Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations.

When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of "living guidelines," whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.

Current Epidemiology of Vocal Cord Dysfunction After Congenital Heart Surgery in Young Infants.

OBJECTIVES: Surgery of the aortic arch poses risk of recurrent laryngeal nerve injury due to the anatomic proximity and can manifest as vocal cord dysfunction after surgery. We assessed risk factors for vocal cord dysfunction and calculated surgical procedure associated rates in young infants after congenital heart surgery. DESIGN: Cross section analysis. SETTING: Forty-four children's hospitals reporting administrative data to Pediatric Health Information System. PARTICIPANTS: Cardiac surgical patients less than or equal to 90 days old and discharged between January 2004 and June 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Overall, 2,319 of 46,567 subjects (5%) had vocal cord dysfunction, increasing from 4% to 7% over the study period. Of those with vocal cord dysfunction, 75% had unilateral partial paralysis. Vocal cord dysfunction was significantly more common in newborn infants (74%), those with aortic arch procedures (77%) and with greater surgical complexity. Rates of vocal cord dysfunction ranged from 0.7% to 22.4% across surgical procedure groups. Vocal cord dysfunction was significantly associated with greater use of: prolonged mechanical ventilation (53% vs 40%), diaphragmatic plication (3% vs 1%), feeding tube use (32% vs 8%), surgical airways (4% vs 2%), and prolonged length of stay (44 vs 21 d). Vocal cord dysfunction testing increased significantly over the study (6-14 %), and vocal cord dysfunction diagnosis increased almost two-fold (odds ratio, 1.9; 95% CI, 1.7-2.1) comparing the last to first study quarters with the increase in vocal cord dysfunction diagnosis occurring predominately in surgeries to the aortic arch supported by cardiopulmonary bypass. However, aortic procedures without cardiopulmonary bypass and nonaortic arch procedures were common surgeries accounting for 27% and 23% of vocal cord dysfunction cases despite low overall vocal cord dysfunction rates (3.7% and 2.6%). CONCLUSIONS: Vocal cord dysfunction complicated all cardiac surgical procedures among infants including those without aortic arch involvement. Increased efforts to determine appropriate indications for prevention, screening and treatment of vocal cord dysfunction among young infants after congenital heart surgery are needed.

Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies.

OBJECTIVES: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury. DATA SOURCES: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies. DATA SYNTHESIS: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies. CONCLUSIONS: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals.

OBJECTIVE: Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children's hospitals. DESIGN: All adults (≥18 years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO-free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes. SETTING: Tertiary care children's hospitals. RESULTS: A total of 4665 adult patients underwent ACHD surgery in 39 children's hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO. CONCLUSIONS: There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.

Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery.

OBJECTIVES: Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival. METHODS: All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed. RESULTS: Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO. CONCLUSIONS: Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.

Hemoglobin Level at Stage 1 Discharge has No Impact on Inter-stage Growth and Stability in Single Ventricle Infants.

Hemoglobin levels (Hgb) of infants with a single ventricle (SV) are traditionally maintained high to maximize oxygen-carrying capacity during stage 1 palliation (S1P), stage 2 palliation (S2P), and between stages (IS). A single-center observational cohort study was performed to determine if red blood cell transfusion during the convalescent phase of the S1P (late S1P transfusion) to achieve higher Hgb is associated with benefits during the IS including improved growth and decreased acute medical events. 137 infants <1 year with SV with SIP undergoing care from January 2008 to June 2015 were retrospectively evaluated. 78 (57%) infants received a late S1P transfusion. Median Hgb at S1P discharge was 15.9 g/dL (IQR 14.7-17.1) and median Hgb S2P at admission was 15.3 g/dL (IQR 14-16.3). Median daily weight gain was 22 g/day during IS (IQR 17-26) and median daily length gain was 0.09 cm (IQR 0.06-0.11). Hgb at SIP discharge was not associated with IS growth or fewer IS acute events. However, late S1P transfusions were associated with illness severity at S1P and more complicated S1P care. Our data suggest that SV infants after S1P, who are steadily recovering, do not benefit from late transfusion to raise their hemoglobin level at discharge.

Use of Extracorporeal Membrane Oxygenation and Mortality in Pediatric Cardiac Surgery Patients With Genetic Conditions: A Multicenter Analysis.

OBJECTIVE: Congenital heart disease is commonly a manifestation of genetic conditions. Surgery and/or extracorporeal membrane oxygenation were withheld in the past from some patients with genetic conditions. We hypothesized that surgical care of children with genetic conditions has increased over the last decade, but their cardiac extracorporeal membrane oxygenation use remains lower and mortality greater. DESIGN: Retrospective cohort study. SETTING: Patients admitted to the Pediatric Health Information System database 18 years old or younger with cardiac surgery during 2003-2014. Genetic conditions identified by International Classification of Diseases, 9th Edition codes were grouped as follows: trisomy 21, trisomy 13 or 18, 22q11 deletion, and all "other" genetic conditions and compared with patients without genetic condition. PATIENTS: A total of 95,253 patients met study criteria, no genetic conditions (85%), trisomy 21 (10%), trisomy 13 or 18 (0.2%), 22q11 deletion (1%), and others (5%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Annual surgical cases did not vary over time. Compared to patients without genetic conditions, trisomy 21 patients, extracorporeal membrane oxygenation use was just over half (odds ratio, 0.54), but mortality with and without extracorporeal membrane oxygenation were similar. In trisomy 13 or 18 patients, extracorporeal membrane oxygenation use was similar to those without genetic condition, but all five treated with extracorporeal membrane oxygenation died. 22q11 patients compared with those without genetic condition had similar extracorporeal membrane oxygenation use, but greater odds of extracorporeal membrane oxygenation mortality (odds ratio, 3.44). Other genetic conditions had significantly greater extracorporeal membrane oxygenation use (odds ratio, 1.22), mortality with extracorporeal membrane oxygenation (odds ratio, 1.42), and even greater mortality odds without (odds ratio, 2.62). CONCLUSIONS: The proportion of children undergoing cardiac surgery who have genetic conditions did not increase during the study. Excluding trisomy 13 or 18, all groups of genetic conditions received and benefited from extracorporeal membrane oxygenation, although extracorporeal membrane oxygenation mortality was greater for those with 22q11 deletion and other genetic conditions.

Pediatricians' Knowledge, Attitudes, and Behaviors to Screening Children After Complicated Mild TBI: A Survey.

OBJECTIVE: To understand pediatricians' attitudes, knowledge, and behaviors about the care of children with complicated mild traumatic brain injury (TBI). PARTICIPANTS: A total of 3500 pediatricians randomly selected from the American Medical Association Master File. DESIGN: It was a cross-sectional survey. MAIN MEASURES: A survey developed to assess pediatricians' attitudes toward following children with complicated mild TBI for cognitive and behavioral sequelae; their knowledge of TBI sequelae; and their usual evaluation and management of children after TBI. RESULTS: There were 576 (16.5%) completed responses. Most pediatricians (51%) see 1 or 2 patients with complicated mild TBI annually. Most do not think that pediatricians are the correct clinician group to be primarily responsible for following children with complicated mild TBI for cognitive (74%) or behavioral sequelae (54%). Pediatricians report difficulty referring children for cognitive (56%) and behavioral (48%) specialty services. Pediatricians have good knowledge of short-term complications of complicated mild TBI. CONCLUSION: Pediatricians do not think they are the clinicians that should primarily care for children after hospitalization for complicated mild TBI; however, other clinicians are frequently not accessible. Pediatricians need educational and referral support to provide surveillance for injury sequelae in this group of children.

Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs.

OBJECTIVES: Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. DESIGN: Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. PATIENTS: All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS: Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.

Reducing Pediatric Sternal Wound Infections: A Quality Improvement Project.

OBJECTIVES: To evaluate whether a quality improvement intervention reduces sternal wound infection rates in children after cardiac surgery. DESIGN: This is a pre- and postintervention quality improvement study. SETTING: A 16-bed cardiac ICU in a university-affiliated pediatric tertiary care children's hospital. PATIENTS: All patients undergoing cardiac surgery via median sternotomy from January 2010 to December 2014 are included. The sternal wound infection rates for primary closure and delayed sternal closure are reported per 100 sternotomies. The hospital-acquired infection records were used to identify preintervention cases, while postintervention cases were collected prospectively. INTERVENTION: Implementation of a sternal wound prevention bundle during the preoperative, intraoperative, and postoperative periods for cardiac surgical cases. MEASUREMENTS AND MAIN RESULTS: During the preintervention period, 32 patients (3.8%) developed sternal wound infection, whereas only 19 (2.1%) developed sternal wound infection during the postintervention period (p = 0.04). The rates of sternal wound infection following primary closure were not significantly different pre- and postintervention (2.4% vs 1.6%; p = 0.35). However, patients with delayed sternal closure had significantly lower postintervention infection rates (10.6% vs 3.9%; p = 0.02). CONCLUSIONS: Implementation of a sternal wound prevention bundle during the perioperative period was associated with lower sternal wound infection rates in surgeries with delayed sternal closure.

Association of Pediatric Cardiac Surgical Volume and Mortality After Cardiac ECMO.

Centers with higher surgical and extracorporeal membrane oxygenation (ECMO) volumes have improved survival for children undergoing pediatric cardiac surgery and ECMO, respectively. We examined the relationship between both cardiac surgical and cardiac ECMO volumes, with survival. Using data from the Pediatric Health Information System, we reviewed patients who underwent ECMO during the hospitalization for cardiac surgery or heart transplantation from January 2003 to June 2014. Among 106,967 patients in 43 centers undergoing a Risk Adjustment for Congenital Heart Surgery-1 1-6 procedure (n = 104,951) or cardiac transplantation (n = 2,016), 2.9% (n = 3,069) underwent ECMO support. Centers were categorized into volume quartiles based on annual ECMO and cardiac surgical volumes. Multivariable logistic regression models controlling for clustering by center and adjusting for factors associated with mortality were constructed. Although mortality was lower in ECMO centers that performed ≥7 ECMO runs (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.22-0.88)] and centers performing ≥158 cardiac surgical cases (OR: 0.37, 95% CI: 0.22-0.63), surgical volume was more strongly associated with ECMO mortality. Centers with higher cardiac surgical volume had fewer ECMO complications. Cardiac surgical volume, compared with ECMO volume, is more strongly associated with cardiac ECMO survival.

Spontaneous Fatal Intraoperative Rupture of Great Vessel During Growing Rod Lengthening: Do Children With Ehlers-Danlos Syndrome Require the Availability of Vascular Expertise? A Case Report and Review of the Literature.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a family of inherited connective tissue diseases. Kyphoscoliotic EDS (kEDS) is associated with severe and early spinal deformity. Very little has been reported regarding the orthopaedic surgical care of kEDS likely due to its rare incidence. A more common subtype is the vascular-type EDS (vEDS, previously labeled type IV), which is associated with reports of vascular complications in the literature. METHODS: The case report of a single, fatal complication of spontaneous rupture of the superior vena cava, after extubation, subsequent to revision minimal growing rod lengthening in a child with kEDS. We additionally review prior reported cases of kEDS for pediatric spine surgery and the sentinel event of spontaneous vascular rupture in all EDS patients. RESULTS: The anterior thoracoabdominal approach in children with kEDS has been associated with severe intravascular complications, with no deaths reported to date. Posterior spinal procedures were associated with frequent overall complications, but no events of perioperative or spontaneous vascular injury were identified before our case.Reports of spontaneous vessel rupture (n=39) appear more frequently in vEDS, but have been documented in patients with EDS type I (classic EDS or cEDS) and kEDS disease. The 30-day mortality in these patients was 59%. The majority of the deaths occurred on the day of the vascular event. Surviving patients overwhelmingly received intraoperative consultation and treatment from either general or vascular surgeons at their respective institutions for assistance. CONCLUSIONS: Providers should consider their proximity to available emergent consultation before operating on patients with EDS of any subtype. LEVEL OF EVIDENCE: Level V-expert opinion.

Reducing Blood Testing in Pediatric Patients after Heart Surgery: Proving Sustainability.

INTRODUCTION: Frequent blood testing increases risk of iatrogenic anemia, infection, and blood transfusion. This study describes 3 years of sustained blood testing reduction from a quality improvement (QI) initiative which began in 2011. METHODS: The cohort consisted of postop children whose surgery had a Risk Adjustment for Congenital Heart Surgery (RACHS) classification consecutively admitted to a tertiary Cardiac Intensive Care Unit. Data were collected for a 2010 preintervention, 2011 intervention, and 2012-13 postintervention periods, tabulating common laboratory studies per patient (labs/pt) and adjusted for length of stay (labs/pt/d). The QI initiative eliminated standing laboratory orders and changed to testing based on individualized patient condition. Adverse outcomes data were collected including reintubation, central line-associated bloodstream infections and hospital mortality. Safety was measured by the number of abnormal laboratory studies, electrolyte replacements, code blue events, and arrhythmias. RESULTS: A total of 1169 patients were enrolled (303 preintervention, 315 intervention, and 551 postintervention periods). The number of labs/pt after the QI intervention was sustained (38 vs. 23 vs. 23) and labs/pt/d (15 vs. 11 vs. 10). The postintervention group had greater surgical complexity (P = 0.002), were significantly younger (P = 0.002) and smaller (P = 0.008). Children with RACHS 3-4 classification in the postintervention phase had significant increased risk of reintubation and arrhythmias. CONCLUSIONS: After the implementation of a QI initiative, blood testing was reduced and sustained in young, complex children after heart surgery. This may or may not have contributed to greater reintubation and arrhythmias among patients with RACHS 3-4 category procedures.

Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment.

BACKGROUND: Although some pediatric patients with small traumatic epidural hematoma (EDH) are observed without surgical drainage, clinical practice remains variable. OBJECTIVES: Create a prediction rule to identify patients with EDH unlikely to fail hospital observation. METHODS: Retrospective review at a level I pediatric trauma center between 2003 and 2014. Presenting clinical and radiographic features were compared between those successfully to failed observation. RESULTS: Two hundred twenty-two patients with EDH whose initial management strategy was observation were analyzed; 196 (88%) were successfully observed. The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed = 5.6mm versus failed observation = 10.9mm, p<0.01), median bleed volume (observed = 2.1ml versus failed observation = 15.7ml, p<0.01), and mass effect (RR 3.7; 95% CI 1.8-7.7). No mass effect, EDH volume<15ml, and no neurologic deficits predicted patients at low risk of failing observation with a positive predictive value of 98% (95% CI 93-99%). There was no difference in median discharge Glasgow outcome scores (5 in both groups, p=0.20). CONCLUSION: Patients with no mass effect and EDH volume <15ml on initial CT scan and no neurologic deficit are at low risk of failing observation. LEVEL OF EVIDENCE: Retrospective cohort level I.

Development and Validation of a Score to Predict Mortality in Children Undergoing Extracorporeal Membrane Oxygenation for Respiratory Failure: Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction Score.

OBJECTIVE: Our objective was to develop and validate a prognostic score for predicting mortality at the time of extracorporeal membrane oxygenation initiation for children with respiratory failure. Preextracorporeal membrane oxygenation mortality prediction is important for determining center-specific risk-adjusted outcomes and counseling families. DESIGN: Multivariable logistic regression of a large international cohort of pediatric extracorporeal membrane oxygenation patients. SETTING: Multi-institutional data. PATIENTS: Prognostic score development: A total of 4,352 children more than 7 days to less than 18 years old, with an initial extracorporeal membrane oxygenation run for respiratory failure reported to the Extracorporeal Life Support Organization's data registry during 2001-2013 were used for derivation (70%) and validation (30%). Bidirectional stepwise logistic regression was used to identify factors associated with mortality. Retained variables were assigned a score based on the odds of mortality with higher scores indicating greater mortality. External validation was accomplished using 2,007 patients from the Pediatric Health Information System dataset. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction score included mode of extracorporeal membrane oxygenation; preextracorporeal membrane oxygenation mechanical ventilation more than 14 days; preextracorporeal membrane oxygenation severity of hypoxia; primary pulmonary diagnostic categories including, asthma, aspiration, respiratory syncytial virus, sepsis-induced respiratory failure, pertussis, and "other"; and preextracorporeal membrane oxygenation comorbid conditions of cardiac arrest, cancer, renal and liver dysfunction. The area under the receiver operating characteristic curve for internal and external validation datasets were 0.69 (95% CI, 0.67-0.71) and 0.66 (95% CI, 0.63-0.69). CONCLUSIONS: Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction is a validated tool for predicting in-hospital mortality among children with respiratory failure receiving extracorporeal membrane oxygenation support.

Hematocrit Levels, Blood Testing, and Blood Transfusion in Infants After Heart Surgery.

OBJECTIVE: To determine whether judicious blood testing impacts timing or amount of packed RBC transfusions in infants after heart surgery. DESIGN: A retrospective study comparing before and after initiation of a quality improvement process. SETTING: A university-affiliated cardiac ICU at a tertiary care children's hospital. PATIENTS: Infants less than 1 year old with Risk Adjustment for Congenital Heart Surgery category 4, 5, 6, or d-transposition of great arteries (Risk Adjustment for Congenital Heart Surgery 3) consecutively treated during 2010 through 2013. INTERVENTION: A quality improvement process implemented in 2011 to decrease routine laboratory testing after surgery. MEASUREMENTS AND MAIN RESULTS: Fifty-two infants preintervention and 214 postintervention had similar age, weight, proportion of cyanotic lesions, and surgical complexity. Infants with single versus biventricular physiology were compared separately. The number of laboratory tests per patient adjusted for cardiac ICU length of stay (laboratory tests/patient/day) was significantly lower in postintervention populations for single and biventricular groups (9 vs 15 and 10 vs 15, respectively; p < 0.001). The proportion of single ventricle patients transfused post- and preintervention was not statistically different (72% vs 90%; p = 0.130). Transfusion in the biventricular groups was the same over time (65% vs 65%). Time to first transfusion was significantly longer in the postintervention single ventricle group (4 vs 1 d; p < 0.001), and was not statistically different in the biventricular patients (4 vs 7 d; p = 0.058). The median hematocrit level at first transfusion was significantly lower (37% vs 40%; p = 0.004) postintervention in the cyanotic population, but did not differ in the biventricular group (31% vs 31%; p = 0.840). CONCLUSION: In infants after heart surgery, blood testing targeted to individual needs significantly decreased the number of blood tests, but did not significantly decrease postoperative blood transfusion.

Complex Chronic Conditions Among Children Undergoing Cardiac Surgery.

Children with complex chronic conditions (CCCs) require a disproportionate amount of inpatient resources and are at increased risk of mortality during hospital admissions. This study examines the impact of non-cardiac, comorbid complex chronic conditions on outcomes in children undergoing congenital heart surgery. All admissions associated with a congenital cardiac surgical procedure in the Kids' Inpatient Database from 1997 to 2012 were examined. Children were classified by the number as well as type (genetic vs. non-genetic) of CCC. Baseline demographics as well as proportion of total inpatient days and total hospitalization charges was assessed. Multivariate regression models examining occurrence of a complication, mortality, prolonged length of stay and high hospitalization charges were constructed. In multivariate models, an increasing number of CCC was associated with increased risk of mortality and complications (mortality: 1 CCC: odds ratio (OR) = 1.17, 95 % CI = 1.03-1.33); ≥2 CCC: OR = 1.54, 95 % CI = 1.26-1.87). Additionally, the presence of a genetic CCC was protective against mortality (OR = 0.71, 95 % CI = 0.56-0.89) while non-genetic CCCs were associated with mortality (OR = 1.62, 95 % CI = 1.41-1.88) and high resource utilization. Over time, the proportion of genetic CCC remained stable while non-genetic CCC increased in prevalence. Complex chronic conditions have a varying association with mortality, morbidity and resource utilization in children undergoing congenital heart surgery. While genetic CCCs were not associated with poor outcomes, non-genetic CCCs were risk factors for morbidity and mortality. These findings suggest that pre-surgical counseling and surgical planning should account for the type of non-cardiac comorbid conditions.

Etiology of postoperative hyponatremia following pediatric intracranial tumor surgery.

OBJECT Cerebral salt wasting (CSW) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) cause postoperative hyponatremia in neurosurgery patients, can be difficult to distinguish clinically, and are associated with increased morbidity. The authors aimed to determine risk factors associated with CSW and SIADH among children undergoing surgery for intracranial tumors. METHODS This retrospective cohort study included children 0-19 years of age who underwent a first intracranial tumor surgery with postoperative hyponatremia (sodium ≤ 130 mEq/L). CSW was differentiated from SIADH by urine output and fluid balance, exclusive of other causes of hyponatremia. The CSW and SIADH groups were compared with basic bivariate analysis and recursive partitioning. RESULTS Of 39 hyponatremic patients, 17 (44%) had CSW and 10 (26%) had SIADH. Patients with CSW had significantly greater natriuresis compared with those with SIADH (median urine sodium 211 vs 28 mEq/L, p = 0.01). Age ≤ 7 years and female sex were significant risk factors for CSW (p = 0.03 and 0.04, respectively). Both patient groups had hyponatremia onset within the first postoperative week. Children with CSW had trends toward increased sodium variability and symptomatic hyponatremia compared with those with SIADH. Most received treatment, but inappropriate treatment was noted to worsen hyponatremia. CONCLUSIONS The authors found that CSW was more common following intracranial tumor surgery and was associated with younger age and female sex. Careful assessment of fluid balance and urine output can separate patients with CSW from those who have SIADH, and high urine sodium concentrations (> 100 mEq/L) support a CSW diagnosis. Patients with CSW and SIADH had similar clinical courses, but responded to different interventions, making appropriate diagnosis and treatment imperative to prevent morbidity.

The Effect of Palliative Care Team Design on Referrals to Pediatric Palliative Care.

BACKGROUND: The American Academy of Pediatrics (AAP) and the American Academy of Hospice and Palliative Medicine (AAHPM) have recommended minimal standards for palliative care (PC) team composition and availability. It is unknown whether team composition affects utilization of PC. OBJECTIVE: The study objective was to describe pediatric PC team composition, evaluate whether composition and availability are associated with utilization, and examine PC referral patterns. METHODS: The study was a descriptive survey. Subjects were pediatric PC team directors or hospital administrators at Pediatric Health Information System (PHIS) hospitals (N = 44). RESULTS: The overall response rate was 86%. Teams varied in size from <1 to 9 full-time members. Average referrals per hospital bed were 0.46, range 0.05-2.13. Among individual PC team roles, referral rates were 34% greater in teams with an advanced nurse practitioner (ANP) (p = 0.07). Likewise, teams with acute pain, chronic pain, or hospice palliative medicine specialists tended to have greater referral rates (39%, 36%, and 25%), though reported differences were not statistically significant. Teams adherent to the original AAP recommendations had a 31% greater referral rate (p = 0.22). Teams available 24 hours daily had similar referral rates to those with less availability (0.47 versus 0.46 [p = 0.94]). CONCLUSIONS: Team composition and availability are not crucial to PC utilization. Hospitals with some personnel but not all recommended team members should create formal teams and modify them over time. The addition of team members that tend to increase referrals, namely ANPs and acute pain, chronic pain, or hospice palliative medicine specialists, should be considered.

Pediatric Organ Donation Potential at a Children's Hospital.

OBJECTIVES: To estimate the organ donation potential of patients dying at a children's hospital. DESIGN: Retrospective cohort study. SETTING: A free-standing, 271-bed, tertiary Children's Hospital with a pediatric trauma center. PATIENTS: Patients dying in any ICU during 2011-2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 224 deaths, 23 (10%) met neurologic criteria for death: 18 donated organs (conversion rate 78%), 47 (19%) died without prior limitation of life-sustaining therapies, and the remaining 69% had withdrawal of life-sustaining therapies. Among those dying after withdrawal of life-sustaining therapies (n = 154), the organ procurement organization was not notified prior to death in 24%, and older patients were more likely to be referred compared to those less than 1 year old. Infection, cancer, and organ dysfunction were the most frequent conditions that disqualified dying patients from suitability for donation. Just over half of children more than 1 year old were suitable for donation after withdrawal of life-sustaining therapies compared to a fifth of infants (19%). Of 45 suitable for donation, 37 (82%) died within 1 hour. None of 7 infants younger than 1 month old died within 20 minutes, compared with 46% of infants between 1 month and 1 year (n = 6) and 72% of older children. Thirty-three families (73%) did not permit donation after circulatory criteria for death whereas 12 (27%) gave permission for donation, and all 12 were actual donors (conversion rate 12/37 [32%]). CONCLUSIONS: The number of pediatric potential candidates for donation after circulatory determination of death was significantly larger than potential candidates for donation after neurologic determination of death at our hospital, but the actual donation rate was significantly lower. Increasing acceptance of donation after circulatory determination of death could increase organ donation. Among all children having withdrawal of life-sustaining therapies, donation after circulatory determination of death potential is less for infants.