Cerebral Oximetry During Pediatric In-Hospital Cardiac Arrest: A Multicenter Study of Survival and Neurologic Outcome.

OBJECTIVES: To determine if near-infrared spectroscopy measuring cerebral regional oxygen saturation (crS o2 ) during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in children. DESIGN: Multicenter, observational study. SETTING: Three hospitals in the pediatric Resuscitation Quality (pediRES-Q) collaborative from 2015 to 2022. PATIENTS: Children younger than 18 years, gestational age 37 weeks old or older with in-hospital cardiac arrest (IHCA) receiving cardiopulmonary resuscitation greater than or equal to 1 minute and intra-arrest crS o2 monitoring. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was ROSC greater than or equal to 20 minutes without extracorporeal membrane oxygenation. Secondary outcomes included SHD and favorable neurologic outcome (FNO) (Pediatric Cerebral Performance Category 1-2 or no change from prearrest). Among 3212 IHCA events (index and nonindex), 123 met inclusion criteria in 93 patients. Median age was 0.3 years (0.1-1.4 yr) and 31% (38/123) of the cardiopulmonary resuscitation events occurred in patients with cyanotic heart disease. Median cardiopulmonary resuscitation duration was 8 minutes (3-28 min) and ROSC was achieved in 65% (80/123). For index events, SHD was achieved in 59% (54/91) and FNO in 41% (37/91). We determined the association of median intra-arrest crS o2 and percent of crS o2 values above a priori thresholds during the: 1) entire cardiopulmonary resuscitation event, 2) first 5 minutes, and 3) last 5 minutes with ROSC, SHD, and FNO. Higher crS o2 for the entire cardiopulmonary resuscitation event, first 5 minutes, and last 5 minutes were associated with higher likelihood of ROSC, SHD, and FNO. In multivariable analysis of the infant group (age < 1 yr), higher crS o2 was associated with ROSC (odds ratio [OR], 1.06; 95% CI, 1.03-1.10), SHD (OR, 1.04; 95% CI, 1.01-1.07), and FNO (OR, 1.05; 95% CI, 1.02-1.08) after adjusting for presence of cyanotic heart disease. CONCLUSIONS: Higher crS o2 during pediatric IHCA was associated with increased rate of ROSC, SHD, and FNO. Intra-arrest crS o2 may have a role as a real-time, noninvasive predictor of ROSC.

Benefits and Limitations of Virtual Recruitment: Perspectives From Subspeciality Directors.

BACKGROUND AND OBJECTIVES: Because of the coronavirus disease 2019 pandemic and recommendations from a range of leaders and organizations, the pediatrics subspecialty 2020 recruitment season was entirely virtual. Minimal data exist on the effect of this change to guide future strategies. The aim of this study was to understand the effects of virtual recruitment on pediatric subspecialty programs as perceived by program leaders. METHODS: This concurrent, triangulation, mixed-methods study used a survey that was developed through an iterative (3 cycles), consensus-building, modified Delphi process and sent to all pediatric subspecialty program directors (PSPDs) between April and May 2021. Descriptive statistics and thematic analysis were used, and a conceptual framework was developed. RESULTS: Forty-two percent (352 of 840) of PSPDs responded from 16 of the 17 pediatric (94%) subspecialties; 60% felt the virtual interview process was beneficial to their training program. A majority of respondents (72%) reported cost savings were a benefit; additional benefits included greater efficiency of time, more applicants per day, greater faculty involvement, and perceived less time away from residency for applicants. PSPDs reported a more diverse applicant pool. Without an in-person component, PSPDs worried about programs and applicants missing informative, in-person interactions and applicants missing hospital tours and visiting the city. A model based upon theory of change was developed to aid program considerations for future application cycles. CONCLUSIONS: PSPDs identified several benefits to virtual recruitment, including ease of accommodating increased applicants with a diverse applicant pool and enhanced faculty involvement. Identified limitations included reduced interaction between the applicant and the larger institution/city.

Development of a Standardized Clinical Assessment and Management Plan for Pediatric Acute Respiratory Distress Syndrome.

Pediatric acute respiratory distress syndrome (PARDS) is one of the most challenging patient populations for a clinician to manage with mortality between 8 and 31%. The project was designed to identify patients with PARDS, implement management guidelines with the goal of standardizing practice. Our objectives were to describe the development and implementation of a protocolized approach to identify patients with PARDS and institute ventilator management guidelines. Patients who met criteria for moderate or severe PARDS as per the Pediatric Acute Lung Injury Consensus Conference (PALICC) definitions were identified using the best practice alert (BPA) in the electronic health record (EHR). Patients who did not meet exclusion criteria qualified for management using the Standardized Clinical Assessment and Management Plan (SCAMP), a quality improvement (QI) methodology with iterative cycles. The creation of a BPA enabled identification of patients with PARDS. With our second cycle, the number of false BPA alerts due to incorrect data decreased from 66.7 (68/102) to 29.2% (19/65; p < 0.001) and enrollment increased from 48.3 (14/29) to 73.2% (30/41; p = 0.03). Evaluation of our statistical process control chart (SPC) demonstrated a shift in the adherence with the tidal volume guideline. Overall, we found that SCAMP methodology, when used in the development of institutional PARDS management guidelines, allows for development of a process to aid identification of patients and monitor adherence to management guidelines. This should eventually allow assessment of impact of deviations from clinical practice guidelines.

Uncommon Etiologies of Shock.

Shock is a state in which the cardiovascular system fails to adequately deliver required substrates to maintain end-organ perfusion, tissue homeostasis, and cellular metabolism. Rapid recognition of shock and intervention is of utmost importance to reverse the shock state. This article reviews uncommon etiologies of shock classified in the following categories: distributive, hypovolemic, cardiogenic, and dissociative shock.

Using Aggregate Vasoactive-Inotrope Scores to Predict Clinical Outcomes in Pediatric Sepsis.

Objectives: The heterogeneity of sepsis makes it difficult to predict outcomes using existing severity of illness tools. The vasoactive-inotrope score (VIS) is a quantitative measure of the amount of vasoactive support required by patients. We sought to determine if a higher aggregate VIS over the first 96 h of vasoactive medication initiation is associated with increased resource utilization and worsened clinical outcomes in pediatric patients with severe sepsis. Design: Retrospective cohort study. Setting: Single-center at Children's Wisconsin in Milwaukee, WI. Patients: One hundred ninety-nine pediatric patients, age less than 18 years old, diagnosed with severe sepsis, receiving vasoactive medications between January 2017 and July 2019. Interventions: Retrospective data obtained from the electronic medical record, calculating VIS at 2 h intervals from 0-12 h and at 4 h intervals from 12-96 h from Time 0. Measurements: Aggregate VIS derived from the hourly VIS area under the curve (AUC) calculation based on the trapezoidal rule. Data were analyzed using Pearson's correlations, Mann-Whitney test, Wilcoxon signed rank test, and classification, and regression tree (CART) analyses. Main Results: Higher aggregate VIS is associated with longer hospital LOS (p < 0.0001), PICU LOS (p < 0.0001), MV days (p = 0.018), increased in-hospital mortality (p < 0.0001), in-hospital cardiac arrest (p = 0.006), need for ECMO (p < 0.0001), and need for CRRT (p < 0.0001). CART analyses found that aggregate VIS >20 is an independent predictor for in-hospital mortality (p < 0.0001) and aggregate VIS >16 for ECMO use (p < 0.0001). Conclusions: There is a statistically significant association between aggregate VIS and many clinical outcomes, allowing clinicians to utilize aggregate VIS as a physiologic indicator to more accurately predict disease severity/trajectory in pediatric sepsis.

Association of Fluid Balance and Survival of Pediatric Patients Treated With Extracorporeal Membrane Oxygenation.

The effect of positive fluid balance (FB) on extracorporeal membrane oxygenation (ECMO) outcomes in pediatric patients remains unknown. We sought to evaluate if positive FB in pediatric intensive care unit (PICU) patients with respiratory and/or cardiac failure necessitating ECMO was associated with increased morbidity or mortality. This was a multicenter retrospective cohort study of data from the deidentified PEDiatric ECMO Outcomes Registry (PEDECOR). Patients entered into the database from 2014 to 2017, who received ECMO support, were included. A total of 168 subjects met the study criteria. Univariate analysis showed no significant difference in total FB on ECMO days 1-5 between survivors and non-survivors [median 90 ml/kg (IQR 18-208.5) for survivors vs. median 139.7 ml/kg (IQR 11.2-300.6) for non-survivors, p = 0.334]. There was also no difference in total FB on ECMO days 1-5 in patients with no change in functional outcome as reflected by the Pediatric Outcome Performance Category (POPC) score vs. those who had worsening in POPC score ≥2 at hospital discharge [median 98 ml/kg (IQR 18-267) vs. median 130 ml/kg (IQR 13-252), p = 0.91]. Subjects that required 50 ml/kg or more of blood products over the initial 5 days of ECMO support had an increased rate of mortality with an odds ratio of 5.8 (95% confidence interval of 2.7-12.3; p = 0.048). Our study showed no association of the noted FB with survival after ECMO cannulation. This FB trend was also not associated with POPC at hospital discharge, MV duration, or ECMO duration. The amount of blood product administered was found to be a significant predictor of mortality.

Acute Care Pediatric Nurse Practitioners as Leaders: Perceptions, Self-Identity, and Role Congruity.

INTRODUCTION: This study aimed to gain an understanding of practicing acute care pediatric nurse practitioners' (AC-PNPs') perceptions of themselves as leaders in both clinical and professional contexts. METHOD: This qualitative study was conducted at a midwestern quaternary care children's hospital. Cultural domain analysis, semistructured interviews, and free listing techniques were employed to identify areas of consensus and variation among a convenience sample of AC-PNPs. RESULTS: Findings demonstrated the AC-PNPs have a limited self-view of leadership. DISCUSSION: Nurse practitioners need additional leadership capacity and capability building during graduate education, the transition to practice, and throughout their careers.

Emergency department utilisation and critical readmission in patients with Fontan circulation.

BACKGROUND: We aimed to conduct a multi-centre study characterising emergency department utilisation and critical readmissions experienced by children with Fontan circulation. METHODS: We conducted a retrospective review of children who underwent the Fontan operation at three institutions (i.e., centres A, B, and C) between 2009 and 2014, with follow-up through December 2015. Multi-variable analyses were performed to determine factors associated for emergency department utilisation within 1 year of surgery, emergency department utilisation at any time following surgery, or critical readmission (defined as admission to ICU, operating room, or cardiac catheterisation). RESULTS: We reviewed 297 patients, of which 147 patients (49%) had 607 emergency department encounters. Forty-six patients (15%) required 71 critical readmissions. Multi-variable analyses revealed centre C (p = 0.02) and post-operative hospitalisation ≥ 14 days (p = 0.03) to be significantly associated with emergency department utilisation within 1 year, whereas centre B (p < 0.001), post-operative hospitalisation ≥ 14 days (p = 0.002), and African-American/Black race (p = 0.04) were significantly associated with critical readmission. CONCLUSIONS: In this multi-centre study, nearly half of patients with Fontan circulation received emergency department care, often presenting with high disease acuity requiring readmission. Emergency department utilisation and need for critical readmission were independently influenced by the centre at which surgery was performed, prolonged post-operative hospitalisation, and racial background. These data could help guide quality improvement efforts aimed at reducing morbidity in this unique patient population.

Rates of Venous Thromboembolism and Central Line-Associated Bloodstream Infections Among Types of Central Venous Access Devices in Critically Ill Children.

OBJECTIVES: Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU. DESIGN: Multicenter, cohort study. SETTING: One hundred forty-eight participating Virtual PICU Systems, LLC, hospital PICU sites. PATIENTS: Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters. CONCLUSIONS: Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.

Diagnostic Bedside Ultrasound Program Development in Pediatric Critical Care Medicine: Results of a National Survey.

OBJECTIVES: To assess current diagnostic bedside ultrasound program core element (training, credentialing, image storage, documentation, and quality assurance) implementation across pediatric critical care medicine divisions in the United States. DESIGN: Cross-sectional questionnaire-based needs assessment survey. SETTING: Pediatric critical care medicine divisions with an Accreditation Council of Graduate Medical Education-accredited fellowship. RESPONDENTS: Divisional leaders in education and/or bedside ultrasound training. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-five of 67 pediatric critical care medicine divisions (82%) with an Accreditation Council of Graduate Medical Education-accredited fellowship provided responses. Overall, 63% of responding divisions (34/54) were clinically performing diagnostic bedside ultrasound studies with no difference between divisions with large versus small units. Diagnostic bedside ultrasound training is available for pediatric critical care medicine fellows within 67% of divisions (35/52) with no difference in availability between divisions with large versus small units. Other core elements were present in less than 25% of all divisions performing clinical studies, with a statistically significant increase in credentialing and documentation among divisions with large units (p = 0.048 and 0.01, respectively). All core elements were perceived to have not only high impact in program development but also high effort in implementation. Assuming that all structural elements could be effectively implemented within their division, 83% of respondents (43/52) agreed that diagnostic bedside ultrasound should be a core curricular component of fellowship education. CONCLUSIONS: Diagnostic bedside ultrasound is increasingly prevalent in training and clinical use across the pediatric critical care medicine landscape despite frequently absent core programmatic infrastructural elements. These core elements are perceived as important to program development, regardless of division unit size. Shared standardized resources may assist in reducing the effort in core element implementation and allow us to measure important educational and clinical outcomes.

Comparison of Complication Rates of Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters in Pediatric Patients.

OBJECTIVES: The purpose of our study is to compare the rate of central line-associated blood stream infections and venous thromboembolism in central venous catheters versus peripherally inserted central catheters in hospitalized children. There is a growing body of literature in adults describing an increased rate of venous thromboembolisms and similar rates of central line-associated blood stream infection associated with peripherally inserted central catheters versus central venous catheters. It is not known if the rate of central line-associated blood stream infection and venous thromboembolism differs between peripherally inserted central catheters and central venous catheters in children. Based on current adult literature, we hypothesize that central line-associated blood stream infection rates for peripherally inserted central catheters and central venous catheters will be similar, and the rate of venous thromboembolism will be higher for peripherally inserted central catheters versus central venous catheters. DESIGN: This is a cohort study using retrospective review of medical records and prospectively collected hospital quality improvement databases. SETTING: Quaternary-care pediatric hospital from October 2012 to March 2016. PATIENTS: All patients age 1 day to 18 years old with central venous catheters and peripherally inserted central catheters placed during hospital admission over the study dates were included. Central venous catheters that were present upon hospital admission were excluded. The primary outcomes were rate of central line-associated blood stream infection and rate of venous thromboembolism. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,709 catheters included in the study, 1,126 were peripherally inserted central catheters and 1,583 were central venous catheters. Peripherally inserted central catheters demonstrated a higher rate of both infection and venous thromboembolism than central venous catheters in all reported measures. In multivariable analysis, peripherally inserted central catheters had increased association with central line-associated blood stream infection (odds ratio of 3.15; 95% CI, 1.74-5.71; p = 0.0002) and increased association with venous thromboembolism (odds ratio of 2.71; 95% CI, 1.65-4.45; p < 0.0001) compared with central venous catheters. CONCLUSIONS: Rates of central line-associated blood stream infection and venous thromboembolism were higher in hospitalized pediatric patients with peripherally inserted central catheters as compared to central venous catheters. Our study confirms the need for further investigation into the safety of central access devices to assist in proper catheter selection.

A Needs Assessment of Brain Death Education in Pediatric Critical Care Medicine Fellowships.

OBJECTIVES: To assess the current training in brain death examination provided during pediatric critical care medicine fellowship. DESIGN: Internet-based survey. SETTING: United States pediatric critical care medicine fellowship programs. SUBJECTS: Sixty-four pediatric critical care medicine fellowship program directors and 230 current pediatric critical care medicine fellows/recent graduates were invited to participate. INTERVENTIONS: Participants were asked demographic questions related to their fellowship programs, training currently provided at their fellowship programs, previous experience with brain death examinations (fellows/graduates), and perceptions regarding the adequacy of current training. MEASUREMENTS AND MAIN RESULTS: Twenty-nine program directors (45%) and 91 current fellows/graduates (40%) responded. Third-year fellows reported having performed a median of five examinations (interquartile range, 3-6). On a five-point Likert scale, 93% of program directors responded they "agree" or "strongly agree" that their fellows receive enough instruction on performing brain death examinations compared with 67% of fellows and graduates (p = 0.007). The responses were similar when asked about opportunity to practice brain death examinations (90% vs 54%; p < 0.001). In a regression tree analysis, number of brain death examinations performed was the strongest predictor of trainee satisfaction. Both fellows and program directors preferred bedside demonstration or simulation as educational modalities to add to the fellowship curriculum. CONCLUSIONS: Pediatric critical care medicine fellows overall perform relatively few brain death examinations during their training. Pediatric critical care medicine fellows and program directors disagree in their perceptions of the current training in brain death examination, with fellows perceiving a need for increased training. Both program directors and fellows prefer additional training using bedside demonstration or simulation. Since clinical exposure to brain death examinations is variable, adding simulated brain death examinations to the pediatric critical care medicine fellowship curriculum could help standardize the experience.

Human Parechovirus as a Cause of Isolated Pediatric Acute Liver Failure.

Among infants, almost half of acute liver failure cases are classified as indeterminate, whereas only a small number of cases show a documented viral infection. We present the first reported case of isolated acute hepatic failure in an infant in the setting of a human parechovirus (HPeV) infection. HPeV also may have been contributory to the posttransplant complication of 2 intussusceptions. This is a 10-month-old girl who presented with only symptoms of fussiness and was noted to have progressive decline in synthetic liver function as well as worsening coagulopathy requiring a liver transplant. The acute liver failure was in the setting of a positive serum RNA HPeV, subtype 3 (HPeV-3), after extensive diagnostic testing with genetic, autoimmune, and infectious causes otherwise negative. After liver transplantation, the postoperative course was complicated by both an ileal-ileal intussusception as well as a jejunal intussusception. Viral testing in pediatric acute liver failure is often performed, but the workup is frequently incomplete. This case report would support more extensive viral testing in this population of patients. In the setting of HPeV, clinicians could be alerted to the possibility of delayed gastrointestinal pathology in the posttransplant phase. Wider use of routine HPeV testing may more clearly define the variable clinical presentations and outcomes.