@article {10490, title = {Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome.}, journal = {Pediatr Crit Care Med}, volume = {18}, year = {2017}, month = {2017 02}, pages = {e86-e91}, abstract = {

OBJECTIVES: Withdrawal syndrome is an adverse reaction of analgesic and sedative therapy, with a reported occurrence rate between 17\% and 57\% in critically ill children. Although some factors related to the development of withdrawal syndrome have been identified, there is weak evidence for the effectiveness of preventive and therapeutic strategies. The main aim of this study was to evaluate the frequency of withdrawal syndrome in Italian PICUs, using a validated instrument. We also analyzed differences in patient characteristics, analgesic and sedative treatment, and patients{\textquoteright} outcome between patients with and without withdrawal syndrome.

DESIGN: Observational multicenter prospective study.

SETTING: Eight Italian PICUs belonging to the national PICU network Italian PICU network.

PATIENTS: One hundred thirteen patients, less than 18 years old, mechanically ventilated and treated with analgesic and sedative therapy for five or more days. They were admitted in PICU from November 2012 to May 2014.

INTERVENTIONS: Symptoms of withdrawal syndrome were monitored with Withdrawal Assessment Tool-1 scale.

MEASUREMENTS AND MAIN RESULTS: The occurrence rate of withdrawal syndrome was 64.6\%. The following variables were significantly different between the patients who developed withdrawal syndrome and those who did not: type, duration, and cumulative dose of analgesic therapy; duration and cumulative dose of sedative therapy; clinical team judgment about analgesia and sedation{\textquoteright}s difficulty; and duration of analgesic weaning, mechanical ventilation, and PICU stay. Multivariate logistic regression analysis revealed that patients receiving morphine as their primary analgesic were 83\% less likely to develop withdrawal syndrome than those receiving fentanyl or remifentanil.

CONCLUSIONS: Withdrawal syndrome was frequent in PICU patients, and patients with withdrawal syndrome had prolonged hospital treatment. We suggest adopting the lowest effective dose of analgesic and sedative drugs and frequent reevaluation of the need for continued use. Further studies are necessary to define common preventive and therapeutic strategies.

}, keywords = {Adolescent, Analgesics, Child, Child, Preschool, Critical Care, Female, Humans, Hypnotics and Sedatives, Iatrogenic Disease, Infant, Infant, Newborn, Intensive Care Units, Pediatric, Italy, Logistic Models, Male, Prospective Studies, Respiration, Artificial, Substance Withdrawal Syndrome}, issn = {1529-7535}, doi = {10.1097/PCC.0000000000001054}, author = {Amigoni, Angela and Mondardini, Maria Cristina and Vittadello, Ilaria and Zaglia, Federico and Rossetti, Emanuele and Vitale, Francesca and Ferrario, Stefania and Savron, Fabio and Coffaro, Giancarlo and Brugnaro, Luca and Amato, Roberta and Wolfler, Andrea and Franck, Linda S} } @article {8508, title = {Efficacy of ketamine in refractory convulsive status epilepticus in children: a protocol for a sequential design, multicentre, randomised, controlled, open-label, non-profit trial (KETASER01).}, journal = {BMJ Open}, volume = {6}, year = {2016}, month = {2016}, pages = {e011565}, abstract = {

INTRODUCTION: Status epilepticus (SE) is a life-threatening neurological emergency. SE lasting longer than 120 min and not responding to first-line and second-line antiepileptic drugs is defined as {\textquoteright}refractory{\textquoteright} (RCSE) and requires intensive care unit treatment. There is currently neither evidence nor consensus to guide either the optimal choice of therapy or treatment goals for RCSE, which is generally treated with coma induction using conventional anaesthetics (high dose midazolam, thiopental and/or propofol). Increasing evidence indicates that ketamine (KE), a strong N-methyl-d-aspartate glutamate receptor antagonist, may be effective in treating RCSE. We hypothesised that intravenous KE is more efficacious and safer than conventional anaesthetics in treating RCSE.

METHODS AND ANALYSIS: A multicentre, randomised, controlled, open-label, non-profit, sequentially designed study will be conducted to assess the efficacy of KE compared with conventional anaesthetics in the treatment of RCSE in children. 10 Italian centres/hospitals are involved in enrolling 57 patients aged 1 month to 18 years with RCSE. Primary outcome is the resolution of SE up to 24 hours after withdrawal of therapy and is updated for each patient treated according to the sequential method.

ETHICS AND DISSEMINATION: The study received ethical approval from the Tuscan Paediatric Ethics Committee (12/2015). The results of this study will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER: NCT02431663; Pre-results.

}, issn = {2044-6055}, doi = {10.1136/bmjopen-2016-011565}, author = {Rosati, Anna and Ilvento, Lucrezia and L{\textquoteright}Erario, Manuela and De Masi, Salvatore and Biggeri, Annibale and Fabbro, Giancarlo and Bianchi, Roberto and Stoppa, Francesca and Fusco, Lucia and Pulitan{\`o}, Silvia and Battaglia, Domenica and Pettenazzo, Andrea and Sartori, Stefano and Biban, Paolo and Fontana, Elena and Cesaroni, Elisabetta and Mora, Donatella and Costa, Paola and Meleleo, Rosanna and Vittorini, Roberta and Conio, Alessandra and Wolfler, Andrea and Mastrangelo, Massimo and Mondardini, Maria Cristina and Franzoni, Emilio and McGreevy, Kathleen S and Di Simone, Lorena and Pugi, Alessandra and Mirabile, Lorenzo and Vigevano, Federico and Guerrini, Renzo} } @article {8301, title = {The Importance of Mortality Risk Assessment: Validation of the Pediatric Index of Mortality 3 Score.}, journal = {Pediatr Crit Care Med}, volume = {17}, year = {2016}, month = {2016 Mar}, pages = {251-6}, abstract = {

OBJECTIVE: To evaluate the performance of the newest version of the Pediatric Index of Mortality 3 score and compare it with the Pediatric Index of Mortality 2 in a multicenter national cohort of children admitted to PICU.

DESIGN: Retrospective, prospective cohort study.

SETTING: Seventeen Italian PICUs.

PATIENTS: All children 0 to 15 years old admitted in PICU from January 2010 to October 2014.

INTERVENTIONS: None.

MEASUREMENT AND MAIN RESULTS: Eleven thousand one hundred nine children were enrolled in the study. The mean Pediatric Index of Mortality 2 and 3 values of 4.9 and 3.9, respectively, differed significantly (p < 0.05). Overall mortality rate was 3.9\%, and the standardized mortality ratio was 0.80 for Pediatric Index of Mortality 2 and 0.98 for Pediatric Index of Mortality 3 (p < 0.05). The area under the curve of the receiver operating characteristic curves was similar for Pediatric Index of Mortality 2 and Pediatric Index of Mortality 3. The Hosmer-Lemeshow test was not significant for Pediatric Index of Mortality 3 (p = 0.21) but was highly significant for Pediatric Index of Mortality 2 (p < 0.001), which overestimated death mainly in high-risk categories.

CONCLUSIONS: Mortality indices require validation in each country where it is used. The new Pediatric Index of Mortality 3 score performed well in an Italian population. Both calibration and discrimination were appropriate, and the score more accurately predicted the mortality risk than Pediatric Index of Mortality 2.

}, issn = {1529-7535}, doi = {10.1097/PCC.0000000000000657}, author = {Wolfler, Andrea and Osello, Raffaella and Gualino, Jenny and Calderini, Edoardo and Vigna, Gianluca and Santuz, Pierantonio and Amigoni, Angela and Savron, Fabio and Caramelli, Fabio and Rossetti, Emanuele and Cecchetti, Corrado and Corbari, Maurizio and Piastra, Marco and Testa, Raffaele and Coffaro, Giancarlo and Stancanelli, Giusi and Gitto, Eloisa and Amato, Roberta and Prinelli, Federica and Salvo, Ida} } @article {1767, title = {Daily practice of mechanical ventilation in Italian pediatric intensive care units: a prospective survey.}, journal = {Pediatr Crit Care Med}, volume = {12}, year = {2011}, month = {2011 Mar}, pages = {141-6}, abstract = {

OBJECTIVES: To assess how children requiring endotracheal intubation are mechanically ventilated in Italian pediatric intensive care units (PICUs).

DESIGN: A prospective, national, observational, multicenter, 6-month study.

SETTING: Eighteen medical-surgical PICUs.

PATIENTS: A total of 1943 consecutive children, aged 0-16 yrs, admitted between November 1, 2006 and April 30, 2007.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Data on cause of respiratory failure, length of mechanical ventilation (MV), mode of ventilation, use of specific interventions were recorded for all children requiring endotracheal intubation for >24 hrs. Children were stratified for age, type of patient, and cause of respiratory failure. A total of 956 (49.2\%) patients required MV via an endotracheal tube; 673 (34.6\%) were ventilated for >24 hrs. The median length of MV was 4.5 days for all patients. If postoperative patients were excluded, the median time was 5 days. Bronchiolitis (6.7\%), pneumonia (6.7\%), and upper airway obstruction (5.3\%) were the most frequent causes of acute respiratory failure, and altered mental status (9.2\%) was the most frequent reason for MV. The overall mortality was 6.7\% with highest rates for heart disease (nonoperative), sepsis, and acute respiratory distress syndrome (26.1\%, 22.2\%, and 16.7\% respectively). Length of stay, associated chronic disease, severity score on admission, and PICU mortality were significantly higher in children who received MV (p < .05) than in children who did not. Controlled MV and pressure support ventilation + synchronized intermittent mandatory ventilation were the most frequently used modes of ventilatory assistance during PICU stay.

CONCLUSIONS: Mechanical ventilation is frequently used in Italian PICUs with almost one child of two requiring endotracheal intubation. Children treated with MV represent a more severe category of patients than children who are breathing spontaneously. Describing the standard care and how MV is performed in children can be useful for future clinical studies.

}, keywords = {Adolescent, Child, Child, Preschool, Clinical Protocols, Female, Humans, Infant, Infant, Newborn, Intensive Care Units, Pediatric, Intubation, Intratracheal, Italy, Male, Prospective Studies, Respiration, Artificial, Respiratory Insufficiency}, issn = {1529-7535}, doi = {10.1097/PCC.0b013e3181dbaeb3}, author = {Wolfler, Andrea and Calderoni, Edoardo and Ottonello, Giancarlo and Conti, Giorgio and Baroncini, Simonetta and Santuz, Pierantonio and Vitale, Pasquale and Salvo, Ida} }