Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients.

OBJECTIVES: The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. DESIGN: Single-center retrospective cohort study. SETTING: Quaternary academic PICU. PATIENTS: Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. CONCLUSIONS: The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

The utility of paired upper and lower respiratory tract sampling for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing in patients with artificial airways.

Early in the coronavirus disease 2019 (COVID-19) pandemic, the CDC recommended collection of a lower respiratory tract (LRT) specimen for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing in addition to the routinely recommended upper respiratory tract (URT) testing in mechanically ventilated patients. Significant operational challenges were noted at our institution using this approach. In this report, we describe our experience with routine collection of paired URT and LRT sample testing. Our results revealed a high concordance between the 2 sources, and that all children tested for SARS-CoV-2 were appropriately diagnosed with URT testing alone. There was no added benefit to LRT testing. Based on these findings, our institutional approach was therefore adjusted to sample the URT alone for most patients, with LRT sampling reserved for patients with ongoing clinical suspicion for SARS-CoV-2 after a negative URT test.

Performance of a Clinical Decision Support Tool to Identify PICU Patients at High Risk for Clinical Deterioration.

OBJECTIVES: To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool. DESIGN: Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours. SETTING: Two quaternary care medical-surgical PICUs-The Children's Hospital of Philadelphia and Cincinnati Children's Hospital Medical Center. PATIENTS: The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution. INTERVENTIONS: We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration. MEASUREMENTS AND MAIN RESULTS: The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis. CONCLUSIONS: Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance.

Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU.

OBJECTIVES: To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. DESIGN: Prospective pre/post observational study. SETTING: A large single-center noncardiac PICU in North America. PATIENTS: All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018. INTERVENTIONS: Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement. MEASUREMENTS AND MAIN RESULTS: Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34-0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31-0.96) while adjusting for tracheal intubation indications and device. CONCLUSIONS: Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.

Routine Neurological Assessments by Nurses in the Pediatric Intensive Care Unit.

BACKGROUND: Brain injury with changes in clinical neurological signs and symptoms can develop while children are undergoing treatment in the intensive care unit. Critical care nurses routinely screen for neurological decline by using serial bedside neurological assessments. However, assessment components, frequency, and communication thresholds are not standardized. OBJECTIVES: To standardize neurological assessment procedures used by nurses, improve compliance with physicians' ordering and nurses' documentation of neurological assessments, and explore the frequency with which changes from preillness neurological status and previous assessments can be detected by using the assessment tool developed. METHODS: A quality improvement intervention was implemented during a 1-year period in a 55-bed pediatric intensive care unit with 274 nurses. Procedures for neurological assessment by nurses were standardized, a system for physicians to order neurological assessments by nurses at a frequency based on the patient's risk for brain injury was developed and implemented, and a system to compare patients' current neurological status with their preillness neurological status was developed and implemented. RESULTS: Process metrics that focused on compliance of ordering and documenting the standardized neurological assessments indicated improvement and sustained compliance greater than 80%. Exploratory analyses indicated that 29% of patients had an episode of neurological decline and that these episodes were more common in patients with developmental disabilities than in patients without such disabilities. CONCLUSIONS: Compliance with physicians' ordering and nurses' documentation of standardized neurological assessments significantly increased and had excellent sustainability. Further work is needed to determine the sensitivity of standardized nurses' neurological assessment tools for clinically meaningful neurological decline.

An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams.

Errors in thinking contribute to harm, delays in diagnosis, incorrect treatments, or failures to recognize clinical changes. Models of cognition are useful in understanding error occurrence and avoidance. Intra-team conflict can represent failures in joint cognitive processing. The authors developed training focused on recognizing and managing cognitive bias and resolving conflicts. The program provides context and introduces models of cognition, concepts of bias, team cognition, conflict resolution, and 2 tools. "IDEA" incorporates 4 de-biasing strategies: Identify assumptions; Don't assume correctness; Explore expectations; Assess alternatives. "TLA" presents strategies for resolving conflicts: Tell your thoughts; Listen actively, and Ask questions. A total of 4941 care providers participated in training using didactic presentations, group discussion, and simulation. Learners rated training effectiveness at 4.68 on a scale of 1 to 5 (5 as optimum) and perceived improvement in recognizing or managing errors. Nonphysician caregivers reported greatest improvement. Training to improve critical thinking is feasible, well received, and effective.

Development and Implementation of a Bedside Peripherally Inserted Central Catheter Service in a PICU.

OBJECTIVES: To create a bedside peripherally inserted central catheter service to increase placement of bedside peripherally inserted central catheter in PICU patients. DESIGN: Two-phase observational, pre-post design. SETTING: Single-center quaternary noncardiac PICU. PATIENTS: All patients admitted to the PICU. INTERVENTIONS: From June 1, 2015, to May 31, 2017, a bedside peripherally inserted central catheter service team was created (phase I) and expanded (phase II) as part of a quality improvement initiative. A multidisciplinary team developed a PICU peripherally inserted central catheter evaluation tool to identify amenable patients and to suggest location and provider for procedure performance. Outcome, process, and balancing metrics were evaluated. MEASUREMENTS AND MAIN RESULTS: Bedside peripherally inserted central catheter service placed 130 of 493 peripherally inserted central catheter (26%) resulting in 2,447 hospital central catheter days. A shift in bedside peripherally inserted central catheter centerline proportion occurred during both phases. Median time from order to catheter placement was reduced for peripherally inserted central catheters placed by bedside peripherally inserted central catheter service compared with placement in interventional radiology (6 hr [interquartile range, 2-23 hr] vs 34 hr [interquartile range, 19-61 hr]; p < 0.001). Successful access was achieved by bedside peripherally inserted central catheter service providers in 96% of patients with central tip position in 97%. Bedside peripherally inserted central catheter service central line-associated bloodstream infection and venous thromboembolism rates were similar to rates for peripherally inserted central catheters placed in interventional radiology (all central line-associated bloodstream infection, 1.23 vs 2.18; p = 0.37 and venous thromboembolism, 1.63 vs 1.57; p = 0.91). Peripherally inserted central catheters in PICU patients had reduced in-hospital venous thromboembolism rate compared with PICU temporary catheter in PICU rate (1.59 vs 5.36; p < 0.001). CONCLUSIONS: Bedside peripherally inserted central catheter service implementation increased bedside peripherally inserted central catheter placement and employed a patient-centered and timely process. Balancing metrics including central line-associated bloodstream infection and venous thromboembolism rates were not significantly different between peripherally inserted central catheters placed by bedside peripherally inserted central catheter service and those placed in interventional radiology.

Design and Implementation of a Pediatric ICU Acuity Scoring Tool as Clinical Decision Support.

BACKGROUND AND OBJECTIVE: Pediatric in-hospital cardiac arrest most commonly occurs in the pediatric intensive care unit (PICU) and is frequently preceded by early warning signs of clinical deterioration. In this study, we describe the implementation and evaluation of criteria to identify high-risk patients from a paper-based checklist into a clinical decision support (CDS) tool in the electronic health record (EHR). MATERIALS AND METHODS: The validated paper-based tool was first adapted by PICU clinicians and clinical informaticians and then integrated into clinical workflow following best practices for CDS design. A vendor-based rule engine was utilized. Littenberg's assessment framework helped guide the overall evaluation. Preliminary testing took place in EHR development environments with more rigorous evaluation, testing, and feedback completed in the live production environment. To verify data quality of the CDS rule engine, a retrospective Structured Query Language (SQL) data query was also created. As a process metric, preparedness was measured in pre- and postimplementation surveys. RESULTS: The system was deployed, evaluating approximately 340 unique patients monthly across 4 clinical teams. The verification against retrospective SQL of 15-minute intervals over a 30-day period revealed no missing triggered intervals and demonstrated 99.3% concordance of positive triggers. Preparedness showed improvements across multiple domains to our a priori goal of 90%. CONCLUSION: We describe the successful adaptation and implementation of a real-time CDS tool to identify PICU patients at risk of deterioration. Prospective multicenter evaluation of the tool's effectiveness on clinical outcomes is necessary before broader implementation can be recommended.

Impact of a Safety Huddle-Based Intervention on Monitor Alarm Rates in Low-Acuity Pediatric Intensive Care Unit Patients.

BACKGROUND: Physiologic monitors generate high rates of alarms in the pediatric intensive care unit (PICU), yet few are actionable. OBJECTIVE: To determine the association between a huddle-based intervention focused on reducing unnecessary alarms and the change in individual patients' alarm rates in the 24 hours after huddles. DESIGN: Quasi-experimental study with concurrent and historical controls. SETTING: A 55-bed PICU. PARTICIPANTS: Three hundred low-acuity patients with more than 40 alarms during the 4 hours preceding a safety huddle in the PICU between April 1, 2015, and October 31, 2015. INTERVENTION: Structured safety huddle review and discussion of alarm causes and possible monitor parameter adjustments to reduce unnecessary alarms. MAIN MEASUREMENTS: Rate of priority alarms per 24 hours occurring for intervention patients as compared with concurrent and historical controls. Balancing measures included unexpected changes in patient acuity and code blue events. RESULTS: Clinicians adjusted alarm parameters in the 5 hours following the huddles in 42% of intervention patients compared with 24% of control patients (𝑃 = .002). The estimate of the effect of the intervention adjusted for age and sex compared with concurrent controls was a reduction of 116 priority alarms (95% confidence interval, 37-194) per 24 hours (𝑃 = .004). There were no unexpected changes in patient acuity or code blue events related to the intervention. CONCLUSIONS: Integrating a data-driven monitor alarm discussion into safety huddles was a safe and effective approach to reducing alarms in low-acuity, highalarm PICU patients.

Medication Reconciliation Improvement Through the Use of Video.

Accurate medication reconciliation at the time of hospital admission is vital to preventing adverse drug events. Compliance with medication reconciliation in our pediatric intensive care unit was low initially with overall medication reconciliation at 70%. Due to the high front line provider turnover in our unit, we focused on technological reminders for completion and used unique and innovative ways to motivate our supervising staff. Our goal was to reach >95% completion within 24 hours for medication reconciliation for all patients admitted to the pediatric intensive care unit. Pre-pilot discussions focused on examples of errors of medication reconciliation within our own institution resulting in patient harm via traditional power point presentation. The initial pilot phase instituted a job aid on how to add the medication reconciliation completion reminder column. Email updates on completion status began one week after initiation. During the implementation and spread phase, fun interactive videos were used to acknowledge roll out to the full unit. Compliance was monitored and humorous biweekly video updates emphasizing accountability were introduced. In the sustain phase, monthly video updates served as education and a reminder for provider staff. The use of a medication reconciliation completion column and reminder emails resulted in goal completion (>95%) by three weeks post intervention for the pilot unit. Overall medication reconciliation completion also reached goal of >95% completion within the entire unit after three weeks of implementation and spread. Compliance fell below goal so video updates were modified utilizing humor and emphasizing accountability. This resulted in sustained compliance now more than forty weeks post implementation. Unit compliance currently remains >95% completion within 24 hours now more than forty weeks post intervention. The use of the medication reconciliation reminder column resulted in improvement in compliance; however, that improvement was not sustained. The addition of humorous videos highlighting accountability allowed for sustained improvements.

High-frequency percussive ventilation and bronchoscopy during extracorporeal life support in children.

Variables affecting duration of pediatric extracorporeal life support (ECLS) are poorly defined. Prior analyses suggested increased mortality risk with prolonged ECLS. Lung recruitment strategies with improved secretion mobilization may shorten ECLS duration. High frequency percussive ventilation (HFPV) has been used, predominantly in inhalational injury, as a mode of ventilation to improve secretion clearance. We describe the application of HFPV and therapeutic bronchoscopies in pediatric ECLS and evaluate outcomes with a same-center historical control population. After May 2011, all children (n = 14) on ECLS were managed with HFPV during extracorporeal support (HFPV cohort). This group's demographics and outcomes were compared with ECLS patients in our unit immediately before the utilization of HFPV (pre-HFPV cohort, n = 22). The HFPV and pre-HFPV cohorts had similar demographics and utilization of venoarterial ECLS. In univariate analysis, the HFPV group underwent more bronchoscopies and experienced more ECLS-free days (days alive and off ECLS) at 30 and 60 days. In multivariate analysis, use of HFPV was independently associated with ECLS-free days. We conclude that use of HFPV and bronchoscopies during ECLS for respiratory failure was associated with an increase in ECLS-free days and that this association should be prospectively evaluated.

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*.

OBJECTIVE: In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events. DESIGN, SETTING, AND PATIENTS: Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU. INTERVENTIONS: Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers. MEASUREMENTS AND MAIN RESULTS: Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01). CONCLUSION: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Safety of prophylactic anticoagulation at a pediatric hospital.

The importance of preventing venous thromboembolism (VTE) in hospitalized adults is well recognized. We recently developed and published our institutional guidelines for the prevention of VTE in high-risk hospitalized patients in a pediatric hospital. The objective of this prospective observational study was to evaluate the safety of anticoagulation after these guidelines were instituted. The primary outcome was major bleeding and secondary outcomes included minor bleeding and VTE. Eighty-nine patients were enrolled, with a mean age of 16.6 years. The most common risk factors for VTE were impaired mobility, lower extremity orthopedic surgery, and obesity. The majority of patients (63%) had 3 or more risk factors. There were 2 major bleeding events, and minor bleeding occurred in 5 patients, all in patients who had undergone major orthopedic surgery. Therefore the risk of major bleeding in orthopedic surgery patients was 4% (2/51), and 0% (0/38) in the remaining patients. No patient developed a non-catheter-related VTE, which was the primary intent of our guidelines. Although there remains much work to be done to optimize VTE strategies in pediatric patients, this study provides information regarding the risks of VTE prophylaxis using a pragmatic approach in hospitalized patients with multiple risk factors for VTE. More studies are needed to better define the risk:benefit ratio in this population.

Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative.

OBJECTIVES: Venous thromboembolism (VTE) prophylaxis for patients at risk is often overlooked in pediatric health care institutions, which provides an opportunity to improve patient care. The objectives of this study were to review our current hospital practice, identify a population at high risk, and formulate institutional guidelines for thromboprophylaxis. METHODS: This was a prospective patient-safety and quality-improvement project performed at a large pediatric tertiary care hospital. We developed criteria for assessing risk and selecting prophylactic intervention through analysis of the age distribution and underlying medical conditions of patients with VTE at our center, literature review of adult recommendations for thromboprophylaxis, and consensus opinion of multiple specialists at our institution. A patient-care policy was developed to assess VTE risk and prescribe the appropriate thromboprophylaxis regimen. The primary outcome measure was compliance with thromboprophylaxis guidelines in patients at risk for VTE. RESULTS: Over the 4-year study period, the observed rate of VTE prophylaxis in patients at risk increased from a baseline of 22% to an average rate of 82%, and there were intermittent improvements up to 100%. CONCLUSIONS: Although some of the details may vary from center to center, many of the discussed principles and practices involved in instituting a VTE-prevention program are applicable to other pediatric institutions. Despite the fact that the risk of VTE in hospitalized children is much lower than that in adults, there are patients in pediatric hospitals who deserve systematic screening and thoughtful application of preventative measures.

Opportunities for antibiotic reduction in mechanically ventilated children.

OBJECTIVE: To identify opportunities to safely reduce antibiotic use in critically ill children with moderately severe respiratory failure. DESIGN: Prospective observational. SETTING: Four pediatric intensive care units at three American tertiary care children's hospitals. PATIENTS: Children aged 2 months to 18 yrs who were mechanically ventilated, had an abnormal chest radiograph, and for whom the attending physicians had initiated antibiotics for presumed bacterial pneumonia. INTERVENTION: Nonbronchoscopic bronchoalveolar lavage. METHODS AND MAIN RESULTS: Eligible children were subjected to nonbronchoscopic bronchoalveolar lavage within 12 hrs of initiating antibiotics. The concentration of bacteria in the lavage fluid was determined by quantitative assay, and the diagnosis of pneumonia was confirmed if >10 (4)pathogenic bacteria/mL were cultivated. Twenty-one subjects were enrolled, in whom 20 nonbronchoscopic bronchoalveolar lavage procedures were completed. Six of 20 subjects had nonbronchoscopic bronchoalveolar lavage results confirmatory of bacterial pneumonia, three additional subjects had bacteria isolated at concentrations below levels conventionally used to diagnose bacterial pneumonia, and the remaining 11 demonstrated no growth. Clinical parameters reflective of severity of disease and laboratory parameters reflective of systemic and local inflammation were tested for their association with a positive nonbronchoscopic bronchoalveolar lavage, but none was demonstrated. CONCLUSIONS: Eleven of 20 mechanically ventilated children treated with antibiotics for presumed infectious pneumonia had undetectable concentrations of bacteria in their lower respiratory tract, and three others had organisms present at low concentrations, suggesting that opportunities exist to reduce antibiotic exposure in this population.

Association of rapid head growth in children following tracheostomy tube placement.

INTRODUCTION: Our clinical observation indicates that some children who have a tracheostomy may experience increasing head circumference as they grow and develop. Accurate assessment and interpretation of growth parameters is an essential component of following child development. Appreciation for variations in growth is especially important in special populations, such as children with a tracheostomy. The aim of this study is to define head growth in children with a tracheostomy. METHOD: This retrospective cohort study includes children who underwent tracheostomy tube placement prior to 2 years of age in a respiratory rehabilitation unit within a children's hospital. Serial head circumference measurements were plotted against age on growth charts adjusted for gestational age. The percentage of patients with accelerated head growth, defined as increased head circumference across two major percentiles within 6 months following tracheostomy, was determined. RESULTS: Fifty-seven percent (20 out of 35 children) demonstrated increased head circumference across two major percentiles within 6 months following tracheostomy. DISCUSSION: Accelerated head growth is associated with the presence of a tracheostomy tube in children in this study. Further investigation is warranted to establish the relationship of head circumference to other growth parameters. In addition, the etiology of this phenomenon requires additional study. Understanding head growth in children with a tracheostomy will promote adequate growth assessment and may lead to improved patient care.

Myocardial ischemia as a result of severe benzodiazepine and opioid withdrawal.

UNLABELLED: Long-term infusion of benzodiazepines and opioids is strongly associated with dependence and withdrawal syndromes. We report the first case of severe benzodiazepine and opioid withdrawal resulting in transient myocardial ischemia. CASE REPORT: A 6-month-old female born at 25 weeks gestation with severe opioid and benzodiazepine dependence resulting from multiple operative procedures and chronic ventilatory support was receiving continuous intravenous infusion of fentanyl and midazolam after trials of enteral methadone and diazepam had been unsuccessful due to gastric intolerance. On postoperative day 5 following Nissen fundoplication and gastrostomy tube placement, she acutely developed tachycardia, hypertension, agitation, loose stools, and yawning. Attempts to provide boluses of benzodiazepines and opioids revealed a very sluggish port in her subclavian central venous catheter. Prompt replacement of the catheter occurred without complication. After resuming infusions and providing additional sedatives and opioids, the loose stools, yawning, and agitation resolved. However, the tachycardia persisted. A 12-lead ECG was notable for significant ST depression in anterior leads. Laboratory studies revealed significantly elevated cardiac enzymes. The patient was transfused with packed red blood cells to optimize oxygen-carrying capacity. Echocardiography demonstrated a small region of dyskinetic apical endocardium. Cardiac enzymes normalized within 48 h. The ECG and echocardiographic findings fully resolved after approximately 70 h. DISCUSSION: We believe that the sluggish central venous catheter port limited delivery of the midazolam and fentanyl to our patient. The resultant tachycardia and hypertension limited diastolic filling of the coronary arteries, resulting in myocardial ischemia. As the withdrawal was treated, heart rate and blood pressure returned to baseline, myocardial perfusion normalized, and the ST depression and the cardiac enzyme values normalized. This report underscores the significant morbidity associated with withdrawal syndromes and the need to recognize withdrawal early and to treat it aggressively.

Trends in operative management of pediatric splenic injury in a regional trauma system.

OBJECTIVE: Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade. METHODS: The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00-865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type. RESULTS: From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0-6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4-8.7) for level 1 trauma centers, 6.3 (5.3-7.4) for level 2 trauma centers, and 5.0 (4.2-5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity. CONCLUSIONS: The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.