Validation of a Simulation-Based Resuscitation Curriculum for Maternal Cardiac Arrest.

OBJECTIVE: To assess the knowledge, skills, and self-efficacy of health care participants completing a simulation-based blended learning training curriculum on managing maternal medical emergencies and maternal cardiac arrest (Obstetric Life Support). METHODS: A formative assessment of the Obstetric Life Support curriculum was performed with a prehospital cohort comprising emergency medical services professionals and a hospital-based cohort comprising health care professionals who work primarily in hospital or urgent care settings and respond to maternal medical emergencies. The training consisted of self-guided precourse work and an instructor-led simulation course using a customized low-fidelity simulator. Baseline and postcourse assessments included multiple-choice cognitive test, self-efficacy questionnaire, and graded Megacode assessment of the team leader. Megacode scores and pass rates were analyzed descriptively. Pre- and post-self-confidence assessments were compared with an exact binomial test, and cognitive scores were compared with generalized linear mixed models. RESULTS: The training was offered to 88 participants between December 2019 and November 2021. Eighty-five participants consented to participation; 77 participants completed the training over eight sessions. At baseline, fewer than half of participants were able to achieve a passing score on the cognitive assessment as determined by the expert panel. After the course, mean cognitive assessment scores improved by 13 points, from 69.4% at baseline to 82.4% after the course (95% CI 10.9-15.1, P <.001). Megacode scores averaged 90.7±6.4%. The Megacode pass rate was 96.1%. There were significant improvements in participant self-efficacy, and the majority of participants (92.6%) agreed or strongly agreed that the course met its educational objectives. CONCLUSION: After completing a simulation-based blended learning program focused on managing maternal cardiac arrest using a customized low-fidelity simulator, most participants achieved a defensible passing Megacode score and significantly improved their knowledge, skills, and self-efficacy.

Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study.

INTRODUCTION: Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members. METHODS: This is a prospective observational study analyzing data obtained between July 2018-December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies. RESULTS: Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of >3 were reported by 100% of participants in all domains (p < .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills. CONCLUSION: This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter.

Coronavirus Disease 2019 in Pediatric Oncology Patients: A Matched-Cohort Analysis of the SCCM Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 Registry.

BACKGROUND: There is a paucity of multicenter data describing the impact of coronavirus disease 2019 (COVID-19) on hospitalized pediatric oncology patients. Using a large, multicenter, Society of Critical Care Medicine (SCCM) Discovery Viral Infection and Respiratory Illness University Study (VIRUS) database, we aimed at assessing outcomes of COVID-19 infection in this population. METHOD: This is a matched-cohort study involving children below 18 years of age hospitalized with COVID-19 between March 2020 and January 2021. Using the VIRUS; COVID-19 Registry database, children with oncologic diseases were compared with propensity score matched (age groups, sex, race, and ethnicity) cohort of children without oncologic diseases for the prevalence of Multisystem Inflammatory Syndrome in Children (MIS-C), intensive care unit (ICU) admission, interventions, hospital, and ICU length of stay. RESULTS: The number of children in the case and control groups was 45 and 180, respectively. ICU admission rate was similar in both groups ([47.7 vs 51.7%], P =0.63). The proportion of children requiring noninvasive and invasive mechanical ventilation, and its duration were similar between groups, same as hospital mortality. Interestingly, MIS-C was significantly lower in the oncology group compared with the control (2.4 vs 24.6%; P =0.0002). CONCLUSIONS: In this study using a multicenter VIRUS database, ICU admission rate, interventions, and outcomes of COVID-19 were similar in children with the oncologic disease compared with control patients. The incidence of MIS-C is lower in oncologic patients.

Association of Early Steroid Administration With Outcomes of Children Hospitalized for COVID-19 Without Multisystem Inflammatory Syndrome in Children.

Importance: There is limited evidence for therapeutic options for pediatric COVID-19 outside of multisystem inflammatory syndrome in children (MIS-C). Objective: To determine whether the use of steroids within 2 days of admission for non-MIS-C COVID-19 in children is associated with hospital length of stay (LOS). The secondary objective was to determine their association with intensive care unit (ICU) LOS, inflammation, and fever defervescence. Design, Setting, and Participants: This cohort study analyzed data retrospectively for children (<18 years) who required hospitalization for non-MIS-C COVID-19. Data from March 2020 through September 2021 were provided by 58 hospitals in 7 countries who participate in the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry. Exposure: Administration of steroids within 2 days of admission. Main Outcomes and Measures: Length of stay in the hospital and ICU. Adjustment for confounders was done by mixed linear regression and propensity score matching. Results: A total of 1163 patients met inclusion criteria and had a median (IQR) age of 7 years (0.9-14.3). Almost half of all patients (601/1163, 51.7%) were male, 33.8% (392/1163) were non-Hispanic White, and 27.9% (324/1163) were Hispanic. Of the study population, 184 patients (15.8%) received steroids within 2 days of admission, and 979 (84.2%) did not receive steroids within the first 2 days. Among 1163 patients, 658 (56.5%) required respiratory support during hospitalization. Overall, patients in the steroids group were older and had greater severity of illness, and a larger proportion required respiratory and vasoactive support. On multivariable linear regression, after controlling for treatment with remdesivir within 2 days, country, race and ethnicity, obesity and comorbidity, number of abnormal inflammatory mediators, age, bacterial or viral coinfection, and disease severity according to ICU admission within first 2 days or World Health Organization ordinal scale of 4 or higher on admission, with a random intercept for the site, early steroid treatment was not significantly associated with hospital LOS (exponentiated coefficient, 0.94; 95% CI, 0.81-1.09; P = .42). Separate analyses for patients with an LOS of 2 days or longer (n = 729), those receiving respiratory support at admission (n = 286), and propensity score-matched patients also showed no significant association between steroids and LOS. Early steroid treatment was not associated with ICU LOS, fever defervescence by day 3, or normalization of inflammatory mediators. Conclusions and Relevance: Steroid treatment within 2 days of hospital admission in a heterogeneous cohort of pediatric patients hospitalized for COVID-19 without MIS-C did not have a statistically significant association with hospital LOS.

Characterization and Outcomes of Hospitalized Children With Coronavirus Disease 2019: A Report From a Multicenter, Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) Registry.

OBJECTIVES: Multicenter data on the characteristics and outcomes of children hospitalized with coronavirus disease 2019 are limited. Our objective was to describe the characteristics, ICU admissions, and outcomes among children hospitalized with coronavirus disease 2019 using Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 registry. DESIGN: Retrospective study. SETTING: Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) registry. PATIENTS: Children (< 18 yr) hospitalized with coronavirus disease 2019 at participating hospitals from February 2020 to January 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was ICU admission. Secondary outcomes included hospital and ICU duration of stay and ICU, hospital, and 28-day mortality. A total of 874 children with coronavirus disease 2019 were reported to Viral Infection and Respiratory Illness Universal Study registry from 51 participating centers, majority in the United States. Median age was 8 years (interquartile range, 1.25-14 yr) with a male:female ratio of 1:2. A majority were non-Hispanic (492/874; 62.9%). Median body mass index (n = 817) was 19.4 kg/m2 (16-25.8 kg/m2), with 110 (13.4%) overweight and 300 (36.6%) obese. A majority (67%) presented with fever, and 43.2% had comorbidities. A total of 238 of 838 (28.2%) met the Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children, and 404 of 874 (46.2%) were admitted to the ICU. In multivariate logistic regression, age, fever, multisystem inflammatory syndrome in children, and pre-existing seizure disorder were independently associated with a greater odds of ICU admission. Hospital mortality was 16 of 874 (1.8%). Median (interquartile range) duration of ICU (n = 379) and hospital (n = 857) stay were 3.9 days (2-7.7 d) and 4 days (1.9-7.5 d), respectively. For patients with 28-day data, survival was 679 of 787, 86.3% with 13.4% lost to follow-up, and 0.3% deceased. CONCLUSIONS: In this observational, multicenter registry of children with coronavirus disease 2019, ICU admission was common. Older age, fever, multisystem inflammatory syndrome in children, and seizure disorder were independently associated with ICU admission, and mortality was lower among children than mortality reported in adults.

Defining Priority Areas for Critical Care Simulation: A Modified Delphi Consensus Project.

Background Simulation is used in critical care for skill development, formative assessment, and interprofessional team performance. Healthcare educators need to balance the relatively high cost to deliver simulation education with the potential impact on healthcare quality. It is unclear how to prioritize simulation in critical care education, especially considering interprofessional needs across adult and pediatric populations. The objective of this study was to prioritize topics for critical care educators developing simulation-based educational interventions. Methodology A modified Delphi process was used to identify and prioritize critical care topics taught using simulation. We disseminated a multi-institutional survey to understand critical care simulation topics using a three-round modified Delphi technique. An expert panel was recruited based on their expertise with simulation-based education through the Society for Simulation in Healthcare and the Society of Critical Care Medicine lists. Critical care topics originated using content derived from multiple critical care board examination contents. Additional content for a critical care simulation-based curriculum was generated. Results Consensus and prioritization were achieved in three rounds, with 52 simulation experts participating. The first Delphi round surveyed priority topics in critical care content and generated additional topics for inclusion in round two. The second Delphi round added the content with the highest-ranked items from round one to generate a set of simulation-based topic priorities. The third Delphi round asked participants to determine the importance of each priority item taught via simulation compared to other modalities for clinical education. This round yielded 106 topics over four domains categorized into (1) Diagnosis and Management of Clinical Problems, (2) Procedural Skills, (3) Teamwork and Communication Skills, and (4) General Knowledge and Knowledge of Technical Adjuncts. Conclusions The modified Delphi survey revealed a prioritized, consensus-based list of topics and domains for critical care educators to focus on when creating a simulation-based critical care curriculum. Future work will focus on developing specific simulation-based critical care curricula.

The Impact of Obesity on Disease Severity and Outcomes Among Hospitalized Children With COVID-19.

OBJECTIVE: To describe the impact of obesity on disease severity and outcomes of coronavirus disease 2019 (COVID-19) among hospitalized children. METHODS: This retrospective cohort study from the Society of Critical Care Medicine Viral Respiratory Illness Universal Study registry included all children hospitalized with COVID-19 from March 2020 to January 2021. Obesity was defined by Centers for Disease Control and Prevention BMI or World Health Organization weight for length criteria. Critical illness definition was adapted from National Institutes of Health criteria of critical COVID. Multivariate mixed logistic and linear regression was performed to calculate the adjusted odds ratio of critical illness and the adjusted impact of obesity on hospital length of stay. RESULTS: Data from 795 patients (96.4% United States) from 45 sites were analyzed, including 251 (31.5%) with obesity and 544 (68.5%) without. A higher proportion of patients with obesity were adolescents, of Hispanic ethnicity, and had other comorbidities. Those with obesity were also more likely to be diagnosed with multisystem inflammatory syndrome in children (35.7% vs 28.1%, P = .04) and had higher ICU admission rates (57% vs 44%, P < .01) with more critical illness (30.3% vs 18.3%, P < .01). Obesity had more impact on acute COVID-19 severity than on multisystem inflammatory syndrome in children presentation. The adjusted odds ratio for critical illness with obesity was 3.11 (95% confidence interval: 1.8-5.3). Patients with obesity had longer adjusted length of stay (exponentiated parameter estimate 1.3; 95% confidence interval: 1.1-1.5) compared with patients without obesity but did not have increased mortality risk due to COVID-19 (2.4% vs 1.5%, P = .38). CONCLUSION: In a large, multicenter cohort, a high proportion of hospitalized children from COVID-19 had obesity as comorbidity. Furthermore, obesity had a significant independent association with critical illness.

Coronavirus Disease 2019-Associated PICU Admissions: A Report From the Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study Registry.

OBJECTIVES: To compare clinical characteristics and outcomes of children admitted to the PICU for severe acute respiratory syndrome coronavirus 2-related illness with or without multisystem inflammatory syndrome in children. The secondary objective was to identify explanatory factors associated with outcome of critical illness defined by a composite index of in-hospital mortality and organ system support requirement. DESIGN: Retrospective cohort study. SETTING: Thirty-eight PICUs within the Viral Infection and Respiratory Illness Universal Study registry from March 2020 to January 2021. PATIENTS: Children less than 18 years with severe acute respiratory syndrome coronavirus 2-related illness with or without multisystem inflammatory syndrome in children. MEASUREMENTS AND MAIN RESULTS: Of 394 patients, 171 (43.4%) had multisystem inflammatory syndrome in children. Children with multisystem inflammatory syndrome in children were more likely younger (2-12 yr vs adolescents; p < 0.01), Black (35.6% vs 21.9%; p < 0.01), present with fever/abdominal pain than cough/dyspnea (p < 0.01), and less likely to have comorbidities (33.3% vs 61.9%; p < 0.01) compared with those without multisystem inflammatory syndrome in children. Inflammatory marker levels, use of inotropes/vasopressors, corticosteroids, and anticoagulants were higher in multisystem inflammatory syndrome in children patients (p < 0.01). Overall mortality was 3.8% (15/394), with no difference in the two groups. Diagnosis of multisystem inflammatory syndrome in children was associated with longer duration of hospitalization as compared to nonmultisystem inflammatory syndrome in children (7.5 d[interquartile range, 5-11] vs 5.3 d [interquartile range, 3-11 d]; p < 0.01). Critical illness occurred in 164 patients (41.6%) and was more common in patients with multisystem inflammatory syndrome in children compared with those without (55.6% vs 30.9%; p < 0.01). Multivariable analysis failed to show an association between critical illness and age, race, sex, greater than or equal to three signs and symptoms, or greater than or equal to two comorbidities among the multisystem inflammatory syndrome in children cohort. Among nonmultisystem inflammatory syndrome in children patients, the presence of greater than or equal to two comorbidities was associated with greater odds of critical illness (odds ratio 2.95 [95% CI, 1.61-5.40]; p < 0.01). CONCLUSIONS: This study delineates significant clinically relevant differences in presentation, explanatory factors, and outcomes among children admitted to PICU with severe acute respiratory syndrome coronavirus 2-related illness stratified by multisystem inflammatory syndrome in children.

Endotracheal tube manipulation during cardiopulmonary resuscitation in the neonatal intensive care unit.

OBJECTIVES: We sought to describe the approach to and impact of endotracheal tube (ETT) placement for cardiopulmonary resuscitation (CPR) occurring in the neonatal intensive care unit (NICU). STUDY DESIGN: A retrospective review of in-NICU CPR from 2012 to 2017 across ten NICUs in San Antonio, Texas. RESULTS: Of 209 CPR events, 22 (10.5%) patients required ETT placement at CPR onset, 23 (11%) had an existing ETT removed and replaced, and 8 (3.4%) both. We found no association between time without an ETT tube during CPR and time to return of spontaneous circulation (ROSC) or rate of ROSC. We found no documented use of a laryngeal mask airway during in-NICU CPR. CONCLUSIONS: For CPR occurring in the NICU, the achievement of ROSC or time to ROSC is not impacted by the need to place an initial AA at the onset of CPR in this contemporary cohort.

Cardiopulmonary Resuscitation in Interfacility Transport: An International Report Using the Ground Air Medical Quality in Transport (GAMUT) Database.

BACKGROUND: With the regionalization of specialty care, there is an increasing need for interfacility transport from local to regional hospitals. There are very limited data on rates of cardiopulmonary resuscitation (CPR) during medical transport and relationship between transport-specific factors, such as transport program type and need of CPR during transport of critically ill patients. We present the first, multicenter, international report of CPR during medical transport using the large Ground and Air Medical qUality Transport (GAMUT) database. METHODS: We retrospectively reviewed the GAMUT database from January 2014 to March 2017 for CPR during transport. We determined the overall CPR rate and CPR rates for adult, pediatric, and neonatal transport programs. The rate of CPR per total transports was expressed as percentage, and then, Spearman's rho nonparametric associations were determined between CPR and other quality metrics tracked in the GAMUT database. Examples include advanced airway presence, waveform capnography usage, average mobilization time from the start of referral until en route, 1st attempt intubation success rate, and DASH1A intubation success (definitive airway sans hypoxia/hypotension on 1st attempt). Data were analyzed using chi-square tests, and in the presence of overall significance, post hoc Bonferroni adjusted z tests were performed. RESULTS: There were 72 programs that had at least one CPR event during the study period. The overall CPR rate was 0.42% (777 CPR episodes/184,272 patient contacts) from 115 programs reporting transport volume and CPR events from the GAMUT database during the study period. Adult, pediatric, and neonatal transport programs (n = 57, 40 and 16, respectively) had significantly different CPR rates (P < 0.001) i.e., 0.68% (555/82,094), 0.18% (138/76,430), and 0.33% (73/21,823), respectively. Presence of an advanced airway and mobilization time was significantly associated with CPR episodes (P < 0.001) (Rs = +0.41 and Rs = -0.60, respectively). Other transport quality metrics such as waveform capnography, first attempt intubation, and DASH1A success rate were not significantly associated with CPR episodes. CONCLUSION: The overall CPR rate during medical transport is 0.42%. Adult, pediatric, and neonatal program types have significantly different overall rates of CPR. Presence of advanced airway and mobilization time had an association with the rate of CPR during transport.

Propofol Infusion Is a Feasible Bridge to Extubation in General Pediatric Intensive Care Unit.

Objective: The current literature on propofol infusion as a bridge to extubation in critically ill children is limited to children with burns and congenital cardiac disease. We hypothesize that propofol infusion is a feasible bridge to extubation in mechanically ventilated, critically ill children. Design: Retrospective chart review. Setting: Pediatric intensive care unit of a tertiary care teaching hospital. Patients: Children < 21 years, admitted to our Pediatric intensive care unit (PICU), requiring mechanical ventilation (MV) for at least 48 h and at least two sedative infusions and who received propofol infusion for 4 to 24 h during anticipated extubation from January 2014 to May 2017. Interventions: None. Measurements and Main Results: We assessed extubation success as primary outcome. We defined extubation success as no re-intubation within 24 h after extubation. We also assessed for occurrence of adverse effects of propofol infusion (1) hemodynamic instability [more than 10% change from pre-propofol baseline heart rate (HR) and mean arterial pressure (MAP) measured 4 h before and during propofol infusion, need for any inotrope and/or fluid bolus] and (2) occurrence of lactic acidosis in absence of any documented sepsis. We compared hemodynamic parameters before and during infusion using Wilcoxon Rank Sum Test (significant p-value ≤ 0.05). We evaluated 35 critically ill, mechanically ventilated children. The median age, weight and duration of MV were 3.8 (IQR: 1.25-10.5) years, 12 (IQR: 6-16.2) kilograms and 111 (IQR: 78-212) h, respectively. Of the 35 patients, 15 (43%) were post-surgical (10 general and 5 cardiac) and the remaining 20 (57%) were non-surgical respiratory failure cases. The median (IQR) propofol infusion dose and duration were 64.7 (53.2-81.1) mcg/kg/min and 7.8 h respectively. Only one patient got re-intubated within 24 h of extubation and was later diagnosed with vascular ring. During propofol infusion, 7/35 (20%) patients exhibited transient drop in MAP > 10% from baseline, but none had lactic acidosis or required an inotrope or fluid bolus. Conclusions: In critically ill, mechanically ventilated patients, propofol infusion used over a short duration (<12 h) was found to be a feasible bridge to extubation. No patient had significant hypotension or lactic acidosis during the infusion.

The Characteristics and Outcomes of Cardiopulmonary Resuscitation within the Neonatal Intensive Care Unit Based on Gestational Age and Unit Level of Care.

OBJECTIVES: This study aimed to describe the variation of in-neonatal intensive care unit (NICU) cardiopulmonary resuscitation (CPR) characteristics and outcomes across different gestational ages and levels of NICU care. STUDY DESIGN: This is a retrospective cohort study of in-NICU CPR events across 10 NICUs in San Antonio, TX from 2012 through 2017. RESULTS: We identified 140 patients experiencing a total of 210 in-NICU CPR events. CPR was performed in 0.23% of Level III and 0.85% of Level IV NICU admissions. Gestational age was inversely related to CPR incidence. The median age at in-NICU CPR was lower for preterm versus term infants (6 vs. 28 days, p = 0.002). With regression modeling, each added minute of chest compression decreased the odds of return to spontaneous circulation by 11%. CONCLUSION: In-NICU CPR incidence rises with decreasing gestational age and increasing level of NICU care. The rate of return of spontaneous circulation decreases significantly with increasing duration of chest compressions. Further study is needed to identify patient factors associated with adverse outcome.

Hands-On Defibrillation Skills of Pediatric Acute Care Providers During a Simulated Ventricular Fibrillation Cardiac Arrest Scenario.

Introduction: Timely defibrillation in ventricular fibrillation cardiac arrest (VFCA) is associated with good outcome. While defibrillation skills of pediatric providers have been reported to be poor, the factors related to poor hands-on defibrillation skills of pediatric providers are largely unknown. The aim of our study was to evaluate delay in individual steps of the defibrillation and human and non-human factors associated with poor hands-on defibrillation skills among pediatric acute care providers during a simulated VFCA scenario. Methods: We conducted a prospective observational study of video evaluation of hands-on defibrillation skills of pediatric providers in a simulated VFCA in our children's hospital. Each provider was asked to use pads followed by paddles to provide 2 J/kg shock to an infant mannequin in VFCA. The hands-on skills were evaluated for struggle with any step of defibrillation, defined a priori as >10 s delay with particular step. The data was analyzed using chi-square test with significant p-value < 0.05. Results: A total of 68 acute care providers were evaluated. Median time to first shock was 97 s (IQR: 60-122.5 s) and did not correlate with provider factors, except previous experience with the defibrillator used in study. The number of providers who struggled (>10 s delay) with each of connecting the pads/paddles to the device, using pads/paddles on the mannequin and using buttons on the machine was 34 (50%), 26 (38%), and 31 (46%), respectively. Conclusions: The defibrillation skills of providers in a tertiary care children's hospital are poor. Both human and machine-related factors are associated with delay in defibrillation. Prior use of the study defibrillator is associated with a significantly shorter time-to-first shock as compared to prior use of any other defibrillator or no prior use of any defibrillator.

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children.

BACKGROUND: Targeted temperature management is recommended for comatose adults and children after out-of-hospital cardiac arrest; however, data on temperature management after in-hospital cardiac arrest are limited. METHODS: In a trial conducted at 37 children's hospitals, we compared two temperature interventions in children who had had in-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose children older than 48 hours and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a score of 70 or higher on the Vineland Adaptive Behavior Scales, second edition (VABS-II, on which scores range from 20 to 160, with higher scores indicating better function), was evaluated among patients who had had a VABS-II score of at least 70 before the cardiac arrest. RESULTS: The trial was terminated because of futility after 329 patients had undergone randomization. Among the 257 patients who had a VABS-II score of at least 70 before cardiac arrest and who could be evaluated, the rate of the primary efficacy outcome did not differ significantly between the hypothermia group and the normothermia group (36% [48 of 133 patients] and 39% [48 of 124 patients], respectively; relative risk, 0.92; 95% confidence interval [CI], 0.67 to 1.27; P=0.63). Among 317 patients who could be evaluated for change in neurobehavioral function, the change in VABS-II score from baseline to 12 months did not differ significantly between the groups (P=0.70). Among 327 patients who could be evaluated for 1-year survival, the rate of 1-year survival did not differ significantly between the hypothermia group and the normothermia group (49% [81 of 166 patients] and 46% [74 of 161 patients], respectively; relative risk, 1.07; 95% CI, 0.85 to 1.34; P=0.56). The incidences of blood-product use, infection, and serious adverse events, as well as 28-day mortality, did not differ significantly between groups. CONCLUSIONS: Among comatose children who survived in-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a favorable functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute; THAPCA-IH ClinicalTrials.gov number, NCT00880087 .).

Neurologic Injury Associated with Rewarming from Hypothermia: Is Mild Hypothermia on Bypass Better than Deep Hypothermic Circulatory Arrest?

Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair. Rewarming from moderate-to-deep hypothermia has been shown to be associated with neuronal injury, neuroinflammation, and loss of cerebrovascular autoregulation. A significantly lesser degree of rewarming is required following mild (33-35°C) hypothermia as compared with moderate (28-32°C), deep (21-27°C), and profound (less than 20°C) hypothermia. Therefore, we believe that mild hypothermia is associated with a lower risk of rewarming-induced neurologic injury. We hypothesize that mild hypothermia with selective antegrade cerebral perfusion during CPB for neonatal aortic arch repair would be associated with improved neurologic outcome.

Defining Optimal Head-Tilt Position of Resuscitation in Neonates and Young Infants Using Magnetic Resonance Imaging Data.

Head-tilt maneuver assists with achieving airway patency during resuscitation. However, the relationship between angle of head-tilt and airway patency has not been defined. Our objective was to define an optimal head-tilt position for airway patency in neonates (age: 0-28 days) and young infants (age: 29 days-4 months). We performed a retrospective study of head and neck magnetic resonance imaging (MRI) of neonates and infants to define the angle of head-tilt for airway patency. We excluded those with an artificial airway or an airway malformation. We defined head-tilt angle a priori as the angle between occipito-ophisthion line and ophisthion-C7 spinous process line on the sagittal MR images. We evaluated medical records for Hypoxic Ischemic Encephalopathy (HIE) and exposure to sedation during MRI. We analyzed MRI of head and neck regions of 63 children (53 neonates and 10 young infants). Of these 63 children, 17 had evidence of airway obstruction and 46 had a patent airway on MRI. Also, 16/63 had underlying HIE and 47/63 newborn infants had exposure to sedative medications during MRI. In spontaneously breathing and neurologically depressed newborn infants, the head-tilt angle (median ± SD) associated with patent airway (125.3° ± 11.9°) was significantly different from that of blocked airway (108.2° ± 17.1°) (Mann Whitney U-test, p = 0.0045). The logistic regression analysis showed that the proportion of patent airways progressively increased with an increasing head-tilt angle, with > 95% probability of a patent airway at head-tilt angle 144-150°.

Therapeutic hypothermia after out-of-hospital cardiac arrest in children.

BACKGROUND: Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited. METHODS: We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest. RESULTS: A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality. CONCLUSIONS: In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

Diagnostic Errors in a PICU: Insights From the Morbidity and Mortality Conference.

OBJECTIVES: To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process. DESIGN: Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports. SETTING: Single tertiary referral PICU in Baltimore, MD. PATIENTS: Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events. CONCLUSIONS: Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive- and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.

Additive Neuroprotection of a 20-HETE Inhibitor with Delayed Therapeutic Hypothermia after Hypoxia-Ischemia in Neonatal Piglets.

The severity of perinatal hypoxia-ischemia and the delay in initiating therapeutic hypothermia limit the efficacy of hypothermia. After hypoxia-ischemia in neonatal piglets, the arachidonic acid metabolite 20-hydroxyeicosatetraenoic acid (20-HETE) has been found to contribute to oxidative stress at 3 h of reoxygenation and to eventual neurodegeneration. We tested whether early administration of a 20-HETE synthesis inhibitor after reoxygenation augments neuroprotection with 3-hour delayed hypothermia. In two hypothermic groups, whole body cooling from 38.5 to 34°C was initiated 3 h after hypoxia-ischemia. Rewarming occurred from 20 to 24 h; then anesthesia was discontinued. One hypothermic group received a 20-HETE inhibitor at 5 min after reoxygenation. A sham-operated group and another hypoxia-ischemia group remained normothermic. At 10 days of recovery, resuscitated piglets with delayed hypothermia alone had significantly greater viable neuronal density in the putamen, caudate nucleus, sensorimotor cortex, CA3 hippocampus, and thalamus than did piglets with normothermic recovery, but the values remained less than those in the sham-operated group. In piglets administered the 20-HETE inhibitor before hypothermia, the density of viable neurons in the putamen, cortex and thalamus was significantly greater than in the group with hypothermia alone. Cytochrome P450 4A, which can synthesize 20-HETE, was expressed in piglet neurons in these regions. We conclude that early treatment with a 20-HETE inhibitor enhances the therapeutic benefit of delayed hypothermia in protecting neurons in brain regions known to be particularly vulnerable to hypoxia-ischemia in term newborns.