February 2023 of Pediatric Critical Care Medicine (PCCM) is an issue worthy of this year’s Society of Critical Care Medicine (SCCM) annual conference. All content is excellent, but my focus this month is to highlight two Late Breaker articles (i.e., not previously published ahead of print) and a Special Article as my Editor’s Choices (1–3), and to draw your attention to this month’s PCCM Connections with another focus on Respiratory Critical Care Practice.
WHAT IS THE POTENTIAL IMPACT OF WITHHOLDING TRANSFUSION IN HEMODYNAMICALLY STABLE CHILDREN WITHOUT CARDIAC DISEASE AND HEMOGLOBIN ABOVE 7 G/DL?
Steffen KM, Tucci M, Doctor A, et al; Pediatric Critical Care Blood Research Network (BloodNet) subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the ABC-PICU Trial (1).
My first Editor’s Choice article is the first PCCM late breaker report for the SCCM meeting. The authors have performed a nonprespecified, secondary analysis of transfusion and outcomes data in over 650 children from 50 international centers recruited (2014−2018) in the age of blood in children in PICUs (ABC-PICU) trial. Our authors are particularly interested in one of the recommendations of the 2018 consensus from the Transfusion and Anemia Expertise Initiative (TAXI), i.e., the red blood cell transfusion threshold of < 7 g/dL (4). Read the article to find out the theoretical consequence of compliance with restrictive transfusion in hemodynamically stable patients on two outcomes (PICU-free and ventilator-free days), and the likely associated odds of new or progressive multiorgan system dysfunction. The editorial provides us with important insight into this post hoc analysis of the ABC-PICU data, as well as giving readers the additional context of implementing the TAXI guidance (5).
WHAT DO WE KNOW ABOUT LONG-TERM CONSEQUENCES OF POST-TRAUMATIC STRESS DISORDER IN PARENTS OF PICU PATIENTS?
Whyte-Nesfield MW, Kaplan D, Eldridge P, et al: Pediatric Critical Care Associated Parental Traumatic Stress: Beyond the First Year (2).
My second Editor’s Choice and late breaker article is a prospective PICU follow-up study of approximately 200 parents who completed assessments about post-traumatic stress (PTS). The study addresses two very important issues: 1) the detrimental effects of acute and subacute parental PTS up to 30 months after PICU discharge; and 2) the identifiable explanatory factors that may be targets for help and mitigation. The editorial is written by one of PCCM’s much valued experts in clinical psychology, and the challenge for us is whether it is time for “the Trauma Informed PICU” (6).
WHAT ARE THE CONTEMPORARY INTERNATIONAL GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME?
Emeriaud G, López-Fernandez YM, Iyer NP, et al; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Executive Summary of the Second Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2) (3).
My third Editor’s Choice article is a Special Article for PCCM that summarizes the work of the second pediatric acute lung injury consensus conference (PALICC-2) group. In this article, 52 international experts have collaborated to update the PALICC 2015 guidelines for pediatric acute respiratory distress syndrome (PARDS) using literature searches through to April 2022. We now have 146 recommendations and statements. PCCM has devoted an extended-page format to this outstanding and important content. In addition to the text and narrative, you will find excellent summaries in tables and figures. There is a full supplement accompanying this issue of PCCM, with 12 articles on specialist topic areas that inform the executive summary. In conjunction, this work represents the 2023 benchmark of 1980 to 2022 data about PARDS.
“PCCM CONNECTIONS” FOR READERS
The publication of PALICC-2 (3) also provides us with another opportunity to focus on respiratory critical care practice (see also the December 2022 issue).
First, we have a feature article (7), with an editorial (8), about critical care and invasive mechanical ventilation (IMV) practices surrounding liver transplantation. The retrospective analysis comes from 12 PICUs in the U.S. and looks at the time course of IMV in 330 children. The editorial helps us to better understand the range in use of IMV in this setting.
Second, we have a database study using the Pediatric Health Information System in the U.S (9). In this article the authors have focused on the timing of tracheostomy at 52 children’s hospitals in over 10,000 children, in the period 2010 to 2020. This unique report is a major resource and needs to be read in conjunction with PCCM’s recent articles on tracheostomy and prolonged IMV (10–14).
Third, it is back to the all-important topic of bronchiolitis and supportive respiratory care. We have two systematic reviews: one on noninvasive ventilation (NIV) in acute respiratory failure–four of 15 articles were about bronchiolitis care (15); the other on use of high-flow nasal cannula (HFNC) oxygen therapy or NIV in 28 reports of bronchiolitis (16). We also have a retrospective study of oxygen exposure during IMV in 176 patients with bronchiolitis, in which the authors are interested in oxygen overuse and the potential for optimal oxygenation targets (17). In this context, please look at the recently published protocol for the randomized controlled trial on conservative versus liberal oxygenation targets in critically ill children (18). To close these readings on bronchiolitis, have a look at the single-center quality improvement initiative on using a protocol for the initiation and weaning of HFNC oxygen for patients with bronchiolitis (19). Accompanying this article, our editorial describes a robust and cogent call to action (20).
Finally, I am pleased to highlight two narrative reviews on the topic of respiratory critical care practice that will be useful additions to your reading of the PALICC-2 guidelines (3). First, go back to the December 2022 issue and the review on “clinical challenges of pediatric ventilation liberation” (21). Next, read the beautifully illustrated PCCM Concise Clinical Physiology Review on approaches to mechanical ventilation for patients with PARDS (22).
1. Steffen KM, Tucci M, Doctor A, et al.; Pediatric Critical Care Blood Research Network (BloodNet) subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: The impact of restrictive transfusion practices on hemodynamically stable critically ill children without heart disease: A secondary analysis of the ABC-PICU trial. Pediatr Crit Care Med 2023; 24:84–92
2. Whyte-Nesfield M, Kaplan D, Eldridge P, et al.: Pediatric critical care–associated parental traumatic stress: Beyond the first year. Pediatr Crit Care Med 2023; 24:93–101
3. Emeriaud G, López-Fernandez YM, Iyer NP, et al.; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) Group: Executive summary of the second guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PALICC-2). Pediatr Crit Care Med 2023; 24:143–168
4. Valentine SL, Bembea MM, Muszynski JA, et al.; Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI): Consensus recommendations for RBC transfusion practices in criticall ill children from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med 2018; 19:884–898
5. Parker RI: RBC transfusion practices: Are we the tortoise or are we the hare? Pediatr Crit Care Med 2023; 24:169–181
6. Colville G: Is it time for the “trauma informed” PICU? Pediatr Crit Care Med 2023; 24:171–173
7. Maue DK, Martinez M, Alcamo A, et al.: Critical care and mechanical ventilation practices surrounding liver transplantation in children: A multicenter collaborative. Pediatr Crit Care Med 2023; 24:102–111
8. Deep A: Duration of invasive mechanical ventilation post-liver transplantation: Does one size fit all? Pediatr Crit Care Med 2023; 24:174–176
9. Mehrotra P, Thomas C, Gerber LM, et al.: Timing of tracheostomies in critically ill infants and children with respiratory failure: A PHIS study. Pediatr Crit Care Med 2023; 24:e66–e75
10. Meyer-Macaulay CB, Dayre McNally J, O’Hearn K, et al.: Factors impacting physician recommendation for tracheostomy placement in pediatric prolonged mechanical ventilation: A cross-sectional survey on stated practice. Pediatr Crit Care Med 2019; 20:e423–e431
11. Biban P: When is prolonged mechanical ventilation long enough to prompt tracheostomy in children? A still unanswered question. Pediatr Crit Care Med 2019; 20:895–897
12. Colleti J Jr, Azevedo RT, de Oliveira Caino FR, et al.: Prolonged mechanical ventilation in children: review of the definition. Pediatr Crit Care Med 2021; 22:e588–e593
13. Butler EK, Killien EY, Groner JI, et al.: Optimal timing of tracheostomy in injured adolescents. Pediatr Crit Care Med 2021; 22:629–641
14. Kohne JG, MacLaren G, Rider E, et al.: Tracheostomy practices and outcomes in children during respiratory extracorporeal membrane oxygenation. Pediatr Crit Care Med 2022; 23:268–276
15. 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
16. Gutiérrez Moreno M, del Villar Guerra P, Medina A, et al.: High-flow oxygen and other noninvasive support therapies in bronchiolitis: Systematic review and network meta-analysis. Pediatr Crit Care Med 2023; 24:133–142
17. Lilien TA, de Sonnaville ESV, van Woensel JBM, et al.: The local and systemic exposure to oxygen in children with severe bronchiolitis on invasive mechanical ventilation: A retrospective cohort study. Pediatr Crit Care Med 2023; 24:e115–e120
18. 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
19. Huang JX, Colwell B, Vadlaputi P, et al.: Protocol-driven initiation and weaning of high-flow nasal cannula for patients with bronchiolitis: A quality improvement initiative. Pediatr Crit Care Med 2023; 24:112–122
20. Marx MHM, Shein SL: Deaf ears, blind eyes, and driverless cars. Pediatr Crit Care Med 2023; 24:177–179
21. van Dijk J, Blokpoel RGT, Abu-Sultaneh S, et al.: Clinical challenges in pediatric ventilation liberation: A meta-narrative review. Pediatr Crit Care Med 2022; 23:999–1008
22. Cruces P: Pediatric acute respiratory distress syndrome: Approaches to mechanical ventilation. Pediatr Crit Care Med 2022; 23:e104–e114