Staged repair of borderline hypoplastic heart disease with early biventricular conversion.

Objective: In select patients with borderline ventricular hypoplasia, we adopted a strategy of initial single-ventricle palliation followed by staged or direct biventricular conversion by 2 years of age. Methods: Between 2018 and 2023, 14 newborns with borderline hypoplastic heart disease deemed high risk for primary biventricular repair underwent palliative procedures as a neonate/infant, followed by staged or direct biventricular conversion. Results: Of the 14 patients, 6 had borderline left ventricles and 8 had borderline right ventricles. Index neonatal operations were performed in 12 patients and included the Norwood operation (n = 5), pulmonary artery band (n = 3), ductal stent (n = 3), and hybrid Norwood (n = 1). Five patients underwent direct biventricular conversion, and the remaining 9 patients underwent staged ventricular recruitment operations at a mean age of 6 months (range, 3-11 months). Ventricular recruitment operations included atrial septation with or without ventricular rehabilitation, atrioventricular valve repair, or outflow tract operations. At a mean duration of 8 months (range, 4-10 months) after ventricular recruitment, there was a significant increase in chamber volume, aortic valve, and mitral valve size in patients with borderline left ventricles, and a normalization of the right ventricle:left ventricle end-diastolic volume ratio in patients with borderline right ventricles. To date, 13 of 14 patients have undergone successful biventricular conversion at a mean age of 16 months (range, 4-31 months). Conclusions: In select newborns with borderline hypoplastic heart disease, single-ventricle palliation followed by staged or direct biventricular conversion may increase infant survival while allowing for early attainment of a biventricular circulation.

Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease.

BACKGROUND: In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters. METHODS: Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist-driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success. RESULTS: A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6-6.5] months and median weight [interquartile range] 4.2 [3.3-6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ([Formula: see text]), and dead-space-to-tidal-volume ratio (all P < .001) but not for [Formula: see text]. ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, [Formula: see text], and dead-space-to-tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H2O, and [Formula: see text] > 10 cm H2O were associated with a decreased odds of ERT success, whereas children ages 1-5 years and an [Formula: see text] of 0.31-0.40 had increased odds of ERT success. CONCLUSIONS: ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that [Formula: see text] was associated with ERT success and that protocols should consider using [Formula: see text] instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.

Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery.

Background: To develop a more holistic measure of congenital heart center performance beyond mortality, we created a composite "textbook outcome" (TO) for the Glenn operation. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single center retrospective study of patients undergoing superior cavopulmonary connection (bidirectional Glenn or Kawashima ± concomitant procedures) from 2005 to 2021. Textbook outcome was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, length of stay (LOS) >75th percentile (17d), and mechanical ventilation duration >75th percentile (2d). Multivariable logistic regression and Cox proportional hazards modeling were used. Results: Fifty-one percent (137/269) of patients met TO. Common reasons for TO failure were prolonged LOS (78/132, 59%) and ventilator duration (67/132, 51%). In multivariable analysis, higher weight [odds ratio, OR: 1.44 (95% confidence interval, CI: 1.15-1.84), P = .002] was a positive predictor of TO achievement while right ventricular dominance [OR 0.47 (0.27-0.81), P = .007] and higher preoperative pulmonary vascular resistance [OR 0.58 (0.40-0.82), P = .003] were negative predictors. After controlling for preoperative factors and excluding operative mortalities, TO achievement was independently associated with a decreased risk of death over long-term follow-up [hazard ratio: 0.50 (0.25-0.99), P = .049]. Textbook outcome achievement was also associated with lower direct cost of care [$137,626 (59,333-167,523) vs $262,299 (114,200-358,844), P < .0001]. Conclusion: Achievement of the Glenn TO is associated with long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality will become a less informative metric. Textbook outcome analysis may represent a more balanced measure of a successful outcome.

Textbook outcome for the Norwood operation-an informative quality metric in congenital heart surgery.

Objectives: To develop a more holistic measure of center performance than operative mortality, we created a composite "textbook outcome" for the Norwood operation using several postoperative end points. We hypothesized that achieving the textbook outcome would have a positive prognostic and financial impact. Methods: This was a single-center retrospective study of primary Norwood operations from 2005 to 2021. Through interdisciplinary clinician consensus, textbook outcome was defined as freedom from operative mortality, open or catheter-based reintervention, 30-day readmission, extracorporeal membrane oxygenation, cardiac arrest, reintubation, length of stay >75%ile from Society of Thoracic Surgeons data report (66 days), and mechanical ventilation duration >75%ile (10 days). Multivariable logistic regression and Cox proportional hazards modeling were used to determine predictive factors for textbook outcome achievement and association of the outcome with long-term survival, respectively. Results: Overall, 30% (58/196) of patients met the textbook outcome. Common reasons for failure to attain textbook outcome were prolonged ventilation (68/138, 49%) and reintubation (63/138, 46%). In multivariable analysis, greater weight (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.17-3.95; P = .02) was associated with achieving the textbook outcome whereas preoperative shock (OR, 0.36; 95% CI, 0.13-0.87; P = .03) and longer bypass time (OR, 0.99; 95% CI, 0.98-1.00; P = .002) were negatively associated. Patients who met the outcome incurred fewer hospital costs ($152,430 [141,798-177,983] vs $269,070 [212,451-372,693], P < .001), and after adjusting for patient factors, achieving textbook outcome was independently associated with decreased risk of all-cause mortality (hazard ratio, 0.45; 95% CI, 0.22-0.89; P = .02). Conclusions: Outcomes continue to improve within congenital heart surgery, making operative mortality a less-sensitive metric. The Norwood textbook outcome may represent a balanced measure of a successful episode of care.

Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants.

BACKGROUND: Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs (PICUs). METHODS: We performed a retrospective study of children < 10 kg receiving postextubation NIV or CPAP in our PICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and re-intubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 h of extubation. We compared successfully extubated and re-intubated subjects using chi-square test for categorical variables and Mann-Whitney test for continuous variables. RESULTS: We studied 51 subjects, median age 44 (interquartile range 0.5-242) d and weight 3.7 (3-4.9) kg. There were no demographic differences between groups, except those re-intubated were more likely to have had cardiac surgery prior to admission (0% vs 14%, P = .040). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%), whereas rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required re-intubation. Re-intubation rate was higher for rescue support (58% vs 28%, P = .032). Subjects with a pH < 7.35 (4.3% vs 42.0%, P = .003) and lower somatic NIRS (39 [24-56] vs 62 [46-72], P = .02) were more likely to be re-intubated. The inspiratory positive airway pressure, expiratory positive airway pressure, and FIO2 were higher in subjects who required re-intubation. CONCLUSIONS: NIV or CPAP use was associated with a re-intubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher FIO2 , lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for re-intubation.

Sustained Total All-Region Perfusion During the Norwood Operation and Postoperative Recovery.

We developed a technique for the Norwood operation utilizing continuous perfusion of the head, heart, and lower body at mild hypothermia named Sustained Total All-Region (STAR) perfusion. We hypothesized that STAR perfusion would be associated with shorter operative times, decreased coagulopathy, and expedited post-operative recovery compared to standard perfusion techniques. Between 2012 and 2020, 80 infants underwent primary Norwood reconstruction at our institution. Outcomes for patients who received successful STAR perfusion (STAR, n = 37) were compared to those who received standard Norwood reconstruction utilizing regional cerebral perfusion only (SNR, n = 33), as well as to Norwood patients reported in the PC4 national database during the same timeframe (n = 1238). STAR perfusion was performed with cannulation of the innominate artery, descending aorta, and aortic root at 32-34°C. STAR patients had shorter median CPB time compared to SNR (171 vs 245 minutes, P < 0.0001), shorter operative time (331 vs 502 minutes, P < 0.0001), and decreased intraoperative pRBC transfusion (100 vs 270 mL, P < 0.0001). STAR patients had decreased vasoactive-inotropic score on ICU admission (6 vs 10.8, P = 0.0007) and decreased time to chest closure (2 vs 4.5 days, P = 0.0004). STAR patients had lower peak lactate (8.1 vs 9.9 mmol/L, P = 0.03) and more rapid lactate normalization (18.3 vs 27.0 hours, P = 0.003). In-hospital mortality in STAR patients was 2.7% vs 15.1% with SNR (P = 0.06) and 10.3% in the PC4 aggregate (P = 0.14). STAR perfusion is a novel approach to Norwood reconstruction associated with excellent survival, decreased transfusions, shorter operative time, and improved convalescence in the early post-operative period.

Association Between Pressure Support During Extubation Readiness Testing and Time to First Extubation in Children With Congenital Heart Disease.

BACKGROUND: Extubation readiness testing (ERT) is often performed in children with congenital heart disease prior to liberation from mechanical ventilation. The ideal ERT method in this population is unknown. We recently changed our ERT method from variable (10, 8, or 6 cm H2O, depending on endotracheal tube size) to fixed (5 cm H2O) pressure support (PS). Our study assessed the association between this change and time to first extubation and need for re-intubation. METHODS: We studied 2 temporally distinct cohorts, one where ERT was conducted with variable PS and another using PS fixed at 5 cm H2O. Data were prospectively collected as part of a quality improvement project. The primary outcome was time to first extubation. Secondary outcomes were need for re-intubation and percentage of successful ERTs. We performed Poisson regression or logistic regression for the association between PS during ERT and time to first extubation or re-intubation, respectively. RESULTS: We included 320 subjects, 186 in the variable PS group and 152 in fixed PS group. In unadjusted analysis, median time to first extubation was longer in the fixed PS group compared to the variable PS group (4.1 [2.0-7.1] d vs 3.1 [1.1-5.9] d, P = .02), and there was no difference in re-intubation rate (11% vs 8%, P = .34). Subjects in the fixed PS group were significantly more likely to be mechanically ventilated after cardiac arrest, have a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of 4 or 5, be extubated on day shift, receive enteral feeds at extubation, have higher respiratory support at extubation, and higher dead-space-to-tidal-volume ratio. After controlling for these variables in multivariable regression, we found no association between the choice of PS and time to first extubation or re-intubation. CONCLUSIONS: The use of a fixed PS of 5 cm H2O instead of variable PS during ERT was not associated with longer time to first extubation or extubation failure.

Survival After Intervention for Single-Ventricle Heart Disease Over 15 Years at a Single Institution.

BACKGROUND: Children with single-ventricle (SV) heart disease possess a spectrum of heart malformations, yet progress through similar hemodynamic states, suggesting differences in outcomes are related to fundamental morphologic differences, patient characteristics, or procedural pathways. We sought to provide a holistic overview of survival after intervention for SV heart disease at our institution. METHODS: SV heart disease was defined as patients born with a hypoplastic or dysfunctional ventricle with uncertain or unacceptable candidacy for a 2-ventricle circulation. Patients were stratified into 8 diagnostic groups and 11 procedural categories based on the initial interventional procedure. RESULTS: Between 2005 and 2020, 381 patients born with SV heart disease underwent intervention at our institution. Ten-year survival was highest for patients with double inlet left ventricle (89% ± 7%) and lowest for patients with hypoplastic left heart syndrome (55% ± 5%). Initial palliation with less invasive procedures, such as ductal stent (4-year: 100%) or pulmonary artery banding (10-year: 95% ± 5%), demonstrated superior survival compared with more invasive procedures such as the Norwood procedure (10-year: 59% ± 4%). Survival of patients who achieved a biventricular circulation was superior to patients who remained with SV physiology (10-year: 87% ± 5% vs 63% ± 3%, P = .04). In a multivariable analysis, chromosomal/syndromic abnormality, lower weight, hybrid Norwood procedure, nonleft ventricular dominance, and earlier year of operation were risk factors for death. CONCLUSIONS: Survival differences in patients with SV heart disease were related primarily to underlying cardiac anatomy, patient characteristics, and procedural complexity. Left ventricular dominance, more recent intervention, and attainment of a 2-ventricle circulation were associated with improved survival.

Extending the radius of family-centered care in the pediatric cardiac intensive care unit through virtual rounding.

BACKGROUND: The arrival of COVID-19 brought urgent limitation of visitation in hospitals across the country. Family-centered care and its delivery rapidly changed and left the family behind-unable to actively participate in their loved one's care. LOCAL PROBLEM: A southeastern academic medical center pediatric cardiac intensive care unit (PCICU) needed to augment family-centered medical rounds when parents could not be at the bedside. No alternative to physical presence for daily medical rounds existed in the PCICU. METHODS: A virtual rounding (VR) program was implemented allowing parents of patients admitted to PCICU to join medical rounds remotely through teleconferencing. Preintervention and postintervention rounding times, staff perceptions of the program, and parental satisfaction scores using the Pediatric Family Satisfaction in the Intensive Care Unit (pFS-ICU) tool were measured. INTERVENTIONS: This quality improvement project implemented a VR program offered to all families of patients in the PCICU. RESULTS: VR did not increase rounding times after implementation (p = .673). Staff satisfaction surveys revealed that staff felt the VR program did not prolong rounding times (p ≤ 0.001), workload impact perceptions improved after intervention (p = <0.001), and staff felt VR should be offered to families in PCICU (p ≤ 0.001). Only nine pFS-ICU surveys were completed giving the family a limited voice in the evaluation of this project. CONCLUSIONS: This project demonstrates that VR can be successfully implemented for family engagement without increased burden on staff.

Catheter related thrombosis in hospitalized infants: A neural network approach to predict risk factors.

INTRODUCTION: We sought to investigate the predictors of catheter-related thrombosis (CRT) in a cohort of critically ill hospitalized infants and using a novel approach (the artificial neural network - ANN) in combination with conventional statistics to identify/confirm those predictors. METHODS: We performed a retrospective analysis of all infants with a central or peripherally inserted central venous catheter (CVC/PICC) between 2015 and 2018. ANN was generated to investigate the predictors of CRT. The predictive variables examined in the ANN were age, gender, weight, co-morbid conditions, line type, use of ultrasound (USG), emergent line placement, location of line tip, any major surgical procedures, use of mechanical ventilation, exposure to cardio-pulmonary bypass (CPB), past-history of CVC/PICC, or thrombosis. Binary logistic regression was performed to calculate odds ratios (ORs) and determine which factors were significant in predicting CRT. RESULTS: Of total of 613 infants, 59.9% of patients had a history of previous CVC or PICC and 12.2% had a history of thrombus as documented by USG in the past three months. CPB exposure was present in 48.1%. The incidence of CRT was 10.7%. Independent predictors of CRT were the line tip in IVC (OR: 2.37, 1.08-5.21, P = 0.032), history of thrombosis (OR: 2.40, 1.16-4.96, P = 0.019), previous CVC/PICC (OR: 2.80, 1.24-6.33, P = 0.014) and exposure to CPB (OR: 2.749, 1.08-6.98, P = 0.034). A sensitivity analysis was performed to determine the normalized importance of each variable used to create the ANN. The most important variables were age (with normalized importance of 100%), history of thrombosis, weight, and exposure to CPB (normalized importance of 68.2%). CONCLUSIONS: Nearly 1 in 10 infants developed CRT. We found that catheter tip in IVC, exposure to CPB, history of vein thrombosis and history of CVC/PICC placement in the past 3 months are independently associated with a higher risk of CRT in infants by using conventional and neural network methods.

Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury.

OBJECTIVES: Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN). METHODS: We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed. RESULTS: Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals. CONCLUSIONS: There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.

Epidemiology, Clinical and Microbiologic Profile and Risk Factors for Inpatient Mortality in Pediatric Severe Sepsis in the United States From 2003 to 2014: A Large Population Analysis.

OBJECTIVE: To evaluate the national trends in pediatric severe sepsis in the United States from 2003 to 2014. STUDY DESIGN: For this study, we included nonoverlapping years of Kids Inpatient database and National Inpatient Sample database while including hospitalizations of children between 1 and 20 years of age from more than 4200 hospitals across the United States. We identified patient hospitalizations with severe sepsis using specific ICD codes and modified Angus Criteria. Trend analysis of various factors associated with severe sepsis was calculated using the Cochrane-Armitage test. Associated foci of infection and comorbid conditions were identified using specific ICD codes, and a multivariate regression analysis with death as outcome variable was done to evaluate for in hospital predictors of mortality. RESULTS: Totally, 109,026 episodes of severe sepsis were identified during the study period between 2003 and 2014. Incidence of severe sepsis hospitalizations increased by 2.5 times (0.64-1.57 per 10,000 population) over the study period with notable concurrent significant decrease in mortality by more than 50%. Lower age, African American, Hispanic ethnicity, complex neurologic conditions, infective endocarditis, immunodeficient states including primary immunodeficiency disorder, HIV, burns, malignancy and transplant status are associated with mortality. There is a significant increase in use of healthcare resources (P < 0.001) with mean charges of 94,966$ despite a notable decrease in mean length of stay (22 vs. 16 days, P < 0.001) over the study period. CONCLUSION: Incidence of pediatric severe sepsis is high leading to a significant use of healthcare resources. This study provides a detailed analysis of associated inpatient factors and comorbidities associated with mortality.

Hospital-Based Emergency Department Visits With Pediatric Burns: Characteristics and Outcomes.

OBJECTIVE: The objective of this study was to examine the characteristics and outcomes in children presenting to emergency departments (EDs) with burn injuries. METHODS: The Nationwide Emergency Department Sample (NEDS) for the years 2008 to 2013 was used. All patients younger than 18 years who visited a hospital-based ED with a burn injury were selected. The study focused on (1) demographics (age, sex, insurance status), (2) characteristics of burns (types, causes), (3) disposition status after ED/hospitalization, (4) charges (ED and hospital), and (5) patient outcomes. Inclusion criteria were a visit to ED in the United States with a burn. Descriptive statistics were used to summarize the findings. RESULTS: During the study period, there were 746,593 ED visits due to burn injuries. Majority were insured by Medicaid (52.8%). Most frequent injuries were burns of wrists/hands (39.5%), lower limbs (24.1%), and upper limb-except wrist/hand (20.1%). The most common causes of burns were heat from electric appliances (37.1%) or hot liquids and vapors (24.8%). Following the ED visit, 89.1% were discharged routinely, and 4.3% were admitted. Mean charge per patient per ED visit was $1117. Total ED charges across the United States was $708.7 million. When admitted, mean length of stay was 5.7 days. Total hospitalization charge across the United States was $1.7 billion. CONCLUSIONS: Pediatric burn injuries require significant resources for stabilization and treatment by EDs. The present study highlights the burden and impact of pediatric burn injuries in the United States.

Epidemiology, Comorbidities, and Outcomes of Posterior Reversible Encephalopathy Syndrome in Children in the United States.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognized entity with certain identified predisposing factors in children. However, the actual incidence, comorbidities, outcomes, and hospitalization charges among children (aged less than 20 years) in the United States are largely unknown. METHODS: We analyzed the Kids' Inpatient Database for incidence of PRES-related hospitalizations, associated diagnoses, in-hospital outcomes, and charges for children in the United States in 2016. We report demographics, risk factors, discharge status, mortality, length of stay, and hospitalization charges. RESULTS: In 2016, 825 pediatric hospitalizations related to PRES were captured in the Kids' Inpatient Database. Hospital discharges including solid organ transplant, bone marrow transplant, hypertension, renal disorder, primary immunodeficiency, malignancy, sepsis, severe sepsis, systemic connective tissue disorder, blood transfusion, hypomagnesemia, and sickle cell anemia were queried for presence of PRES. The majority of patients were discharged home. We found that PRES-related hospitalizations were significantly associated with increased length of stay and hospitalization charges in 2016 (P < 0.001). A mortality rate of 3.2% was found in PRES-related hospitalizations when compared with 0.4% in non-PRES hospitalizations (P < 0.001). CONCLUSION: PRES accounted for 0.04% of the hospitalizations in this database. Hypertension and the presence of a renal disorder are the most significant risk factors found to be associated with PRES. The presence of PRES was associated with a significant increase in hospitalization charges and increased length of stay.

Clinical trials and future directions in pediatric acute respiratory distress syndrome.

The pediatric acute respiratory distress syndrome (PARDS), a description specific for children with acute respiratory distress syndrome (ARDS), was proposed in the recent Pediatric Acute Lung Injury Consensus Conference (PALICC, 2015). This recent standardization of PARDS diagnosis is expected to aid in uniform earlier recognition of the entity, enable use of consistent management strategies and potentially increase the ease of enrollment in future PARDS clinical trials-all of which are expected to optimize outcomes in PARDS. Clinical trials in PARDS are few but ongoing studies are expected to lay the foundation for future clinical studies. The Randomized Evaluation of Sedation Titration for Respiratory Failure trial (RESTORE) trial has revealed that a goal directed sedation protocol does not reduce the duration of invasive ventilation in critically ill children. PROSpect trial is a large multi-institute clinical trial that is expected to reveal optimal ventilation strategies and patient positioning (supine vs. prone) in patients with severe PARDS. The PARDS neuromuscular blockade (NMB) study is expected to yield important information about the impact of active NMB on PARDS outcomes. Information from these studies could be used to design future clinical trials in PARDS and to lessen the anecdotal or extrapolated experiences from adult clinical studies that often guide clinical practices in PARDS management. Finally, it is expected that these definitions and management strategies will be revised periodically as our understanding of PARDS evolves. Emerging data on PARDS subtypes suggest that patient heterogeneity is an important factor in designing these clinical trials.

Outcomes associated with peripherally inserted central catheters in hospitalised children: a retrospective 7-year single-centre experience.

OBJECTIVES: The use of peripherally inserted central catheters (PICCs) are an integral part of caring for hospitalised children. We sought to estimate the incidence of and identify the risk factors for complications associated with PICCs in an advanced registered nurse practitioners (ARNP)-driven programme. DESIGN: Retrospective cohort study. SETTING: Single-centre, large quaternary children's hospital. PARTICIPANTS: Hospitalised children who had PICC inserted from 1 January 2010 to 31 December 2016. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: A total of 2558 PICCs were placed during the study period. Mean age at PICC insertion was 8.7 years, mean dwell time was 17.7 days. The majority of PICCs (97.8%) were placed by ARNP. Most were placed in a single attempt (79.6%). Mean PICC residual external length outside was 2.1±2.7 cm. The rate of central line-associated bloodstream infection (CLABSI), thrombosis and significant bleeding were 1.9%, 1% and 0.2%, respectively. The CLABSI rate in infants and early childhood was higher than those aged ≥5 years (2.8%, 3.1%, respectively vs 1.3%). In a multivariate analysis after adjustment of confounding effects of race and gender, infants (OR= 2.24, CI=1.14 to 4.39, p=0.02) and early childhood cohort (OR=2.37, CI=1.12 to 5.01, p=0.02) were associated with significantly higher odds of developing CLABSI compared with ≥5 years old. In the early childhood cohort, PICCs with longer residual external catheter length (OR=1.30, 95% CI=1.07 to 1.57, p=0.008) and those placed in the operating room (OR=5.49, 95% CI=1.03 to 29.19, p=0.04), were associated with significantly greater risk of developing CLABSI. CONCLUSIONS: The majority of PICCs were successfully placed by ARNPs on the first attempt and had a low incidence of complications. Infants required more attempts for successful PICC placement than older children. The presence of residual external catheter length and placement in the operating room were independent predictors of CLABSI in younger children.

Use of extracorporeal membrane oxygenation and associated outcomes in children hospitalized for sepsis in the United States: A large population-based study.

OBJECTIVE: The American College of Critical Care Medicine recommends that children with persistent fluid, catecholamine, and hormone-resistant septic shock be considered for extracorporeal membrane oxygenation (ECMO) support. Current national estimates of ECMO use in hospitalized children with sepsis are unknown. We sought to examine the use of ECMO in these children and to examine the overall outcomes such as in-hospital mortality, length of stay (LOS), and hospitalization charges (HC). METHODS: A retrospective analysis of the National Inpatient Sample, which approximates a 20% stratified sample of all discharges from United States community hospitals, was performed. All children (≤ 17 years) who were hospitalized for sepsis between 2012 and 2014 were included. The associations between ECMO and outcomes were examined by multivariable linear and logistic regression models. RESULTS: A total of 62,310 children were included in the study. The mean age was 4.2 years. ECMO was provided to 415 of the children (0.67% of the cohort with sepsis). Comparative outcomes of sepsis in children who received ECMO versus those who did not included in-hospital mortality rate (41% vs 2.8%), mean HC ($749,370 vs $90,568) and mean LOS (28.8 vs 9.1 days). After adjusting for confounding factors, children receiving ECMO had higher odds of mortality (OR 11.15, 95% CI 6.57-18.92, p < 0.001), longer LOS (6.6 days longer, p = 0.0004), and higher HC ($510,523 higher, p < 0.0001). CONCLUSIONS: Use of ECMO in children with sepsis is associated with considerable resource utilization but has 59% survival to discharge. Further studies are needed to examine the post discharge and neurocognitive outcomes in survivors.

Characterization of Suicide and Deliberate Self-Harm Among Children in the United States.

We analyzed data from the Nationwide Emergency Department Sample (NEDS) database for the years 2008 to 2013 to characterize deliberate self-harm among children and adolescents presenting to an emergency department (ED) in the United States. All ED visits for patients aged 19 years or younger involving any self-inflicted injuries were selected. We identified 594 658 ED visits involving self-harm. The majority of patients were female (65.8%), and between ages 16 and 19 years (62.6%). Most were treated and released from the ED (44.9%). The most common mechanisms involved injury by cutting/piercing instruments (26.4%) or poisoning by analgesics or antipyretics (21.5%). There was decrease in ED visits involving 16 to 19 year olds (-8%), and an increase in visits involving 13 to 15 year olds (+45%), 11 to 12 year olds (+94%), and 10 year olds or younger (16%). Our findings highlight a new vulnerable younger population at risk for self-inflicted injuries.