Methylprednisolone dosing for pediatric critical asthma: a single-center cohort study.

Objective: We aimed to characterize intravenous (IV) methylprednisolone (MP) dosing regimens and clinical outcomes for children hospitalized for critical asthma (CA).Methods: A single-center, retrospective review was performed of children admitted to the pediatric intensive care unit (PICU) for CA between September 2015 and October 2019. Patients 5 to 17 years old, initiated on continuous nebulized albuterol, and prescribed at least one dose of IV MP were included. The primary outcome was to characterize PICU MP dosing. Cohorts were then compared by MP dosing: conservative-dose methylprednisolone (CDMP, < 0.5 mg/kg/dose every 6 hours) and standard-dose methylprednisolone (SDMP, > 0.5 mg/kg/dose every 6 hours). Clinical efficacy endpoints were duration of continuous nebulized albuterol and PICU length of stay (LOS). Safety endpoints included corticosteroid-related adverse events.Results: Of 168 children studied, 50 (29.8%) were prescribed CDMP and 118 (70.2%) SDMP. The overall mean MP dose was 31.3 ± 19.6 mg (weight-adjusted: 0.77 ± 0.32 mg/kg/dose). Compared to those prescribed SDMP, those prescribed CDMP had a shorter median duration of continuous nebulized albuterol (12.8 [IQR: 10.5-20] versus 17.3 [IQR: 11.3-29.7] hours, p = 0.019) and median PICU LOS (0.9 [IQR: 0.7-1.4] versus 1.2 [IQR: 0.9-1.8] days, p = 0.012). No corticosteroid-related adverse events were observed. In adjusted models, weight-adjusted IV MP dose was not associated with PICU LOS or duration of continuous nebulized albuterol.Conclusions: Intravenous MP dosing for pediatric CA varied widely in our study sample. Prospective, controlled trials are required to validate our observations including clinical efficacy and safety endpoints.

Vitamin K Prescribing Trends Among Critically Ill Children Hospitalized for Sepsis: A Multicenter Observational Cohort Study.

Objective: Vitamin K (VK) is commonly prescribed for pediatric sepsis-induced coagulopathy without trial-derived evidence to support its use for this indication. The purpose of this study was to characterize national prescribing trends for VK in this population. Patients and Methods: This is a multicenter retrospective cohort study using the Pediatric Health Information System registry including children 0 to 17 years of age hospitalized for sepsis in the pediatric intensive care unit from January 2016 through December 2022. The primary outcome was overall, annual, and center-specific VK prescribing rates. Descriptive data included demographics, length of stay, and rates of VK deficiency, hepatic insufficiency, red blood cell (RBC) transfusion, venous thromboembolism (VTE), and mortality. VK prescribing trends were assessed using Joinpoint regression. Descriptive statistics employed included Wilcoxon rank-sum, student's t, and chi-square tests. Results: Of the 31 221 encounters studied, 4539 (14.6%) were prescribed VK (median center-specific rate: 14.2%; interquartile range [IQR]: 8.8-21%) with a linear annual trend decreasing from 17.3% in 2016 to 13.3% in 2022 (-0.6%/year, r2 = .661). Those prescribed VK had greater rates of hepatic dysfunction (20.5% vs 3.1%), RBC transfusion (26.5% vs 11.2%), VTE (12.5% vs 4.6%), mortality (17.1% vs 4.4%), and median length of stay (16 [IQR: 8-33] vs 8 [4-15] days) (all P < .001). VK deficiency was diagnosed in 0.2% of encounters. Conclusions: In this multicenter retrospective cohort, VK prescribing was common among critically ill children diagnosed with sepsis. Phased trials are needed to demonstrate clinical efficacy and safety for VK in this population.

Hospital-Acquired Venous Thromboembolism and Invasive Mechanical Ventilation: A Report From the Children's Hospital Acquired Thrombosis Consortium.

OBJECTIVES: To determine if the duration of invasive mechanical ventilation (IMV) was associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children. DESIGN: A multicenter, matched case-control study as a secondary analysis of Children's Hospital Acquired Thrombosis (CHAT) Consortium registry. SETTING: PICUs within U.S. CHAT Consortium participating centers. PATIENTS: Children younger than 21 years old admitted to a PICU receiving IMV for greater than or equal to 1 day duration from January 2012 to March 2022 were included for study. Cases with HA-VTE were matched 1:2 to controls without HA-VTE by patient age groups: younger than 1, 1-12, and older than 12 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was IMV duration in days. Descriptive data included demographics, anthropometrics, HA-VTE characteristics (i.e., type, location, and timing), central venous catheterization data, thromboprophylaxis practices, and Braden Q mobility scores. Descriptive, comparative, and associative (multivariate conditional logistic regression for HA-VTE) statistics were employed. A total of 152 cases were matched to 304 controls. Cases with HA-VTE were diagnosed at a median of 7 days (interquartile range [IQR], 3-16 d) after IMV. The HA-VTE were limb deep venous thromboses in 130 of 152 (85.5%) and frequently central venous catheterization-related (111/152, 73%). Cases with HA-VTE experienced a longer length of stay (median, 34 d [IQR, 18-62 d] vs. 11.5 d [IQR, 6-21 d]; p < 0.001) and IMV duration (median, 7 d [IQR, 4-15 d] vs. 4 d [IQR, 1-7 d]; p < 0.001) as compared with controls. In a multivariate logistic model, greater IMV duration (adjusted odds ratio, 1.09; 95% CI, 1.01-1.17; p = 0.023) was independently associated with HA-VTE. CONCLUSIONS: Among critically ill children undergoing IMV, HA-VTE was associated with greater IMV duration. If prospectively validated, IMV duration should be included as part of prothrombotic risk stratification and future pediatric thromboprophylaxis trials.

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.

High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study.

INTRODUCTION: We aimed to describe patient characteristics and clinical outcomes for children hospitalized for status asthmaticus (SA) receiving high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). METHODS: We performed a single center, retrospective cohort study among 39 children admitted for SA aged 5-17 years from January 2016 to May 2019 to a quaternary pediatric intensive care unit (PICU). Cohorts were defined by BiPAP versus HFNC exposure and assessed to determine if differences existed in demographics, anthropometrics, comorbidities, asthma severity indices, historical factors, duration of noninvasive ventilation, and asthma-related clinical outcomes (i.e. length of stay, mechanical ventilation rates, exposure to concurrent sedatives/anxiolysis, and rate of adjunctive therapy exposure). RESULTS: Thirty-three percent (n = 13) received HFNC (33%) and 67% (n = 26) BiPAP. Children receiving BiPAP had greater age (10.9 ± 3.7 vs. 6.8 ± 2.2 years, P < 0.01), asthma severity (proportion with severe NHLBI classification: 38% vs. 0%, P < 0.01; median pediatric asthma severity score: 13[12,14] vs. 10[9,12], P < 0.01), previous PICU admissions (62% vs. 15%, P = 0.01), frequency of prescribed anxiolysis/sedation (42% vs. 8%, P = 0.02), and median duration of continuous albuterol (1.7[1,3.1] vs. 0.9[0.7,1.6] days, P = 0.03) compared to those on HFNC. Those on HFNC more commonly were treated comorbid bacterial pneumonia (69% vs. 19%, P < 0.01). No differences in NIV duration, mortality, mechanical ventilation rates, or LOS were observed. CONCLUSIONS: Our data suggest a trial of BiPAP or HFNC appears well tolerated in children with SA. Prospective trials are needed to establish modality superiority and identify patient or clinical characteristics that prompt use of HFNC over BiPAP.

Heliox for Pediatric Critical Asthma: A Multicenter, Retrospective, Registry-Based Descriptive Study.

BACKGROUND: In cases of critical asthma (CA), heliox may be applied as an adjunctive rescue therapy to avoid invasive mechanical ventilation (MV), improve deposition of aerosolized medications, and enhance laminar airflow through obstructed airways. Using the Pediatric Health Information System (PHIS) registry, we evaluate heliox prescribing and explored for differences in MV rates and hospital length of stay (LOS) among children with and without heliox exposure. METHODS: We performed a retrospective cohort study using PHIS data from 42 pediatric intensive care units among children 5-17 years of age admitted for CA from 2010 through 2019. Primary outcomes were heliox prescribing rates and trends. Secondary outcomes were invasive MV rates and LOS assessed in a subgroup of children receiving ≥ 1 adjunctive intervention(s). RESULTS: Of the 19,780 studied, heliox was prescribed in 12.5% and linearly declined from 16.1% in 2010 to 5.6% in 2019. The overall MV rate was 12.8% and was lower in subjects receiving heliox alone (4.9%) compared to heliox plus alternative adjunctive therapies [31.2%] or children receiving non-heliox adjunctive therapies [22.1%], P < .01). Accounting for MV, no difference in LOS was observed. In exploratory adjusted models, MV free hospitalization was associated with heliox-only exposure (OR: 0.33, 95% CI: 0.17-0.63, P < .01) and exposure to multiple adjunctive therapies was associated with MV (OR: 2.48, 95% CI: 1.56-3.94, P < .01). CONCLUSIONS: In this multicenter retrospective study from 42 children's hospitals, heliox prescribing for CA declined over the last decade. Subjects receiving multiple adjunctive therapies more commonly required invasive MV perhaps indicating a greater severity of illness. At this time, prospective trials needed to identify the role of heliox for pediatric CA.

Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive Study.

BACKGROUND: Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma. METHODS: We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay. RESULTS: Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R2 = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia. CONCLUSIONS: In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.

Venous Thromboembolism among Critically Ill Children: A Narrative Review.

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality among hospitalized patients, including children. In recent years, it has become clear that hospitalization and critical illness bestow an increased VTE risk in pediatrics and relate to mortality and life-limiting comorbidities. For critically ill children, reported rates of VTE vary by study sampling techniques, presence of inherited or acquired thrombophilia, acute and chronic immobility, underlying illness prompting hospitalization, and clinical factors related to illness severity such as central venous catheterization, length of stay, mechanical ventilation, and patient age. Accordingly, critically ill children with new signs of venous congestion, acute inflammation, or unexplained acute organ dysfunction should be routinely evaluated for VTE. This narrative review summarizes recent and historical literature regarding risk factors, prevention, presentation, treatment, and outcomes of VTE in critically ill children. In addition, we identify knowledge gaps and priorities for future collaborative research on this vital condition. Special attention is given to the clinical trial opportunities, challenges, and ongoing efforts in thromboprophylaxis in critically ill children, including those hospitalized for disease related to novel coronavirus (COVID-19) and multisystem inflammatory disease in children.

Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus.

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

Standardized Work Rounds Enhance Teaming, Comprehensiveness, Shared Mental Model Development, and Achievement Rate of End-of-Shift Goals.

OBJECTIVES: To determine the impact of standardized PICU work rounds on the frequency of ideal teaming behaviors, rounds comprehensiveness, shared mental model index development, and rate of completed end-of-shift goals. DESIGN: A single-center, pre-post, prospective cohort study. SETTING: A 259-bed, quaternary, pediatric referral center. PATIENTS: Children 0-18 years old from November 2018 to January 2020. INTERVENTIONS: Standardized, bedside, nurse-led PICU work rounds, emphasizing ideal teaming behaviors using a collaboratively developed rounding script and quality/safety checklist. MEASUREMENTS AND MAIN RESULTS: Study data were collected by direct observation and immediate postrounds participant questionnaire data. Primary outcomes were frequency of observed ideal teaming behaviors, rounds comprehensiveness, efficiency (rounds content divided by duration), shared mental model index (congruence among rounds participants regarding key healthcare data and planning), rounds face validity, and achievement rate of rounds-established, end-of-shift goals. During study, 154 encounters were observed (50 preintervention, 52 after Plan-Do-Study-Act cycle 1, and 52 after Plan-Do-Study-Act cycle 2). We observed improvements in overall shared mental model index (24-87%), rounds comprehensiveness (72-98%), and ideal teaming behaviors (including closed-loop communication: 82-100%; responsibility delegation: 74-100%; interdependence behaviors: 26-98%, all p < 0.01) by the end of study. Nursing presentations accounted for 3.6 ± 1.5 minutes of rounds and rounds duration was unchanged postintervention (11 ± 5 min preintervention and 11 ± 4 min after Plan-Do-Study-Act cycle 2, p > 0.99). Face validity, assessed using questionnaire data from 953 participants, revealed positive attitudes regarding efficiency, clarity, and participant self-value. Greatest enhancements in self-value were noted among advanced practice providers and respiratory therapists. On exploratory modeling, we noted associations between ideal teaming behaviors, rounds comprehensiveness, and shared mental model index. Similarly, we noted a positive association between the shared mental model index and the rate of achieved rounds-established, end-of-shift goals (odds ratio, 8.9; 95% CI, 1.7-46; p < 0.01). CONCLUSIONS: Standardization of PICU work rounds may encourage ideal teaming behaviors, enhance rounds comprehensiveness, strengthen the congruence of participant shared mental model, and affect the rate of achieved goals established during rounds without compromising workplace efficiency.

Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome.

OBJECTIVES: Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates. DESIGN: Single-center, retrospective cohort study. SETTING: A total of 259-bed, quaternary, pediatric referral center. PATIENTS: Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04). CONCLUSIONS: Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.

Volatile anesthetic agents for life-threatening pediatric asthma: A multicenter retrospective cohort study and narrative review.

BACKGROUND: Volatile anesthetic agents are described as rescue therapy for children invasively ventilated for critical asthma. Yet, data are currently limited to case series. AIMS: Using the Virtual Pediatric Systems database, we assessed children admitted to a pediatric intensive care unit invasively ventilated for life-threatening asthma and hypothesized ventilation duration and mortality rates would be lower for subjects exposed to volatile anesthetics compared with those without exposure. METHODS: We performed a multicenter retrospective cohort study among nine institutions including children 5-17 years of age invasively ventilated for asthma from 2013 to 2019 with and without exposure to volatile anesthetics. Primary outcomes were ventilation duration and mortality. Secondary outcomes included patient characteristics, length of stay, and anesthetic-related adverse events. A subgroup analysis was performed evaluating children intubated ≥2 days. RESULTS: Of 203 children included in study, there were 29 (14.3%) with and 174 (85.7%) without exposure to volatiles. No differences in odds of mortality (1.1, 95% CI: 0.3-3.9, p > .999) were observed. Subjects receiving volatiles experienced greater median difference in length of stay (4.8, 95% CI: 1.9-7.8 days, p < .001), ventilation duration (2.3, 95% CI: 1-3.3 days, p < .001), and odds of extracorporeal life support (9.1, 95% CI: 1.9-43.2, p = .009) than those without volatile exposure. For those ventilated ≥2 days, no differences were detected in mortality, ventilation duration, length of stay, arrhythmias, or acute renal failure. However, the odds of extracorporeal life support remained greater for those receiving volatiles (7.6, 95% CI: 1.3-44.5, p = .027). No children experienced malignant hyperthermia or hepatic failure after volatile exposure. CONCLUSIONS: For intubated children for asthma, no differences in mechanical ventilation duration or mortality between those with and without volatile anesthetic exposure were observed. Although volatiles may represent a viable rescue therapy for severe cases of asthma, definitive, and prospective trials are still needed.

Temperature Elevation During Neonatal and Pediatric Fixed Wing Transport in a Subtropic Climate: A Descriptive Study.

OBJECTIVE: We sought to describe the degree of temperature elevation (∆T) among children transported in a subtropical climate (Florida) via fixed wing aircraft and identify potential relationships between patient weight and ∆T. METHODS: We performed a retrospective cohort study in children < 18 years of age undergoing interfacility transport via fixed wing aircraft from January 2016 through July 2020. The study outcomes were ∆T, maximum patient temperature, ambient temperature, and heat index. Bivariate cohorts defined by patient weight (5 kg) were compared using Fisher exact, Student t-, and Wilcoxon rank sum analyses. Exploratory testing included receiver operator characteristic curve analyses and unadjusted logistic regression. RESULTS: Of the 58 children studied, 25 (43%) were ≤ 5 kg, and 33 (57%) were > 5 kg. Compared with children > 5 kg, those ≤ 5 kg had greater ∆T (0.8° ± 0.6°C vs. 0.2° ± 0.3°C), maximum patient temperature (37.3° ± 0.6°C vs. 36.8° ± 0.4°C), and proportion with ≥ 1°C ∆T (36% vs. 3%). No child > 5 kg had a temperature > 38°C, and no differences were observed for heat index or ambient temperature. Receiver operating characteristic analysis of patient weight on ∆T ≥ 1°C yielded an area under the curve of 0.86 (cutoff of 3.5 kg; sensitivity = 81.3%, specificity = 80%). Patient weight was inversely associated with ∆T ≥ 1°C (odds ratio = 0.69; 95% confidence interval, 0.49-0.96). CONCLUSIONS: Young children appear at greatest risk for developing environmental hyperthermia during interfacility fixed wing transport.

Stress ulcer prophylaxis in children with status asthmaticus receiving systemic corticosteroids: a descriptive study assessing frequency of clinically important bleeding.

Objective: To determine the frequency of clinically important bleeding (CIB) among children hospitalized for status asthmaticus with and without exposure to stress ulcer prophylaxis (SUP).Methods: We performed a single-center, retrospective cohort in 217 children admitted for asthma exacerbation aged 5-18 years from May 2015 to May 2017. We assessed cohorts with and without exposure to SUP to determine if differences in frequency of CIB exist. Study outcomes included frequency of CIB, gastrointestinal complications (occult bleeding, macroscopic bleeding, gastric perforation, and acquired gastritis), and SUP-related adverse events (ventilator associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and acute thrombocytopenia).Results: Ninety-two (42%) children received SUP of which 82 were admitted to the pediatric intensive care unit (PICU). There were no differences in asthma severity or known risk factors for CIB in children with and without SUP in the PICU subcohort. We observed no CIB or SUP-related adverse events. Two subjects acquired gastritis in the no-SUP cohort and one additional subject experienced occult gastrointestinal bleeding with spontaneous symptom resolution.Conclusion: Children admitted for status asthmaticus with and without SUP had no observed incidence of CIB. In this specific population, we propose a prerequisite assessment for the presence of known stress ulcer related gastrointestinal bleeding risk factors prior to the blanket administration of SUP.

Transcutaneous Carbon Dioxide Monitoring During Apnea Testing for Determination of Neurologic Death in Children: A Retrospective Case Series.

OBJECTIVES: Determination of neurologic death in children is a clinical diagnosis based on absence of neurologic function with irreversible coma and apnea. Apnea testing during determination of neurologic death assesses spontaneous respiration when PaCO2 increases to greater than or equal to 60 and greater than or equal to 20 mm Hg above pre-apneic baseline. The utility of transcutaneous carbon dioxide measurements during apnea testing in children is unknown. We seek to determine the degree of correlation between paired transcutaneous carbon dioxide and PaCO2 values during apnea testing for determination of neurologic death. DESIGN: Single-center, retrospective case series. SETTING: Twenty-eight bed PICU in a 259-bed, tertiary care, referral center. PATIENTS: Children 0-18 years old undergoing determination of neurologic death between May 2017 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were paired transcutaneous carbon dioxide and PaCO2 values obtained during determination of neurologic death. Primary analyses included Pearson correlation coefficient, Bland-Altman bias and limits of agreement, and comparative statistics. Descriptive data included demographics, admission diagnoses, hemodynamics, Vasoactive Inotropic Scores, and arterial blood gas measurement. Eight children underwent 15 determination of neurologic death examinations resulting in 31 paired transcutaneous carbon dioxide and PaCO2 values for study. Transcutaneous carbon dioxide and PaCO2 correlated well (r = 0.94; p < 0.01). Bias between transcutaneous carbon dioxide and PaCO2 was -3.29 ± 7.14 mm Hg. Differences in means did not correlate with Vasoactive Inotropic Score (r = 0.2) or patient temperature (r = 0.11). Receiver operator characteristic curve of transcutaneous carbon dioxide after 3-10 minutes of apnea to discriminate positive apnea testing by the standard of PaCO2 yielded an area under the curve of 0.91 and threshold of greater than or equal to 64 mm Hg (sensitivity, 91.7%; specificity, 100%; positive predictive value, 100%; negative predictive value, 92.3%; accuracy, 95.9%). CONCLUSIONS: During apnea testing for determination of neurologic death in children, noninvasive transcutaneous carbon dioxide monitoring demonstrated high correlation, accuracy, and minimal bias when compared with PaCO2. Further validation is required before any recommendation to replace PaCO2 with noninvasive transcutaneous carbon dioxide monitoring can be proposed. However, concurrent transcutaneous carbon dioxide data may limit unnecessary apnea time and associated hemodynamic instability or respiratory decompensation by approximating goal arterial blood sampling to document target PaCO2.

Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes.

OBJECTIVES: Infants with critical congenital heart disease undergoing cardiothoracic surgery commonly experience chronic malnutrition and growth failure. We sought to determine whether placement of a percutaneous endoscopic gastrostomy was associated with reduced moderate-severe malnutrition status and to describe percutaneous endoscopic gastrostomy-related clinical and safety outcomes in this population. DESIGN: Single-center, retrospective cohort study. SETTING: Two hundred fifty-nine-bed, tertiary care, pediatric referral center. PATIENTS: Children with congenital heart disease less than 2 months old undergoing cardiothoracic surgery from 2007 to 2013 with and without percutaneous endoscopic gastrostomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were weight for age z scores during hospitalization, at 6 months, and 1 year after cardiothoracic surgery. Secondary outcomes were frequency of percutaneous endoscopic gastrostomy revision, percutaneous endoscopic gastrostomy complications, and mortality. Statistical analyses included Wilcoxon rank-sum, Fisher exact, and Student t tests. Two hundred twenty-two subjects met study criteria, and 77 (35%) had percutaneous endoscopic gastrostomy placed at a mean of 45 ± 31 days after cardiothoracic surgery. No differences were noted for demographics, comorbidities, and weight for age z score at birth and at the time of cardiothoracic surgery. The percutaneous endoscopic gastrostomy cohort had greater Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk category (4 [4-5] vs 4 [2-4]) and length of stay (71 d [49-101 d] vs 26 d [15-42 d]). Mean weight for age z score at the time of percutaneous endoscopic gastrostomy was -2.8 ± 1.3. Frequency of moderate-severe malnutrition (weight for age z score, ≤ -2) was greater in children with percutaneous endoscopic gastrostomy at discharge (78% vs 48%), 6 months (61% vs 16%), and 1 year (41% vs 2%). Index mortality was lower in children with percutaneous endoscopic gastrostomy at 30 days (8% vs 0%) and hospital discharge (19% vs 4%). However, no mortality differences were observed after discharge. Growth velocity after percutaneous endoscopic gastrostomy was greater (44 ± 19 vs 10 ± 9 g/d). Children tolerated percutaneous endoscopic gastrostomy without hemodynamic compromise, minor percutaneous endoscopic gastrostomy complications, and anticipated percutaneous endoscopic gastrostomy revisions. Children without mortality had percutaneous endoscopic gastrostomy removal at a median duration of 253 days (133-545 d). Children with univentricular physiology had improved in-hospital mean growth velocity (6.3 vs 24.4 g/d; p < 0.01) and reduced 1-year rate moderate-severe malnutrition (66.7% vs 36.9%; p < 0.01) after percutaneous endoscopic gastrostomy placement. CONCLUSIONS: Percutaneous endoscopic gastrostomy placement was well tolerated and associated with improved postoperative growth velocity in children with critical congenital heart disease undergoing cardiothoracic surgery less than 2 months old. These findings were also noted in our subanalysis of children with univentricular physiology. Persistent rates of moderate-severe malnutrition were noted at 1-year follow-up. Although potential index mortality benefit was observed, definitive data are still needed.

Transcutaneous carbon dioxide measurements in fruits, vegetables and humans: A prospective observational study.

BACKGROUND: Transcutaneous carbon dioxide measurement (TcCO2) is frequently used as a surrogate for arterial blood gas sampling in adults and children with critical illness. Data from noninvasive TcCO2 monitoring assists with clinical decisions regarding mechanical ventilation settings, estimation of metabolic consumption and determination of adequate end-organ tissue perfusion. OBJECTIVES: To report TcCO2 values obtained from various fruits, vegetables and elite critical care medicine specialists. DESIGN: Prospective, observational, nonblinded cohort study. SETTINGS: Single-centre, tertiary paediatric referral centre and organic farmers' market. PARTICIPANTS: Vegetables and fruits included 10 samples of each of the following: red delicious apple (Malus domestica), manzano banana (Musa sapientum), key lime (Citrus aurantiifolia), miniature sweet bell pepper (Capsicum annuum), sweet potato (Ipomoea batatas) and avocado (Persea americana). Ten human controls were studied including a paediatric intensivist, a paediatric inpatient hospital physician, four paediatric resident physicians and four paediatric critical care nurses. INTERVENTIONS: None. MAIN OUTCOME MEASURES: TcCO2 values for each species and device response times. RESULTS: TcCO2 readings were measurable in all study species except the sweet potato. Mean ±â€ŠSD values of TcCO2 for human controls [4.34 ±â€Š0.37 kPa (32.6 ±â€Š2.8 mmHg)] were greater than apples [3.09 ±â€Š0.19 kPa (23.2 ±â€Š1.4 mmHg), P < 0.01], bananas [2.73 ±â€Š0.28 kPa (20.5 ±â€Š2.1 mmHg), P < 0.01] and limes [2.76 ±â€Š0.52 kPa (20.7 ±â€Š3.9 mmHg), P < 0.01] but no different to those of avocados [4.29 ±â€Š0.44 kPa (32.2 ±â€Š3.3 mmHg), P = 0.77] and bell peppers [4.19 ±â€Š1.13 kPa (31.4 ±â€Š8.5 mmHg), P = 0.68]. Transcutaneous response times did not differ between research cohorts and human controls. CONCLUSION: We found nonroot, nontuberous vegetables to have TcCO2 values similar to that of healthy, human controls. Fruits yield TcCO2 readings, but substantially lower than human controls.

Standardization of Pediatric Interfacility Transport Handover: Measuring the Development of a Shared Mental Model.

OBJECTIVES: To determine if standardization of pediatric interfacility transport handover is associated with the development of a prototypical shared mental model between healthcare providers. DESIGN: A single center, prepost, retrospective cohort study. SETTINGS: A 259-bed, tertiary care, pediatric referral center. PATIENTS: Children 0 to 18 years old transferred to our critical care units or emergency center from October 2016 to February 2017. INTERVENTIONS: Standardization of interfacility handover using a multidisciplinary checklist, didactic teaching, and simulation conducted midway through the study period. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a shared mental model index defined as percent congruence among handover participants regarding key patient healthcare data including patient identification, diagnoses, transport interventions, immediate postadmission care plans, and anticipatory guidance for ongoing care. Secondary outcomes were handover comprehensiveness and teaming metrics such as efficiency, attendance, interruption frequency, and team member inclusion. During the study period, 100 transport handovers were observed of which 50 were preintervention and 50 post. A majority of handovers represented transfers to the emergency center (41%) or PICU (45%). There were no observable differences between prepost intervention cohorts by general characteristics, admission diagnoses, or severity of illness metrics including Pediatric Index of Mortality-3-Risk of Mortality, length of stay, mortality, frequency of invasive and noninvasive ventilation, and vasoactive use. The shared mental model index increased from 38% to 78% following standardization of handover. Attendance (76% vs 94%), punctuality (91.5% vs 98%), attention (82% vs 92%), summarization (42% vs 72%), and provision of anticipatory guidance (42% vs 58%) also improved. Efficiency was unchanged with a mean handover duration of 4 minutes in both cohorts. CONCLUSIONS: Considerable enhancements in handover quality, team participation, and the development of a shared mental model after standardization of interfacility transport handover were noted. These findings were achieved without compromising handover efficiency.

Short-Term Peripheral Vasoactive Infusions in Pediatrics: Where Is the Harm?

OBJECTIVE: Pediatric shock represents a major cause of morbidity and mortality in the United States. Standardization of treatment such as volume resuscitation and vasoactive administration has resulted in improved patient outcomes. Vasoactives have been anecdotally associated with peripheral IV infiltration and extravasation. There is a paucity of evidence in pediatrics to determine the ideal route of vasoactive infusions and what, if any, risk factors and harm are associated with peripheral IV infiltration and extravasation. We aim to assess the frequency of and risk factors for peripheral IV infiltration and extravasation during peripheral IV vasoactive infusions in children admitted to the PICU. DESIGN: A retrospective, cohort study of all children admitted to a PICU from January 2012 to June 2014. SETTING: Forty-four-bed PICU at Children's National Health System. PATIENTS: All children 0-18 years old receiving a vasoactive infusion through a peripheral IV for a minimum of 1 hour. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcomes of this study were incidence of peripheral IV infiltration and extravasation and resultant tissue injury. Secondary outcomes were peripheral IV characteristics and vasoactive infusion data. One hundred two patients met inclusion criteria. Sixty-two percent (63/102) were admitted with the diagnosis of septic shock. The most commonly used vasoactive agent was dopamine. The median peak Vasoactive Infusion Score was 10 (6-14). Peripheral IV infiltration and extravasation incidence was 2% (2/102) and neither event resulted in injury requiring medical or surgical intervention. CONCLUSIONS: Vasoactive infusions through peripheral IV in children admitted to the PICU with shock were observed to have a low incidence of peripheral IV infiltration and extravasation and resultant tissue injury. Short-term delivery of vasoactives via peripheral IV catheter in a highly monitored PICU setting appears to be safe.

Fluid Overload and Cumulative Thoracostomy Output Are Associated With Surgical Site Infection After Pediatric Cardiothoracic Surgery.

OBJECTIVES: To determine the impact of cumulative, postoperative thoracostomy output, amount of bolus IV fluids and peak fluid overload on the incidence and odds of developing a deep surgical site infection following pediatric cardiothoracic surgery. DESIGN: A single-center, nested, retrospective, matched case-control study. SETTING: A 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital. PATIENTS: Cases with deep surgical site infection following cardiothoracic surgery were identified retrospectively from January 2010 through December 2013 and individually matched to controls at a ratio of 1:2 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, primary cardiac diagnosis, and procedure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twelve cases with deep surgical site infection were identified and matched to 24 controls without detectable differences in perioperative clinical characteristics. Deep surgical site infection cases had larger thoracostomy output and bolus IV fluid volumes at 6, 24, and 48 hours postoperatively compared with controls. For every 1 mL/kg of thoracostomy output, the odds of developing a deep surgical site infection increase by 13%. By receiver operative characteristic curve analysis, a cutoff of 49 mL/kg of thoracostomy output at 48 hours best discriminates the development of deep surgical site infection (sensitivity 83%, specificity 83%). Peak fluid overload was greater in cases than matched controls (12.5% vs 6%; p < 0.01). On receiver operative characteristic curve analysis, a threshold value of 10% peak fluid overload was observed to identify deep surgical site infection (sensitivity 67%, specificity 79%). Conditional logistic regression of peak fluid overload greater than 10% on the development of deep surgical site infection yielded an odds ratio of 9.4 (95% CI, 2-46.2). CONCLUSIONS: Increased postoperative peak fluid overload and cumulative thoracostomy output were associated with deep surgical site infection after pediatric cardiothoracic surgery. We suspect the observed increased thoracostomy output, fluid overload, and IV fluid boluses may have altered antimicrobial prophylaxis. Although analysis of additional pharmacokinetic data is warranted, providers may consider modification of antimicrobial prophylaxis dosing or alterations in fluid management and diuresis in response to assessment of peak fluid overload and fluid volume shifts in the immediate postoperative period.