Acceptability and Feasibility of Text Message Interface to Assess Parents' Real-time PICU Experiences.

INTRODUCTION: Parents of children in the pediatric intensive care unit (PICU) experience substantial stress; a parent's perception of their child's illness severity, more than objective measures, predicts psychological outcomes. No tools exist to assess parents' real-time experiences. This pilot study evaluated the feasibility and acceptability of a text-based tool to measure parental experience. METHODS: Inclusion criteria included PICU stay >48 h, physician approval, smartphone access, and English-speaking caregiver. Eligible parents received a text-based baseline survey and surveys every other day while hospitalized regarding their mood/experiences and optional open-ended questions regarding stressors. They received post-discharge follow-up surveys at 1 week and 1, 3, and 6 months. Follow-up surveys assessed mood and symptoms of depression, anxiety, and post-traumatic stress. Interviews and surveys about the interface were conducted 1 week and 3 months following discharge. Feasibility was assessed by descriptive statistics (eg, response rates), and acceptability was assessed by descriptive statistics (survey results) and thematic analyses of interviews. RESULTS: Of 20 enrolled participants, the first 5 were excluded due to technical issues. Of the 15 included, results demonstrated feasibility and acceptability. Most participants (86%) completed all surveys during the PICU stay and continued to complete surveys at a high rate: 79%-94% 3 months post-discharge. All participants agreed that the system was easy to use and were satisfied with the system at discharge, and 91% remained satisfied 3 months post-discharge. Additionally, 76% reported comfort, and 69% reported benefit. From the interviews, participants lauded the system's convenience and applicability of content. Some proposed changes to improve ergonomics. Many suggested this interface could help teams better support families. CONCLUSIONS: A text-based interface for measuring experience in the PICU is feasible and acceptable to parents. Further research can explore how this could identify parents most at risk of adverse psychological sequelae and lead to earlier supportive interventions.

Dexmedetomidine for sedation during hematopoietic stem cell harvest apheresis and leukapheresis in the PICU: Guideline development.

BACKGROUND: Hematopoietic stem cell (HSC) harvest apheresis and leukapheresis are performed in the pediatric intensive care unit (PICU) for high-risk pediatric patients who require procedural sedation. Patients need central access either with their own central lines, ports or require apheresis catheter (CVL) placement. Previously, patients were either awake or emerging from sedation on PICU admission. Uncertainty regarding procedural sedation plans caused delays initiating sedation and apheresis. A guideline was developed to standardize Dexmedetomidine (DEX) for procedural sedation. We investigated if guideline implementation would improve efficiency during PICU admission as demonstrated by shorter time intervals for initiation of sedation, apheresis, PICU length of stay and less alternative sedating medication. METHODS: Data was collected retrospectively from electronic health records of preguideline and post-guideline patients who were admitted to the PICU for sedated apheresis. We compared demographic and clinical characteristics, time intervals for sedation, apheresis, PICU length of stay, and sedation agents between the two groups using Fisher Exact tests and Mann-Whitney tests, as appropriate. RESULTS: The groups did not differ in age or weight at the time of apheresis. All intervals of time compared were shorter post-guideline. Time intervals from admission to start of sedation, admission to start of apheresis, and admission to end of apheresis were statistically significantly different. The type and number of alternative sedating medications administered did not differ between the two groups. CONCLUSION: This guideline implementation improved efficiency during PICU admission. This study might have been too small to demonstrate statistically significant differences in other time intervals studied.

Understanding mothers' perception of child's illness: Adapting the CONNECT Instrument for pediatrics.

AIMS AND OBJECTIVES: To adapt the CONNECT Instrument for use in the paediatric population, to assess validity of this instrument after its adaptation and to assess concordance between mothers' perception of their child's illness and providers' understanding of mothers' perceptions. BACKGROUND: The CONNECT Instrument (Patient Education and Counseling, 73, 2008, 232-239) was validated in an adult outpatient population to characterise both patients' perspectives and physicians' understanding of their patients' perspectives for several dimensions of the illness experience. However, this did not include the paediatric population or advanced practice providers. DESIGN: A two-part prospective, cross-sectional, observational study to assess the validity of CONNECT for Pediatrics and to assess perception of illness. METHODS: The CONNECT Instrument (Patient Version) was adapted from its original form and modified to CONNECT for Pediatrics to facilitate use in the inpatient paediatric population. Eighty-five participants were enrolled including mothers, advanced practice providers and physicians from 2013-2014 during a child's scheduled admission to a paediatric epilepsy monitoring unit. Principal components analysis and inter-item reliability were analysed, and differences in the six mean domain scores were assessed using repeated measures analysis of variance (RM-ANOVA). Reporting of this research adheres to the STROBE guidelines (See Appendix S1). RESULTS: Our analysis indicated that the modifications made provided a relatively valid and reliable instrument. There were overall statistically significant differences between the mother and physician groups, specifically in the domains of meaning and preference for partnership. CONCLUSIONS: Paediatric advanced practice providers and physicians do have an understanding of mothers' perception of illness. RELEVANCE TO CLINICAL PRACTICE: The ability of physicians and advanced practice providers to understand mothers' perceptions of illness is increasingly important in a changing healthcare environment. CONNECT for Pediatrics facilitates the identification of mothers' perception of their child's illness and provides the opportunity for paediatric advanced practice providers and physicians to understand parents' perception of illness.

Comparison of prostaglandin and mechanical cervical ripening in the setting of small for gestational age neonates.

Objective: The objective of this study is to determine whether cervical ripening with misoprostol (MP) is associated with higher rates of cesarean delivery (CD) compared with dinoprostone (DP) or Pitocin/Foley balloon (PFB) in infants found to be small for gestational age (SGA). Study design: Single center institution based cohort study of all inductions between 2008 and 2012 where birth weight was found to be as SGA (< 10th percentile). Maternal demographic, obstetric, and labor characteristics were compared between SGA births where cervical ripening with MP, DP, or PFB was used as the primary agent. The primary outcome was CD after attempted induction between the three study groups which included MP, DP, and PFB. Secondary outcomes included inability to achieve active labor (defined as cervical dilation of 6 cm or greater), cervical dilation at the time of CD, the incidence of CD for the indication of non-reassuring fetal status, and neonatal outcomes including Apgar scores and admission to neonatal intensive care unit. Multivariable logistic regression was performed to evaluate the association of these outcomes with MP as the induction agent versus the referent groups, PFB. Results: Of 260 inductions where the infant was found to be SGA by birth weight during the 5-year period, 172 (66.2%) patients were induced using MP, 38 (14.6%) with DP, and 50 (19.2%) with PFB. There were no differences in baseline characteristics between groups (age, race, BMI, parity, induction indication, birth weights, or maternal comorbidities). MP did not increase rate of CD which was 25.6%, 26.3%, and 22.0% in the MP, DP, and PFB groups, respectively (p = .86). There were also no differences in incidence of CD for non-reassuring fetal well-being (NRFWB), failure to attain active labor, or cervical dilation at time of CD between induction groups. NICU admission was 18%, 18%, and 16% (p = .94) between MP, DP, and PFB groups, respectively. MP was not associated with an increased rate of CD when compared with the other two agents combined, aOR 0.93 (0.67-1.30, 95% CI). Conclusion: MP appears to have similar efficacy and safety when compared with other cervical ripening agents in pregnancies complicated by SGA.

Accuracy of Sonographically Estimated Fetal Weight Near Delivery in Pregnancies Complicated With Diabetes Mellitus.

OBJECTIVES: The purpose of this study was to evaluate the accuracy of sonographic estimations of fetal weight (FW) and signed percent error between pregnant patients with and without diabetes mellitus (DM). METHODS: We conducted a retrospective cohort study of all singleton nonanomalous live births who delivered after 34 weeks and received a sonographic estimation of FW within 2 weeks of delivery at the University of Cincinnati Medical Center between 2008 and 2011. Our primary outcome compared the ΔFW and signed percent error between DM and non-DM pregnancies. Sensitivity and specificity were calculated for the prediction of FW greater than 4000 g in each study group. Linear regression analysis assessed correlation coefficients, R2 values, and variance of the ΔFW by live birth weight. RESULTS: The mean ΔFWs were 62 and 103 g for non-DM and DM pregnancies, respectively (P = .04). However, the signed percent error (mean ± SD, 1.7% ± 9.8% versus 2.6% ± 9.9%; P = .15) was similar between the study groups. Linear regression comparing the ΔFW to the live birth weight revealed a weak correlation in DM (r = 0.34; R2 = 0.11) and non-DM pregnancies, (r = 0.17; R2 = 0.03) pregnancies. Overall sensitivity for the prediction of FW greater than 4000 g was poor (0.41 and 0.62 in non-DM and DM pregnancies). However, the specificity was high (0.97 and 0.99 for both groups). CONCLUSIONS: Although DM alters the biometric measurements of the fetus with increasing thoracoabdominal size, there are no clinically significant alterations in the accuracy of sonography for FW prediction when performed near delivery. Sonography is highly specific for birth weight greater than 4000 g, which is helpful for delivery planning and management.

Prostaglandin versus mechanical dilation and the effect of maternal obesity on failure to achieve active labor: a cohort study.

PURPOSE: Assess the impact of obesity on successful cervical ripening with mechanical versus prostaglandin ripening. MATERIALS AND METHODS: We compared obese to non-obese women in an analysis stratified by induction method, prostaglandin versus mechanical. Misoprostol dosing was the same for obese and non-obese women. Pitocin was titrated to effect. Our primary outcome was failure to achieve active labor. Secondary outcomes included overall cesarean delivery rate, doses of misoprostol used and need for protocol deviation. RESULTS: Obese women had a higher cesarean delivery rate with misoprostol (35% versus 26%, p = 0.03) but not with mechanical ripening (31% versus 29%, p = 0.69). Obesity was associated with a higher rate of failure to achieve active labor in women undergoing prostaglandin ripening with misoprostol (24 versus 15%, p = 0.01) but not in women undergoing mechanical ripening (19 versus 15%, p = 0.55). After controlling for confounding variables, obese women who underwent cervical ripening with misoprostol had a higher rate of failure to achieve active labor, aOR 1.29 (95%CI: 1.00-1.67), which was not seen with mechanical ripening, aOR 1.09 (95%CI: 0.69-1.73). CONCLUSION: Obese women receiving the same dose of misoprostol as non-obese women have higher rates of failure to achieve active labor, an effect not seen with mechanical ripening.

Pleural effusion in a child with a ventriculoperitoneal shunt and congenital heart disease.

We present the unique case of an 8 month old infant who required extracorporeal membrane oxygenation (ECMO) after neonatal repair of tetralogy of Fallot. While on ECMO, he developed grade 3 intraventricular hemorrhage resulting in hydrocephalus requiring ventriculoperitoneal (VP) shunt placement at 5 months of life. He presented to cardiology clinic with a 2-month history of poor weight gain, tachypnea, and grunting and was found to have a large right sided pleural effusion. This was proven to be cerebrospinal fluid (CSF) accumulation secondary to poor peritoneal absorption with subsequent extravasation of CSF into the thoracic cavity via a diaphragmatic defect. After diaphragm repair, worsening ascites from peritoneal malabsorption led to shunt externalization and ultimate conversion to a ventriculoatrial (VA) shunt. This is the second reported case of VA shunt placement in a child with congenital heart disease and highlights the need to consider CSF extravasation as the cause of pleural effusions in children with VP shunts.

Association of Fetal Abdominal-Head Circumference Size Difference With Shoulder Dystocia: A Multicenter Study.

Objective This study aims to determine if shoulder dystocia is associated with a difference in the fetal abdominal (AC) to head circumference (HC) of 50 mm or more noted on antenatal ultrasound. Study Design A multicenter matched case-control study was performed comparing women who had shoulder dystocia to controls who did not. Women with vaginal births of live born nonanomalous singletons ≥ 36 weeks of gestation with an antenatal ultrasound within 4 weeks of delivery were included. Controls were matched for gestational age, route of delivery, and diabetes status. Results We identified 181 matched pairs. Only 5% of the fetuses had an AC to HC of ≥ 50 mm. The proportion of AC to HC difference of ≥ 50 mm was significantly higher in shoulder dystocia cases (8%) than controls (1%, p = 0.002). With multivariate regression, the three significant factors associated with shoulder dystocia were AC to HC ≥ 50 mm (odds ratio [OR], 7.3; confidence interval [CI], 1.6-33.3; p = 0.010), femur length (OR, 1.1; CI, 1.0-1.2; p = 0.002), and induced labor (OR, 1.8; CI, 1.1-3.1; p = 0.027). Conclusion A prenatal ultrasound finding of a difference in AC to HC of ≥ 50 mm while uncommon is associated with shoulder dystocia.

Increasing maternal body mass index and the accuracy of sonographic estimation of fetal weight near delivery.

OBJECTIVES: To evaluate whether an increasing body mass index (BMI) influences the accuracy of sonographic estimation of fetal weight. METHODS: We performed a retrospective cohort study of singleton deliveries over a 2-year period in a single institution. Patients were included if they had a fetal weight estimation within 2 weeks of delivery. The Δ estimated fetal weight (EFW) was calculated by subtracting the sonographic EFW from the birth weight and compared among our study groups, which were based on the maternal BMI class. We also compared the absolute percentage error of estimation, rate of substantial error greater than 20%, rate of underestimation, and ability to predict fetal weight greater than 4000 g. Post hoc power analysis determined that our study group of 1200 patients allowed for an α of .05 and ß of .90. RESULTS: We included 1177 women in our analysis. The median ΔEFW varied between study groups: 137, 202, 157, 200, and 189 g, respectively, in normal-weight, overweight, and obese classes 1, 2, and 3 (P = .01). The median percentage error of estimation between study groups varied between 5.0% in normal-weight women and 7.1% in class 2 obese women (P= .05). The rate of substantial error was similar between study groups and varied between 2.7% in class 1 obese women and 4.3% in normal-weight and class 2 obese women. Linear regression analysis showed a weak association between maternal BMI and ΔEFW (R(2) = 0.005; r = 0.069). CONCLUSIONS: The absolute ΔEFW was lower in normal-weight women; however, the percentage error of the EFW was similar between women of varying BMI classifications, as was the rate of substantial error and the rate of underestimation of the EFW.