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

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

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

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

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

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

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

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

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

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

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

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

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

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