Assessing the Effect of Augmented Reality on Procedural Outcomes During Ultrasound-Guided Vascular Access.

OBJECTIVE: Augmented reality devices are increasingly accepted in health care, though most applications involve education and pre-operative planning. A novel augmented reality ultrasound application, HoloUS, was developed for the Microsoft HoloLens 2 to project real-time ultrasound images directly into the user's field of view. In this work, we assessed the effect of using HoloUS on vascular access procedural outcomes. METHODS: A single-center user study was completed with participants with (N = 22) and without (N = 12) experience performing ultrasound-guided vascular access. Users completed a venipuncture and aspiration task a total of four times: three times on study day 1, and once on study day 2 between 2 and 4 weeks later. Users were randomized to use conventional ultrasound during either their first or second task and the HoloUS application at all other times. Task completion time, numbers of needle re-directions, head adjustments and needle visualization rates were recorded. RESULTS: For expert users, task completion time was significantly faster using HoloUS (11.5 s, interquartile range [IQR] = 6.5-23.5 s vs. 18.5 s, IQR = 11.0-36.5 s; p = 0.04). The number of head adjustments was significantly lower using the HoloUS app (1.0, IQR = 0.0-1.0 vs. 3.0, IQR = 1.0-5.0; p < 0.0001). No significant differences were identified in other measured outcomes. CONCLUSION: This is the first investigation of augmented reality-based ultrasound-guided vascular access using the second-generation HoloLens. It demonstrates equivalent procedural efficiency and accuracy, with favorable usability, ergonomics and user independence when compared with traditional ultrasound techniques.

Pediatric Residency Point-of-Care Ultrasound Training Needs Assessment and Educational Intervention.

Background Prior studies showed that point-of-care ultrasound (POCUS) training is not commonly offered in pediatric residency. We assessed the need for a pediatric POCUS curriculum by evaluating pediatric trainees' attitudes toward the use of POCUS and identifying barriers to training. We also aimed to evaluate the impact of a POCUS educational intervention on self-efficacy and behavior. Methods We conducted a cross-sectional survey of pediatric residents in a single large freestanding children's hospital distributed via an institutional listserv and administered online. The survey included opinion-rating of statements regarding POCUS and barriers to training. We also offered a two-week POCUS course with online modules and hands-on scanning. Participating residents completed pre- and post-course knowledge assessments and follow-up surveys up to 12 months following the course to assess POCUS use and self-report confidence on POCUS indications, acquisition, interpretation, and clinical application. Results Forty-nine respondents were included in the survey representing all three pediatric levels with 16 specialty interest areas. Ninety-six percent of trainees reported that POCUS is an important skill in pediatrics. Ninety-two percent of trainees reported that residency programs should teach residents how to use POCUS. The most important perceived barriers to POCUS training were scheduling availability for POCUS rotations and lack of access to an ultrasound machine. Fourteen participants completed the pre- and post-course knowledge tests, with eight and six participants also completing the six- and 12-month follow-up surveys, respectively. Self-ratings of confidence were significantly improved post-intervention in indications (P = 0.007), image acquisition (P = 0.002), interpretation (P = 0.002), and clinical application (P = 0.004). This confidence improvement was sustained up to 6-12 months (P = 0.004-0.032). Participants also reported higher categorical POCUS use after course completion (P = 0.031). Conclusions Pediatric trainees perceive POCUS as an important skill, hold favorable opinions towards the use of POCUS, and support POCUS training within a pediatric residency. A POCUS course can improve resident POCUS knowledge, instill confidence, and motivate higher POCUS use. Further study is needed to evaluate POCUS applications in pediatric medicine to develop a standardized POCUS curriculum and establish a training guideline for pediatric residency.

The Association of Pediatric Critical Care Medicine Training Programs with Research Publication Productivity and Employment Outcomes of Their Graduates.

Our objective was to associate characteristics of pediatric critical care medicine (PCCM) fellowship training programs with career outcomes of PCCM physicians, including research publication productivity and employment characteristics. This is a descriptive study using publicly available data from 2557 PCCM physicians from the National Provider Index registry. We analyzed data on a systematic sample of 690 PCCM physicians representing 62 fellowship programs. There was substantial diversity in the characteristics of fellowship training programs in terms of fellowship size, intensive care unit (ICU) bed numbers, age of program, location, research rank of affiliated medical school, and academic metrics based on publication productivity of their graduates standardized over time. The clinical and academic attributes of fellowship training programs were associated with publication success and characteristics of their graduates' employment hospital. Programs with greater publication rate per graduate had more ICU beds and were associated with higher ranked medical schools. At the physician level, training program attributes including larger size, older program, and higher academic metrics were associated with graduates with greater publication productivity. There were varied characteristics of current employment hospitals, with graduates from larger, more academic fellowship training programs more likely to work in larger pediatric intensive care units (24 [interquartile range, IQR: 16-35] vs. 19 [IQR: 12-24] beds; p < 0.001), freestanding children's hospitals (52.6 vs. 26.3%; p < 0.001), hospitals with fellowship programs (57.3 vs. 40.3%; p = 0.01), and higher affiliated medical school research ranks (35.5 [IQR: 14-72] vs. 62 [IQR: 32, unranked]; p < 0.001). Large programs with higher academic metrics train physicians with greater publication success (H index 3 [IQR: 1-7] vs. 2 [IQR: 0-6]; p < 0.001) and greater likelihood of working in large academic centers. These associations may guide prospective trainees as they choose training programs that may foster their career values.

Diaphragmatic Thickening Fraction by Ultrasound in Mechanically Ventilated Pediatric Patients: Pilot Observations During Spontaneous Breathing Trials.

OBJECTIVES: In critically ill, mechanically ventilated adults, diaphragmatic atrophy and reduced diaphragmatic thickening fraction (DTF) has been associated with poor extubation outcomes. Diaphragmatic ultrasound assessment in critically ill pediatric patients shows similar results, though studies are on-going. We sought to explore the feasibility and utility of using DTF, obtained during a spontaneous breathing trial (SBT) in predicting weaning outcomes. METHODS: We conducted a prospective, observational study in a single-center tertiary noncardiac pediatric intensive care unit (PICU) in a children's hospital. Mechanically ventilated pediatric patients were included except for those with preexisting conditions of neuromuscular weakness, diaphragm paresis, or chronic respiratory failure requiring non-invasive or invasive mechanical ventilation at baseline. A convenience sample of 38 patients were included in the study. RESULTS: Weaning failure occurred in 10/38 (26%) instances with 9/38 (24%) occurring due to failed SBT and 1/38 (2%) due to failed extubation requiring reintubation. Median DTF was 24% (IQR: 12-33). DTF was significantly lower in instances of failed SBT, 12% compared to 27% (P < .01). The odds ratio (OR) of SBT failure utilizing: TF < 25% is 12 (CI: 1.33-108.0, Z-score: 2.22, P = .027), TV <5 mL/kg was 10.4 (CI: 1.76-61.67, Z-score: 2.58, P = .01), and combined TV <5 mL/kg and TF < 25% is 17.6 (CI: 1.19-259.61, Z-score: 2.09, P = .04). CONCLUSIONS: Our preliminary study suggests that ultrasound measurements of diaphragm thickening fraction during spontaneous breaths in mechanically ventilated pediatric patients may be a useful addition in predicting weaning readiness.

A Comparison of Clinical Characteristics and Outcomes Between Indigenous and Non-Indigenous Patients Presenting to Townsville Hospital Emergency Department With Chest Pain.

BACKGROUND: Indigenous Australians have a high rate of ischaemic heart disease (IHD). There is a paucity of local data for North Queensland regarding the clinical characteristics of Indigenous people who present to the emergency department (ED) with chest pain. The aim of the study is to compare the cardiovascular risk factors, social characteristics, and the clinical outcomes between Indigenous and non-Indigenous patients who presented with cardiac-related chest pain. METHODS: This is a retrospective single-centre audit. The data was collected through chart reviews of chest pain presentations to the Townsville University Hospital Emergency Department, Queensland, Australia, from January to December 2017. We categorised the patients into Indigenous and non-Indigenous groups and compared their cardiac risk factors and social characteristics. We further classified the patients into three diagnosis groups and we measured the clinical outcomes in the patients with a diagnosis of cardiac-related chest pain. We used a data linkage to the Registry of Births, Deaths and Marriages for the death outcomes. A multivariable analysis was done to determine the risk of major adverse cardiac event (MACE) for Indigenous vs non-Indigenous patients. RESULTS: Indigenous patients were over-represented making up 19.1% of the total cohort (compared with 11.1% of the North Queensland Indigenous population) and presented at a younger age (median age: 45 vs 52, p<0.005). Traditional cardiovascular risk factors were significantly higher in Indigenous patients. The incidence of discharge against medical advice was also higher (6.5% vs 2.7%, p<0.005). There was an underutilisation of the local chest pain pathway amongst the Indigenous group (35.8% vs 44.7%, p<0.005). In patients with a diagnosis of cardiac-related chest pain, the rate of receiving invasive coronary angiogram procedures was similar in both cohorts (44.5% vs 43.7%, p=0.836). With regards to outcomes, Indigenous patients suffered from acute coronary syndrome (ACS) at a younger median age (51 vs 64, p<0.005) and were more likely to have severe three vessel disease (17% vs 6%, p<0.005) leading to coronary bypass graft surgery (CABG) (19% vs 6%, p<0.005). When adjusted for age, gender, and comorbidities, Indigenous patients were more likely to have MACE within 1 year of their chest pain presentation, compared with non-Indigenous patients with the same diagnosis (adjusted odds ration [AOR]=2.0, 95% CI [1.1, 3.8], p=0.03). CONCLUSION: In our study, Indigenous patients carried a heavier burden of cardiovascular risk factors, presented at a younger age, with more severe coronary disease and had a higher rate of CABG. We found an underutilisation of the local chest pain protocol amongst the Indigenous cohort, which suggests a need to improve support structures in the ED. In our multivariable analysis, Indigenous patients suffered from a significantly higher MACE compared to non-Indigenous patients which indicates that more collaborative efforts are needed to improve the cardiovascular health of local Aboriginal and Torres Strait Islander people.

Strain Echocardiography and Myocardial Dysfunction in Critically Ill Children With Multisystem Inflammatory Syndrome Unrecognized by Conventional Echocardiography: A Retrospective Cohort Analysis.

OBJECTIVES: Multisystem inflammatory syndrome in children is a newly defined complication of severe acute respiratory syndrome coronavirus 2 infection that can result in cardiogenic shock in the pediatric population. Early detection of cardiac dysfunction is imperative in directing therapy and identifying patients at highest risk for deterioration. This study compares the strengths of conventional and strain echocardiography in identifying cardiac dysfunction in critically ill children with multisystem inflammatory syndrome in children and their association with ICU therapeutic needs and clinical outcomes. DESIGN: Retrospective, observational cohort study. SETTING: A large, quaternary care PICU. PATIENTS: Sixty-five pediatric patients admitted to the PICU with the diagnosis of multisystem inflammatory syndrome in children from March 2020 to March 2021. INTERVENTIONS: Global longitudinal strain four chamber was measured retrospectively by strain echocardiography and compared with conventional echocardiography. Cardiac dysfunction was defined by left ventricular ejection fraction less than 55% and global longitudinal strain four chamber greater than or equal to -17.2%. Clinical variables examined included cardiac biomarkers, immune therapies, and ICU interventions and outcomes. MEASUREMENTS AND MAIN RESULTS: Twenty-four patients (37%) had abnormal left ventricular ejection fraction and 56 (86%) had abnormal global longitudinal strain four chamber. Between patients with normal and abnormal left ventricular ejection fraction, we failed to identify a difference in cardiac biomarker levels, vasoactive use, respiratory support needs, or ICU length of stay. Global longitudinal strain four chamber was associated with maximum cardiac biomarker levels. Abnormal global longitudinal strain four chamber was associated with greater odds of any vasoactive use (odds ratio, 5.8; 95% CI, 1.3-25.3; z-statistic, 2.3; p = 0.021). The number of days of vasoactive infusion was correlated with global longitudinal strain four chamber (r = 0.400; 95% CI, 2.4-3.9; p < 0.001). Children with abnormal strain had longer ICU length of stay (4.5 d vs 2 d; p = 0.014). CONCLUSIONS: Our findings suggest strain echocardiography can detect abnormalities in cardiac function in multisystem inflammatory syndrome in children patients unrecognized by conventional echocardiography. These abnormalities are associated with increased use of intensive care therapies. Evaluation of these patients with strain echocardiography may better identify those with myocardial dysfunction and need for more intensive therapy.

Triple threat: New presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias.

Patients with diabetes have increased susceptibility to infection with Severe acute respiratory syndrome-coronavirus 2 and increased morbidity and mortality from Coronavirus disease 2019 (COVID-19) infection. Mortality from COVID-19 is sometimes caused by cardiac arrhythmias. Electrolyte disturbances in patients with diabetic ketoacidosis (DKA) can increase the risk of cardiac arrhythmias. Despite these correlations, little has been reported about the co-incidence of these three conditions: COVID-19, DKA and cardiac arrhythmias. In this case report we describe two children with COVID-19, new-onset DKA and cardiac arrhythmias. These cases emphasize the importance of close cardiac and electrolyte monitoring in patients with COVID-19 infection.

Association Between Indigenous Status and Severity of Coronary Artery Disease: A Comparison of Coronary Angiogram Findings in Patients With Chest Pain Presenting to a Regional Hospital Emergency Department.

BACKGROUND: Coronary artery disease (CAD) remains the leading cause of death amongst Indigenous Australians accounting for 12.1% of all deaths in this population. However, there is little evidence to suggest that Indigenous status is an independent risk factor for the development of coronary artery disease. This study assessed the association between Indigenous status and the severity of CAD in patients presenting with chest pain at a regional hospital emergency department. METHODS: This was a retrospective single-centre audit over 12 months from January to December 2017. Charts were reviewed for both Indigenous and non-Indigenous patients 18 years and older who presented with chest pain and subsequently underwent an invasive coronary angiogram. Multivariable logistic regression was performed to examine the association of Indigenous status with the severity of CAD. RESULTS: Indigenous patients are 2.7 times more likely to experience significant CAD compared to non-Indigenous patients (Adjusted odds ratio [AOR]=2.73, 95% CI [1.38, 5.39], p≤0.001) even after adjusting for other risk factors. Those aged 65 years and older are more prone to significant CAD (AOR=2.96, 95% CI [1.12, 7.78], p=0.03), while women were less likely to have significant CAD compared to men, (AOR=0.46, 95% CI [0.27, 0.78], p<0.01). CONCLUSION: In this study cohort, our analysis indicates that there is a strong association between Indigenous status and significant coronary artery disease, independent of the increased burden of traditional cardiovascular risk factors among Indigenous Australians.

Point-of-Care Ultrasound Assessment of the Inferior Vena Cava in Mechanically Ventilated Critically Ill Children.

OBJECTIVES: The objective of this study was to compare the ultrasound-measured inferior vena cava distensibility index (IVCdi), inferior vena cava distensibility variability (IVCdv), and inferior vena cava-to-aorta ratio (IVC/Ao) to other common methods to assess fluid status in mechanically ventilated pediatric critically ill patients. These methods include central venous pressure (CVP), percent fluid overload by weight (%FOw), and percent fluid overload by volume (%FOv). METHODS: This was a prospective observational study of a convenience sample of 50 mechanically ventilated pediatric patients. Ultrasound measurements of the inferior vena cava and aorta were obtained, and the IVCdi, IVCdv, and IVC/Ao were calculated and compared to CVP, %FOw, and %FOv. RESULTS: The median %FOw was 5%, and the median %FOv was 10%. The mean CVP ± SD was 8.6 ± 4 mm Hg. The CVP had no significant correlation with %FOw or %FOv. There was no significant correlation of the IVCdi with CVP (r = -0.145; P = .325) or %FOv (r = 0.119; P = .420); however, the IVCdi had a significant correlation with %FOw (P = .012). There was also no significant relationship of the IVCdv with CVP (r = -0.135; P = .36) or %FOv (r = 0.128; P = .385); however, there was a significant correlation between the IVCdv and %FOw (P = .012). There was no relationship between the IVC/Ao and any other measures of fluid status. CONCLUSIONS: In this cohort of mechanically ventilated pediatric intensive care unit patients, many commonly used markers of fluid status showed weak correlations with each other. The IVCdi and IVCdv significantly correlated with %FOw and may have potential as markers for fluid overload in this patient population.

Outcomes Analysis of Children Diagnosed With Hemophagocytic Lymphohistiocytosis in the PICU.

OBJECTIVES: Describe a single center experience of hemophagocytic lymphohistiocytosis in a PICU over a 10-year period, to identify clinical features that may be associated with worse outcomes, including mortality, hospital and ICU length of stay, and functional and cognitive impairments on discharge. DESIGN: Retrospective electronic medical record review, 2007-2017. SETTING: PICU located in a large urban academic quaternary care children's hospital. PATIENTS: All children admitted with hemophagocytic lymphohistiocytosis to our PICU from 2007 to 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were identified utilizing International Classification of Diseases, 9th Revision and International Classification of Diseases, 10th Revision codes. Each chart was reviewed for demographic information, hemophagocytic lymphohistiocytosis diagnostic criteria, laboratory data, Pediatric Risk of Mortality Score III, clinical features and events of ICU stay, and PICU and hospital (length of stay). Mortality at 1 year and change in Functional Status Scale from admission to discharge were recorded. There were 42 admissions with 33 unique patients. Median Pediatric Risk of Mortality score at admission was 9 (interquartile range, 7-16). Median PICU length of stay was 7 days (interquartile range, 2-21 d) and hospital length of stay was 24 days (interquartile range, 14-37 d). During their ICU stay, 56% of patients received mechanical ventilation, 43% required vasoactives, 18% required continuous renal replacement therapy, and 5% received extracorporeal life support. Clinical factors related to increased PICU length of stay included Pediatric Risk of Mortality III score (p = 0.019), maximum lactate dehydrogenase (p = 0.017), maximum total bilirubin (p = 0.042), need for mechanical ventilation (p = 0.002), vasoactive use (p = 0.02), and secondary infection (p = 0.007). The most common therapies for hemophagocytic lymphohistiocytosis included steroids (93%), etoposide (55%), and anakinra (48%). Of the 26 patients who survived to hospital discharge, 19% had newly acquired morbidities. Overall 1-year mortality was 42%. CONCLUSIONS: Hemophagocytic lymphohistiocytosis diagnosed in the PICU is a disease with high mortality. Patients who survive to discharge had relatively little morbidity, however, the mortality risk in the year following discharge continued to remain high.

Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis.

Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.

PICU Autopsies: Rates, Patient Characteristics, and the Role of the Medical Examiner.

OBJECTIVES: Autopsy rates in North American Children's hospitals have not been recently evaluated. Our objectives were 1) to determine the autopsy rates from patients cared for in PICUs during a portion of their hospital stay, 2) to identify patient characteristics associated with autopsies, and 3) to understand the relative role of medical examiner cases. DESIGN: Secondary analysis of data prospectively collected from a sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 2011 and April 2013. SETTING: Eight quaternary care PICUs. PATIENTS: Patients in the primary study were less than 18 years old, admitted to a PICU and not moribund on PICU admission. Patients included in this analysis were those who died during their hospital stay. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sociodemographic, clinical, hospital, and PICU data were compared between patients who had autopsies conducted and those who did not and between medical examiner and nonmedical examiner autopsies. Of 10,078 patients, 275 died of which 36% (n = 100) had an autopsy performed. Patients with cancer who died were less likely to receive autopsies (p = 0.005), whereas those who died after trauma or cardiac arrest had autopsies performed more often (p < 0.01). Autopsies were more common in patients with greater physiologic instability at admission (p < 0.001), and those who received more aggressive PICU care. Medical examiner cases comprised nearly half of all autopsies (n = 47; 47%) were conducted in patients presenting with greater physiologic instability (p < 0.001) and more commonly after catastrophic events such as cardiac arrest or trauma (p < 0.001). CONCLUSIONS: In this first multicenter analysis of autopsy rates in children, 36% of deaths had autopsies conducted, of which nearly half were conducted by the medical examiner. Deaths with autopsy are more likely to be previously healthy children that had catastrophic events prior to admission.

Diagnostic Bedside Ultrasound Program Development in Pediatric Critical Care Medicine: Results of a National Survey.

OBJECTIVES: To assess current diagnostic bedside ultrasound program core element (training, credentialing, image storage, documentation, and quality assurance) implementation across pediatric critical care medicine divisions in the United States. DESIGN: Cross-sectional questionnaire-based needs assessment survey. SETTING: Pediatric critical care medicine divisions with an Accreditation Council of Graduate Medical Education-accredited fellowship. RESPONDENTS: Divisional leaders in education and/or bedside ultrasound training. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-five of 67 pediatric critical care medicine divisions (82%) with an Accreditation Council of Graduate Medical Education-accredited fellowship provided responses. Overall, 63% of responding divisions (34/54) were clinically performing diagnostic bedside ultrasound studies with no difference between divisions with large versus small units. Diagnostic bedside ultrasound training is available for pediatric critical care medicine fellows within 67% of divisions (35/52) with no difference in availability between divisions with large versus small units. Other core elements were present in less than 25% of all divisions performing clinical studies, with a statistically significant increase in credentialing and documentation among divisions with large units (p = 0.048 and 0.01, respectively). All core elements were perceived to have not only high impact in program development but also high effort in implementation. Assuming that all structural elements could be effectively implemented within their division, 83% of respondents (43/52) agreed that diagnostic bedside ultrasound should be a core curricular component of fellowship education. CONCLUSIONS: Diagnostic bedside ultrasound is increasingly prevalent in training and clinical use across the pediatric critical care medicine landscape despite frequently absent core programmatic infrastructural elements. These core elements are perceived as important to program development, regardless of division unit size. Shared standardized resources may assist in reducing the effort in core element implementation and allow us to measure important educational and clinical outcomes.

Confidence level of pediatric trainees in management of shock states.

AIM: To assess overall confidence level of trainees in assessing and treating shock, we sought to improve awareness of recurrent biases in clinical decision-making to help address appropriate educational interventions. METHODS: Pediatric trainees on a national listserv were offered the opportunity to complete an electronic survey anonymously. Four commonly occurring clinical scenarios were presented, and respondents were asked to choose whether or not they would give fluid, rank factors utilized in decision-making, and comment on confidence level in their decision. RESULTS: Pediatric trainees have a very low confidence level for assessment and treatment of shock. Highest confidence level is for initial assessment and treatment of shock involving American College of Critical Care Medicine/Pediatric Advanced Life Support recommendations. Children with preexisting cardiac comorbidities are at high risk of under-resuscitation. CONCLUSION: Pediatric trainees nationwide have low confidence in managing various shock states, and would benefit from guidance and teaching around certain common clinical situations.

Diabetic ketoacidosis, hyperuricemia and encephalopathy intractable to regular-dose insulin.

BACKGROUND: Diabetic ketoacidosis (DKA) in children less than 1 year of age is a rare occurrence. Typical presentation includes a prodrome of weight loss and polyuria with subsequent presentation to medical care when acidosis becomes symptomatic. CASE PRESENTATION: We describe an unusual case of a previously healthy infant with a 3 days' history of constipation, presenting acutely with abdominal pain, lethargy, and dehydration. On initial evaluation, our patient had profound encephalopathy, with marked tachypnea and work of breathing. Arterial blood gas revealed a pH of 6.9, pCO2 of 20 and a bicarbonate level of <5. There was profound leukocytosis (WBC 77 K/µL), hyperuricemia (uric acid 15.9 mg/dL), and evidence of pre-renal azotemia [blood urea nitrogen (BUN) 54, Cr 0.82]. Blood glucose was >700 mg/dL. Despite fluid resuscitation and insulin infusion of 0.1 unit/kg/h, which are the mainstays of therapy for DKA, her severe metabolic acidosis and altered mental status did not improve. Differential diagnosis for her metabolic derangements included inborn errors of metabolism, insulin receptor defects, toxic ingestions, and septic shock secondary to an underlying oncologic or intra-abdominal process. The patient was treated with broad spectrum antibiotics and rasburicase. She continued to have significant shock for the first 30 h of her hospital stay, requiring moderate vasoactive support. Due to her refractory acidosis and persistent hyperglycemia, insulin infusion was increased to 0.15 units/kg/h. A hemoglobin A1C obtained on the second hospital day revealed a level of 7.4 and helped to solidify the diagnosis. CONCLUSIONS: Metabolic acidosis in an infant requires a broad differential. Rasburicase should be considered in hyperuricemia and DKA.

Outcome of Pediatric Critical Care Medicine Abstracts Presented at North American Academic National Meetings.

OBJECTIVES: Pediatric critical care medicine abstracts presented at North American national academic meetings have not been followed up to determine their publication outcomes. Our objective was to determine the following: 1) the proportion of these presentations that are published in peer-reviewed journals within 5 years; 2) the impact of trainee status on time to and success of publication; and 3) the quality of the research as reflected in the publishing journal's impact factor. DESIGN: Four years of abstracts (2007-2011) were reviewed from the American Academy of Pediatrics, Pediatric Academic Societies, and Society of Critical Care Medicine national meetings. Pediatric critical care medicine abstracts were delineated by the meeting or identified by keyword search. Data included mode of presentation, trainee status of first author, publication status within 5 years based on a PubMed search, trainee position in the journal of publication authorship list, and the impact factor of journal of publication. MEASUREMENTS AND MAIN RESULTS: We evaluated 267 pediatric critical care medicine abstracts, 85-94 from each meeting. Overall, 41% were published, with the highest rate in Pediatric Academic Societies abstracts (54% Pediatric Academic Societies, 38% Society of Critical Care Medicine, and 33% American Academy of Pediatrics; p = 0.011). Mean time to publication was 22 (± 3) months and did not differ by conference or presentation mode. Journal first authorship was retained in 84%. Journal impact factor was highest in Society of Critical Care Medicine abstracts (3.38 Society of Critical Care Medicine, 2.64 Pediatric Academic Societies, and 1.92 American Academy of Pediatrics; p = 0.006). First author trainee status was not associated with publication rate, time to publication, and impact factor. A total of 100% of trainees but only 79% of nontrainees who published retained first authorship. CONCLUSIONS: Less than half of pediatric critical care medicine research abstracts presented at North American national academic meetings culminate in articles. Pediatric Academic Societies had the highest publication success rate, and Society of Critical Care Medicine abstracts were published in journals with the highest impact factors. All trainees who were first authors retained that status in the journal publications.

Association of timing of tracheostomy on clinical outcomes in PICU patients.

OBJECTIVES: Tracheostomy is a common procedure in the ICU when prolonged mechanical ventilation is expected. Although adult data show morbidity and mortality benefits over translaryngeal intubation, there is no consensus on optimal timing. In the pediatric population, there is sparse data regarding morbidities associated with duration of ventilation prior to tracheostomy. Our objective was to associate timing of tracheostomy with clinical outcomes in PICU patients. DESIGN: This is a retrospective cohort study of patients undergoing tracheostomy. Patient factors and duration of ventilation prior to tracheostomy were collected on each patient. Morbidities such as ventilator-associated pneumonia, central catheter-associated bloodstream infection, and cardiopulmonary arrests were examined both pre- and posttracheostomy. ICU and total hospital length of stay as well as mortality were recorded. For data analysis regarding tracheostomy timing, patients were stratified into early and late groups using a cutoff of 14 days. SETTING: The PICUs and cardiac ICUs in a quaternary-care children's hospital. PATIENTS: All patients undergoing tracheostomy over a 3-year period. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients were analyzed with a median of 22 days of ventilation prior to tracheostomy. Patient factors associated with longer pretracheostomy ventilation included congenital heart disease and vasoactive drug use. Clinical events associated with longer pretracheostomy ventilation included bloodstream infection, ventilator-associated pneumonia, and cardiac arrest. Age, congenital heart disease, vasoactive drug use, bloodstream infection, and ventilator-associated pneumonia each independently increased pretracheostomy ventilator days. Median ICU length of stay after tracheostomy was 18 days. For each pretracheostomy ventilator day, ICU length of stay increased by 0.5 days and hospital length of stay increased by 1.9 days. For patients undergoing early tracheostomy, ICU and total hospital lengths of stay were 4 days and 4 weeks shorter, respectively. CONCLUSIONS: Analysis of our results suggests that a longer duration of ventilation prior to tracheostomy is associated with increased ICU morbidities and length of stay. Early tracheostomy may have significant benefits without adversely affecting mortality.

Extracorporeal life support for a 5-week-old infant with idiopathic pulmonary hemosiderosis.

UNLABELLED: Idiopathic pulmonary hemosiderosis is a rare disease defined by the triad of iron deficiency anemia, hemoptysis, and diffuse pulmonary infiltrates on chest radiograph. Idiopathic pulmonary hemosiderosis is known to cause dyspnea and, in some cases, acute onset of massive pulmonary hemorrhage which is traditionally treated with conventional mechanical ventilation or high-frequency oscillation in conjunction with immunosuppressive therapy. In this case report, we describe a 5-week-old infant presenting with hemoptysis, massive pulmonary hemorrhage, and significant hypercapnic respiratory failure. The patient failed conventional ventilation but responded well to extracorporeal life support that was initiated early in his course. Idiopathic pulmonary hemosiderosis was suspected in light of his response to high-dose steroids and was confirmed by subsequent lung biopsies. CONCLUSION: Patients with severe pulmonary hemorrhage secondary to idiopathic pulmonary hemosiderosis can be safely supported with extracorporeal life support when conventional therapies have been exhausted.