Validation of the Survey of Sleep Quality in the Pediatric Intensive Care Unit (SSqPICU).

STUDY OBJECTIVES: Observational data suggest pediatric intensive care unit-related sleep and circadian disruption (PICU-SCD) affects many critically ill children. Multi-center trials exploring PICU-SCD have been impractical as measuring sleep in this setting is challenging. This study validates a questionnaire for caregivers to describe children's sleep in the PICU. METHODS: This prospective, multi-center, case-control study enrolled caregivers of children in four PICUs or in a hospital-based sleep lab (controls). Survey items were compiled from validated adult ICU and pediatric in- and outpatient sleep questionnaires. Control responses were compared to polysomnography to determine accuracy. A score was calculated by summing the level of disruption of sleep timing, duration, efficiency, quality, and daytime sleepiness and irritability. RESULTS: In 152 PICU and 61 sleep lab caregivers, sleep survey items had acceptable internal reliability (α=0.75) and reproducibility on re-test surveys (ICC>0.600). Caregivers could not assess sleep of sedated children. Factor analysis identified three sub-scales of PICU-SCD. Control parents had good agreement with polysomnography sleep onset time (κ=0.823) and sleep onset latency (κ=0.707). There was a strong correlation between sleep scores derived by parental reporting to those by polysomnography (r=0.844, p<0.001). Scores had a linear association with caregiver-reported child sleep quality. There were no site-specific differences in sleep quality. Nearly all respondents found the survey easy to understand and of appropriate length. CONCLUSIONS: The SSqPICU provides a reliable, accurate description of inpatient sleep disruption in non-sedated children, generalizable across PICUs. It offers practical means to quantify PICU-SCD daily in future investigations.

Comparison of Epworth Sleepiness Scale and OSA-18 Scores With Polysomnography in Children.

OBJECTIVE: Our goal is to determine if there is a correlation between Modified Epworth Sleepiness Scale (M-ESS) scores, obstructive sleep apnea (OSA)-18 scores, and polysomnography (PSG) outcomes in children. STUDY DESIGN: Retrospective chart review. SETTING: Pediatric otolaryngology clinic. METHODS: Charts of consecutive children presenting from July 2021 to July 2023 were reviewed. Demographics, body mass index (BMI), BMI Z score, M-ESS score, OSA-18 score, PSG results, and sleep apnea severity were included. One-way analysis of variance and Pearson/Spearman correlation coefficients were calculated. RESULTS: Three hundred sixty-seven children were included, 162 (44.1%) girls and 205 (55.9%) boys. Mean patient age was 7.8 (95% confidence interval [CI]: 7.3-8.3) years. M-ESS score was 6.3 (n = 348, 95% CI: 5.8-6.8), mean OSA-18 score was 56.2 (n = 129, 95% CI: 53.0-59.4). Mean apnea-hypopnea index (AHI) was 10.1 (95% CI: 8.7-11.4) events/h, obstructive AHI 9.3 (95% CI: 8.0-12.7) events/h, respiratory distress index 14.6 (95% CI: 8.4-20.8) events/h, and oxygen saturation nadir 89.8% (95% CI: 89.1-90.4). Sixty-two children (17.2%) had mild, 192 (53.5%) moderate, and 105 (29.2%) severe sleep apnea. M-ESS score correlated weakly to AHI (r = .19, P = <.001), and OSA-18 score to oxygen saturation nadir (r = -.16, P = .002). After logistic regression adjusted for age and BMI, neither clinical scores were independently associated with AHI. CONCLUSION: M-ESS and OSA-18 scores have a weak correlation with OSA severity in children. More reliable, age-appropriate screening tools are needed in pediatric sleep apnea.

Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study.

STUDY OBJECTIVES: Reduced sleep duration and work hour variability contribute to medical error and physician burnout. This study assesses the relationships between physician performance, burnout, and the dimensions of sleep beyond hours slept. METHODS: This was an ancillary analysis of 3 years of data from an international prospective cohort study: the Intern Health Study. Actigraphy data from 3,654 intern physicians capturing sleep timing, regularity, efficiency, and duration were used individually and combined as a composite sleep health index to measure the association of multidimensional sleep patterns on self-reported medical errors and burnout. RESULTS: From 2017-2019, interns' work hours decreased by 4 hours per week and total sleep time also decreased (6.7 to 5.99 hours), and sleep efficiency, timing, and regularity all worsened (all P < .05). In the 21.2% of participants who committed an error, there was no difference in sleep duration, timing, or regularity. Lower sleep efficiency was associated with higher odds of committing an error (P = .003) and higher burnout scores (P < .001). Although overall sleep quality was poor in the entire cohort, interns in the lowest quintile of sleep duration, regularity, and efficiency had higher burnout scores than those in the best quintile. CONCLUSIONS: Sleep efficiency, not duration, was associated with increased self-reported medical errors and burnout in intern physicians. Overall sleep quality and duration worsened despite fewer hours worked. Future studies on physician burnout should measure all aspects of sleep health. CITATION: Hassinger AB, Velez C, Wang J, Mador MJ, Wilding GE, Mishra A. Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study. J Clin Sleep Med. 2024;20(2):221-227.

How Pediatric Sleep Disordered Breathing Impacts Parental Fatigue.

OBJECTIVE: Previous research has indicated that sleep disordered breathing (SDB) can lead to a decreased quality of life in children and their families as compared to children who do not have SDB. The purpose of this study was to examine fatigue levels in parents who had young children who were impacted by sleep symptoms as determined by the OSA-18 scale. STUDY DESIGN: Survey. SETTING: Three pediatric otolaryngology clinics associated with a tertiary care children's hospital in Buffalo, NY. METHODS: Fatigue levels for parents of children with OSA-18 ≥ 60 were assessed using the Fatigue Severity Scale and the Chalder Fatigue Scale. Consecutive parents with at least one child between the ages of 1 and 10 were recruited. Parents scored their youngest child on the OSA-18 scale. RESULTS: Of the 261 respondents included, 37 parents had a child with an OSA-18 score ≥60. The majority, 211 (82.1%), of participants reported 2 caregivers in the household while 30 (11.7%) had 1 caregiver in the household. Parents of children with OSA-18 ≥60 had a significantly higher mean fatigue score, 16.5 ± 5.8, compared to their counterparts, 11.9 ± 5.2, on the Chalder Fatigue Scale (P < .001). Similar results were reported for the total score on the Fatigue Severity Scale, 34.7 ± 10.8 compared to 28.9 ± 12.0 (P = .004). CONCLUSION: Parents of children with OSA-18 score ≥60 are significantly more fatigued than parents of children with lower scores. Recognition of this is important for the health care community as it impacts not just the child with OSA but also their family.

Urinary biomarkers as indicators of acute kidney injury in critically ill children exposed to vancomycin.

STUDY OBJECTIVE: The standard of care for detecting acute kidney injury (AKI) is change in serum creatinine (SCr) and urine output, which are limited. This study aimed to compare urinary biomarkers neutrophil gelatinase-associated lipocalin (uNGAL) with kidney injury molecule-1 (uKIM-1) in critically ill children exposed to vancomycin who did and did not develop AKI as defined by changes in SCr. DESIGN: Single-center, prospective, clinical, observational cohort study. SETTING: Tertiary care children's hospital in an urban setting. PATIENTS: Children aged 0 (corrected gestational age 42 weeks) to 18 years admitted to the intensive care unit who received vancomycin were included. INTERVENTION: None. MEASUREMENTS: The primary outcome was mean change in uNGAL and uKIM-1 between AKI and no-AKI groups. AKI was defined as a minimum 50% increase in SCr from baseline over a 48 h period, within 7 days of first vancomycin exposure. Three urine samples were collected: baseline (between 0 and 6 h of first vancomycin dose), second (18-24 h after the "baseline"), and third (18-24 h after the second sample). Concentrations of uKIM-1 and uNGAL were measured in each sample. MAIN RESULTS: Forty-eight children (52% male; median age 6 years) were included. Eight (16.7%) children developed AKI. Mean changes in uNGAL (713.196 ± 1,216,474 vs. 16.101 ± 37.812 pg/mL; p = 0.0004) and uKIM-1 (6060 ± 11.165 vs. 340 ± 542 pg/mL; p = 0.0015) were greater in children with AKI versus no-AKI, respectively. CONCLUSIONS: uNGAL and uKIM-1 concentrations increased significantly more in critically ill children with AKI compared with those with no-AKI during the first 48-72 h of vancomycin exposure and may be useful as prospective biomarkers of AKI.

Pediatric Intensive Care Unit related Sleep and Circadian Dysregulation: a focused review.

The pediatric intensive care unit (PICU) is bright, loud, and disruptive to children. Strategies to improve the sleep of adults in the ICU have improved delirium and mortality rates. Children need more sleep than adults for active growth, healing, and development when well; this is likely true when they are critically ill. This review was performed to describe what we know in this area to date with the intent to identify future directions for research in this field. Since the 1990s, 16 articles on 14 observational trials have been published investigating the sleep on a total of 312 critically ill children and the melatonin levels of an additional 144. Sleep measurements occurred in 9 studies through bedside observation (n = 2), actigraphy (n = 2), electroencephalogram (n = 1) and polysomnography (n = 4), of which polysomnography is the most reliable. Children in the PICU sleep more during the day, have fragmented sleep and disturbed sleep architecture. Melatonin levels may be elevated and peak later in critically ill children. Early data suggest there are at-risk subgroups for sleep and circadian disruption in the PICU including those with sepsis, burns, traumatic brain injury and after cardiothoracic surgery. The available literature describing the sleep of critically ill children is limited to small single-center observational studies with varying measurements of sleep and inconsistent findings. Future studies should use validated measurements and standardized definitions to begin to harmonize this area of medicine to build toward pragmatic interventional trials that may shift the paradigm of care in the pediatric intensive care unit.

Parental survey of the sleep patterns and screen time in US school children during the first 6 months of the COVID-19 pandemic.

BACKGROUND: This study compared sleep duration, screen exposure and sleep quality in school-aged children before COVID-19 to that during school closures and again when schools re-opened in fall 2020. METHODS: Cross-sectional anonymous, online survey of parents of children 5-13 years old. Questions elicited information about sleep timing and quality, screen time, and schooling at three distinct periods: before the pandemic, when schools first closed and then re-opened in the fall. RESULTS: Respondents described 101 children who were an average of 8.5 years old and 51% male. In lockdown, children slept 25 min more (95%CI 00:13-00:38) due to later wake times (75 min, 95% CI 0:57-1:34) with later bedtimes (29 min, 95%CI 0:00-0:58). When schools re-opened, sleep duration returned to pre-pandemic levels, but sleep onset and offset times remained later. Despite more sleep, sleep quality and habits (e.g. bedtime refusal) worsened during lockdown and did not normalize in fall 2020. During lockdown, screen time increased in 65% of all children, and 96% of those in private schools. When schools reopened, 78% of children in hybrid/virtual learning had more than 4 h of screen exposure daily. Less screen time was associated with twofold higher odds of better sleep (OR 2.66, 95%CI 1.15-6.14). CONCLUSIONS: Although school-aged children had more total sleep when schools were closed, sleep quality and habits worsened. Upon return to school, sleep times and quality did not normalize and were linked to screen time.

Parental Knowledge of Obstructive Sleep Apnea Symptoms and Tonsillectomy in Children.

OBJECTIVE: Obstructive sleep apnea (OSA) is present in approximately 2% to 5% of children; however, only 15% of parents are reported to be knowledgeable about OSA in children. Sleep apnea in children can lead to cardiopulmonary disease, abnormal weight gain, failure to thrive, or learning difficulties. The purpose of our study is to assess parental knowledge of pediatric OSA to identify any knowledge gaps. STUDY DESIGN: Survey. SETTING: Three pediatric otolaryngology clinics associated with a tertiary care children's hospital in Buffalo, NY. METHODS: In June of 2021, parents of pediatric (0-18 years) otolaryngology patients completed a survey on their knowledge of OSA. Parents were asked to rank their concern about OSA and identify symptoms of OSA. Parental demographic data collected included gender, age, race, and educational level. Respondents were asked if their child had undergone a sleep study or tonsillectomy. RESULTS: Of the 246 parents included, 77 (31.4%) parents had a child who had a tonsillectomy, 40 (16.3%) had a child who had a sleep study done, and 25 (10.2%) had a child with both done. For recognizing the symptoms of pediatric OSA the mean was 6.3 (95% CI 5.8-6.8) out of 13 total. Symptoms least likely recognized were nocturnal enuresis and hyperactivity, 65 (27%) and 91 (37%) of parents correctly identifying these symptoms, respectively. Greater concern about OSA correlated with greater cumulative knowledge score (P < .001). Parents whose child had undergone a tonsillectomy were more likely to be concerned about OSA in children compared to non-tonsillectomy parents (P = .003), and sleep study parents were also more likely to be concerned about OSA than non-sleep study parents (P = .045). CONCLUSION: Parents who attended a pediatric otolaryngology clinic have knowledge gaps about pediatric sleep.

Sleep patterns of US healthcare workers during the first wave of the COVID-19 pandemic.

PURPOSE: During the first few months of the COVID-19 outbreak, healthcare workers (HCW) faced levels of personal risk, emotional distress, and professional strain not seen in their lifetimes. This study described how these stressors influenced various aspects of their sleep patterns. METHODS: From May 19 to June 20, 2020, an electronic, cross-sectional survey was administered to a convenience sample of in- and outpatient HCW in a large, nonprofit healthcare system. Respondents described the pandemic's initial impact on personal and professional life and various sleep dimensions: regularity, efficiency, duration, timing, quality, and daytime sleepiness. RESULTS: Two hundred seven providers responded, representing 17 different healthcare roles. Most (82%) were women with a median age of 39 years (IQR1-3, 31-53). A majority of respondents (81%) worked in an inpatient setting, with half (46%) primarily on the "frontline." Approximately one-third of respondents (37%) were physicians and one-quarter (28%) were nurses. Overall, 68% of HCW reported at least one aspect of sleep worsened during the beginning of the pandemic; the most impacted were daytime sleepiness (increased in 43%) and sleep efficiency (worse in 37%). After adjusting for COVID exposure and burnout, frontline providers had twofold higher odds of poor pandemic sleep, aOR 2.53, 95%CI 1.07-5.99. Among frontline providers, physicians were fivefold more likely to develop poor pandemic sleep compared to nurses (OR 5.73, 95%CI 1.15-28.57). CONCLUSIONS: During the initial wave of COVID-19, a majority of HCW reported a decline in sleep with an increase in daytime sleepiness and insomnia. Frontline workers, specifically physicians, were at higher risk.

Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary.

Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.

Renal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference.

CONTEXT: Renal dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE: To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children. DATA SOURCES: PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION: Included studies evaluated critically ill children with renal dysfunction, performance characteristics of assessment tools for renal dysfunction, and outcomes related to mortality, functional status, or organ-specific or other patient-centered outcomes. Studies with adults or premature infants (≤36 weeks' gestational age), animal studies, reviews, case series, and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION: Data were extracted from included studies into a standard data extraction form by task force members. RESULTS: The systematic review supported the following criteria for renal dysfunction: (1) urine output <0.5 mL/kg per hour for ≥6 hours and serum creatinine increase of 1.5 to 1.9 times baseline or ≥0.3 mg/dL, or (2) urine output <0.5 mL/kg per hour for ≥12 hours, or (3) serum creatinine increase ≥2 times baseline, or (4) estimated glomerular filtration rate <35 mL/minute/1.73 m2, or (5) initiation of renal replacement therapy, or (6) fluid overload ≥20%. Data also support criteria for persistent renal dysfunction and for high risk of renal dysfunction. LIMITATIONS: All included studies were observational and many were retrospective. CONCLUSIONS: We present consensus criteria for renal dysfunction in critically ill children.

Dantrolene-Induced Hepatitis: A Rare Culprit in the PICU.

Dantrolene is used for reversal of malignant hyperthermia and for improvement in spasticity following stroke which are Food and Drug Administration-approved indications. It is an infrequently used medication in the pediatric intensive care unit and is usually continued from the operating room or sedation suite after suspicion for malignant hyperthermia, secondary to other medications and anesthetic agents. Hepatitis has been described as a side effect of the medication after prolonged use and at doses of more than 100 mg/d mainly in adults. We described in this case report a patient in which the drug was used for sympathetic overactivity in the PICU and development of asymptomatic hepatitis on day 3 after starting the medication at a dose much lower than previously described.

Impact of a Multidisciplinary Sepsis Initiative on Knowledge and Behavior in a Pediatric Center.

OBJECTIVE: Our institution performed an educational initiative targeting previously identified barriers to pediatric sepsis recognition and treatment. We hypothesized that provider knowledge, attitude, and behavior would be improved 1 year after implementation. METHODS: This was a prospective, observational study of a multi-faceted quality initiative introduced to providers in the Emergency Department, inpatient wards, and Pediatric Intensive Care Unit of a tertiary care children's hospital. Educational platforms consisted of quarterly electronic sepsis "newsletters," brightly colored posters highlighting protocol and screening strategies displayed throughout the hospital, and low-fidelity simulation sessions (drills) led by trained staff and incorporated into daily workflows. The content was driven by feedback from a baseline needs assessment of sepsis education. One year after implementation, the needs assessment was repeated. RESULTS: Over 3 months, facilitators conducted 197 drills and captured a majority of nurses (89%), pediatrics residents (96%), and respiratory therapists (62%). By 6 months, 241 sessions had been completed. Approximately 55.4% of the 442 eligible staff participated in our post-intervention survey. Overall, knowledge of diagnostic criteria for pediatric sepsis and septic shock increased from pre-intervention levels (P = 0.015). Among post-implementation respondents, drill participants outperformed their colleagues (P = 0.001). A greater percentage of post-intervention respondents indicated comfort with sepsis recognition (P < 0.001), and fewer reported hesitating to bring sepsis concerns to their care team (P < 0.01). CONCLUSIONS: Our findings suggest that a multidisciplinary curriculum balancing active education-through brief, targeted simulation-and general awareness-through electronic resources and a poster campaign-can improve sepsis-related knowledge, attitude, and behavior among pediatric practitioners.

Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

OBJECTIVES: Pediatric acute respiratory distress syndrome is heterogeneous, with a paucity of risk stratification tools to assist with trial design. We aimed to develop and validate mortality prediction models for patients with pediatric acute respiratory distress syndrome. DESIGN: Leveraging additional data collection from a preplanned ancillary study (Version 1) of the multinational Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study, we identified predictors of mortality. Separate models were built for the entire Version 1 cohort, for the cohort excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths. Models were externally validated in a cohort of intubated pediatric acute respiratory distress syndrome patients from the Children's Hospital of Philadelphia. SETTING: The derivation cohort represented 100 centers worldwide; the validation cohort was from Children's Hospital of Philadelphia. PATIENTS: There were 624 and 640 subjects in the derivation and validation cohorts, respectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The model for the full cohort included immunocompromised status, Pediatric Logistic Organ Dysfunction 2 score, day 0 vasopressor-inotrope score and fluid balance, and PaO2/FIO2 6 hours after pediatric acute respiratory distress syndrome onset. This model had good discrimination (area under the receiver operating characteristic curve 0.82), calibration, and internal validation. Models excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths also demonstrated good discrimination (all area under the receiver operating characteristic curve ≥ 0.84) and calibration. In the validation cohort, models for intubated pediatric acute respiratory distress syndrome (including and excluding neurologic deaths) had excellent discrimination (both area under the receiver operating characteristic curve ≥ 0.85), but poor calibration. After revision, the model for all intubated subjects remained miscalibrated, whereas the model excluding neurologic deaths showed perfect calibration. Mortality models also stratified ventilator-free days at 28 days in both derivation and validation cohorts. CONCLUSIONS: We describe predictive models for mortality in pediatric acute respiratory distress syndrome using readily available variables from day 0 of pediatric acute respiratory distress syndrome which outperform severity of illness scores and which demonstrate utility for composite outcomes such as ventilator-free days. Models can assist with risk stratification for clinical trials.

Selecting a pharmacotherapy regimen for patients with chronic insomnia.

INTRODUCTION: Chronic insomnia, whether it is primary or in combination with another medical or psychiatric disorder, is a prevalent condition associated with significant morbidity, reduced productivity, increased risk of accidents, and poor quality of life. Pharmacologic and behavioral treatments have equivalent efficacy with each having its own advantages and limitations. AREAS COVERED: The purpose of this perspective is to delineate the limitations encountered in implementing cognitive behavioral therapy (CBT) and to review the pharmacological treatments designed to target the different phenotypes of insomnia. The discussions address how to choose the optimal medication or combination thereof based on patients' characteristics, available medications, and the presence of comorbid conditions. Selective nonbenzodiazepine sedative 'Z-drug' hypnotics, melatonin receptor agonist-ramelteon, and low-dose doxepin are the agents of choice for treatment of primary and comorbid insomnia. EXPERT OPINION: A pharmacological intervention should be offered if cognitive behavioral therapy for insomnia is not available or has failed to achieve its goals. Increasing evidence of the significant adverse consequences of long-term benzodiazepines should limit the prescription of these agents to specific conditions. Testing novel dosing regimens with a combination of hypnotic classes augmented with CBT deserve further investigation.

Early Use of Adjunctive Therapies for Pediatric Acute Respiratory Distress Syndrome: A PARDIE Study.

Rationale: Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS).Objectives: To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations.Methods: This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks.Measurements and Main Results: We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use.Conclusions: The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.

Guideline Adherence and Antibiotic Utilization by Community Pediatricians, Private Urgent Care Centers, and a Pediatric Emergency Department.

Pediatric antibiotic prescriptions originate from an increasingly broad range of ambulatory settings. In this retrospective study, pharyngitis, otitis media, sinusitis, pneumonia, and upper respiratory infection cases, at 11 primary care offices, 2 independent urgent care centers (UCCs), and a pediatric emergency department in Western New York, were analyzed relative to medical society practice guidelines and antibiotic utilization. Of 2358 eligible visits across all sites, 25% were for study diagnoses, with 38% at UCC (P < .01). Across all sites, 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection. At primary care offices and UCCs, guideline recommended first-line agents for pharyngitis and otitis media were used in only 58% and 63% of treated cases, respectively. Overall, an estimated 9855 to 12 045 avoidable antibiotic and 8030 non-guideline antibiotic courses annually are represented by the 14 sites studied. These and other study findings highlight numerous opportunities for outpatient pediatric antibiotic stewardship.

Predictors of Negative Pressure Ventilation Response in Pediatric Acute Respiratory Failure.

BACKGROUND: Use of negative pressure ventilation is neither well described nor widespread in pediatric critical care; existing data are from small, specialized populations. We sought to describe a general population of critically ill subjects with acute respiratory failure supported with negative pressure ventilation to find predictors of response or failure. METHODS: We conducted a retrospective cohort study of subjects 0-18 y old admitted to a single (non-cardiac) pediatric ICU who received acute respiratory failure support via negative pressure ventilation from May 2015 through May 2016. RESULTS: In 118 subjects, the most common causes of acute respiratory failure were viral bronchiolitis (86.4%) and pneumonia (15.3%). A majority of subjects (68.6%) stabilized with negative pressure ventilation and did not need a change of respiratory support; in those who failed with negative pressure ventilation, median time to respiratory support change was 5.1 h (interquartile range 1.9-11.0). Subjects stabilized with negative pressure ventilation did not differ from those needing a change of respiratory support in terms of age, comorbidities, or FIO2 at initiation of ventilation. Compared to those who did not respond to negative pressure ventilation, mean SpO2 /FIO2 was higher at 1 h after start of negative pressure ventilation (218.8 vs 131.7) in those who did respond. Subjects with SpO2 /FIO2 < 192 after 1 h on negative pressure ventilation support had 5-fold higher odds of needing a respiratory support change (odds ratio 5.143, 95% CI 1.17-22.7, P = .031). Analysis of SpO2 /FIO2 was limited by 81.3% (96/118) of subjects who had an SpO2 > 97% at 1 h after the start of negative pressure ventilation. CONCLUSIONS: Negative pressure ventilation successfully supported 69% of pediatric subjects with all-cause acute respiratory failure. Oxygen requirement was lower in subjects who were responsive to negative pressure ventilation within 1 h of initiation. Standardized negative pressure ventilation protocols should include weaning of supplemental oxygen to determine responsiveness.

Short-Term Adverse Outcomes Associated With Hypoglycemia in Critically Ill Children.

OBJECTIVES: Previous studies report worse short-term outcomes with hypoglycemia in critically ill children. These studies relied on intermittent blood glucose measurements, which may have introduced detection bias. We analyzed data from the Heart And Lung Failure-Pediatric INsulin Titration trial to determine the association of hypoglycemia with adverse short-term outcomes in critically ill children. DESIGN: Nested case-control study. SETTING: Thirty-five PICUs. A computerized algorithm that guided the timing of blood glucose measurements and titration of insulin infusion, continuous glucose monitors, and standardized glucose infusion rates were used to minimize hypoglycemia. PATIENTS: Nondiabetic children with cardiovascular and/or respiratory failure and hyperglycemia. Cases were children with any hypoglycemia (blood glucose < 60 mg/dL), whereas controls were children without hypoglycemia. Each case was matched with up to four unique controls according to age group, study day, and severity of illness. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 112 (16.0%) of 698 children who received the Heart And Lung Failure-Pediatric INsulin Titration protocol developed hypoglycemia, including 25 (3.6%) who developed severe hypoglycemia (blood glucose < 40 mg/dL). Of these, 110 cases were matched to 427 controls. Hypoglycemia was associated with fewer ICU-free days (median, 15.3 vs 20.2 d; p = 0.04) and fewer hospital-free days (0 vs 7 d; p = 0.01) through day 28. Ventilator-free days through day 28 and mortality at 28 and 90 days did not differ between groups. More children with insulin-induced versus noninsulin-induced hypoglycemia had zero ICU-free days (35.8% vs 20.9%; p = 0.008). Outcomes did not differ between children with severe versus nonsevere hypoglycemia or those with recurrent versus isolated hypoglycemia. CONCLUSIONS: When a computerized algorithm, continuous glucose monitors and standardized glucose infusion rates were used to manage hyperglycemia in critically ill children with cardiovascular and/or respiratory failure, severe hypoglycemia (blood glucose < 40 mg/dL) was uncommon, but any hypoglycemia (blood glucose < 60 mg/dL) remained common and was associated with worse short-term outcomes.