Investigating Associations Between Nonadherence to Guideline-Recommended Treatment of Pediatric Seizures and Adverse Outcomes: A Canadian Feasibility Study.

BACKGROUND: Emerging evidence suggests that nonadherence to treatment guidelines for seizures may affect patient outcomes. We examined the feasibility of conducting a larger investigation to test this hypothesis in the pediatric population. METHODS: We retrospectively reviewed charts of patients aged ≤18 years who presented with seizure to the emergency departments of two Ontario hospitals in 2019 to 2021. Patients were grouped by seizure duration (<5 minutes [n = 37], ≥5 minutes [n = 41]). We examined nonadherence to guideline-recommended treatment, adverse outcomes (hospitalization, length of stay, respiratory complications), and missing values for key variables. RESULTS: Of 78 patients, 34 (44%) did not receive guideline-recommended treatment. Nonadherence was similar in the two groups (<5 minutes: 46%; ≥5 minutes: 41%). Common deviations included administering an antiseizure medication (ASM) for seizures of less than five minutes (46%), a delay (>10 minutes) between the first and second ASM doses (50%), and use of a benzodiazepine for the third dose (45%). Hospitalizations were common in both seizure duration groups (∼90%), whereas respiratory complications were relatively rare. Time of seizure onset was missing in 51% of charts, and none contained the time of first contact with emergency services when patients were transported by ambulance. CONCLUSION: We found evidence of substantial nonadherence to guideline-recommended treatment of pediatric seizures. Medical records do not contain sufficient information to comprehensively investigate this issue. A multicenter prospective study is the most feasible option to examine the association between nonadherence to guideline-recommended treatment and patient outcomes.

Outcomes and follow-up for children intubated in an adult-based community hospital system: A retrospective chart review.

Objectives: Emergency intubation is a high-risk procedure in children. Studies describing intubation practices in locations other than pediatric centres are scarce and varied. This study described pediatric intubations in adult-based community emergency departments (EDs) and determined what factors were associated with intubated-related adverse events (AEs) and described outcomes of children transferred to a quaternary care pediatric institution. Methods: This is a retrospective review of data collected between January 2006 and March 2017 at Lakeridge Health and Hospital for Sick Children (SickKids). Patients were <18 years and intubated in Lakeridge Health EDs; those intubated prior to ED arrival were excluded. Primary outcomes were intubation first-pass success (FPS) and AEs secondary to intubation. Results: Patients (n = 121) were analyzed, and median (interquartile range (IQR)) age was 3.7 (0.4-14.3) years. There were 76 (62.8%) FPS, with no difference between pediatricians (n = 25, 23%) or anaesthetists (n = 12, 11%), versus all other providers (paramedic n = 13 (12%), ED physician n = 37 (34%), respiratory therapist n = 20 (18%), transfer team n = 2 (2%)). The proportion of AEs was 24 (19.8%, n = 21 minor, n = 3 major), with no significant difference between pediatricians or anaesthetists versus all other providers. Data from 68 children transferred to SickKids were available, with the majority extubated within a short median (IQR) time of admission, 1.2 (0.29-3.8) days. Conclusions: Pediatric intubations were rare in a Canadian adult-based community hospital system. Most intubations demonstrated FPS with relatively few AEs and no significant differences between health provider type. Future investigations should utilize multi-centred data to inform strategies suited for organizations' unique practice cultures, including training programs.

Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review.

INTRODUCTION: Bronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity. METHODS: A retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant. RESULTS: The mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96-7.75)) versus not (4.70 (4.20-5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6-2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (-0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively. CONCLUSIONS: A large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.

Clinical Determination of Brain Death in Children Supported by Extracorporeal Membrane Oxygenation.

BACKGROUND/OBJECTIVE: Children supported by extracorporeal membrane oxygenation (ECMO) are at risk of catastrophic neurologic injury and brain death. Timely determination of brain death is important for minimizing psychological distress for families, resource allocation, and organ donation. Reports of successful determination of brain death in pediatric patients supported by ECMO are limited. The determination of brain death by clinical criteria requires apnea testing, which has historically been viewed as challenging in patients supported by ECMO. We report eight pediatric patients who underwent a total of 14 brain death examinations, including apnea testing, while supported by veno-arterial ECMO (VA-ECMO), resulting in six cases of clinical determination of brain death. METHODS: We performed a retrospective review of the medical records of pediatric patients who underwent brain death examination while supported by VA-ECMO between 2010 and 2018 at a single tertiary care children's hospital. RESULTS: Eight patients underwent brain death examination, including apnea testing, while supported by VA-ECMO. Six patients met criteria for brain death, while two had withdrawal of technical support after the first examination. During the majority of apnea tests (n = 13/14), the ECMO circuit was modified to achieve hypercarbia while maintaining oxygenation and hemodynamic stability. The sweep flow was decreased prior to apnea testing in ten brain death examinations, carbon dioxide was added to the circuit during three examinations, and ECMO pump flows were increased in response to hypotension during two examinations. CONCLUSIONS: Clinical determination of brain death, including apnea testing, can be performed in pediatric patients supported by ECMO. The ECMO circuit can be effectively modified during apnea testing to achieve a timely rise in carbon dioxide while maintaining oxygenation and hemodynamic stability.

Early critical care course in children after liver transplant.

Objective. To review the critical care course of children receiving orthotopic liver transplantation (OLT). Methods. A retrospective chart review of patients admitted to the pediatric critical care following OLT performed in our center between 1988 and 2011. Results. A total of 149 transplants in 145 patients with a median age of 2.7 (IQR 0.9-7) years were analyzed. Mortality in the first 28 days was 8%. The median length of stay (LOS) was 7 (4.0-12.0) days. The median length of mechanical ventilation (MV) was 3 (1.0-6.2) days. Open abdomen, age, and oxygenation index on the 2nd day predicted LOS. Open abdomen, age, amount of blood transfused during surgery, and PRISM III predicted length of MV. 28% of patients had infection and 24% developed acute rejection. In recent group (2000-2011) OLT was performed in younger patients; the risk of infection and acute rejection was reduced and patients required longer LOS and MV compared with old group (1988-1999). Conclusion. The postoperative course of children after OLT is associated with multiple complications. In recent years OLT was performed in younger children; living donors were more common; the rate of postoperative infection and suspected rejection was reduced significantly; however patients required longer MV and LOS in the PCCU.

Intensive care unit acquired weakness in children: Critical illness polyneuropathy and myopathy.

BACKGROUND AND AIMS: Intensive care unit acquired weakness (ICUAW) is a common occurrence in patients who are critically ill. It is most often due to critical illness polyneuropathy (CIP) or to critical illness myopathy (CIM). ICUAW is increasingly being recognized partly as a consequence of improved survival in patients with severe sepsis and multi-organ failure, partly related to commonly used agents such as steroids and muscle relaxants. There have been occasional reports of CIP and CIM in children, but little is known about their prevalence or clinical impact in the pediatric population. This review summarizes the current understanding of pathophysiology, clinical presentation, diagnosis and treatment of CIP and CIM in general with special reference to published literature in the pediatric age group. SUBJECTS AND METHODS: Studies were identified through MedLine and Embase using relevant MeSH and Key words. Both adult and pediatric studies were included. RESULTS: ICUAW in children is a poorly described entity with unknown incidence, etiology and unclear long-term prognosis. CONCLUSIONS: Critical illness polyneuropathy and myopathy is relatively rare, but clinically significant sequelae of multifactorial origin affecting morbidity, length of intensive care unit (ICU) stay and possibly mortality in critically ill children admitted to pediatric ICU.

Management of raised intracranial pressure in children with traumatic brain injury.

Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI). The current guidelines and management strategies are aimed at maintaining adequate cerebral perfusion pressure and treating elevated ICP. Despite controversies, ICP monitoring is important particularly after severe TBI to guide treatment and in developed countries is accepted as a standard of care. We provide a narrative review of the recent evidence for the use of ICP monitoring and management of ICP in pediatric TBI.

Anomalous origin of left main coronary artery from the right sinus of Valsalva leading to sudden death.

A 14-year-old female was brought to the emergency room with chest pain, shortness of breath and cyanosis. She was previously well with the exception of one previous post-exertion seizure-like event. On this day, she had been jogging when she complained of chest pain and collapsed. Her initial vital signs were heart rate 58/min, blood pressure 70/40 mmHg, respiratory rate 50/min, temperature 37 °C, and SaO2 68%. Electrocardiogram showed significant ST changes. She received multiple fluid boluses and dopamine was initiated (5-20 µg/kg/min). She was intubated and started on norepinephrine (0.05-0.5 µg/kg/min) for refractory hypotension. During the resuscitation, echocardiography showed poor left ventricular function with an ejection fraction of 38%. The coronary arteries could not be visualized clearly. To maintain cardiac output, epinephrine by infusion (0.1-3.0 µg/kg/min) was added, and she received multiple epinephrine boluses. Despite maximum ventilatory support and escalating inotropes, cardiac output rapidly deteriorated, and she developed an agonal rhythm with non-reactive pupils. Resuscitation was discontinued. Autopsy demonstrated an anomalous origin of left coronary artery from the right aortic sinus of Valsalva with acute myocardial ischemia. We describe the sudden coronary death of a young patient, and we review congenital coronary artery pathophysiology, screening difficulties and potential interventions.