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Introduction
Current institution
Publications
Publications (170)
Objectives
We evaluated the Phoenix criteria and the Phoenix Sepsis Score in a multicenter retrospective cohort of critically ill children with a clinical diagnosis of sepsis or septic shock in Bolivia. In addition, we aimed to assess whether management in a PICU at high altitude in the Bolivian Andes was associated with the performance of the resp...
Background: Acute kidney injury (AKI) is common among children with critical illness and is associated with high morbidity and mortality. Risk prediction models designed for clinical decision support implementation offer an opportunity to identify and proactively mitigate AKI risks. Existing models have been primarily validated on single-center dat...
Hemodynamic support in critically ill children with septic shock is a pervasive challenge in the intensive care settings. Cardiovascular involvement in sepsis entails both macro- and microcirculation abnormalities, with the main treatment objectives seeking to increase cardiac output and improve tissue perfusion, respectively. Fluid therapy and vas...
Objective
To determine the prognostic value of the Pediatric Sequential Organ Failure Assessment (pSOFA) to discriminate critical events, including code events and intubations, in the pediatric intensive care unit (PICU).
Methods
We performed an observational cohort study of all critical events in a quaternary care PICU between 5/2020 and 4/2023....
Background
When coronavirus disease 2019 (COVID-19) mitigation efforts waned, viral respiratory infections (VRIs) surged, potentially increasing the risk of postviral invasive bacterial infections (IBIs). We sought to evaluate the change in epidemiology and relationships between specific VRIs and IBIs [complicated pneumonia, complicated sinusitis a...
Rationale
The high‐flow nasal cannula (HFNC) device is commonly used to treat pediatric severe acute asthma. However, there is little evidence regarding its effectiveness in real‐world practice.
Objectives
We sought to compare the physiologic effects and clinical outcomes for children treated for severe acute asthma with HFNC versus matched contro...
Rationale
More targeted management of severe acute pediatric asthma could improve clinical outcomes.
Objectives
To identify distinct clinical phenotypes of severe acute pediatric asthma using variables obtained in the first 12 h of hospitalization.
Methods
We conducted a retrospective cohort study in a quaternary care children's hospital from 201...
Background
Sepsis poses a grave threat, especially among children, but treatments are limited owing to heterogeneity among patients. We sought to test the clinical and biological relevance of pediatric septic shock subclasses identified using reproducible approaches.
Methods
We performed latent profile analyses using clinical, laboratory, and biom...
Objectives
The publication of the Phoenix criteria for pediatric sepsis and septic shock initiates a new era in clinical care and research of pediatric sepsis. Tools to consistently and accurately apply the Phoenix criteria to electronic health records (EHRs) is one part of building a robust and internally consistent body of research across multipl...
Objectives:
Transcutaneous carbon dioxide (Tcco2) monitoring can noninvasively assess ventilation by estimating carbon dioxide (CO2) levels in the blood. We aimed to evaluate the accuracy of Tcco2 monitoring in critically ill children by comparing it to the partial pressure of arterial carbon dioxide (Paco2). In addition, we sought to determine th...
OBJECTIVES
To determine whether use of a language other than English (LOE) would be associated with medical complexity, and whether medical complexity and LOE together would be associated with worse clinical outcomes.
METHODS
The primary outcome of this single-site retrospective cohort study of PICU encounters from September 1, 2017, through Augus...
OBJECTIVES/GOALS: Fluid boluses are administered to hypotensive, critically ill children but may not reverse hypotension, leading to delay of vasoactive infusion, end-organ damage, and mortality. We hypothesize that a machine learning-based model will predict which children will have sustained response to fluid bolus. METHODS/STUDY POPULATION: We w...
Objectives
Identification of children with sepsis-associated multiple organ dysfunction syndrome (MODS) at risk for poor outcomes remains a challenge. We sought to the determine reproducibility of the data-driven “persistent hypoxemia, encephalopathy, and shock” (PHES) phenotype and determine its association with inflammatory and endothelial biomar...
Importance
Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host respon...
Importance
The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach.
Objective
To derive and validate novel criteria for pediatric sepsis and septic shock across different...
Background: Multiple organ dysfunction syndrome (MODS) disproportionately drives morbidity and mortality among critically ill patients. However, we lack a comprehensive understanding of its pathobiology. Identification of genes associated with a persistent MODS trajectory may shed light on underlying biology and allow for accurate prediction of tho...
Introduction
Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the a...
OBJECTIVE
Perform a scoping review of supervised machine learning in pediatric critical care to identify published applications, methodologies, and implementation frequency to inform best practices for the development, validation, and reporting of predictive models in pediatric critical care.
DESIGN
Scoping review and expert opinion.
SETTING
We q...
Background
Sepsis poses a grave threat, especially among children, but treatments are limited due to clinical and biological heterogeneity among patients. Thus, there is an urgent need for precise subclassification of patients to guide therapeutic interventions.
Methods
We used clinical, laboratory, and biomarker data from a prospective multi-cent...
Background
Identifying phenotypes in sepsis patients may enable precision medicine approaches. However, the generalisability of these phenotypes to specific patient populations is unclear. Given that paediatric cancer patients with sepsis have different host response and pathogen profiles and higher mortality rates when compared to non-cancer patie...
Background
Characterizing Post-Acute Sequelae of COVID (SARS-CoV-2 Infection), or PASC has been challenging due to the multitude of sub-phenotypes, temporal attributes, and definitions. Scalable characterization of PASC sub-phenotypes can enhance screening capacities, disease management, and treatment planning.
Methods
We conducted a retrospective...
Objective
New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional...
Objective:
Bacterial infections (BIs) are common, costly, and potentially life-threatening in critically ill patients. Patients with suspected BIs may require empiric multidrug antibiotic regimens and therefore potentially be exposed to prolonged and unnecessary antibiotics. We previously developed a BI risk model to augment practices and help sho...
Background:
Following development and validation of a sepsis prediction model described in a companion article, we aimed to use quality improvement and safety methodology to guide the design and deployment of clinical decision support (CDS) tools and clinician workflows to improve pediatric sepsis recognition in the inpatient setting.
Methods:
C...
Background and objectives:
Early recognition and treatment of pediatric sepsis remain mainstay approaches to improve outcomes. Although most children with sepsis are diagnosed in the emergency department, some are admitted with unrecognized sepsis or develop sepsis while hospitalized. Our objective was to develop and validate a prediction model of...
Objective
Identification of children with sepsis-associated multiple organ dysfunction syndrome (MODS) at risk for poor outcomes remains a challenge. Data-driven phenotyping approaches that leverage electronic health record (EHR) data hold promise given the widespread availability of EHRs. We sought to externally validate the data-driven ‘persisten...
Objectives:
In this systematic review and meta-analysis we asked: Do predictors of fluid responsiveness in children perform comparably: 1) in the PICU as in non-PICU settings? 2) in shock states compared with nonshock states? Additionally, 3) is there an association between preload responsiveness and clinical response?
Data sources:
Ovid Medline...
Objectives:
Untangling the heterogeneity of sepsis in children and identifying clinically relevant phenotypes could lead to the development of targeted therapies. Our aim was to analyze the organ dysfunction trajectories of children with sepsis-associated multiple organ dysfunction syndrome (MODS) to identify reproducible and clinically relevant s...
Background:
Timely ventilator liberation can prevent morbidities associated with invasive mechanical ventilation in the pediatric ICU (PICU). There currently exists no standard benchmark for duration of invasive mechanical ventilation in the PICU. This study sought to develop and validate a multi-center prediction model of invasive mechanical vent...
Sepsis is a leading cause of global mortality in children, yet definitions for pediatric sepsis are outdated and lack global applicability and validity. In adults, the Sepsis-3 Definition Taskforce queried databases from high-income countries to develop and validate the criteria. The merit of this definition has been widely acknowledged; however, i...
Background:
Positive fluid balance (FB) is associated with poor outcomes in critically ill children but has not been studied in pediatric liver transplant (LT) recipients. Our goal is to investigate the relationship between postoperative FB and outcomes in pediatric LT recipients.
Methods:
We performed a retrospective cohort study of first-time...
Objective:
Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for po...
Objectives:
We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed.
Design:
International consensus conference serie...
Objectives:
The use of electronic algorithms, clinical decision support systems, and other clinical informatics interventions is increasing in critical care. Pediatric acute respiratory distress syndrome (PARDS) is a complex, dynamic condition associated with large amounts of clinical data and frequent decisions at the bedside. Novel data-driven t...
Background
While acute kidney injury (AKI) is a common complication in COVID-19, data on post-AKI kidney function recovery and the clinical factors associated with poor kidney function recovery is lacking.
Methods
A retrospective multi-centre observational cohort study comprising 12,891 hospitalized patients aged 18 years or older with a diagnosis...
Background
Untangling the heterogeneity of sepsis in children and identifying clinically relevant phenotypes could lead to the development of enrichment strategies and targeted therapies. In this study, our aim was to analyze the organ dysfunction-based trajectories of children with sepsis-associated multiple organ dysfunction syndrome (MODS) to id...
Commentary on https://ccforum.biomedcentral.com/articles/10.1186/s13054-022-03977-3
Importance
The COVID-19 pandemic has been associated with an increase in mental health diagnoses among adolescents, though the extent of the increase, particularly for severe cases requiring hospitalization, has not been well characterized. Large-scale federated informatics approaches provide the ability to efficiently and securely query health car...
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and como...
We propose a novel metric evaluating the impact an exposure to a large positive fluid balance over time has on clinical outcomes in children with respiratory failure, termed "fluid overload mechanically ventilated" (FOMV) days. We performed a retrospective cohort study of mechanically ventilated children. Using multivariable regression analyses, ea...
Continuous cardiorespiratory physiological monitoring is a cornerstone of care in hospitalized children. The data generated by monitoring devices coupled with machine learning could transform the way we provide care. This scoping review summarizes existing evidence on novel approaches to continuous cardiorespiratory monitoring in hospitalized child...
Pediatric critical care addresses prevention, diagnosis, and treatment of organ dysfunction in the setting of increasingly complex patients, therapies, and environments. Soon burgeoning data science will enable all aspects of intensive care: driving facilitated diagnostics, empowering a learning health-care environment, promoting continuous advance...
Background
Multiple organ dysfunction syndrome (MODS) disproportionately drives sepsis morbidity and mortality among children. The biology of this heterogeneous syndrome is complex, dynamic, and incompletely understood. Gene expression signatures correlated with MODS trajectories may facilitate identification of molecular targets and predictive enr...
Objectives:
To determine whether there are clinically relevant and reproducible Vasoactive Inotrope Score (VIS) trajectories in children with shock during the acute phase of critical illness.
Design:
Retrospective, observational cohort study.
Setting:
Two tertiary, academic PICUs.
Patients:
Children (< 18 yr old) who required vasoactive infu...
Background:
More than half of children with pediatric acute liver failure (PALF) experience hepatic encephalopathy (HE), which is related to poor outcomes; however, HE is difficult to diagnose in children. The objective of this study was to evaluate if heart rate variability (HRV), a continuous measure of autonomic nervous system function, was rel...
Machine learning models may be integrated into clinical decision support (CDS) systems to identify children at risk of specific diagnoses or clinical deterioration to provide evidence-based recommendations. This use of artificial intelligence models in clinical decision support (AI-CDS) may have several advantages over traditional "rule-based" CDS...
Motivation:
Sepsis is a leading cause of death and disability in children globally, accounting for ∼3 million childhood deaths per year. In pediatric sepsis patients, the multiple organ dysfunction syndrome (MODS) is considered a significant risk factor for adverse clinical outcomes characterized by high mortality and morbidity in the pediatric in...
Objective: The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working...
Given the growing number of prediction algorithms developed to predict COVID-19 mortality, we evaluated the transportability of a mortality prediction algorithm using a multi-national network of healthcare systems. We predicted COVID-19 mortality using baseline commonly measured laboratory values and standard demographic and clinical covariates acr...
Objective
The incidence of deterioration and associated characteristics are largely unknown for children transported for admission from referring emergency departments (EDs) to general inpatient units. This study describes this population and identifies associated preadmission characteristics.
Methods
This single-center cohort study included child...
Objectives:
To assess the current landscape of clinical decision support (CDS) tools in PICUs in order to identify priority areas of focus in this field.
Design:
International, quantitative, cross-sectional survey.
Setting:
Role-specific, web-based survey administered in November and December 2020.
Subjects:
Medical directors, bedside nurses...
Introduction
Multiple organ dysfunction (MOD) is a common pathway to morbidity and death in critically ill children. Defining organ dysfunction is challenging, as we lack a complete understanding of the complex pathobiology. Current pediatric organ dysfunction criteria assign the same diagnostic value—the same “weight”— to each organ system. While...
Objectives:
Unrecognized clinical deterioration during illness requiring hospitalization is associated with high risk of mortality and long-term morbidity among children. Our objective was to develop and externally validate machine learning algorithms using electronic health records for identifying ICU transfer within 12 hours indicative of a chil...
This cohort study uses data from the US National COVID Cohort Collaborative to evaluate upper airway infections in children during the surge of the Omicron (B.1.1.529) variant of SARS-CoV-2 in the US.
Versión en Español del 1er Consenso Latinoamericano de Sepsis con link de acceso directo al artículo completo con soporte de evidencia de cada recomendación.
Objective
Microbiology culture reports contain critical information for important clinical and public health applications. However, microbiology reports often have complex, semistructured, free-text data that present a barrier for secondary use. Here we present the development and validation of an open-source package designed to ingest free-text mi...
Objectives:
The autonomic nervous system (ANS) can both modulate and be modulated by the inflammatory response during critical illness. We aimed to determine whether heart rate variability (HRV), a measure of ANS function, is associated with proinflammatory biomarker levels in critically ill children.
Design:
Two cohorts were analyzed. The first...
Objectives:
To determine if greater cumulative exposure to oxygen despite adequate oxygenation over the first 24 hours of mechanical ventilation is associated with multiple organ dysfunction syndrome at 7 days and inhospital mortality in critically ill children.
Design:
Retrospective, observational cohort study.
Setting:
Two urban, academic PI...
Background
Reports of SARS-CoV-2 causing laryngotracheobronchitis (commonly known as croup) have been limited to small case series. Early reports suggest the Omicron (B.1.1.529) strain of SARS-CoV-2 (the dominant circulating US strain since the week of 12/25/2021) replicates more efficiently in the conducting airways. This may increase the risk of...
The complex physiology and medical requirements of children with sepsis and multiple organ dysfunction syndrome (MODS) challenge traditional care coordination models. While the involvement of multiple clinical subspecialty services is often necessary to support different care processes and individual organ system dysfunctions, it can also delay the...
Objective: Re-hospitalization after sepsis can lead to impaired quality of life. Predictors of re-hospitalization could help identify sepsis survivors who may benefit from targeted interventions. Our goal was to determine whether low heart rate variability (HRV), a measure of autonomic nervous system dysfunction, is associated with re-hospitalizati...
CONTEXT
Renal dysfunction is associated with poor outcomes in critically ill children.
OBJECTIVE
To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children.
DATA SOURCES
PubMed...
