Standardized Implementation of Evidence-based Guidelines to Decrease Blood Transfusions in Pediatric Intensive Care Units.

INTRODUCTION: Despite evidence that red blood cell (RBC) transfusions may be associated with more harm than benefit, current transfusion practices vary significantly. This multicenter, quality improvement study aimed to sustainably decrease the rate of RBC transfusions in pediatric intensive care units (PICUs). METHODS: This 16-month prospective study included 5 PICUs. We implemented a standardized project plan including education, bedside tools, real-time reminders, and email feedback. We collected data from consecutive transfusions during pre-implementation (Phase I), postimplementation (Phase II), and post-stabilization phases (Phase III). RESULTS: Of the 2,064 RBC transfusions, we excluded 35% (N = 729) from analysis in patients undergoing extracorporeal membrane oxygenation. Transfusion/1,000 admissions improved throughout the study periods from a baseline 209.6 -199.8 in Phase II and 195.8 in Phase III (P value < 0.05). There were fewer transfusions outside of the hemoglobin threshold guideline, decreasing from 81% of transfusions outside of guidelines in Phase I to 74% in Phases II and III, P < 0.05. Study phase, site, co-management status, service of requesting provider, admit reason, previous transfusion status, and age were associated with transfusion above guideline threshold. CONCLUSIONS: Multicenter collaboration can successfully deploy a standardized plan that adheres to implementation science principles to sustainably decrease the rate of RBC transfusion outside of guideline thresholds. However, we did not decrease the total number of transfusions in our study. The complexity of multiple specialties co-managing patients is common in the contemporary PICU. Educational initiatives aimed at one specialty may have limited effectiveness in a multifaceted system of care.

Auricular Acupuncture for the Treatment of Pediatric Migraines in the Emergency Department.

OBJECTIVES: Headache remains a frequent complaint for children presenting to a pediatric emergency department (ED). Typical treatments include oral or intravenous medications, but do not always relieve pain. An alternative intervention is auricular acupuncture. It has been shown to be effective in the treatment of migraines in adults. The objective of this study was to evaluate the utility and adverse effects of auricular acupuncture in the treatment of pediatric migraines in the ED. METHODS: This was a prospective, interventional, cohort study of patients 8 to 18 years of age. Efficacious ear points were located by needle contact or electrical point finder with attention to 2 migraine lines on the ear. ASP gold semipermanent ear needles were placed in the efficacious points and patients were monitored for 15 minutes. The primary outcome was the change in preintervention and postintervention pain scores using a numerical self-reported pain visual analog scale (VAS). RESULTS: Nineteen patients elected to enroll in the study. The mean change in the VAS scores was both clinically and statistically significant at 7.03 (interquartile range, 6-8.5) with a P value of less than 0.001. Two patients elected to withdraw from the study secondary to incomplete resolution of migraine pain despite improvement in VAS scores. There were no known adverse events. CONCLUSIONS: With all subjects showing improvement or resolution of migraine headache, this pilot study introduces an alternative intervention to pediatric migraine management. Further studies are needed to evaluate the duration of symptom resolution and comparative effectiveness; auricular acupuncture seems to be a valid alternative.

A selective insecticidal protein from Pseudomonas mosselii for corn rootworm control.

The coleopteran insect western corn rootworm (WCR, Diabrotica virgifera virgifera) is an economically important pest in North America and Europe. Transgenic corn plants producing Bacillus thuringiensis (Bt) insecticidal proteins have been useful against this devastating pest, but evolution of resistance has reduced their efficacy. Here, we report the discovery of a novel insecticidal protein, PIP-47Aa, from an isolate of Pseudomonas mosselii. PIP-47Aa sequence shows no shared motifs, domains or signatures with other known proteins. Recombinant PIP-47Aa kills WCR, two other corn rootworm pests (Diabrotica barberi and Diabrotica undecimpunctata howardi) and two other beetle species (Diabrotica speciosa and Phyllotreta cruciferae), but it was not toxic to the spotted lady beetle (Coleomegilla maculata) or seven species of Lepidoptera and Hemiptera. Transgenic corn plants expressing PIP-47Aa show significant protection from root damage by WCR. PIP-47Aa kills a WCR strain resistant to mCry3A and does not share rootworm midgut binding sites with mCry3A or AfIP-1A/1B from Alcaligenes that acts like Cry34Ab1/Cry35Ab1. Our results indicate that PIP-47Aa is a novel insecticidal protein for controlling the corn rootworm pests.

Reversibility of Severe Cerebral Magnetic Resonance Imaging Changes Associated with Ethylene Glycol Toxicity.

Ethylene glycol (EG), commonly found in antifreeze and deicing solutions, continues to be a cause of morbidity and mortality in the pediatric population. EG metabolism produces toxins that cause metabolic acidosis and calcium oxalate deposition throughout the body. Deposition in the central nervous system is associated with significant neurologic sequelae, including altered mental status, seizures, and cerebral edema. We present a case of intentional EG poisoning in a 17-year-old male with resulting cerebral edema and coma. Neuroimaging studies were initially normal but eventually demonstrated diffuse abnormalities on both cranial computed tomography and magnetic resonance imaging (MRI). The patient ultimately made a complete recovery with resolution of the MRI abnormalities noted at the peak of illness. While neuroimaging is often incorporated into the management of EG poisoning, this is the first case report to show the evolution of EG-related MRI changes before, during, and after the resolution of EG-induced intracranial hypertension.

Ancillary Studies in Evaluating Pediatric Brain Death.

When confounding variables exist that inhibit the ability to diagnose brain death clinically in pediatric patients, ancillary tests may provide additional information for the practitioner in evaluating for the presence or absence of brain death. Multiple options exist but differ in availability, ease of administration, cost, safety profile, and reliability to accurately diagnose brain death. An important desirable quality of an ancillary test is eliminating false positives, which imply brain death when brain death is in fact not present. More commonly available ancillary studies include electroencephalograms, brain angiography through various modalities, brain stem auditory evoked potentials, and transcranial Doppler ultrasound. At this time, there is not an ancillary test with 100% reliability in diagnosing brain death that can replace the clinical brain death exam. Therefore, practitioners need to understand the strengths and limitations of the ancillary studies available at their hospital.

A selective insecticidal protein from Pseudomonas for controlling corn rootworms.

The coleopteran insect western corn rootworm (WCR) (Diabrotica virgifera virgifera LeConte) is a devastating crop pest in North America and Europe. Although crop plants that produce Bacillus thuringiensis (Bt) proteins can limit insect infestation, some insect populations have evolved resistance to Bt proteins. Here we describe an insecticidal protein, designated IPD072Aa, that is isolated from Pseudomonas chlororaphis. Transgenic corn plants expressing IPD072Aa show protection from WCR insect injury under field conditions. IPD072Aa leaves several lepidopteran and hemipteran insect species unaffected but is effective in killing WCR larvae that are resistant to Bt proteins produced by currently available transgenic corn. IPD072Aa can be used to protect corn crops against WCRs.

Critical care telemedicine: evolution and state of the art.

OBJECTIVES: To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda. DATA SOURCES: Review of the published medical literature, governmental documents, and opinions of experts from the Society of Critical Care Medicine ICU Telemedicine Committee. DATA SYNTHESIS: Formal ICU telemedicine programs now support 11% of nonfederal hospital critically ill adult patients. There is increasingly robust evidence of association with lower ICU (0.79; 95% CI, 0.65-0.96) and hospital mortality (0.83; 95% CI, 0.73-0.94) and shorter ICU (-0.62 d; 95% CI, -1.21 to -0.04 d) and hospital (-1.26 d; 95% CI, -2.49 to -0.03 d) length of stay. Physicians in training report experiences with telemedicine intensivists that are positive and increased patient safety. Early studies suggest that implementation of ICU telemedicine programs has been associated with lower numbers of malpractice claims and costs. The requirements for Medicare reimbursement and states with legislation addressing providing professional services by telemedicine are detailed. CONCLUSIONS: The inclusion of an ICU telemedicine program as a major part of their critical care delivery paradigm has been implemented for 11% of critically ill U.S. adults as a solution for the problem of access to adult critical care services. Implementation of an ICU telemedicine program is one practical way to increase access and reduce mortality as well as length of stay. ICU telemedicine research including comparative effectiveness studies is urgently needed.

Comparison of end-tidal CO2 and Paco2 in children receiving mechanical ventilation.

OBJECTIVE: To determine whether end-tidal CO(2) (Petco(2)) measurement provides a reliable estimate of ventilation in critically ill children who are mechanically ventilated. DESIGN: Prospective, nonrandomized, consecutive enrollment study. SETTING: A university-affiliated children's hospital pediatric intensive care unit. PATIENTS: All intubated, mechanically ventilated pediatric patients. INTERVENTIONS: All Petco(2)-Paco(2) pairs were from patients ventilated with a Servo 300 Ventilator (Siemens-Elema AB, Stockholm, Sweden). When a blood gas sample was obtained, Petco(2) as measured by a continuous mainstream Petco(2) capnograph was recorded. Measurements: The results of blood gas measurements and corresponding Petco(2) measurements were recorded. Demographic data and primary diagnosis were noted. Petco(2)-Paco(2) pairs obtained from patients with intracardiac shunts or obtained during high-frequency oscillation or extracorporeal membrane oxygenation at the time of measurement were excluded from analysis. Linear regression was used to analyze Petco(2)-Paco(2) pairs. Repeated measure analysis of variance with the mixed-model algorithm in SAS software (SAS Institute, Carey, NC) was used to analyze the trend in the Petco(2) and Paco(2) relationship. Chi-square was used to analyze categorical data. Statistical significance was considered p <.05. RESULTS: A total of 129 children were enrolled, and 1708 paired Paco(2) and Petco(2) measurements were recorded. The mean age +/- sd was 4.1 +/- 5.6 yrs. Paco(2) positively correlated with Petco(2). The linear equation for the regression analysis was y = 0.71x (95% confidence interval, 0.69-0.73) + 8.93 (95% confidence interval, 7.89-9.97), with r (2) =.716 and p <.001. The Petco(2)-Paco(2) difference was 10 mm Hg (1.33 kPa) difference between the Petco(2) and Paco(2). However, only 111 of 1068 (10%) Petco(2)-Paco(2) pairs had a difference of >10 mm Hg (1.33 kPa) in patients with a Pao(2)/Fio(2) ratio >200. Trend analysis showed the Petco(2)-Paco(2) difference increased with increasing duration of mechanical ventilation. CONCLUSION: In most intubated, mechanically ventilated infants and children, Petco(2) reliably estimates ventilation.