CONTEXT:influenza Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America.treatment, OBJECTIVE: To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection.Design, Setting, and frequency PATIENTS: A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric = intensive care units (ICUs) in Canada between April 16 and August 12, 2009. MAIN OUTCOME MEASURES: The primary outcome measures onset were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay. RESULTS:at Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47)RESULTS: community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age Setting, was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at observational 28 days was 14.3%(95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time infection from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission ICU was 1 day (IQR, -2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD]Lung score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic 43 (mean [SD] ratio of Pao(2) to fraction of inspired oxygen [Fio(2)] of 147 [128] mm Hg) at ICU admission. Mechanical with ventilation was received by 136 patients (81. %). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU 47) stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%),Neuraminidase high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3. %). Overall mortality among critically ill patients at Assessment 90 days was 17.3%(95% confidence interval, 12. %-24. %; n = 29). CONCLUSION: Critical illness due to 2009 influenza A(H1N1) in was Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a Canada requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.Published online October 12, 2009 (doi:10.1001/jama.2009.1496).

OBJECTIVE::pediatric To determine the impact of a restrictive vs. a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome syndrome in children post cardiac surgery. The optimal transfusion threshold after cardiac surgery in children is unknown. DESIGN:: Randomized, controlled trial.the SETTING:: Tertiary pediatric intensive care units. PATIENTS:: Participants are a subgroup of pediatric patients post cardiac surgery from the TRIPICU with (Transfusion Requirements in Pediatric Intensive Care Units) study. Exclusion criteria specific to the cardiac surgery subgroup included: age <28 days were and patients remaining cyanotic. INTERVENTION:: Critically ill children with a hemoglobin </=95 g/L within 7 days of pediatric intensive care or unit admission were randomized to receive prestorage leukocyte-reduced red-cell transfusion if their hemoglobin dropped either <70 g/L (restrictive) or 95 patients g/L (liberal). MEASUREMENTS AND MAIN RESULTS:: Postoperative cardiac patients (n = 125) from seven centers were enrolled. The restrictive (n surgery = 63) and liberal (n = 62) groups were similar at baseline in age (mean +/- standard deviation = 31.4 is +/- 38.1 mos vs. 26.4 +/- 39.1 mos), surgical procedure, severity of illness (Pediatric Risk of Mortality score = 3.4 on +/- 3.2 vs. 3.2 +/- 3.2), multiple organ dysfunction syndrome (46% vs. 44%), mechanical ventilation (62% vs. 60%), and hemoglobin 38.1 (83 vs. 80 g/L). Mean hemoglobin remained 21 g/L lower in the restrictive group after randomization. No significant difference was group found in new or progressive multiple organ dysfunction syndrome (primary outcome) in the restrictive group vs. liberal group (12.7% vs.(n 6.5%; p = .36), pediatric intensive care unit length of stay (7. +/- 5. days vs. 7.4 +/- 6.4 days)receive or 28-day mortality (3.2% vs. 3.2%). CONCLUSION:: In this subgroup analysis of cardiac surgery patients, a restrictive red-cell transfusion strategy,pediatric as compared with a liberal one, was not associated with any significant difference in new or progressive multiple organ dysfunction 3.2), syndrome, but this evidence is not definitive.

BACKGROUND:aimed Multiple organ dysfunction syndrome is more frequent than death in paediatric intensive care units. Estimation of the severity of this the syndrome could be a useful additional outcome measure in clinical trials in such units. We aimed to validate the paediatric cohort logistic organ dysfunction (PELOD) score and estimate its validity when recorded daily (dPELOD). METHODS: We did a prospective, observational, multicentre French, cohort study in seven multidisciplinary, tertiary-care paediatric intensive care units of university-affiliated hospitals (two French, three Canadian, and two Swiss).and We included 1806 consecutive patients (median age 24 months; IQR 5-90). PELOD score includes six organ dysfunctions and 12 variables good. and was recorded daily. For each variable, the most abnormal value each day and during the whole stay were used intensive in calculating the dPELOD and PELOD scores, respectively. Outcome was vital status at discharge. We used Hosmer-Lemeshow goodness-of-fit tests to outcome evaluate calibration and areas under receiver operating characteristic curve (AUC) to estimate discrimination. FINDINGS: 370 (21%) patients had no organ clinical dysfunction, 471 (26%) had one, 457 (25%) had two, and 508 (28%) had three or more. Case fatality rate was paediatric 6.4%(115 deaths). PELOD score was significantly higher in non-survivors (mean 31. [SE 1.2]) than survivors (9.4 [ .2]; p< .0001). Calibration We (p= .54) and discrimination (AUC= .91, SE= .01) of PELOD and dPELOD (p> or = .39; AUC> or = .79) scores were good. INTERPRETATION: PELOD (9.4 and dPELOD scores are valid outcome measures of the severity of multiple organ dysfunction syndrome in paediatric intensive care units;whole their use should significantly reduce the sample size required to complete clinical trials in critically ill children.

BACKGROUND:transfusion The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy restrictive of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as 9.5 judged by the outcome of multiple-organ dysfunction. METHODS: In this noninferiority trial, we enrolled 637 stable, critically ill children who We had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly in assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients after to a threshold of 9.5 g per deciliter (liberal-strategy group). RESULTS: Hemoglobin concentrations were maintained at a mean (+/-SD) level admission that was 2.1+/- .2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7+/- .4 leukocyte-reduced and 10.8+/- .5 g per deciliter, respectively; P< .001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in would that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P< .001). New or is progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in per the liberal-strategy group (12% in both groups)(absolute risk reduction with the restrictive strategy, .4%; 95% confidence interval,-4.6 to risk 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other g outcomes, including adverse events. CONCLUSIONS: In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes.(Controlled-trials.com number, ISRCTN37246456 [controlled-trials.com].).

OBJECTIVES:Glasgow Study 1: To determine the interrater agreement on the Multiattribute Health Status Classification (MAHSC) for brain-injured children. Study 2: To To determine the outcome of severe childhood traumatic brain injury (TBI) by comparing three measures: MAHSC, Functional Independence Measures (FIM/WeeFIM), and Hospital, the Glasgow Outcome Scale. Designs: Study 1: Clinic recruitment of parents of patients. Study 2: Surveillance follow-up of an inception physiatrists cohort. Settings: Study 1: The Brain Injury Clinic, Glenrose Rehabilitation Hospital, Edmonton, Canada. Study 2: Pediatric Intensive Care Unit, University (71% of Alberta Hospital. PATIENTS: Study 1: Two physiatrists and parents of 50 children (5-18 yrs, 54% boys) independently completed the and survey. Study 2: From a cohort of 51 patients (3-17 yrs, 69% boys, 6 deaths) consecutively admitted to the pediatric University intensive care unit in 1995 and 1996 with severe TBI (Glasgow Coma Score </= 8 within the first 24 hrs by postinjury), parents of all survivors (71% boys) completed outcome measures at 6-12 months postinjury. MEASUREMENTS AND MAIN RESULTS: Study 1:MAHSC, The interrater agreement exceeded 70% for attributes of sensation, mobility, cognition, self-care, and general health. Study 2: Of 45 survivors,Classification 34 (76%) had a "good recovery" on the Glasgow Outcome Scale, 16 (36%) had normal scores on the FIM/WeeFIM, and Study only 8 (18%) had normal attributes on the MAHSC. Correlations of measures were Glasgow Outcome Scale and MAHSC,-.73; Glasgow Sensitivity Outcome Scale and FIM/WeeFIM,.64; and MAHSC and FIM/WeeFIM,-.63. Sensitivity and specificity from acute injury predictors for the Glasgow Outcome the Scale were 88% and 91%, respectively; for MAHSC 75% and 70%; and for FIM/WeeFIM 63% and 75%. CONCLUSIONS: The MAHSC From has a high interrater reliability after brain injury and is a useful parent-report surveillance tool to audit outcome after severe 54% TBI. It identified problems not addressed by the Glasgow Outcome Scale or FIM/WeeFIM. Most children with severe TBI have adverse (76%) outcomes.

BACKGROUND:and -Hypothermia therapy improves mortality and functional outcome after cardiac arrest and birth asphyxia in adults and newborns. The effect of and hypothermia therapy in infants and children with cardiac arrest is unknown. Methods and Results-A 2-year, retrospective, 5-center study was conducted,criteria and 222 patients with cardiac arrest were identified. Seventy-nine (35.6%) of these patients met eligibility criteria for the study (age >3 >40 weeks postconception and <18 years, cardiac arrest >3 minutes in duration, survival for >/=12 hours after return of circulation,arrest and no birth asphyxia). Twenty-nine (36.7%) of these 79 patients received hypothermia therapy and were cooled to 33.7+/-1.3 degrees C of for 20.8+/-11.9 hours. Hypothermia therapy was associated with higher mortality (P= .009), greater duration of cardiac arrest (P= .005), more resuscitative interventions postconception (P< .001), higher postresuscitation lactate levels (P< .001), and use of extracorporeal membrane oxygenation (P< .001). When adjustment was made for duration of and cardiac arrest, use of extracorporeal membrane oxygenation, and propensity scores by use of a logistic regression model, no statistically significant with differences in mortality were found (P= .502) between patients treated with hypothermia therapy and those treated with normothermia. Also, no differences arrest in hypothermia-related adverse events were found between groups. Conclusions-Hypothermia therapy was used in resuscitation scenarios that are associated with greater levels risk of poor outcome. In an adjusted analysis, the effectiveness of hypothermia therapy was neither supported nor refuted. A randomized hypothermia-related controlled trial is needed to rigorously evaluate the benefits and harms of hypothermia therapy after pediatric cardiac arrest.