Objective To determine prevalence of delirium in critically-ill children and explore associated risk factors. Design Multi-institutional point-prevalence study. Setting Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia. Patients All children admitted to the pediatric critical care units on designated study days (n=994). Intervention Children were screened for delirium using the Cornell Assessment of Pediatric Delirium (CAPD) by the bedside nurse. Demographic and treatment-related variables were collected. Measurements and Main Results Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age < 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and anti-epileptics. Conclusions Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes, and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

WHAT'S KNOWN ON THIS SUBJECT: Pediatric Brain Injury Research Network investigators recently derived a highly sensitive clinical prediction rule for pediatric abusive head trauma (AHT). WHAT THIS STUDY ADDS:The performance of this AHT screening tool has been validated. Four clinical variables, readily available at the time of admission, detect pediatric AHT with high sensitivity in intensive care settings. abstract BACKGROUND AND OBJECTIVE: To reduce missed cases of pediatric abusive head trauma (AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to validate the screening performance of this AHT CPR in a new, equivalent patient population. METHODS:We conducted a prospective, multicenter, observational, cross-sectional study. Applying the same inclusion criteria, definitional criteria for AHT, and methods used in the completed derivation study, Pediatric Brain Injury Research Network investigators captured complete clinical, historical, and radiologic data on 291 acutely headinjured children ,3 years of age admitted to PICUs at 14 participating sites, sorted them into comparison groups of abusive and nonabusive head trauma, and measured the screening performance of the AHT CPR. RESULTS:In this new patient population, the 4-variable AHT CPR demonstrated sensitivity of .96, specificity of .46, positive predictive value of .55, negative predictive value of .93, positive likelihood ratio of 1.67, and negative likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified 98% of study patients who were ultimately diagnosed with AHT.CONCLUSIONS: Four readily available variables (acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture) identify AHT with high sensitivity in young, acutely head-injured children admitted to the PICU. Pediatrics 2014;134:e1537-e1544

Objectives Although critically ill children are at increased risk for developing deep venous thrombosis, there are few pediatric studies establishing the prevalence of thrombosis or the efficacy of thromboprophylaxis. We tested the hypothesis that thromboprophylaxis is infrequently used in critically ill children even for those in whom it is indicated. Design Prospective multinational cross-sectional study over four study dates in 2012. Setting Fifty-nine PICUs in Australia, Canada, New Zealand, Portugal, Singapore, Spain, and the United States. Patients All patients less than 18 years old in the PICU during the study dates and times were included in the study, unless the patients were 1) boarding in the unit waiting for a bed outside the PICU or 2) receiving therapeutic anticoagulation. Interventions None. Measurements and Main Results Of 2,484 children in the study, 2,159 (86.9%) had greater than or equal to 1 risk factor for thrombosis. Only 308 children (12.4%) were receiving pharmacologic thromboprophylaxis (e.g., aspirin, low-molecular-weight heparin, or unfractionated heparin). Of 430 children indicated to receive pharmacologic thromboprophylaxis based on consensus recommendations, only 149 (34.7%) were receiving it. Mechanical thromboprophylaxis was used in 156 of 655 children (23.8%) 8 years old or older, the youngest age for that device. Using nonlinear mixed effects model, presence of cyanotic congenital heart disease (odds ratio, 7.35; p < 0.001) and spinal cord injury (odds ratio, 8.85; p = 0.008) strongly predicted the use of pharmacologic and mechanical thromboprophylaxis, respectively. Conclusions Thromboprophylaxis is infrequently used in critically ill children. This is true even for children at high risk of thrombosis where consensus guidelines recommend pharmacologic thromboprophylaxis.

Cerebrovascular accidents are one of the life-threatening complications of diabetic ketoacidosis (DKA) in children and adolescents. Our objective was to evaluate the effect of DKA and its treatment on factors known to affect thrombotic activity (protein C; protein S; von Willebrand factor, fibrinogen; homocysteine; and folate) by comparing seven adolescents with DKA prior to treatment and at 6, 24, and 120 hours after initiation of treatment. We found that protein C activity was significantly decreased by DKA, but normalized slowly following treatment. Free protein S was low throughout the study. Protein C antigen and protein S antigen showed varying degrees ofchange within the first 24 hours, but remained in the normal range, with the exception of the initial value of protein C antigen, which was elevated. von Willebrand factor (vWF) antigen and vWF activity were both significantly increased prior to treatment, but decreased with treatment. However, vWF activity remained elevated at 120 hours. Fibrinogen concentrations showed no significant changes throughout the study. Homocysteine was significantly decreased prior to treatment and increased with the initiation of treatment Folate was significantly increased prior to treatment, and decreased to high normal levels. The increased vWF and the decreased levels of protein C activity and of free protein S support the hypothesis that DKA and its treatment results in a prothrombotic state and activation of the vascular endothelium, which, in turn, predispose to cerebrovascular accidents.

rs12252 was not associated with susceptibility to influenza-related critical illness in children or with critical illness severity. Our data also do not support it being a splice site.