Association of Hyperoxia During Cardiopulmonary Bypass and Postoperative Delirium in the Pediatric Cardiac ICU.

OBJECTIVE: ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium. DESIGN: Secondary analysis of data obtained from a prospective cohort study. SETTING: Twenty-two-bed pediatric cardiac ICU in a tertiary children's hospital. PATIENTS: All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605-2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668-2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752-2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859-1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918-1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. -0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05). CONCLUSIONS: Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.

The Physical Abilities and Mobility Scale as a New Measure of Functional Progress in the PICU.

Assessing functional motor changes and their relationship to discharge needs in the pediatric intensive care unit (PICU) population is difficult given challenges quantifying small functional gains with current tools. Therefore, we compared the Physical Abilities and Mobility Scale (PAMS) to the Functional Status Scale (FSS) in PICU patients to assess correlation and differences and association with discharge needs. This study was a retrospective chart review of all patients (2-18 years old) admitted to the PICU and cardiac PICU for over 9 months who received early mobility services, including PAMS and FSS scoring. Correlation between scales, relationship of scores to disposition, and logistic regression model of changes in PAMS in relation to disposition were determined. Data were obtained for 122 patients. PAMS and FSS scores strongly negatively correlated (Spearman's ρ = - 0.85), but with a nonlinear relationship, as the PAMS more readily differentiated among patients with higher functional status. The median FSS at discharge was 12.5 for those recommended an inpatient rehabilitation facility (IRF) ( n = 24), versus 9 for those recommended discharge home ( n = 83, Δ 3.5, 95% confidence interval [CI]: 1-6, around one-tenth of FSS scale). The corresponding median PAMS were 42 and 66 (Δ 24, 95% CI: 10-30, one-fourth of PAMS scale). Although not statistically significant, a logistic regression model was consistent with patients who showed modest change in PAMS across hospitalization but persistent deficits (PAMS < 60) were more likely to be recommended an IRF. The PAMS correlates to the FSS, but appears more sensitive to small functional changes, especially in higher functioning patients. It may be useful in prognosticating discharge needs.

Early Estimate of Nirsevimab Effectiveness for Prevention of Respiratory Syncytial Virus-Associated Hospitalization Among Infants Entering Their First Respiratory Syncytial Virus Season - New Vaccine Surveillance Network, October 2023-February 2024.

Respiratory syncytial virus (RSV) is the leading cause of hospitalization among infants in the United States. In August 2023, CDC's Advisory Committee on Immunization Practices recommended nirsevimab, a long-acting monoclonal antibody, for infants aged <8 months to protect against RSV-associated lower respiratory tract infection during their first RSV season and for children aged 8-19 months at increased risk for severe RSV disease. In phase 3 clinical trials, nirsevimab efficacy against RSV-associated lower respiratory tract infection with hospitalization was 81% (95% CI = 62%-90%) through 150 days after receipt; post-introduction effectiveness has not been assessed in the United States. In this analysis, the New Vaccine Surveillance Network evaluated nirsevimab effectiveness against RSV-associated hospitalization among infants in their first RSV season during October 1, 2023-February 29, 2024. Among 699 infants hospitalized with acute respiratory illness, 59 (8%) received nirsevimab ≥7 days before symptom onset. Nirsevimab effectiveness was 90% (95% CI = 75%-96%) against RSV-associated hospitalization with a median time from receipt to symptom onset of 45 days (IQR = 19-76 days). The number of infants who received nirsevimab was too low to stratify by duration from receipt; however, nirsevimab effectiveness is expected to decrease with increasing time after receipt because of antibody decay. Although nirsevimab uptake and the interval from receipt of nirsevimab were limited in this analysis, this early estimate supports the current nirsevimab recommendation for the prevention of severe RSV disease in infants. Infants should be protected by maternal RSV vaccination or infant receipt of nirsevimab.

Vascular thrombosis after pediatric liver transplantation: Is prevention achievable?

Background: Vascular thromboses (VT) are life-threatening events after pediatric liver transplantation (LT). Single-center studies have identified risk factors for intra-abdominal VT, but large-scale pediatric studies are lacking. Methods: This multicenter retrospective cohort study of isolated pediatric LT recipients assessed pre- and perioperative variables to determine VT risk factors and anticoagulation-associated bleeding complications. Results: Within seven postoperative days, 31/331 (9.37%) patients developed intra-abdominal VT. Open fascia occurred more commonly in patients with VT (51.61 vs 23.33%) and remained the only independent risk factor in multivariable analysis (OR = 2.84, p = 0.012). Patients with VT received more blood products (83.87 vs 50.00%), had significantly higher rates of graft loss (22.58 vs 1.33%), infection (50.00 vs 20.60%), and unplanned return to the operating room (70.97 vs 16.44%) compared to those without VT. The risk of bleeding was similar (p = 0.2) between patients on and off anticoagulation. Conclusions: Prophylactic anticoagulation did not increase bleeding complications in this cohort. The only independent factor associated with VT was open fascia, likely a graft/recipient size mismatch surrogate, supporting the need to improve surgical techniques to prevent VT that may not be modifiable with anticoagulation.

An evidence-based protocol for sensory soothing in paediatric intensive care.

In recent years, an increasing body of literature has highlighted the significant sequelae of a paediatric intensive care unit admission for children and their families. More innovative bedside approaches are needed to support children's coping and development and help minimize the use of sedatives, given their known deleterious effects. To support nursing staff in managing agitation in critically ill infants and children, a 'Sensory Pyramid' program was built in collaboration with occupational therapists, child life specialists and critical care nursing staff at an academic medical center in the United States. Anchored in evidence-based and developmentally appropriate non-pharmacologic sensory soothing techniques, the protocol outlines escalating comfort interventions nurses can employ that are safe and feasible for implementation by bedside staff and families.

Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury.

OBJECTIVES: The acute cerebral physiologic effects of ketamine in children have been incompletely described. We assessed the acute effects of ketamine on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children with severe traumatic brain injury (TBI). DESIGN: In this retrospective observational study, patients received bolus doses of ketamine for sedation or as a treatment for ICP crisis (ICP > 20 mm Hg for > 5 min). Administration times were synchronized with ICP and CPP recordings at 1-minute intervals logged in an automated database within the electronic health record. ICP and CPP were each averaged in epochs following drug administration and compared with baseline values. Age-based CPP thresholds were subtracted from CPP recordings and compared with baseline values. Trends in ICP and CPP over time were assessed using generalized least squares regression. SETTING: A 30-bed tertiary care children's hospital PICU. PATIENTS: Children with severe TBI who underwent ICP monitoring. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed data from 33 patients, ages 1 month to 16 years, 22 of whom received bolus doses of ketamine, with 127 doses analyzed. Demographics, patient, and injury characteristics were similar between patients who did versus did not receive ketamine boluses. In analysis of the subset of ketamine doses used only for sedation, there was no significant difference in ICP or CPP from baseline. Eighteen ketamine doses were given during ICP crises in 11 patients. ICP decreased following these doses and threshold-subtracted CPP rose. CONCLUSIONS: In this retrospective, exploratory study, ICP did not increase following ketamine administration. In the setting of a guidelines-based protocol, ketamine was associated with a reduction in ICP during ICP crises. If these findings are reproduced in a larger study, ketamine may warrant consideration as a treatment for intracranial hypertension in children with severe TBI.

Critical Care and Mechanical Ventilation Practices Surrounding Liver Transplantation in Children: A Multicenter Collaborative.

OBJECTIVES: We aimed to determine which characteristics and management approaches were associated with postoperative invasive mechanical ventilation (IMV) and with a prolonged course of IMV in children post liver transplant as well as describing the utilization of critical care resources. DESIGN: Retrospective, multicenter, cohort study of children who underwent an isolated liver transplantation between January 2017 and December 2018. SETTING: Twelve U.S., pediatric, liver transplant centers. PATIENTS: Three hundred thirty children post liver transplant admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six patients died in our cohort. The median length of PICU stay was 4.5 days (interquartile range [IQR], 2.9-8.2 d). Most patients were initially monitored with arterial catheters (96%), central venous pressures (95%), and liver ultrasound (93%). Anticoagulation (80%), blood product administration (52.4%), and vasoactive agents (23.0%) were commonly used therapies in the first 7 days. In multivariable logistic regression analysis, age (adjusted odds ratio [aOR] 0.9 [0.86-0.95]), open fascia (aOR 7.0 [95% CI, 2.6-18.9]), large center size (aOR 4.3 [95% CI 2.2-8.3]), and higher Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores (aOR 1.04 [95% CI, 1.01-1.06]) were associated with postoperative IMV. In multivariable logistic regression analysis, postoperative day 0 peak inspiratory pressure (PIP) (aOR 1.2 [95% CI, 1.1-1.3]), large center size (aOR 2.9 [95% CI, 1.6-5.4]), and age (aOR 0.89 [95% CI, 0.85-0.95]) were associated with length of IMV greater than 24 hours. Length of IMV greater than 24 hours was associated with bleeding complications ( p = 0.03), infections ( p = 0.03), graft loss ( p = 0.02), and reoperation ( p = 0.03). CONCLUSIONS: Younger age, preoperative hospitalization, large center size, and open fascia are associated with use of IMV, and younger age, large center size, and postoperative day 0 PIP are associated with prolonged IMV on multivariable analysis. Longer IMV is associated with negative outcomes, making it an important clinical marker.

Improving Delirium Assessments in Vanderbilt Pediatric and Pediatric Cardiovascular Intensive Care Units.

Introduction: Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments. Methods: We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children's Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool. Results: Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022. Conclusions: Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.

Caregiver perceptions of an early mobility and communication protocol in the pediatric ICU.

PURPOSE: Early mobility (EM) and patient communication have known benefits for critically ill patients, but perceived barriers exist, notably related to family and caregiver concerns. Caregiver perceptions of an EM and communication therapy protocol in the pediatric intensive care unit (PICU) were assessed. METHODS: Caregivers of PICU patients at a free-standing academic children's hospital completed a survey using a Likert-type agreement scale on their perceptions surrounding the safety of EM, benefits of EM and communication, and barriers to EM and communication services. RESULTS: Forty caregivers completed the survey. Most agreed or strongly agreed that EM helped their child get stronger (76%), improved their child's mood (57%), helped them to be involved in their child's care (86%), and improved their child's overall experience (78%). Most disagreed with statements relating to EM causing fear or pain (57%). Caregivers agreed that communication therapy improved overall ICU experience (75%). Free-text comments emphasized meaningful relationships with rehabilitation and unit staff. CONCLUSION: Caregivers perceived EM and communication interventions as enriching to their child's ICU experience and the majority did not perceive that EM caused fear or pain.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility.

RATIONALE: A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE: To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN: The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS: Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS: The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS: The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Prospective Validation of the Preschool Confusion Assessment Method for the ICU to Screen for Delirium in Infants Less Than 6 Months Old.

OBJECTIVES: ICU delirium is a predictor of greater morbidity and higher mortality in the pediatric population. The diagnostic obstacles and validity of delirium monitoring among neonates and young infants have yet to be fully delineated. We sought to validate the Preschool Confusion Assessment Method for the ICU in neonates and young infants and determine delirium prevalence in this young population. DESIGN: Prospective cohort study to validate the Preschool Confusion Assessment Method for the ICU for the assessment of ICU delirium in neonates and young infants compared with the reference standard, Child and Adolescent Psychiatry. SETTING: Tertiary medical center PICU, including medical, surgical, and cardiac patients. PARTICIPANTS: Infants less than 6 months old admitted to the PICU regardless of admission diagnosis. MEASUREMENTS AND MAIN RESULTS: We enrolled 49 patients with a median age of 1.8 months (interquartile range, 0.7-4.1 mo), 82% requiring mechanical ventilation. Enrolled patients were assessed for delirium in blinded-fashion by the research team using the Preschool Confusion Assessment Method for the ICU and independently assessed by the psychiatry reference rater using Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A total of 189 paired assessments were completed, and the Preschool Confusion Assessment Method for the ICU performed with a sensitivity of 95% (95% CI, 89-100%), specificity of 81% (68-90%), "negative and positive predictive values" of 97% (94-100%) and 69% (55-79%), respectively, compared with the reference rater. Delirium prevalence was 47%, with higher rates of 61% observed among neonates (< 1 mo old) and 39% among infants 1-6 months old. CONCLUSIONS: The Preschool Confusion Assessment Method for the ICU is a valid screening tool for delirium monitoring in infants less than 6 months old. Delirium screening was feasible in this population despite evolving neurocognition and arousal architecture. ICU delirium was prevalent among infants. The consequence of acute brain dysfunction during crucial neurocognitive development remains unclear. Future studies are necessary to determine the long-term impact of ICU delirium and strategies to reduce associated harm in critically ill infants.

Utilization of ICU Rehabilitation Services in Pediatric Patients With a Prolonged ICU Stay.

OBJECTIVES: To describe rehabilitation practice patterns among critically ill children with prolonged ICU stays and explore the association between institution-level utilization of rehabilitative services and patient outcomes. DESIGN: Retrospective cohort study using an administrative database of inpatient clinical and resource utilization data from participating pediatric hospitals in the United States. Center-level utilization of physical therapy and occupational therapy among critically ill patients was used to divide hospitals by quartile into high utilization centers or standard utilization centers. SETTING: Fifty-one pediatric hospitals in the United States. PATIENTS: Critically ill pediatric patients with prolonged critical illness (defined as an ICU length of stay of at least 7 d) discharged from July 2016 to June 2017. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Seventeen thousand four hundred seventy encounters met criteria for study inclusion. Of those, 6,040 (35%) were not charged for either physical therapy or occupational therapy services. There was wide variability in center-level utilization of rehabilitative services while in the ICU, ranging from 81% utilization of physical therapy or occupational therapy services among high utilization centers to 46% utilization among centers within the lowest quartile. In univariate analyses, children cared for at an high utilization center were less likely to require discharge to an inpatient rehabilitation facility (1.7% vs 3.5%; p < 0.001) and less likely to incur a new pressure injury (2.2% vs 3.1%; p = 0.001). In multivariable analyses, the direction and magnitude of effects remained similar, although the effect was no longer statistically significant (discharge to inpatient rehabilitation facility: odds ratio, 0.64; 95% CI, 0.18-2.26; pressure injury: odds ratio, 0.77; 95% CI, 0.48-1.24). CONCLUSIONS: Institutional use of rehabilitative services for children with prolonged critical illness varies greatly in the United States. Further research is needed into the potential benefits for patients cared for at centers with high usage of rehabilitation services in the ICU during prolonged critical illness.

Improving assessment of child growth in a pediatric hospital setting.

BACKGROUND: Accurate anthropometric measurements are essential for assessing nutritional status, monitoring child growth, and informing clinical care. We aimed to improve height measurements of hospitalized pediatrics patients through implementation of gold standard measurement techniques. METHODS: A quality improvement project implemented computerized training modules on anthropometry and standardized wooden boards for height measurements in a tertiary children's hospital. Heights were collected pre- and post-intervention on general pediatric inpatients under 5 years of age. Accuracy of height measurements was determined by analyzing the variance and by comparing to World Health Organization's defined biologically plausible height-for-age z-scores. Qualitative interviews assessed staff attitudes. RESULTS: Ninety-six hospital staff completed the anthropometry training. Data were available on 632 children pre- and 933 post-intervention. Training did not increase the proportion of patients measured for height (78.6% pre-intervention vs. 75.8% post-intervention, p = 0.19). Post-intervention, wooden height boards were used to measure height of 34.8% patients, while tape measures and wingspan accounted for 42.0% and 3.5% of measurements, respectively. There was no improvement in the quality of height measurements based on plausibility (approximately 3% height-for-age z-scores measurements flagged out of range pre- and post-intervention), digit preference (13.4% of digits pre- and 12.3% post-intervention requiring reclassification), or dispersion of measurements (height-for-age z-scores standard deviation 1.9 pre- and post-intervention). Staff reported that using the wooden board was too labor consuming and cumbersome. CONCLUSIONS: Our findings suggest that efforts to improve anthropometric measurements of hospitalized children have multiple obstacles, and further investigation of less cumbersome methods of measurements may be warranted.

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics.

PURPOSE OF REVIEW: We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting. RECENT FINDINGS: Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition. SUMMARY: Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.

Changes in Provider Perceptions Regarding Early Mobility in the PICU.

OBJECTIVES: Early mobility in the PICU is safe and feasible. However, PICUs continue to meet barriers to implementing early mobility. PICU providers were surveyed before and after initiating an early mobility protocol to determine perceived barriers and continued challenges in performing early mobility. DESIGN: This single-center prospective study surveyed PICU providers regarding 26 potential barriers to early mobility using a five-point Likert scale. A survey was distributed 1 month prior to and 6 months after beginning an early mobility protocol. SETTING: Free-standing academic tertiary care children's hospital. SUBJECTS: PICU providers of various professions. INTERVENTIONS: Implementation of PICU-wide early mobility protocol. MEASUREMENTS AND MAIN RESULTS: Paired pre- and post-early mobility protocol implementation surveys from 97 providers were compared. System-based barriers decreased after implementation of the early mobility protocol, such as lack of guidelines (75-20%; p < 0.01), inadequate training (74-33%; p < 0.01), lack of early mobility orders (72-30%; p < 0.01), and delayed recognition of early mobility candidates (68-35%; p < 0.01). Difficulty coordinating early mobility sessions, although significantly decreased, still remained a concern for 66% of providers in the postsurvey. Lack of resources, specifically staff (85-82%; p = 0.68) and equipment (67-60%; p = 0.36), also remained significant barriers. Presence of an endotracheal tube was a barrier for only 29% of providers' post-early mobility protocol, compared with 69% prior (p < 0.01). Clinical instability remained a top concern (82-79%; p = 0.63) as well as agitation (74-67%; p = 0.23). Day shift providers, with more early mobility exposure, perceived fewer barriers compared with night shift providers. Ninety percentage of post-early mobility survey participants felt that early mobility positively impacted their patients. CONCLUSIONS: Implementation of an early mobility protocol significantly changed provider perceptions regarding barriers to early mobility. Certain factors, such as staff availability, coordination difficulty, equipment shortage, and patient clinical factors, continue to be significant challenges to early mobility in the PICU population.

Development and implementation of an early mobility program for mechanically ventilated pediatric patients.

PURPOSE: Early mobility (EM) is being used in adult ICUs in an effort to treat and prevent intensive care unit acquired weakness (ICU-AW) and Post-Intensive Care Syndrome (PICS). Data supports children suffer from ICU-AW and PICS as well. Our objective was to create and implement an EM protocol for pediatric patients receiving invasive mechanical ventilation. METHODS: A multidisciplinary EM committee was formed to create and implement an EM protocol in a quarternary care PICU. A quality database was used to prospectively monitor patient tolerance of EM sessions and for serious adverse events, defined as unplanned extubation, hemodynamic instability, loss of central venous line, loss of arterial line, displacement of ECMO cannula, or cardiopulmonary arrest. RESULTS: Between December 2013 and October 2016, 74 patients received EM for a total of 130 unique sessions. No serious adverse events occurred. Two patients had an oxygen desaturation episode during mobility that resolved with ventilator modifications, and one patient had nasogastric tube displacement during mobility. CONCLUSIONS: Early mobility is attainable in a quaternary care PICU population without serious adverse events, using a multidisciplinary approach and appropriate staff education. Further research is needed to understand the physical and neurocognitive benefits of EM in children.

A Novel Weaning Protocol for High-Flow Nasal Cannula in the PICU.

OBJECTIVE: High-flow nasal cannula use in the PICU continues to increase; however, a protocol for weaning patients has yet to be published. This study aimed to create an efficient and safe protocol for weaning high-flow nasal cannula. DESIGN: A Respiratory Assessment Score was created using two validated scoring systems. A protocol was established for set "holidays" off high-flow nasal cannula, where nasal cannula flow was reduced to age-based low-flow nasal cannula rates if Respiratory Assessment Scores met certain criteria. SETTING: The PICU at Children's Healthcare of Atlanta at Egleston, a quaternary level hospital affiliated with Emory University. PATIENTS: Patients treated in the PICU with high-flow nasal cannula from August 2013 to March 2014. Exclusions included apnea, heliox therapy, oxygen saturations less than 92% with a FIO2 greater than 50%, admitted to PICU less than 6 hours, progression to intubation prior to scoring, or those ordered by physician to not receive holidays based on clinical status. INTERVENTIONS: Patients who qualified for a "holiday" based on Respiratory Assessment Score were trialed off high-flow nasal cannula and rescored afterwards to assess tolerance. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-three patients were treated with high-flow nasal cannula, with the most common diagnosis being bronchiolitis (43%). Of these 133 patients, 119 (89.5%) successfully weaned to low-flow nasal cannula within four holiday attempts. Eighty-three patients (70%) weaned with only one attempt. Fourteen patients (10.5%) failed to wean. Reasons for failure were reintubation, increasing flow on high-flow nasal cannula, too high of Respiratory Assessment Score to meet weaning criteria, or slow weaning after failed attempts. Holidays did not precipitate clinical deterioration or lead to immediate intubation. CONCLUSIONS: Our study suggests that a high-flow nasal cannula "holiday" protocol is a safe and effective way to successfully wean PICU patients off high-flow nasal cannula. Additional investigation including validation of the scoring system used is warranted.

High flow nasal cannula use outside of the ICU; factors associated with failure.

OBJECTIVES: High flow nasal cannula (HFNC) use is increasing in pediatrics. Few studies exist examining the safety of HFNC use outside the intensive care unit (ICU). This study aimed to characterize patient qualities associated with failure of HFNC use outside the ICU. STUDY DESIGN: A retrospective chart review of patients placed on HFNC outside the ICU from September 2011 to July 2013 was completed. Failure was defined as intubation or cardiopulmonary arrest. Two-sample tests and binary logistic regression determined significant factors associated with failed HFNC administration, both unadjusted and adjusted for hospital. RESULTS: Two hundred thirty-one patients met inclusion criteria, with 192 receiving treatment for a primary respiratory diagnosis (83%). Fourteen (6%) progressed to HFNC failure; 12 transferred to the ICU and were intubated, two with congenital heart disease suffered cardiopulmonary arrest on the floor. Two-sample tests revealed failure patients were more likely to have a cardiac history (P = 0.026), history of intubation (P = 0.040), and require higher fraction of inspired oxygen (FiO2 ) (median 100%; 25th-75th 60-100%; P = <0.001). Hospital adjusted logistic regression further demonstrated failure patients were more likely to be treated with higher FiO2 (OR: 38.3; 95% CI: 4.0-366.3; P = 0.002), and less likely to have a diagnosis of bronchiolitis (OR: 0.3; 95% CI: 0.1-0.9; P = 0.048). CONCLUSIONS: High FiO2 requirements, history of intubation, and cardiac co-morbidity are associative predictors of HFNC failure. Bronchiolitis patients may be treated with HFNC outside of the ICU with lower odds of failure. Pediatr Pulmonol. 2017;52:806-812. © 2017 Wiley Periodicals, Inc.