SCRATCH Trial: An Initiative to Reduce Excess Use of High-Flow Nasal Cannula.

OBJECTIVES: We aimed to reduce unnecessary use of high-flow nasal cannula (HFNC) at lower flow rates through the implementation of a standard daily trial off HFNC at a medium-sized academic center. METHODS: We used an interprofessional quality improvement collaboration to develop and implement interventions to reduce HFNC waste in children aged 1 month to 24 months with bronchiolitis who were admitted to the inpatient ward or ICU. Key interventions included development and implementation of the Simple Cannula/Room Air Trial for Children (SCRATCH Trial), a standard trial off HFNC for eligible infants. Process measures were selected as metrics of use of the newly developed trial. The primary outcome measure was hours of treatment with ≤8 L per minute (LPM) of HFNC. Additional outcome measures included total hours of treatment with HFNC and length of stay. RESULTS: A total of 271 patients were included in this study, 131 in the preimplementation group and 140 in the postimplementation group. The mean hours of treatment below our a priori determined waste line (≤8 LPM of HFNC) decreased from 36.3 to 16.8 hours after SCRATCH Trial implementation, and mean length of stay decreased from 4.1 to 3.0 days. CONCLUSIONS: The SCRATCH Trial was successfully implemented across hospital units, with a significant reduction in hours on ≤8 LPM of flow. Rapid discontinuation of HFNC appears feasible and may be associated with a shorter length of stay.

PICU Early Mobilization and Impact on Parent Stress.

BACKGROUND AND OBJECTIVES: Early mobilization of critically ill children may improve outcomes, but parent refusal of mobilization therapies is an identified barrier. We aimed to evaluate parent stress related to mobilization therapy in the PICU. METHODS: We conducted a cross-sectional survey to measure parent stress and a retrospective chart review of child characteristics. Parents or legal guardians of children admitted for ≥1 night to an academic, tertiary-care PICU who were proficient in English or Spanish were surveyed. Parents were excluded if their child's death was imminent, child abuse or neglect was suspected, or there was a contraindication to child mobilization. RESULTS: We studied 120 parent-child dyads. Parent mobilization stress was correlated with parent PICU-related stress (rs [119] = 0.489; P ≤ .001) and overall parent stress (rs [110] = 0.272; P = .004). Increased parent mobilization stress was associated with higher levels of parent education, a lower baseline child functional status, more strenuous mobilization activities, and mobilization therapies being conducted by individuals other than the children's nurses (all P < .05). Parents reported mobilization stress from medical equipment (79%), subjective pain and fragility concerns (75%), and perceived dyspnea (24%). Parent-reported positive aspects of mobilization were clinical improvement of the child (70%), parent participation in care (46%), and increased alertness (38%). CONCLUSIONS: Parent mobilization stress was correlated with other measures of parent stress and was associated with child-, parent-, and therapy-related factors. Parents identified positive and stressful aspects of mobilization therapy that can guide clinical care and educational interventions aimed at reducing parent stress and improving the implementation of mobilization therapies.

Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission.

BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%-99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, -0.053-0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

Mobilization Therapy in the Pediatric Intensive Care Unit: A Multidisciplinary Quality Improvement Initiative.

BACKGROUND: Mobilization is safe and associated with improved outcomes in critically ill adults, but little is known about mobilization of critically ill children. OBJECTIVE: To implement a standardized mobilization therapy protocol in a pediatric intensive care unit and improve mobilization of patients. METHODS: A goal-directed mobilization protocol was instituted as a quality improvement project in a 20-bed cardiac and medical-surgical pediatric intensive care unit within an academic tertiary care center. The mobilization goal was based on age and severity of illness. Data on severity of illness, ordered activity limitations, baseline functioning, mobilization level, complications of mobilization, and mobilization barriers were collected. Goal mobilization was defined as a ratio of mobilization level to severity of illness of 1 or greater. RESULTS: In 9 months, 567 patient encounters were analyzed, 294 (52%) of which achieved goal mobilization. The mean ratio of mobilization level to severity of illness improved slightly but nonsignificantly. Encounters that met mobilization goals were in younger (P = .04) and more ill (P < .001) patients and were less likely to have barriers (P < .001) than encounters not meeting the goals. Complication rate was 2.5%, with no difference between groups (P = .18). No serious adverse events occurred. CONCLUSIONS: A multidisciplinary, multiprofessional, goal-directed mobilization protocol achieved goal mobilization in more than 50% of patients in this pediatric intensive care unit. Undermobilized patients were older, less ill, and more likely to have mobilization barriers at the patient and provider level.

Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs.

OBJECTIVES: Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. DESIGN: Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. PATIENTS: All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS: Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.

Providing adult and pediatric care in the same unit: multiple considerations.

As always in acute and critical care, preparation is fundamental to positive patient and family outcomes. Although integration of diverse age populations may occur rarely in a unit, strategic planning should be in place for such occurrences,with relevant competencies considered, addressed, and evaluated on a continuing basis.

Volatile anesthetic rescue therapy in children with acute asthma: innovative but costly or just costly?.

OBJECTIVES: To describe volatile anesthesia (VA) use for pediatric asthma, including complications and outcomes. DESIGN: Retrospective cohort study. SETTING: Children's hospitals contributing to the Pediatric Health Information System between 2004-2008. PATIENTS: Children 2-18 years old with a primary diagnosis code for asthma supported with mechanical ventilation. INTERVENTION: Those treated with VA were compared to those not treated with VA or extracorporeal membrane oxygenation. Hospital VA use was grouped as none, <5%, 5-10% and >10% among intubated children. MEASUREMENTS AND MAIN RESULTS: One thousand five hundred and fifty-eight patients received mechanical ventilation at 40 hospitals for asthma: 47 (3%) received VA treatment at 11 (28%) hospitals. Those receiving a VA were significantly less likely to receive inhaled b-agonists, ipratropium bromide, and heliox, but more likely to receive neuromuscular blocking agents than patients treated without VA. Length of mechanical ventilation, hospital stay (length of stay [LOS]) and charges were significantly greater for those treated with VA. Aspiration was more common but death and air leak did not differ. Patients at hospitals with VA use >10% were significantly less likely to receive inhaled b agonist, ipratropium bromide, methylxanthines, and heliox, but more likely to receive systemic b agonist, neuromuscular blocking agents compared to those treated at hospitals not using VA. LOS, duration of ventilation, and hospital charges were significantly greater for patients treated at centers with high VA use. CONCLUSIONS: Mortality does not differ between centers that use VA or not. Patients treated at centers with high VA use had significantly increased hospital charges and increased LOS.

Neurologic complications and neurodevelopmental outcome with extracorporeal life support.

Extracorporeal life support is used to support patients of all ages with refractory cardiac and/or respiratory failure. Extracorporeal membrane oxygenation (ECMO) has been used to rescue patients whose predicted mortality would have otherwise been high. It is associated with acute central nervous system (CNS) complications and with long- term neurologic morbidity. Many patients treated with ECMO have acute neurologic complications, including seizures, hemorrhage, infarction, and brain death. Various pre-ECMO and ECMO factors have been found to be associated with neurologic injury, including acidosis, renal failure, cardiopulmonary resuscitation, and modality of ECMO used. The risk of neurologic complication appears to vary by age of the patient, with neonates appearing to have the highest risk of acute central nervous system complications. Acute CNS injuries are associated with increased risk of death in a patient who has received ECMO support. ECMO is increasingly used during cardiopulmonary resuscitation when return of spontaneous circulation is not achieved rapidly and outcomes may be good in select populations. Economic analyses have shown that neonatal and adult respiratory ECMO are cost effective. There have been several intriguing reports of active physical rehabilitation of patients during ECMO support that is well tolerated and may improve recovery. Although there is evidence that some patients supported with ECMO appear to have very good outcomes, there is limited understanding of the long-term impact of ECMO on quality of life and long-term cognitive and physical functioning for many groups, especially the cardiac and pediatric populations. This deserves further study.

Treatment of refractory pulmonary arterial hypertension with inhaled epoprostenol in an infant with congenital heart disease.

Epoprostenol is a potent arterial vasodilator, and its administration by inhalation localizes its effects to the pulmonary circulation. In this case report, we describe a 3-month-old male patient with significant refractory pulmonary hypertension after pulmonary artery banding and placement of a Blalock-Taussig shunt. This patient continued to have significant hypoxic episodes despite maximal therapy with sedation, alkalinization, sildenafil, and inhaled nitric oxide. After the addition of inhaled epoprostenol, improvements in both clinical response and echocardiography-based hemodynamics were observed. The case supports a synergistic role among the agents in the treatment of pulmonary arterial hypertension from congenital heart disease.

Survival of candida sepsis in extracorporeal membrane oxygenation.

OBJECTIVE: To report the survival of fungal sepsis in extracorporeal membrane oxygenation. DESIGN: Single case report. SETTING: Tertiary referral children's hospital pediatric intensive care unit. PATIENTS: A single case report of an infant with congenital heart disease who developed candida sepsis while supported postoperatively with extracorporeal membrane oxygenation. RESULTS: This infant survived a prolonged episode of candidemia after repair of congenital heart disease, which required extracorporeal membrane oxygenation support. The patient has no identified sequelae at 6-month follow-up and continues on long-term fluconazole therapy for candida endocarditis. CONCLUSIONS: Candidemia, particularly Candida albicans species, may not be a contraindication for extracorporeal membrane oxygenation support. With antifungal therapy and adequate inotropic use to counter the effects of septicemia, survival can be maintained until the patient adequately recovers, allowing decannulation, removal of all catheters, and eventual bloodstream sterility.

Interactive Web sites for families and physicians of pediatric intensive care unit patients: a preliminary report.

OBJECTIVE: To describe our experience with a Web-based communications program for the patients, families, and referring physicians of patients admitted to our pediatric intensive care unit. DESIGN: Prospective descriptive case series for a 32-month period from April 2000 through January 2003. SETTING: Sixteen-bed multidisciplinary medical-surgical pediatric intensive care unit (PICU). SUBJECTS: Seventy-three of 78 patients admitted to the PICU for > or =3 days and their families participated in the study, along with 26 referring physicians. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We found that 77% (474/619) of surveyed family members and friends thought that the Web page helped them share information, 13% (82/619) were unsure, and only <1% (4/619) thought it did not help them share information. When comparing respondents who thought the Web page helped them share information with those who did not or those who did not know, internet use was significantly associated with thinking that the Web page helped them share information (p =.0007). Seventy-three percent (19/26) of physicians thought that Web page-based communication was easier than present methods to convey patient information, and 62% (16/26) replied that the Web-based communication met their expectation. Fifty-four percent (14/26) of physicians thought they were more likely to refer patients to our PICU because of the Web-based communication; this was significantly associated with physician assessment that the Web-based communication was easier than the present methods of communicating with referring physicians (p =.003). CONCLUSIONS: We conclude that both families and referring physicians find Web-based communications during a child's PICU hospitalization to be very helpful. We suggest that the Web-based PICU communications be developed and studied for both medical and economic impact.

Heparin-induced thrombocytopenia (HIT) in pediatric cardiac surgery: an emerging cause of morbidity and mortality.

Unfractionated heparin (UFH) is immunogenic, and heparin-dependent antibodies can be demonstrated 5 to 10 days postoperatively in 25% to 50% of adult postcardiac surgery patients. In a minority of these cases (1% to 3% if UFH is continued longer than 1 week) these antibodies strongly activate platelets, causing thrombocytopenia and massive thrombin generation (HIT syndrome). HIT is an intensely procoagulant disorder, and in adult cardiac surgery patients carries both significant thrombotic morbidity (38% to 81%) and mortality (28%). Despite the ubiquitous use of UFH in pediatric intensive care units, and the repeated and sustained exposures to UFH in neonates and young children with congenital heart disease, HIT has been infrequently recognized and reported in this patient population. However, emerging experience at our institution and elsewhere suggests that HIT is significantly under-recognized in pediatric congenital heart disease patients, and may in fact have an incidence and associated thrombotic morbidity and mortality in this patient group comparable to that seen in adult cardiac surgery patients. This article will review HIT in pediatric patients with congenital heart disease and emphasize the special challenges posed in clinical recognition, laboratory diagnosis, and treatment of HIT in this patient group. We will also outline our experience with the off-label use of the direct thrombin inhibitor, argatroban, in pediatric patients with HIT.

Advances in postoperative care of pediatric cardiac patients.

PURPOSE OF REVIEW: The past two decades have seen tremendous technological advances in the care of infants and children with congenital and acquired heart disease. Recent advances in postoperative management have made it possible to support smaller and more fragile infants, extended the capabilities of extracorporeal circulation, and have brought new and innovative monitoring capabilities to the intensive care unit. RECENT FINDINGS: We chose to focus our review on four main themes: management of pulmonary hypertension, mechanical support of the myocardium, near infrared spectroscopy, and heparin-induced thrombocytopenia. SUMMARY: As operative and cardiopulmonary bypass techniques have evolved, early complete repair in neonates and repair of more complex lesions is now possible, creating new challenges for postoperative care in the intensive care unit. Additionally, recognition and management of newly appreciated complications is essential.

Submersion and asphyxial injury.

Drowning and other asphyxial injuries are important causes of childhood morbidity and mortality. In this review, the epidemiology, pathophysiology, and treatments applied to near-drowning victims are discussed, with an emphasis on the difficulties encountered attempting to predict outcome using current methods.