Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores.

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages. Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores. The toolkit includes the pim3 and pelod2 commands and is compatible with Stata versions 12 and above. It features robust data validation, error messaging, a graphical interface, and support for SI and Imperial units. The toolkit's accuracy was validated through unit testing and synthetic data, comparing results with existing implementations. Results: In performance tests, the toolkit exhibited a median processing time of 21.82 seconds for PELOD-2, 14.06 seconds for PIM-3, and 9.74 seconds for Simplified PIM-3, when applied to datasets of 10,000,000 records. It consistently achieved 100% accuracy in both synthetic data tests and manual spot checks. Conclusion: The toolkit decreases processing time and improves accuracy in calculating pediatric critical care severity scores such as PELOD-2, PIM-3, and Simplified PIM-3. Its application in large datasets and validation highlights its utility as a tool for streamlining pediatric critical care research.

The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R2): Pilot Testing in a Two-Phase Cohort Study, 2017-2021.

OBJECTIVES: Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R2). DESIGN: A two-phase cohort study was carried out from 2017 to 2021. SETTING: Two similarly sized and organized PICUs in the United States. PATIENTS: Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure. INTERVENTIONS: R2 seven-item chronotherapeutic bundle, including: 1) replication of child's pre-hospital daily routine (i.e., sleep/wake, feeding, activity patterns); 2) cycled day-night light/sound modulation; 3) minimal effective sedation; 4) night fasting with bolus enteral daytime feedings; 5) early progressive mobility; 6) nursing care continuity; and 7) parent diaries. MEASUREMENTS AND MAIN RESULTS: Children underwent environmental (light, sound) and patient (actigraphy, activity log, salivary melatonin, electroencephalogram) monitoring. Parents completed the Child's Daily Routine and Sleep Survey (CDRSS) and Family-Centered Care Scale. The primary outcome was post-extubation daytime activity consolidation (Daytime Activity Ratio Estimate [DARE]). Twenty baseline-phase (2017-2019) and 36 intervention-phase (2019-2021) participants were enrolled. During the intervention phase, nurses used the CDRSS to construct children's PICU schedules. Overall compliance with nurse-implemented R2 elements 1-5 increased from 18% (interquartile range, 13-30%) at baseline to 63% (53-68%) during the intervention phase (p < 0.001). Intervention participants were exposed to their pre-hospitalization daily routine (p = 0.002), cycled day-night light/sound modulation (p < 0.001), and early progressive mobility on more PICU days (p = 0.02). Sedation target identification, enteral feeding schedules, and nursing care continuity did not differ between phases. Parent diaries were seldom used. DARE improved during the intervention phase and was higher pre-extubation (median 62% vs. 53%; p = 0.04) but not post-extubation (62% vs. 57%; p = 0.56). CONCLUSIONS: In the PICU, implementation of an individualized nurse-implemented chronotherapeutic bundle is feasible. Children who received the R2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.

Population-based study of factors associated with severe paediatric drowning events in Maryland.

INTRODUCTION: Paediatric drowning is an injury associated with significant morbidity and mortality. OBJECTIVE: The objective is to describe drowning trends, including associations with inpatient hospitalisation or fatality, in a state-wide paediatric cohort to inform prevention strategies. METHODS: In this retrospective cohort study using the Health Services Cost Review Commission database, we used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify patients aged 0-19 years with an outpatient (including emergency department) or inpatient medical encounter following a non-fatal or fatal drowning event between 2016 and 2019. Descriptive statistics and logistic regression were used to summarise the data and evaluate associations with inpatient hospitalisation or fatality. RESULTS: There were 541 medical encounters for drowning events, including 483 non-fatal outpatient encounters, 42 non-fatal inpatient encounters and 16 fatal cases. Overall, most patients were boys, 0-4 years, white and lived in urban settings. White children accounted for 66% of encounters among those aged 0-4 years, whereas non-white children accounted for 62% of visits among those aged 10-19 years. Non-white children were more likely than white children to experience a fatal drowning (OR 3.6, 95% CI: 1.2 to 11.5). Adolescents were more likely than younger children to be hospitalised (OR 3.1, 95% CI: 1.6 to 6.5) and had higher charges in outpatient (p=0.002) and inpatient settings (p=0.003). DISCUSSION: Our study revealed high fatality rates among non-white children and high admission rates among adolescents.

Preemptive airway management planning: A retrospective evaluation of the pediatric difficult airway consultation service.

BACKGROUND/AIMS: The pediatric Difficult Airway Consultation Service (pDACS) was created in 2017 to identify patients with potentially difficult airways and create airway management plans prior to airway management. METHODS: Consults were either nurse-initiated, physician-initiated, or both nurse-and-physician-initiated and were examined for demographic and clinical factors. If a child had difficult airway risk factors, a consult note with airway management recommendations was completed. RESULTS: We included 419 consults from the 4-year study period for analysis. Sixty-one patients had chronic tracheostomies in place and thus, were analyzed separately. Of the remaining 358 consults, 50% (n = 179) were nurse-initiated, 30.2% (n = 108) physician-initiated, and 19.8% (n = 71) nurse-and-physician-initiated consults. Differences in observed frequency of airway edema (difference, 6.3%; 95%CI 0.1%-12.5%; p = .04), cleft lip/palate (difference, 8.1%; 95%CI 0.07%-16.3%, p = .04), craniofacial abnormalities (difference, 12.3%; 95%CI 1.9%-22.7%, p = .02), and trauma/burn (difference, 6.5%; 95%CI 0.09%-12.8%, p = .04) were calculated. Observed frequencies were higher in physician-initiated compared to nurse-initiated consults. Airway edema was also more prevalent in dual nurse-and-physician-initiated consults (difference, 8.7%; 95%CI 1.6%-15.8%; p = .01). Physician-initiated consults were associated with a greater proportion of high-risk difficult airways than nurse-initiated consults (difference, 26.7%; 95%CI 14.0%-39.4%, p < .001). Approximately 41.9% of patients at high-risk for having a difficult airway were identified by nurse-screening only. Using bag-valve-mask was often the primary ventilation recommendation (89.3%, n = 108) and supraglottic airway placement was the most common tertiary plan (74.2%, n = 83). Direct laryngoscopy (47.1%, n = 65) and videolaryngoscopy (40.6%, n = 56) were the most recommended modes of intubation. Three patients with airway emergencies had previously documented airway management plans and were successfully intubated without complications following the primary intubation technique recommended in their consult note. CONCLUSIONS: In our study, nurse-screening identified patients at high-risk for a difficult airway that would likely not have been identified prior to initiation of a screening protocol. Furthermore, airway management plans outlined prior to an emergent difficult airway event may increase first-attempt success at securing the difficult airway, reducing morbidity and mortality.

Repositioning Guidelines to Decrease Pressure Injury in the Pediatric Intensive Care Unit: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement (QI) project was to develop and implement repositioning guidelines that reduce pressure injury (PI) in hemodynamically unstable pediatric intensive care unit (PICU) patients. PARTICIPANTS AND SETTING: All PICU patient ages 0 to 36 months who required sedation for invasive mechanical ventilation and had a Braden Q score ≤ 18 were eligible for inclusion. The project was implemented in 116 patients preimplementation and 100 postimplementation. Their median t age was 5 months (interquartile range 2-13 months). The QI project setting was an academic hospital PICU with a Level I trauma center located in the Mid-Atlantic Region of the United States. APPROACH: A pre-post observational design was used to compare the at-risk population for 21 weeks before (August-December 2018) and after (August-December 2019) implementing repositioning guidelines. Turn attempts were undertaken every 2 hours. Repositioning attempts were defined as (1) full (30°); (2) partial (15°); (3) unable to turn owing to hemodynamic instability; or (4) noncompliance. The primary outcome was incidence of Stage II or higher PI. OUTCOMES: We found a significant reduction in the incidence of PI before and after implementation of the repositioning intervention (16.4% vs 2.0%, P = .0003). IMPLICATIONS FOR PRACTICE: A structured intervention for repositioning hemodynamically unstable PICU patients has the potential to significantly lower PI incidence in a group of hemodynamically unstable children.

Delirium Screening in Critically Ill Children: Secondary Analysis of the Multicenter PICU Up! Pilot Trial Dataset, 2019-2020.

OBJECTIVES: To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices. DESIGN: A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168). SETTING: Six PICUs in the United States. PATIENTS: One thousand sixty-four patients who were admitted to a PICU for 3 or more days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1064 patients, 74% (95% CI, 71-76%) underwent delirium screening at least once during their PICU stay. On 57% of the 8965 eligible patient days, screening was conducted. The overall prevalence of delirium was 46% across all screened days, and 64% of screened patients experienced delirium at some point during their PICU stay. Factors associated with greater adjusted odds ratio (aOR) of increased daily delirium screening included PICU stay longer than 15 days compared with 1-3 days (aOR 3.36 [95% CI, 2.62-4.30]), invasive mechanical ventilation as opposed to room air (aOR 1.67 [95% CI, 1.32-2.12]), dexmedetomidine infusions (aOR 1.23 [95% CI, 1.04-1.44]) and propofol infusions (aOR 1.55 [95% CI, 1.08-2.23]). Conversely, decreased aOR of daily delirium screening was associated with female gender (aOR 0.78 [95% CI, 0.63-0.96]), and the administration of continuous infusions of opioids (aOR 0.75 [95% CI, 0.63-0.90]) or ketamine (aOR 0.48 [95% CI, 0.29-0.79]). Neither patient age, the presence of family or physical restraints, or benzodiazepine infusions were associated with daily delirium screening rates. CONCLUSIONS: In the 2019-2020 PICU UP! cohort, across six PICUs, delirium screening occurred on only 57% of days, despite the presence of established practices. Female gender, patients in the early stages of their PICU stay, and patients not receiving mechanical ventilation were associated with lower odds of daily delirium screening. Our results highlight the need for structured quality improvement processes to both standardize and increase the frequency of delirium screening.

In-Hospital Violence and Its Impact on Critical Care Practitioners.

OBJECTIVES: To provide a narrative review of hospital violence (HV) and its impact on critical care clinicians. DATA SOURCES: Detailed search strategy using PubMed and OVID Medline for English language articles describing HV, risk factors, precipitating events, consequences, and mitigation strategies. STUDY SELECTION: Studies that specifically addressed HV involving critical care medicine clinicians or their practice settings were selected. The time frame was limited to the last 15 years to enhance relevance to current practice. DATA EXTRACTION: Relevant descriptions or studies were reviewed, and abstracted data were parsed by setting, clinician type, location, social media events, impact, outcomes, and responses (agency, facility, health system, individual). DATA SYNTHESIS: HV is globally prevalent, especially in complex care environments, and correlates with a variety of factors including ICU stay duration, conflict, and has recently expanded to out-of-hospital occurrences; online violence as well as stalking is increasingly prevalent. An overlap with violent extremism and terrorism that impacts healthcare facilities and clinicians is similarly relevant. A number of approaches can reduce HV occurrence including, most notably, conflict management training, communication initiatives, and visitor flow and access management practices. Rescue training for HV occurrences seems prudent. CONCLUSIONS: HV is a global problem that impacts clinicians and imperils patient care. Specific initiatives to reduce HV drivers include individual training and system-wide adaptations. Future methods to identify potential perpetrators may leverage machine learning/augmented intelligence approaches.

Delphi Process for Validation of Fluid Treatment Algorithm for Critically Ill Pediatric Trauma Patients.

INTRODUCTION: While intravenous fluid therapy is essential to re-establishing volume status in children who have experienced trauma, aggressive resuscitation can lead to various complications. There remains a lack of consensus on whether pediatric trauma patients will benefit from a liberal or restrictive crystalloid resuscitation approach and how to optimally identify and transition between fluid phases. METHODS: A panel was comprised of physicians with expertise in pediatric trauma, critical care, and emergency medicine. A three-round Delphi process was conducted via an online survey, with each round being followed by a live video conference. Experts agreed or disagreed with each aspect of the proposed fluid management algorithm on a five-level Likert scale. The group opinion level defined an algorithm parameter's acceptance or rejection with greater than 75% agreement resulting in acceptance and greater than 50% disagreement resulting in rejection. The remaining were discussed and re-presented in the next round. RESULTS: Fourteen experts from five Level 1 pediatric trauma centers representing three subspecialties were included. Responses were received from 13/14 participants (93%). In round 1, 64% of the parameters were accepted, while the remaining 36% were discussed and re-presented. In round 2, 90% of the parameters were accepted. Following round 3, there was 100% acceptance by all the experts on the revised and final version of the algorithm. CONCLUSIONS: We present a validated algorithm for intavenous fluid management in pediatric trauma patients that focuses on the de-escalation of fluids. Focusing on this time point of fluid therapy will help minimize iatrogenic complications of crystalloid fluids within this patient population.

Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study.

OBJECTIVE: To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units. METHODS: A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours. RESULTS: Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events. CONCLUSION: Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

Implementation Science Research in Pediatric Critical Care Medicine.

OBJECTIVES: Delay or failure to consistently adopt evidence-based or consensus-based best practices into routine clinical care is common, including for patients in the PICU. PICU patients can fail to receive potentially beneficial diagnostic or therapeutic interventions, worsening the burden of illness and injury during critical illness. Implementation science (IS) has emerged to systematically address this problem, but its use of in the PICU has been limited to date. We therefore present a conceptual and methodologic overview of IS for the pediatric intensivist. DESIGN: The members of Excellence in Pediatric Implementation Science (ECLIPSE; part of the Pediatric Acute Lung Injury and Sepsis Investigators Network) represent multi-institutional expertise in the use of IS in the PICU. This narrative review reflects the collective knowledge and perspective of the ECLIPSE group about why IS can benefit PICU patients, how to distinguish IS from quality improvement (QI), and how to evaluate an IS article. RESULTS: IS requires a shift in one's thinking, away from questions and outcomes that define traditional clinical or translational research, including QI. Instead, in the IS rather than the QI literature, the terminology, definitions, and language differs by specifically focusing on relative importance of generalizable knowledge, as well as aspects of study design, scale, and timeframe over which the investigations occur. CONCLUSIONS: Research in pediatric critical care practice must acknowledge the limitations and potential for patient harm that may result from a failure to implement evidence-based or professionals' consensus-based practices. IS represents an innovative, pragmatic, and increasingly popular approach that our field must readily embrace in order to improve our ability to care for critically ill children.

Speech-language pathologist involvement in the paediatric intensive care unit.

PURPOSE: To measure the prevalence of speech-language pathologist (SLP) involvement and associated trends for critically ill children in United States (US) paediatric intensive care units (PICU) through secondary analysis of the Prevalence of Acute Rehab for Kids in the PICU (PARK-PICU) study data. METHOD: A secondary analysis of cross-sectional point prevalence study conducted over 1 day in 82 US PICUs. Data collected included SLP presence, patients' age, length of stay, medical interventions, aetiology, admission data, Glasgow Coma Scale scores, staffing involvement, and family presence. RESULT: Among 961 patients, 82 were visited by an SLP on the study day for a prevalence of 8.5%. Most visits were for children <3 years old. The odds of SLP involvement were lower for children who were 7-12 years old (vs. age 0-2; adjusted odds ratio [aOR] 0.28; 95% CI 0.1-0.8), were mechanically ventilated via endotracheal tube (vs. room air; aOR 0.02; 95% CI 0.005-0.11), or had mild or severe disability (mild vs. no disability; aOR 0.34; 95% CI 0.16-0.76 and severe vs. no disability; aOR 0.39; 95% CI 0.17-0.90). Concurrent physical and/or occupational therapy involvement was associated with higher odds of SLP involvement (aOR 3.6; 95% CI 2.1-6.4). CONCLUSION: SLP involvement is infrequent in US PICUs. PICU teams should be educated about the scope of SLP practice, to support communication and oral feeding needs during early recovery from critical illness.

Comfort and Coordination among Interprofessional Care Providers Involved in Intubations in the Pediatric Intensive Care Unit.

Background: Successful execution of invasive procedures in acute care settings, including tracheal intubation, requires careful coordination of an interprofessional team. The stress inherent to the intensive care unit (ICU) environment may threaten the optimal communication and planning necessary for the safe execution of this complex procedure. The objective of this study is to characterize the perceptions of interprofessional team members surrounding tracheal intubations in the pediatric ICU (PICU). Methods: This is a single-center survey-based study of staff involved in the intubation of pediatric patients admitted to a tertiary level academic PICU. Physicians, nurses, and respiratory therapists (RT) involved in tracheal intubations were queried via standardized, discipline-specific electronic surveys regarding their involvement in procedural planning and overall awareness of and comfort with the intubation plan. Qualitative variables were assessed by both Likert scales and free-text comments that were grouped and analyzed thematically. Results: One hundred and eleven intubation encounters were included during the study time period, of which 93 (84%) had survey responses from at least 2 professional teams. Among those included in the analysis, the survey was completed 244 times by members of the PICU teams including 86 responses from physicians, 76 from nurses, and 82 from RTs. Survey response rates were >80% from each provider team. There were significant differences in interprofessional team comfort with nurses feeling less well informed and comfortable with the intubation plan and process compared to physicians and RTs (p < 0.001 for both). Qualitative themes including clear communication, adequate planning and preparation prior to procedure initiation, and clear definition of roles emerged among both affirmative and constructive comments. Conclusions: Exploration of provider perceptions and emergence of constructive themes expose opportunities for teamwork improvement strategies involving intubations in the PICU. The use of a preintubation checklist may improve organization and communication amongst team members, increase provider morale, decrease team stress levels, and, ultimately, may improve patient outcomes during this high stakes, coordinated event.

Dendrimer nanotherapy targeting of glial dysfunction improves inflammation and neurobehavioral phenotype in adult female Mecp2-heterozygous mouse model of Rett syndrome.

Rett syndrome is an X-linked neurodevelopmental disorder caused by mutation of Mecp2 gene and primarily affects females. Glial cell dysfunction has been implicated in in Rett syndrome (RTT) both in patients and in mouse models of this disorder and can affect synaptogenesis, glial metabolism and inflammation. Here we assessed whether treatment of adult (5-6 months old) symptomatic Mecp2-heterozygous female mice with N-acetyl cysteine conjugated to dendrimer (D-NAC), which is known to target glia and modulate inflammation and oxidative injury, results in improved behavioral phenotype, sleep and glial inflammatory profile. We show that unbiased global metabolomic analysis of the hippocampus and striatum in adult Mecp2-heterozygous mice demonstrates significant differences in lipid metabolism associated with neuroinflammation, providing the rationale for targeting glial inflammation in this model. Our results demonstrate that treatment with D-NAC (10 mg/kg NAC) once weekly is more efficacious than equivalently dosed free NAC in improving the gross neurobehavioral phenotype in symptomatic Mecp2-heterozygous female mice. We also show that D-NAC therapy is significantly better than saline in ameliorating several aspects of the abnormal phenotype including paw clench, mobility, fear memory, REM sleep and epileptiform activity burden. Systemic D-NAC significantly improves microglial proinflammatory cytokine production and is associated with improvements in several aspects of the phenotype including paw clench, mobility, fear memory, and REM sleep, and epileptiform activity burden in comparison to saline-treated Mecp2-hetereozygous mice. Systemic glial-targeted delivery of D-NAC after symptom onset in an older clinically relevant Rett syndrome model shows promise in improving neurobehavioral impairments along with sleep pattern and epileptiform activity burden. These findings argue for the translational value of this approach for treatment of patients with Rett Syndrome.

Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study / Reabilitação física em unidades de terapia intensiva pediátrica brasileiras: um estudo multicêntrico de prevalência pontual

ABSTRACT Objective: To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units. Methods: A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours. Results: Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events. Conclusion: Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

RESUMO Objetivo: Determinar a prevalência e os fatores associados à reabilitação física de crianças em estado grave em unidades de terapia intensiva pediátrica brasileiras. Métodos: Realizou-se um estudo de prevalência pontual multicêntrico, transversal, de 2 dias, abrangendo 27 unidades de terapia intensiva pediátrica (do total de 738) no Brasil em abril e junho de 2019. Este estudo brasileiro fez parte de um grande estudo multinacional chamado Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). O desfecho primário foi a prevalência de mobilidade proporcionada pela fisioterapia ou pela terapia ocupacional. Foram coletados prospectivamente dados clínicos sobre a mobilidade do paciente, possíveis eventos de segurança de mobilidade e barreiras de mobilização em pacientes admitidos por ≥ 72 horas. Resultados: As crianças com idade inferior a 3 anos eram 68% da população de pacientes. A prevalência de mobilidade fornecida pelo terapeuta foi de 74%, ou 277 dos 375 pacientes-dia. A mobilidade para fora do leito foi mais positivamente associada à presença de familiares (razão de chance ajustada de 3,31; IC95% 1,70 - 6,43) e mais negativamente associada às linhas arteriais (razão de chance ajustada de 0,16; IC95% 0,05 - 0,57). Foram relatadas barreiras à mobilização em 27% dos pacientes-dia, sendo a mais comum a falta de prescrição médica (n = 18). Registaram-se eventuais eventos de segurança em 3% de todos os eventos de mobilização. Conclusão: A mobilidade proporcionada pelo terapeuta nas unidades de terapia intensiva pediátrica brasileiras é frequente. A presença de familiares foi alta e positivamente associada à mobilidade para fora do leito. A presença de fisioterapeutas 24 horas por dia nas unidades de terapia intensiva pediátrica brasileiras pode exercer papel importante na mobilização de crianças em estado grave.

Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit?

Endotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.

The association of a scholarly concentrations program with medical students' matched residencies.

PURPOSE: Many medical school curricula include Scholarly Concentrations (SC) programs. While studies have examined how these programs affect students' future research involvement, the association of SC programs with students' specialty choices is uncertain. This study examines the SC program factors associated with congruence between the specialty focus of students' SC projects and the clinical specialty they matched into for residency. METHODS: The authors conducted a retrospective cohort study of all students participating in the SC program at Johns Hopkins University School of Medicine for graduating classes 2013-2020. They used data from program questionnaires to categorize students' specialty interests (baseline) and SC program experiences (post-program). The authors categorized each student's project into specialties according to their faculty mentors' primary appointments, abstracted student publications from SCOPUS, and abstracted residency program rankings from Doximity Residency Navigator. The authors used multivariable logistic regression to calculate adjusted odds ratios (aOR) for specialty-congruent matching (same specialty as SC project) and for matching into a Doximity-ranked top 20 or top 10 program. RESULTS: Overall, 35.3% of the 771 students matched into the same specialty as their SC projects. Increased odds of specialty-congruent matching occurred with 'definite' interest in the specialty at baseline [aOR (95% CI): 1.76 (0.98-3.15)] (P = 0.06) and with increasing publications with SC mentors [aOR (95% CI): 1.16 (1.03-1.30)] (P = 0.01). Congruence between SC specialty focus and matched specialty conferred no significant difference in odds of matching to a Doximity-ranked top 20 or top 10 program. CONCLUSIONS: Baseline certainty of specialty interest and research productivity were associated with specialty congruence. However, as completing an SC project in a given specialty was not associated with increased odds of matching into that specialty nor into a higher Doximity-ranked program, SC program directors should advise students to pursue SC projects in any topic of personal interest.

The Effects of Intraoperative Methadone on Postoperative Pain Control in Pediatric Patients: A Scoping Review.

Inadequate perioperative pain control has deleterious effects on children's development and can lead to heightened pain experiences and the avoidance of future medical procedures. Reports of perioperative use of methadone in children are increasing, as it has a favorable pharmacodynamic profile; however, the effectiveness of methadone in reducing postoperative pain has not been established. We, therefore, aimed to provide a scoping review of the literature comparing the effect of intraoperative methadone versus other opioids on postoperative opioid consumption, pain scores, and adverse events in pediatric patients. We identified studies in PubMed, Scopus, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception to January 2023. Postoperative opioid consumption, pain scores, and adverse events were extracted for analysis. We screened 1864 studies, of which 83 studies were selected for full-text review. Five studies were included in the final analysis. Postoperative opioid consumption was decreased overall in children who received methadone compared to those who did not. The majority of studies indicated that methadone was superior to other opioids in reported pain scores, while the frequency of adverse events was similar between the groups. Although the data reviewed highlight a potential benefit of intraoperative methadone in pediatric patients, 4 of the 5 studies had serious methodological concerns. Thus, we cannot make strong recommendations for the regular use of methadone in the perioperative setting at this time. Our results highlight the need for large, well-designed randomized trials to fully evaluate the safety and efficacy of intraoperative methadone in diverse pediatric surgical populations.

The Reviewer Academy of the Society of Critical Care Medicine: Key Principles and Strategic Plan.

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers.