Remote triage in paediatric critical care: A Canadian provincial-wide cohort study.

OBJECTIVE: To describe remote triage of 'potentially' critically ill or injured children in a western Canadian province and to examine the associated factors with 'missings' in vital sign items recorded in centralized telephone triage consultations. METHODS: This is a provincial-wide prospective cohort study. We included all children under 17 years of age consulted through the central transport coordination centres in Alberta from June 2016 to July 2017. We labeled a value as 'missing' when the actual value was not identified in the audio records. RESULTS: In total, 429 cases were included in this study. The median duration of triage calls was 6.8 minutes. Although the patients' demographics and primary diagnoses were similar, backgrounds of the referring physicians and hospitals were significantly different between the two cohorts (i.e., patients referred to Calgary versus Edmonton). The proportion of 'missings' among the vital sign items varied significantly, in which capillary refilling time (60%), pupils (86%), Glasgow Coma Scale (GCS) (79%), and level of respiratory effort (50%) were not well recorded, whereas heart rate (proportion of 'missings': 12%), SpO2 (20%), and respiratory rate (26%) were recorded reasonably well. The lower proportion of 'missings' was observed in older aged patients for several vital sign items including systolic blood pressure and GCS. CONCLUSIONS: The proportion of missing vital signs recorded varied significantly. The 'missings' could be associated with referring physician's background and patients' demographics such as 'age' that should be considered for the improvement of triage quality in the future.

Fluid Accumulation in Critically Ill Children.

OBJECTIVES: To describe the characteristics of fluid accumulation in critically ill children and evaluate the association between the degree, timing, duration, and rate of fluid accumulation and patient outcomes. DESIGN: Retrospective cohort study. SETTING: PICUs in Alberta, Canada. PATIENTS: All children admitted to PICU in Alberta, Canada, between January 1, 2015, and December 31, 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 1,017 patients were included. Fluid overload % increased from median (interquartile range) 1.58% (0.23-3.56%; n = 1,017) on day 1 to 16.42% (7.53-27.34%; n = 111) on day 10 among those remaining in PICU. The proportion of patients (95% CI) with peak fluid overload % greater than 10% and greater than 20% was 32.7% (29.8-35.7%) and 9.1% (7.4-11.1%), respectively. Thirty-two children died (3.1%) in PICU. Peak fluid overload % was associated with greater PICU mortality (odds ratio, 1.05; 95% CI, 1.02-1.09; p = 0.001). Greater peak fluid overload % was associated with Major Adverse Kidney Events within 30 days (odds ratio, 1.05; 95% CI, 1.02-1.08; p = 0.001), length of mechanical ventilation (B coefficient, 0.66; 95% CI, 0.54-0.77; p < 0.001), and length of PICU stay (B coefficient, 0.52; 95% CI, 0.46-0.58; p < 0.001). The rate of fluid accumulation was associated with PICU mortality (odds ratio, 1.15; 95% CI, 1.01-1.31; p = 0.04), Major Adverse Kidney Events within 30 days (odds ratio, 1.16; 95% CI, 1.03-1.30; p = 0.02), length of mechanical ventilation (B coefficient, 0.80; 95% CI, 0.24-1.36; p = 0.005), and length of PICU stay (B coefficient, 0.38; 95% CI, 0.11-0.66; p = 0.007). CONCLUSIONS: Fluid accumulation occurs commonly during PICU course and is associated with considerable mortality and morbidity. These findings highlight the need for the development and evaluation of interventional strategies to mitigate the potential harm associated with fluid accumulation.

Effects of Medical Transport on Outcomes in Children Requiring Intensive Care.

BACKGROUND AND OBJECTIVES: The need to centralize patients for specialty care in the setting of regionalization may delay access to specialist services and compromise outcomes, particularly in a large geographic area. The aim of this study was to explore the effects of interhospital transferring of children requiring intensive care in a Canadian regionalization model. METHODS: A retrospective cohort design with a matched pair analysis was adopted to compare the outcomes in children younger than 17 years admitted to a pediatric intensive care unit (PICU) of a Canadian children's hospital by a specialized transport team (pediatric critical care transported [PCCT] group) and those children admitted directly to PICU from its pediatric emergency department (PED group). The outcomes of interest included mortality 72 hours from initial contact with the critical care team (ie, either PICU transport team or intrahospital PICU team). RESULTS: In total, 680 (27%) transports met our inclusion criteria, whereas 866 (7%) cases of 11 570 total PICU admissions were admitted directly from the emergency department. A total of 493 pairs were formed for the matched analyses. Odds of mortality within 72 hours in the PCCT group were significantly higher than in the PED group (odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.07-4.45; P = .032). When excluding cases who had at least one episode of cardiac arrest before involvement of the pediatric critical care (PCC) transport team, the OR dropped to 1.66 (95% CI: 0.77-3.46). CONCLUSIONS: Children transported from nonpediatric hospitals had a higher 72-hour mortality when compared to those children admitted directly to a children's hospital PICU from its own PED in a Canadian regionalized health-care model.

Variation in Practice Related to the Use of High Flow Nasal Cannula in Critically Ill Children.

OBJECTIVES: To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children. DESIGN: Multinational cross-sectional questionnaire survey conducted in 2018. SETTING: The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand. MEASUREMENT: Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula. INTERVENTIONS: None. MAIN RESULTS: We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents. CONCLUSIONS: Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association.

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Epidemiology of Pediatric Critical Care Transport in Northern Alberta and the Western Arctic.

OBJECTIVE: Specialized pediatric critical care transport teams are essential to pediatric retrieval systems. This study aims to describe the contemporary transports performed by a Canadian pediatric critical care transport team and to compare the treatment and outcomes of children referred from high-level care (hospitals offering pediatric services where an adult ICU exists) and nonhigh-level care (all other hospitals) hospitals. DESIGN: A descriptive cohort study. SETTING: The Stollery Children's Hospital in Edmonton, Alberta, Western Canada. PATIENTS: Children younger than 17 years old transported by the transport team from referral hospitals within the Stollery Children's Hospital catchment area to Stollery Children's Hospital between 1998 and 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Characteristics of transports, patient demographics presenting vital signs, and outcomes were described overall and compared by transport-related time and referral hospital types (high-level care and nonhigh-level care). In total, 3,352 transports met the inclusion criteria; 1,049 were retrieved from eight high-level care hospitals and 2,303 from 53 nonhigh-level care hospitals; the median one-way transport distance was 383 kilometers, and 70% of the transports were air transports. The annual number of transports has increased during the study period. The PICU admission rate was between 40% and 55%. Transports from high-level care hospitals had significantly higher odds of being admitted to the PICU (odds ratio, 1.96; 95% CI, 1.31-2.93). The odds of intubation at the referral hospital were higher in the high-level care group, but the odds of intubation upon PICU admission was similar between the two groups. Mortality during or after transport was not significantly different between high-level care and nonhigh-level care hospitals. CONCLUSIONS: The current transport system has multiple priorities with regard to efficiency and quality. The medical services at referral hospitals may affect the likelihood of PICU admission and subsequent PICU length of stay; however, no negative impact was observed in other outcomes including mortality.

Use of high-flow nasal cannula oxygen therapy in infants and children.

Heated, humidified high-flow nasal cannula (HHHFNC) therapy provides warmed, humidified oxygen to infants and children in respiratory distress at flow rates that deliver higher oxygen concentrations and some positive airway pressure compared with standard low-flow therapy. Increased use and experience is informing practice and establishing the benefits of HHHFNC use in a variety of clinical conditions. The focus of this practice point is to describe best practices for HHHFNC in (non- neonatal) paediatric patients with moderate-to-severe respiratory distress and to offer a safe, practical approach to oxygen delivery, and support.

The Clinical Impact of Heated Humidified High-Flow Nasal Cannula on Pediatric Respiratory Distress.

OBJECTIVES: To assess the impact on a single PICU of introducing high-flow nasal cannula as a management tool for respiratory distress. DESIGN: Retrospective cohort study, including an interrupted time series analysis with a propensity score adjustment and a matched-pair analysis. SETTING: A single university-affiliated children's hospital PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Differences in clinical outcomes when comparing the pre-high-flow nasal cannula era (2004-2008) and the high-flow nasal cannula era (2010-2014), excluding 2009 as a washout period, and clinical impacts of high-flow nasal cannula as an exposure of interest. A total of 1,766 children met the inclusion criteria (pre-high-flow nasal cannula era: 699 patients; high-flow nasal cannula era: 1,067 patients). High-flow nasal cannula was used in 455 patients (42.6%) in the high-flow nasal cannula era. The interrupted time series analysis failed to show a statistically significant difference in PICU length of stay, but the duration of invasive ventilation was shortened by an average of 2.3 days in the high-flow nasal cannula era group (95% CI, 0.2-4.4; p = 0.030). The PICU intubation rate in the high-flow nasal cannula era was 0.72 times that of the pre-high-flow nasal cannula era (95% CI, 0.63-0.84; p < 0.001). A total of 373 pairs were formed for the matched-pair analysis. The odds for being intubated in the PICU for those patients using high-flow nasal cannula was 0.06 (95% CI, 0.02-0.16; p < 0.001) when compared with those who did not use high-flow nasal cannula. The PICU length of stay increased by 2.9 days in those patients in which high-flow nasal cannula was used (95% CI, 1.3-4.4; p < 0.001). CONCLUSIONS: The introduction of high-flow nasal cannula as a therapy for respiratory distress in the PICU was associated with a significant decrease in the PICU intubation rate with no associated change in mortality.

Pediatric Extracorporeal Life Support Transport in Western Canada: Experience over 14 years.

This retrospective cohort study describes all children transported on extracorporeal life support (ECLS) by the Stollery Children's Hospital Pediatric Transport team (SCH-PTT) between 2004 and 2018. We compared outcomes and complications between primary (SCH-PTT performed ECLS cannulation) vs. secondary (cannulation performed by referring facility) transports, as well as secondary transports from referring centers with and without an established ECLS cannulation program. SCH-PTT performed 68 ECLS transports during the study period. Median (IQR) transport distance was 298 (298-1,068) kilometers. Mean (SD) times from referral call to ECLS-initiation were: primary transports 7.8 (2.9) vs. 2.5(3.5) hours for secondary transports, p value < 0.001. Complications were common (n = 65, 95%) but solved without leading to adverse outcomes. There were no significant differences in the number of complications between primary and secondary transports. There was no significant difference in survival to ECLS decannulation between primary 9 (90%) and secondary transports 43 (74%), p value = 0.275. ECLS survival was higher for children cannulated by the SCH-PTT or a center with an ECLS cannulation program: 42 (82%) vs. 10 (59%), p value = 0.048. Critically ill children on ECLS can be safely transported by a specialized pediatric ECLS transport team. Secondary transports from a center with an ECLS cannulation program are also safe and have similar results as primary transports.

Autoresuscitation after pediatric cardiac arrest: is hyperventilation a cause?

There are a number of reports of delayed return of spontaneous circulation after pulseless arrest (the Lazarus phenomenon) in adults. There are no published reports of this phenomenon in children. We report 2 pediatric cases of the Lazarus phenomenon, likely caused by unintentional hyperventilation during resuscitation.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest.

INTRODUCTION: In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. METHODS: We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. RESULTS: There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86). CONCLUSIONS: Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Pediatric timing of epinephrine doses: A systematic review.

AIM: To evaluate the optimal timing and doses of epinephrine for Infants and children suffering in-hospital or out-of-hospital cardiac arrest. METHODS: We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for human randomized clinical trials and observational studies including comparative cohorts. Two investigators reviewed relevance of studies, extracted the data, conducted meta-analyses and assessed the risk of bias using the GRADE and CLARITY frameworks. Authors of the eligible studies were contacted to obtain additional data. Critically important outcomes included return of spontaneous circulation, survival to hospital discharge and survival with good neurological outcome. RESULTS: We identified 7 observational studies suitable for meta-analysis and no randomized clinical trials. The overall certainty of evidence was very low. For the critically important outcomes, the earlier administration of epinephrine was favorable for both in-hospital and out-of-hospital cardiac arrest. Because of a limited number of eligible studies and the presence of severe confounding factors, we could not determine the optimal interval of epinephrine administration. CONCLUSIONS: Earlier administration of the first epinephrine dose could be more favorable in non-shockable pediatric cardiac arrest. The optimal interval for epinephrine administration remains unclear.

Music Use for Sedation in Critically ill Children (MUSiCC trial): a pilot randomized controlled trial.

OBJECTIVE: To demonstrate feasibility of a music medicine intervention trial in pediatric intensive care and to obtain information on sedation and analgesia dose variation to plan a larger trial. MATERIAL AND METHODS: Pilot randomized controlled trial (RCT) was conducted at the Stollery Children's Hospital general and cardiac intensive care units (PICU/PCICU). The study included children 1 month to 16 years of age on mechanical ventilation and receiving sedation drugs. Patients were randomized in a 1:1:1 ratio to music, noise cancellation or control. The music group received classical music for 30 min three times/day using headphones. The noise cancellation group received the same intervention but with no music. The control group received usual care. RESULTS: A total of 60 patients were included. Average enrollment rate was 4.8 patients/month, with a consent rate of 69%. Protocol adherence was achieved with patients receiving > 80% of the interventions. Overall mean (SD) daily Sedation Intensity Score was 52.4 (30.3) with a mean (SD) sedation frequency of 9.75 (7.21) PRN doses per day. There was a small but statistically significant decrease in heart rate at the beginning of the music intervention. There were no study related adverse events. Eighty-eight percent of the parents thought the headphones were comfortable; 73% described their child more settled during the intervention. CONCLUSIONS: This pilot RCT has demonstrated the feasibility of a music medicine intervention in critically ill children. The study has also provided the necessary information to plan a larger trial.

Misinterpretations of Guidelines Leading to Incorrect Diagnosis of Brain Death: A Case Report and Discussion.

Guidelines describe the process necessary for the diagnosis of brain death. We present a case of a 3-month-old former 36-week-gestation infant after a prolonged out-of-hospital cardiac arrest of 37 minutes who was clinically diagnosed as brain dead at 120 hours after the event. Unusual findings included a normal slightly sunken anterior fontanelle, normal cerebral blood flow perfusion scan at 73 hours after the event, only localized parieto-temporal edema on the latest computed tomographic (CT) scan of the brain at 48 hours after the event, and discussion of whether nonconvulsive seizures could have confounded the examination for brain death. In light of these unusual findings, we discuss and highlight what may be common misinterpretations of brain death guidelines that led to the mistaken diagnosis of death (as opposed to severe neurologic injury) in this child.

Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.

The approach to delayed resuscitation in paediatric cardiac arrest: A survey of paediatric intensivists in Canada.

AIM: To determine how long a period of having had no cardiopulmonary-resuscitation (CPR) (delay time) is considered to result in subsequent futile efforts at resuscitation. METHODS: In 2007 a survey was mailed to all 77 paediatric intensivists in Canada. Three scenarios of witnessed cardiac arrest were presented: out-of-hospital, in-hospital, and in-hospital with extracorporeal-CPR (E-CPR). Each scenario asked what delay time would make attempts at resuscitation futile for survival to hospital discharge, and for survival to hospital discharge in a better than vegetative state. Comparisons of median [inter-quartile range] used Wilcoxon-signed-rank or Friedman tests with Bonferroni corrections. RESULTS: The response rate was 49/77 (64%). The delay time was significantly different between rhythms within all scenarios (p<.001); and was significantly shorter for survival than for better than vegetative survival (p<.006) except when E-CPR was to be used. The delay time was not significantly different between the in-hospital and out-of-hospital scenario with the same rhythms (p>.01). The delay time was significantly shorter in scenarios with asystole versus pulseless electrical activity with (p=.010) or without (p<.001) an arterial line with absent pulsation. In out-of-hospital arrest, the delay time for survival varied from 15 [10-20]min for asystole to 20 [15-20]min for pulseless electrical activity. In in-hospital scenarios, the delay time for survival varied from 10 [10-20]min for asystole, to 15 [10-20]min for most other rhythms. CONCLUSION: A delay time of 15 [10-20] (range 5-30)min was considered futile for survival. This has implications for pronouncing death in donation after cardiac death.