Interfacility Transport Shock Index Is Associated With Decreased Survival in Children.

BACKGROUND: Shock index, the ratio of heart rate to systolic blood pressure that changes with age, is associated with mortality in adults after trauma and in children with sepsis. We assessed the utility of shock index to predict sepsis diagnosis and survival in children requiring interfacility transport to a tertiary care center. METHODS: We studied children aged 1 month to 21 years who had at least 2 sets of vital signs recorded during interfacility transport to the Children's Hospital of Pittsburgh by our critical care transport team. Subjects were divided into 4 age groups: group 1 (<1 year), group 2 (1-3 years), group 3 (4-11 years), and group 4 (≥12 years). Children were also grouped into sepsis or nonsepsis group based on the International Classification of Diseases, Ninth Revision categories. Primary outcome was survival to hospital discharge. RESULTS: Of 3519 children studied, 493 (14%) had sepsis. Initial shock index decreased with increasing age: group 1, 1.45 ± 0.42 (mean ± SD); group 2, 1.35 ± 0.32; group 3, 1.20 ± 0.34; and group 4, 1.00 ± 0.32 (P < 0.001). Initial shock index was increased in children with sepsis versus those with no sepsis overall and in all age groups (all P < 0.05). Initial shock index showed a trend for association with survival in univariate analysis (P = 0.05) but was not associated with survival in a multivariable logistic regression. Highest quartile of shock index was associated with need for intensive care unit admission posttransport. CONCLUSIONS: Increased shock index in children requiring intrafacility transport was associated with hospital discharge diagnosis of sepsis but not hospital survival.

Diastolic hypotension is an unrecognized risk factor for ß-agonist-associated myocardial injury in children with asthma.

OBJECTIVES: Tachycardia and diastolic hypotension have been associated with ß-2 agonist use. In the setting of ß-agonist-induced chronotropy and inotropy, diastolic hypotension may limit myocardial blood flow. We hypothesized that diastolic hypotension is associated with ß-agonist use and that diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury in children with asthma. DESIGN: Two patient cohorts were collected. The first, consisting of patients transported for respiratory distress having received at least 10 mg of albuterol, was studied for development of tachycardia and hypotension. The second, consisting of patients who had troponin measured during treatment for status asthmaticus with continuous albuterol, was studied for factors associated with elevated troponin. Exclusion criteria for both cohorts included age younger than 2 years old, sepsis, pneumothorax, cardiac disease, and antihypertensive use. Albuterol dose, other medications, and vital signs were collected. Diastolic and systolic hypotension were defined as an average value below the fifth percentile for age and tachycardia as average heart rate above the 98th percentile for age. PATIENTS: Ninety of 1,390 children transported for respiratory distress and 64 of 767 children with status asthmaticus met inclusion criteria. MEASUREMENTS AND MAIN RESULTS: Diastolic hypotension occurred in 56% and 98% of the first and second cohorts, respectively; tachycardia occurred in 94% and 95% of the first and second cohorts, respectively. Diastolic hypotension and tachycardia had a weak linear correlation with albuterol dose (p = 0.02 and p = 0.005, respectively). Thirty-six percent had troponin > 0.1 ng/mL (range, 0-12.6). In multivariate analysis, interaction between diastolic hypotension and tachycardia alone was associated with elevated troponin (p = 0.02). CONCLUSIONS: Diastolic hypotension and tachycardia are dose-dependent side effects of high-dose albuterol. In high-risk patients with status asthmaticus treated with albuterol, diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury. Diastolic hypotension, especially combined with tachycardia, could be a reversible risk factor for myocardial injury related to ß-agonist use.

Plasma exchange in a 13-year-old male with acute intravascular hemolysis and acute kidney injury after placement of a ventricular assist device.

Intravascular hemolysis and resulting plasma-free hemoglobin elevation has been associated with acute kidney injury via several mechanisms. Proximal tubular injury due to iron compound deposition and nitric oxide sequestration with subsequent impairment of the microcirculation and hypoperfusion are specific adverse effects of intravascular hemolysis that may contribute to acute kidney injury. Therefore, removal of plasma-free hemoglobin and restoration of normal nitric oxide vasodilatory mechanisms may play a beneficial role in treating acute kidney injury secondary to acute intravascular hemolysis. We report herein the case of a 13-year-old patient with severe intravascular hemolysis and acute kidney injury and describe the role of plasma exchange with plasma replacement in his successful recovery.

Discontinuation of prolonged infusions of dexmedetomidine in critically ill children with heart disease.

PURPOSE: To describe changes in hemodynamic variables, sedation, and pain score after discontinuation of prolonged infusions of dexmedetomidine in a pediatric population of critically ill cardiac patients. METHODS: Retrospective case series of patients who received continuous infusions of dexmedetomidine for longer than 3 days in a pediatric cardiac intensive care unit from 2008 to 2010. RESULTS: Sixty-two patients, age 5.2 months (range 0.3 months-17 years) and weight 5.1 kg (range 2.2-84 kg), were included. Thirty-nine patients (63%) were younger than 1 year of age. Median duration of dexmedetomidine infusion was 5.8 days (range 4-26 days) and median infusion dose was 0.71 µg/kg/h (range 0.2-2.1 µg/kg/h). Median weaning time and dose at discontinuation were 43 h (range 0-189 h) and 0.2 µg/kg/h (range 0.1-1.3 µg/kg/h). Tachycardia, transient hypertension and agitation were observed in 27, 35 and 27% of patients. Episodes of tachycardia were more frequent in children older than 1 year of age (61 vs. 8%, p < 0.001), patients who received dexmedetomidine for 4 days when compared to those who received 5 days or longer (48 vs. 17%, p = 0.011), and patients whose infusion was discontinued abruptly (42 vs. 14%, p = 0.045). Tachyarrhythmias were seen in nine patients (15%) after discontinuation of the dexmedetomidine infusion. Adequate sedation and analgesia scores at the moment of infusion discontinuation were seen in 90 and 88% of patients, respectively. CONCLUSIONS: Our study suggests that tachycardia, transient hypertension, and agitation are frequently observed in pediatric cardiac intensive care unit patients after discontinuing prolonged dexmedetomidine infusions.

Updated American College of Critical Care Medicine--pediatric advanced life support guidelines for management of pediatric and neonatal septic shock: relevance to the emergency care clinician.

Shock is a major preventable cause of morbidity and mortality in children referred to emergency care. The recently updated American College of Critical Care Medicine guidelines for the management of newborns and children with septic shock emphasize the role of emergency care in improving survival and functional outcomes. Implementation of these guidelines of stepwise use of fluids, antibiotics, and, if necessary, inotropes within the first hour of admission to the emergency department can reduce mortality and neurological morbidity risks 2-fold. Therapies should be goal directed to maintain age-specific threshold heart rates and blood pressure as well as a capillary refill of less than 3 seconds or 2 seconds or less. Inotropes should be delivered through peripheral intravenous or intraosseous access when central access is unavailable because delay in inotrope delivery can greatly increase mortality risks. Emergency care systems should be organized to facilitate recognition, triage, and treatment of shock in the first hour. Emergency departments should be stocked with ready access to antibiotics, fluids, and inotrope infusions, and clinicians should be trained in the delivery of goal-directed fluid, antibiotics, and inotrope therapies in the first hour of resuscitation. For newborns, in addition to fluids, antibiotics, and inotropes, a prostaglandin infusion should be available within 10 minutes if duct-dependent congenital heart disease is a possibility.

Effect of dexmedetomidine on pulmonary artery pressure after congenital cardiac surgery: A pilot study.

OBJECTIVE: To characterize the effects of dexmedetomidine on the pulmonary artery pressure in patients after congenital cardiac surgery. DESIGN: Prospective observational pilot study. SETTING: Pediatric cardiac intensive care unit at a university hospital. PATIENTS: Twenty-two patients who received dexmedetomidine after cardiothoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: An echocardiogram was performed at three time points: 1) baseline (T0); 2) 6 mins after dexmedetomidine loading (T1); and 3) 1 hr after initiation of dexmedetomidine infusion (T2). Transthoracic echocardiography was used to estimate pulmonary artery pressure based on tricuspid regurgitant velocity (4 x Velocity2) plus central venous pressure. Twenty-two patients aged 0.9 yrs old (interquartile range, 7.9) were enrolled at a median of 1 hr (1.5) after surgery. Dexmedetomidine loading, 0.62 microg/kg (0.5), was given in all patients followed by 0.5 microg/kg/hr (0.6) at T1 and 0.65 microg/kg/hr (0.5) at T2. None of the patients had any increase in pulmonary artery pressure. Overall, the pulmonary artery pressure decreased from 30 mm Hg (13) at T0 to 24 mm Hg (10) at T1 and 26 mm Hg (8) at T2 (p < .001). The pulmonary artery pressure/systemic systolic blood pressure ratio decreased from 33% (12) at T0 to 23% (15) at T1 and 25% (13) at T2 (p = .002). There was no difference in the left ventricular function, Fio2, oxygen %, Po2, CO2, and vasoactive agents. CONCLUSIONS: Administration of dexmedetomidine after congenital cardiac surgery was not associated with any increase in pulmonary artery pressure.

Mortality and functional morbidity after use of PALS/APLS by community physicians.

OBJECTIVES: To test the hypothesis that pediatric shock is a common cause of death and functional morbidity and that pediatric advanced life support (PALS)/advanced pediatric life support (APLS) resuscitation in the community hospital setting improves child health outcomes. METHODS: This study included all children consecutively transported to 5 regional, tertiary care children's hospitals over 4 years, and is a prospective cohort study comparing outcomes in children who did or did not receive PALS/APLS resuscitation in the community hospital. RESULTS: Shock occurred in 37% of the patients transferred to the tertiary centers. Regardless of trauma status, children with shock had an increased mortality rate compared with those without shock (all patients: 11.4% vs 2.6%), trauma patients (28.3% vs 1.2%), and nontrauma patients (10.5% vs 2.8%). Early shock reversal was associated with reduced mortality (5.06% vs 16.37%) and functional morbidity (1.56% vs 4.11%) rates. Early use of PALS/APLS-recommended interventions was associated with reduced mortality (8.69% vs 15.01%) and functional morbidity (1.24% vs 4.23%) rates. After controlling for center, severity of illness, and trauma status, early reversal of shock and use of PALS/APLS-recommended interventions remained associated with reduced morbidity and mortality rates. CONCLUSIONS: Shock is common in children who are transferred for tertiary care. Pediatric shock recognition and resuscitation in the community hospital improves survival and functional outcome regardless of diagnostic category. The development of shock/trauma systems for children with and without trauma seems prudent.

Pediatric specialized transport teams are associated with improved outcomes.

OBJECTIVE: The goal was to test the hypothesis that interfacility transport performed by a pediatric critical care specialized team, compared with nonspecialized teams, would be associated with improved survival rates and fewer unplanned events during the transport process. METHODS: A single-center, prospective, cohort study was performed between January 2001 and September 2002. A total of 1085 infants and children at referral community hospitals with requests for retrieval by the Children's Hospital of Pittsburgh transport team were studied; 1021(94%) were transported by a specialty team and 64 (6%) by nonspecialized teams. Unplanned events during the transport process and 28-day mortality rates were assessed. RESULTS: Unplanned events occurred for 55 patients (5%) and were more common among patients transported by nonspecialized teams (61% vs 1.5%). Airway-related events were most common, followed by cardiopulmonary arrest, sustained hypotension, and loss of crucial intravenous access. After adjustment for illness severity, only the use of a nonspecialized team was independently associated with an unplanned event, and death was more common among patients transported by nonspecialized teams (23% vs 9%). CONCLUSION: Transport of critically ill children to a pediatric tertiary care center can be conducted more safely with a pediatric critical care specialized team than with teams lacking specific training and expertise in pediatric critical care and pediatric transport medicine.

Intensive plasma exchange increases a disintegrin and metalloprotease with thrombospondin motifs-13 activity and reverses organ dysfunction in children with thrombocytopenia-associated multiple organ failure.

BACKGROUND: Thrombocytopenia-associated multiple organ failure (TAMOF) is a poorly understood syndrome in critically ill children. A disintegrin and metalloprotease with thrombospondin motifs (ADAMTS-13), formerly known as von Willebrand factor (VWF) cleaving protease, is decreased in adults with VWF-mediated thrombotic microangiopathy, and intensive plasma exchange (PEx) both replenishes ADAMTS-13 and improves outcome in these patients. OBJECTIVES: To determine whether: 1) critically ill children with TAMOF syndrome have decreased ADAMTS-13 activity, 2) ADAMTS-13 activity correlates with platelet counts and VWF antigen, 3) the autopsies from patients who died with reduced ADAMTS-13 activity have VWF-rich microthrombi, and 4) intensive PEx will restore ADAMTS-13 activity and facilitate organ failure resolution. DESIGN: First study: observational. Second study: randomized control trial. SETTING: Single center university pediatric intensive care unit. PATIENTS: First study: thirty-seven consecutive children (17 males and 20 females; ages ranging from 9 days to 23 years) identified with > or = 2 organs dysfunction were enrolled. Seventy-six percent of these children had thrombocytopenia (platelet counts < 100,000/mm3). Five additional critically ill children without MOF were also enrolled. In the second study, children with severe TAMOF (platelet counts < 100,000/mm3 and > 3 organ failure) were randomized to PEx or standard therapy. Primary physicians and parents agreed to enrollment in 10 of the 20 eligible patients with ages ranging from 1 year to 18 years. Five patients received PEx and 5 patients received standard therapy. RESULTS: First study: children with TAMOF (n = 28) had decreased ADAMTS-13 activity, but similar plasminogen activator inhibitor-1 activity and prothrombin time compared to children with MOF without thrombocytopenia (n = 9, p < 0.05). All non-survivors (n = 7) had TAMOF, reduced ADAMTS-13 activity, and VWF-rich microvascular thromboses at autopsy. In the second study, PEx (n = 5, median 12 days, 4-28 days) restored ADAMTS-13 activity and organ function, compared to standard therapy (n = 5, p < 0.05). CONCLUSIONS: Children with TAMOF syndrome can have VWF-mediated thrombotic microangiopathy. Similar to adult experience, PEx can replenish ADAMTS-13 activity and reverse organ failure.

Extubation after cardiothoracic surgery in neonates, children, and young adults: One year of institutional experience.

OBJECTIVE:: Describe risk factors associated with successful and early extubation in the pediatric cardiac intensive care unit. DESIGN:: Retrospective chart review. SETTING:: University hospital, cardiac intensive care unit. MEASUREMENTS AND MAIN RESULTS:: Review of 212 consecutive surgical admissions from January 2003 to January 2004, excluding deaths. Preoperative, intraoperative, and postoperative variables were studied. Successful extubation was defined as no reintubation at any time during the cardiac intensive care unit course and early extubation was defined as mechanical ventilation 24 hrs after surgery. A history of prematurity (odds ratio [OR], 5.84, 2.29-14.9; p < .001), base excess (OR, 1.47, 1.27-1.70; p < .001), cardiopulmonary bypass time (OR, 1.01, 1.01 to -1.2; p < .05), and the need for surgical reintervention (OR, 18.29, 2.78 to -120.07; p < .05) were associated with intubation for >24 hrs. CONCLUSION:: Extubation without the need for reintubation can be achieved in nearly all children following cardiothoracic surgery. The majority of successful extubations can be achieved within 24 hrs of surgery.

Use of dexmedetomidine in children after cardiac and thoracic surgery.

OBJECTIVE: In this report, we describe our experience with the use of dexmedetomidine in spontaneously breathing as well as in mechanically ventilated patients, after congenital cardiac and thoracic surgery. DESIGN: Retrospective case series. SETTING: University hospital, pediatric cardiac intensive care unit. PATIENTS: Thirty-three spontaneously breathing and five mechanically ventilated patients who received dexmedetomidine after cardiothoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-eight patients, age 8 +/- 1.1 yrs old and weight 29 +/- 3.8 kg, were included. Seven patients (18%) were <1 yr old. Dexmedetomidine was used as a primary sedative and analgesic agent, and when its effect was considered inadequate, despite incremental infusion doses, a rescue agent was administered. The initial dexmedetomidine infusion dose was 0.32 +/- 0.15 microg/kg/hr followed by an average infusion of 0.3 +/- 0.05 microg/kg/hr (range 0.1-0.75 microg/kg/hr). There was a trend toward higher dexmedetomidine infusion requirement in patients <1 yr old compared with older children, 0.4 +/- 0.13 vs. 0.29 +/- 0.17 microg/kg/hr (p = .06). Desired sedation and analgesia were achieved during 93% and 83% of the dexmedetomidine infusion, respectively. According to the intensive care unit sedation scale (score 0-3) and two pain scales (Numeric Visual Analog Scale and Face, Legs, Activity, Cry, and Consolability, score 0-10), the mean sedation score was 1.3 +/- 0.6 (mild sedation) and the mean pain score was 1.5 +/- 0.9 (mild pain). The most frequently rescue drugs administered were fentanyl, morphine, and midazolam. Overall, 49 rescue doses of sedatives/analgesics were given. Patients <1 yr old required more rescue boluses than older children, 22 boluses (3.19 +/- 0.8) vs. 27 boluses (0.8 +/- 0.2, p = .003). Throughout the dexmedetomidine infusion there was no significant change in the systolic and diastolic blood pressure trend. Six patients (15%) had documented hypotension. In three, hypotension resolved with decreasing the dexmedetomidine infusion dose whereas in the other three, hypotension resolved after discontinuing the infusion. Although there was a trend toward lower heart rates, this was not clinically significant. One patient had an episode of considerable bradycardia without hypotension, which resolved shortly after discontinuing the dexmedetomidine infusion. No significant changes in the arterial blood gases or respiratory rates were observed. There was no mortality, and the total intensive care unit length of stay was 19 +/- 2 hrs. CONCLUSIONS: Our data suggest that dexmedetomidine is a well-tolerated and effective agent for both spontaneously breathing and mechanically ventilated patients following congenital cardiac and thoracic surgery.

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

OBJECTIVE: In response to the landmark 1999 report by the Institute of Medicine and safety initiatives promoted by the Leapfrog Group, our institution implemented a commercially sold computerized physician order entry (CPOE) system in an effort to reduce medical errors and mortality. We sought to test the hypothesis that CPOE implementation results in reduced mortality among children who are transported for specialized care. METHODS: Demographic, clinical, and mortality data were collected of all children who were admitted via interfacility transport to our regional, academic, tertiary-care level children's hospital during an 18-month period. A commercially sold CPOE program that operated within the framework of a general, medical-surgical clinical application platform was rapidly implemented hospital-wide over 6 days during this period. Retrospective analyses of pre-CPOE and post-CPOE implementation time periods (13 months before and 5 months after CPOE implementation) were subsequently performed. RESULTS: Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94-5.55) after adjustment for other mortality covariables. CONCLUSIONS: We have observed an unexpected increase in mortality coincident with CPOE implementation. Although CPOE technology holds great promise as a tool to reduce human error during health care delivery, our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.

Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children.

OBJECTIVE: To determine whether multiplying the internal diameter of the endotracheal tube (ETT) by 3 (3x ETT size) is a reliable method for determining correct depth of oral ETT placement in the pediatric population. DESIGN: Prospective, observational. SETTING: University-affiliated, 12-bed pediatric intensive care unit. PATIENTS: Orally intubated pediatric intensive care unit patients of < or =12 yrs of age. INTERVENTIONS: Demographics, ETT size, and depth of ETT placement measured from the lip were obtained. Correct placement, defined as the tip of the ETT below the thoracic inlet and > or =0.5 cm above the carina, was determined by chest radiograph. MEASUREMENTS AND MAIN RESULTS: Suggested ETT size based on the Pediatric Advanced Life Support (PALS) age-based formula and the Broselow tape-length-based guidelines were determined. A total of 174 of 226 ETTs (77%) were correctly positioned. If practitioners utilized the 3x ETT size for the actual tubes chosen, 170 of 226 (75%) would have been accurately placed. More accurate were the 3x PALS-based ETT size (81%) and 3x Broselow-suggested ETT size (85%). The use of the Broselow ETTs to determine the depth would have led to a significantly improved ETT position (p = .009) compared with the actual ETT. CONCLUSION: The commonly used formula of 3x tube size for ETT depth in children results in 15-25% malpositioned tubes. Practitioners can improve the reliability of this formula by utilizing the recommended ETT size as suggested by the Broselow tape. A more reliable method is necessary to avoid ETT malposition.

Guidelines for the inter- and intrahospital transport of critically ill patients.

OBJECTIVE: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient. DATA SOURCE: Expert opinion and a search of Index Medicus from January 1986 through October 2001 provided the basis for these guidelines. A task force of experts in the field of patient transport provided personal experience and expert opinion. STUDY SELECTION AND DATA EXTRACTION: Several prospective and clinical outcome studies were found. However, much of the published data comes from retrospective reviews and anecdotal reports. Experience and consensus opinion form the basis of much of these guidelines. RESULTS OF DATA SYNTHESIS: Each hospital should have a formalized plan for intra- and interhospital transport that addresses a) pretransport coordination and communication; b) transport personnel; c) transport equipment; d) monitoring during transport; and e) documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process. CONCLUSION: The transport of critically ill patients carries inherent risks. These guidelines promote measures to ensure safe patient transport. Although both intra- and interhospital transport must comply with regulations, we believe that patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel.

Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome.

OBJECTIVE: Experimental and clinical studies of septic shock support the concept that early resuscitation with fluid and inotropic therapies improves survival in a time-dependent manner. The new American College of Critical Care Medicine-Pediatric Advanced Life Support (ACCM-PALS) Guidelines for hemodynamic support of newborns and children in septic shock recommend this therapeutic approach. The objective of this study was to determine whether early septic shock reversal and use of resuscitation practice consistent with the new ACCM-PALS Guidelines by community physicians is associated with improved outcome. METHODS: A 9-year (January 1993-December 2001) retrospective cohort study was conducted of 91 infants and children who presented to local community hospitals with septic shock and required transport to Children's Hospital of Pittsburgh. Shock reversal (defined by return of normal systolic blood pressure and capillary refill time), resuscitation practice concurrence with ACCM-PALS Guidelines, and hospital mortality were measured. RESULTS: Overall, 26 (29%) patients died. Community physicians successfully achieved shock reversal in 24 (26%) patients at a median time of 75 minutes (when the transport team arrived at the patient's bedside), which was associated with 96% survival and >9-fold increased odds of survival (9.49 [1.07-83.89]). Each additional hour of persistent shock was associated with >2-fold increased odds of mortality (2.29 [1.19-4.44]). Nonsurvivors, compared with survivors, were treated with more inotropic therapies (dopamine/dobutamine [42% vs 20%] and epinephrine/norepinephrine [42% vs 6%]) but not increased fluid therapy (median volume; 32.9 mL/kg vs 20.0 mL/kg). Resuscitation practice was consistent with ACCM-PALS Guidelines in only 27 (30%) patients; however, when practice was in agreement with guideline recommendations, a lower mortality was observed (8% vs 38%). CONCLUSIONS: Early recognition and aggressive resuscitation of pediatric-neonatal septic shock by community physicians can save lives. Educational programs that promote ACCM-PALS recommended rapid, stepwise escalations in fluid as well as inotropic therapies may have value in improving outcomes in these children.

The state of pediatric interfacility transport: consensus of the second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference.

Interfacility transport of pediatric and neonatal patients for advanced or specialty medical care is an integral part of our medical delivery system. Assessment of current services and planning for the future are imperative. As part of this process, the American Academy of Pediatrics and the Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in Chicago in June 2000. Ninety-nine total participants, representing 25 states and 5 international locations, debated and discussed issues relevant to the developing specialty of pediatric transport medicine. These topics included: 1) the role of the medical director, 2) benchmarking of neonatal and pediatric transport programs, 3) clinical research, 4) accreditation, 5) team configuration, 6) economics of transport medicine in health care delivery, 7) justification of transport teams in institutions, and 8) international transport/extracurricular transport opportunities. Insights and conclusions from this meeting of transport leaders are presented in the consensus statement.