensive care unit (PICU) database according to the Directory of Clinical Databases (DoCDat) criteria.

Design And Setting: A survey was conducted between April 1 and June 15, 2018, among the Sainte Justine PICU research group.

Population: Every member of this group whose research activity required the use of the database and/or who was involved in the development/validation of the database.

Interventions: None.

Measurements And Main Results: All 10 research team members (one Information Technology specialist, one junior medical student, and eight clinician researchers) who used the high-resolution database fulfilled the survey (100% response rate). The median quality level of the Sainte Justine PICU database across all the 10 criteria was 3 (2-4), rated on a 1 (worst) to 4 (best) numeric scale. When compared with previously assessed databases through the DoCDat criteria, we found that the Sainte Justine PICU database performance was similar.

Conclusions: The PICU high-resolution database appeared of good quality when subjectively assessed by the DoCDat criteria. Further validation procedures are mandatory. We suggest that data quality assessment and validation procedures should be reported when creating a new database.
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http://dx.doi.org/10.1111/jep.13193DOI Listing
February 2020

Relationship Between Diaphragmatic Electrical Activity and Esophageal Pressure Monitoring in Children.

Pediatr Crit Care Med 2019 07;20(7):e319-e325

Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montréal, QC, Canada.

Objectives: Mechanical ventilation is an essential life support technology, but it is associated with side effects in case of over or under-assistance. The monitoring of respiratory effort may facilitate titration of the support. The gold standard for respiratory effort measurement is based on esophageal pressure monitoring, a technology not commonly available at bedside. Diaphragmatic electrical activity can be routinely monitored in clinical practice and reflects the output of the respiratory centers. We hypothesized that diaphragmatic electrical activity changes accurately reflect changes in mechanical efforts. The objectives of this study were to characterize the relationship between diaphragmatic electrical activity and esophageal pressure.

Design: Prospective crossover study.

Setting: Esophageal pressure and diaphragmatic electrical activity were simultaneously recorded using a specific nasogastric tube in three conditions: in pressure support ventilation and in neurally adjusted ventilatory support in a random order, and then after extubation.

Patients: Children in the weaning phase of mechanical ventilation.

Interventions: The maximal swing in esophageal pressure and esophageal pressure-time product, maximum diaphragmatic electrical activity, and inspiratory diaphragmatic electrical activity integral were calculated from 100 consecutive breaths. Neuroventilatory efficiency was estimated using the ratio of tidal volume/maximum diaphragmatic electrical activity.

Measurements And Main Results: Sixteen patients, with a median age of 4 months (interquartile range, 0.5-13 mo), and weight 5.8 kg (interquartile range, 4.1-8 kg) were included. A strong linear correlation between maximum diaphragmatic electrical activity and maximal swing in esophageal pressure (r > 0.95), and inspiratory diaphragmatic electrical activity integral and esophageal pressure-time product (r > 0.71) was observed in all ventilatory conditions. This correlation was not modified by the type of ventilatory support.

Conclusions: On a short-term basis, diaphragmatic electrical activity changes are strongly correlated with esophageal pressure changes. In clinical practice, diaphragmatic electrical activity monitoring may help to inform on changes in respiratory efforts.
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http://dx.doi.org/10.1097/PCC.0000000000001981DOI Listing
July 2019

Mechanical ventilation causes diaphragm dysfunction in newborn lambs.

Crit Care 2019 Apr 16;23(1):123. Epub 2019 Apr 16.

Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada.

Background: Diaphragm weakness occurs rapidly in adult animals treated with mechanical ventilation (MV), but the effects of MV on the neonatal diaphragm have not been determined. Furthermore, it is unknown whether co-existent lung disease exacerbates ventilator-induced diaphragmatic dysfunction (VIDD). We investigated the impact of MV (mean duration = 7.65 h), either with or without co-existent respiratory failure caused by surfactant deficiency, on the development of VIDD in newborn lambs.

Methods: Newborn lambs (1-4 days) were assigned to control (CTL, non-ventilated), mechanically ventilated (MV), and MV + experimentally induced surfactant deficiency (MV+SD) groups. Immunoblotting and quantitative PCR assessed inflammatory signaling, the ubiquitin-proteasome system, autophagy, and oxidative stress. Immunostaining for myosin heavy chain (MyHC) isoforms and quantitative morphometry evaluated diaphragm atrophy. Contractile function of the diaphragm was determined in isolated myofibrils ex vivo.

Results: Equal decreases (25-30%) in myofibrillar force generation were found in MV and MV+SD diaphragms compared to CTL. In comparison to CTL, both MV and MV+SD diaphragms also demonstrated increased STAT3 transcription factor phosphorylation. Ubiquitin-proteasome system (Atrogin1 and MuRF1) transcripts and autophagy indices (Gabarapl1 transcripts and the ratio of LC3B-II/LC3B-I protein) were greater in MV+SD relative to MV alone, but fiber type atrophy was not observed in any group. Protein carbonylation and 4-hydroxynonenal levels (indices of oxidative stress) also did not differ among groups.

Conclusions: In newborn lambs undergoing controlled MV, there is a rapid onset of diaphragm dysfunction consistent with VIDD. Superimposed lung injury caused by surfactant deficiency did not influence the severity of early diaphragm weakness.
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http://dx.doi.org/10.1186/s13054-019-2409-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469194PMC
April 2019

Transfusion-Associated Circulatory Overload in ICUs: A Scoping Review of Incidence, Risk Factors, and Outcomes.

Crit Care Med 2019 06;47(6):849-856

Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada.

Transfusion-associated circulatory overload is the most frequent serious adverse transfusion reaction, with an incidence close to 1% of transfused patients in the general adult population. Patients in ICUs are probably more at risk of transfusion-associated circulatory overload as they are more frequently transfused and associated with more comorbidities. However, the epidemiology of transfusion-associated circulatory overload in ICU is not well characterized, leading to a risk of underdiagnosis.

Objectives: We conducted a scoping review to describe the incidence, risk factors, and outcomes of transfusion-associated circulatory overload in PICU and adult ICU.

Data Sources: PubMed, Ovid Medline, Ovid All EBM Reviews, Ovid Embase, and EBSCO CINAHL COMPLETE.

Study Selection: Two reviewers independently screened each article for inclusion criteria. Studies were eligible if they reported data on incidence, risk factors, or outcomes of transfusion-associated circulatory overload in at least 10 ICU patients.

Data Synthesis: Among 5,926 studies identified, nine were included. Five studies were prospective, and four were retrospective. The definition of transfusion-associated circulatory overload varied among studies. The pooled incidence of transfusion-associated circulatory overload was of 5.5% (95% CI, 2.6-9.4%) in adult ICUs (four studies, 2,252 patients, high heterogeneity). In PICUs, two studies (345 patients) reported 0 cases, and a third study (136 patients) reported variable incidences between 1.5% and 76%, depending on diagnostic criteria. Risk factors for transfusion-associated circulatory overload included positive fluid balance, the number and type of products transfused, rate of transfusion, and cardiovascular and renal comorbidities. Transfusion-associated circulatory overload was associated with increased ICU and hospital lengths of stay, whereas the association with mortality was not consistent.

Conclusions: Transfusion-associated circulatory overload is frequent in ICU patients and is associated with adverse outcomes. The lack of a pediatric-adjusted definition of transfusion-associated circulatory overload may lead to a risk of underdiagnosis of this condition in PICUs. Further research is warranted to improve the knowledge of transfusion-associated circulatory overload and the safety of transfusion in ICU patients.
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http://dx.doi.org/10.1097/CCM.0000000000003743DOI Listing
June 2019

Impact of Spontaneous Breathing Trial on Work of Breathing Indices Derived From Esophageal Pressure, Electrical Activity of the Diaphragm, and Oxygen Consumption in Children.

Respir Care 2019 May 11;64(5):509-518. Epub 2018 Dec 11.

Pediatric Intensive Care Unit, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, Québec, Canada.

Background: The present study aimed to characterize the behavior of 3 components of respiratory muscle function during mechanical ventilation weaning in children to better understand the respective impact of a spontaneous breathing trial on ventilatory mechanical action (esophageal pressure [P], ventilatory demand (electrical activity of the diaphragm [EA]), and oxygen consumption.

Methods: This was a prospective single-center study. All children > 1 months and <18 y old who were intubated and on mechanical ventilation, and who were hospitalized in the pediatric ICU were eligible. Subjects considered as ready to extubate were included. Simultaneous recordings of oxygen consumption, P, and EA were performed during 3 steps: before, during, and after the spontaneous breathing test.

Results: Twenty subjects (median age, 5.5 mo) were included. Half of them were admitted for a respiratory cause. The increase in P swings and esophageal pressure-time product during the spontaneous breathing trial was not significant ( = .33 and = .75, respectively), and a similar trend was observed with peak EA ( = .06). Oxygen consumption obtained by indirect calorimetry was stable in the 3 conditions ( = .98).

Conclusions: In these children who were critically ill, a spontaneous breathing trial induced a moderate and nonsignificant increase in work of breathing, as reflected by the respiratory drive with EA and respiratory mechanics with P. However, indirect calorimetry did not seem to be a sensitive tool to assess respiratory muscle function during the weaning phase in children who were on mechanical ventilation, especially when work of breathing was slightly increased.
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http://dx.doi.org/10.4187/respcare.06351DOI Listing
May 2019

Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV).

J Pediatr 2019 02 14;205:112-119.e4. Epub 2018 Nov 14.

Lyon University Hospital, Hôpital Femme Mère Enfant, Medical Intensive Care Unit, Bron, France; University of Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France; INSERM 955-Eq13, Institut Mondor de Recherche Biomédicale, Créteil, France.

Objective: To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation.

Study Design: Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmHO continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed.

Results: Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmHO*s/minute [IQR, 156-282] cmHO*s/minute vs 353 cmHO*s/minute [IQR, 249-386 cmHO*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmHO/µV [IQR, 0.9-1.3 cmHO/µV] vs 0.7 cmHO/µV [IQR, 0.6-1.2 cmHO/µV], respectively; P = .022).

Conclusions: This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population.

Trial Registration: Clinicaltrials.gov: NCT02602678.
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http://dx.doi.org/10.1016/j.jpeds.2018.09.066DOI Listing
February 2019

Ventilator-Associated Pneumonia and Events in Pediatric Intensive Care: A Single Center Study.

Pediatr Crit Care Med 2018 12;19(12):1106-1113

Pediatric Intensive Care Unit, Sainte-Justine University Hospital Center, Montreal, QC, Canada.

Objectives: Ventilator-associated pneumonia is the second most common nosocomial infection in pediatric intensive care. The Centers for Disease Control and Prevention recently issued diagnosis criteria for pediatric ventilator-associated pneumonia and for ventilator-associated events in adults. The objectives of this pediatric study were to determine the prevalence of ventilator-associated pneumonia using these new Centers for Disease Control and Prevention criteria, to describe the risk factors and management of ventilator-associated pneumonia, and to assess a simpler method to detect ventilator-associated pneumonia with ventilator-associated event in critically ill children.

Design: Retrospective, observational, single-center.

Setting: PICU in a tertiary-care university hospital.

Patients: Consecutive critically ill children mechanically ventilated for greater than or equal to 48 hours between November 2013 and November 2015.

Interventions: None.

Measurements And Main Results: Of 304 patients mechanically ventilated for greater than or equal to 48 hours, 284 were included. Among them, 30 (10.6%) met clinical and radiologic Centers for Disease Control and Prevention criteria for ventilator-associated pneumonia, yielding an prevalence of 7/1,000 mechanical ventilation days. Median time from mechanical ventilation onset to ventilator-associated pneumonia diagnosis was 4 days. Semiquantitative culture of tracheal aspirates was the most common microbiological technique. Gram-negative bacteria were found in 60% of patients, with a predominance of Haemophilus influenzae and Pseudomonas aeruginosa. Antibiotic therapy complied with adult guidelines. Compared with patients without ventilator-associated pneumonia, those with ventilator-associated pneumonia had significantly longer median durations of mechanical ventilation (15 vs 6 d; p < 0.001) and PICU stay (19 vs 9 d; p < 0.001). By univariate analysis, risk factors for ventilator-associated pneumonia were younger age, reintubation, acute respiratory distress syndrome, and continuous enteral feeding. Among the 30 patients with ventilator-associated pneumonia, 17 met adult ventilator-associated event's criteria (sensitivity, 56%).

Conclusions: Ventilator-associated pneumonia is associated with longer times on mechanical ventilation and in the PICU. Using the ventilator-associated event criteria is of interest to rapidly screen for ventilator-associated pneumonia in children. However, sensitivity must be improved by adapting these criteria to children.
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http://dx.doi.org/10.1097/PCC.0000000000001720DOI Listing
December 2018

Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

Pediatr Crit Care Med 2018 09;19(9):884-898

Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA.

Objectives: To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

Design: Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children.

Setting: Not applicable.

Intervention: None.

Subjects: Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion.

Methods: A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

Measurements And Results: The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations.

Conclusions: The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.
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http://dx.doi.org/10.1097/PCC.0000000000001613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126913PMC
September 2018

Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

Pediatr Crit Care Med 2018 09;19(9S Suppl 1):S114-S120

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital and Université de Montréal, Montreal, QC, Canada.

Objectives: To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

Design: Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.

Methods: The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The respiratory subgroup included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

Results: Transfusion and Anemia Expertise Initiative experts developed seven recommendations focused on children with acute respiratory failure. All recommendations reached agreement (> 80%). Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/dL. Specific RBC transfusion strategies using physiologic-based metrics and biomarkers could not be elaborated.

Conclusions: The Transfusion and Anemia Expertise Initiative Consensus Conference developed specific recommendations regarding RBC transfusion management in critically ill children with respiratory failure, as well as recommendations to guide future research. Clinical recommendations emphasize relevant hemoglobin thresholds. Research recommendations emphasize the need to identify appropriate physiologic thresholds, suggest a better understanding of alternatives to RBC transfusion, and identify the need for better evidence on hemoglobin thresholds that might be used in specific subpopulations of critically ill children.
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http://dx.doi.org/10.1097/PCC.0000000000001619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126368PMC
September 2018

Safety of tracheal intubation in the presence of cardiac disease in paediatric ICUs.

Cardiol Young 2018 Jul 25;28(7):928-937. Epub 2018 Apr 25.

8Department of Anesthesiology and Critical Care Medicine,The Children's Hospital of Philadelphia,Philadelphia,PA,USA.

IntroductionChildren with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.Materials and methodsWe sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.

Results: A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.

Conclusions: The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
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http://dx.doi.org/10.1017/S1047951118000495DOI Listing
July 2018