Organ Donation in Canadian PICUs: A Cross-Sectional Survey, 2021-2022.

OBJECTIVES: To understand contemporary pediatric organ donation programs in Canadian PICUs, including: policies and practices, data collection and reporting, and system and process barriers. DESIGN: A cross-sectional survey carried out 2021-2022. SETTING: Canadian PICUs affiliated with a donor physician network. SUBJECTS: Pediatric intensivists identified as the donation program lead, or most knowledgeable about donation for their institution. MEASUREMENTS AND MAIN RESULTS: A 19-item survey was developed through collaboration with stakeholders from the organ donation and transplantation community within Canada. Domains and items were generated and reduced iteratively during an in-person workshop. Pretesting and pilot testing were completed to ensure readability, flow, clinical sensibility, and construct validity. Fifteen of 16 (94%) invited Canadian PICUs from seven provinces completed the survey representing 88% (15/18) of all noncardiac Canadian PICUs. Surveys were completed between June 2021 and September 2022. All units support donation after death by neurologic criteria (DNC); 14 of 15 indicated donation policies were in place and 1 of 15 indicated no policy but the ability to facilitate donation. Thirteen of 15 units (87%) support donation after death by circulatory criteria (DCC) with policies in place, with 11 of 13 of these indicating routine support of donation opportunities. The majority (13/15) of units identified a donation champion. Of the 16 identified champions across these centers, 13 were physicians and were registered nurses or nurse practitioners. Eight of 13 units (62%) with donation champions had positions supported financially, of which 5 units came from the Organ Donation Organization and the other 3 came from the provincial health authority. Finally, only 3 of 15 PICU donation programs have a pediatric donation committee with family involvement. Variability exists in identification (including determination of death practices), referral, and approach for donation between units. CONCLUSIONS: Although all Canadian PICUs support donation after DNC donation, and most support donation after DCC, variability exists in the identification, referral, and approach of potential donors. There is a notable lack of family involvement in pediatric donation programs. There are many opportunities for standardization of PICU donation programs which may result in improved rates of pediatric organ donation in Canada.

Quality of clinical care provided during simulated pediatric cardiac arrest: a simulation-based study.

PURPOSE: We sought to assess compliance to resuscitation guidelines during pediatric simulated cardiac arrests in a pediatric intensive care unit (PICU) and to identify performance gaps to target with future training. METHODS: In a prospective observational study in a PICU, ten cardiac arrest scenarios were developed for resuscitation training and video recorded. The video recordings were examined for times to start cardiopulmonary resuscitation (CPR), delivery of first shock, CPR quality (rate, depth), length of pauses, chest compression fraction (CCF), ventilation, pulse/rhythm assessment, compressors' rotation, and leader's behaviours. The primary outcome was percentage of events compliant to Pediatric Advance Life Support guidelines. RESULTS: Compliance to guidelines was poor in the 23 simulation events studied. The median [interquartile range] time to start CPR was 29 [16-76] sec and 320 [245-421] sec to deliver the first shock. A total of 306 30-sec epochs of CPR were analyzed; excellent CPR (≥ 90% compressions in target for rate and depth) was achieved in 22 (7%) epochs. More than a quarter of the CPR pauses lasted > 10 seconds (33/127, 26%) with just one task performed in most of them; CCF was ≥ 80% in 19/23 (82.6%) events. Ventilation rate for intubated patients was greater than 10 breaths·min-1 in 15/27 (56%) of one-minute epochs observed. CONCLUSIONS: Review of simulated resuscitation events found suboptimal compliance with resuscitation guidelines, particularly the times to starting CPR and delivering the first shock, as well as compression rate and depth.

RéSUMé: OBJECTIF: Nous avons tenté d'évaluer l'observance des directives de réanimation pendant les arrêts cardiaques pédiatriques simulés dans une unité de soins intensifs pédiatriques (USIP) et d'identifier les écarts de performance afin d'aiguiller la formation future. MéTHODE: Dans une étude observationnelle prospective réalisée au sein d'une USIP, dix scénarios d'arrêt cardiaque ont été élaborés à des fins de formation en réanimation et enregistrés sur vidéo. Les enregistrements vidéo ont été étudiés pour évaluer le délai d'initiation de la réanimation cardiorespiratoire (RCR) et d'administration du premier choc, ainsi que la qualité de la RCR (fréquence, profondeur), la durée des pauses, la fraction des compressions thoraciques (FCT), la ventilation, l'évaluation du pouls/rythme, la rotation des compresseurs et les comportements du leader. Le critère d'évaluation principal était le pourcentage d'événements conformes aux directives de Soins avancés en réanimation pédiatrique (SARP). RéSULTATS: L'observance des directives était faible dans les 23 sessions étudiées. Le temps médian [écart interquartile] était de 29 [16­76] sec avant d'amorcer la RCR et de 320 [245­421] sec avant d'administrer le premier choc. Au total, 306 séquences de 30 sec de RCR ont été analysées; une RCR excellente (≥ 90 % des compressions situées dans la cible de fréquence et de profondeur) a été réalisée dans 22 (7 %) séquences. Plus d'un quart des pauses de RCR ont duré > dix secondes (33/127, 26 %), avec une seule tâche réalisée dans la plupart; la FCT était de ≥ 80 % dans 19/23 (82,6 %) sessions. Chez les patients intubés, la fréquence de ventilation était supérieure à 10 respirations·min-1 dans 15/27 (56 %) des séquences d'une minute observées. CONCLUSION: Le passage en revue des événements de réanimation simulés a décelé une observance sous-optimale des directives de réanimation, particulièrement en ce qui touche au délai de l'initiation de la RCR et du premier choc, ainsi qu'à la fréquence et à la profondeur des compressions.

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report.

OBJECTIVES: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Bedside chest compression skills: Performance and skills retention in in-hospital trained pediatric providers. A simulation study.

PURPOSE: To assess the effects of a real-time feedback device and refresher sessions in acquiring and retaining chest compression skills. METHODS: Healthcare providers participated in refresher sessions at 3-time points (blocks) over 1-year. At each block, chest compression (CC) skills were assessed on an infant and adult task trainer, in one 2-min trial without feedback (blinded), and up to three 2-min trials with feedback (unblinded). Skills retention over time was explored at three time lags: 1-3, 3-6, >6 months. Data collected included chest compression rate (100-120/min), depth (4 cm for infants and 5 cm for adults), and recoil between compressions. RESULTS: Among 194 participants, achievement of excellent CC (≥90% of adequate compressions for all parameters) increased with feedback. Linear mixed models found significant (p < 0.05) improvement in rate, depth, and recoil. Performance between last unblinded trial in block 1 with the following blinded trial in block 2 significantly decayed in rate on both task trainers irrespective of time passed, while depth and recoil performance were maintained only for infants. CONCLUSIONS: A real-time visual feedback device improved CC skills with better results in infants. Skills decayed over time despite two refresher sessions with feedback.

Pediatric sand aspiration managed using bronchoscopy and extracorporeal membrane oxygenation.

Sand aspiration is a rare but potentially fatal occurrence to consider in near-drownings, accidental burials or cave-ins. Optimal management is not well defined.