Evaluating a standardized protocol for the management of diabetes insipidus in pediatric neurosurgical patients.

OBJECTIVES: Central diabetes insipidus (DI) is a known complication following surgical resection of a suprasellar mass. There are limited data analyzing the outcomes of a standardized protocol for the management of postoperative DI in the pediatric population. We sought to fill this gap and hypothesized that utilizing a standardized protocol for fluid management (3-bag system) would reduce serum sodium fluctuations in the postoperative period after suprasellar surgery. METHODS: A retrospective chart review was performed. Patients were identified with the following criteria: age ≤ 18 years, undergoing a surgical procedure for suprasellar mass that also had postoperative DI. The primary outcome was the variability in serum sodium during the first 48 h and between 48 and 120 h postoperatively. RESULTS: There were 21 encounters pre-protocol and 22 encounters post-protocol for neurosurgical procedures. Use of the standardized protocol was associated with a lower range of sodium within 48 h postoperatively (p=0.065) and 83% lower odds of hypernatremia (Na>150 mmol/L) within 48 h postoperatively (CI 0.039-0.714) after controlling for age, gender, and prior DI diagnosis. History of DI conferred a lower risk of hypernatremia as well as less sodium fluctuation within 48 h postoperatively. Younger patients, those <9.7 years of age were associated with increased risk of hyponatremia and greater sodium fluctuations during the postoperative period. CONCLUSIONS: In patients with postoperative DI after suprasellar surgery, using a standardized protocol for fluid management (3-bag system) appears to reduce serum sodium variability in the first 48 h after surgery.

Expanding Faculty Development of Teaching Skills: A National Needs Assessment of Pediatric Critical Care Medicine Faculty.

OBJECTIVES: High-quality clinical teaching is an essential element in preparing trainees to become independently competent clinicians. In order to better understand the context-specific faculty development needs of teaching faculty in a specific community, we sought to determine the self-reported teaching skill deficits of pediatric critical care medicine faculty and their preferences and motivations regarding faculty development to enhance their teaching. DESIGN: Modified Delphi technique was used to create an online survey in which respondents rated their need for education on a variety of teaching skills, their preferred learning modalities, and factors that motivate their participation in faculty development. SETTING: Pediatric Critical Care Medicine divisions at the 64 sites in the United States with fellowship programs. SUBJECTS: Five-hundred forty-five Pediatric Critical Care Medicine faculty who teach fellows and other trainees. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Response rate was 40%. Respondents reported a median of 8.5 years (interquartile range, 4-16 yr) as teaching faculty. The median age of faculty was 44.6 years (interquartile range, 38-50 yr). Only 20% of respondents indicated that improving their teaching was a low priority. Thirty-six percent of respondents had not participated in any formal teaching skill development as faculty. The most frequently cited factors motivating engagement in faculty development were education being included as part of regularly attended conferences, resources readily available when needed, and participation promoted by a supervisor. Preferred learning modalities included a brief discussion with a colleague, a 10-minute video, and a regular conference series. CONCLUSIONS: Pediatric Critical Care Medicine faculty reported they experience challenges in teaching and would benefit from faculty development training aimed at improving their knowledge and skills about being an educator. Preferred learning methods and motivating factors highlight the importance of efficiency in content delivery and endorsement by faculty supervisors. Consideration of these needs and preferences may be useful in creating context-focused, community of practice-based faculty development programs.

Extracorporeal Membrane Oxygenation (ECMO) Risk Stratification in Newborns with Congenital Diaphragmatic Hernia (CDH).

BACKGROUND: A means for early postnatal stratification of ECMO risk in CDH newborns could be used to comparatively assess the utilization and outcomes of ECMO use between centers. While multiple CDH mortality risk calculators are available, no validated tool exists specifically for prediction of ECMO use. The purpose of this study was to derive and validate an ECMO risk stratification model. METHODS: The study population was obtained from CDH Study Group registry for the period between 2007 and 2016. Only centers offering ECMO were included. The cohort was restricted to ECMO candidates and then divided into derivation and validation sets. Using all relevant perinatal predictors in the registry, univariate analysis was performed for the composite outcome of ECMO use or death without ECMO use. The model was derived using the derivation cohort with multivariable logistic regression and automatic stepwise forward selection (P < 0.05 for qualifying variables), and a c-statistic was obtained. The model was then tested on the validation cohort. Sample reuse validation and bootstrap validation were performed. The validated model was then tested for accuracy on CDH subgroups. RESULTS: There were 1992 patients in the derivation cohort. Four significant variables were identified in the final ECMO risk model: 1-min and 5-min Apgar scores and highest and lowest post-ductal partial pressure of CO2 during the first 24 h of life. The model c-statistic was 0.824 which was confirmed with cross-validation and bootstrap optimism correction. The validation cohort c-statistic was 0.823 (N = 993). The model had good discrimination for left and right CDH, inborn and outborn patients, patients born before and after 2011, and high and low volume centers. The model performed significantly better for postnatally diagnosed patients. CONCLUSIONS: This study represents proof-of-concept that a risk model can accurately estimate the probability of ECMO use in CDH newborns. This stratification could assist centers as a metric for assessment of ECMO usage and outcomes. Refinement and prospective validation of this model should be carried out prior to clinical application. LEVEL OF EVIDENCE: 3.

Enteral topiramate in a pediatric patient with refractory status epilepticus: a case report and review of the literature.

We describe the use of topiramate in a healthy 12-year-old (88-kg) male who developed refractory generalized convulsive status epilepticus. Seizures persisted despite aggressive use of benzodiazepines (intravenous lorazepam; oral clorazepate), barbiturates (i.e., phenobarbital, pentobarbital), and hydantoins. The child's seizures were controlled with nasogastrically administered topiramate in doses up to 500 mg twice daily (11.4 mg/kg/day). The patient did not display any clinical or laboratory signs of metabolic acidosis while receiving topiramate. Topiramate should be considered as a treatment option in refractory status epilepticus.

Are pediatric critical care medicine fellowships teaching and evaluating communication and professionalism?

OBJECTIVES: To describe the teaching and evaluation modalities used by pediatric critical care medicine training programs in the areas of professionalism and communication. DESIGN: Cross-sectional national survey. SETTING: Pediatric critical care medicine fellowship programs. SUBJECTS: Pediatric critical care medicine program directors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survey response rate was 67% of program directors in the United States, representing educators for 73% of current pediatric critical care medicine fellows. Respondents had a median of 4 years experience, with a median of seven fellows and 12 teaching faculty in their program. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication. However, six of the eight (75%) required elements of communication evaluated were not specifically taught by all programs. Faculty role modeling was the most commonly used technique to teach professionalism in 44% of the content areas evaluated, and didactics was the technique used in 44% of other professionalism content areas. Thirteen of the 16 required elements of professionalism (81%) were not taught by all programs. Evaluations by members of the healthcare team were used for assessment for both competencies. The use of a specific teaching technique was not related to program size, program director experience, or training in medical education. CONCLUSIONS: A wide range of techniques are currently used within pediatric critical care medicine to teach communication and professionalism, but there are a number of required elements that are not specifically taught by fellowship programs. These areas of deficiency represent opportunities for future investigation and improved education in the important competencies of communication and professionalism.

Prevalence of adverse events in pediatric intensive care units in the United States.

OBJECTIVES: Selection of relevant patient safety interventions for the pediatric intensive care (PICU) requires identification of the types and severity of adverse events (AEs) and adverse drug events (ADEs) that occur in this setting. The study's objectives were to: 1) determine the rates of AEs/ADEs, including types, severity, and preventability, in PICU patients; 2) identify population characteristics associated with increased risk of AEs/ADEs; 3) develop and test a PICU specific trigger tool to facilitate identification of AEs/ADEs. DESIGN, SETTING, PATIENTS: Retrospective, cross-sectional, randomized review of 734 patient records who were discharged from 15 U.S. PICUs between September and December 2005. INTERVENTION: A novel PICU-focused trigger tool for AE/ADE detection. MEASUREMENTS AND RESULTS: Sixty-two percent of PICU patients had at least one AE. A total of 1488 AEs, including 256 ADEs, were identified. This translates to a rate of 28.6 AEs and 4.9 ADEs per 100 patient-days. The most common types of AEs were catheter complications, uncontrolled pain, and endotracheal tube malposition. Ten percent of AEs were classified as life-threatening or permanent; 45% were deemed preventable. Higher adjusted rates of AEs were found in surgical patients (p = .02), patients intubated at some point during their PICU stay (p = .002), and patients who died (p < .001). Surgical patients had higher preventable adjusted AE (p = .01) and ADE rates (p = .02). The adjusted cumulative risk of an AE per PICU day was 5.3% and 1.6% for an ADE alone. There was a 4% increase in adjusted ADEs rates for every year increase in age. CONCLUSIONS: AEs and ADEs occur frequently in the PICU setting. These data provide areas of focus for evidence-based prevention strategies to decrease the substantial risk to this vulnerable pediatric population.

Natural course following pediatric tracheostomy.

OBJECTIVE: To describe the hospital course of pediatric posttracheostomy patients, their underlying diagnosis, and their demographic characteristics. DESIGN: Retrospective, descriptive record review. SETTINGS: Academic tertiary Pediatric Critical Care Unit. METHODS AND RESULTS: One hundred and forty-one patients 1 month to 20 years old identified and included in the study. The length of in-hospital stay ranged from 14 to 280 days. The most common indications for tracheostomy were ventilation of chronic lung disease (CLD), subglottic stenosis, or combination at 44.7% of the cases followed by neurological cases 26.2%. Patients requiring prolonged stay were more likely to have pulmonary hypertension (odds ratio [OR] = 5.43), gastrointestinal reflux (OR = 2.09), prior episodes of failure to thrive (OR = 4.17), feeding failure requiring feeding tube (OR = 3.32), and tracheitis (OR = 4.17). The chances for home ventilation requirement increased with long preoperative in-hospital ventilation time and high ventilator respiratory rate on the day of tracheostomy as 0.98 days for each preoperative day and 0.94 days for each set ventilator breath (set respiratory rate per minute). The survival rate was 98.9% for the first 30 days and 78% afterward. CONCLUSION: Chronic lung disease, subglottic stenosis, and combinations are the most common causes for tracheostomy at present followed for tracheostomy due to neurological problems. Children requiring tracheostomy have lengthy hospital stay. Establishing an accurate diagnosis helps predict the length of hospitalization and the need for home ventilation; however, in less clear cases, the length of stay can be predicted from the presence of pulmonary hypertension, reflux, and failure to thrive. The mortality rate is low at the postoperative period and increases depending upon the underline reason for tracheostomy referral.

Severe systemic reaction to Loxosceles reclusa spider bites in a pediatric population.

OBJECTIVE: To report 6 children who had severe systemic reaction after spider bites requiring pediatric intensive care unit admission and to describe their clinical presentation, hospital course, and outcome. METHODS: A retrospective analysis was done to identify patients presenting with brown recluse spider bites. Charts of children admitted to the intensive care unit were reviewed. RESULTS: Six previously healthy African-American children, aged 3 to 15 years, with brown recluse spider bites were admitted to the pediatric intensive care unit. All had fever, jaundice, and evidence of hemolytic anemia. Four of 6 children had hypotension. One child developed mental status changes, acute renal failure secondary to rhabdomyolysis, and hyperkalemia and required emergent hemodialysis. All children fully recovered. CONCLUSION: Although most cases of brown recluse spider bites are benign requiring no intervention, severe systemic reactions may occur in the pediatric population resulting in admission to the pediatric intensive care unit. These systemic reactions may include hemolytic anemia, hypotension, and renal failure.