BackgroundContinuous Glucose Monitoring (CGM) has become an increasingly investigated tool, especially with regards to monitoring of diabetic and critical care patients. The continuous glucose data allows the calculation of several glucose variability parameters, however, without specific application the interpretation of the results is time-consuming, utilizing extreme efforts. Our aim was to create an open access software [Glycemic Variability Analyzer Program (GVAP)], readily available to calculate the most common parameters of the glucose variability and to test its usability.MethodsThe GVAP was developed in MATLAB® 2010b environment. The calculated parameters were the following: average area above/below the target range (Avg. AUC-H/L); Percentage Spent Above/Below the Target Range (PATR/PBTR); Continuous Overall Net Glycemic Action (CONGA); Mean of Daily Differences (MODD); Mean Amplitude of Glycemic Excursions (MAGE). For verification purposes we selected 14 CGM curves of pediatric critical care patients. Medtronic® Guardian® Real-Time with Enlite® sensor was used. The reference values were obtained from Medtronic®’s own software for Avg. AUC-H/L and PATR/PBTR, from GlyCulator for MODD and CONGA, and using manual calculation for MAGE.ResultsThe Pearson and Spearman correlation coefficients were above 0.99 for all parameters. The initial execution took 30 minutes, for further analysis with the Windows® Standalone Application approximately 1 minute was needed.ConclusionsThe GVAP is a reliable open access program for analyzing different glycemic variability parameters, hence it could be a useful tool for the study of glycemic control among critically ill patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12938-015-0035-3) contains supplementary material, which is available to authorized users.

BackgroundAmplitude-integrated electroencephalography (aEEG) is a useful tool to determine the severity of neonatal hypoxic-ischemic encephalopathy (HIE). Our aim was to assess the prevalence and study the origin of false normal aEEG recordings based on 85 aEEG recordings registered before six hours of age.MethodsRaw EEG recordings were reevaluated retrospectively with Fourier analysis to identify and describe the frequency patterns of the raw EEG signal, in cases with inconsistent aEEG recordings and clinical symptoms. Power spectral density curves, power (P) and median frequency (MF) were determined using the raw EEG. In 7 patients non-depolarizing muscle relaxant (NDMR) exposure was found. The EEG sections were analyzed and compared before and after NDMR administration.ResultsThe reevaluation found that the aEEG was truly normal in 4 neonates. In 3 neonates, high voltage electrocardiographic (ECG) artifacts were found with flat trace on raw EEG. High frequency component (HFC) was found as a cause of normal appearing aEEG in 10 neonates. HFC disappeared while P and MF decreased significantly upon NDMR administration in each observed case.ConclusionOccurrence of false normal aEEG background pattern is relatively high in neonates with HIE and hypothermia. High frequency EEG artifacts suggestive of shivering were found to be the most common cause of false normal aEEG in hypothermic neonates while high voltage ECG artifacts are less common.

BackgroundContinuous glucose monitoring (CGM) originally was developed for diabetic patients and it may be a useful tool for monitoring glucose changes in pediatric intensive care unit (PICU). Its use is, however, limited by the lack of sufficient data on its reliability at insufficient peripheral perfusion. We aimed to correlate the accuracy of CGM with laboratory markers relevant to disturbed tissue perfusion.Patients and MethodsIn 38 pediatric patients (age range, 0–18 years) requiring intensive care we tested the effect of pH, lactate, hematocrit and serum potassium on the difference between CGM and meter glucose measurements. Guardian® (Medtronic®) CGM results were compared to GEM 3000 (Instrumentation laboratory®) and point-of-care measurements. The clinical accuracy of CGM was evaluated by Clarke Error Grid -, Bland-Altman analysis and Pearson’s correlation. We used Friedman test for statistical analysis (statistical significance was established as a p < 0.05).ResultsCGM values exhibited a considerable variability without any correlation with the examined laboratory parameters. Clarke, Bland-Altman analysis and Pearson’s correlation coefficient demonstrated a good clinical accuracy of CGM (zone A and B = 96%; the mean difference between reference and CGM glucose was 1,3 mg/dL, 48 from the 780 calibration pairs overrunning the 2 standard deviation; Pearson’s correlation coefficient: 0.83).ConclusionsThe accuracy of CGM measurements is independent of laboratory parameters relevant to tissue hypoperfusion. CGM may prove a reliable tool for continuous monitoring of glucose changes in PICUs, not much influenced by tissue perfusion, but still not appropriate for being the base for clinical decisions.

Establishment of a proper hemodynamic monitoring system in order to achieve optimal care among critically ill patients is fundamental. In contrast to invasive patient-checking systems, which were introduced decades ago and used in both adult and pediatric intensive care, the non-invasive methods have become more popular in recent years due to technical advancements in intensive care and patient monitoring. This increase in popularity can be attributed to the higher degree of safety and reduced complication rates as well as to its being more economical. Our summary focuses on the ICON® patient monitoring system. This newly engineered, non-invasive tool is based on electrical cardiometry, and uses hemodynamic parameters in both neonatal and pediatric care as well as in adults. The operating principle is simple: the conductivity of the blood in the aorta shows time-dependent changes. Prior to the opening of the aortic valve, the orientation of the red blood cells (RBCs) is random, and it is not until the contraction of the aorta that the RBCs and the opening of the aortic valve achieve a parallel position. The tool senses the conductivity between four placed electrodes, and measures the stroke volume (SV) and cardiac output (CO), before calculating other additional parameters (eg.: systemic vascular resistance) by tracing the variation of bioimpedance according to changes in the heart cycle. The most important advantages of ICON® are the measurements that are made available immediately as well as continuously, and the low complication rate that originates from its non-invasive operation. ICON® is a new, promising hemodynamic device in the tool belt of intensive care. Due to the nature of the device, it is possible to evaluate the status of the patient on a continuous basis, allowing for optimal care. To identify the more accurate clinical indications further measures will be necessary. Orv Hetil. 2018; 159(44): 1775–1781.

In antithymocyte globulin (ATG) treated patients occasionally bradycardia has been noticed. Therefore, we retrospectively analyzed the occurrence of bradycardia in ATG-treated children. Using medical records between 2007 and 2012 we identified children undergoing a combined therapy with ATG and glucocorticoids (ATG group, n = 22). The incidence of bradycardia was compared to that registered in children treated with glucocorticoids alone (glucocorticoid alone group, n = 21). Heart rates (HR) were registered before and on days 0-3, 4-7 and 8-14 after the ATG or steroid administration. The rate of bradycardic episodes was higher during ATG therapy than in the steroid alone group, while severe bradycardia occurred only in the ATG group (97 versus 32, p = 0.0037, and 13 versus 0, p = 0.0029, respectively). There was an interaction between the time and treatment group on HR (p = 0.046). Heart rates in ATG and steroid alone groups differed significantly on day 0-3 and day 4-7 (p = 0.046, p = 0.006, respectively). Within the ATG group HR was lower on days 4-7 compared to the days before and the days 8-14 values (p < 0.001, 95%CI: 0.020-0.074). These findings indicate that transient asymptomatic bradycardia is probably more common with ATG therapy than previously reported. HR should be closely monitored during and after ATG therapy.

Background and aims: Nutritional support may improve outcome during Pediatric Intensive Care Unit (PICU) stay, but guidelines are limited and based on consensus rather than evidence. Aims: We aimed to study current practice in nutritional management of PICUs worldwide. Methods: An online questionnaire, composed of 59 questions, was distributed to members of the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The IRB waived the need for informed consent. Results: We analysed 189 questionnaires accounting for 89000 admissions in 156 PICUs covering 52 countries. A nutritional protocol and nutrition support team (NST) are present in respectively 52% and 57% of PICUs. Presence of a NST is associated with number of beds and admissions. Energy requirements are based on various equations and few PICUs use indirect calorimetry (14%). Lipid targets range from < 1.5 to > 3.5 g/ kg/day, protein targets from 0.9 to 3 g/kg/day. Glucose administration during the first 24 hours varies from <2 to >10 mg/kg/min. Enteral nutrition (EN), preferably by gastric tube (68-88%), is started within 24 hours after admission in 60% of the PICUs. In 55% of the PICUs parenteral nutrition (PN) is started within 48 hours in patients intolerable to EN. Insufficient EN, providing < 50% or < 80% of target calories, is respectively supplemented with PN in 48% and 24% of PICUs. Conclusions: Nutritional practices, in terms of requirements, timing and route, are highly variable in PICUs worldwide. Even the limited available guidelines are not consistently followed. The potential impact on outcome warrants uniform evidence based guidelines with consistent implementation.

research where there is exposure to background radiation and no therapeutic benefit to participants. Methods The ethical and regulatory issues encountered in the ERA-NET PRIOMEDCHILD project 'Paediatric Accelerator Mass Spectrometry Evaluation Research Study (PAMPER)' were analysed. These included the project design, scientific and ethical reviews, informed consent and recruitment processes. Infants 0-2 years were recruited in Estonia and the UK to study the pharmacokinetics (PK) of acetaminophen using accelerator mass spectrometry (AMS) bioanalysis. The study was considered in the context of the scientific, regulatory, and ethical frameworks guiding Phase 0 studies in adults and children. Results The science and ethics were developed in the protocol design and informed consent process, which resulted in approval of the study by research ethics committees in the UK and Estonia. Fifty-two babies were recruited into the study, with an acceptance rate of 50% among the parents approached. The study results demonstrated PK comparability between microdosing and therapeutic dosing in young children. Conclusions The PAMPER study showed the feasibility and validity of microdosing AMS PK studies in children, This methodology may provide a safer and more ethically robust approach for paediatric PK studies in certain drug models than more traditional PK study designs. The parameters and validation methods for microdosing AMS PK studies need to be reflected in regulatory guidance from the EMA, FDA and other authorities.Intensive Care I Background and aims The last decade gave clear evidence that hyper/hypoglycemia and glucose variability are associated with increased mortality in critically ill patients. Continuous glucose monitor (CGM) is a new device in paediatric critical care units (PICU) with clear advantages in glucose monitoring. The aim of our study was to survey the incidence of glucose regulation disorders in our PICU and specify the association between the PRISM III score and the glycemic variability [mean amplitude of glycemic action (MAGE)]. Methods We evaluated 22 children: mean age: 1.3 years, mean length of PICU stay: 18 days; 20/22 patients were on invasive mechanical ventilation; 6/22 needed vasoactive agent therapy. CGM duration: 1-12 days. Interstitial glucose level was monitored by Guardian ® REAL Time CGM (Medtronic ® ). Reference glucose values were obtained from blood gas analyzer or pointof-care glucose analyzer. We used Spearman correlation to evaluate the association between PRISM III and the MAGE. Results Hypo-and hyperglycemia (CGM glucose < 55 mg/dl / CGM glucose > 180 mg/dl) were detected in 4.6% and 2.5% of measurements, respectively. The mean MAGE (meaningful excursion >45 mg/dl) and PRISM III were 78 mg/dl and 19. We found a significant correlation between PRISM III and MAGE (r = 0,55; p < 0.05). Pearson's correlation coefficient (0.82) and Clarke Error Grid analysis (96% clinical accuracy) proved a good reliability of the CGM. PS-129Conclusions Glucose homeostasis disorders are frequent...