Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship.

OBJECTIVES: Pediatric procedural sedation has been increasingly performed by pediatric intensivists over the past decade. Pediatric Critical Care Medicine fellowship guidelines do not specify how fellows obtain proficiency in pediatric procedural sedation. We sought to survey the state of pediatric procedural sedation training during fellowship and whether fellows thought it was sufficient. DESIGN: A 21-question survey gathered data on pediatric procedural sedation training provided to Pediatric Critical Care Medicine fellows. Surveys were sent to fellowship directors with instructions to distribute to second- and third-year fellows or recent graduates. Over 2 months, up to three e-mail reminders were sent to fellowship directors whose program had not completed at least one survey. SUBJECTS: Senior fellows and graduates of 65 active Accreditation Council for Graduate Medical Education Pediatric Critical Care Medicine fellowship programs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-five percent of fellowship programs (42/65) returned at least one response. Ninety senior fellows and 27 recent graduates responded. Of respondents, 38% received pediatric procedural sedation training during the fellowship, and 32% reported mandatory training. Nine percent of programs used simulation. Although 61% who received training felt adequately prepared to perform pediatric procedural sedation, 25% needed additional preceptorship to sedate independently. Nearly one third (31%) reported that completion of a predetermined number of cases was required to sedate independently. Forty-eight percent reported a minimum number of cases was required for hospital credentialing. Nearly 45% were allowed to perform pediatric procedural sedation off the unit after receiving credentials. When asked if inadequate pediatric procedural sedation training would be a deterrent to applying for a position that included pediatric procedural sedation, 8.6% replied yes, 52.6% replied no, and 38.8% replied they were unsure. CONCLUSIONS: Pediatric procedural sedation lacks a clearly defined training pathway. Most fellows find pediatric procedural sedation a valuable skill set. We propose that all Pediatric Critical Care Medicine fellows receive training that includes pediatric procedural sedation critical incident simulation and cases performed outside the PICU to establish proficiency.

Barriers to Communication in a PICU: A Qualitative Investigation of Family and Provider Perceptions.

OBJECTIVES: Family and medical provider perceptions of communication barriers within the PICU are poorly understood. We designed a qualitative study to characterize the perspective of families and medical providers of critically ill children regarding communication barriers. The identified barriers may be used to direct efforts to improve communication. DESIGN: Semi-structured interviews were conducted from August 2017 to January 2018. Interviews were audio recorded and professionally transcribed verbatim. SETTING: A PICU at a tertiary care academic center. PATIENTS: Forty-two families whose children were admitted to the PICU (excluding patients receiving end-of-life care or with protective services involvement) and 12 PICU staff members, including nurses, residents, fellows, and attending's. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: An interprofessional team of a physician, nurse manager, and medical student coded the transcripts. Interviewing continued until thematic saturation was reached. Codes were organized into common themes using a modified constant comparative method. The families interviewed represented 16 previously healthy children, and 26 children with a chronic health condition. Staff interviewed included three residents, three fellows, three attending intensivists, and three nurses. Participants' perceptions and experiences of barriers to communication included the following: 1) Communication breakdowns related to coordination of care among several services, 2) Family-centered rounds are insufficient for effective communication, 3) Undervaluing the knowledge of families of children with chronic health conditions or special needs, and 4) Communication breakdowns occur across provider hand-offs. Theme 3 was identified by families, but not by providers. CONCLUSIONS: Families and medical providers both identified several barriers to communication. However, only families identified the barrier "Undervaluing the knowledge of families with chronically ill children." Future work should explore these barriers and the discrepancy in perception between providers and families to determine if there are interventions that improve both family satisfaction and patient care.

Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies.

BACKGROUND/AIMS: Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. METHODS: We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. RESULTS: A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). CONCLUSIONS: More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.

Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia-Outside the Operating Room for Esophagogastroduodenoscopy and Colonoscopy in Children: Age Is an Independent Predictor of Outcomes.

OBJECTIVES: Procedural sedation/anesthesia outside the operating room for a variety of procedures is well described with an overall low adverse event rate in certain settings. Adverse event associated with procedural sedation/anesthesia outside the operating room for gastrointestinal procedures have been described, albeit in small, single-center studies with wide variance in outcomes. Predictors of such outcomes are unclear. We aimed to estimate the prevalence of adverse event in children undergoing procedural sedation/anesthesia outside the operating room for esophagogastroduodenoscopy, colonoscopy, or both to identify predictors of adverse event. DESIGN/SETTING/PATIENTS: Retrospective analysis of Pediatric Sedation Research Consortium database, a large data repository of pediatric patients aged 21 years old or younger undergoing procedural sedation/anesthesia outside the operating room during September 2007 to November 2011. Twenty-two of the 40 centers provided data pertaining to the procedure of interest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome variable is any adverse event. Independent variables include: age (five groups), sex, American Societyof Anaesthesiologists status, procedure (esophagogastroduodenoscopy, colonoscopy, or both), provider responsible, medication used, location, and presence of coexisting medical conditions. Descriptive statistics used to summarize the data. Using multivariablelogistic regression model, odds ratio, 95% CI) were computed. A total of 12,030 procedures were performed (esophagogastroduodenoscopy, 7,970; colonoscopy, 1,378; and both, 2,682). A total of 96.9% of patients received propofol. Eighty-three percent were performed in a sedation unit. Prevalence of adverse event was 4.8%. The most common adverse event were persistent desaturations (1.5%), airway obstruction (1%), cough (0.9%), and laryngospasm (0.6%). No deaths or CPR occurred. Infants and children aged 5 years old or younger had a higher adverse event rate than older children (15.8%, 7.8% vs 4%). Regression analysis revealed age 5 years old or younger, American Society of Anaesthesiologists greater than or equal to 2, esophagogastroduodenoscopy ± colonoscopy, and coexisting medical conditions of obesity and lower airway disease were independent predictors of higher adverse event. CONCLUSIONS: Overall prevalence of any adverse event was 4.8%. Independent predictors of adverse events in procedural sedation/anesthesia outside the operating room in pediatric esophagogastroduodenoscopy/colonoscopy onoscopy were identified. Recognition of such risk factors may enable optimization of procedural sedation.

Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk.

This study aimed to create a pediatric sedation scoring system independent of the American Society of Anesthesiology Physical Status (ASA-PS) classification that is predictive of adverse events, facilitates objective stratification, and resource allocation. Multivariable regression and machine learning algorithm analysis of 134,973 sedation encounters logged in to the Pediatric Sedation Research Consortium (PSRC) database between July 2007 and June 2011. Patient and procedure variables were correlated with adverse events with resultant ß -regression coefficients used to assign point values to each variable. Point values were then summed to create a risk assessment score. Validation of the model was performed with the 2011 to 2013 PSRC database followed by calculation of ROC curves and positive predictive values. Factors identified and resultant point values are as follows: 1 point: age ≤ 6 months, cardiac diagnosis, asthma, weight less than 5th percentile or greater than 95 th , and computed tomography (CT) scan; 2 points: magnetic resonance cholangiopancreatography (MRCP) and weight greater than 99th percentile; 4 points: magnetic resonance imaging (MRI); 5 points: trisomy 21 and esophagogastroduodenoscopy (EGD); 7 points: cough at the time of examination; and 18 points: bronchoscopy. Sum of patient and procedural values produced total risk assessment scores. Total risk assessment score of 5 had a sensitivity of 82.69% and a specificity of 26.22%, while risk assessment score of 11 had a sensitivity of 12.70% but a specificity of 95.29%. Inclusion of ASA-PS value did not improve model sensitivity or specificity and was thus excluded. Higher risk assessment scores predicted increased likelihood of adverse events during sedation. The score can be used to triage patients independent of ASA-PS with site-specific cut-off values used to determine appropriate sedation resource allocation.

Cystatin C in children on chronic hemodialysis.

BACKGROUND: Cystatin C (CyC) concentration has been suggested as a marker of middle-molecule accumulation, hemodialysis (HD) adequacy and for estimating residual renal function (RRF), but it has not been studied in pediatric HD. High CyC is associated with increased cardiovascular disease (CVD). We investigated CyC kinetics and the effect of RRF on CyC in a pediatric HD population. METHODS: A total of 21 HD sessions and 20 interdialytic periods were analyzed in seven patients, age 5-19 years, of whom four were anuric (A) and three were non-anuric (NA). CyC was measured before (preHD) and after (postHD) three standard HD sessions in 1 week and prior to the first session of the following week. RESULTS: We found no difference (p=0.67) in CyC concentration between preHD CyC (9.85 ± 2.15 mg/l; A vs. NA, p=0.37) and postHD CyC (10.04 ± 2.83 mg/l; A vs NA, p=0.28). The weekly average preHD CyC median concentration was 10.14 mg/l (A vs. NA, p=0.87) and correlated with age (r=0.808, p=0.03) and height measurement (r=0.799, p=0.03), but not with RRF, single-pool Kt/V, ultrafiltration, HD duration or blood liters processed. CONCLUSIONS: Cystatin C is very elevated in children on HD. It does not rise between HD sessions, is not removed by standard HD and remains at steady state; therefore, elimination is extrarenal. Low RRF does not affect CyC elimination. CyC increases with age and height. If a high CyC concentration can be proven to have a causative role in the development of CVD, routine intensified HD regimens in children may be indicated for its removal.

Analysis of procedural sedation provided by pediatricians.

BACKGROUND: Pediatric procedural sedation outside of the operating room is performed by a variety of pediatric specialists. Using the database from the Pediatric Sedation Research Consortium (PSRC), patient demographics, medications used, diagnoses, complications, and procedures involved when pediatricians provided sedation in this cohort, were described. 'Pediatrician' was defined as a general pediatrician, cardiologist, endocrinologist, gastroenterologist, hematologist/oncologist, neurologist, pulmonologist or hospitalist. METHODS: Data were collected by the PSRC, a group of 35 institutions dedicated to improving sedation care for children. Members prospectively enrolled consecutive patients who received sedation or anesthesia for diagnostic or therapeutic procedures. Data on demographics, primary diagnoses, procedures, medications, interventions, and complications were collected and stored on a Web-based data collection tool. RESULTS: A total of 12 113 sedations performed by pediatricians were submitted from 1 July 2004 to 31 December 2008, compared to 119 665 cases performed by non-pediatricians. Pediatrician patients were more frequently non-emergency American Society of Anesthesiologists (ASA) class I or II, aged 2-8 years old, with a neurologic primary diagnosis, being sedated for a radiologic procedure with a sedative. Distraction techniques were used more frequently in the pediatrician group (11.9% vs 3.1%). The most common complication encountered was inadequate sedation, which occurred 2.2% of the time. CONCLUSIONS: Pediatricians sedate for a variety of patients within the PSRC, but the patients tended to be younger, predominately ASA class I or II, non-emergency, and undergoing non-painful procedures when compared to non-pediatrician providers. The patient demographics, medications used, diagnoses, complications, and procedures involved varied between the groups significantly. Complication rates were similar between the groups.

Hyperkalemia and ventricular tachycardia after outpatient ureteral valve reimplantation: a case report.

OBJECTIVE: This study aimed to report on a toddler who presented with progressively worsening abdominal pain and obstructive uropathy 1 week after ureteral valve reimplantation. Acute renal failure resulted in critical hyperkalemia. METHODS: Chart review of presentation, physical examination, laboratory tests, and treatment. RESULTS: Initial potassium level was 10 mEq/L; ventricular tachycardia was observed and treated. CONCLUSIONS: More commonly, hyperkalemia results from overuse/overdose of supplementation or in patients with known renal failure. Although less common, obstructive uropathy should be considered in any patient with recent instrumentation of the urinary tract and coincident complications can be significant.

Dexmedetomidine for Sedation During Pediatric Noninvasive Ventilation.

BACKGROUND: Noninvasive ventilation (NIV) facilitates management of acute respiratory failure without intubation. Many pediatric patients cannot tolerate the discomfort associated with noninvasive support and require sedation with agents that may decrease respiratory drive. Dexmedetomidine does not decrease respiratory drive, and we hypothesized that its use would increase tolerance of noninvasive respiratory support without increasing risk for intubation. METHODS: A retrospective chart review was performed of all subjects at least 3 months of age with acute respiratory failure requiring NIV who were admitted to the pediatric ICU at a children's hospital for a 3-y period from 2015-2018. Subjects were stratified to those receiving continuous dexmedetomidine versus those not receiving sedation. Medical history was reviewed for developmental delay (DD) or intellectual disability (ID) as well as basic demographic information. To control the association between these variables with both dexmedetomidine use and intubation, augmented inverse probability weighting was utilized to establish equivalent baselines between the dexmedetomidine and no-sedation groups. Primary outcome was intubation rate within 6 h of initiation of dexmedetomidine infusion or NIV. RESULTS: Based on the strong association between age and dexmedetomidine use, a statistical model including subjects > age 5 was not able to be generated, and these subjects were excluded from final analysis. One-hundred eight subjects were included in the final statistical analysis, with 60 receiving dexmedetomidine and 48 receiving no sedation. Dexmedetomidine was effective at reducing agitation, with no difference noted in intubation rate at 6 h between subjects receiving dexmedetomidine versus no sedation (13.1 vs 12.4%). CONCLUSIONS: Dexmedetomidine may allow tolerance of NIV in acute respiratory failure without increasing risk for intubation, especially in preschool age patients and those with DD or ID. A larger study involving multiple centers would help support our conclusions.

Efficacy of Intravenous Ketamine in Adolescent Treatment-Resistant Depression: A Randomized Midazolam-Controlled Trial.

Objective: Adolescent depression is prevalent and is associated with significant morbidity and mortality. Although intravenous ketamine has shown efficacy in adult treatment-resistant depression, its efficacy in pediatric populations is unknown. The authors conducted an active-placebo-controlled study of ketamine's safety and efficacy in adolescents. Methods: In this proof-of-concept randomized, double-blind, single-dose crossover clinical trial, 17 adolescents (ages 13-17) with a diagnosis of major depressive disorder received a single intravenous infusion of either ketamine (0.5 mg/kg over 40 minutes) or midazolam (0.045 mg/kg over 40 minutes), and the alternate compound 2 weeks later. All participants had previously tried at least one antidepressant medication and met the severity criterion of a score >40 on the Children's Depression Rating Scale-Revised. The primary outcome measure was score on the Montgomery-Åsberg Depression Rating Scale (MADRS) 24 hours after treatment. Results: A single ketamine infusion significantly reduced depressive symptoms 24 hours after infusion compared with midazolam (MADRS score: midazolam, mean=24.13, SD=12.08, 95% CI=18.21, 30.04; ketamine, mean=15.44, SD=10.07, 95% CI=10.51, 20.37; mean difference=-8.69, SD=15.08, 95% CI=-16.72, -0.65, df=15; effect size=0.78). In secondary analyses, the treatment gains associated with ketamine appeared to remain 14 days after treatment, the latest time point assessed, as measured by the MADRS (but not as measured by the Children's Depression Rating Scale-Revised). A significantly greater proportion of participants experienced a response to ketamine during the first 3 days following infusion as compared with midazolam (76% and 35%, respectively). Ketamine was associated with transient, self-limited dissociative symptoms that affected participant blinding, but there were no serious adverse events. Conclusions: In this first randomized placebo-controlled clinical trial of intravenous ketamine in adolescents with depression, the findings suggest that it is well tolerated acutely and has significant short-term (2-week) efficacy in reducing depressive symptoms compared with an active placebo.Reprinted from Am J Psychiatry 2021; 178:352-362 with permission from American Psychiatric Association Publishing.

Efficacy of Intravenous Ketamine in Adolescent Treatment-Resistant Depression: A Randomized Midazolam-Controlled Trial.

OBJECTIVE: Adolescent depression is prevalent and is associated with significant morbidity and mortality. Although intravenous ketamine has shown efficacy in adult treatment-resistant depression, its efficacy in pediatric populations is unknown. The authors conducted an active-placebo-controlled study of ketamine's safety and efficacy in adolescents. METHODS: In this proof-of-concept randomized, double-blind, single-dose crossover clinical trial, 17 adolescents (ages 13-17) with a diagnosis of major depressive disorder received a single intravenous infusion of either ketamine (0.5 mg/kg over 40 minutes) or midazolam (0.045 mg/kg over 40 minutes), and the alternate compound 2 weeks later. All participants had previously tried at least one antidepressant medication and met the severity criterion of a score >40 on the Children's Depression Rating Scale-Revised. The primary outcome measure was score on the Montgomery-Åsberg Depression Rating Scale (MADRS) 24 hours after treatment. RESULTS: A single ketamine infusion significantly reduced depressive symptoms 24 hours after infusion compared with midazolam (MADRS score: midazolam, mean=24.13, SD=12.08, 95% CI=18.21, 30.04; ketamine, mean=15.44, SD=10.07, 95% CI=10.51, 20.37; mean difference=-8.69, SD=15.08, 95% CI=-16.72, -0.65, df=15; effect size=0.78). In secondary analyses, the treatment gains associated with ketamine appeared to remain 14 days after treatment, the latest time point assessed, as measured by the MADRS (but not as measured by the Children's Depression Rating Scale-Revised). A significantly greater proportion of participants experienced a response to ketamine during the first 3 days following infusion as compared with midazolam (76% and 35%, respectively). Ketamine was associated with transient, self-limited dissociative symptoms that affected participant blinding, but there were no serious adverse events. CONCLUSIONS: In this first randomized placebo-controlled clinical trial of intravenous ketamine in adolescents with depression, the findings suggest that it is well tolerated acutely and has significant short-term (2-week) efficacy in reducing depressive symptoms compared with an active placebo.

Proteinuria in children with sickle cell disease.

BACKGROUND: Sickle cell nephropathy is characterized by proteinuria that starts in childhood and may lead to renal failure. Microalbuminuria is used as a marker of glomerular damage. There are no data on the extent and type of proteinuria other than microalbuminuria in children with sickle cell disease (SCD). Our goal was characterization of glomerular permselectivity and tubular proteinuria in children with SCD. The improved characterization will allow earlier recognition and prevention of renal damage. METHODS: Thirty-two stable patients with haemoglobin SS (HbSS) (15 boys and 17 girls, age 9.57 +/- 5.45 years, 8 months to 19 years) were investigated. All patients had normal renal function and tested negative for proteinuria with a dipstick method. Markers of glomerular permselectivity used were albumin (marker of charge selectivity and less severe pore-size selectivity) and immunoglobulin G (IgG, marker of more severe pore-size selectivity). The marker of tubular injury used was retinol-binding protein (RBP, marker of proximal tubular dysfunction). These proteins were measured in urine spot samples using nephelometry. We did not include a control group as values in healthy subjects were previously published. RESULTS: Total protein excretion was elevated in 41% (13/32) of all patients and, of these 13 patients, 38.5% (5/13) had increased microalbuminuria, 15% (2/13) had increased excretion of RBP and 23% (3/13) had increased excretion of IgG. Increased total proteinuria that was not detected by testing for microalbuminuria was found in 61.5% (8/13) of patients. The youngest patient was 3 years old. Increased microalbuminuria was present in 25% (8/32) of all patients and was detected as early as 4 years of age. Of these, 62% (5/8) also had increased total protein excretion and 62% (5/8) also had increased IgG excretion. A total of 62.5% were older than 10 years. RBP excretion was elevated in 16% (5/32) of patients, all of whom were 7-14 years old. None of these patients had increased microalbuminuria or increased excretion of IgG. IgG excretion was elevated in 16% (5/32) of patients and was accompanied by increased microalbuminuria. All patients with increased IgG excretion were > or = 13 years old. We found a weak positive correlation between microalbuminuria and age (0.323, P = 0.07). We did not find a significant correlation between any type of proteinuria and disease morbidity. Ten of the thirty-two patients received hydroxyurea treatment and 60% (6/10) had no proteinuria. Twelve of the thirty-two patients received chronic exchange transfusions and 42% (5/12) had no proteinuria. CONCLUSION: We found early glomerular selectivity damage in children with SCD, which is secondary to both size-selectivity and charge-selectivity impairment. Microalbuminuria alone does not adequately detect early renal damage in children with SCD. Proximal tubular dysfunction is seen in younger children and is independent of glomerular damage. We suggest that children with SCD be tested for both total protein and IgG excretion in the urine in addition to albumin. Knowing the extent and type of renal damage may allow earlier recognition of renal injury and prompt earlier initiation of preventive therapies.

Sedation and Analgesia Using Medications Delivered via the Extravascular Route in Children Undergoing Laceration Repair.

OBJECTIVES: To describe the method of delivery, dosage regimens, and outcomes of sedatives and analgesics administered via the extravascular route for laceration repair in children. METHODS: Medline, Embase, and International Pharmaceutical Abstracts were searched using the keywords "child," "midazolam," "ketamine," dexmedetomidine," "fentanyl," "nitrous oxide" (N2O), and "laceration repair." Articles evaluating the use of extravascular sedation in children for laceration repair published in the English language between 1946 and June 2017 were included. Two authors independently screened each article for inclusion. Reports were excluded if they did not contain sufficient details on dosage regimen and outcomes. RESULTS: A total of 16 reports representing 953 children receiving sedatives and analgesics via the extravascular route were included for analyses. A statistical analysis was not performed because of heterogeneity in dosing and types of analyses conducted. Midazolam and N2O were the most common agents, with oral (PO) midazolam being the most common agent. Other agents that have supporting data were intranasal (IN) dexmedetomidine, IN ketamine, IN midazolam, PO diazepam, PO ketamine, transmucosal (TM) midazolam, and TM fentanyl. CONCLUSIONS: Most of the agents administered through the extravascular route were efficacious. Selection of the agents should be based on perceived need for analgesia versus sedation, patient accessibility, and adverse drug events. Future research is needed to determine the optimal agent and route for laceration repair.

Use of Simulation to Improve Cardiopulmonary Resuscitation Performance and Code Team Communication for Pediatric Residents.

INTRODUCTION: Cardiorespiratory events are infrequent in pediatric teaching hospitals but can lead to significant morbidity and mortality. Clear communication within the response team prevents delays in action and allows all team members to contribute to providing optimum management. This resource was developed to simulate high-acuity and low-frequency events for pediatric residents. The scenario options are recurrent supraventricular tachycardia, prolonged QT syndrome, myocarditis, and respiratory syncytial virus bronchiolitis. METHODS: The simulation is best performed in a simulation center with audio- and video-recording capabilities but could also be performed in situ in the pediatric intensive care unit or emergency room. Necessary personnel include a simulation technician and two instructors. A code cart, mock medications, and defibrillator with hands-free pads appropriate for the mannequin are necessary supplies. Critical actions include initial survey and intervention, rhythm recognition, cardiopulmonary resuscitation (CPR), use of defibrillator, and administration of anti-arrhythmic medications when needed. At the conclusion of the scenario, a formal debriefing with learners using structured feedback is performed. RESULTS: These cases have been used with groups of pediatric or emergency medicine residents approximately 16 times over the past 3 years. Learners have reported that participation increased their confidence and comfort with management of cardiorespiratory events and that communication technique practice improved their teamwork and sign-out skills. Rhythm recognition and CPR performance scores during the simulation scenarios improved, with subjective improvement during actual cardiorespiratory events. DISCUSSION: This resource advances learner knowledge of Pediatric Advanced Life Support algorithms and teamwork communication and identifies learner knowledge and management deficits.

Relationship between Interdialytic Weight Gain and Blood Pressure in Pediatric Patients on Chronic Hemodialysis.

Overhydration is reported to be the main cause of hypertension (HTN) as well as to have no association with HTN in hemodialysis (HD) population. This is the first report of the relationship between interdialytic weight gain (IDWG) and pre-HD blood pressure (BP) in pediatric patients in relation to residual urine output (RUO). We studied 170 HD sessions and interdialytic periods performed during a 12-week period in 5 patients [age 4-17 years, weight 20.8-66 kg, 3 anuric (102 HD sessions), and 2 nonanuric (68 HD sessions)]. BP is presented as systolic BP index (SBPI) and diastolic BP index (DBPI), calculated as systolic or diastolic BP/95th percentile for age, height, and gender. IDWG did not differ (P > 0.05) between anuric and nonanuric pts. There was a positive but not significant correlation between IDWG and both pre-HD SBPI (r = 0.833, P = 0.080) and pre-HD DBPI (r = 0.841, P = 0.074). Pre-HD SBPI (1.01 ± 0.12 versus 1.13 ± 0.18) and DBPI (0.92 ± 0.16 versus 1.01 ± 0.24) were higher in nonanuric patents (P < 0.001 and P < 0.01, resp.). Pre-HD HTN may not be solely related to IDWG and therapies beyond fluid removal may be needed. Individualized approach to HTN management is necessary in pediatric dialysis population.

Discontinuation of Antimicrobial Prophylaxis (AP) in Children With Spina Bifida: A Case Series Analysis.

BACKGROUND: Spina bifida increases the risk for urinary tract infections (UTI). Antimicrobial prophylaxis (AP) reduces symptomatic UTI's but selects resistant organisms. Measures to ensure regular and complete emptying of the bladder combined with treatment of constipation reduce the risk for UTI. OBJECTIVES: Demonstrate that close adherence to a catheterization regimen in children with spina bifida (Selective Treatment - ST) reduces the need for antimicrobial prophylaxis. METHODS: Case series analysis of pediatric spina bifida clinic patients where routine antimicrobial prophylaxis was replaced by clean-catch catheterization and daily bowel regimen (ST). Retrospective chart review of 67 children (mean entry age: 24 months, median age: 4 months; 32 Males, 35 Females) enrolled between 1986 - 2004. Mean follow-up was 128.6 months (range 3 - 257 months). Asymptomatic and symptomatic UTI incidences were noted on AP and ST protocols. Creatinine clearance at study entry and follow-up was calculated by the age appropriate method. A multivariable regression model with delta Glomerular Filtration Rate (GFR) as the dependent variable, independent sample t-test and Wilcoxon rank sum were performed with SAS v. 9.2. RESULTS: The mean number of infections while on AP was 8.7 (95% CI 5.72, 11.68) and was 1.0 on ST (95% CI 0.48, 1.43). 5 infections on the AP protocol required intravenous (IV) antibiotics due to resistance to oral therapy, but none on ST. Comparing change in GFR between both protocols (AP vs. ST) found a significant difference in the change of GFR by treatment protocol. CONCLUSIONS: AP did not prevent UTIs and resulted in more resistant organisms requiring IV antibiotics. Discontinuing AP allowed the return of susceptibility to oral antimicrobials and significantly improved GFR in those children who had previously been on AP. Adherence to a catheterization regimen with prompt treatment of symptomatic UTI conserved renal function and prevented selection of resistant organisms.