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Keywords: adolescents; blood pressure monitoring, ambulatory; blood pressure; hypertension; pediatrics EN adolescents blood pressure monitoring, ambulatory blood pressure hypertension pediatrics e125 e126 2 07/14/22 20220801 NES 220801 Current pediatric ambulatory blood pressure monitor (ABPM) guidelines[1] define hypertension as mean blood pressure (BP) >95th percentile for sex and age/height and load >=25%. Unclassifiable patients were also reclassified to hypertension or normal BP using the adult threshold[5] for mean BP only. Patients reclassified to hypertension had significantly higher loads for night systolic and diastolic BP and 24-hour systolic BP compared with those with normal BP. [Extracted from the article]

Objectives: Paralleling improved outcomes in critically ill patients, survival for pediatric acute kidney injury has improved. Continuous renal replacement therapy is the preferred modality to optimize fluid and electrolyte management as well as nutritional support for children developing acute kidney injury in the PICU. However, some patients remain too fragile for transition to intermittent renal replacement therapies and require continuous renal replacement therapy for a prolonged period. Characteristics of this cohort and factors impacting outcomes are not well known. We aimed to describe the characteristics of pediatric patients requiring prolonged continuous renal replacement therapy and evaluate the factors impacting hospital survival., Design: Retrospective chart review., Setting: Tertiary PICU., Patients: Children requiring prolonged continuous renal replacement therapy. Prolonged continuous renal replacement therapy was defined as continuous renal replacement therapy dependence greater than or equal to 28 days. Primary outcome was hospital mortality., Interventions: None., Measurements and Main Results: From 2013 to 2016, 344 patients received continuous renal replacement therapy, 36 (10%) received continuous renal replacement therapy for greater than or equal to 28 days. Seventeen patients (47%) were female. Overall mortality was 44% (16/36); 69% (11/16) of nonsurvivors died of sepsis. Pediatric Logistic Organ Dysfunction score was significantly higher in nonsurvivors. Mortality rate was significantly higher in patients who were neutropenic at continuous renal replacement therapy start. Neutropenia (defined as absolute neutrophil count < 1,500/mm) at continuous renal replacement therapy start was the only independent predictor of mortality. One in four survivors did not recover renal function and remained dialysis dependent., Conclusions: Prolonged continuous renal replacement therapy patients are at high risk of nonrecovery of renal function and require close monitoring. The majority of nonsurvivors in the study group died from sepsis. Neutropenia at continuous renal replacement therapy initiation was associated with increased risk of mortality. Progression of underlying disease process could explain the higher death rate in patients with neutropenia; however, inadequate treatment of infectious complications could be another explanation to explore further in future studies.

Objectives: Describe quality improvement process improvements in protein delivery of continuous renal replacement therapy initiation., Design: Prospective study., Setting: PICU and cardiovascular ICU within a quaternary care children's hospital., Patients: PICU and cardiovascular ICU patients receiving continuous renal replacement therapy for greater than 48 hours. Inborn errors of metabolism were excluded., Interventions: Plan-Do-Study-Act cycles were initiated. Cycle 1 developed interdisciplinary quality improvement group continuously monitoring nutrition care with thrice weekly bedside safety rounds and protein prescriptions within nephrologist's notes. Cycle 2 included education to intensivists. Cycle 3 initiated monthly quality improvement meetings reviewing nutritional care goals., Measurements and Main Results: Primary outcome was percentage of time patients met protein goals in the first 5 days of continuous renal replacement therapy. Secondary outcome was percentage of time patients met protein goals for duration of continuous renal replacement therapy. Cohort (n = 55) mean age was 8.1 years (SD ± 6.8), 62% male, and 31% malnutrition at baseline. Percent of time meeting protein goals by day 5 was 22%, 33%, and 71% and percent of time meeting protein goals throughout was 35%, 39%, and 75% of groups 1, 2, and 3, respectively. Significant improvement occurred after Plan-Do-Study-Act 3 (group 2 vs group 3; p < 0.01) for primary and secondary outcomes., Conclusions: Implementation of an interprofessional quality improvement team significantly decreased number of continuous renal replacement therapy days with unmet protein goals and improved protein delivery.

Objectives: Standard intensive care treatment is inadequate to keep children with liver failure alive without catastrophic complications to ensure successful transplant, as accumulation of endogenous protein-bound toxins often lead to hepatic encephalopathy, hepatorenal syndrome, cardiovascular instability, and multiple organ failure. Given paucity of proven treatment modalities for liver failure, blood purification using different extracorporeal treatments as a bridge to transplantation is used, but studies evaluating the safety and efficacy of combination of these therapies, especially in pediatric liver failure, are lacking. We describe our experience at a major tertiary children's hospital, where a unique hybrid extracorporeal treatment protocol has been instituted and followed for acute liver failure or acute-on-chronic liver failure as a bridge to transplantation. This protocol combines high-flux continuous renal replacement therapy for hyperammonemia, therapeutic plasma exchange for coagulopathy, and albumin-assisted dialysis (molecular adsorbent recirculating system) for hepatic encephalopathy., Design: Retrospective observational study., Setting: Freestanding tertiary children's hospital and liver transplant referral center., Patients: All patients with acute liver failure/acute-on-chronic liver failure receiving hybrid extracorporeal therapy over 24 months., Intervention: Hybdrid extracorporeal therapy., Measurements and Main Results: Fifteen children (age 3 yr [0.7-9 yr]; 73% male) with acute liver failure/acute-on-chronic liver failure who were either listed or actively considered for listing and met our protocol criteria were treated with hybrid extracorporeal therapy; 93% were ventilated, and 80% were on vasoactive support. Of these, two patients recovered spontaneously, four died prior to transplant, and nine were successfully transplanted; 90-day survival post orthotopic liver transplant was 100%. Overall survival to hospital discharge was 73%., Conclusions: Hybrid extracorporeal therapies can be effectively implemented in pediatric liver failure as a bridge to transplantation. Overall complexity and heavy resource utilization need to be carefully considered in instituting these therapies in suitable candidates.