Anand Acharya

A Randomized Controlled Trial of Corticosteroids in Pediatric Septic Shock: A Pilot Feasibility Study*

Objective: To determine the feasibility of conducting a randomized controlled trial of corticosteroids in pediatric septic shock. Design: Randomized, double-blind, placebo controlled trial. Setting: Seven tertiary level PICUs in Canada. Patients: Children newborn to 17 years old inclusive with suspected septic shock. Intervention: Administration of IV hydrocortisone versus placebo until hemodynamic stability is achieved or for a maximum of 7 days. Measurements and Main Results: One hundred seventy-four patients were potentially eligible of whom 101 patients met eligibility criteria. Fifty-seven patients were randomized, and 49 patients (23 and 26 patients in the hydrocortisone and placebo groups, respectively) were included in the final analysis. The mean time from screening to randomization was 2.4 ± 2.1 hours and from screening to first dose of study drug was 3.8 ± 2.6 hours. Forty-two percent of potentially eligible patients (73/174) received corticosteroids prior to randomization: 38.5% (67/174) were already on corticosteroids for shock at the time of screening, and in 3.4% (6/174), the treating physician wished to administer corticosteroids. Six of 49 randomized patients (12.2%) received open-label steroids, three in each of the hydrocortisone and placebo groups. Time on vasopressors, days on mechanical ventilation, PICU and hospital length of stay, and the rate of adverse events were not statistically different between the two groups. Conclusions: This study suggests that a large randomized controlled trial on early use of corticosteroids in pediatric septic shock is potentially feasible. However, the frequent use of empiric corticosteroids in otherwise eligible patients remains a significant challenge. Knowledge translation activities, targeted recruitment, and alternative study designs are possible strategies to mitigate this challenge.

Abstract P-316: THE IMPACT OF THE PRESENCE OF LONG-STAY PATIENTS ON PEDIATRIC INTENSIVE CARE UNIT PATIENT FLOW

The integrity of the rectum tissue of rats in group RC was superior to that of CB and NT groups with less inflammatory infiltration under mucosa in the former group. Escherichia coli was found in the culture plate containing tissues of MLN in the RC group. On the other hand, Escherichia coli, Proteus vulgaris, Stenotrophomonas maltophilia, and Acinetobacter lwoffii were detected in culture plates containing tissues of MLN, spleen, and liver in NT and CB groups. The concentration of DAO and D-lactate decreased at 12h in group RC, which was predominant than that in group CB, and increased at 24h in both RC and CB groups (P<0.05).

Abstract P-039: DEFINING LONG-STAY PATIENTS IN THE PEDIATRIC INTENSIVE CARE UNIT

Long-stay patients (LSPs) account for ~8% of admissions to pediatric intensive care units (PICUs) and use up to 50% of hospital resources, but there is no consensus definition for LSPs. Therefore, we surveyed key PICU stakeholders to assess their perspectives regarding the importance of defining LSPs, the components the definition should include, the preferred method for deriving the definition, and the definitions’ characteristics.

Random serum free cortisol and total cortisol measurements in pediatric septic shock

Abstract Background The aim of the study was to examine the relationship between serum total cortisol (TC) and free cortisol (FC) levels in children with septic shock and the relationship of these levels with baseline illness severity. Methods A sub-study of a randomized controlled trial (RCT) of hydrocortisone vs. placebo in pediatric septic shock conducted in seven academic pediatric intensive care units (PICUs) in Canada on children aged newborn to 17 years. Thirty children with septic shock had serum sent for TC and FC measurement within 6 h of meeting the study eligibility criteria. Results Baseline FC and TC levels were strongly correlated with baseline Pediatric Risk of Mortality (PRISM) score (R2=0.759, p<0.001; R2=0.717, p<0.001) and moderately correlated with admission Vasotropic Inotropic Score (VIS) (R2=0.489, p<0.001; R2=0.316, p<0.001). Serum TC levels were highly correlated with FC levels (R2=0.92, p<0.001) and showed strong agreement (R2=0.98, p<0.001 on a Bland-Altman plot). The ratio of FC to TC moderately correlated with TC levels (R2=0.46, p<0.001) but did not correlate with baseline albumin levels (R2=0.19, p=0.13). Conclusions Random TC and FC levels are strongly correlated, show strong agreement and are reflective of illness severity in children with septic shock. As such, isolated FC measurement does not appear to provide added information relative to TC in acutely ill children with septic shock.

A Pragmatic Method for Identification of Long-Stay Patients in the PICU

OBJECTIVES To develop a pragmatic method of identifying long-stay patients (LSPs) in the PICU. METHODS We surveyed 40 expert stakeholders in 14 Canadian PICUs between February 2015 and March 2015 to identify key factors to use for defining LSPs in the PICU. We then describe a pragmatic method using these factors to analyze 523 admissions to an academic, tertiary-care PICU from February 1, 2015, to January 31, 2016. RESULTS The overall response rate was 70% (28 of 40). Of respondents, 75% (21of 28) stated that it was important to define LSPs and identified present and future resource consumption (18 of 21 [86%] and 16 of 21 [76%], respectively) as the key reasons for defining LSPs. Respondents valued a definition that was consistent and ranked a percentile cutoff as the preferred analytic method for defining LSPs. Of respondents, 86% (24 of 28) though the LSP definition should include factors other than length of stay. We developed a surrogate marker for LSPs using mechanical ventilation and presence of a central venous catheter in our sample population to compare to varying percentile cutoffs. We identified 108 patients at the 80th percentile as LSPs who used 67% of total bed days and had a median length of stay of 11.3 days. CONCLUSIONS We present a pragmatic method for the retrospective identification of LSPs in the PICU that incorporates unit- and/or patient-specific characteristics. The next steps would be to validate this method using other patient and/or unit characteristics in different PICUs and over time.