Pediatric Interfacility Transport Curriculum: Its Impact on the Pediatric Intensive Care and Emergency Medicine Fellows' Performance and Confidence.

OBJECTIVE: Pediatric interfacility transports are frequent. Despite the absence of a formal pediatric transport curriculum in eastern Canada, directly managing patients during transport and medical direction of the referring center and transport team are part of the pediatric critical care medicine (PCCM) and pediatric emergency medicine (PEM) program requirements. The authors developed a pediatric interfacility transport curriculum and measured its impact on fellows' confidence and performance. METHODS: This was a pilot interventional prospective study in Montreal, Canada. Postcurriculum surveys were used to measure confidence, and high-fidelity simulations were used to measure performance. A target threshold for confidence was defined before implementation, and pre- and post values were compared. The simulation scenario and assessment checklist were locally developed. RESULTS: The participants were 11 PCCM and 3 PEM fellows. The content of the curriculum and educational methods were selected based on the literature and a needs assessment survey. All participants rated themselves as confident at the end of the curriculum. Eighty-three percent of the participants were deemed proficient with a perfect interrater agreement. CONCLUSION: The pediatric transport curriculum had a positive impact on PEM and PCCM fellows' confidence and performance in transport. Further studies should look at the impact of such a curriculum on participants' real-life performance and patient care.

Massive Hemorrhage Protocol Application and Teamwork Skills.

OBJECTIVE: Massive hemorrhages (MHs) are rare but serious complications of pediatric trauma and obstetric cases. This study aimed to evaluate the impact of interprofessional simulation to improve adherence to a MH protocol (MHP), teamwork skills and confidence levels during a hemorrhagic crisis situation.Methods: This was a pre-post experimental study conducted at a tertiary care mother-child simulation center. Pediatric emergency and obstetric teams were submitted to simulated trauma and postpartum MH scenarios. Training consisted of two case scenarios followed by debriefing sessions and a lecture on the MHP. The primary outcome was adherence to MHP processes (checklist) measured prior to and 2 weeks following training sessions. Other outcomes were the measure of teamwork skills (Mayo High Performance Teamwork Scale) and confidence of the participants. RESULTS: Sixty-two health care professionals were involved in eight interprofessional teams. Mean scores for adherence to the MHP improved from 19.1 in the pretraining phase to 25.8 in the posttraining phase (difference of 6.7; 95% confidence interval [CI] = 4.4 to 8.9). Mean scores pertaining to teamwork skills also improved significantly between pre- and posttraining phases (difference = 3.9; 95% CI = 1.5 to 6.4). Confidence questionnaires showed significant improvements in the posttraining phase (difference = 6.9; 95% CI = 5.3 to 8.3). CONCLUSIONS: Targeted training involving simulation and protocol review improved participant adherence to MHP processes and teamwork skills. Confidence levels improved across all disciplines.

Hyperosmolar therapy in pediatric traumatic brain injury: a retrospective study.

OBJECTIVES: The objectives of the study are to describe the use of hyperosmolar therapy in pediatric traumatic brain injury (TBI) and examine its effect on intracranial pressure (ICP) and cerebral perfusion pressure (CPP). DESIGN: A retrospective review of patients with severe TBI admitted to the pediatric intensive care unit (PICU) was conducted. Inclusion criteria were ICP monitoring and administration of a hyperosmolar agent (20 % mannitol or 3 % hypertonic saline) within 48 h of PICU admission; for which dose and timing were recorded. For the first two boluses received for increased ICP (>20 mmHg), the impact on ICP and CPP was assessed during the following 4 h, using repeated measures ANOVA. Co-interventions to control ICP (additional hyperosmolar agent, propofol, or barbiturate bolus) and serum sodium were also documented. SETTING: A tertiary care pediatric hospital center. PATIENTS: Children aged 1 month to 18 years, with severe traumatic brain injury (Glasgow Coma Score ≤ 8) and intracranial pressure (ICP) monitor. RESULTS: Sixty-four patients were eligible, of which 16 met inclusion criteria. Average age was 11 years (SD ± 4) and median Glasgow Coma Score was 6 (range 4-7). Seventy percent of boluses were 3 % hypertonic saline, with no identified baseline difference associated with this initial choice. Both mannitol and hypertonic saline were followed by a non-significant decrease in ICP (mannitol, p = 0.055 and hypertonic saline, p = 0.096). There was no significant change in CPP post bolus. A co-intervention occurred in 69 % of patients within the 4 h post hyperosmolar agent, and eight patients received continuous 3 % saline. CONCLUSION: In pediatric TBI with intracranial hypertension, mannitol and 3 % hypertonic saline are commonly used, but dose and therapeutic threshold for use vary without clear indications for one versus another. Controlled trials are warranted, but several barriers were identified, including high exclusion rate, multiple co-interventions, and care variability.

ICP monitoring in children: why are we not adhering to guidelines?

BACKGROUND: Despite pediatric guidelines, variability exists in the management of severe traumatic brain injury (TBI), as somewhere between 7 and 60% of children undergo intracranial pressure (ICP) monitoring. Reasons for this low adherence to TBI management guidelines remain unclear. The objective of this study was to evaluate the current practices at CHU Sainte-Justine with regards to ICP monitoring in severe TBI and explore the reasons why ICP monitoring is not undertaken. METHODS: A retrospective review was conducted of all patients age 1 month to 18 years, with severe TBI (Glasgow Coma Scale (GCS) ≤8) from 2007 to 2014. Presence of ICP monitoring, head imaging reports, and reasons for lack of monitoring were recorded. RESULTS: Sixty-four patients with severe TBI were admitted. Twenty (31%) patients had invasive ICP monitoring in the first 6 h and 5 in the following 24 h. Improvement of the GCS on arrival to tertiary care center (20%, n = 13) and moribund status (20%, n = 13) were the two main reasons ICP monitoring was not undertaken. Fourteen patients (21%) with reassuring cerebral tomography (Rotterdam scores 1-3) and median GCS 7 (IQR 6-8) were initially followed with clinical surveillance, five of which ended up with an ICP monitor (>6 h). CONCLUSION: Our study confirms that many children with severe TBI do not undergo ICP monitoring, mainly due to rapid improvement or moribund status. A subgroup of patients, with reassuring cerebral CT scan, was not monitored. Further research is necessary to assess if imaging should be considered in ICP indication, as in adult guidelines.

The critically-ill pediatric hemato-oncology patient: epidemiology, management, and strategy of transfer to the pediatric intensive care unit.

Cancer is a leading cause of death in children. In the past decades, there has been a marked increase in overall survival of children with cancer. However, children whose treatment includes hematopoietic stem cell transplantation still represent a subpopulation with a higher risk of mortality. These improvements in mortality are accompanied by an increase in complications, such as respiratory and cardiovascular insufficiencies as well as neurological problems that may require an admission to the pediatric intensive care unit where most supportive therapies can be provided. It has been shown that ventilatory and cardiovascular support along with renal replacement therapy can benefit pediatric hemato-oncology patients if promptly established. Even if admissions of these patients are not considered futile anymore, they still raise sensitive questions, including ethical issues. To support the discussion and potentially facilitate the decision-making process, we propose an algorithm that takes into account the reason for admission (surgical versus medical) and the hemato-oncological prognosis. The algorithm then leads to different types of admission: full-support admission, "pediatric intensive care unit trial" admission, intensive care with adapted level of support, and palliative intensive care. Throughout the process, maintaining a dialogue between the treating physicians, the paramedical staff, the child, and his parents is of paramount importance to optimize the care of these children with complex disease and evolving medical status.

Pediatric traumatic brain injury: an update.

PURPOSE OF REVIEW: The developing brain is particularly vulnerable to traumatic brain injury (TBI), leading to frequent disability or death. This article is an update of the pediatric specificities of TBI management. RECENT FINDINGS: We review the evidences with regards to general management and therapeutic goals to prevent secondary injuries in pediatric TBI patients. Recent controversies in neurocritical care, such as multimodal neuromonitoring, hyperventilation, barbiturate coma, hypothermia, and decompressive surgery, are also highlighted. SUMMARY: Many therapeutic modalities in pediatric TBI have a low level of evidence. Further research is needed to establish clear resuscitation goals. Universal objectives may not be suitable for all patients; intensive neuromonitoring may help in identifying individual therapeutic goals and guiding the selection of treatments.

Population pharmacokinetics of intravenous pantoprazole in paediatric intensive care patients.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: The use of intravenous pantoprazole, a proton pump inhibitor, has been increasing in the paediatric intensive care unit. Despite this increased use, data on the disposition of intravenous pantoprazole in paediatric intensive care patients are very scarce. WHAT THIS STUDY ADDS: Our population approach has determined the pharmacokinetic parameters of intravenous pantoprazole in paediatric intensive care patients and the relative importance of factors influencing its disposition. Pantoprazole clearance was significantly influenced by developmental changes and by the presence of systemic inflammatory syndrome, hepatic dysfunction and CYP2C19 inhibitors. AIMS: To characterize the pharmacokinetics of intravenous pantoprazole in a paediatric intensive care population and to determine the influence of demographic factors, systemic inflammatory response syndrome (SIRS), hepatic dysfunction and concomitantly used CYP2C19 inducers and inhibitors on the drug's pharmacokinetics. METHODS: A total of 156 pantoprazole concentration measurements from 20 patients (10 days to 16.4 years of age) at risk for or with upper gastrointestinal bleeding, who received pantoprazole doses ranging from 19.9 to 140.6 mg/1.73 m(2)/day, were analysed using a population pharmacokinetic approach (nonmem program). RESULTS: The best structural model for pantoprazole was a two-compartment model with zero order infusion and first-order elimination. Body weight, SIRS, age, hepatic dysfunction and presence of CYP2C19 inhibitors were significant covariates affecting clearance (CL), accounting for 75% of interindividual variability. Only body weight significantly influenced central volume of distribution (V(c)). In the final population model, the estimated CL and V(c) were 5.28 l h(-1) and 2.22 l, respectively, for a typical 5-year-old child weighing 20 kg. Pantoprazole CL increased with weight and age, whereas the presence of SIRS, CYP2C19 inhibitors and hepatic dysfunction, when present separately, significantly decreased pantoprazole CL by 62.3, 65.8 and 50.5%, respectively. For patients aged between 6 months and 5 years without SIRS, CYP2C19 inhibitor or hepatic dysfunction, the predicted pantoprazole CL is faster than that reported in adults. CONCLUSION: These results provide important information for physicians regarding selection of a starting dose and dosing regimens of pantoprazole for paediatric intensive care patients based on factors frequently encountered in this population.

Venous thromboembolism after severe injury in children.

BACKGROUND: Deep vein thrombosis and pulmonary embolism are considered common complications after major trauma. Their incidence and the associated risk factors have rarely been identified in injured children. METHODS: Severely injured children (age <18 years; admitted in a pediatric intensive care unit or length of stay > or = 72 h) with a discharge diagnosis of venous thromboembolism (VTE; deep venous thrombosis and/or pulmonary embolism) were identified from the institutional trauma registry between January 1, 1999 and April 31, 2002. The study centers included a dedicated pediatric trauma center and an adult trauma center with pediatric patients. Risk factors for VTE were identified using multivariate analysis. RESULTS: VTE was found in 11 of the 3,291 admissions, for a rate of 3.3/1,000 admissions. Children with VTE were older and had higher Injury Severity Scores. Independent risk factors for VTE included thoracic injuries [odds ratio (OR): 6.9; 95% confidence interval (CI): 1.4-35.1] and spinal injuries (OR: 37.4; 95% CI: 3.5-396.7). The greatest risk of VTE was in children with central venous catheters (OR: 64.0; 95% CI: 16.8-243.9). CONCLUSION: Older children with high Injury Severity Scores, thoracic injuries, spinal injuries or venous catheters are at risk for VTE. Because VTE prophylaxis, screening and treatment are associated with complications and costs, it is essential to identify subgroups of pediatric patients in whom these strategies might be studied.

Group A streptococcal meningitis in a pediatric patient following cochlear implantation: report of the first case and review of the literature.

The Food and Drug Administration published a public health warning on the association of bacterial meningitis and cochlear implants in June 2002. This article reports the first case of group A streptococcal (GAS) meningitis in a cochlear-implanted patient, followed by a review on cochlear implantation and GAS meningitis.