Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation.

BACKGROUND: Inflammatory and endothelial activation responses during extracorporeal membrane oxygenation (ECMO) support in children are poorly understood. In this study, we aimed to determine if circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and with neurologic outcomes in children on ECMO. METHODS: We conducted a secondary analysis of a two-center prospective observational study of 99 neonatal and pediatric ECMO patients. Inflammatory (interferon gamma [IFNγ], interleukin-6 [IL-6], IL-1ß, tumor necrosis factor alpha [TNFα]), endothelial activation (E-selectin, P-selectin, intercellular adhesion molecule-3 [ICAM-3], thrombomodulin [TM]), and fibrinolytic markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1]) were measured in plasma on days 1, 2, 3, 5, 7, and every third day thereafter during the ECMO course. RESULTS: All ECMO day 1 inflammatory biomarkers were significantly elevated in children with abnormal vs. normal neuroimaging. ECMO day 1 and peak levels of IL-6 and PAI-1 were significantly elevated in children who died compared to those who survived to hospital discharge. Tested biomarkers showed no significant association with long-term neurobehavioral outcomes measured using the Vineland Adaptive Behavioral Scales, Second Edition. CONCLUSIONS: High levels of circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and abnormal neuroimaging in children on ECMO. IMPACT: The inflammatory, endothelial activation, and fibrinolytic profile of children on ECMO differs by primary indication for extracorporeal support. Proinflammatory biomarkers on ECMO day 1 are associated with abnormal neurologic imaging in children on ECMO in univariable but not multivariable models. In multivariable models, a pronounced proinflammatory and prothrombotic biomarker profile on ECMO day 1 and longitudinally was significantly associated with mortality. Further studies are needed to identify inflammatory, endothelial, and fibrinolytic profiles associated with increased risk for neurologic injury and mortality through potential mediation of bleeding and thrombosis.

Pediatric Safety Restraint Use in Motor Vehicle Crashes at a Level I Safety-Net Trauma Center.

BACKGROUND: Adherence to child passenger safety recommendations is essential to prevent death and injury in children involved in motor vehicle crashes. Parents may not undertake the proper safety measures, which can lead to increase injury. METHODS: A safety net, level I trauma center's database was used to identify admitted children (age<15 y/o) involved in motor vehicle crashes over a 2-y period to investigate safety restraint device use and compliance with state recommendations. Variables evaluated were crash characteristics, presence and method of passenger restraint, demographics, Glasgow Coma Scale, and Injury Severity Score. Excluded were patients where restraint characteristics could not be identified and those discharged from the trauma center. RESULTS: Eighty patients met inclusion criteria. Thirty-two (40%) children were unrestrained. Safety restraint device was noted in 48 (60%) children with 13 (27.1%) patients improperly restrained. The most common method of improper restraint (6, 46.2%) was traveling in the front seat before the age state law recommends. With respect to proper, improper, and no restraint, age (7.31 ± 14.26, 5.76 ± 3.24, P = 0.36), female sex (17, 8, 13, P = 0.32), low-income status (14, 5, 24, P = 0.28), and race (P = 0.08) did not differ between the groups. The unrestrained children had statistically lower initial Glasgow Coma Scale and higher Injury Severity Score and were more often involved in high-risk mechanism of Injury motor vehicle crashes. CONCLUSIONS: Despite recommendations and regulations regarding child passenger safety measures, there are a significant number of children that remain suboptimally restrained who are admitted to a safety-net trauma center. Further research is needed to understand the barriers to increase the compliance with recommendations along with targeted educational campaigns in low-compliance populations.

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

OBJECTIVES: To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. DESIGN: Single-center, prospective, observational trial. SETTING: Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. PATIENTS: Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. CONCLUSIONS: On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

Anesthetic considerations for magnetic resonance imaging-guided right-heart catheterization in pediatric patients: A single institution experience.

Cardiac catheterization is an integral part of medical management for pediatric patients with congenital heart disease. Owing to age and lack of cooperation in children who need this procedure, general anesthesia is typically required. These patients have increased anesthesia risk secondary to cardiac pathology. Furthermore, multiple catheterization procedures result in exposure to harmful ionizing radiation. Magnetic resonance imaging-guided right-heart catheterization offers decreased radiation exposure and diagnostic imaging benefits over traditional fluoroscopy but potentially increases anesthetic complexity and risk. We describe our early experience with anesthetic techniques and challenges for pediatric magnetic resonance imaging-guided right-heart catheterization.

Comparison of Pediatric Cardiopulmonary Resuscitation Quality in Classic Cardiopulmonary Resuscitation and Extracorporeal Cardiopulmonary Resuscitation Events Using Video Review.

OBJECTIVES: To assess differences in cardiopulmonary resuscitation quality in classic cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation events using video recordings of actual pediatric cardiac arrest events. DESIGN: Single-center, prospective, observational trial. SETTING: Tertiary-care pediatric teaching hospital, cardiac ICU. PATIENTS: All patients admitted to the pediatric cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventeen events comprising 264.5 minutes of cardiopulmonary resuscitation were included: 11 classic cardiopulmonary resuscitation events (87.5 min) and six extracorporeal cardiopulmonary resuscitation events (177 min). Events were divided into 30-second epochs, and cardiopulmonary resuscitation quality markers were assessed using video and telemetry data review of goal endpoints: end-tidal carbon dioxide greater than or equal to 15 mm Hg, diastolic blood pressure greater than or equal to 30 mm Hg, chest compression fraction greater than 80% per epoch, and chest compression rate between 100 and 120 chest compression per minute. Additionally, each chest compression pause (hands-off event) was recorded and timed. When compared with extracorporeal cardiopulmonary resuscitation, classic cardiopulmonary resuscitation epochs were more likely to have end-tidal carbon dioxide greater than or equal to 15 mm Hg (56% vs 6.2%; p = 0.01) and provide chest compression between 100 and 120 times per minute (112 vs 134 chest compression per minute; p < 0.001). No difference was found between classic cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation in compliance with diastolic blood pressure greater than or equal to 30 mm Hg (38% classic cardiopulmonary resuscitation vs 30% extracorporeal cardiopulmonary resuscitation). There were 135 hands-off events: 52 in classic cardiopulmonary resuscitation and 83 in extracorporeal cardiopulmonary resuscitation (p = 0.12). CONCLUSIONS: Classic cardiopulmonary resuscitation had superior adherence to end-tidal carbon dioxide goals and chest compression rate guidelines than extracorporeal cardiopulmonary resuscitation.

Can Telemedicine Improve Adherence to Resuscitation Guidelines for Critically Ill Children at Community Hospitals? A Randomized Controlled Trial Using High-Fidelity Simulation.

OBJECTIVES: Children transferred from community hospitals lacking specialized pediatric care are more seriously ill than those presenting to pediatric centers. Pediatric consultation and adherence to management guidelines improve outcomes. The aims of the study were (1) to assess whether telemedicine consultation in critical situations is feasible and (2) to compare the impact of pediatric critical care medicine (PCCM) consultation via telemedicine versus telephone on community hospital adherence to resuscitation guidelines through a randomized controlled telemedicine trial. METHODS: In situ, high-fidelity simulation scenarios of critically ill children presenting to a community hospital and progressing to cardiopulmonary arrest were performed. Scenarios were randomized to PCCM consultation via telephone (control) or telemedicine (intervention). Primary outcome measure was proportion of teams who successfully defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia. RESULTS: The following 30 scenarios were completed: 15 control and 15 intervention. Only 11 (37%) of 30 teams, defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia; control: 6 (40%) of 15 versus intervention: 5 (33%) of 15, P = 0.7. Request for or use of backboard during cardiopulmonary resuscitation occurred in 24 (80%) of 30 scenarios; control: 9 (60%) of 15 versus intervention: 15 (100%) of 15, P = 0.006. Request for or use of stepstool during cardiopulmonary resuscitation occurred in 6 (20%) of 30 scenarios; control: 1 (7%) of 15 versus intervention: 5 (33%) of 15, P = 0.07. CONCLUSIONS: This study demonstrates the feasibility of using telemedicine to support acute management of children who present to community hospitals. Neither study arm adhered to current resuscitation guidelines and telemedicine consultation with PCCM experts was not associated with improvement. However, further research on optimizing telemedicine impact on the quality of pediatric care at community hospitals is warranted.

Risk assessment and anesthetic management of patients with Williams syndrome: a comprehensive review.

Since the first description in 1961, several case reports have documented an increased incidence of anesthesia-related cardiac arrest in patients with Williams-Beuren syndrome, commonly known as Williams syndrome (WS). Widespread arteriopathy secondary to an elastin gene defect results in various cardiac defects, including supravalvar aortic stenosis (SVAS) and coronary artery anomalies, which can increase the risk of myocardial ischemia. Even though patients with WS are known to have increased risk of adverse events during anesthesia and sedation, they often undergo several procedures that require anesthesia during their lifetimes, and cases of perianesthetic cardiac arrest continue to be reported. To date, no prospective studies have been reported that quantify anesthetic risk in individual patients with WS. In this article, we review the clinical manifestations of WS, propose a consensus, expert-informed method to estimate anesthetic risk based on the current literature, and provide recommendations for periprocedural management of this patient population.

Acute Renal and Hepatic Failure in an Adolescent: An Unusual Presentation of Multiple Aortic Aneurysms.

Aortic dissection secondary to thoracoabdominal aortic aneurysms is very uncommon in children, and this life-threatening diagnosis requires a high clinical index of suspicion. Unlike adults, in whom atherosclerosis, inflammation, and advanced age are typically contributing factors, aortic dissection in children is usually due to nonatherosclerotic causes.Aortic aneurysms can be asymptomatic when small but, when significantly enlarged, can compromise organ function and dissect, resulting in high mortality rates. It is therefore critical that children with this uncommon condition be identified early when medical or surgical management can potentially improve outcome. We describe a 15-year-old patient with multiple aortic aneurysms with dissection whose presentation includes chronic anemia, acute-on-chronic renal failure with hyperkalemia, and liver injury.

Glial fibrillary acidic protein in children with congenital heart disease undergoing cardiopulmonary bypass.

OBJECTIVE: To determine whether blood levels of the brain-specific biomarker glial fibrillary acidic protein rise during cardiopulmonary bypass for repair of congenital heart disease. METHODS: This is a prospective observational pilot study to characterise the blood levels of glial fibrillary acidic protein during bypass. Children <21 years of age undergoing bypass for congenital heart disease at Johns Hopkins Hospital and Texas Children's Hospital were enrolled. Blood samples were collected during four phases: pre-bypass, cooling, re-warming, and post-bypass. RESULTS: A total of 85 patients were enrolled between October, 2010 and May, 2011. The median age was 0.73 years (range 0.01-17). The median weight was 7.14 kilograms (range 2.2-86.5). Single ventricle anatomy was present in 18 patients (22%). Median glial fibrillary acidic protein values by phase were: pre-bypass: 0 ng/ml (range 0-0.35); cooling: 0.039 (0-0.68); re-warming: 0.165 (0-2.29); and post-bypass: 0.112 (0-0.97). There were significant elevations from pre-bypass to all subsequent stages, with the greatest increase during re-warming (p = 0.0001). Maximal levels were significantly related to younger age (p = 0.03), bypass time (p = 0.03), cross-clamp time (p = 0.047), and temperature nadir (0.04). Peak levels did not vary significantly in those with single ventricle anatomy versus two ventricle repairs. CONCLUSION: There are significant increases in glial fibrillary acidic protein levels in children undergoing cardiopulmonary bypass for repair of congenital heart disease. The highest values were seen during the re-warming phase. Elevations are significantly associated with younger age, bypass and cross-clamp times, and temperature nadir. Owing to the fact that glial fibrillary acidic protein is the most brain-specific biomarker identified to date, it may act as a rapid diagnostic marker of brain injury during cardiac surgery.

A survey of anesthesiologists' knowledge of American Heart Association Pediatric Advanced Life Support Resuscitation Guidelines.

AIM OF STUDY: Determine anesthesiologists' knowledge of the 2005 American Heart Association (AHA) Pediatric Advanced Life Support (PALS) recommendations. METHODS: After obtaining institutional review board approval, a survey was sent in February 2007 to members of the Society for Pediatric Anesthesia via a web-based survey tool, and re-sent to nonresponders five times over the following 7 months. RESULTS: Overall response rate was 51% (389/768 members). Eighty-five percent of respondents had pediatric anesthesia fellowships, 71% provided anesthesia primarily to children, 71% had been in practice >10 years, 29% had PALS or APLS training during the previous year, and 37% had a patient requiring chest compressions in the previous year. Overall, 89% of respondents knew the correct initial dose of epinephrine (adrenaline) for asystole, 44% knew subsequent management for asystole if initial epinephrine dose was ineffective, 49% knew defibrillation sequence to treat pulseless ventricular tachycardia (VT), and 73% knew the medication sequence to treat pulseless VT. Only those respondents who reported to be in practice for >10 years scored significantly (p<0.0001) better on all resuscitation treatment questions. Respondents who had PALS or APLS training in the previous year or previous 2 years scored significantly better on the defibrillation sequence for pulseless VT (p=0.001 and p=0.045, respectively), and the medication sequence for pulseless VT (p=0.0005 and p=0.011, respectively) when compared with those who had no previous training. CONCLUSION: Deficiencies exist in the knowledge of current AHA PALS guidelines among anesthesiologists. Formal resuscitation training programs should be considered in ongoing continuing medical education.

The daily goals communication sheet: a simple and novel tool for improved communication and care.

This tool directs the health care team to discuss specific goals of care and best-practice safety measures daily for each patient and to ensure goal understanding and implementation.

Early Perioperative Management After Pediatric Cardiac Surgery: Review at PCICS 2014.

The sessions of the symposium held in December 2014 allow us to capitalize on the shared knowledge and experience that arise from both cardiac anesthesia and cardiac intensive care. During this session, topics that crossed traditional boundaries of pediatric cardiac intensive care and pediatric cardiac anesthesia were presented and discussed. This article summarizes the five topics presented at the symposium.

Anticoagulation monitoring during pediatric extracorporeal membrane oxygenation.

The best method of monitoring anticoagulation during extracorporeal membrane oxygenation (ECMO) is unknown. We conducted a prospective observational study in a tertiary pediatric intensive care unit. Antifactor Xa, antithrombin (AT), and factor VIII activity (FVIII) were measured in blood samples collected at 6, 12, and every 24 hours, respectively, of ECMO. We enrolled 34 children who underwent 35 ECMO runs from April 2008 to September 2010. Activated clotting time (ACT) and heparin doses were higher, whereas antifactor Xa levels were lower in neonates compared to infants/children. Median antifactor Xa was 0.4 IU/ml, median AT was 60%, and median FVIII was 67%. Heparin infusion rate, antifactor Xa, and antithrombin (AT) increased, FVIII was stable, and ACT decreased with each day on ECMO. ACT had poor agreement with antifactor Xa (42%). AT was inversely correlated with ACT (r = -0.33), even after adjusting for heparin dose, and positively correlated with antifactor Xa (r = 0.57). This study emphasizes the age differences as well as the variability over days of coagulation monitoring assays during ECMO. ACT is poorly correlated with antifactor Xa and AT modifies the relationship between ACT and the heparin dose, indicating that results should be interpreted with caution when managing anticoagulation on ECMO. Additional studies are warranted to determine optimal ECMO anticoagulation monitoring.

Inhaled epoprostenol therapy for pulmonary hypertension: Improves oxygenation index more consistently in neonates than in older children.

The purpose of this study was to determine the efficacy of inhaled epoprostenol for treatment of acute pulmonary hypertension (PH) in pediatric patients and to formulate a plan for a prospective, randomized study of pulmonary vasodilator therapy in this population. Inhaled epoprostenol is an effective treatment for pediatric PH. A retrospective chart review was conducted of all pediatric patients who received inhaled epoprostenol at a tertiary care hospital between October 2005 and August 2007. The study population was restricted to all patients under 18 years of age who received inhaled epoprostenol for greater than 1 hour and had available data for oxygenation index (OI) calculation. Arterial blood gas values and ventilator settings were collected immediately prior to epoprostenol initiation, and during epoprostenol therapy (as close to 12 hours after initiation as possible). Echocardiograms were reviewed during two time frames: Within 48 hours prior to therapy initiation and within 96 hours after initiation. Of the 20 patients in the study population, 13 were neonates, and the mean OI for these patients improved during epoprostenol administration (mean OI before and during therapy was 25.6±16.3 and 14.5±13.6, respectively, P=0.02). Mean OI for the seven patients greater than 30 days of age was not significantly different during treatment (mean OI before and during therapy was 29.6±15.0 and 25.6±17.8, P=0.56). Improvement in echocardiographic findings (evidence of decreased right-sided pressures or improved right ventricular function) was demonstrated in 20% of all patients. Inhaled epoprostenol is an effective therapy for the treatment of selected pediatric patients with acute PH. Neonates may benefit more consistently from this therapy than older infants and children. A randomized controlled trial is needed to discern the optimal role for inhaled prostanoids in the treatment of acute PH in childhood.

Use of the Laryngeal Mask Airway-Aintree Intubating Catheter-fiberoptic bronchoscope technique for difficult intubation.

STUDY OBJECTIVE: To determine whether intubation using an Aintree Intubation Catheter (AIC), fiberoptic intubation (FOB), and Laryngeal Mask Airway (LMA) is safe and effective for securing the airway in patients who are difficult to intubate after induction of general anesthesia. DESIGN: Retrospective review of departmental difficult airway database procedures completed between July 2006 and December 2009. SETTING: Academic medical center. MEASUREMENTS AND MAIN RESULTS: During the study period, 128 of 500 patients entered into the difficult airway database underwent the LMA-AIC-FOB technique for intubation. One hundred nineteen (93%) of the 128 patients were successfully intubated by the LMA-AIC-FOB technique, and 9 required an alternate technique. No patient who underwent the LMA-AIC-FOB technique experienced an airway-related mortality or required an emergency surgical airway procedure. CONCLUSION: The LMA-AIC-FOB technique is safe and effective for patients who are difficult to intubate after induction of anesthesia.