Early Rehabilitation in Critically ill Children: A Two Center Implementation Study.

OBJECTIVES: To implement an early rehabilitation bundle in two Canadian PICUs. DESIGN AND SETTING: Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2). PATIENTS: All children under 18 years old admitted to the PICU were eligible for the intervention. INTERVENTIONS: A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement. CONCLUSIONS: A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Native Aortic Valve Infective Endocarditis Secondary to Community-Acquired Methicillin-Resistant Staphylococcus aureus: A Case Report and Literature Review.

Infective endocarditis (IE) refers to a microbial infection affecting either a heart valve or endocardium, resulting in tissue damage and the formation of vegetation. Native aortic valve endocarditis in children is rare and is associated with serious complications related to valvular insufficiency and systemic embolizations. As reports about community-acquired methicillin-resistant Staphylococcus aureus (MRSA) native aortic valve endocarditis in children are very scarce, we report this case along with a literature review about its complications and management. Here, we report the case of a seven-month-old infant who was previously healthy and presented with signs and symptoms of shock and systemic embolizations secondary to native aortic valve IE. His blood culture showed MRSA. He developed aortic valve insufficiency heart failure and multiorgan septic emboli that progressed to fatal refractory multiorgan failure. The management of complicated aortic valve endocarditis in children is challenging and needs a multidisciplinary team approach and prompt intervention.

Critical pertussis: A multi-centric analysis of risk factors and outcomes in Oman.

OBJECTIVES: To identify risk factors and outcomes of patients with critical pertussis. DESIGN: Retrospective observational cohort study. SETTING: Sultan Qaboos University Hospital and The Royal Hospital, Muscat, Oman. SUBJECTS: Children aged <13 years presenting to the emergency departments and diagnosed with laboratory-confirmed pertussis by polymerase chain reaction between January 2013 and December 2018. MEASUREMENTS AND MAIN RESULTS: In total, 157 patients were diagnosed with pertussis, of which 12% (n = 19) had critical pertussis. Patients with critical pertussis had a higher white blood cell count (WBCC) [adjusted odds ratio (aOR) 1.05; 95% confidence interval (CI) 1.02-1.08; P = 0.003], absolute lymphocyte count (ALC) (aOR 1.08; 95% CI 1.03-1.15; P = 0.004) and absolute neutrophil count (ANC) (aOR 1.05; 95% CI 1.01-1.10; P = 0.032) than patients with non-critical pertussis, even after multi-variate adjustment. The area under the curve for discriminatory accuracy of laboratory variables was 0.75 (95% CI 0.65-0.85), 0.74 (95% CI 0.64-0.84) and 0.72 (95% CI 0.60-0.83) for maximum WBCC, ALC and ANC, respectively, with Youden's cut-off values of 31.5 × 109/L, 19.9 × 109/L and 5.0 × 109/L, respectively. CONCLUSIONS: In children, higher WBCC, ALC and ANC were significant predictors of critical pertussis. A cut-off level of 31.5 × 109/L for WBCC was associated with critical pertussis.

Life threatening hyperkalemia treated with prolonged continuous insulin infusion.

Hyperkalemia is a life threatening electrolyte imbalance that may be fatal if not treated appropriately. There are multiple medications used to treat hyperkalemia to lower it to a safe level. We report a case of a 4-month old infant with Pseudohypoaldosteronism who had cardiac arrest secondary to severe hyperkalemia of 12.3mmol/l. It was refractory to anti hyperkalemic medications that necessitated the transfer of the patient to a tertiary hospital for dialysis. The potassium level has dropped gradually to a normal level with continuous insulin infusion and dextrose for almost 12 hours that waved the need of the dialysis. This case highlights the effectiveness of prolonged continuous insulin infusion in treating life-threatening hyperkalemia especially in hospitals where there are no dialysis services available or until the dialysis is initiated.