Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

BACKGROUND: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1–6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event

Resting Energy Expenditure assessment in mechanically ventilated critically ill children: the importance of Indirect Calorimetry

Introduction. Malnutrition is common in critically ill children, and is considered a negative prognostic factor for their clinical outcomes1,2. Traditionally, Resting Energy Expenditure (REE) is calculated using predictive equations. These equations might be inaccurate in the critical scenario. Indirect Calorimetry (IC) is the gold standard to measure REE and allows tailored nutrition support3 . Aim of the study was to evaluate the accuracy of commonly employed equations as compared to IC-derived values in critically ill children. Methods. Children admitted to our unit between January 2017 and March 2019, aged &lt;18 years and mechanically ventilated were enrolled. Endotracheal tube leak &gt;10% and/or a fraction of inspired oxygen 650.6 constituted exclusion criteria. Harris-Benedict, Schofield and WHO formulae were applied to estimate REE. We performed IC for 30 minutes and REE was measured. The agreement between IC- and equation-based values of REE was assessed via paired t-test and BlandAltman analysis. Data are expressed as mean and standard deviation. Statistical significance was defined as p&lt;0.05. Results. Forty-four critically ill children (4.3\ub14.2 years, 18.1\ub116.4 kg) admitted for acute respiratory failure (n=24), neurological (n=13) or other diseases (n=7) were studied. Measured REE ranged between 16 and 89 kcal/kg/die (mean 43\ub115). Typically, all formulae significantly over-estimated the REE, as compared to IC (Table 1). Furthermore, the Bland-Altman analysis revealed wide limits of agreement, suggesting low accuracy of the prediction equations. Conclusions. In critically ill, mechanically ventilated patients REE is on average significantly lower than predicted by currently applied equations. This finding might be explained by a reduced work of breathing and/or the use of sedatives and paralyzing agents. Measurement of REE through IC is essential to avoid over/underfeeding in this population. References 1. Agostoni C et al. JPGN 2016 2. Taku Oshima et al. Clinical Nutr 2017 3. Smallwood CD et al. J Pediatr. 201

Gas-exchange and resting energy expenditure measurement with indirect calorimetry in children supported with non-invasive ventilation

Introduction. Nutrition plays a fundamental role in critically ill children and personalized nutritional therapy requires the measurement of resting energy expenditure (REE) [1-2]. Indirect calorimetry (IC) is the gold standard for REE assessment and is based on V\ue22fO2 and V\ue22fCO2 measurements. Furthermore, IC provides information on carbohydrates/lipids consumption by defining the respiratory quotient (RQ). However, while IC is validated for spontaneously breathing and mechanically ventilated patients, it is not for patients undergoing non-invasive ventilation (NIV) [3]. Aim of the study is therefore to validate IC for children undergoing NIV by comparing IC results obtained during spontaneous breathing with data gathered during NIV-CPAP (continuous positive airway pressure). Methods. Patients (age &lt;6 years) admitted to our pediatric intensive care unit (PICU) and weaning from NIV-CPAP were enrolled. Two IC measurements (Canopy mode) were performed for 20 minutes in randomized order in the following conditions: 1) Spontaneous breathing (SB), 2) NIV-CPAP (performed by single-limb circuit and vented mask). Average values for V\ue22fCO2 , V\ue22fO2, RQ and REE were obtained in the two conditions. Comparison between groups was performed via paired t-test. Agreement was assessed via Bland-Altman analysis. Statistical significance was defined as p&lt;0.05. Results. Four patients (median age 8 months, median weight 8 kg) were enrolled. V\ue22fCO2 , V\ue22fO2, RQ and REE did not differ significantly between groups. Limits of agreement (LOA) and BIAS indicate a good agreement between the two measures (Table 1). Conclusions. Our preliminary data suggest that IC can be accurately performed in children undergoing NIV using a single limb circuit with intentional leaks. These results need to be confirmed on a broader cohort of critically ill children. References 1. De Cosmi V et al. Nutrients. 2017, 18:9 2. Mehta NM et al. Pediatr Crit Care Med. 2017, 18:675-715 3. Taku Oshima et al. Clinical Nutr 2017; 36:651-66

Fluid therapy in mechanically ventilated critically ill children: the sodium, chloride and water burden of fluid creep

Background: Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU). We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. Methods: Critically ill children aged 643 years and invasively ventilated for 6548 h between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 h following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. Results: Forty-three patients (median 7 months (IQR 3-15)) were enrolled. Patients received 1004 \ub1 284 ml of water daily (153 \ub1 36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4 \ub1 4.8 mEq/kg/day of sodium and 13.6 \ub1 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417 \ub1 221 ml (64 \ub1 30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p &lt; 0.001). Conclusions: Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children

Efficacy and safety of exogenous surfactant therapy in patients under 12 months of age invasively ventilated for severe bronchiolitis (SURFABRON): Protocol for a multicentre, randomised, double-blind, controlled, non-profit trial

Introduction Some evidence indicates that exogenous surfactant therapy may be effective in infants with acute viral bronchiolitis, even though more confirmatory data are needed. To date, no large multicentre trials have evaluated the effectiveness and safety of exogenous surfactant in severe cases of bronchiolitis requiring invasive mechanical ventilation (IMV). Methods and analysis This is a multicentre randomised, placebo-controlled, double-blind study, performed in 19 Italian paediatric intensive care units (PICUs). Eligible participants are infants under the age of 12 months hospitalised in a PICU, suffering from severe acute hypoxaemic bronchiolitis, requiring IMV. We adopted a more restrictive definition of bronchiolitis, including only infants below 12 months of age, to maintain the population as much homogeneous as possible. The primary outcome is to evaluate whether exogenous surfactant therapy (Curosurf, Chiesi Pharmaceuticals, Italy) is effective compared with placebo (air) in reducing the duration of IMV in the first 14 days of hospitalisation, in infants suffering from acute hypoxaemic viral bronchiolitis. Secondary outcomes are duration of non-invasive mechanical ventilation in the post-extubation phase, number of cases requiring new intubation after previous extubation within 14 days from randomisation, PICU and hospital length of stay (LOS), duration of oxygen dependency, effects on oxygenation and ventilatory parameters during invasive mechanical respiratory support, need for repeating treatment within 24 hours of first treatment, use of other interventions (eg, high-frequency oscillatory ventilation, nitric oxide, extracorporeal membrane oxygenation), mortality within the first 14 days of PICU stay and before hospital discharge, side effects and serious adverse events. Ethics and dissemination The trial design and protocol have received approval by the Italian National Agency for Drugs (AIFA) and by the Regional Ethical Committee of Verona University Hospital (1494CESC). Findings will be disseminated through publication in peer-reviewed journals, conference/meeting presentations and media. Trial registration number Clinicaltrials.gov, issue date 22 May 2019. NCT03959384