Pediatric Critical Care Medicine Journal
The journal Pediatric Critical Care Medicine is the Federation’s official journal. The journal covers a full range of scientific content. Additionally, the journal includes abstracts of selected articles published in Chinese, French, Italian, Japanese, Portuguese and Spanish translations – making news of advances in the field available to pediatric and neonatal intensive and critical care practitioners worldwide. Read More about The Journal Subscriber to the Journal Here
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Editor’s Choice
The Pediatric Critical Care Medicine (PCCM) Editor-in-Chief, Robert C. Tasker, MBBS, MD, FRCP highlights three articles he wants to draw readers’ attention to in each issue.
We will be posting these on our website each month, and invite you to come back and peruse these monthly.
PCCM Editor-in-Chief, Robert C. Tasker’s “Editor’s Choices” November 2023
PCCM Editor-in-Chief, Robert C. Tasker’s “Editor’s Choices” October 2023
PCCM Editor-in-Chief, Robert C. Tasker’s “Editor’s Choices” September 2023
PCCM Editor-in-Chief, Robert C. Tasker’s “Editor’s Choices” August 2023
Editor’s Choice Articles for November 2023
Tasker, Robert C. MBBS, MD, FRCP1,2,3
November 2023 and a new venture for Pediatric Critical Care Medicine (PCCM): a whole issue focused on cardiac intensive care. The Associate Editor for cardiac critical care, Dr. Paul A. Checchia, has written a Foreword for the issue that focuses on two example themes in PCCM and Cardiac Critical Care Research (1). Our expectation is that the broad range in cardiac-related reading material will be welcomed (e.g., pharmacology and toxicology, laboratory measurement, airway management, extracorporeal life support, outcomes and psychosocial care, implementation science, and clinical trials). My task is not to detract from this month’s cardiac emphasis and perspective, but to highlight three Editor’s Choice articles that will also make non-cardiac intensive care clinicians want to read and engage with the cardiac intensive care research reports this November. Because this is a special month, I will add to each of my three choices additional material that would normally fall within the educational content found in the section called PCCM Connections for Readers. Therefore, this month I will use my main highlights as a guide to further reading about extracorporeal cardiopulmonary resuscitation (E-CPR), durable vascular access in neonates, and point-of-care ultrasound (POCUS).
Lasa JJ, Guffey D, Bhalala U, et al: Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database (2).
There are 650 patients with cardiac disease who underwent E-CPR between 2010 and 2018 in the U.S. Virtual Pediatric System (VPS, LLC) database. The authors report associations between PICU type (i.e., general mixed versus solely cardiac), unit bed capacity, patient category (i.e., surgical, or medical cardiac patient), and outcomes.
PCCM Connections for Readers: There are two other E-CPR-related articles in the November issue. First, there is an Extracorporeal Life Support Organization (ELSO) registry study of 567 patients without congenital cardiac disease who underwent E-CPR between 2017 and 2019 (3). As you read this material, compare the VPS and the ELSO studies. In the ELSO study, the authors examined patient-level factors associated with greater or lesser odds of in-hospital mortality. Next, there is a single-center, retrospective study of 87 patients with a range of diagnoses who underwent E-CPR between 2014 and 2020. The authors focused on the relationship between the timing of resuscitation-dosing of epinephrine and the associated immediate hemodynamic outcomes (e.g., afterload) and extracorporeal membrane oxygenation (ECMO) pump parameters after cannulation (4). There is a very helpful editorial accompanying the article (5); also go back to the 2020 systematic review of E-CPR (6).
Mills M, Chanani N, Wolf M, et al: Durable Vascular Access in Neonates in the Cardiac ICU: A Novel Technique for Tunneled Femoral Central Venous Catheters (7).
My next Editor’s Choice article describes a two-puncture approach to place a tunneled femoral central venous line in neonates in the cardiac intensive care unit. The authors designed this technique and placed this form of vascular access in 161 patients between 2017 and 2021. The report comes with technical aspects, equipment list, a training video, and performance and morbidity data. There is a thoughtful editorial accompanying the article, with interesting history of medicine details (8).
PCCM Connections for Readers: There is one other recent technical note about venous access that will be of interest alongside the above report. You may recall that clinicians from three tertiary care units in the United States caring for infants with congenital heart disease described their experience of real-time, ultrasound-guided umbilical vein cannulation–incidentally, a beautifully illustrated account (9).
Maxson IN, Su E, Brown KA, et al; Pediatric Research Collaborative on Critical Ultrasound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: A Program of Assessment Model for Point-of-Care Ultrasound Training for Pediatric Critical Care Providers: A Comprehensive Approach to Enhance Competency-Based Point-of-Care Ultrasound Training (10).
My third Editor’s Choice article is about competency with POCUS and how we incorporate training at the bedside. During the last three years we have published reports about using POCUS for each of the following: assessing fluid responsiveness in mechanically ventilated and hemodynamically unstable neonates (11); identifying likely etiology of acute respiratory failure in children (12,13); placing umbilical venous cannulas in neonates with congenital heart disease (9); and, in this month’s issue, quantifying the akinetic heart at unexpected cardiac arrest (14). We now have a position paper and call to action by the PeRCCUS (Pediatric Research Collaborative on Critical Ultrasound) subgroup of the PALISI (Pediatric acute lung injury and Sepsis Investigators) network (15). It is well worth a read by all educators: look closely at the framework presented in the Figures and Tables.
PCCM Connections for Readers: There are two themes that will be relevant connections for readers. First, the educational dimension for cardiac intensive care higher professional training. In 2022, PCCM published details of the cardiac critical care fellowship curriculum and the entrustable professional activity (EPA) levels needed for clinical and administrative competency (16–18). The PeRCCUS group has now added more EPAs to that list. Second, we can consider the new PeRCCUS article as a natural progression of the 2021 debate about regulating critical care ultrasound by pediatric critical care practitioners (19,20).
1. Checchia PA: Pediatric Critical Care Medicine and cardiac critical care research. Pediatr Crit Care Med. 2023; 24:887–889
2. Lasa JJ, Guffey D, Bhalala U, et al.: Critical care unit characteristics and extracorporeal cardiopulmonary resuscitation survival in the pediatric cardiac population: Retrospective analysis of the Virtual Pediatric System database. Pediatr Crit Care Med. 2023; 24:910–918
3. Beni CE, Rice-Townsend SE, Esangbedo ID, et al.: Outcome of extracorporeal cardiopulmonary resuscitation in pediatric patients without congenital cardiac disease: Extracorporeal Life Support Organization registry study. Pediatr Crit Care Med. 2023; 24:927–936
4. Kucher NM, Marquez AM, Guerguerian AM, et al.: Epinephrine dosing use during extracorporeal cardiopulmonary resuscitation: Single-center retrospective cohort. Pediatr Crit Care Med. 2023; 24:e531–e539
5. Butt W: Cardiopulmonary resuscitation, epinephrine and extracorporeal membrane oxygenation: Finding the right balance. Pediatr Crit Care Med. 2023; 24:975–978
6. Esangbedo ID, Brunetti MA, Campbell FM, et al.: Pediatric extracorporeal cardiopulmonary resuscitation A systematic review. Pediatr Crit Care Med. 2020; 21:e934–e943
7. Mills M, Chanani N, Wolf M, et al.: Durable vascular access in neonates in the cardiac ICU: A novel technique for tunneled femoral central venous catheters. Pediatr Crit Care Med. 2023; 24:919–926
8. Su E, Bhargava V, Gil DV, et al.: The path to durable access in critically ill children: Not a straight line. Pediatr Crit Care Med. 2023; 24:969–972
9. Kozyak BW, Fraga MV, Juliano CE, et al.: Real-time ultrasound guidance for umbilical venous cannulation in neonates with congenital heart disease. Pediatr Crit Care Med. 2022; 23:e257–e266
10. Maxson IN, Su E, Brown KA, et al.: Pediatric Research Collaborative on Critical Ultrasound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: A program of assessment model for point-of-care ultrasound training for pediatric critical care providers: a comprehensive approach to enhance competency-based point-of-care ultrasound training. Pediatr Crit Care Med. 2023; 24:e511–e519
11. Oulego-Erroz I, Terroba-Seara S, Alonso-Quintela P, et al.: Respiratory variation in aortic blood flow velocity in hemodynamically unstable, ventilated neonates A pilot study of fluid responsiveness. Pediatr Crit Care Med. 2021; 22:380–391
12. DeSanti RL, Al-Subu AM, Cowan EA, et al.: Point-of-care ultasound to diagnose the etiology of acute respiratory failure at admission to the PICU. Pediatr Crit Care Med. 2021; 22:722–732
13. Conlon T, Keim G: Pathophysiology versus etiology using lung ultrasound Clinical correlation required. Pediatr Crit Care Med. 2021; 22:761–763
14. Su E, Dutko A, Ginsburg S, et al.: Death and ultrasound evidence of the akinetic heart in pediatric cardiac arrest. Pediatr Crit Care Med. 2023; 24:e568–e572
15. Randolph AG, Bembea MM, Cheifetz IM, et al.; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Evolution of an investigator-initiated research network. Pediatr Crit Care Med. 2022; 23:1056–1066
16. Werho DK, DeWitt AG, Owens ST, et al.: Establishing entrustable professional activities in pediatric cardiac critical care. Pediatr Crit Care Med. 2022; 23:54–59
17. Tabbutt S, Krawczeski C, McBride M, et al.: Standardized training for physicians practicing pediatric cardiac critical care. Pediatr Crit Care Med. 2022; 23:60–64
18. Checchia PA: It is time to raise the bar with a board. Pediatr Crit Care Med. 2022; 23:74–75
19. Su E, Soni NJ, Blaivas M, et al.: Regulating critical care ultrasound, it is all in the interpretation. Pediatr Crit Care Med. 2021; 22:e253–e258
20. Conlon TW, Kantor DB, Hirshberg EL, et al.: A call to action for the pediatric critical care community. Pediatr Crit Care Med. 2021; 22:e410–e414
Editor’s Choice Articles for October 2023
Tasker, Robert C. MBBS, MD, FRCP1,2,3
My three Editor’s Choices for the October issue of Pediatric Critical Care Medicine (PCCM) highlight important aspects of what is understood by brain involvement during critical illness. We now use a range in terminologies, but what do they mean and what is their significance? So, my three choices are: first, sepsis and “encephalopathy”; second, sepsis and “acute disorders of consciousness”; and third, outcome after “acquired brain injury.” The PCCM Connections for Readers focuses on team continuity during prolonged PICU admission.
Sanchez-Pinto LN, Bennet T, Stroup EK, et al: Derivation, Validation, and Clinical Relevance of a Pediatric Sepsis Phenotype With Persistent Hypoxemia, Encephalopathy, and Shock (1).
In my first Editor’s Choice we return to the topic of time course and trajectory in sepsis and septic shock (2–5), but with the added nuance of a phenotype that includes the term “encephalopathy.” However, what is meant by “encephalopathy” in this context? Our authors identified encephalopathy retrospectively using a Glasgow Coma Scale (GCS) score that was most frequently in the category 10 to 12 (1,6), which would be classified as a moderate severity injury in traumatic brain injury (TBI).
The 2012–2018 cohort has over 15,000 pediatric patients with sepsis-associated multiple organ dysfunction syndrome (MODS) and the encephalopathy phenotype was present in 1-in-3 cases (1). Please read the report as well because the accompanying editorial which, together, provide important details about the meaning and trajectory of such brain symptomatology during sepsis-associated MODS (7).
Cheung C, Kernan K, Berg RA, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (8).
My next Editor’s Choice article is a secondary analysis of data from the multicenter, prospective PHENOMS (Phenotyping Sepsis-Induced Multiple Organ Failure Study) cohort, 2015–2017 (5,9). The authors defined “acute disorder of consciousness” as a GCS score below 12 in the absence of sedatives on the initial study day of sepsis-induced organ failure; therefore, in essence, a definition like the criterion for encephalopathy used in my first Editor’s Choice (1).
In a population of 401 patients, 1-in-5 cases had the depressed GCS phenotype, and the authors go on to describe clinical and laboratory characteristics—another theme that we have followed closely in PCCM (5,9–11). The editorial gives us a broad view of how we can “unravel the intricate relationship between sepsis, organ dysfunction, and neurologic manifestations in pediatric patients” (12).
As a reader of PCCM you may also want to review our recent material about timing of acute neurologic dysfunction in relation to sepsis recognition (13,14) and the choice of clinical assessment (15). Finally, also consider the computational phenotype of “acute brain dysfunction” regarding database research—based on using neuroimaging or electroencephalography as part of evaluating neurologic change—which had better diagnostic performance than the GCS in sepsis (16).
Williams CN, Hall TA, Baker VA, et al: Follow-up After PICU Discharge for Patients With Acquired Brain Injury: The Role of an Abbreviated Neuropsychological Evaluation and a Return-to-School Program (17).
My third Editor’s Choice article about brain health extends the Journal’s theme on follow-up programs and PICU outcomes and is a link between neurology during PICU admission and morbidity at follow-up. For example, in 2021, there was a scoping review of instruments and methods for assessing overall health after PICU admission (18) and, in 2022, there was description of a core outcome measurement set for evaluating PICU survivorship (19,20). The Journal also published three descriptions of structured follow-up by clinical programs in Canada, the United States, and the Netherlands (21–24). There was the most comprehensive and detailed clinical research analysis of physical, emotional/behavioral, and neurocognitive developmental outcomes 2−4 years after PICU admission in over 600 patients from a randomized clinical trial cohort (25,26).
Two neurocritical programs in the US describe a multidisciplinary 1-month follow-up of 289 school-aged children at-risk of cognitive impairment, because of “acquired brain injury” most commonly due to TBI with GCS 9 to 13 (17); rather like the GCS of patients in my first two Editor’s Choices (see above). Of note here, the authors describe using an abbreviated battery of neuropsychological tests that proved useful in identifying new impairments and screening for referral to specialist services. There is an accompanying editorial (27).
This third Editor’s Choice article (17), when considered in conjunction with the other choices (1,8), made me want to re-read the 1- and 3-month outcomes work of the LAPSE (Life After Pediatric Sepsis Evaluation) investigators in their 2014–2017 sepsis cohort (28,29), and their most recent publications (i.e., one also appearing in this month’s issue (30), and another with 12-month outcomes appearing later this year (31)). There is much to consider.
This month’s topic for educational review is a Society of Critical Care Medicine (SCCM)-endorsed Special Article from the Lucile Packard Foundation PICU continuity panel (32). Thirty-seven experts have generated 17 consensus statements about continuity strategies for long-stay PICU patients. Please read the article and, as context, see the experts’ previous survey of contemporary practices and perceptions in US PICUs with training fellowship programs (33) and the accompanying editorial published in June 2023 (34).
This Special Article adds to the Journal’s compendium on pediatric chronic critical illness. I recommend the scoping review on case definition of pediatric chronic critical illness (35) and the description of prevalence in a single center (36). Next, consider reading about an overlapping entity called pediatric complex chronic condition (or medical complexity); it has variable identification in US PICUs (37), yet accounts for high-frequency PICU utilization (38). Finally, read the qualitative analysis of clinical care strategies that support parents of children with complex chronic conditions, particularly during their child’s end-of-life care in the PICU (39,40).
1. Sanchez-Pinto LN, Bennet T, Stroup EK, et al.: Derivation, validation, and clinical relevance of a pediatric sepsis phenotype with persistent hypoxemia, encephalopathy, and shock. Pediatr Crit Care Med. 2023; 24:795–806
2. Trujillo Rivera EA, Patel AK, Zeng-Treitler Q, et al.: Severity trajectories of pediatric inpatients using the criticality index. Pediatr Crit Care Med. 2021; 22:e19–e32
3. Rivera EAT, Patel AK, Chamberlain JM, et al.: Criticality: A new concept of severity of illness for hospitalized children. Pediatr Crit Care Med. 2021; 22:e33–e43
4. Perizes EN, Chong G, Sanchez-Pinto LN: Derivation and validation of vasoactive inotrope score trajectory groups in critically ill children with shock. Pediatr Crit Care Med. 2022; 23:1017–1026
5. Horvat CM, Fabio A, Nagin DS, et al.; on behalf of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Mortality risk in pediatric sepsis based on C-reactive protein and ferritin levels. Pediatr Crit Care Med. 2022; 23:968–979
6. Matics TJ, Sanchez-Pinto LN: Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the Sepsis-3 definitions in critically ill children. JAMA Pediatr. 2017; 171:e172352
7. Balcarcel D, Fitzgerald JC, Alcamo AM: Unmasking critical illness: using machine learning and biomarkers to see what lies beneath. Pediatr Crit Care Med. 2023; 24:869–871
8. Cheung C, Kernan KF, Berg RA, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Acute disorders of consciousness in pediatric severe sepsis and organ failure: Secondary analysis of the multicenter phenotyping sepsis-induced multiple organ failure study. Pediatr Crit Care Med. 2023; 24:840–848
9. Dean MJ for the Collaborative Pediatric Critical Care Research Network (CPCCRN) investigators: Evolution of the collaborative pediatric critical care research network (CPCCRN). Pediatr Crit Care Med. 2022; 23:1049–1055
10. Badke CM, Marsillio LE, Carroll MS, et al.: Development of a heart rate variability risk score to predict organ dysfunction and death in critically ill children. Pediatr Crit Care Med. 2021; 22:e437–e447
11. Badke CM, Carroll MS, Weese-Mayer DE, et al.: Association between heart rate variability and inflammatory biomarkers in critically ill children. Pediatr Crit Care Med. 2022; 23:e289–e294
12. Miksa M: Beyond survival: Insights from the Phenotyping Sepsis-Induced Multiple Organ Failure study on the neurological impact of pediatric sepsis. Pediatr Crit Care Med. 2023; 24:877–880
13. Alcamo AM, Weiss SL, Fitzgerald JC, et al.; Sepsis Prevalence, Outcomes and Therapies (SPROUT) Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Outcomes associated with timing of neurologic dysfunction onset relative to pediatric sepsis recognition. Pediatr Crit Care Med. 2022; 23:593–605
14. Smith CM: Late-onset neurologic dysfunction in pediatric sepsis – what brains might learn from kidneys and persistent acute kidney injury. Pediatr Crit Care Med. 2022; 23:659–661
15. Kirschen MP, Smith KA, Snyder M, et al.: Serial neurologic assessment in pediatrics (SNAP): A new tool for bedside neurologic assessment of critically ill children. Pediatr Crit Care Med. 2021; 22:483–495
16. Alcamo AM, Barren GJ, Becker AE, et al.: Validation of a computational phenotype to identify acute brain dysfunction in pediatric sepsis. Pediatr Crit Care Med. 2022; 23:1027–1036
17. Williams CN, Hall TA, Baker VA, et al.: Follow-up after PICU discharge for patients with acquired brain injury: The role of an abbreviated neuropsychological evaluation and a return-to-school program. Pediatr Crit Care Med. 2023; 24:807–817
18. Carlton EF, Pinto N, Smith M, et al.; POST-PICU Investigators of the PALISI Network and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Overall health following pediatric critical illness: A scoping review of instruments and methodology. Pediatr Crit Care Med. 2021; 22:1061–1071
19. Pinto NP, Maddux AB, Dervan LA, et al.; POST-PICU Investigators of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN): A core outcome measurement set for pediatric critical care. Pediatr Crit Care Med. 2022; 23:893–907
20. LaRosa JM, Scholefield BR, Kudchadkar SR: Measure to improve like PROs: Patient-related outcomes in survivors of pediatric critical illness. Pediatr Crit Care Med. 2022; 23:946–949
21. Ducharme-Crevier L, La KA, Francois T, et al.: PICU follow-up clinic: Patient and family outcomes 2 months after discharge. Pediatr Crit Care Med. 2021; 22:935–943
22. Smith M, Grassia K, Zimmerman JJ: Acknowledging the importance of follow-up after childhood critical illness. Pediatr Crit Care Med. 2021; 22:998–1000
23. Hickey E, Johnson T, Kudchadkar SR, et al.: Persistence matters! Hurdles and high points of PICU follow-up clinic. Pediatr Crit Care Med. 2022; 23:e397–e399
24. De Sonnaville ESV, van Woensel JBM, van Goudoever JB, et al.; Emma Children’s Hospital Amsterdam UMC Follow Me Program Consortium: Structured multidisciplinary follow-up after pediatric intensive care: A model for continuous data-driven health care innovation. Pediatr Crit Care Med. 2023; 24:484–498
25. Verlinden I, Guiza F, Dulfer K, et al.: Physical, emotional/behavioral, and neurocognitive developmental outcome from 2 to 4 years after PICU admission: A secondary analysis of the early versus late parenteral nutrition randomized controlled trial cohort. Pediatr Crit Care Med. 2022; 23:580–592
26. Maddux AB, Fink EL: The post-PICU growth curve. Pediatr Crit Care Med. 2022; 23:656–658
27. Colville G: Building bridges: Integration of PICU follow-up with aftercare in the community. Pediatr Crit Care Med. 2023; 24:871–874
28. Wong HR, Reeder RW, Banks R, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network (CPCCRN) and the Life After Pediatric Sepsis Evaluation (LAPSE) Investigators: Biomarkers for estimating risk of hospital mortality and long-term quality-of-life morbidity after surviving pediatric septic shock: A secondary analysis of the Life After Pediatric Sepsis Evaluation investigation. Pediatr Crit Care Med. 2021; 22:8–15
29. Kamps NN, Banks R, Reeder RW, et al.: The association of early corticosteroid therapy with clinical and health-related quality of life outcomes in children with septic shock. Pediatr Crit Care Med. 2022; 23:687–697
30. Stenson EK, Banks RK, Reeder RW, et al.: Fluid balance and its association with mortality and health-related quality of life: A nonprespecified secondary analysis of the Life After Pediatric Sepsis Evaluation. Pediatr Crit Care Med. 2023; 24:829–839
31. Workman JK, Reeder RW, Banks RK, et al.: Change in functional status during hospital admission and long-term health-related quality of life among pediatric septic shock survivors. Pediatr Crit Care Med. 2023 Jun 22. [online ahead of print]
32. Edwards JD, Wocial LD, Madrigal VN, et al.: Continuity strategies for long-stay PICU patients: Consensus statements from the Lucile Packard Foundation PICU continuity panel. Pediatr Crit Care Med. 2023; 24:849–861
33. Williams EP, Madrigal VN, Leone TA, et al.: Primary intensivists and nurses for long-stay patients: A survey of practices and perceptions at academic PICUs. Pediatr Crit Care Med. 2023; 24:436–446
34. Gouda SR, Hoehn KS: Walking a tightrope: Balancing continuity for long-stay patients and wellness for clinicians in an ever-evolving landscape. Pediatr Crit Care Med. 2023; 24:512–514
35. Zorko DJ, McNally JD, Rochwerg B, et al.; International Pediatric Chronic Critical Illness Collaborative: Defining pediatric chronic critical illness: A scoping review. Pediatr Crit Care Med. 2023; 24:e91–e103
36. Shappley RKH, Noles DL, Spentzas T: Pediatric chronic critical illness: Validation, prevalence, and impact in a children’s hospital. Pediatr Crit Care Med. 2021; 22:e636–e639
37. Heneghan JA, Goodman DM, Ramgopal S: Variable identification of children with medical complexity in United States PICUs. Pediatr Crit Care Med. 2023; 24:56–61
38. Heneghan JA, Akande M, Goodman DM, et al.: High-frequency utilization of the PICU. Pediatr Crit Care Med. 2022; 23:e230–e239
39. Bogetz JF, Revette A, DeCourcey DD: Clinical care strategies that support parents of children with complex chronic conditions. Pediatr Crit Care Med. 2021; 22:595–602
40. Pinto NP, Morrison WE: Supporting children with complex chronic conditions and their families at the end of life. Pediatr Crit Care Med. 2021; 22:669–671
Editor’s Choice Articles for September 2023
Tasker, Robert C. MBBS, MD, FRCP1,2,3
The September 2023 issue and this year has already proven to be important for improving our understanding of pediatric acute respiratory distress syndrome (PARDS); Pediatric Critical Care Medicine (PCCM) has published 16 articles so far. Therefore, my three Editor’s Choice articles this month highlight yet more PCCM material about PARDS by covering the use of noninvasive ventilation (NIV), the trajectory in cytokine profile during illness, and a new look at lung mechanics. The PCCM Connections for Readers give us the opportunity to focus on some clinical biomarkers of severity and mortality risk during critical illness.
Emeriaud G, Pons-Odena M, Bhalla AK, et al; Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study (1).
Whether to use noninvasive respiratory support during the development of PARDS has been debated for several years. The discussion was featured in the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC-1) guidance and was still ongoing in the 2023 PALICC-2 report (2,3). However, in early 2023, PCCM published a systematic review and meta-analysis of NIV support in PARDS (4). The Journal also published a Concise Clinical Physiology Review on PARDS pathophysiology that described the differential detrimental effect of spontaneous breathing in mild versus severe PARDS, and the potential for developing ventilator-induced lung injury (VILI) and, so-called, patient self-inflicted lung injury (P-SILI) (5).
The PARDS Incidence and Epidemiology (PARDIE) investigators now report a planned ancillary study of their 2016/2017 prospective cohort in which 160 of 708 PARDS cases underwent NIV at the time of PARDS diagnosis (1). These are unique data, albeit from 6 years ago–but this is as good it gets. Our editorialists even go so far as to say that the PARDIE-NIV work is a “game changer” for decision-making in clinical practice (6), and it may even lead to more clinical research into the entity they call “NIV-induced lung injury” (which may be P-SILI).
Ardila SM, Weeks HM, Dahmer MK, et al; Biomarkers in Children with Acute Lung Injury and Randomized Evaluation for Sedation Titration for Respiratory Failure (RESTORE) Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: A Targeted Analysis of Serial Cytokine Measures and Nonpulmonary Organ System Failure in Children With Acute Respiratory Failure: Individual Measures and Trajectories Over Time (7).
My next Editor’s Choice article is a secondary analysis of data from the Biomarkers in Acute Lung Injury (BALI) ancillary study–a component of the Randomized Evaluation for Sedation Titration for Respiratory Failure (RESTORE) trial–which included some sepsis patients, but of note there were over 350 patients with PARDS (8). The new report by the BALI-RESTORE investigators focuses on trajectories in clinical state and inflammatory cytokines (7). Of note, the work adds to PCCM’s ongoing literature about trajectories and phenotype. Review, for example, other reports on trajectory-based phenotype: in sepsis, related to changes in C-reactive protein and ferritin levels (9,10); or in prolonged shock, related to changes in vasoactive inotrope score and cytokines (11,12); or in moderate to severe PARDS, related to persistence of hypoxemia (13).
Taking all this work together, we have the making of a coherent narrative about patient trajectory in an inflammation-shock-PARDS continuum (7–13). I wonder whether this axis will converge with another research narrative within PCCM: the literature about machine learning and dynamic modeling of real-time criticality, deterioration, and mortality risk (14–20).
Cruces P, Moreno D, Reveco S, et al: Plateau Pressure and Driving Pressure in Volume- and Pressure-Controlled Ventilation: Comparison of Frictional and Viscoelastic Resistive Components in Pediatric Acute Respiratory Distress Syndrome (21).
My third Editor’s Choice article about PARDS focuses on lung mechanics. For some context, during 2021 to 2023 the Journal published reports about mechanical ventilation and the potential lung exposure to the energy of mechanical power and the risk of VILI (22–24), and about the mechanics of ventilator-driving pressure and this transmitted energy (using the “power” calculations) (25,26). However, there has been little about airway resistance during mechanical ventilation in PARDS (4,27).
We now have some detailed physiology of lung frictional, viscoelastic and elastic resistive components during volume-controlled and pressure-controlled ventilation in 18 PARDS patients (21). Please read this clinical report along with the author’s Concise Clinical Physiology Review on PARDS pathophysiology that appeared in the February 2023 issue (4).
This month’s special topic for educational review is biomarker research, whether related to severity of illness and mortality risk during critical illness, or whether related to severity of potential toxic exposure because of treatment during critical illness. There are three articles that bring these ideas together in the September 2023 issue.
Begin with the article reporting the association between a compound variable–the Lactate-Albumin ratio (i.e., severity biomarker)–rather than each of its components alone, with mortality and multiple organ dysfunction in over 600 PICU patients (28). There is an accompanying editorial (29), and it is also worth looking at a PCCM 2022 international report about lactate and severity of illness scoring (30).
Next, read about the association between potentially excess oxygen exposure (i.e., severity exposure) and death in over 3,000 mechanically ventilated children (31). The report builds on a 2022 paper in the Journal using the same oxygen exposure metric (32), and there is an accompanying editorial (33). What is of real importance and concern when we consider the other PCCM literature and commentaries on excess oxygen exposure (34–37) is that they all point in the direction of potential for toxicity and risk of harm. We must now eagerly await the findings of the United Kingdom randomized multicenter trial of conservative versus liberal oxygenation targets in critically ill children in the PICU (Oxy-PICU) (38,39). Recruitment of over 2,000 mechanically ventilated children finished early 2023.
Finally, complete this month’s educational review by reading about hyperferritinemia (i.e., severity biomarker) in severe Dengue infection (40). This new work not only adds to PCCM’s narrative about Dengue, but it also ties in with the other literature on trajectory in ferritin in sepsis (9,10).
1. Emeriaud G, Pons-Odena M, Bhalla AK, et al.: Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Noninvasive ventilation for pediatric acute respiratory distress syndrome: Experience from the 2016/2017 pediatric acute respiratory distress syndrome incidence and epidemiology prospective cohort study. Pediatr Crit Care Med. 2023; 24:715–727
2. Carroll CL, Napolitano N, Pons-Odena M, et al.; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Noninvasive respiratory support for pediatric acute respiratory distress syndrome: From the second pediatric acute lung injury consensus conference. Pediatr Crit Care Med. 2023; 24:S135–S147
3. Emeriaud G, Lopez-Fernandez YM, Iyer NP, et al.; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) Group on behalf of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Executive summary of the second international guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PALICC-2). Pediatr Crit Care Med. 2023; 24:143–168
4. Boghi D, Kim KW, Kim JH, et al.: Noninvasive ventilation for acute respiratory failure in pediatric patients: A systematic review and meta-analysis. Pediatr Crit Care Med. 2023; 24:123–132
5. Cruces P: Pediatric acute respiratory distress syndrome: approaches in mechanical ventilation. Pediatr Crit Care Med. 2023; 24:e104–e114
6. Milesi C, Baleine J, Mortamet G, et al.: Noninvasive ventilation in pediatric acute respiratory distress syndrome: Another dogma bites the dust. Pediatr Crit Care Med. 2023; 24:783–785
7. Ardila SM, Weeks HM, Dahmer MK, et al.: Biomarkers in Children with Acute Lung Injury and Randomized Evaluation for Sedation Titration for Respiratory Failure (RESTORE) Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: A targeted analysis of serial cytokine measures and nonpulmonary organ system failure in children with acute respiratory failure: Individual measures and trajectories over time. Pediatr Crit Care Med. 2023; 24:727–737
8. Dahmer MK, Quasney MW, Sapru A, et al.; BALI and RESTORE Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Interleukin-1 receptor antagonist is associated with pediatric acute respiratory distress syndrome and worse outcomes in children with acute respiratory failure. Pediatr Crit Care Med. 2018; 19:930–938
9. Dean JM; Collaborative Pediatric Critical Care Research Network (CPCCRN) Investigators: Evolution of the collaborative pediatric critical care research network. Pediatr Crit Care Med. 2022; 23:1049–1055
10. Horvat CM, Fabio A, Nagin DS, et al.; on behalf of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Mortality risk in pediatric sepsis based on C-reactive protein and ferritin levels. Pediatr Crit Care Med. 2022; 23:968–979
11. Perizes EN, Ching G, Sanchez-Pinto LN: Derivation and validation of vasoactive inotrope score trajectory groups in critically ill children with shock. Pediatr Crit Care Med. 2022; 23:1017–1026
12. Badke CM, Carroll MS, Weese-Mayer DE, et al.: Association between heart rate variability and inflammatory biomarkers in critically ill children. Pediatr Crit Care Med. 2022; 23:e289–e294
13. Sanchez-Pinto LN, Bennett TD, Stroup EK, et al.: Derivation, validation, and clinical relevance of a pediatric sepsis phenotype with persistent hypoxemia, encephalopathy, and shock. Pediatr Crit Care Med. 2023 June 2. [online ahead of print]
14. Rivera EAT, Patel AK, Chamberlain JM, et al.: Criticality: A new concept of severity of illness for hospitalized children. Pediatr Crit Care Med. 2021; 22:e33–e43
15. Aczon MD, Ledbetter DR, Laksana E, et al.: Continuous prediction of mortality in the PICU: A recurrent neural network model in a single-center dataset. Pediatr Crit Care Med. 2021; 22:519–529
16. Bennett TD, Russell S, Albers DJ: Neural networks for mortality prediction: ready for prime time? Pediatr Crit Care Med. 2021; 22:578–581
17. Rivera EAT, Chamberlain JM, Patel AK, et al.: Dynamic mortality risk predictions for children in ICUs: Development and validation of machine learning tools. Pediatr Crit Care Med. 2022; 23:344–352
18. Sanchez-Pinto LN, Bennett TD: Evaluation of machine learning models for clinical prediction problems. Pediatr Crit Care Med. 2022; 23:405–408
19. Rust LOH, Gorham TJ, Bambach S, et al.: The deterioration risk index: Developing and piloting a machine learning algorithm to reduce pediatric inpatient deterioration. Pediatr Crit Care Med. 2023; 24:322–333
20. Bennett TD: Pediatric deterioration detection using machine learning. Pediatr Crit Care Med. 2023; 24:347–349
21. Cruces P, Moreno D, Reveco S, et al.: Plateau pressure and driving pressure in volume- and pressure-controlled ventilation: Comparison of frictional and viscoelastic resistive components in pediatric acute respiratory distress syndrome. Pediatr Crit Care Med. 2023; 24:750–760
22. Proulx F, Emeriaud G, Francois T, et al.: Oxygenation defects, ventilatory ratio, and mechanical power during severe pediatric acute respiratory distress syndrome: Longitudinal time sequence analyses in a single-center retrospective cohort. Pediatr Crit Care Med. 2022; 23:22–33
23. Khemani RG: Should we embrace mechanical power to understand the risk of ventilator-induced lung injury in children? Pediatr Crit Care Med. 2022; 23:71–74
24. Percy AG, Mai MV, Bhalla AK, et al.: Mechanical power is associated with mortality in pediatric acute respiratory distress syndrome. Pediatr Crit Care Med. 2023; 24:e307–e316
25. Diaz F, Gonzalez-Dambrauskas S, Cristiani F, et al.: Driving pressure and normalized energy transmission calculations in mechanically ventilated children without lung disease and pediatric acute respiratory distress syndrome. Pediatr Crit Care Med. 2021; 22:870–878
26. van Schelven P, Koopman AA, Burgerhof JGM, et al.: Driving pressure is associated with outcome in pediatric acute respiratory failure. Pediatr Crit Care Med. 2022; 23:e136–e144
27. Bruno F, Andreolio C, Garcia PCR, et al.: The relevance of airway resistance in children requiring mechanical ventilatory support. Pediatr Crit Care Med. 2022; 23:e483–e488
28. Ray CC, Pollack MM, Gai J, et al.: The association of the lactate-albumin ratio with mortality and multiple organ dysfunction in PICU patients. Pediatr Crit Care Med. 2023; 24:760–767
29. Butt WW: The lactate-albumin ratio predicts multi-organ dysfunction syndrome and death but is it ready to use? Pediatr Crit Care Med. 2023; 24:785–787
30. Morris KP, Kapetanstrataki M, Wilkins B, et al.: Lactate, base excess, and the pediatric index of mortality: Exploratory study of an international, multicenter dataset. Pediatr Crit Care Med. 2022; 23:e268–e276
31. Geva A, Akhondi-Asl A, Mehta NM: Validation and extension of the association between potentially excess oxygen exposure and death in mechanically ventilated children. Pediatr Crit Care Med. 2023; 24:e434–e440
32. Balcarcel DR, Coates BM, Chong G, et al.: Excessive oxygen supplementation in the first day of mechanical ventilation is associated with multiple organ dysfunction and death in critically ill children. Pediatr Crit Care Med. 2022; 23:89–98
33. Jones GAL, Peters MJ: Towards causality with liberal oxygen use? Pediatr Crit Care Med. 2022; 23:135–137
34. Beshish AG, Jahadi O, Mello A, et al.: Hyperoxia during cardiopulmonary bypass is associated with mortality in infants undergoing cardiac surgery. Pediatr Crit Care Med. 2021; 22:445–453
35. Horvat C: Statistical note: Confounding and causality in observational studies. Pediatr Crit Care Med. 2021; 22:496–498
36. Peters MJ: Linking hyperoxia and harm: Consequence or merely subsequence? Pediatr Crit Care Med. 2021; 22:501–503
37. Jones GAL, Eaton S, Orford M, et al.; Oxy-PICU Investigators of the Paediatric Critical Care Society Study Group (PCCS-SG): Randomization to a liberal versus conservative oxygenation target: Redox responses in critically ill children. Pediatr Crit Care Med. 2023; 24:e137–e146
38. Peters MJ, Ramnarayan P, Scholefield BR, et al.; United Kingdom Paediatric Critical Care Society Study Group (PCCS-SG): The United Kingdom paediatric critical care society study group: The 20-year journey toward pragmatic, randomized clinical trials. Pediatr Crit Care Med. 2022; 23:1067–1075
39. Chang I, Thomas K, O’Neill Gutierrez L, et al.: Protocol for a randomized multiple center trial of conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU): Oxygen in pediatric intensive care. Pediatr Crit Care Med. 2022; 23:736–744
40. Lakshmanan C, Ranjit S, Natraj R, et al.: Hyperferritinemia in severe Dengue infection: Single-center retrospective cohort study. Pediatr Crit Care Med. 2023; 24:e409–416
Editor’s Choice Articles for August 2023
Tasker, Robert C. MBBS, MD, FRCP1,2,3
There are three excellent Editor’s Choice articles for the August 2023 issue of Pediatric Critical Care Medicine (PCCM). First, a much-awaited report from the Society of Critical Care Medicine (SCCM) ICU liberation campaign focused on a bundle of six quality improvement (QI) initiatives in the PICU. Second, a study to better understand physician experiences with families as they respond to the potential diagnosis of their child’s death by neurologic criteria (DNC). Third, a multidisciplinary evaluation of an algorithm for testing practices and approach to differential diagnosis in PICU patients with new fever or instability. The PCCM Connections for Readers focuses on practices during life support with extracorporeal membrane oxygenation (ECMO).
Lin JC, Srivastava A, Malone S, et al; Society of Critical Care Medicine’s Pediatric ICU Liberation Campaign Collaborative: Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative (1).
SCCM’s six-component ABCDEF (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention, and management; Early mobility and exercise; Family engagement and empowerment) “Bundle” creates management goals aimed at optimizing pediatric care and family participation during critical illness. We have the benefit of the 2022 SCCM clinical practice guidelines (CPG) on “prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility” (2). The new SCCM report extends the CPG by addressing PICU-wide and individual feasibility and outcomes associated with CPG implementation. Readers, please note that PCCM has published other reports about implementing QI-related bundles of care (3–6) and, in this context, the new article is extensive and wide-reaching.
The SCCM ABCDEF bundle was implemented in 632 patients, during 6,252 days of PICU care, when there were 47 deaths. The accompanying editorial makes us pause for thought and reflect on the current findings (7). Overall, the pediatric SCCM ABCDEF study is important, it must be read, and we clearly need to make refinements to our clinical research in this area.
Lin JC, Srivastava A, Malone S, et al; Society of Critical Care Medicine’s Pediatric ICU Liberation Campaign Collaborative: Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative (1).
SCCM’s six-component ABCDEF (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention, and management; Early mobility and exercise; Family engagement and empowerment) “Bundle” creates management goals aimed at optimizing pediatric care and family participation during critical illness. We have the benefit of the 2022 SCCM clinical practice guidelines (CPG) on “prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility” (2). The new SCCM report extends the CPG by addressing PICU-wide and individual feasibility and outcomes associated with CPG implementation. Readers, please note that PCCM has published other reports about implementing QI-related bundles of care (3–6) and, in this context, the new article is extensive and wide-reaching.
The SCCM ABCDEF bundle was implemented in 632 patients, during 6,252 days of PICU care, when there were 47 deaths. The accompanying editorial makes us pause for thought and reflect on the current findings (7). Overall, the pediatric SCCM ABCDEF study is important, it must be read, and we clearly need to make refinements to our clinical research in this area.
Paquette ED, Ross LF, Chavez J, Frader JE: Refusals of the Determination of Death by Neurologic Criteria: A Mixed Methods Study of Physician Perspectives on Refusals Cases (8).
My second Editor’s Choice article is about physician perspectives of parent/family refusals at the time of determination of DNC. By way of background, start with the contemporary international literature (2020 to 2023) on determination of death. For example, review the 2020 World Brain Death Project report (9) and the 2023 CPG for a brain-based definition of death in children and adults in Canada (10). Then consider the work about the public’s understanding of the definition and determination of death. There is a 2022 scoping review (11), a 2023 national survey of public opinion in Canada (12), and a 2023 report of interviews in family members with relatives dying after determination of DNC (13). Despite these detailed articles on families at the time of death, we have heard little about physicians and their decision-making when families refuse testing for the determination of DNC (14).
PCCM publishes a report about refusals to allow examination for determination of DNC from an online survey of 80 pediatric intensivists and neurologists, with detailed phone interviews in 12 of the respondents. The clinicians describe their approaches when managing refusals, and the impact of these decisions on their medical teams. This work echoes previous PCCM publications on the topics of therapeutic alliance between parents and physicians (15) and communications about prognosis (16–18). Our editorial writer also adds to our understanding with more context about the United States 1980 Uniform Determination of Death Act, the case of Jahi McMath, and a personal view (19).
Sick-Samuels AC, Booth LD, Milstone M, et al: A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability (20).
My final Editor’s Choice article returns to the topic of QI in the PICU (1). Over 2021 to 2023, the QI themes of antibiotic stewardship (21–23), bacterial investigations (24,25), and diagnostic accuracy (26,27), have had extended coverage in PCCM, and all this material is worth reviewing. Now, in this latest QI report (20), the authors follow PCCM’s guidance on reporting QI studies (28,29) and describe their pre- versus postimplementation findings (4,290 versus 2,843) of an algorithm for PICU patients with new fever or clinical instability. There is an accompanying editorial (30); also read another relevant article and editorial about serial tracheal aspirate cultures in the PICU (31,32).
This month’s special topic for educational review is life support with ECMO. There are five articles about ECMO in the August 2023 issue (33–37): an extracorporeal life support organization database study of neonates undergoing life support with either centrifugal or conventional roller pumps (33); two articles on outcomes in specific patient populations, with one about status asthmaticus (34) and the other about neonates with congenital diaphragmatic hernia (35); and, last, two articles about acute care during life support–a literature review of nutrition (36) and an electroencephalography study of seizure identification (37).
Finally, another highlight for me in the narrative essay series is the article entitled “The Exchange” (38).
1. Lin JC, Srivastava A, Malone S, et al.; Society of Critical Care Medicine’s Pediatric ICU Liberation Campaign Collaborative: Caring for critically ill children with the ICU liberation bundle (ABCDEF): Results of the pediatric collaborative. Pediatr Crit Care Med. 2023; 24:636–651
2. Smith HAB, Besunder JB, Betters KA, et al.: 2022 Society of Critical Care Medicine clinical practice guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility. Pediatr Crit Care Med. 2022; 23:e74–e110
3. Jones IGR, Freidman S, Vu M, et al.: Improving daily patient goal-setting and team communications: the Liber8 glass door project. Pediatr Crit Care Med. 2023; 24:382–390
4. Geva A, Albert BD, Hamilton S, et al.: eSIMPLER: A dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. Pediatr Crit Care Med. 2021; 22:898–905
5. Yang Y, Akhondi-sl A, Geva A, et al.: Implementation of an analgesia-sedation protocol is associated with reduction in midazolam usage in the PICU. Pediatr Crit Care Med. 2021; 22:e513–e523
6. Patel RV, Redivo J, Nelliot A, et al.: Early mobilization in a PICU: A qualitative sustainability analysis of PICU Up!. Pediatr Crit Care Med. 2021; 22:e233–e242
7. Shime N, MacLaren G: ICU liberation bundles and the legend of three arrows. Pediatr Crit Care Med. 2023; 24:703–705
8. Paquette ED, Ross LF, Chavez J, et al.: Refusals of the determination of death by neurologic criteria: A mixed methods study of physician perspectives on refusals cases. Pediatr Crit Care Med. 2023; 24:628–635
9. Greer DM, Shemie SD, Lewis A, et al.: Determination of brain death/death by neurologic criteria: The World Brain Death Project. JAMA. 2023; 324:1078–1097
10. Shemie SD, Wilson LC, Hornby L, et al.: A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: A 2023 clinical practice guideline. Can J Anaesth. 2023; 70:483–557
11. Zheng K, Sutherland S, Hornby L, et al.: Public understandings of the definition and determination of death: A scoping review. Transplantation Direct. 2022; 8:e1300
12. Sarti AJ, Honarmand K, Sutherland S, et al.: When is a person dead? The Canadian public’s understanding of death and death determination: A nationwide survey. Can J Anesth. 2023; 70:617–627
13. Sarti AJ, Sutherland S, Meade M, et al.: Death determination by neurologic criteria – what do families understand? Can J Anesth. 2023; 70:637–650
14. Truog RD, Morrison W, Kirschen M: What should we d when families refuse testing for brain death? AMA J Ethics. 2020; 22:e986–e994
15. Suttle M, Hall MW, Pollack MM, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN): Therapeutic alliance between bereaved parents and physicians in the PICU. Pediatr Crit Care Med. 2021; 22:e243–e252
16. Rissman L, Derrington S, Rychlik K, et al.: Parent and physician report of discussions about prognosis for critically ill children. Pediatr Crit Care Med. 2021; 22:785–794
17. McSherry ML, Kudchadkar SR: Prognostic conversations in the PICU: Are we even coming close? Pediatr Crit Care Med. 2021; 22:844–847
18. Gupta D, October TW, Wolfe AMHJ: Characteristics of prognostic statements during family conferences of critically ill children. Pediatr Crit Care Med. 2023; 24:34–40
19. Truog RD: Why do families reject the diagnosis of brain death, and how should we respond? Pediatr Crit Care Med. 2023; 24:701–703
20. Sick-Samuels AC, Booth LD, Milstone AM, et al.: A novel comprehensive algorithm for evaluation of PICU patients with new fever or instability. Pediatr Crit Care Med. 2023; 24:670–680
21. Fontela PS, Gaudreault J, Dagenais M, et al.; Canadian Critical Care Trials Group: Clinical reasoning behind antibiotic use in PICUs: A qualitative study. Pediatr Crit Care Med. 2022; 23:e126–e135
22. Madden K: Risk and resistance: Examining our antibiotic use. Pediatr Crit Care Med. 2022; 23:227–228
23. Chorafa E, Komatsiouli V, Iosifidis E, et al.: Antimicrobial stewardship programs in PICU settings: A systematic review. Pediatr Crit Care Med. 2023; 24:e20–e27
24. Woods-Hill CZ, Koontz DW, Voskertchain A, et al.: Consensus recommendations for blood culture use in critically ill children using a modified Delphi approach. Pediatr Crit Care Med. 2021; 22:774–784
25. Dewan M, Wolfe H, Stalets EL: Relentless improvement: Overcoming the “active resisters and organizational constipators” to drive change. Pediatr Crit Care Med. 2021; 22:842–844
26. Cifra CL, Custer JW, Singh H, et al.: Diagnostic errors in pediatric critical care: A systematic review. Pediatr Crit Care Med. 2021; 22:701–712
27. Wetzel RC: Diagnosis: A tricky, never-ending business. Pediatr Crit Care Med. 2021; 22:758–761
28. Bartman T, Brilli RJ: Quality improvement studies in pediatric critical care medicine. Pediatr Crit Care Med. 2021; 22:662–668
29. Inata Y, Nakagami-Yamaguchi E, Ogawa Y, et al.: Quality assessment of the literature on quality improvement in PICUs: A systematic review. Pediatr Crit Care Med. 2021; 22:553–560
30. Karube T, Karsies TJ: Can we change the culture around fever in the PICU? Pediatr Crit Care Med. 2023; 24:705–707
31. Feldman E, Shah SS, Ahn D: Low diagnostic utility of frequent serial tracheal aspirate cultures in the PICU. Pediatr Crit Care Med. 2023; 24:681–689
32. Prinzi AM, Chiotos K: Repeat tracheal aspirate cultures: A port in the storm or a sinking ship? Pediatr Crit Care Med. 2023; 24:708–710
33. Undar A, Kunselman AR, Barbaro RP, et al.: Centrifugal or roller pumps for neonatal venovenous extracorporeal membrane oxygenation: Extracorporeal life support organization database comparison of mortality and morbidity. Pediatr Crit Care Med. 2023; 24:662–669
34. Pineda EY, Sallam M, Breuer RK, et al.: Asthma cases treated with inhaled anesthetics or extracorporeal membrane oxygenation: A virtual pediatric systems database study of outcomes. Pediatr Crit Care Med. 2023; 24:e397–e402
35. O’Hara JE, Buchmiller TL, Bechard LJ, et al.: Long-term functional outcomes at 1-year after hospital discharge in critically ill neonates with congenital diaphragmatic hernia. Pediatr Crit Care Med. 2023; 24:e372–e381
36. Dennis JL, Jordan J, Rice M, et al.: Enteral nutrition during extracorporeal membrane oxygenation in the neonatal and pediatric populations: A literature review. Pediatr Crit Care Med. 2023; 24:e382–e389
37. Danzer E, Massey SL, Flohr SJ, et al.: Extracorporeal membrane oxygenation for neonates with congenital diaphragmatic hernia: Prevalence of seizures and outcomes. Pediatr Crit Care Med. 2023; 24:e224–e235
38. Bratt Carle JL: The exchange. Pediatr Crit Care Med. 2023; 24:690–691