The COMFORT scale is a measurement tool to assess distress, sedation and pain in nonverbal paediatric patients. Several studies have described the COMFORT scale, but no formal assessment of the methodological quality has been undertaken. Therefore, we performed a systematic review to study the clinimetric properties of the (modified) COMFORT scale in children up to 18 years. We searched Central, CINAHL, Embase, Medline, PsycInfo and Web of Science until December 2014. The selection, data extraction and quality assessment were performed independently by two reviewers. Quality of the included studies was appraised using the COSMIN checklist. We found 30 studies that met the inclusion criteria. Most participants were ventilated children up to 4 years without neurological disorders. The results on internal consistency and interrater reliability showed values of >0.70 in most studies, indicating an adequate reliability. Construct validity resulted in correlations between 0.68 and 0.84 for distress, between 0.42 and 0.94 for sedation and between 0.31 and 0.96 for pain. The responsiveness of the (modified) COMFORT scale seems to be adequate. The quality of the included studies ranged from poor to excellent. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain. The included studies were clinically and methodologically heterogeneous, hampering firm conclusions. What does this review add?:• An in-depth assessment of the clinimetric properties of the COMFORT scale.• The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain.

Objectives: Ventilator-associated pneumonia is one of the most frequent hospital-acquired infections in mechanically ventilated children. We reviewed the literature on the effectiveness of ventilator care bundles in critically ill children.

BackgroundCitrate is preferred over heparin as an anticoagulant in adult continuous renal replacement therapy (CRRT). However, its potential adverse effects and data on use in CRRT in infants and toddlers is limited. We conducted a prospective study on using citrate in CRRT in critically ill small children.MethodsChildren who underwent CRRT with the smallest filter in our PICU between November 2011 and November 2016 were included. Both heparin and citrate were applied according to a strict protocol. Our primary outcome was circuit survival time. Secondary outcomes were alkalosis, citrate toxicity, and number of red blood cell transfusions.ResultsHeparin was used in six patients (121 circuits, total CRRT time 3723 h). Citrate was used in 14 patients (105 circuits, total CRRT time 4530 h). Median circuit survival time with heparin was 21 h (IQR 14.5–27.5) compared to 45.2 h (IQR 37.5–52.8) with citrate (p < 0.001). Actual administered effluent dose compared to prescribed dose was 85% (IQR 69–98%) with heparin compared to 92% (IQR 88–98%) with citrate (p = 0.31). No patient treated with citrate developed citrate toxicity. No other differences in electrolytes were found between the two CRRT regimes. In the heparin group, a median of 6.5 units of red blood cells (IQR 1.5–23.8) were given during CRRT, compared to three in the citrate group (IQR 2.0–5.0, p = 0.12).ConclusionsUse of regional citrate significantly prolongs circuit survival time and thereby should increase CRRT efficiency when compared to heparin. In addition, citrate appears safe for CRRT in critically ill small children.