Purchase the second edition of Comprehensive Critical Care: Pediatric, available in both print and eBook format, and increase your pediatric critical care knowledge. This new edition was developed by leading experts in the field, includes the newest research and information, and is the most complete textbook for the study of pediatric critical care.
This compendium explores 16 core knowledge areas, including:
Infectious Disease, Immunology and Inflammation
Renal and Electrolyte Disturbances
Metabolism and Endocrinology
Hematology and Oncology
Gastroenterology and Nutrition
Anesthesiology, Pain and Sedation
Principles of Monitoring
Legal and Ethical Issues
Core Knowledge in Scholarly Activities
Comprehensive Critical Care: Pediatric includes up-to-date information on the full range of pediatric critical care topics, with hundreds of charts and tables to aid study and suggested readings to guide further exploration.
The publication is available for purchase in the SCCM Store, just $195 for members ($255 for nonmembers).
The use of steroids in patients with inotrope/pressor–resistant septic shock is controversial in both adult and pediatric populations. While these patients’ hemodynamics may improve with adjunctive steroid treatment, the metabolic and immune costs may negate a definitive survival benefit. However, little has been written about the effects glucocorticoids have on global gene expression in patients with septic shock. Wong and colleagues address this topic by using a transcriptomics approach to characterize the genomic response of pediatric patients in septic shock who have received glucocorticoids. They found that the administration of corticosteroids in pediatric septic shock is associated with additional repression of genes corresponding to adaptive immunity. They did not comment on actual immune suppression, though, as qualitative evaluations of immunity were not performed.
Ultimately, steroid use in catecholamine-resistant septic shock — even in seemingly low doses — can have significant consequences in a patient’s ability to fight an initial infection or even subsequent nosocomial infections unrelated to the patient’s illness severity or infecting organism. This fact, coupled with the absence of definitive outcome benefits, should give pediatric critical care practitioners pause before prescribing steroids in children with septic shock.
Pneumonia is either the first or second most common ventilator-associated event (VAE) seen in the pediatric intensive care unit. The reported incidence varies widely among studies (from 0.3 to 45.1 per 1,000 ventilator days). The lack of a consistent, gold-standard definition for what had been traditionally referred to as ventilator-associated pneumonia (VAP) plays a large part in this variance.
The U.S. Centers for Disease Control and Prevention (CDC) defines VAP as a positive bacterial culture from a tracheal aspirate (more than 104 colony-forming units [cfu] from a sample obtained via bronchoalveolar lavage) and/or purulent secretions (more than 25 neutrophils and fewer than 10 epithelial cells per low-power field) in a patient who requires mechanical ventilation and has acutely worsening oxygenation. However, other investigators have defined VAP by the presence of pathogenic bacteria in tracheal aspirate in conjunction with new chest radiographic findings and fever or leukocytosis. Studies by Srinivasan and colleagues and Carcillo et al have found that the presence of pneumonia is associated with high antimicrobial use and increased morbidity, mortality, hospital length of stay, and costs. The Society of Critical Care Medicine, in partnership with the Critical Care Societies Collaborative, also has been working closely with the CDC to develop the VAE surveillance definition algorithm, representing a purposeful departure from VAP toward more purposeful, objective measures of conditions and complications occurring in adult patients on mechanical ventilation. The findings of the VAP Surveillance Definition Working Group, which has only focused on adult patients, were published in the November 2013 issue of Critical Care Medicine. It is clear, the development and use of a standardized definition is essential.
A follow-up to Question Set 1, the newly released Question Set 2 provides a review of new and different topics, including infectious disease and immunologic, neurologic, trauma-related, and hematologic/oncologic critical care topics.
This self-study tool is designed for physicians working on board preparation and maintenance of certification (MOC) and is comprised of 100 questions and rationales with accompanying study materials.
Participants will gain an online board examination experience consisting of:
100 multiple choice questions similar to those covered on the actual exam, accompanied by evidence-based rationales
A list of keywords and references from missed questions for further study
20 points toward MOC part II in pediatrics and 6 continuing medical education/continuing education credit hours
More than 90,000 patients await kidney transplant, according to the U.S. Organ Procurement and Transplantation Network. Approximately 16,000 transplants occur every year, but 35,000 patients are added to the list annually.
Because of this growing list of patients with end-stage renal disease who need new kidneys, transplant surgeons are seeking innovative ways to increase the donor pool. Recently, a number of transplant surgeons began utilizing younger and smaller kidney donors by transplanting their organs en bloc into single recipients. Common reported complications of using smaller kidneys include increased graft thrombosis and hyperfiltration injury. However, in their report on outcomes utilizing kidneys transplanted from donors weighing less than 15 kg (even some less than 10 kg), Sharma and coworkers reported 5-year graft survival at 92%, statistically no different than standard deceased or living donor kidney transplants.
The detrimental effects of hyperglycemia in critically ill patients has been well described in the literature. However, the benfefits of maintaining normoglycemia using insulin infusions has been controversial. In 2009, The New England Journal of Medicine published a study by the NICE-SUGAR Study Investigators that appeared to answer the question about risks and benefits of intensive insulin therapy. Studying more than 6,000 subjects, the authors showed an increase in mortality in critically ill adults who underwent intensive glucose control, compared to those who underwent conventional control of their blood sugars. Interestingly, in the same year, a pediatric study was published in Lancet by Vlasselaers et al that demonstrated a decrease in mortality and length of pediatric intensive care unit (PICU) stay in those patients who had intensive glucose control, compared to the conventional therapy. Though it should be noted that while this study randomized 700 children, it was a single-center trial whose subjects were primarily children who had undergone cardiac surgery (around 75%).
In this study by Macrae et al, the authors randomized more than 1,300 critically ill children from 13 centers to undergo either tight glucose control (maintaining blood glucose levels between 72-126 mg/dl) or conventional therapy (infusing insulin only in patients whose blood glucose levels were over 216 mg/dl until they dropped to 180 mg/dl). The authors recruited children between the ages of 36 weeks of corrected gestational age and 16 years of age. Like the the Vlasselaers study, a predominance of subjects underwent cardiac surgery compared to other reasons for PICU admission (around 60% and 40%, respectivley). The aims of this study were to assess whether tight glycemic control could reduce morbidity and mortality rates and associated costs for critically ill children compared to conventional therapy.
The presence of acute kidney injury (AKI) and fluid overload can adversely affect outcomes in children with critical illness. Continuous renal replacement therapy (CRRT) is one therapeutic modality that can improve outcomes in these patients. However, the trigger when to initiate this therapy is not known. There are studies suggesting that degree of fluid overload may be such a trigger but this does not seem to provide the entire answer. In adults, some studies have suggested that early initiation of CRRT in critically ill patients can improve outcomes compared to late initiation, although there is a paucity of evidence in children. The authors of this study sought to assess the effect timing of CRRT has on mortality in critically ill children.
Pediatric traumatic brain injury (TBI) remains the leading cause of mortality in children younger than 19 years. Most people think that the secondary brain injury following TBI occurs in the setting of elevated intracranial pressure (ICP) and diminished cerebral perfusion pressure (CPP). These physiologic measurements are thought to affect outcomes, so current guidelines recommend treatment of both elevated ICPs and decreased CPPs, although the thresholds for CPPs have not been well established in children. Although a smaller study looked at CPP in children with TBI, this work by Allen et al is the largest study to date that attempts to determine these thresholds.
Using a prospective, observational cohort, the authors examined data from TBI-trac, an online data repository run by the Brain Trauma Foundation. This databank collects information about patients with severe TBI and uses these data to track guideline compliance at 22 different trauma centers and for research. In this report, the authors reviewed the data on patients treated between 2000 and 2008.
In all, the authors studied 2074 records and divided the patients into categories based on age: 0-5 years (55 patients), 6-11 years (65 patients), 12-17 years (197 patients), and 18 years or older (1757 patients). They subsequently defined high and low CPP thresholds for each age group to determine if these thresholds impacted short-term survival. For those in the youngest group, the authors chose 30 mm Hg for a low CPP threshold (CPP-L) and 40 mm Hg for a high threshold (CPP-H). For subjects in the group 6-11 years, the CPP-L was 35 mm Hg and the CPP-H was 50 mm Hg. For the subjects 12 years or older, the CPP-L selected was 50 mm Hg and the CPP-H was 60 mm Hg. CPP values between the high and low thresholds were labeled as CPP-B.
You are invited to participate in a national survey of clinical practice patterns and awareness of the incidence and outcomes in pediatric acute kidney injury (AKI). The study, being conducted by Amanda Hassinger, MD, at the Women and Children’s Hospital of Buffalo, New York, USA, seeks to elucidate the divide between AKI research and bedside practice.
The survey consists of 25 questions about acute kidney injury and should take no longer than 15 minutes to complete. Participation is voluntary, and you are free to withdraw from this study at any time.
The study has been approved by the Children and Youth Institutional Review Board of the State University of New York at Buffalo. Participation is not associated with any risk as the survey collects no identifying information on the respondent, and all responses will be recorded anonymously. While you will not experience any direct benefits from participation, your input could inform future research and practice guidelines for the detection and management of pediatric acute kidney injury.
If you have any questions regarding the survey or this research project in general, please contact Dr. Hassinger at firstname.lastname@example.org. For questions concerning your rights as a research participant, please contact the Children and Youth Institutional Review Board of the State University of New York at Buffalo (+1 716 878-7141).
Surfactant depletion and dysfunction play an important role in the pathophysiology of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Reports have detailed impairments in surfactant activity related both to dilutional effects from leaking alveolar proteins and effects from chemical alterations by phospholipases and reactive oxygen species. Additionally, the content of large surfactant aggregates and surfactant proteins A and B, necessary to maintain alveolar integrity, are reduced secondary to problems with processing and metabolism.
As such, the notion that repletion of surfactant could improve outcomes in adult and pediatric patients with ARDS has been studied in a number of investigations. The authors of a trial published in the September issue of Pediatric Critical Care Medicine detail some of these works, explaining that most successes have been in small trials whose results were not replicated in larger ones.
Submissions for the 7th World Congress on Pediatric Intensive and Critical Care (PICC 2014) are now open. Contribute to this multidisciplinary scientific program by submitting your abstract for an oral or poster presentation. The deadline for submissions is December 15, 2013. All accepted abstracts will be published in Pediatric Critical Care Medicine.
Medications approved for adults often have additional uses in pediatric patients. Such is the case — as described by Wessel and colleagues — for clopidogrel, an agent that blocks the P2Y12 component of adenosine diphosphate (ADP) receptors on the surface of platelets. ADP receptors prevent the activation of the glycoprotein IIb/IIIa receptor complex, thereby reducing aggregation. Clopidogrel is used most commonly as a prophylactic antiplatelet therapy in adults with atherosclerotic cardiovascular disease, but is increasingly employed in the pediatric population, particularly in those with cardiac disease. Pediatric cardiovascular practitioners are using clopidogrel (along with the standard aspirin) to prevent the thrombosis of systemic-to-pulmonary-artery shunts in patients with complex cyanotic heart disease; however, the safety and efficacy of this practice have never been looked at prospectively. In the June 20 issue of The New England Journal of Medicine, investigators created a multicenter, event-driven trial to evaluate clopidogrel’s effect on infants.
A total of 906 subjects were enrolled, 467 in the clopidogrel group and 439 in the placebo group. The authors found that adding clopidogrel to conventional therapies (i.e., aspirin) did not affect mortality from any cause or shunt-thrombosis-related morbidity. Although no statistically significant differences were detected in total subjects with adverse events, the authors found more neurologic events in the clopidogrel group versus the placebo group. Read the full Concise Critical Appraisal.
Metabolomics is a relatively new technology that involves the measurement of an organism’s global metabolic response to some physiologic stress. The study of this technology is gaining momentum, as measurement of a person’s metabolic profile in easily accessible biological fluids can help distinguish disease states from non-disease states earlier. Thus, patients could receive appropriate therapies earlier, which can improve outcomes in cases such as pneumonia and sepsis. In the May 2013 issue of Respiratory and Critical Care Medicine, the authors used 1H proton nuclear magnetic resonance spectroscopy to measure the concentrations of 58 different metabolites in serum samples taken from 140 pediatric subjects from 11 different institutions. Read more…
The April/May issue of Critical Connections focuses on managing sepsis in the intensive care unit, highlighting various strategies, from the use of early goal-directed therapy to implementing the Surviving Sepsis Campaign (SSC) guideline recommendations and bundles. Find the following articles:
Surviving Sepsis Campaign Enters Second Decade with Dynamic Plans
Rapid Identification of Sepsis: The Value of Screening Tools
Early Goal-Directed Therapy: Contemporary Care and Controversies
Ongoing Clinical Trials in Sepsis
Challenges in Pediatric Sepsis
The latest issue also features an article highlighting the growing concern over physician burnout and providing strategies for identifying the problem and improving performance.