Topical Pharyngeal Anesthesia in Sedated Pediatric Patients Undergoing Esophagogastroduodenoscopy.

OBJECTIVES: Pediatric patients undergoing esophagogastroduodenoscopy (EGD) commonly receive procedural sedation for comfort and to facilitate the procedure. EGD with procedural sedation carries the risk of several airway incidents and/or adverse events (AIAE). Topical pharyngeal anesthetics (TPAs) can blunt the airway reflexes and decrease the incidence of laryngospasm but has not been well studied with EGD under procedural sedation. We aimed to study the effect of adding a TPA to propofol-based sedation on the rate of AIAE. METHODS: This is a single-center, retrospective, observational cohort study. We compare AIAE rates (coughing, gagging, apnea, airway obstruction, and laryngospasm) in children who received TPA as part of their propofol-based procedural sedation for EGD with those who did not receive TPA. RESULTS: In 2021, 73 patients received TPA as part of the procedural sedation for EGD and 123 did not. The overall rate of AIAE was high with 75 (38%) patients experiencing 1 or more AIAE. Patients who received benzocaine spray experienced more AIAE than the control group [adjusted odds ratio (aOR) = 1.16; 95% confidence interval (CI): 1.01-1.34; P = 0.037]. Coughing, gagging, apnea with desaturation rates, and laryngospasm were similar in both groups (coughing aOR = 1.01; 95% CI: 0.91-1.13; P = 0.814; gagging aOR = 1.01; 95% CI: 0.91-1.13; P = 0.814; apnea aOR = 0.99; 95% CI: 0.95-1.04; P = 0.688; laryngospasm OR = 1.01; 95% CI: 0.95-1.07; P = 0.71). The rate of airway obstruction requiring jaw thrust was higher in the benzocaine group but did not reach statistical significance (aOR = 1.11; 95% CI: 0.97-1.26; P = 0.133). CONCLUSION: The use of topical pharyngeal benzocaine in children undergoing EGD with propofol-based sedation is associated with a higher overall AIAE rate. Most of the AIAE were mild incidents and only 7 patients experienced true adverse events.

Common Barriers to Reporting Medical Errors.

BACKGROUND: Medical errors are the third leading cause of death in the United States. Reporting of all medical errors is important to better understand the problem and to implement solutions based on root causes. Underreporting of medical errors is a common and a challenging obstacle in the fight for patient safety. The goal of this study is to review common barriers to reporting medical errors. METHODS: We systematically reviewed the literature by searching the MEDLINE and SCOPUS databases for studies on barriers to reporting medical errors. The preferred reporting items for systematic reviews and meta-analyses guideline was followed in selecting eligible studies. RESULTS: Thirty studies were included in the final review, 8 of which were from the United States. The majority of the studies used self-administered questionnaires (75%) to collect data. Nurses were the most studied providers (87%), followed by physicians (27%). Fear of consequences is the most reported barrier (63%), followed by lack of feedback (27%) and work climate/culture (27%). Barriers to reporting were highly variable between different centers.

Diagnostic accuracy among trainees to safely confirm peripherally inserted central catheter (PICC) placement using bedside ultrasound.

BACKGROUND: Real-time utilization of ultrasound to confirm peripherally inserted central catheter (PICC) placement improves efficacy and reduces patient radiation exposure. We evaluated if novice ultrasound users could accurately confirm appropriate PICC tip location via ultrasound assessment. METHODOLOGY: A prospective data collection study was conducted in an academic center with an established PICC team. Novice ultrasonography users performed 2 echocardiographic views (subcostal and apical 4 chamber) and noted position of visible wire. The presence of central bubbles (visualized in the heart) after a saline infusion, as well as time to bubbles (push-to-bubbles) seen in all patients, was also recorded. Image quality and confidence in imaging acquisition was also recorded. RESULTS: Twenty-eight patients between ages 0 and 18 were enrolled over the study period with mean patient age of 10 years and median weight of 34 kg. The quality of image acquisition was rated as great only 34-44%. The wire was visualized only 25% of the time. The median push-to-bubble time when the PICC was later confirmed to be in appropriate positioning was 1.5 seconds with a delay of greater than 3 seconds 40% of the time when the line was malpositioned. The overall positive predictive value of ultrasound identifying malpositioned lines in this study was 43%. CONCLUSIONS: With this PICC placement technique, ultrasound confirmation of PICC placement by novice ultrasound users was not superior to confirmation with chest radiograph. There may remain potential for future ultrasound protocols, with pediatric-specific technology or echogenic catheter tips, to reduce radiation exposure from chest radiograph during PICC line positioning verification.

Enteral Pentobarbital in the Difficult to Sedate Critically Ill Children.

OBJECTIVE: Difficult analgosedation is common and challenging in the pediatric intensive care unit (PICU). It is important to study alternative and supplemental sedatives for when the first-line agents become -insufficient. METHODS: In this retrospective chart-review study, we report our center's experience in using intermittent doses of enteral pentobarbital as an adjunct sedative in 13 difficult to sedate critically ill and mechanically ventilated children. We compare the average sedation score and cumulative doses of other -sedatives (opioids, benzodiazepines and alpha-2 agonists) in the 24 hours before and 24 hours after enteral -pentobarbital initiation. RESULTS: The addition of enteral pentobarbital was associated with lower State Behavioral State (SBS) scores in 8 out of the 13 patients and on average smaller doses of opioids (decreased by 11%), benzodiazepines (BZD) (decreased by 5%) and alpha-agonists (decreased by 20%). No adverse effects were noted attributable to pentobarbital administration. CONCLUSION: Enteral pentobarbital seems to be safe and effective agent in the difficult to sedate critically ill child.

Provider's Perception of Parental Anxiety in the Pediatric Intensive Care Unit.

Parents of critically ill children in the Pediatric Intensive Care Unit (PICU) commonly experience new or worsening anxiety, which can lead to long-term sequelae in the form of post-traumatic stress disorder (PTSD). To investigate how well the PICU providers recognize and assess parental anxiety, we assessed the acute and baseline anxiety level of 30 parents in the PICU with the State-Trait Anxiety Inventory (STAI) and compared the results with the PICU physician's and nurses' assessments. All but four parents experienced higher acute anxiety scores compared to baseline, with a 34% increase in the number of parents with moderate and high anxiety scores. All PICU providers performed poorly in recognizing and assessing parental anxiety, with a tendency to underestimate the level of anxiety. Proper screening tools and strategies are essential to recognize and help parents in distress and potentially prevent long-term psychological sequelae.

High-Frequency Percussive Ventilation in Viral Bronchiolitis.

BACKGROUND: High-frequency percussive ventilation (HFPV) is an alternative mode of mechanical ventilation that has been shown to improve gas exchange in subjects with severe respiratory failure. We hypothesized that HFPV use would improve ventilation and oxygenation in intubated children with acute bronchiolitis. METHODS: In this single-center prospective cohort study we included mechanically ventilated children in the pediatric ICU with bronchiolitis 1-24 months old who were transitioned to HFPV from conventional invasive mechanical ventilation from November 2018-April 2020. Patients with congenital heart disease, on extracorporeal membrane oxygenation (ECMO), and with HFPV duration < 12 h were excluded. Subject gas exchange metrics and ventilator parameters were compared before and after HFPV initiation. RESULTS: Forty-one of 192 (21%) patients intubated with bronchiolitis underwent HFPV, and 35 met inclusion criteria. Median age of cohort was 4 months, and 60% were previously healthy. All subjects with available oxygenation saturation index (OSI) measurements pre-HFPV met pediatric ARDS criteria (31/35, 89%). Mean CO2 decreased from 65.4 in the 24 h pre-HFPV to 51 (P < .001) in the 24 h post initiation. SpO2 /FIO2 was significantly improved at 24 h post-HFPV (153.3 to 209.7, P = .001), whereas the decrease in mean OSI at 24 h did not meet statistical significance (11.9 to 10.2, P = .15). The mean peak inspiratory pressure (PIP) decreased post-HFPV from 29.7 to 25.0 at 24 h (P < .001). No subjects developed an air leak or hemodynamic instability secondary to HFPV. Two subjects required ECMO, and of these, one subject died. CONCLUSIONS: HFPV was associated with significant improvement in ventilation and decreased exposure to high PIPs for mechanically ventilated children with bronchiolitis in our cohort and had a potential association with improved oxygenation. Our study shows that HFPV may be an effective alternative mode of ventilation in patients with bronchiolitis who have poor gas exchange on conventional invasive mechanical ventilation.

Inferior Vena Cava Filter in Childhood Septic Deep Vein Thrombosis.

Inferior vena cava (IVC) filter in venous thromboembolism (VTE) is an alternative to anticoagulation when the latter is contraindicated. The use of IVC filter in pediatrics continues to be rare and has not increased despite the ever-increasing rates of childhood VTE. Historically, septic VTE was regarded as a contraindication to IVC filter. Safety and efficacy of IVC filters in septic VTE have been reported in adult patients but not in pediatric patients. In this study, we reported a safe use of IVC filter in a critically ill 12-year-old patient with a large IVC thrombus and multiple pulmonary embolisms with favorable outcome.

Practice Variability in Screening and Treating Pediatric Critical Illness Delirium: Survey.

The best practice in pediatric delirium (PD) screening and treatment is still unknown. Current recommendations come from small studies and adult data. In this article, we surveyed the Pediatric Critical Care Medicine fellowship directors on PD screening and treatment practices in their centers. We reported high variability in the screening and treatment practices for PD in large academic medical centers in the United States. The Cornell Assessment of Pediatric Delirium tool is the most commonly used tool for screening, and quetiapine is the most commonly used pharmacologic agent. A national guideline on PD screening, prevention, and treatment is needed to standardize practice and provide guidance.

Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer.

Severe sepsis (SS) in pediatric oncology patients is a leading cause of morbidity and mortality. We investigated the incidence of and risk factors for morbidity and mortality among children diagnosed with cancer from 2008 to 2012, and admitted with SS during the 3 years following cancer diagnosis. A total of 1,002 children with cancer were included, 8% of whom required pediatric intensive care unit (PICU) admission with SS. Death and/or multiple organ dysfunction syndrome occurred in 34 out of 99 PICU encounters (34%). Lactate level and history of stem-cell transplantation were significantly associated with the development of death and/or organ dysfunction ( p < 0.05).

Urinary biomarkers as indicator of chronic inflammation and endothelial dysfunction in obese adolescents.

BACKGROUND: Obesity is a pro-inflammatory state that may predispose patients to acute coronary syndrome characterized by chronic low grade inflammation resulting in endothelial dysfunction (ED). The aim of the study was to evaluate urinary biomarkers of inflammation and ED in adolescents with obesity. METHODS: Sixty three subjects were recruited for the study. Twenty healthy adolescents with normal body mass (NW), 14 overweight (OW), 29 obese (OA) subjects were selected. An EndoPat 2000 device was used to measure the reactive hyperemia index (RHI). First morning fasting urine samples were tested for interleukin 6 (IL-6), endothelin 1 (ET-1), alpha-1-acid glycoprotein (AGP), tumor necrosis factor- α (TNF-α) and corrected to urinary creatinine. RESULTS: Urinary TNF-α was significantly higher in OA group (52.4 ± 15.3 pg/mg) compared to adolescents with NW (14.1 ± 1.2 pg/mg, P = 0.04). ET-1 levels were found to be higher in OW (5.18 ± 1.6 pg/mg) compared with NW (3 · 47 ± 0.3 pg/mg, P = 0.24); and higher in OA (8.48 ± 3.1 pg/mg) compared to both NW (P = 0.19) and OW (P = 0.40). Similarly a higher AGP level was observed in OW (864.8 ± 156 ng/mg) and OA (808.3 ± 186 ng/mg) compared to NW (653 ± 69 ng/mg) (P = 0.16 & 0.49 respectively). Inflammatory markers namely, TNF-α, IL-6 and AGP significantly and positively correlated with each other and with ET-1, a marker for endothelial dysfunction. This significant correlation was also observed when tested separately in the subgroups (NW, OW and OA). There were no differences in RHI levels among the study groups. CONCLUSION: Urinary TNF-alpha is significantly elevated in obese adolescents and correlates with urinary ET-1, which is recognized as a biomarker for endothelial dysfunction. Since obesity is a chronic inflammatory state, elevated urinary TNF-alpha might be used as a non invasive tool to monitor the level of that inflammation.

Acute Lymphocytic Leukemia with Bilateral Renal Masses Masquerading as Nephroblastomatosis.

Acute lymphoblastic leukemia (ALL) is the most common malignancy in the pediatric patient population. However, renal involvement as the primary manifestation of ALL is rare. We report a case of a 4-year-old boy with bilateral renal lesions resembling nephroblastic rests as the first finding of early stage ALL preceding hematological changes and subsequent classic clinical findings by two weeks. These renal hypodensities completely resolved after one week of induction chemotherapy. This case demonstrates that renal involvement can be the only initial presenting finding of leukemia. Children with lesions resembling nephroblastic rests need appropriate surveillance due to the risk of malignant disease.

Cold induced sweating syndrome with urinary system anomaly association.

Mutation in the cytokine receptor-like factor 1 and the cardiotrophin-like cytokine (CRLF1 or CLCF1 genes) phenotypically presents as cold induced sweating syndrome (CISS), which is a rare autosomal recessive disorder. The syndrome is characterized by paradoxical sweating in cold weather, dysmorphic facial features, musculoskeletal deformities, difficulty in feeding, and unexplained recurrent episodes of high-grade fever. We are presenting the first case of CISS with urinary system anomaly, which might relate to CRLF1/CLCF1 complex role in the embryonal nephrogenesis.