Development of pediatric multidisciplinary extracorporeal membrane oxygenation simulations: A novel educational program to enhance team communication and emergency preparedness.

INTRODUCTION: Pediatric extracorporeal membrane oxygenation (ECMO) is a high risk, low-volume technology. Infrequency of this technology and associated complications may translate to unfamiliarity of identification and management of potentially life-threatening events, which may require knowledge and procedural skills to be performed quickly. Providers involved in managing ECMO must be able to promptly identify and initiate management for such events, particularly when surgical colleagues are not readily available. METHODS: A multidisciplinary ECMO simulation program was implemented in a tertiary children's hospital. Over 18 months, a prospective, observational study was conducted evaluating simulations involving circuit and patient emergencies, teamwork and communication behaviors and technical skills. An on-line survey was sent to participants following sessions to evaluate post-simulation confidence, lessons learned and potential barriers to implementation of necessary skills and behaviors. RESULTS: Ten simulation sessions occurred during implementation. Mean participants per session was 7 (range: 5-11). Eight Pediatric Cardiac Intensive Care Unit attendings, four Advance Practice Nurses, 54 pediatric intensive care unit registered nurses, and 55 pediatric respiratory therapists attended. Tasks with highest self-reported increase in confidence were related to (1) diagnosis (tension pneumothorax, oxygenator failure, and ventricular tachycardia), (2) fluid administration and (3) early and efficient mobilization for ECPR, with less reported confidence increase with technical skills More than 90% of participants provided a task or behavior they would implement if a specific emergency was encountered in real-life following simulation training. Real-life application occurred following simulations with participants reporting direct impact of training on their ability to perform the skill efficiently and correctly. CONCLUSIONS: Implementation of ECMO multidisciplinary simulations provides structured opportunities for the team to learn and practice ECMO skills together in scenarios they may encounter without surgical presence. Ensuring competency of providers through implementation of such a program may improve patient safety through enhanced team communication, knowledge, and hands-on experience.

Reactive uptake of ozone to azo dyes in a coated-wall flow tube.

Azo dyes are the most common colorants in consumer products, including clothing and cosmetics. Some azo dyes and their products from reductive degradation are known to be mutagenic, so dermal exposure to these species has been studied extensively. In contrast, oxidative degradation of azo dyes in consumer products has not been studied so thoroughly. In the indoor environment, ozone is ubiquitous, so reactive uptake of ozone to azo dyes could lead to dermal exposure to other classes of degradation products. Here, we report the first measurements of the reactive uptake of ozone to thin films of three widely used commercial azo dyes: sunset yellow, amaranth, and tartrazine. Steady-state uptake was observed for all three dyes, under all conditions investigated, even at the lowest relative humidity (RH) of 0%. The uptake coefficients increased with RH. For sunset yellow at 100 ppb of ozone, the value at 80% RH, (2.0 ± 0.5) × 10-7, was 2.5 times greater than that at 0% RH, (8 ± 1) × 10-8, consistent with plasticization of the thin film due to absorption of water. The uptake coefficient of sunset yellow at 80% RH exhibited an inverse dependence on the ozone mixing ratio, approaching an asymptote of 1 × 10-7 above 250 ppb. At 80% RH and 100 ppb of ozone, the uptake coefficients for the three dyes were similar, (2.0 ± 0.5) × 10-7 for sunset yellow, (2.7 ± 0.6) × 10-7 for amaranth, and (3.2 ± 0.3) × 10-7 for tartrazine, despite differences in structural parameters related to the number of reactive sites at the surface. Together, these results are consistent with ozone diffusing into the thin film and the dye molecules mixing between the layers, such that reaction is not restricted to the surface of the film. Finally, the results are suggestive of a role for azo dyes, including the occurrence of their oxidation products, in indoor chemistry.

Cat scratch-induced Pasteurella multocida necrotizing cellulitis in a dog.

BACKGROUND: In humans, rapidly developing Pasteurella multocida cellulitis after a cat scratch or bite is a well-known entity that sometimes progresses to necrotizing fasciitis and can be fatal. CASE REPORT: A 3-year-old female spayed whippet dog developed ecchymosis, swelling and pain within 24 h of being scratched by a cat on the ventral thorax. Over the following days, while being treated only with pain medications, the lesions rapidly progressed into haemorrhagic bullae with expanding skin necrosis. A heavy growth of P. multocida was seen on bacterial cultures, and histological examination showed marked, suppurative panniculitis with necrosis of the epidermis, dermis and panniculus. Special histological stains highlighted a moderate amount of Gram-negative coccobacilli admixed with inflammatory cells. Complete resolution was achieved with surgical debridement, skin grafting and intravenous antibiotic treatment. Positive bacterial culture for P. multocida, in conjunction with the history, clinical findings, histology results and the rapid response to therapy, strongly supports a diagnosis of P. multocida necrotizing cellulitis. CONCLUSIONS AND CLINICAL IMPORTANCE: Complications of cat bite-associated P. multocida infections in humans are well known. To the authors' knowledge, this is the first documentation of P. multocida necrotizing cellulitis in a dog following a cat scratch wound. This case highlights the rapidity and severity of P. multocida cellulitis, if not recognized and treated early. Veterinarians should include P. multocida in the differential diagnosis of any local wound infection following a cat scratch.