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Objective: To compare the level of agreement between proximal (near the subject) and distal (inside the ventilator) measured airway occlusion pressure at 100 ms (P0.1) and occlusion pressure (ΔPocc), and to study the correlation between ΔPocc and peak-to-trough esophageal pressure (ΔPes)., Design: Secondary analysis of prospectively collected physiology dataset (2021-2022)., Setting: Medical-surgical 20-bed PICU., Patients: Children younger than 18 years with and without acute lung injury ventilated greater than 24 hours and spontaneously breathing with appropriate triggering of the ventilator., Interventions: None., Measurements and Main Results: Data from three expiratory hold maneuvers (with a maximum of three breaths during each maneuver) in 74 subjects (118 measurements) with median age 3 months (interquartile range 1-17), and primary respiratory failure due to a pulmonary infection in 41/74 (55.4%) were studied. The median proximal ∆Pocc was 6.7 cm H2O (3.1-10.7) and median P0.1 4.9 cm H2O (4.1-6.0) for the first breath from the maneuver; both increased significantly (p < 0.001) with the subsequent two breaths during the same maneuver. Median distal ∆Pocc was 6.8 (2.9-10.8) and P0.1 4.6 (3.9-5.6) cm H2O; both increased significantly (p < 0.001) with the two subsequent breaths. Proximal and distal ΔPocc (r > 0.99, p < 0.001) and P0.1 (r > 0.80, p < 0.001) were correlated. Correlation between ventilator displayed and Y-piece measured ΔPocc (r > 0.99) and P0.1 (r = 0.85) was good. Mean (sd) difference for ΔPocc was 0.13 (0.21); levels of agreement were -0.28 and 0.54. For P0.1, mean (sd) difference was -0.36 (1.14) and levels of agreement -2.61 and 1.88. There was a high correlation between ΔPes and ∆Pocc (r = 0.92) for the same breath and a good correlation with ΔPes from the preceding breath (r = 0.76). There was a poor correlation with the transpulmonary pressure (r = 0.37)., Conclusions: ΔPocc is not affected by measurement site, whereas P0.1 may be overestimated or underestimated. ΔPocc was highly correlated with the peak-to-trough esophageal pressure, supporting the concept that inspiratory effort can also be quantified noninvasively by measuring ΔPocc., Competing Interests: Dr. Rudolph’s institution received funding from ZonMW (project number 848041002); she received support for article research from ZonMW. Dr. Kneyber received funding from Getinge, Chiesi, and Metran. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

To describe outcomes of a cohort of patients with paediatric acute liver failure (PALF) treated with either one of two extracorporeal therapies (ECT) - continuous renal replacement therapy (CRRT) and molecular adsorbent recirculatory system (MARS®). Retrospective, observational, cohort study at two European paediatric intensive care units (PICUs) - UK (2006-2017, CRRT) and the Netherlands (2003-2017, MARS® and CRRT). Patients were children (0-18 years) admitted to the PICU with PALF who required CRRT or MARS®. Between each group, we compared baseline characteristics, biochemical parameters at 0 and 24 h after commencing MARS®/CRRT, and clinical outcomes. In total, 95 patients (23 MARS®, 72 CRRT) were included. The median age at admission for the whole cohort was 4.3 years (interquartile range (IQR) 1.0-12.1), and 47/95 (49.5%) of patients had an indeterminate aetiology. A lower proportion of patients in the MARS® group were on inotropes or were ventilated at admission, and they had a lower Pediatric Index of Mortality 3 risk % than the CRRT group (14.5% (7.5-22) vs 20.4% (16.8-26.4), p = 0.002). After treatment, there were no significant differences detected between groups in survival with native liver, or overall survival (15/23 (65.2%) for MARS® and 49/72 (68.1%) for CRRT, p = 0.998)., Conclusion: We did not detect a significant difference in clinical outcomes between PALF patients treated with CRRT or MARS®, despite a relatively sicker cohort in the CRRT group. Further high-quality evidence is necessary regarding the role of extracorporeal therapies in PALF, with consideration of clinical outcomes, feasibility, and cost., What Is Known: • Outcomes for children with paediatric acute liver failure (PALF) have improved in recent years secondary to improved supportive care aimed at avoiding liver transplantation. • Extracorporeal therapies, in particular continuous renal replacement therapy (CRRT), are increasingly applied in the management of these children; however few studies have compared outcomes between different extracorporeal therapies., What Is New: • In this retrospective study across two centres, outcomes between patients with PALF treated with CRRT were compared to patients treated with MARS®. • There was no significant difference in key clinical outcomes between groups, including survival with native liver and overall survival., Competing Interests: Declarations. Competing interests: AkD is Chair of Scientific Affairs of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) and Chair of the Working Group for Liver Failure in ESPNIC. MK is Medical President of ESPNIC. All other authors have no conflicts of interest to declare., (© 2025. The Author(s).)

Paediatric critical care units are designed for children at a vulnerable stage of development, yet the evidence base for practice and policy in paediatric critical care remains scarce. In this Health Policy, we present a roadmap providing strategic guidance for international paediatric critical care trials. We convened a multidisciplinary group of 32 paediatric critical care experts from six continents representing paediatric critical care research networks and groups. The group identified key challenges to paediatric critical care research, including lower patient numbers than for adult critical care, heterogeneity related to cognitive development, comorbidities and illness or injury, consent challenges, disproportionately little research funding for paediatric critical care, and poor infrastructure in resource-limited settings. A seven-point roadmap was proposed: (1) formation of an international paediatric critical care research network; (2) development of a web-based toolkit library to support paediatric critical care trials; (3) establishment of a global paediatric critical care trial repository, including systematic prioritisation of topics and populations for interventional trials; (4) development of a harmonised trial minimum set of trial data elements and data dictionary; (5) building of infrastructure and capability to support platform trials; (6) funder advocacy; and (7) development of a collaborative implementation programme. Implementation of this roadmap will contribute to the successful design and conduct of trials that match the needs of globally diverse paediatric populations., Competing Interests: Declaration of interests LJS received grants from the Swiss Personalized Health Network, Personalized Health-Related Technologies Switzerland, Nomis Foundation, Thomas & Doris Ammann Foundation, National Institutes of Health (NIH), National Health and Medical Research Council, and Medical Research Future Funds. KSG received support from a National Health and Medical Research Council Emerging Leader Fellowship. BMM received grants from EuroQoL and the Society of Critical Care Medicine; and serves as President of the World Federation of Pediatric Intensive and Critical Care Societies and the Critical Care Society of South Africa. NN received grants from Actuated Medical and Philips Respironics. AA received travel support from the WHO. JHL received grants from the Thrasher Foundation (USA) and the National Research Medical Council (Singapore). MJP received grants from the National Institute for Health and Care Research Health Technology Assessment and serves on the general funding committee. JF-S received grants from the Universidad de La Sabana. HRF received a grant from NIH. PF received grants from the Canadian Institutes of Health Research. MCJK received a grant from NIH and consultancy fees from Metran. KM received funding from the Children's Hospital of Eastern Ontario Foundation; and is chair of the Canadian Critical Care Trials Group., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Objectives: Intravenous midazolam is widely used for sedation in critically ill children. Sometimes, these children develop a paediatric delirium (PD). Our aim was to determine the relationship between midazolam serum concentration and the development of new PD in critically ill children., Design: Prospective observational pilot study., Setting: Paediatric Intensive Care Unit (PICU), Groningen, the Netherlands., Patients: All children admitted to the PICU from October-December 2019 who received continuous midazolam administration., Interventions: None., Measurements and Main Results: Twenty-five percent (n = 7) of the included patients (n = 28) developed new PD. In most patients, PD occurred following midazolam dose reduction. The median cumulative midazolam dose was higher in patients who developed PD compared to those without PD. We analysed 104 blood samples to determine the midazolam concentrations. To determine whether patients had PD, the Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) score was used. Patients suffering PD (n = 7) had a lower median midazolam concentration on that day compared with the day prior to PD detection. Analysis of the active metabolites, 1-hydroxymidazolam and 1-hydroxymidazolam glucuronide, showed similar results., Conclusions: PD may be linked to a sudden and significant reduction in the midazolam concentration in critically ill children. Further investigation in larger patient populations is necessary to validate our findings.