Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study.

OBJECTIVE: Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN: Secondary analysis of multicenter retrospective cohort study. SETTING: Ten PICUs in the United States between 2009 and 2021. PATIENTS: Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS: Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.

Child Opportunity Index and Pediatric Intensive Care Outcomes: A Multicenter Retrospective Study in the United States.

OBJECTIVES: To evaluate for associations between a child's neighborhood, as categorized by Child Opportunity Index (COI 2.0), and 1) PICU mortality, 2) severity of illness at PICU admission, and 3) PICU length of stay (LOS). DESIGN: Retrospective cohort study. SETTING: Fifteen PICUs in the United States. PATIENTS: Children younger than 18 years admitted from 2019 to 2020, excluding those after cardiac procedures. Nationally-normed COI category (very low, low, moderate, high, very high) was determined for each admission by census tract, and clinical features were obtained from the Virtual Pediatric Systems LLC (Los Angeles, CA) data from each site. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 33,901 index PICU admissions during the time period, median patient age was 4.9 years and PICU mortality was 2.1%. There was a higher percentage of admissions from the very low COI category (27.3%) than other COI categories (17.2-19.5%, p < 0.0001). Patient admissions from the high and very high COI categories had a lower median Pediatric Index of Mortality 3 risk of mortality (0.70) than those from the very low, low, and moderate COI groups (0.71) ( p < 0.001). PICU mortality was lowest in the very high (1.7%) and high (1.9%) COI groups and highest in the moderate group (2.5%), followed by very low (2.3%) and low (2.2%) ( p = 0.001 across categories). Median PICU LOS was between 1.37 and 1.50 days in all COI categories. Multivariable regression revealed adjusted odds of PICU mortality of 1.30 (95% CI, 0.94-1.79; p = 0.11) for children from a very low versus very high COI neighborhood, with an odds ratio [OR] of 0.996 (95% CI, 0.993-1.00; p = 0.05) for mortality for COI as an ordinal value from 0 to 100. Children without insurance coverage had an OR for mortality of 3.58 (95% CI, 2.46-5.20; p < 0.0001) as compared with those with commercial insurance. CONCLUSIONS: Children admitted to a cohort of U.S. PICUs were often from very low COI neighborhoods. Children from very high COI neighborhoods had the lowest risk of mortality and observed mortality; however, odds of mortality were not statistically different by COI category in a multivariable model. Children without insurance coverage had significantly higher odds of PICU mortality regardless of neighborhood.

The Pediatric Data Science and Analytics Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators Network: Use of Supervised Machine Learning Applications in Pediatric Critical Care Medicine Research.

OBJECTIVE: Perform a scoping review of supervised machine learning in pediatric critical care to identify published applications, methodologies, and implementation frequency to inform best practices for the development, validation, and reporting of predictive models in pediatric critical care. DESIGN: Scoping review and expert opinion. SETTING: We queried CINAHL Plus with Full Text (EBSCO), Cochrane Library (Wiley), Embase (Elsevier), Ovid Medline, and PubMed for articles published between 2000 and 2022 related to machine learning concepts and pediatric critical illness. Articles were excluded if the majority of patients were adults or neonates, if unsupervised machine learning was the primary methodology, or if information related to the development, validation, and/or implementation of the model was not reported. Article selection and data extraction were performed using dual review in the Covidence tool, with discrepancies resolved by consensus. SUBJECTS: Articles reporting on the development, validation, or implementation of supervised machine learning models in the field of pediatric critical care medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 5075 identified studies, 141 articles were included. Studies were primarily (57%) performed at a single site. The majority took place in the United States (70%). Most were retrospective observational cohort studies. More than three-quarters of the articles were published between 2018 and 2022. The most common algorithms included logistic regression and random forest. Predicted events were most commonly death, transfer to ICU, and sepsis. Only 14% of articles reported external validation, and only a single model was implemented at publication. Reporting of validation methods, performance assessments, and implementation varied widely. Follow-up with authors suggests that implementation remains uncommon after model publication. CONCLUSIONS: Publication of supervised machine learning models to address clinical challenges in pediatric critical care medicine has increased dramatically in the last 5 years. While these approaches have the potential to benefit children with critical illness, the literature demonstrates incomplete reporting, absence of external validation, and infrequent clinical implementation.

Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data.

OBJECTIVES: To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD). DESIGN: Secondary analysis of data collected for the Death One Hour After Terminal Extubation study. SETTING: Nine U.S. hospitals. PATIENTS: Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010-2021). MEASUREMENTS AND MAIN RESULTS: Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/F io2 ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4-11.0 yr). The median TTD was 15 minutes (IQR, 8-23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3-1.8 mg/kg/hr) ( n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11-0.44 mg/kg/hr) ( n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD. CONCLUSIONS: Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.

The Impact of Strict Public Health Restrictions on Pediatric Critical Illness.

OBJECTIVES: To characterize the impact of public health interventions on the volume and characteristics of admissions to the PICU. DESIGN: Multicenter retrospective cohort study. SETTING: Six U.S. referral PICUs during February 15, 2020-May 14, 2020, compared with the same months during 2017-2019 (baseline). PATIENTS: PICU admissions excluding admissions for illnesses due to severe acute respiratory syndrome coronavirus 2 and readmissions during the same hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was admission volumes during the period of stay-at-home orders (March 15, 2020-May 14, 2020) compared with baseline. Secondary outcomes were hospitalization characteristics including advanced support (e.g., invasive mechanical ventilation), PICU and hospital lengths of stay, and mortality. We used generalized linear mixed modeling to compare patient and admission characteristics during the stay-at-home orders period to baseline. We evaluated 7,960 admissions including 1,327 during March 15, 2020-May 14, 2020. Daily admissions and patients days were lower during the period of stay-at-home orders compared with baseline: median admissions 21 (interquartile range, 17-25) versus 36 (interquartile range, 30-42) (p < 0.001) and median patient days 93.0 (interquartile range, 55.9-136.7) versus 143.6 (interquartile range, 108.5-189.2) (p < 0.001). Admissions during the period of stay-at-home orders were less common in young children and for respiratory and infectious illnesses and more common for poisonings, endocrinopathies and for children with race/ethnicity categorized as other/unspecified. There were no differences in hospitalization characteristics except fewer patients received noninvasive ventilation during the period of stay-at-home orders. CONCLUSIONS: Reductions in PICU admissions suggest that much of pediatric critical illness in younger children and for respiratory and infectious illnesses may be preventable through targeted public health strategies.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study.

OBJECTIVES: To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs. DESIGN: Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017. SETTING: One hundred and seventeen PICUs in the United States. PATIENTS: Patients less than 18 years old admitted with an active diagnosis of burn at admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state. CONCLUSIONS: Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Vascular Access in Critically Ill Pediatric Patients With Obesity.

OBJECTIVES: Pediatric obesity is highly prevalent and has been associated with poor outcomes for hospitalized children. Vascular access is essential in critically ill patients. The aim of this study was to evaluate whether critically ill children with obesity are more likely to undergo vascular device insertion (excluding peripheral IV catheters) and develop related complications. DESIGN: Multi-institutional retrospective observational cohort study. SETTING: Ninety-four U.S. PICUs included in the Virtual Pediatric Systems, LLC database. PATIENTS: 120,272 unique patients 2 to less than 18 years old admitted between January 2009 and December 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized into normal weight, overweight, and obese (class 1, 2, or 3); underweight patients were excluded. We used mixed-effects multivariable logistic regression to test body mass index category as an independent predictor of vascular device placement and associated complications, adjusted for age, sex, severity of illness, primary diagnosis, presence of a complex chronic condition, and admission related to trauma or surgery. A total of 73,964 devices were placed in 45,409 patients (37.8% of the total cohort received a vascular device). Most device types placed differed significantly by weight status. Subjects with class 3 obesity were less likely (odds ratio, 0.74; 95% CI, 0.67-0.81) to undergo placement of any device compared with normal weight patients. Patients with all classes of obesity were more likely to undergo placement of a peripherally inserted central catheter, with the strongest association in those with class 2 obesity (odds ratio, 1.26; 95% CI, 1.14-1.40). Class 1 and class 3 obesity were independent risk factors for developing a complication, with odds ratio of 1.31 (95% CI, 1.11-1.53) and 1.45 (95% CI, 1.07-1.99), respectively. CONCLUSIONS: Severe obesity is associated with decreased overall likelihood of placement of a vascular access device but increased likelihood of peripherally inserted central catheter placement and of device-related complications.

Sudden Cardiac Arrest Due to Hemophagocytic Lymphohistiocytosis in a Child.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation. CASE REPORT: A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function.

Time of Admission to the PICU and Mortality.

OBJECTIVES: To evaluate for any association between time of admission to the PICU and mortality. DESIGN: Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014. SETTING: One hundred and twenty-nine PICUs in the United States. PATIENTS: Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons. CONCLUSIONS: Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

Computerized physician order entry improves compliance with a manual exchange transfusion protocol in the pediatric intensive care unit.

AIM: To evaluate the use of a computerized physician order entry (CPOE) protocol on manual red blood cell (RBC) exchange transfusion in critically ill children with sickle cell disease. METHODS: We conducted a retrospective study of children with sickle cell disease who received a manual RBC exchange transfusion before (2001 to 2008, n=22) and after (2008 to 2009, n=11) implementation of a CPOE protocol. Outcomes included compliance with protocol, percentage reduction in sickle hemoglobin, and peak hemoglobin during exchange. RESULTS: Compliance with the manual exchange protocol improved after introduction of CPOE (pre-CPOE: 20 protocol violations vs. post-CPOE: 3 violations, P=0.02). Percentage reduction in sickle hemoglobin also improved (pre-CPOE: 55% vs. post-CPOE: 70%, P=0.04), whereas peak hemoglobin during RBC exchange was similar (pre-CPOE: 12.0 g/dL vs. post-CPOE: 11.5 g/dL, P=0.25). However, hemoglobin levels after the mean of 7 hours of exchange were significantly higher pre-CPOE (pre-CPOE: 11.5 g/dL vs. post-CPOE: 10.5 g/dL, P=0.006). CONCLUSIONS: Use of CPOE for manual RBC exchange transfusion in children is associated with improved protocol compliance, improved reduction of sickle hemoglobin, and better maintenance of hemoglobin levels in a goal range during prolonged exchanges.

Mechanisms to expedite pediatric clinical trial site activation: The DOSE trial experience.

BACKGROUND: Timely trial start-up is a key determinant of trial success; however, delays during start-up are common and costly. Moreover, data on start-up metrics in pediatric clinical trials are sparse. To expedite trial start-up, the Trial Innovation Network piloted three novel mechanisms in the trial titled Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multi-site, randomized, double-blind, placebo-controlled trial in the pediatric intensive care setting. METHODS: The three novel start-up mechanisms included: 1) competitive activation; 2) use of trial start-up experts, called site navigators; and 3) supplemental funds earned for achieving pre-determined milestones. After sites were activated, they received a web-based survey to report perceptions of the DOSE start-up process. In addition to perceptions, metrics analyzed included milestones met, time to start-up, and subsequent enrollment of subjects. RESULTS: Twenty sites were selected for participation, with 19 sites being fully activated. Across activated sites, the median (quartile 1, quartile 3) time from receipt of regulatory documents to site activation was 82 days (68, 113). Sites reported that of the three novel mechanisms, the most motivating factor for expeditious activation was additional funding available for achieving start-up milestones, followed by site navigator assistance and then competitive site activation. CONCLUSION: Study start-up is a critical time for the success of clinical trials, and innovative methods to minimize delays during start-up are needed. Milestone-based funds and site navigators were preferred mechanisms by sites participating in the DOSE study and may have contributed to the expeditious start-up timeline achieved. CLINICALTRIALS: gov #: NCT03938857.

Nonadherence to appropriate tidal volume and PEEP in children with pARDS at a single center.

BACKGROUND: Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015. OBJECTIVE: To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS. METHODS: Retrospective cohort study of children 1 month to <18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU). RESULTS: At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIO2 was ≥50%, PEEP was appropriate in 19/60 (32%) cases versus 26/26 (100%) with FIO2 < 50% (p < 0.0001). pARDS was documented in the progress note in 7/86 (8%) patients at 24 h. Severity of pARDS, documentation in the progress note, and other clinical factors were not significantly associated with use of appropriate tidal volume and PEEP, however pARDS was documented more commonly in patients with severe pARDS. CONCLUSIONS: In a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO2 ≥ 50%, respectively.

Adenoviral Respiratory Infection-Associated Mortality in Children: A Retrospective Case Series.

Viral respiratory infections are a leading cause of illness and hospitalization in young children worldwide. Case fatality rates in pediatric patients with adenoviral lower respiratory tract infection requiring intensive care unit (ICU) admission have been reported between 7 and 22%. We investigated the demographics and clinical characteristics in pediatric mortalities associated with adenoviral respiratory infection at 12 academic children's hospitals in the United States. There were 107 mortality cases included in our study, 73% of which had a chronic medical condition. The most common chronic medical condition was immunocompromised state in 37 cases (35%). The incidences of pediatric acute respiratory distress syndrome (78%) and multiple organ dysfunction syndrome (94%) were profound. Immunocompetent cases were more likely to receive mechanical ventilation within the first hour of ICU admission (60 vs. 14%, p < 0.001) and extracorporeal membrane oxygenation (27 vs. 5%, p = 0.009), and less likely to receive continuous renal replacement therapy (20 vs. 49%, p = 0.002) or have renal dysfunction (54 vs. 78%, p = 0.014) as compared with immunocompromised cases. Immunocompromised cases were more likely to have bacteremia (57 vs. 16%, p < 0.001) and adenoviremia (51 vs. 17%, p < 0.001) and be treated with antiviral medications (81 vs. 26%, p < 0.001). We observed a high burden of nonrespiratory organ system dysfunction in a cohort of pediatric case fatalities with adenoviral respiratory infection. The majority of cases had a chronic medical condition associated with an increased risk of complications from viral respiratory illness, most notably immunocompromised state. Important treatment differences were noted between immunocompromised and immunocompetent cases.

Associations Between Weight and Lower Respiratory Tract Disease Outcomes in Hospitalized Children.

OBJECTIVE: To identify associations between weight status and clinical outcomes in children with lower respiratory tract infection (LRTI) or asthma requiring hospitalization. METHODS: We performed a retrospective cohort study of 2 to 17 year old children hospitalized for LRTI and/or asthma from 2009 to 2019 using electronic health record data from the PEDSnet clinical research network. Children <2 years, those with medical complexity, and those without a calculable BMI were excluded. Children were classified as having underweight, normal weight, overweight, or class 1, 2, or 3 obesity based on Body Mass Index percentile for age and sex. Primary outcomes were need for positive pressure respiratory support and ICU admission. Subgroup analyses were performed for children with a primary diagnosis of asthma. Outcomes were modeled with mixed-effects multivariable logistic regression incorporating age, sex, and payer as fixed effects. RESULTS: We identified 65 132 hospitalizations; 6.7% with underweight, 57.8% normal weight, 14.6% overweight, 13.2% class 1 obesity, 5.0% class 2 obesity, and 2.8% class 3 obesity. Overweight and obesity were associated with positive pressure respiratory support (class 3 obesity versus normal weight odds ratio [OR] 1.62 [1.38-1.89]) and ICU admission (class 3 obesity versus normal weight OR 1.26 [1.12-1.42]), with significant associations for all categories of overweight and obesity. Underweight was also associated with positive pressure respiratory support (OR 1.39 [1.24-1.56]) and ICU admission (1.40 [1.30-1.52]). CONCLUSIONS: Both underweight and overweight or obesity are associated with increased severity of LRTI or asthma in hospitalized children.

Thrombotic disease in critically ill children.

OBJECTIVES: To summarize a) epidemiology of arterial and venous thromboembolism, pulmonary embolism, and deep venous thrombosis in children; b) the risk factors for thrombosis in the pediatric intensive care unit; c) diagnostic techniques for arterial/venous thromboembolism; and d) the current recommendations for management and prevention of thromboembolic disease in critically ill children. DATA SOURCE: Literature review, using National Library of Medicine PubMed and the following terms: arterial, venous thromboembolism; deep venous thrombosis; pulmonary embolism; thrombosis; as well as citations of interest from these articles. STUDY SELECTION: Both pediatric and adult literature addressing thrombotic disease were reviewed. DATA EXTRACTION AND SYNTHESIS: Articles were chosen for more extensive discussion when containing prospective studies, guidelines for practice, or data in critically ill patients. When data in children were unavailable, applicable data in adults were referenced. Due to the paucity of data in critically ill children, available adult and pediatric data were combined with institutional experience to provide suggestions for current practice and future inquiry. CONCLUSIONS: Increasing awareness regarding the recognition and current approaches to management and prevention of thromboembolic disease in children is needed among pediatric intensivists, so outcome of these life-threatening processes might be improved.

Simulated pediatric resuscitation use for personal protective equipment adherence measurement and training during the 2009 influenza (H1N1) pandemic.

BACKGROUND: Previous experience with simulated pediatric cardiac arrests (that is, mock codes) suggests frequent deviation from American Heart Association (AHA) basic and advanced life support algorithms. During highly infectious outbreaks, acute resuscitation scenarios may also increase the risk of insufficient personal protective equipment (PPE) use by health care workers (HCWs). Simulation was used as an educational tool to measure adherence with PPE use and pediatric resuscitation guidelines during simulated cardiopulmonary arrests of 2009 influenza A patients. METHODS: A retrospective, observational study was performed of 84 HCWs participating in 11 in situ simulations in June 2009. Assessment included (1) PPE adherence, (2) confidence in PPE use, (3) elapsed time to specific resuscitation maneuvers, and (4) deviation from AHA guidelines. RESULTS: Observed adherence with PPE use was 61% for eye shields, 81% for filtering facepiece respirators or powered air-purifying respirators, and 87% for gown/gloves. Use of a "gatekeeper" to control access and facilitate donning of PPE was associated with 100% adherence with gown and respirator precautions and improved respirator adherence. All simulations showed deviation from pediatric basic life support protocols. The median time to bag-valve-mask ventilation improved from 4.3 to 2.7 minutes with a gatekeeper present. Rapid isolation carts appeared to improve access to necessary PPE. Confidence in PPE use improved from 64% to 85% after the mock code and structured debriefing. CONCLUSIONS: Large gaps exist in the use of PPE and self-protective behaviors, as well as adherence to resuscitation guidelines, during simulated resuscitation events. Intervention opportunities include use of rapid isolation measures, use of gatekeepers, reinforcement of first responder roles, and further simulation training with PPE.

Weight Status and Risk of Inpatient Admission for Children With Lower Respiratory Tract Disease.

OBJECTIVES: To identify associations between weight category and hospital admission for lower respiratory tract disease (LRTD), defined as asthma, community-acquired pneumonia, viral pneumonia, or bronchiolitis, among children evaluated in pediatric emergency departments (PEDs). METHODS: We performed a retrospective cohort study of children 2 to <18 years of age evaluated in the PED at 6 children's hospitals within the PEDSnet clinical research network from 2009 to 2019. BMI percentile of children was classified as underweight, healthy weight, overweight, and class 1, 2, or 3 obesity. Children with complex chronic conditions were excluded. Mixed-effects multivariable logistic regression was used to assess associations between BMI categories and hospitalization or 7- and 30-day PED revisits, adjusted for covariates (age, sex, race and ethnicity, and payer). RESULTS: Among 107 446 children with 218 180 PED evaluations for LRTD, 4.5% had underweight, 56.4% had healthy normal weight, 16.1% had overweight, 14.6% had class 1 obesity, 5.5% had class 2 obesity, and 3.0% had class 3 obesity. Underweight was associated with increased risk of hospital admission compared with normal weight (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.69-1.84). Overweight (OR 0.87; 95% CI 0.85-0.90), class 1 obesity (OR 0.88; 95% CI 0.85-0.91), and class 2 obesity (OR 0.91; 95% CI 0.87-0.96) had negative associations with hospital admission. Class 1 and class 2, but not class 3, obesity had small positive associations with 7- and 30-day PED revisits. CONCLUSIONS: We found an inverse relationship between patient weight category and risk for hospital admission in children evaluated in the PED for LRTD.

Predictors of need for mechanical ventilation at discharge after tracheostomy in the PICU.

BACKGROUND: The objective of this study was to determine factors predictive of need for mechanical ventilation (MV) upon discharge from the pediatric intensive care unit (PICU) among patients who receive a tracheostomy during their stay. METHODS: This was a retrospective cohort study using the Virtual PICU Systems (VPS) database. Patients <18 years old admitted between 2009-2011 who required MV for at least 3 days and received a tracheostomy during their PICU stay were included. RESULTS: A total of 680 pediatric patients from 74 PICUs were included, of whom 347 (51%) remained on MV at the time of PICU discharge. Neonates (30/38, 79%) and infants (129/203, 64%) required MV at PICU discharge after tracheostomy more often than adolescents (66/141, 47%) and children (122/298, 41%). Time on MV pre-tracheostomy was longer among those who required MV at discharge (median 18.3 vs. 13.8 days, P < 0.0001); however, number of failed extubations was similar (median 1 for both groups, P = 0.97). On mixed-effects multivariable regression analysis, the age categories of neonate (OR 2.9, 95%CI 1.1-7.6, P = 0.03), and infant (OR 1.7, 95%CI 1.1-2.8, P = 0.03), and ventilator days prior to tracheostomy (OR 1.01, 95%CI 1.0-1.02, P = 0.01) were significantly associated with increased odds of MV upon PICU discharge, while being a trauma admission was associated with decreased odds (OR 0.45, 95%CI 0.28-0.73, P = 0.001). CONCLUSIONS: Younger patients and those with prolonged courses of MV prior to tracheostomy are more likely to continue to need MV upon PICU discharge.