The Utilization of Critical Care Resources in Pediatric Neurocritical Care Patients.

OBJECTIVES: To define the prevalence of neurologic diagnoses and evaluate the utilization of critical care and neurocritical care (NCC) resources among children admitted to the PICU. DESIGN: Retrospective cohort analysis. SETTING: Data submitted to the Virtual Pediatric Systems (VPS) database. PATIENTS: All children entered in VPS during 2016 (January 1, 2016, to December 31, 2016). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 128,688 patients entered into VPS and were comprised of 24.3% NCC admissions and 75.7% general PICU admissions. The NCC cohort was older, represented more scheduled admissions, and was more frequently admitted from the operating room. The NCC cohort also experienced a greater decline in prehospitalization to posthospitalization functional status and required more frequent use of endotracheal intubation, arterial lines, and foley catheters but had an overall shorter duration of PICU and hospital length of stay with a higher mortality rate. One thousand seven hundred fifteen patients at 12 participating institutions were entered into a novel, pilot NCC module evaluating sources of secondary neurologic injury. Four hundred forty-eight patients were manually excluded by the data entrant, leaving 1,267 patients in the module. Of the patients in the module, 75.8% of patients had a NCC diagnosis as their primary diagnosis; they experienced a high prevalence of pathophysiologic events associated with secondary neurologic insult (ranging from hyperglycemia at 10.5% to hyperthermia at 36.8%). CONCLUSIONS: In children admitted to a VPS-contributing PICU, a diagnosis of acute neurologic disease was associated with greater use of resources. We have identified the most common etiologies of acute neurologic disease in the 2016 VPS cohort, and such admissions were associated with significant decrease in functional status, as well as an increase in mortality.

The Impact of Coronavirus Disease 2019 Pandemic on U.S. and Canadian PICUs.

OBJECTIVES: There are limited reports of the impact of the coronavirus disease 2019 pandemic focused on U.S. and Canadian PICUs. This hypothesis-generating report aims to identify the United States and Canadian trends of coronavirus disease 2019 in PICUs. DESIGN AND SETTING: To better understand how the coronavirus disease 2019 pandemic was affecting U.S. and Canadian PICUs, an open voluntary daily data collection process of Canadian and U.S. PICUs was initiated by Virtual Pediatric Systems, LLC (Los Angeles, CA; http://www.myvps.org) in mid-March 2020. Information was made available online to all PICUs wishing to participate. A secondary data collection was performed to follow-up on patients discharged from those PICUs reporting coronavirus disease 2019 positive patients. MEASUREMENTS AND MAIN RESULTS: To date, over 180 PICUs have responded detailing 530 PICU admissions requiring over 3,467 days of PICU care with 30 deaths. The preponderance of cases was in the eastern regions. Twenty-four percent of the patients admitted to the PICUs were over 18 years old. Fourteen percent of admissions were under 2 years old. Nearly 60% of children had comorbidities at admission with the average length of stay increasing by age and by severity of comorbidity. Advanced respiratory support was necessary during 67% of the current days of care, with 69% being conventional mechanical ventilation. CONCLUSIONS: PICUs have been significantly impacted by the pandemic. They have provided care not only for children but also adults. Patients with coronavirus disease 2019 have a high frequency of comorbidities, require longer stays, more ventilatory support than usual PICU admissions. These data suggest several avenues for further exploration.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

OBJECTIVES: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients.

OBJECTIVES: To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness. DESIGN: Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach. SETTING: Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database. PATIENTS: Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90. CONCLUSIONS: This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Impact of 24/7 In-Hospital Intensivist Coverage on Outcomes in Pediatric Intensive Care. A Multicenter Study.

RATIONALE: The around-the-clock presence of an in-house attending critical care physician (24/7 coverage) is purported to be associated with improved outcomes among high-risk children with critical illness. OBJECTIVES: To evaluate the association of 24/7 in-house coverage with outcomes in children with critical illness. METHODS: Patients younger than 18 years of age in the Virtual Pediatric Systems Database (2009-2014) were included. The main analysis was performed using generalized linear mixed effects multivariable regression models. In addition, multiple sensitivity analyses were performed to test the robustness of our findings. MEASUREMENTS AND MAIN RESULTS: A total of 455,607 patients from 125 hospitals were included (24/7 group: 266,319 patients; no 24/7 group: 189,288 patients). After adjusting for patient and center characteristics, the 24/7 group was associated with lower mortality in the intensive care unit (ICU) (24/7 vs. no 24/7; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33-0.80; P = 0.002), a lower incidence of cardiac arrest (OR, 0.73; 95% CI, 0.54-0.99; P = 0.04), lower mortality after cardiac arrest (OR, 0.56; 95% CI, 0.340-0.93; P = 0.02), a shorter ICU stay (mean difference, -0.51 d; 95% CI, -0.93 to -0.09), and shorter duration of mechanical ventilation (mean difference, -0.68 d; 95% CI, -1.23 to -0.14). CONCLUSIONS: In this large observational study, we demonstrated that pediatric critical care provided in the ICUs staffed with a 24/7 intensivist presence is associated with improved overall patient survival and survival after cardiac arrest compared with patients treated in ICUs staffed with discretionary attending coverage. However, results from a few sensitivity analyses leave some ambiguity in these results.

Association of Freestanding Children's Hospitals With Outcomes in Children With Critical Illness.

OBJECTIVES: Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness. DESIGN: Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score. SETTING: Retrospective study from an existing national database, Virtual PICU Systems (LLC) database. PATIENTS: Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p < 0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p < 0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p < 0.001; reintubation: 3.4% vs 3.8%, p < 0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001). CONCLUSIONS: In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.

Association of house staff training with mortality in children with critical illness.

AIM: To evaluate the association of house staff training with mortality in children with critical illness. METHODS: Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009-2013) were included. The study population was divided in two study groups: hospitals with residency programme only and hospitals with both residency and fellowship programme. Control group constituted hospitals with no residency or fellowship programme. The primary study outcome was mortality before intensive care unit (ICU) discharge. Multivariable logistic regression models were fitted to evaluate association of training programmes with ICU mortality. RESULTS: A total of 336 335 patients from 108 centres were included. Case-mix of patients among the hospitals with training programmes was complex; patients cared for in the hospitals with training programmes had greater severity of illness, had higher resource utilisation and had higher overall admission risk of death compared to patients cared for in the control hospitals. Despite caring for more complex and sicker patients, the hospitals with training programmes were associated with lower odds of ICU mortality. CONCLUSION: Our study establishes that ICU care provided in hospitals with training programmes is associated with improved adjusted survival rates among the Virtual PICU database hospitals in the United States.

Pediatric Index of Cardiac Surgical Intensive Care Mortality Risk Score for Pediatric Cardiac Critical Care.

OBJECTIVE: Comparison of clinical outcomes is imperative in the evaluation of healthcare quality. Risk adjustment for children undergoing cardiac surgery poses unique challenges, due to its distinct nature. We developed a risk-adjustment tool specifically focused on critical care mortality for the pediatric cardiac surgical population: the Pediatric Index of Cardiac Surgical Intensive care Mortality score. DESIGN: Retrospective analysis of prospectively collected pediatric critical care data. SETTING: Pediatric critical care units in the United States. PATIENTS: Pediatric cardiac intensive care surgical patients. INTERVENTIONS: Prospectively collected data from consecutive patients admitted to ICUs were obtained from The Virtual PICU System (VPS, LLC, Los Angeles, CA), a national pediatric critical care database. Thirty-two candidate physiologic, demographic, and diagnostic variables were analyzed for inclusion in the development of the Pediatric Index of Cardiac Surgical Intensive care Mortality model. Multivariate logistic regression with stepwise selection was used to develop the model. MEASUREMENTS AND MAIN RESULTS: A total of 16,574 cardiac surgical patients from the 55 PICUs across the United States were included in the analysis. Thirteen variables remained in the final model, including the validated Society of Thoracic Surgeons-European Association of Cardio-Thoracic Surgery Congenital Heart Surgery Mortality (STAT) score and admission time with respect to cardiac surgery, which identifies whether the patient underwent the index surgical procedure before or after admission to the ICU. Pediatric Index of Cardiac Surgical Intensive Care Mortality (PICSIM) performance was compared with the performance of Pediatric Risk of Mortality-3 and Pediatric Index of Mortality-2 risk of mortality scores, as well as the STAT score and STAT categories by calculating the area under the curve of the receiver operating characteristic from a validation dataset: PICSIM (area under the curve = 0.87) performed better than Pediatric Index of Mortality-2 (area under the curve = 0.81), Pediatric Risk of Mortality-3 (area under the curve = 0.82), STAT score (area under the curve = 0.77), STAT category (area under the curve = 0.75), and Risk Adjustment for Congenital Heart Surgery-1 (area under the curve = 0.74). CONCLUSIONS: This newly developed mortality score, PICSIM, consisting of 13 risk variables encompassing physiology, cardiovascular condition, and time of admission to the ICU showed better discrimination than Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, and STAT score and category for mortality in a multisite cohort of pediatric cardiac surgical patients. The introduction of the variable "admission time with respect to cardiac surgery" allowed prediction of mortality when patients are admitted to the ICU either before or after the index surgical procedure.

Association of center volume with outcomes in critically ill children with acute asthma.

BACKGROUND: Little is known about the relation between center volume and outcomes in children requiring intensive care unit (ICU) admission for acute asthma. OBJECTIVE: To evaluate the association of center volume with the odds of receiving positive pressure ventilation and length of ICU stay. METHODS: Patients 2 to 18 years of age with the primary diagnosis of asthma were included (2009-2012). Center volume was defined as the average number of mechanical ventilator cases per year for any diagnoses during the study period. In multivariable analysis, the odds of receiving positive pressure ventilation (invasive and noninvasive ventilation) and ICU length of stay were evaluated as a function of center volume. RESULTS: Fifteen thousand eighty-three patients from 103 pediatric ICUs with the primary diagnosis of acute asthma met the inclusion criteria. Seven hundred fifty-two patients (5%) received conventional mechanical ventilation and 964 patients (6%) received noninvasive ventilation. In multivariable analysis, center volume was not associated with the odds of receiving any form of positive pressure ventilation in children with acute asthma, with the exception of high- to medium-volume centers. However, ICU length of stay varied with center volume and was noted to be longer in low-volume centers compared with medium- and high-volume centers. CONCLUSION: In children with acute asthma, this study establishes a relation between center volume and ICU length of stay. However, this study fails to show any significant relation between center volume and the odds of receiving positive pressure ventilation; further analyses are needed to evaluate this relation in more detail.

Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries.

OBJECTIVE: To empirically derive the optimal measure of pharmacologic cardiovascular support in infants undergoing cardiac surgery with bypass and to assess the association between this score and clinical outcomes in a multi-institutional cohort. DESIGN: Prospective, multi-institutional cohort study. SETTING: Cardiac ICUs at four academic children's hospitals participating in the Pediatric Cardiac Critical Care Consortium during the study period. PATIENTS: Children younger than 1 year at the time of surgery treated postoperatively in the cardiac ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three hundred ninety-one infants undergoing surgery with bypass were enrolled consecutively from November 2011 to April 2012. Hourly doses of all vasoactive agents were recorded for the first 48 hours after cardiac ICU admission. Multiple derivations of an inotropic score were tested, and maximum vasoactive-inotropic score in the first 24 hours was further analyzed for association with clinical outcomes. The primary composite "poor outcome" variable included at least one of mortality, mechanical circulatory support, cardiac arrest, renal replacement therapy, or neurologic injury. High vasoactive-inotropic score was empirically defined as more than or equal to 20. Multivariable logistic regression was performed controlling for center and patient characteristics. Patients with high vasoactive-inotropic score had significantly greater odds of a poor outcome (odds ratio, 6.5; 95% CI, 2.9-14.6), mortality (odds ratio, 13.2; 95% CI, 3.7-47.6), and prolonged time to first extubation and cardiac ICU length of stay compared with patients with low vasoactive-inotropic score. Stratified analyses by age (neonate vs infant) and surgical complexity (low vs high) showed similar associations with increased morbidity and mortality for patients with high vasoactive-inotropic score. CONCLUSIONS: Maximum vasoactive-inotropic score calculated in the first 24 hours after cardiac ICU admission was strongly and significantly associated with morbidity and mortality in this multi-institutional cohort of infants undergoing cardiac surgery. Maximum vasoactive-inotropic score more than or equal to 20 predicts an increased likelihood of a poor composite clinical outcome. The findings were consistent in stratified analyses by age and surgical complexity.

Creation and Implementation of a Pediatric Advanced Practice Nurse Critical Care Fellowship Program.

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Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.

Pediatric Trauma Assessment and Management Database: Leveraging Existing Data Systems to Predict Mortality and Functional Status after Pediatric Injury.

BACKGROUND: Efforts to improve pediatric trauma outcomes need detailed data, optimally collected at lowest cost, to assess processes of care. We developed a novel database by merging 2 national data systems for 5 pediatric trauma centers to provide benchmarking metrics for mortality and non-mortality outcomes and to assess care provided throughout the care continuum. STUDY DESIGN: Trauma registry and Virtual Pediatric Systems, LLC (VPS) from 5 pediatric trauma centers were merged for children younger than 18 years discharged in 2013 from a pediatric ICU after traumatic injury. For inpatient mortality, we compared risk-adjusted models for trauma registry only, VPS only, and a combination of trauma registry and VPS variables (trauma registry+VPS). To estimate risk-adjusted functional status, we created a prediction model de novo through purposeful covariate selection using dichotomized Pediatric Overall Performance Category scale. RESULTS: Of 688 children included, 77.3% were discharged from the ICU with good performance or mild overall disability and 17.6% with moderate or severe overall disability or coma. Inpatient mortality was 5.1%. The combined dataset provided the best-performing risk-adjusted model for predicting mortality, as measured by the C-statistic, pseudo-R2, and Akaike Information Criterion, when compared with the trauma registry-only model. The final Pediatric Overall Performance Category model demonstrated adequate discrimination (C-statistic = 0.896) and calibration (Hosmer-Lemeshow goodness-of-fit p = 0.65). The probability of poor outcomes varied significantly by site (p < 0.0001). CONCLUSIONS: Merging 2 data systems allowed for improved risk-adjusted modeling for mortality and functional status. The merged database allowed for patient evaluation throughout the care continuum on a multi-institutional level. Merging existing data is feasible, innovative, and has potential to impact care with minimal new resources.

Risk factors for mechanical ventilation and reintubation after pediatric heart surgery.

OBJECTIVE: To determine the prevalence of and risk factors associated with the need for mechanical ventilation in children following cardiac surgery and the need for subsequent reintubation after the initial extubation attempt. METHODS: Patients younger than 18 years who underwent cardiac operations for congenital heart disease at one of the participating pediatric intensive care units (ICUs) in the Virtual PICU Systems (VPS), LLC, database were included (2009-2014). Multivariable logistic regression models were fitted to identify factors likely associated with mechanical ventilation and reintubation. RESULTS: A total of 27,398 patients from 62 centers were included. Of these, 6810 patients (25%) were extubated in the operating room (OR), whereas 20,588 patients (75%) arrived intubated in the ICU. Of the patients who were extubated in the OR, 395 patients (6%) required reintubation. In contrast, 2054 patients (10%) required reintubation among the patients arriving intubated postoperatively in the ICU. In adjusted models, patient characteristics, patients undergoing high-complexity operations, and patients undergoing operations in lower-volume centers were associated with higher likelihood for the need for postoperative mechanical ventilation and need for reintubation. Furthermore, the prevalence of mechanical ventilation and reintubation was lower among the centers with a dedicated cardiac ICU in propensity-matched analysis among centers with and without a dedicated cardiac ICU. CONCLUSIONS: This multicenter study suggests that proportion of patients extubated in the OR after heart operation is low. These data further suggest that extubation in the OR can be done successfully with a low complication rate.

Variability in the structure and care processes for critically injured children: A multicenter survey of trauma bay and intensive care units.

PURPOSE: Evaluate national variation in structure and care processes for critically injured children. METHODS: Institutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use. RESULTS: About one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type. CONCLUSION: Variability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care.

Risk factors and outcomes of in-hospital cardiac arrest following pediatric heart operations of varying complexity.

BACKGROUND: Multi center data regarding cardiac arrest in children undergoing heart operations of varying complexity are limited. METHODS: Children <18 years undergoing heart surgery (with or without cardiopulmonary bypass) in the Virtual Pediatric Systems (VPS, LLC) Database (2009-2014) were included. Multivariable mixed logistic regression models were adjusted for patient's characteristics, surgical risk category (STS-EACTS Categories 1, 2, and 3 classified as "low" complexity and Categories 4 and 5 classified as "high" complexity), and hospital characteristics. RESULTS: Overall, 26,909 patients (62 centers) were included. Of these, 2.7% had cardiac arrest after cardiac surgery with an associated mortality of 31%. The prevalence of cardiac arrest was lower among patients undergoing low complexity operations (low complexity vs. high complexity: 1.7% vs. 5.9%). Unadjusted outcomes after cardiac arrest were significantly better among patients undergoing low complexity operations (mortality: 21.6% vs. 39.1%, good neurological outcomes: 78.7% vs. 71.6%). In adjusted models, odds of cardiac arrest were significantly lower among patients undergoing low complexity operations (OR: 0.55, 95% CI: 0.46-0.66). Adjusted models, however, showed no difference in mortality or neurological outcomes after cardiac arrest regardless of surgical complexity. Further, our results suggest that incidence of cardiac arrest and mortality after cardiac arrest are a function of patient characteristics, surgical risk category, and hospital characteristics. Presence of around the clock in-house attending level pediatric intensivist coverage was associated with lower incidence of post-operative cardiac arrest, and presence of a dedicated cardiac ICU was associated with lower mortality after cardiac arrest. CONCLUSIONS: This study suggests that the patients undergoing high complexity operations are a higher risk group with increased prevalence of post-operative cardiac arrest. These data further suggest that patients undergoing high complexity operations can be rescued after cardiac arrest with a high survival rate.

Variation of ventilation practices with center volume after pediatric heart surgery.

BACKGROUND: This study was designed to evaluate the odds of mechanical ventilation and duration of mechanical ventilation after pediatric cardiac surgery across centers of varying center volume using the Virtual PICU Systems database. HYPOTHESIS: Children receiving cardiac surgery at high-volume centers will be associated with lower odds of mechanical ventilation and shorter duration of mechanical ventilation, compared with low-volume centers. METHODS: Patients age <18 years undergoing operations (with or without cardiopulmonary bypass) for congenital heart disease at one of the participating intensive care units in the Virtual PICU Systems database were included (2009-2013). Logistic regression models and Cox proportional hazards models were fitted for the probability of conventional mechanical ventilation and duration of mechanical ventilation, respectively, to investigate the difference in the outcomes between different center volume groups with/without adjustment for other risk factors. RESULTS: A total of 10 378 patients from 43 centers qualified for inclusion. Of these, 7648 (74%) patients received conventional mechanical ventilation after cardiac surgery. Higher center volume was significantly associated with lower odds of mechanical ventilation after cardiac surgery (odds ratio: 2.68, 95% confidence interval: 2.15-3.35). However, patients receiving mechanical ventilation in these centers were associated with longer duration of mechanical ventilation, compared with lower-volume centers (hazard ratio: 1.26, 95% confidence interval: 1.16-1.37). This association was most prominent in the lower surgical-risk categories. CONCLUSIONS: Large clinical practice variations were demonstrated for mechanical ventilation following pediatric cardiac surgery among intensive care units of varied center volumes.

Selective fiberoptic left main-stem intubation for severe unilateral barotrauma in a 24-week premature infant.

A 24-week premature infant developed severe right-sided pulmonary barotrauma secondary to mechanical ventilation for respiratory distress syndrome (RDS). High-frequency oscillatory ventilation and permissive hypercapnia were initiated. A chest tube was placed to relieve a pneumothorax, and a catheter was inserted into an air-filled cyst for drainage. These maneuvers failed to improve the child's respiratory status. The child's left main-stem bronchus was then successfully fiberoptically intubated for single-lung ventilation in order to reduce the unilateral barotrauma. Single-lung ventilation was effectively and safely continued for 5 days, with complete resolution of the pulmonary barotrauma.

Uvulopalatopharyngoplasty with tonsillectomy and adenoidectomy as a treatment for obstructive sleep apnea in neurologically impaired children.

RATIONALE: Children with neurologic impairment often present with airway obstruction that may require intervention. No single method of airway intervention is universally appropriate and effective in this patient population. This study was performed to examine the effectiveness of using adenotonsillectomy and uvulopalatopharyngoplasty (UPPP) in resolving obstructive apnea (OA) in patients with neurologic impairment. METHODS: A retrospective chart review of 15 patients with neurologic impairment and OA treated with adenotonsillectomy and UPPP between 1986 and 1998 at Children's Hospital of Wisconsin (CHW) was performed. All patients in the series had their primary area of obstruction in the posterior oropharynx involving the soft palate, pharyngeal walls and base of tongue. Post-operative improvement following adenotonsillectomy and UPPP was examined. Measures of improvement were based primarily on recorded lowest oxygen saturations, but clinical parameters, flexible upper airway endoscopy and polysomnography were used as well. RESULTS: Patient improvement was documented in 87% of patients treated with this modality. For the group, the mean lowest recorded oxygen saturation demonstrated a statistically significant improvement from 65% pre-operatively to 85% post-operatively (P = 0.005). In long-term follow-up of these patients, 77% (10 of 13) of those showing initial improvement have done well and have required no further airway intervention. However, 23% of these patients demonstrated the need for further airway intervention during follow-up. CONCLUSIONS: Adenotonsillectomy with UPPP is worthy of consideration in certain neurologically impaired patients with moderate to severe OA, limited primarily to the posterior pharyngeal area. Initial improvement may not be permanent and close long-term follow-up of patients is imperative.

Epidemiology and outcomes of in-hospital cardiac arrest in critically ill children across hospitals of varied center volume: a multi-center analysis.

OBJECTIVE: To describe epidemiology and outcomes associated with cardiac arrest among critically ill children across hospitals of varying center volumes. METHODS: Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009-2013) were included. Patients with both cardiac and non-cardiac diagnoses were included. Data on demographics, patient diagnosis, cardiac arrest, severity of illness and outcomes were collected. Hierarchical cluster analysis was performed to categorize all the participating centers into low, low-medium, high-medium, and high volume groups using the center volume characteristics (annual hospital discharges per center, annual extracorporeal membrane oxygenation per center, and annual mechanical ventilators per center). Multivariable models were used to evaluate association of center volume with incidence of cardiac arrest, and mortality after cardiac arrest, adjusting for patient and center characteristics. RESULTS: Of 329,982 patients (108 centers), 2.2% (n=7390) patients had cardiac arrest with an associated mortality of 35% (n=2586). In multivariable models controlling for patient and center characteristics, center volume was not associated with either the incidence of cardiac arrest (OR: 1.00; 95% CI: 0.95-1.06; p=0.98), or mortality in those with cardiac arrest (OR: 0.93; 95% CI: 0.82-1.06; p=0.27). These associations were similar across cardiac and non-cardiac disease categories. Furthermore, we demonstrated that there was no correlation between incidence of cardiac arrest and mortality in those with cardiac arrest across different study hospitals in adjusted models. CONCLUSIONS: Both incidence of cardiac arrest, and mortality in those with cardiac arrest vary substantially across hospitals. However, center volume is not associated with either of these outcomes, after adjusting for patient and center characteristics.