Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs.

OBJECTIVES: To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived. DESIGN: A cross-sectional survey. SETTING: U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships. SUBJECTS: One senior physician and one senior nurse at each institution. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility. CONCLUSIONS: Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.

The impact of a fellow-driven debriefing program after pediatric cardiac arrests.

BACKGROUND: In the United States, post-cardiac arrest debriefing has increased, but historically it has occurred rarely in our pediatric intensive care unit (PICU). A fellow-led debriefing tool was developed as a tool for fellow development, as well as to enhance communication amongst a multidisciplinary team. METHODS: A curriculum and debriefing tool for fellow facilitators was developed and introduced in a 41-bed cardiac and medical PICU. Pre- and post-intervention surveys were sent to multidisciplinary PICU providers to assess effectiveness of debriefings using newly-trained leaders, as well as changes in team communication. RESULTS: Debriefing occurred after 84% (63/75) of cardiac arrests post-intervention. Providers in various team roles participated in pre-intervention (129 respondents/236 invitations) and post-intervention (96 respondents /232 invitations) surveys. Providers reported that frequently occurring debriefings increased from 9 to 58%, pre- and post-intervention respectively (p < .0001). Providers reported frequent identification and discussion of learning points increased from 32% pre- to 63% post-intervention. In the 12 months post-intervention, 62% of providers agreed that the overall quality of communication during arrests had improved, and 61% would be more likely to request a debriefing after cardiac arrest. CONCLUSION: The introduction of a fellow-led debriefing tool resulted in regularly performed debriefings after arrests. Despite post-intervention debriefings being led by newly-trained facilitators, the majority of PICU staff expressed satisfaction with the quality of debriefing and improvement in communication during arrests, suggesting that fellow facilitators can be effective debrief leaders.

Randomized Trial of Intranasal Fentanyl Versus Intravenous Morphine for Abscess Incision and Drainage.

OBJECTIVES: Abscess incision and drainage (I&D) are painful and distressing procedures in children. Intranasal (IN) fentanyl is an effective analgesic for reducing symptomatic pain associated with fractures and burns but has not been studied for reducing procedural pain during abscess I&D. Our objective was to compare the analgesic efficacy of IN fentanyl with intravenous (IV) morphine for abscess I&D in children. METHODS: We performed a randomized noninferiority trial in children aged 4 to 18 years undergoing abscess I&D in a pediatric emergency department. Patients received IN fentanyl (2 µg/kg; maximum, 100 µg) or IV morphine (0.1 mg/kg; maximum, 8 mg). The primary outcome, determined independently by blinded assessors, was the Observational Scale of Behavioral Distress-Revised (OSBD-R). The prestated margin of noninferiority (Δ) was 1.80. Secondary outcomes included self-reported pain, treatment failure, and patient and parental satisfaction. RESULTS: We enrolled 20 children (median age, 15.4 years), 10 in each group. The difference between total OSBD-R scores was -13.45 (95% confidence interval, -24.24 to -2.67), favoring IN fentanyl.There was less self-reported pain in patients who received IN fentanyl immediately after the procedure. Four patients (40%) receiving IV morphine had treatment failures and required moderate sedation or had the procedure terminated. More patients who received IN fentanyl were satisfied with the analgesic administered compared with those who received IV morphine. CONCLUSIONS: In a small sample of children aged 4 to 18 years undergoing abscess I&D, IN fentanyl was noninferior, and potentially superior, to IV morphine for reducing procedural pain and distress.

Optimized multisite ventricular pacing in postoperative single-ventricle patients.

Ventricular dyssynchrony is associated with morbidity and mortality after palliation of a single ventricle. The authors hypothesized that resynchronization with optimized temporary multisite pacing postoperatively would be safe, feasible, and effective. Pacing was assessed in the intensive care unit within the first 24 h after surgery. Two unipolar atrial pacing leads and four bipolar ventricular pacing leads were placed at standardized sites intraoperatively. Pacing was optimized to maximize mean arterial pressure. The protocol tested 11 combinations of the 4 different ventricular lead sites, 6 atrioventricular delays (50-150 ms), and 14 intraventricular delays. Optimal pacing settings were thus determined and ultimately compared in four configurations: bipolar, unipolar, single-site atrioventricular pacing, and intrinsic rhythm. Each patient was his or her own control, and all pacing comparisons were implemented in random sequence. Single-ventricle palliation was performed for 17 children ages 0-21 years. Pacing increased mean arterial pressure (MAP) versus intrinsic rhythm, with the following configurations: bipolar multisite pacing increased MAP by 2.2 % (67.7 ± 2.4 to 69.2 ± 2.4 mmHg; p = 0.013) and unipolar multisite pacing increased MAP by 2.8 % (67.7 ± 2.4 to 69.6 ± 2.7 mmHg; p = 0.002). Atrioventricular single-site pacing increased MAP by 2.1 % (67.7 ± 2.4 to 69.1 ± 2.5 mmHg: p = 0.02, insignificant difference under Bonferroni correction). The echocardiographic fractional area change in nine patients increased significantly only with unipolar pacing (32 ± 3.1 to 36 ± 4.2 %; p = 0.02). No study-related adverse events occurred. Multisite pacing optimization is safe and feasible in the early postoperative period after single-ventricle palliation, with improvements in mean arterial pressure and fractional area shortening. Further study to evaluate clinical benefits is required.

Effects of biventricular pacing on left heart twist and strain in a porcine model of right heart failure.

BACKGROUND: Biventricular pacing (BiVP) improves cardiac output (CO) in selected cardiac surgery patients, but response remains variable, necessitating a better understanding of the mechanism. Accordingly, we used speckle tracking echocardiography (STE) to analyze BiVP during acute right ventricular pressure overload (RVPO). MATERIALS AND METHODS: In nine pigs, the inferior vena cava (IVC) was snared to decrease CO and establish a control model. Heart block was induced, the pulmonary artery snared, and BiVP initiated. Echocardiograms of the left ventricular midpapillary level were taken at varying atrioventricular delay (AVD) and interventricular delay (VVD) for STE analysis of regional circumferential strain (CS) and radial strain (RS). Echocardiograms were taken of the left ventricular base, midpapillary, and apex during baseline, IVC occlusion, and each BiVP setting for STE analysis of twist, apical and basal rotations, CS, RS, and synchrony. Indices were correlated against CO with mixed linear models. RESULTS: During IVC occlusion, CO correlated with twist, apical rotation, RS, RS synchrony, and CS (P < 0.05). During RVPO with BiVP, CO only correlated with RS synchrony and CS (P < 0.05). During AVD and VVD variations, CO was associated with free wall RS (P < 0.008). CO correlated with septal wall CS during AVD variation and free wall CS during VVD variation (P < 0.008). CONCLUSIONS: In an open chest model, twist, RS, RS synchrony, and CS analyzed by STE may be noninvasive surrogates for changes in CO. During RVPO, changes in RS synchrony and CS with varying regional strain contributions may be the primary mechanism in which BiVP improves CO. Lack of correlation of remaining indices may reflect postsystolic function.

Successful treatment of severe mechanical mitral valve thrombosis with tissue plasminogen activator in a 7-month-old infant.

Severe thrombosis of a mechanical valve is a rare complication in pediatric patients. Thrombolytic therapy as treatment of mechanical mitral valve thrombosis has rarely been reported in young infants. We report the successful treatment with recombinant tissue-type plasminogen activator of a mechanical mitral valve thrombus in a 7 month-old patient with trisomy 21, complete atrioventricular canal defect and pulmonary hypertension status post complete atrioventricular canal repair and subsequent prosthetic mitral valve replacement. He presented with respiratory decompensation and shock secondary to severe mechanical mitral valve stenosis. Serial echocardiograms showed significant resolution of the thrombus within 18 h of infusion with no major bleeding complications during the treatment course. Although a rare complication of mechanical valve placement in pediatrics, thrombosis of mechanical valves may result in severe hemodynamic and respiratory compromise. This case demonstrates that thrombolytic therapy is a feasible option for the treatment of critical thrombosis in pediatric patients after MVR.

Nitric oxide-associated pulmonary edema in children with pulmonary venous hypertension.

Nitric oxide (NO)-associated pulmonary edema is rarely reported in children; in adults, it is often associated with left-sided heart failure. We report a case series of children with NO-associated pulmonary edema, which was defined as new multilobar alveolar infiltrates and worsening hypoxemia within 24 h of initiation or escalation of NO and radiologic or clinical improvement after NO discontinuation. We identified six patients (0.4-4 years old) with ten episodes of NO-associated pulmonary edema. Diagnoses included atrioventricular canal defect with mitral valve disease (n = 2), pulmonary atresia and major aorta-pulmonary collateral arteries (n = 2), total anomalous pulmonary venous return (n = 1), and pulmonary veno-occlusive disease (n = 1). All patients had evidence of pulmonary venous hypertension, and two had mitral valve disease resulting in clinical evidence of left-sided heart failure. Pulmonary edema improved or resolved within 24 h of discontinuing NO. At cardiac catheterization, mean left atrial pressure was <15 mmHg in three of three patients (none with mitral valve disease), whereas pulmonary artery occlusion pressure was >15 mmHg in two of five patients. In conclusion, we describe six young children with NO-associated pulmonary edema and pulmonary venous hypertension. Only two of these children had left-sided heart failure: Left atrial pressure as well as pulmonary artery occlusion pressure may not be helpful in identifying children at risk for NO-associated pulmonary edema.

Implementation of a Formal Debriefing Program After Pediatric Rapid Response Team Activations.

BACKGROUND: Debriefing after pediatric rapid response team activations (RRT-As) in a tertiary care children's hospital was identified to occur only sporadically. The lack of routine debriefing after RRT-As was identified as a missed learning opportunity. OBJECTIVE: We implemented a formal debriefing program and assessed staff attitudes toward and experiences with debriefing after pediatric RRT-As. METHODS: Real-time feedback for pediatrics residents captured clinical and debriefing data for each RRT-A from July 2014 to June 2016. The debriefing on physiology, team communication, and anticipation of clinical deterioration was introduced in July 2015. To assess debriefing perceptions, residents, intensive care fellows, nurses, and respiratory therapists participated in anonymous preintervention and postintervention surveys. We also developed a workshop to teach residents how to lead debriefing. RESULTS: Debriefing after RRT-As increased from 26% preintervention to 46% postintervention (P < .0001). A total of 43 of 76 pediatrics residents (57%) attended at least 1 of 4 debriefing workshops. Both preintervention and postintervention, more than 80% (70 of 78 preintervention and 54 of 65 postintervention) of health professionals surveyed strongly agreed or agreed that there was a benefit to debriefing after RRT-As. Postintervention, 65% (26 of 40) of respondents strongly agreed or agreed that debriefing improved their understanding of the RRT-A process. The rate of debriefing was sustained at 46% (6 months after the end of the study period). CONCLUSIONS: Debriefing frequency after pediatric RRT-As significantly increased with the introduction of a formal debriefing program. A majority of health professionals and trainees reported this practice was a valuable experience.

Improved perception of communication and compliance with a revised, intensive care unit-specific bedside communication sheet.

Although many pediatric intensive care units (PICUs) use beside communication sheets (BCSs) to highlight daily goals, the optimal format is unknown. A site-specific BCS could improve both PICU communication and compliance completing the BCS. Via written survey, PICU staff at an academic children's hospital provided recommendations for improving and revising an existing BCS. Pre- and post-BCS revision, PICU staff were polled regarding PICU communication and BCS effectiveness, and daily compliance for completing the BCS was monitored. After implementation of the revised BCS, staff reporting "excellent" or "very good" day-to-day communication within the PICU increased from 57% to 77% (P = .02). Compliance for completing the BCS also increased significantly (75% vs 83%, P = .03). Introduction of a focused and concise BCS tailored to a specific PICU leads to improved perceptions of communication by PICU staff and increased compliance completing the daily BCS.

Short-term reduction in intrinsic heart rate during biventricular pacing after cardiac surgery: a substudy of a randomized clinical trial.

BACKGROUND: The Biventricular Pacing After Cardiac Surgery trial investigates hemodynamics of temporary pacing in selected patients at risk of left ventricular dysfunction. This trial demonstrates improved hemodynamics during optimized biventricular pacing compared with atrial pacing at the same heart rate 1 and 2 hours after bypass and reduced vasoactive-inotropic score over the first 4 hours after bypass. However, this advantage of biventricular versus atrial pacing disappears 12 to 24 hours later. We hypothesized that changes in intrinsic heart rate can explain variable effects of atrial pacing in this setting. METHODS: Heart rate, mean arterial pressure, cardiac output, and medications depressing heart rate were analyzed in patients randomized to continuous biventricular pacing (n = 16) or standard of care (n = 18). RESULTS: During 30-second testing periods without pacing, intrinsic heart rate was lower in the paced group 12 to 24 hours after bypass (76.5 ± 17.5 vs 91.7 ± 13.0 beats per minute; P = .040) but not 1 or 2 hours after bypass. Cardiac output (4.4 ± 1.2 vs 3.6 ± 1.9 L/min; P = .054) and stroke volume (53 ± 2 vs 42 ± 2 mL; P = .051) increased overnight in the paced group. Vasoactive medication doses were not different between groups, whereas dexmedetomidine administration was prolonged over postoperative hours 12 to 24 in the paced group (793 ± 528 vs 478 ± 295 minutes; P = .013). CONCLUSIONS: These observations suggest that hemodynamic benefits of biventricular pacing 12 to 24 hours after cardiopulmonary bypass lead to withdrawal of sympathetic drive and decreased intrinsic heart rate. Depression of intrinsic rate increases the apparent benefit of atrial pacing in the chronically paced group but not in the control group. Additional study is needed to define clinical benefits of these effects.

Primary endpoints of the biventricular pacing after cardiac surgery trial.

BACKGROUND: This study sought to determine whether optimized biventricular pacing increases cardiac index in patients at risk of left ventricular dysfunction after cardiopulmonary bypass. Procedures included coronary artery bypass, aortic or mitral surgery and combinations. This trial was approved by the Columbia University Institutional Review Board and was conducted under an Investigational Device Exemption. METHODS: Screening of 6,346 patients yielded 47 endpoints. With informed consent, 61 patients were randomized to pacing or control groups. Atrioventricular and interventricular delays were optimized 1 (phase I), 2 (phase II), and 12 to 24 hours (phase III) after bypass in all patients. Cardiac index was measured by thermal dilution in triplicate. A 2-sample t test assessed differences between groups and subgroups. RESULTS: Cardiac index was 12% higher (2.83±0.16 [standard error of the mean] vs 2.52±0.13 liters/minute/square meter) in the paced group, less than predicted and not statistically significant (p=0.14). However, when aortic and aortic-mitral surgery groups were combined, cardiac index increased 29% in the paced group (2.90±0.19, n=14) versus controls (2.24±0.15, n=11) (p=0.0138). Using a linear mixed effects model, t-test revealed that mean arterial pressure increased with pacing versus no pacing at all optimization points (phase I 79.2±1.7 vs 74.5±1.6 mm Hg, p=0.008; phase II 75.9±1.5 vs 73.6±1.8, p=0.006; phase III 81.9±2.8 vs 79.5±2.7, p=0.002). CONCLUSIONS: Cardiac index did not increase significantly overall but increased 29% after aortic valve surgery. Mean arterial pressure increased with pacing at 3 time points. Additional studies are needed to distinguish rate from resynchronization effects, emphasize atrioventricular delay optimization, and examine clinical benefits of temporary postoperative pacing.

Temporary biventricular pacing decreases the vasoactive-inotropic score after cardiac surgery: a substudy of a randomized clinical trial.

OBJECTIVE: Vasoactive medications improve hemodynamics after cardiac surgery but are associated with high metabolic and arrhythmic burdens. The vasoactive-inotropic score was developed to quantify vasoactive and inotropic support after cardiac surgery in pediatric patients but may be useful in adults as well. Accordingly, we examined the time course of this score in a substudy of the Biventricular Pacing After Cardiac Surgery trial. We hypothesized that the score would be lower in patients randomized to biventricular pacing. METHODS: Fifty patients selected for increased risk of left ventricular dysfunction after cardiac surgery and randomized to temporary biventricular pacing or standard of care (no pacing) after cardiopulmonary bypass were studied in a clinical trial between April 2007 and June 2011. Vasoactive agents were assessed after cardiopulmonary bypass, after sternal closure, and 0 to 7 hours after admission to the intensive care unit. RESULTS: Over the initial 3 collection points after cardiopulmonary bypass (mean duration, 131 minutes), the mean vasoactive-inotropic score decreased in the biventricular pacing group from 12.0 ± 1.5 to 10.5 ± 2.0 and increased in the standard of care group from 12.5 ± 1.9 to 15.5 ± 2.9. By using a linear mixed-effects model, the slopes of the time courses were significantly different (P = .02) and remained so for the first hour in the intensive care unit. However, the difference was no longer significant beyond this point (P = .26). CONCLUSIONS: The vasoactive-inotropic score decreases in patients undergoing temporary biventricular pacing in the early postoperative period. Future studies are required to assess the impact of this effect on arrhythmogenesis, morbidity, mortality, and hospital costs.

Response of mean arterial pressure to temporary biventricular pacing after chest closure during cardiac surgery.

OBJECTIVES: We have previously demonstrated that biventricular pacing increased cardiac output within 1 hour of weaning from cardiopulmonary bypass in selected patients. To assess the possible sustained benefit, we reviewed in the present study the effects of biventricular pacing on the mean arterial pressure after chest closure. METHODS: A total of 30 patients (mean ejection fraction 35% ± 15%, mean QRS 119 ± 24 ms) underwent coronary bypass and/or valve surgery. The mean arterial pressure was maximized during biventricular pacing using atrioventricular delays of 90 to 270 ms and interventricular delays of +80 to -80 ms during 20-second intervals in random sequence. Optimized biventricular pacing was finally compared with atrial pacing at a matched heart rate and to a sinus rhythm during 30-second intervals. Vasoactive medication and fluid infusion rates were held constant. The arterial pressure was digitized, recorded, and integrated. Statistical significance was assessed using linear mixed effects models and Bonferroni's correction. RESULTS: Optimized atrioventricular delay, ranging from 90 to 270 ms, increased the mean arterial pressure 4% versus nominal and 7% versus the worst (P < .001). Optimized interventricular delay increased pressure 3% versus nominal and 7% versus the worst. Optimized biventricular pacing increased the mean arterial pressure 4% versus sinus rhythm (78.5 ± 2.4 vs 75.1 ± 2.4 mm Hg; P = .002) and 3% versus atrial pacing (76.4 ± 2.7 mm Hg; P = .017). CONCLUSIONS: Temporary biventricular pacing improves the hemodynamics after chest closure, with effects similar to those within 1 hour of bypass. Individualized optimization of atrioventricular delay is warranted, because the optimal delay was longer in 80% of our patients than the current recommendations for temporary postoperative pacing.