Lessons and Insights From the Implementation of the Cohort Model for a PICU: A Case Study Research.

OBJECTIVES: The subspecialty cohort model allows for creation of smaller diagnosis pools, enabling concentration of expertise and collaboration. Given unknown effects of this model on team dynamics in a PICU, we examined how the cohort-model implementation was perceived by our providers and how this organizational change affected the work environment. DESIGN: Case study research approach consisting of surveys, operational observations, and semistructured interviews. A descriptive survey was derived from an integrated conceptual framework (i.e., teamwork and psychologic safety). Sensitized by the framework and quantitative survey data, we conducted a thematic analysis from field notes and interview data. SETTING: A quaternary-care, children's hospital with a 31-bed PICU. SUBJECTS: PICU providers and nurses and subspecialists. INTERVENTION: Implementation of the subspecialty cohort model. MEASUREMENTS AND MAIN RESULTS: A total of 308 and 269 responses from pre- and postcohort surveys, respectively, were analyzed. Overall, 76% of physicians and 74% of nurses viewed the cohort model favorably. Three themes emerged: community-from disruption to redistribution, transforming identity-expert or generalist, and expansive learning from focused practice. The findings provided insights, informed by a theory of "Community of Practice," as lessons learned and ways to enhance the cohort model. CONCLUSIONS: Our transition to a cohort PICU model offers lessons on impacts of PICU model changes on communities and teams. These theory-informed insights and implications can guide others undergoing similar transitions.

Virtual Communication Embedded Bedside ICU Rounds: A Hybrid Rounds Practice Adapted to the Coronavirus Pandemic.

OBJECTIVES: Coronavirus disease 2019 containment strategies created challenges with patient-centered ICU rounds. We examined how hybrid rounds with virtual communication added to in-person rounds could facilitate social distancing while maintaining patient-centered care. DESIGN: Continuous quality improvement. SETTING: Quaternary care referral pediatric hospital. PATIENTS: Daytime rounds conducted on PICU patients. INTERVENTIONS: Following a needs assessment survey and pilot trials, multiple technological solutions were implemented in a series of plan-do-study-act cycles. Hybrid rounds model was deployed where a videoconference platform was used to establish communication between the bedside personnel (nurse, patient/family, and partial ICU team) with remotely located remaining ICU team, ancillary, and consultant providers. Floor labels marking 6-feet distance were placed for rounders. MEASUREMENTS AND MAIN RESULTS: Outcome metrics included compliance with social distancing, mixed methods analysis of surveys, direct interviews of providers and families, and reports of safety concerns. The clinicians adopted hybrid rounds readily. Compliance with social distancing and use of floor labels needed reminders. One-hundred fourteen providers completed the feedback survey. Twenty-five providers and 11 families were interviewed. Feedback about hybrid rounds included inability to teach effectively, suboptimal audio-video quality, loss of situational awareness of patient/unit acuity, alarm interference, and inability to socially distance during other ICU interactions. Benefits noted were improved ancillary input, fewer interruptions, improved efficiency, opportunity to integrate with data platforms, and engage remote consultants and families. Nurses and families appreciated the efforts to ensure safety but wanted the ICU attending/fellow supervising the team to participate at bedside, during rounds. Clinicians appreciated the multidisciplinary input but felt that teaching was difficult. CONCLUSIONS: Hybrid rounds employed during pandemic facilitated social distancing while retaining patient-centered multidisciplinary ICU rounds but compromised teaching during rounds. A change to ingrained rounding habits needs team commitment and ongoing optimization. The hybrid rounds model has potential for generalizability to other settings.

Comparing Vasoactive-Inotropic Score Reporting Strategies in the PICU Relative to Mortality Risk.

OBJECTIVES: High Vasoactive-Inotropic Scores have demonstrated association with poor outcomes in pediatric cardiac ICUs and are being calculated more frequently in studies of critically ill noncardiac patients. Available studies differ in their approach to assigning Vasoactive-Inotropic Scores, making direct comparisons difficult. The goal of this investigation is to compare multiple approaches to Vasoactive-Inotropic Score assignment to determine their strength of association with mortality in a general pediatric intensive care population. In doing so, we aim to help validate the use of the Vasoactive-Inotropic Score in noncardiac patients and to help inform future studies of the relative strength of available approaches in assigning this score. DESIGN: Retrospective chart review. SETTING: PICU at an academic freestanding children's hospital. PATIENTS: Two-thousand seven-hundred fifty-two consecutive patients admitted over a 17-month time period were screened for receiving inotrope or vasopressor therapies regardless of disease process. Four-hundred seventy-four patients met inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For each patient treated with continuous infusions of vasoactive medications, a Vasoactive-Inotropic Score was calculated (and then recalculated) every time they had a documented dose change. Multiple strategies were evaluated to generate receiver operating characteristic curves in relation to mortality. Area under the curve was greatest when evaluating the maximum Vasoactive-Inotropic Score (Max Any) during the initial treatment course (0.788) with an increasing relative risk as the score increased. The Vasoactive-Inotropic Score at 48 hours after treatment initiation had next highest area under the curve (0.736). Primary diagnosis categories were also analyzed, and area under the curve was greatest for the cardiovascular group (0.879). CONCLUSIONS: Increasing Vasoactive-Inotropic Scores for patients in the PICU are associated with mortality risk. The scoring strategy used can influence the strength of the association, as can the primary diagnosis category.

Critical appraisal of Zabrocki et al: Extracorporeal membrane oxygenation for pediatric respiratory failure: survival and predictors of mortality. Crit Care Med 2011; 39:364-370.

OBJECTIVE: To review the findings and discuss the implications of pediatric respiratory failure treated with extracorporeal membrane oxygenation. DESIGN: A critical appraisal of Extracorporeal membrane oxygenation for pediatric respiratory failure: Survival and predictors of mortality by Zabrocki et al (Crit Care Med 2011; 39:364370) and review of the relevant literature. FINDINGS: In this review of international data from 1993 to 2007, pediatric patients diagnosed with respiratory failure that met inclusion criteria and were treated with extracorporeal membrane oxygenation had an overall survival of 57%. This percentage did not change significantly over the study period; however, the number of patients with comorbidities did increase from 19% in 1993 to 47% in 2007. Survival varied significantly depending on diagnosis (83% for status asthmaticus vs. 23% for fungal pneumonia) and associated comorbidities (59% for chronic lung disease vs. 5% for hematopoietic stem cell transplantation). Clinical features associated with decreased survival included precannulation mechanical ventilation in excess of 14 days and venoarterial cannulation. CONCLUSIONS: This study confirms that precannulation diagnoses and variables play a role in prognosis when pediatric patients with respiratory failure are treated with extracorporeal membrane oxygenation. Results of this investigation demonstrate that survival is improving in patients without comorbidities and that patients can be mechanically ventilated for up to 14 days prior to extracorporeal support initiation before mortality is increased.

Characterization of Propofol Use For Non-Procedural Sedation in a Pediatric Intensive Care Unit.

OBJECTIVE: Given the limited literature describing propofol use in pediatric patients, this study aimed to describe the dosing and duration of propofol infusions for non-procedural sedation in the pediatric intensive care unit (PICU). The secondary objectives were to describe the change in concomitant sedative requirements from the 24-hour period before propofol initiation to the 24-hour period after discontinuation of propofol and to review the frequency of adverse events. METHODS: This retrospective descriptive cohort study evaluated children 1 month to less than 18 years old who received a continuous infusion of propofol for non-procedural sedation in the PICU between May 2018 and August 2020. RESULTS: One hundred thirty propofol infusions representing 127 unique patients (median age, 2.9 years) were included. The median (IQR) propofol infusion duration was 18 (10-28) hours, and the median (IQR) average dose was 4.1 (2.9-5.6) mg/kg/hr. Extubation was attempted in 96 patients (74%) within 24 hours of propofol infusion discontinuation. For patients that remained intubated with continuous sedation, concomitant continuous opioid and midazolam requirements decreased by 20% (p = 0.865) and 43% (p = 0.011), respectively. Patients receiving propofol for over 24 hours experienced the largest percent decrease in concomitant sedation with midazolam. There were no confirmed cases of propofol-related infusion syndrome (PRIS). CONCLUSIONS: Durations and doses of propofol infusions for non-procedural sedation vary widely at our institution. Propofol may be beneficial as an adjunct sedative, but prospective studies are needed to further explore the effect of propofol on decreasing the requirements of concomitant opioids and benzodiazepines.

Severe Pediatric COVID-19 Pneumonia Treated With Adjuvant Anakinra.

BACKGROUND AND OBJECTIVES: To compare previous hemophagocytic lymphohistiocytosis criteria with adult coronavirus disease 2019 (COVID-19)-associated hyperinflammatory syndrome (cHIS) criteria for the diagnosis of hyperinflammation in pediatric patients with COVID-19. The secondary objective was to assess treatment response to intravenous (IV) anakinra in these patients. METHODS: This case series included children admitted to the PICU for COVID-19 pneumonia with hyperinflammation and treated with IV anakinra between July 2020 to April 2021. Hyperinflammatory criteria were determined for each patient. Clinical course, chest imaging, and inflammatory marker trends were assessed pre- and post-anakinra treatment. RESULTS: All patients had a cHIS criteria score of ≥5. Two patients met 2004-hemophagocytic lymphohistiocytosis criteria. Only the patient that required extracorporeal membrane oxygenation met the H-Score cut-off value. All but one patient had a decrease in their inflammatory markers and improvement in clinical status with early initiation of adjunctive IV anakinra. CONCLUSIONS: In this case series, adult cHIS criteria were successfully used to identify pediatric COVID-19 patients with hyperinflammation. Ferritin levels decreased after the early initiation of IV anakinra.

Reprogramming virus nanoparticles to bind metal ions upon activation with heat.

We have reprogrammed the stimulus-responsive conformational change property of a virus nanoparticle (VNP) to enable the surface exposure of metal binding motifs upon activation with heat. The VNP is based on the widely investigated adeno-associated virus (AAV). An intrinsic bioactive functionality of AAV was genetically replaced with a hexahistidine (His) tag. The peptide domain with the inserted His tag is normally inaccessible. Upon external stimulation with heat, the VNP undergoes a conformational change, resulting in externalization of His tag-containing domains and the conferred ability to bind metal. We show that beyond this newfound functionality of the capsid, the VNPs maintain many of the wild-type capsid properties. Our work lays the groundwork for developing stimulus-responsive VNPs that can be used as "smart" building blocks for the creation of higher order structures.

Prevention of Latent Safety Threats: A Quality Improvement Project to Mobilize a Portable CT.

INTRODUCTION: Transporting critically ill patients to diagnostic imaging for needed studies can be challenging and even prohibitive. A portable computerized tomography (CT) scanner allows the patient to remain in the intensive care unit, but presents new positioning and team challenges. Before activation of a portable CT scanner in our pediatric intensive care unit and through the use of iterative simulation-based Plan-Do-Study-Act (PDSA) cycles in the clinical environment, a multidisciplinary team of bedside caregivers determined optimal patient positioning, equipment needs, and specific staffing and choreography to develop detailed portable CT guidelines. METHOD: Our team engaged stakeholders from radiology, critical care, respiratory therapy, environmental services, facilities operations, and the CT vendor to develop scenarios. Simulations included infant and pediatric patients who required critical invasive monitoring and treatment devices, such as ventilators, and high-risk intracardiac and intravascular lines. Scenario objectives centered on the safe positioning, transfer, and scanning of the patient. Trained simulation specialists from the hospital's simulation center facilitated simulation sessions. RESULTS: Simulation-based PDSA testing identified 31 latent safety threats, including the need for a custom bed adapter due to pediatric patients' variable size. We paused portable CT activation pending the custom adapter's availability and remediation of other latent safety threats. Additional simulation-based PDSA cycles further refined the process once the custom adapter was available. CONCLUSIONS: Simulation identified unanticipated latent safety threats before the implementation of a portable CT scanner.

A multidisciplinary approach to VA ECMO cannulation in children.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) supports gas exchange and circulation in critically ill patients. This study describes a multidisciplinary approach to ECMO cannulation using the expertise of pediatric surgery (PS) and interventional radiology (IR). MATERIAL AND METHODS: Pediatric patients (<18 years) undergoing percutaneous cannulation for peripheral veno-arterial (VA) ECMO by PS and IR from April 2017 to May 2018 were included. Cardiac patients and children cannulated by PS alone were excluded. RESULTS: Five patients were included in the series. Median age was 16 [12.5-17] years and 3 were female. Median ECMO arterial and venous catheter sizes were 19 [17-22] Fr and 25 [25-28] Fr, respectively. Both catheters were placed in the common femoral vessels. A 6Fr antegrade distal perfusion cannula (DPC) was also placed in the superficial femoral artery by IR at the time of cannulation. The median time from admission to procedure start was 10 [7-50] hours and the children were on ECMO for a median length of 3.2 [2.3-4.8] days. There were two episodes of bleeding. No patients had loss of limb circulation. CONCLUSION: A multidisciplinary approach to peripheral VA ECMO cannulation is feasible and safe. Maintenance of limb perfusion by percutaneous placement and removal of DPC may be an advantage of this collaborative approach. LEVEL OF EVIDENCE: IV. TYPE OF RESEARCH: Case series.

Management of severe pulmonary Langerhans cell histiocytosis in children.

Patients with pulmonary Langerhans cell histiocytosis (LCH) typically have a benign course but may have extensive cystic lung disease with rare life-threatening complications including multiple and recurrent pneumothoraces and respiratory failure. We report seven severely affected pediatric patients treated with chemotherapy, aggressive chest tube management, and pleurodesis of whom five survived. Patients with extraordinary amounts of pulmonary cystic disease and multiple pneumothoraces due to LCH can have remarkable, curative outcomes with early recognition, optimal LCH-directed therapy, and supportive care.