Dornase alfa in mechanically ventilated children with bronchiolitis: A retrospective cohort study.

The utility of the mucolytic dornase alfa in bronchiolitis has not been established, yet it is commonly used. The objective of this study was to compare outcomes of dornase alfa to standard of care treatments for bronchiolitis in mechanically ventilated pediatric patients. This was a retrospective, cohort study conducted at a single-center children's hospital evaluating pediatric patients with a diagnosis of bronchiolitis that required hospitalization and mechanical ventilation from January 1, 2010 to December 31, 2019. The primary outcome evaluated was length of time on mechanical ventilation. Secondary outcomes were pediatric intensive care unit (PICU) length of stay and length of hospitalization. Multiple linear regressions were used to assess the association of age, oxygen saturation index (OSI), positive end-expiratory pressure values, blood pH levels, respiratory syncytial virus status, and the use of other mucolytics, bronchodilator therapy, or chest physiotherapy treatment. Seventy-two patients were included in the study with 41 patients who were treated with dornase alfa. The patients who received dornase alfa had an average of 33.04 h longer on mechanical ventilation than those who did not (p = 0.0487). On average, they also had longer PICU and hospital stays by 2.05 days (p = 0.053) and 2.74 days (p = 0.02), respectively. In this study, pediatric patients who received dornase alfa had higher baseline OSI measurements than those who received standard of care, which impacted the primary outcome of time on mechanical ventilation and secondary outcome of time in the PICU. However, OSI, or any other variable, did not significantly affect results for the other secondary outcome of length of hospitalization. This study supports existing evidence that dornase alfa is not beneficial for bronchiolitis in pediatric patients, even in severe cases. Further prospective, randomized controlled trials are necessary to validate these outcomes.

Documentation of Sepsis in Patients Meeting Pediatric Sepsis Criteria: An Area for Improvement.

OBJECTIVE: Documentation is a critical aspect for properly evaluating a patient's medical status. In order to accurately diagnose sepsis promptly, the need for proper documentation becomes even more necessary. We conducted a retrospective chart review to assess accuracy and frequency of sepsis documentation by electronic medical records (EMR) review. The patients are children aged 0 to 18 years of age in whom the sepsis trigger tool fired in the EMR and were admitted on the inpatient floor or pediatric intensive care unit. METHODS: An EMR sepsis notification alert is currently utilized by our institution. Two pediatric intensivists reviewed the EMR charts of hospitalized, pediatric patients in whom the notification fired. The primary outcome was to identify the patients who met criteria for sepsis according to the 2005 International Pediatric Consensus Conference Guidelines. In patients who met the criteria, physician charting was inspected manually to evaluate documentation of sepsis and/or septic shock within 24 hours of meeting sepsis criteria. RESULTS: Using the 2005 International Pediatric Consensus Conference Guidelines, 359 patients met sepsis criteria. Of those, 24 (7 percent) were documented to have sepsis and/or septic shock in the EMR. Sixteen of those patients had septic shock, while the remaining eight had sepsis. CONCLUSION: Although sepsis is not uncommon, it is often not documented appropriately in electronic medical records. Hypothesized explanations include difficulty in diagnosing sepsis and using alternative diagnoses. This study demonstrates the ambiguity of the current pediatric sepsis criteria and difficulty capturing this diagnosis in the EMR.

Examination of Early Endotracheal Aspirate Cultures in Children with Acute Respiratory Failure Due to Presumed Acute Respiratory Tract Infection.

OBJECTIVE: To determine the yield of early endotracheal aspirate cultures in mechanically ventilated pediatric patients with acute respiratory failure due to acute respiratory tract infection and endeavor to guide antibiotic choice in acute respiratory failure with concern for infectious etiology. RESULTS: One-hundred ten admissions were included. Of those samples, 61 percent (67 out of 110) had bacterial growth in tracheal aspirate samples. Ninety percent (99 out of 110) patients have received antibiotics and in 47 percent (53 out of 110) antibiotics were optimized or discontinued according to the culture results. There were no difference in duration of mechanical ventilation or PICU stay in patients with positive versus negative cultures (p: 0.613, P: 0.337). CONCLUSIONS: Our study shows a high yield of positive tracheal aspirate cultures in infants, children and adolescents with acute respiratory failure. The cultures identify common organisms, helps to guide initial antibiotics choice, as well as later optimization or antibiotic discontinuation.

Determining Social Needs for Pediatric Patients in a Sioux Falls Pediatric Clinic.

INTRODUCTION: Social adversities such as financial insecurity, poor access to healthcare, shortage of food, and housing concerns can significantly impact health, especially for pediatric patients. The American Academy of Pediatrics recommends that pediatricians address social risks and provide interventions. This is a study where a social needs assessment screening tool was implemented at a general pediatrics clinic in Sioux Falls, South Dakota, to determine the needs of patients in the community with secondary outcomes evaluating ethnic differences in social needs. METHODS: Caregivers of pediatric patients being seen for a well-child examination were asked to participate by completing a social needs assessment form. If social needs were indicated, the clinic's health coach or the integrative health therapist contacted families to address the social need with resources available in the community. RESULTS: Caregivers completed 240 forms. Sixty-eight (31 percent) of caregivers had at least one need, house utilities being the most common followed by childcare. Total number of needs was significantly affected by race and insurance status with more needs identified in American Indian and Black ethnicities and those with public insurance. CONCLUSIONS: This was a successful implementation of a social needs assessment tool at a General Pediatric clinic. Further development and implementation of screening tools is necessary to continue to determine social needs of patients.

Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis.

OBJECTIVE: Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program. METHODS: This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses. RESULTS: Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents. CONCLUSIONS: There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

Necessity of Intracranial Imaging in Infants and Children With Macrocephaly.

BACKGROUND: Macrocephaly is frequently encountered in pediatrics and often leads to imaging. There are no recommendations from the American Academy of Pediatrics or the American College of Radiology providing imaging guidelines for macrocephaly. The goal of this study is to identify risk factors for pathologic macrocephaly and to aid the clinician in identifying patients that would benefit from imaging. METHODS: We conducted a medical record review throughout a multistate health care system, Sanford Health, from January 1, 2012 to December 31, 2016. Patients with macrocephaly were identified by problem list in children aged less than 36 months. Data collection included basic demographics, imaging modality, developmental delay, prematurity, seizures, focal neurological symptoms, family history of macrocephaly, sedation used, and sedation complications. RESULTS: A total of 169 patients were included in the analysis. Imaging modalities included 39 magnetic resonance imagings (23.1%), 47 cranial computed tomographies (27.8%), and 83 head ultrasounds (49.1%). Imaging results demonstrated 13 abnormal studies with five of those studies being abnormal with high clinical yield. Patients with abnormal studies were more likely to have developmental delay (P = 0.04) or neurological symptoms (P = 0.015). Positive family history of macrocephaly was predictive of normal imaging (P = 0.004). There were no sedation complications. CONCLUSIONS: Intracranial imaging does not appear to be necessary in children with no risk factors and or a positive family history of macrocephaly. Risk factors such as developmental delay or neurological symptoms could identify children at risk for imaging abnormalities that require further management.

Use of Intranasal Dexmedetomidine as a Solo Sedative for MRI of Infants.

BACKGROUND: Dexmedetomidine, a selective α-2 receptor agonist, can be delivered via the intranasal (IN) route and be used for procedural sedation. The drug's favorable hemodynamic profile and relative ease of application make it a promising agent for sedation during radiologic procedures, although there are few studies on its efficacy for MRI studies. METHODS: A retrospective chart review was performed between June 2014 and December 2016. Outpatients between 1 and 12 months of age who received 4 µg/kg of IN dexmedetomidine for MRI were included in the analysis. Our aim with this study was to determine the rate of successful completion of the sedation procedure without the need for a rescue drug (other than repeat IN dexmedetomidine). RESULTS: A total of 52 subjects were included in our study. Median (interquartile range) patient age was 7 (5-8) months. Median (interquartile range) procedure length was 40 (35-50) minutes. Overall success rate (including first dose and any rescue dose IN) of dexmedetomidine was 96.2%. None of the patients had significant adverse effects related to dexmedetomidine. CONCLUSIONS: IN dexmedetomidine is an effective solo sedative agent for MRI in infants.

Safety and Utility of Continuous Ketamine Infusion for Sedation in Mechanically Ventilated Pediatric Patients.

OBJECTIVES: The selection of sedative medications for mechanically ventilated pediatric patients remains an ongoing clinical challenge. Although continuous ketamine infusion has been used in this population, support for its use remains largely anecdotal. This study describes a single institution's use of ketamine infusions as part of a sedation protocol in the pediatric intensive care unit (PICU). METHODS: This was a retrospective study of children who received ketamine infusions as part of a multidrug sedation protocol in a 12-bed PICU at a tertiary children's hospital. Outcomes included effectiveness of ketamine infusion in providing adequate sedation as determined by State Behavioral Scale (SBS) scores and incidence of adverse events. RESULTS: A total of 22 children receiving ketamine continuous infusion as part of a multidrug sedation protocol from February 2014 through October 2015 were eligible and enrolled in the study. Ketamine continuous infusion was administered in addition to at least 2 other sedation infusions at an average rate of 1.02 ± 0.50 mg/kg/hr, with a range of 0.07 to 2.0 mg/kg/hr. The duration of ketamine was 65.7 ± 41.01 hours, with a range of 19 to 153 hours. There was no significant change in SBS scores before and after initiation of ketamine infusion. Although not statistically significant, patients with inadequate sedation prior to starting ketamine required fewer bolus sedation doses and had improved sedation after ketamine was started. There were no reported adverse events. CONCLUSIONS: The addition of a ketamine infusion as part of a multidrug sedation regimen was at least as effective as patients' regimen prior to ketamine addition in this population of intubated pediatric patients, with no adverse events.

Hypertension in the Pediatric Intensive Care Unit.

Hypertension in the pediatric intensive care unit (PICU) is common and it contributes to the overall morbidity and mortality. Patients may present with hypertensive emergencies or hypertension can manifest itself later in PICU course. Although hypertension can be seen in most patients during hospitalization, patients with some specific diseases and conditions are more prone to hypertension. Hypertension should be recognized promptly and treated accordingly. Different pathophysiologic mechanisms can be responsible for the hypertension and management differs based on the underlying etiology. Any patient with a hypertensive emergency must be admitted to PICU, and treatment and diagnostic workup should be initiated immediately.

Pupillometry in brain death: differences in pupillary diameter between paediatric and adult subjects.

OBJECTIVES: The determination of brain death in neonates, infants, children and adults relies on a clinical diagnosis based on the absence of neurological function with a known irreversible cause of brain injury. Evaluation of pupil size and non-reactivity is a requisite for determination of brain death. There are no studies in the literature that quantitatively assess pupil size in brain dead children and adults. METHODS: Infants, children and adults diagnosed with brain death were included in the study. Pupils were measured with a quantitative pupillometer (Forsite; Neuroptics, Irvine, CA, USA). Median, minimum and maximum pupil sizes were documented and the results were adjudicated for age, vasopressor use and temperature. RESULTS: Median right and left pupil sizes were 5.01 ± 0.85 mm and 5.12 ± 0.87 mm, respectively, with a range between 3.69 and 7.34 mm. Paediatric pupils were larger than adult pupils (right pupil 5.53 vs 4.73 mm p: 0.018; left pupil 5.87 vs 4.77 mm P: 0.03), and there was no correlation of pupil size with temperature or increasing number of vasopressors. CONCLUSION: This is the first study in the literature objectively evaluating pupil sizes in infants, children and adults diagnosed with brain death. We observed variation between observed pupil size and that expected based on brain death determination guidelines.