POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care.

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

Measured CPAP in a Noninvasive Pediatric Airway and Lung Model.

BACKGROUND: Bronchiolitis is the most common cause of admission in children < 2 y of age in the United States. The standard of care involves supportive measures, including noninvasive interventions such as CPAP. CPAP is traditionally delivered through a full face mask; however, pediatric ICUs have been exploring the use of the RAM cannula by Neotech as a mode of CPAP delivery. The level of CPAP delivered via the RAM cannula is uncertain. We performed an in vitro study to determine the level of CPAP delivered via the RAM cannula utilizing a pediatric lung model. METHODS: Models of 7 sizes of pediatric upper airways, produced with a 3-dimensional printer, were connected to a breathing simulator. We applied each size of RAM cannula to weight-appropriate airway and lung compliance parameters, delivering pressures of 5, 7, and 10 cm H2O using a ventilator in the CPAP mode. Leaks of 0%, 20%, 40%, and 60% were generated to emulate a complete seal, a poor fit, and open-mouth breathing. The outcome measure was the difference in CPAP, referred to as "%leak effect," measured by the lung simulator relative to the CPAP set on the ventilator. RESULTS: We found that set CPAP of 5-10 cm H2O generated measured CPAP ranging from 2.6 to 9.7 cm H2O. For the set CPAP levels of 5, 7, and 10 cm H2O, the mean %leak effect values of measured CPAP from the set CPAP were -25%, -26%, and -25.7%, respectively. For each specific cannula-airway combination, increasing the set pressure and decreasing the air leak resulted in higher levels of CPAP delivered. CONCLUSIONS: The RAM cannula delivered varying amounts of CPAP, with a percent loss of approximately -25% depending on the level of leak in the system. With minimal leak, it is conceivable that the RAM cannula can be used to deliver clinically meaningful CPAP.

Adult COVID-19 Patients Cared for in a Pediatric ICU Embedded in a Regional Biothreat Center: Disease Severity and Outcomes.

The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH2O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible.

Distracted Driving Laws and Motor Vehicle Crash Fatalities.

BACKGROUND: Motor vehicle crashes (MVCs) continue to be the leading cause of death in youth 16 to 24 years old in the United States. Distracted driving has been shown to increase the risk of MVCs in all drivers, particularly teenagers. We aimed to determine the association between fatal MVC rates involving 16- to 19-year-old drivers and state distracted driving laws. METHODS: We conducted a retrospective time series analysis of fatal MVCs in the United States involving drivers and passengers 16 to 19 years old from 2007 to 2017 using the Fatality Analysis Reporting System. Multivariable negative binomial regression analysis was performed to compare MVC rates across states on the basis of different types and strengths of distracted driving laws. RESULTS: There were 38 215 drivers 16 to 19 years old involved in fatal MVCs from 2007 to 2017. Incidence of fatal MVCs was highest for 19-year-old drivers (27.2 out of 100 000 19-year-old persons) and lowest for 16-year-olds (10.7 out of 100 000). States with primarily enforced texting bans had lower MVC fatality rates overall involving 16- to 19-year-old drivers (adjusted incidence rate ratio: 0.71; 95% confidence interval: 0.67-0.76). Texting bans and handheld bans for all drivers were associated with decreased MVC fatalities in all age groups. CONCLUSIONS: In the United States, primarily enforced distracted driving laws are associated with a lower incidence of fatal MVCs involving 16- to 19-year-old drivers. Bans on all handheld device use and texting bans for all drivers are associated with the greatest decrease in fatal MVCs. Adoption of universal handheld cellphone bans in all states may reduce the incidence of distracted driving and decrease MVC fatalities.