Gonzalo Garcia Guerra

• University of Alberta

OBJECTIVES: In survivors of illnesses or surgeries requiring PICU admission, there is a risk of posttraumatic stress disorder (PTSD). We aimed to estimate PTSD prevalence and potential contributing factors in survivors of PICU admission. DATA SOURCES: We performed a PROSPERO registered systematic review (CRD42022348997; Registered August 2022) usin...

To determine: (i) frequency of probable post-traumatic stress disorder (PTSD) in mothers of infants after complex cardiac surgery (CCS), (ii) predictors of probable PTSD, and (iii) impact on child neurodevelopment. The Impact of Event Scale—Revised (IES-R) was administered to 60 mothers of infants ≥ 6 months after CCS at ≤ 6 weeks of age. The IES-R...

Background The rate of vitamin D deficiency (VDD) in critically ill children worldwide has been estimated at 50%. These children are at risk of multiple organ dysfunction, chronic morbidity, and decreased health related quality of life (HRQL). Pediatric and adult ICU clinical trials suggest that VDD is associated with worse clinical outcomes, altho...

Objective: To determine the 2-year neurodevelopmental outcomes for survivors of neonatal cardiac surgery for the most common right ventricular outflow tract obstructive lesions: Tetralogy of Fallot and pulmonary atresia with a ventricular septal defect. Study design: A single-center, consecutive cohort of 77 children underwent neonatal surgery f...

Background Withholding parenteral nutrition (PN) until one week after PICU admission facilitated recovery from critical illness and protected against emotional and behavioral problems 4 years later. However, the intervention increased the risk of hypoglycemia, which may have counteracted part of the benefit. Previously, hypoglycemia occurring under...

Background Acute kidney injury (AKI) in critically ill children is associated with increased risk for short- and long-term adverse outcomes. Currently, there is no systematic follow-up for children who develop AKI in intensive care unit (ICU). Objective This study aimed to assess variation regarding management, perceived importance, and follow-up...

This retrospective cohort study aimed to compare blood component transfusion before and after the implementation of a restrictive transfusion strategy (RTS) in pediatric cardiac Extracorporeal Life Support (ECLS) patients. The study included children admitted to the pediatric cardiac intensive care unit (PCICU) at the Stollery Children's Hospital w...

This retrospective cohort study describes all children transported on extracorporeal life support (ECLS) by the Stollery Children's Hospital Pediatric Transport team (SCH-PTT) between 2004 and 2018. We compared outcomes and complications between primary (SCH-PTT performed ECLS cannulation) vs. secondary (cannulation performed by referring facility)...

Background & Aims Hypophosphatemia during critical illness has been associated with adverse outcome. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. We investigated the occurrence of early RFH, its association with clinical outcome, and the impact of ea...

Objectives To determine potentially modifiable risk factors for a complicated Glenn procedure (cGP) and whether a cGP predicted adverse neurodevelopmental and functional outcomes. A cGP was defined as post-operative death, heart transplant, extracorporeal life support, Glenn takedown, or prolonged ventilation. Methods All 169 patients having a Gle...

Objectives: PICU patients face long-term developmental impairments, partially attributable to early parenteral nutrition (PN) versus late-PN. We investigated how this legacy and harm by early-PN evolve over time. Design: Preplanned secondary analysis of the multicenter PEPaNIC-RCT (ClinicalTrials.gov, NCT01536275) that enrolled 1,440 critically...

Objective To demonstrate feasibility of a music medicine intervention trial in pediatric intensive care and to obtain information on sedation and analgesia dose variation to plan a larger trial. Material and methods Pilot randomized controlled trial (RCT) was conducted at the Stollery Children’s Hospital general and cardiac intensive care units (P...

Background The PEPaNIC multicenter randomized controlled trial (RCT) has shown that early administration of supplemental parenteral nutrition (early-PN) as compared with withholding PN for 1 week (late-PN) induced long-term internalizing, externalizing and total emotional/behavioral problems in critically ill children, as observed 4 years later. Ea...

This comparison study of two groups within an inception cohort aimed to compare the frequency of motor impairment between preschool children with univentricular and biventricular critical congenital heart disease (CHD) not diagnosed with cerebral palsy/acquired brain injury, describe and compare their motor profiles and explore predictors of motor...

Objectives: Acute kidney injury occurs frequently in children during critical illness and is associated with increased morbidity, mortality, and health resource utilization. We aimed to examine the association between acute kidney injury duration and these outcomes. Design: Retrospective cohort study. Settings: PICUs in Alberta, Canada. Patie...

Background and aims Following the results of the paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial, the new ESPGHAN/ESPEN/ESPR/CSPEN and ESPNIC guidelines recommend to consider withholding parenteral macronutrients for 1 week, while providing micronutrients, in critically ill c...

Background: In critically ill children, omitting early use of parenteral nutrition (late-PN versus early-PN) reduced infections, accelerated weaning from mechanical ventilation, and shortened PICU stay. We hypothesized that fasting-induced ketogenesis mediates these benefits. Methods: In a secondary analysis of the PEPaNIC RCT (N = 1440), the im...

Objectives: To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs. Design: National 2-day point prevalence study. Setting: Thirteen PICUs across Canada. Patients: Children with a minimum 72-hour PICU length of stay on the allocated study day. Interventions: None. Measurements and main results:...

Background & aims In the absence of methodologically sound randomized controlled trials (RCTs), current recommendations for timing and amount of enteral nutrition (EN) in critically ill children are based on observational studies. These studies have associated achievement of a higher EN intake in critically ill children with improved outcome. Inher...

Background: There is limited information about HRQL after pediatric heart transplantation at a young age. Methods: Prospective follow-up study of children who received a heart transplant at age ≤4 years. HRQL was assessed using the PedsQLTM 4.0 at age 4.5 years. This cohort was compared with healthy children, children with CHD, and with chronic...

Background The PEPaNIC randomised controlled trial, which recruited 1440 critically ill infants and children in 2012–15, showed that withholding parenteral nutrition for 1 week (late-parenteral nutrition), compared with early supplementation within 24 h of admission to the paediatric intensive care unit (early-parenteral nutrition), prevented infec...

Background & Aims Early use of parenteral nutrition (early-PN), as compared with withholding it for one week (late-PN), in the PICU, has shown to slow down recovery from critical illness and impair long-term development of 6 neurocognitive/behavioural/emotional functions assessed 2 years later. Given that key steps in brain maturation occur at diff...

Introduction: In adults and children, withholding parenteral nutrition (PN) for 1 week in ICU (late PN), hereby accepting macronutrient deficit early during critical illness, as compared with supplementing insufficient enteral nutrition with PN (early PN), accelerates weaning from mechanical ventilation, reduces infections, and shortens ICU stay1,2...

Background The PEPaNIC RCT, which investigated critically ill children admitted to the pediatric intensive care unit, showed that early administration of parenteral nutrition (early PN) as compared with withholding PN for 1 week (late PN) negatively affected 6 neurocognitive functions assessed 2 years later (1). However, it is theoretically possibl...

Aim: Between 2012-2015, the PEPaNIC randomized controlled trial, which included 1440 critically ill infants and children, showed that withholding parenteral nutrition during the first week in the pediatric intensive care unit (PICU) (late-PN), as compared with initiating supplemental PN early (early-PN), improved PICU outcomes (1) and improved neur...

Aim: Pediatric intensive care relies on plastic indwelling medical devices softened by phthalates. Phthalates leach into the circulation and concerns about toxicity were raised. Exceeding a certain threshold of di(2-ethylhexyl)phthalate (DEHP) exposure in the pediatric intensive care unit (PICU) has been associated with an attention deficit 4 years...

Background: Stress induced by pain and anxiety is common in pediatric intensive care unit (PICU) patients. Sedation/analgesia in PICU is usually achieved through various analgesics and sedatives. Excessive use of these drugs can put patients at risk for hemodynamic/respiratory instability, prolonged ventilation, withdrawal, delirium, and critical...

Background Management of patients with hypoplastic left heart syndrome has benefited from advancements in medical and surgical care. Outcomes have improved, although survival and long‐term functional and cognitive deficits remain a concern. Methods and Results This is a cohort study of all consecutive patients with hypoplastic left heart syndrome...

Background: Early use of parenteral nutrition in the paediatric intensive care unit (PICU) negatively affects development of executive functions, externalising behaviour, and visual-motor integration 2 years later, compared with omitting parenteral nutrition until PICU day 8 (late parenteral nutrition). The molecular basis of this finding is uncer...

Importance The clinical consequences of red blood cell storage age for critically ill pediatric patients have not been examined in a large, randomized clinical trial. Objective To determine if the transfusion of fresh red blood cells (stored ≤7 days) reduced new or progressive multiple organ dysfunction syndrome compared with the use of standard-i...

Background: The aim of the study was to determine opinions and knowledge regarding the process of obtaining informed consent to participate in observational research in pediatric intensive care. Methods: Survey 1 asked decision makers what model(s) of consent was acceptable for each type of observational research both before and after background...

Purpose Increased systemic cortisol availability during adult critical illness is determined by reduced binding-proteins and suppressed breakdown rather than elevated ACTH. Dynamics, drivers and prognostic value of hypercortisolism during pediatric critical illness remain scarcely investigated. Methods This preplanned secondary analysis of the PEP...

Purpose: To systematically synthesize randomized controlled trial data on the efficacy of music to provide sedation and analgesia, and reduce incidence of delirium, in critically ill patients. Material and methods: Relevant databases (Medline, PubMed, Embase, CINAHL, Cochrane, Alt Healthwatch, LILACS, PsycINFO, CAIRSS, RILM) were searched from i...

Introduction: Non-thyroidal illness (NTI), which occurs with fasting and in response to illness, is characterized by thyroid hormone inactivation with low triiodothyronine (T3) and high reverse T3 (rT3), followed by suppressed thyrotropin (TSH). Withholding supplemental parenteral nutrition early in pediatric critical illness (late-PN), thus accep...

Abstract Background Children who have suffered from critical illnesses that required treatment in a paediatric intensive care unit (PICU) have long-term physical and neurodevelopmental impairments. The mechanisms underlying this legacy remain largely unknown. In patients suffering from chronic diseases hallmarked by inflammation and oxidative stres...

Abstract Background We aimed to determine predictors of, and outcomes after, veno-arterial extracorporeal membrane oxygenation instituted within 48 h after cardiac surgery (early ECMO) in young infants. Methods Patients ≤ 6 weeks old having cardiac surgery from 2003 to 2012 were enrolled prospectively. Patients cannulated pre-operatively, intra-ope...

Objectives: To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists. Design: A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive...

Objective: To reduce bilateral delayed-onset progressive sensory permanent hearing loss using a systems-wide quality improvement project with adherence to best practice for the administration of furosemide. Design: Prospective cohort study with regular audiologic follow-up assessment of survivors both before and after a 2007-2008 quality improve...

Background: The paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial showed that, compared with early parenteral nutrition, withholding supplemental parenteral nutrition for 1 week in the paediatric intensive care unit (PICU; late parenteral nutrition) reduced infections and acce...

Objectives: To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation in children admitted after cardiac surgery. Design: Retrospective pre-/postintervention cohort study. Setting: Stollery Children's Hospital tertiary care pediatric cardiac ICU. Patients: Children admitted to the pediatric cardiac ICU...

Functional abilities are needed for activities of daily living. In general, these skills expand with age. We hypothesised that, in contrast to what is normally expected, children surviving the Fontan may have deterioration of functional abilities, and that peri-Fontan stroke is associated with this deterioration. All children registered in the West...

Background & aims: Energy is essential for the treatment and recovery of children admitted to Pediatric Intensive Care Units (PICU). There are significant immediate and long-term health consequences of both under- and over-feeding in this population. Energy requirements of critically ill children vary depending on age, nutritional status, sepsis,...

Background We aimed to test a novel method of delivery of chloral hydrate (CH) sedation in ventilated critically ill young children. Methods Children < 12 years old, within 72 hours of admission, who were ventilated, receiving enteral tube-feeds, with intermittent CH ordered were enrolled after signed consent. Patients received a CH loading-dose o...

Purpose: To describe noise levels in a pediatric cardiac intensive care unit, and to determine the relationship between sound levels and patient sedation requirements. Materials and methods: Prospective observational study at a pediatric cardiac intensive care unit (PCICU). Sound levels were measured continuously in slow A weighted decibels dB(A...

Background: Large randomised controlled trials have shown that early supplemental parenteral nutrition in patients admitted to adult and paediatric intensive care units (PICUs) is harmful. Overdosing of energy with too little protein was suggested as a potential reason for this. This study analysed which macronutrient was associated with harm caus...

Background: Remote ischemic preconditioning involves providing a brief ischemia-reperfusion event to a tissue to create subsequent protection from a more severe ischemia-reperfusion event to a different tissue/organ. The few pediatric remote ischemic preconditioning studies in the literature show conflicting results. Aim: We conducted a pilot ra...

Objective: Acute kidney injury occurs early in PICU admission and increases risks for poor outcomes. We evaluated the feasibility of a multicenter acute kidney injury biomarker urine collection protocol and measured diagnostic characteristics of urine neutrophil gelatinase-associated lipocalin, interleukin-18, and liver fatty acid binding protein...

Background: The accuracy of arterial lines (AL) using the flush test or stopcock test has not been described in children, nor has the difference between invasive arterial blood pressure (IABP) versus non-invasive cuff (NIBP) blood pressure. Methods: After ethics approval and consent, we performed the flush test and stopcock test on AL (to determ...

The objective of this study is to describe the neurologic, neurocognitive and functional outcomes of children aged under 6 years supported on the Berlin Heart EXCOR ventricular assist device (VAD) followed in the Complex Pediatric Therapies Follow-up Program (CPTFP). Sixteen patients were prospectively followed through this longitudinal, developmen...

Pediatric cardiac arrests occur rarely but carry a low likelihood of survival and functional outcome.¹ Arrests are frequently precipitated by acute respiratory failure (accounting for 72% of hospital pediatric cardiac arrests and 42% of in-hospital pediatric cardiac arrests).² Hence, considerable emphasis is placed on assisted ventilation as part o...

Background: Despite the fact that almost all critically ill children experience some degree of pain or anxiety, there is a lack of high-quality evidence to inform preferred approaches to sedation, analgesia, and comfort measures in this environment. We conducted this survey to better understand current comfort and sedation practices among Canadian...

Background & aims: Indirect calorimetry (IC) is considered gold standard for assessing energy needs of critically ill children as predictive equations and clinical status indicators are often unreliable. Accurate assessment of energy requirements in this vulnerable population is essential given the high risk of over or underfeeding and the consequ...

Background: Short-term continuous-flow ventricular assist devices (STCF-VADs) are increasingly being used in the pediatric population. However, little is known about the outcomes in patients supported with these devices. Methods: All pediatric patients supported with a STCF-VAD, including the Thoratec PediMag or CentriMag, or the Maquet RotaFlow...

Background Recent trials have questioned the benefit of early parenteral nutrition in adults. The effect of early parenteral nutrition on clinical outcomes in critically ill children is unclear. Methods We conducted a multicenter, randomized, controlled trial involving 1440 critically ill children to investigate whether withholding parenteral nutr...

Objective. To determine if early pre- and postoperative enteral feeding was associated with improved postoperative outcomes in infants with hypoplastic left heart syndrome undergoing the Norwood procedure. Study Design. Retrospective chart review of infants undergoing stage 1 surgical palliation for hypoplastic left heart syndrome. Results. Baselin...

Background and objectives: Little is known about chronic neuromotor disability (CND) including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery (CCS). We sought to determine the frequency and presentation of CND in this population while exploring potentially modifiable acute care...

Extracorporeal Cardiopulmonary Resuscitation (E-CPR) is the initiation of extracorporeal life support during active chest compressions. There are no studies describing detailed neurocognitive outcomes of this population. We aim to describe the survival and neurocognitive outcomes of children who received E-CPR. Prospective cohort study. Children wh...

Patients with congenital heart disease have a number of risk factors for the development of chronic kidney disease (CKD). It is well known that CKD has a large negative impact on health outcomes. It is important therefore to consider that patients with congenital heart disease represent a population in whom long-term primary and secondary preventio...

Early administration of antibiotics for sepsis, and of fluid boluses and vasoactive agents for septic shock, is recommended. Evidence for this in children is limited. The Alberta Sepsis Network prospectively enrolled eligible children admitted to the Pediatric Intensive Care Unit (PICU) with sepsis from 04/2012-10/2014. Demographics, severity of il...

BACKGROUND Survival rates after neonatal Complex Cardiac Surgery (CCS) for congenital heart disease (CHD) have increased. Surviving children face neurodevelopmental and neuromotor challenges. While neuro-cognitive difficulties have been reported; little research has been done on motor impairments. Permanent non-progressive motor impairments are cer...

The state-of-the-art nutrition used for critically ill children is based essentially on expert opinion and extrapolations from adult studies or on studies in non-critically ill children. In critically ill adults, withholding parenteral nutrition (PN) during the first week in ICU improved outcome, as compared with early supplementation of insufficie...

Background Short-term continuous-flow ventricular assist devices (STCF-VADs) are increasingly being used in the pediatric population. However, little is known about the outcomes in patients supported with these devices. Methods All pediatric patients supported with a STCF-VAD, including the Thoratec PediMag or CentriMag, or the Maquet RotaFlow, be...

Iron overload cardiomyopathy secondary to β-thalassemia major is a potentially reversible condition managed with chelation and medical hemodynamic support, as bridge-to-recovery or transplant. We describe our experience, and challenges faced, in a pediatric patient with iron overload cardiomyopathy secondary to β-thalassemia major, requiring bivent...

-Survival following pediatric cardiac extracorporeal life support (ECLS) is guarded and neurological morbidity varies widely. Our objective is to report our ten-year experience with cardiac ECLS, including survival and kindergarten entry neurocognitive outcomes; to identify predictors of mortality or adverse neurocognitive outcomes; and to compare...

To assess the health-related quality of life of children who received cardiac extracorporeal life support. We hypothesized that extracorporeal life support survivors have lower health-related quality-of-life scores when compared with a healthy sample, with children with chronic conditions, and with children who had surgery for congenital heart dise...

BACKGROUND Extra Corporeal Life Support (ECLS) has evolved to a standard of care in many pediatric centers, with thousands of patients supported to date. There is a lack of studies examining long-term outcomes including health related quality of life (HRQL). OBJECTIVES We aim to assess the HRQL of children who received cardiac ECLS, and to compare...

Background Airway Pressure Release Ventilation (APRV) is widely used in adult critical care settings. However, information on the use of APRV in the pediatric population is limited.Methods All patients admitted to the medical-surgical pediatric intensive care unit with a diagnosis of Acute Respiratory Distress Syndrome (ARDS) who received APRV for...

The primary objective is to describe the practice patterns of nonprocedural propofol use in a single-center referral PICU. The secondary objective is to describe the rate of concordance of propofol use with the PICU local practice of a maximum mean rate of 4 mg/kg/hr and a maximum duration of 24 hours and to assess for signs and symptoms of propofo...