Reduction in Mortality Following Pediatric Rapid Response Team Implementation.

OBJECTIVE: To evaluate the effectiveness of a physician-led rapid response team program on morbidity and mortality following unplanned admission to the PICU. DESIGN: Before-after study. SETTING: Single-center quaternary-referral PICU. PATIENTS: All unplanned PICU admissions from the ward from 2005 to 2011. INTERVENTIONS: The dataset was divided into pre- and post-rapid response team groups for comparison. MEASUREMENTS AND MAIN RESULTS: A Cox proportional hazards model was used to identify the patient characteristics associated with mortality following unplanned PICU admission. Following rapid response team implementation, Pediatric Risk of Mortality, version 3, illness severity was reduced (28.7%), PICU length of stay was less (19.0%), and mortality declined (22%). Relative risk of death following unplanned admission to the PICU after rapid response team implementation was 0.685. CONCLUSIONS: For children requiring unplanned admission to the PICU, rapid response team implementation is associated with reduced mortality, admission severity of illness, and length of stay. Rapid response team implementation led to more proximal capture and aggressive intervention in the trajectory of a decompensating pediatric ward patient.

Left main coronary artery dissection in pediatric sport-related chest trauma.

BACKGROUND: Traumatic coronary artery dissection (CAD) after blunt chest trauma (BCT) is extremely rare, particularly in children. Among coronary dissections, left main coronary artery (LMCA) dissection is the least common, with only two pediatric cases reported previously. Manifestations of coronary dissections can range from ST segment changes to sudden death. However, these manifestations are not specific and can be present with other cardiac injuries. To our knowledge we present the first pediatric case of traumatic LMCA dissection after sport-related BCT that was treated successfully with coronary stenting. CASE REPORT: A 14-year-old child sustained BCT during a baseball game. Early in the clinical course, he had episodes of ventricular dysrhythmias, diffuse ST changes, rising troponin I, and hemodynamic instability. Emergent cardiac catheterization revealed an LMCA dissection with extension into the proximal left anterior descending artery (LADA). A bare metal stent was placed from the LMCA to the LADA, which improved blood flow through the area of dissection. He has had almost full recovery of myocardial function and has been managed as an outpatient with oral heart failure and antiplatelet medications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case highlights that CAD, although rare, can occur after pediatric BCT. Pediatric emergency responders must have a heightened awareness that evidence of ongoing myocardial ischemia, such as evolving and focal myocardial infarction on electrocardiogram, persistent elevation or rising troponin I, and worsening cardiogenic shock, can represent a coronary event and warrant further evaluation. Cardiac catheterization can be both a diagnostic and therapeutic modality in such cases. Early recognition and management is vital for myocardial recovery.

A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19.

BACKGROUND: Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES: To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19. METHODS: A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values. RESULTS: At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked. CONCLUSIONS: Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.

Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement.

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

Donation after cardiac death in pediatric critical care.

OBJECTIVE: To describe the unmet need for pediatric organs, the history of donation after cardiac death (DCD), implementation of DCD policies in children's hospitals, and the current U.S. experience with DCD in children. DESIGN: Review of existing literature and national data regarding DCD. SETTING: Three children's hospitals and a national organ procurement network. PATIENTS: Nationwide review of pediatric candidates for transplantation and pediatric DCD donors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Interest in DCD has greatly increased over the past several years due to limited organ availability for transplantation. Leading medical groups have evaluated and endorsed DCD, and more hospitals are offering DCD as part of end-of-life care options for dying patients and to increase donation. Children's hospitals need to evaluate this concept and develop ethically sound polices to meet the needs of patients and families. Preliminary reports regarding organ function from DCD donors are promising, and DCD is increasing. CONCLUSIONS: The widening gap between the need for organs and the availability of organs from brain-dead donors has led to a resurgence of both interest in and use of organs donated after cardiac death. Children's hospitals need to explore DCD as an option in select circumstances to serve grieving families who would like to donate and to increase organ availability for transplantation. DCD programs are dependent on input and support from critical care providers.

Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery.

BACKGROUND: Extracorporeal life support (ECLS) has been used for over two decades in select patients after cardiac surgery. We previously described factors associated with death in this population. We now review our recent experience to reassess factors related to mortality. METHODS: All pediatric patients who received ECLS support within 7 days after surgery between July 1995 and June 2001 were examined to describe clinical features associated with survival. We compared the results with our prior report to assess changes in practice and outcome. RESULTS: Seventy-four patients were followed. Fifty percent survived to discharge. Hospital survival was not significantly related to patient age, cannulation site, or indication. Thirty-five percent of patients required hemofiltration while on ECLS and were significantly less likely to survive (23% vs 65%). A multivariate analysis combining all children from our prior report with the present cohort revealed that patients who received hemofiltration were five times more likely to die (odds ratio 5.01, 95% confidence interval 2.11-11.88). Children with an adequate two-ventricular repair had lower risk of death (odds ratio 0.42, 95% confidence interval 0.19-0.91) after adjusting for patient age, study period, and hours elapsed before initiation of ECLS after surgery. CONCLUSIONS: Patients with an adequate two-ventricle repair have significantly higher hospital survival, whereas those with single ventricle physiology or need for dialysis have decreased survival.

Extracorporeal membrane oxygenation cannula malposition in the azygos vein in an infant.

INTRODUCTION: Misplacement of extracorporeal membrane oxygenation (ECMO) venous cannula in the azygos vein has previously been described only in newborns. CASE: For the first time, we report an aberrant ECMO cannula placement in the azygos vein in a child outside neonatal period. History of chronic lung disease and ligation of persistent ductus arteriosus leading to elevated right ventricular pressure was the potential risk factor. CONCLUSIONS: This rare complication should be considered whenever the patient has inadequate venous return on ECMO and it can be easily ruled out with a lateral chest radiograph.

A novel error-reporting tool in pediatric intensive care.

Patient safety is a critical component of the U.S. healthcare system: thousands of people, including children, die or are injured yearly as a result of medical error. We designed and implemented a novel error-reporting tool for the pediatric intensive care unit. More errors were reported with the use of this paper-based tool than with the existing computerized error-reporting system. We also developed a scoring system to assess potential harm to the patient. The tool provided information about frequent and high-risk errors that guided successful improvements in patient care and safety and the achievement of measurable success.

Extracorporal life support for pulmonary hemorrhage in children: a case series.

OBJECTIVE: To examine the use and outcome of extracorporeal life support in children with severe respiratory failure caused by pulmonary hemorrhage. DESIGN: Retrospective case series report. SETTING: Pediatric intensive care unit in a university children's hospital. PATIENTS: Eight patients <19 yrs of age who required extracorporeal life support for severe respiratory failure associated with pulmonary hemorrhage. INTERVENTIONS: Venoarterial or venovenous extracorporeal life support. MEASUREMENTS: Ventilatory support parameters and systemic PaO2/FiO2 ratio before extracorporeal life support, time on extracorporeal life support, number of ventilator days, number of intensive care unit days, number of hospital days, continued bleeding on extracorporeal life support, and survival. MAIN RESULTS: All patients had resolution of their pulmonary hemorrhage within 24 hrs. All patients survived to decannulation, extubation, and hospital discharge. All patients are alive, with follow-up times ranging from 1 to 10 yrs. CONCLUSIONS: Extracorporeal life support is not contraindicated in patients with severe respiratory failure with associated pulmonary hemorrhage and may be a life-sustaining supportive therapy.