A Multicenter Survey of Pediatric-Neonatal Transport Teams in the United States to Assess the Impact of the Coronavirus Disease 2019 Pandemic on Staffing.

OBJECTIVE: The coronavirus disease 2019 pandemic has resulted in unprecedented burnout in frontline health care providers. However, the impact of the pandemic on interfacility pediatric and neonatal transport team members has not been studied. The current study uses a survey design to document the impact of the pandemic on pediatric and neonatal transport team members with a focus on staffing and resilience promotion strategies. METHODS: Data for this study came from a short cross-sectional survey distributed to members of the American Academy of Pediatrics Section on Transport Medicine. RESULTS: Sixty-six teams responded (around 45%). Forty-one respondents (62%) reported vacancies on their transport teams, with 35 (53.8%) reporting more vacancies during the pandemic. Forty percent of highly trained registered nurses and respiratory therapists from specialty teams left their positions for those with better compensation during the pandemic. Forty-two percent of respondents were not trained to recognize burnout, stress, or compassion fatigue. CONCLUSION: Our study shows that half of the respondents had more vacancies during the pandemic than in previous years and reported difficulty in filling those positions. We were unable to link the vacancies to the pandemic and burnout because hospitalizations and transports in the pediatric facilities decreased during the pandemic; however, we do report that coronavirus disease 2019 exposure before the vaccine was a source of stress for team members. There are opportunities to improve the identification of burnout and to foster resilience and boost retention of this highly skilled niche workforce.

Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion.

BACKGROUND: While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children. OBJECTIVE: Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion. MATERIALS AND METHODS: We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017. RESULTS: Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days. CONCLUSION: Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.

Paramedic rhythm interpretation misclassification is associated with poor survival from out-of-hospital cardiac arrest.

BACKGROUND: Early recognition and rapid defibrillation of shockable rhythms is strongly associated with survival in out of hospital cardiac arrest (OHCA). Little is known about the accuracy of paramedic rhythm interpretation and its impact on survival. We hypothesized that inaccurate paramedic interpretation of initial rhythm would be associated with worse survival. METHODS: This is a retrospective cohort analysis of prospectively collected OHCA data over a nine-year period within a single, urban, fire-based EMS system that utilizes manual defibrillators equipped with rhythm-filtering technology. We compared paramedic-documented initial rhythm with a reference standard of post-event physician interpretation to estimate sensitivity and specificity of paramedic identification of and shock delivery to shockable rhythms. We assessed the association between misclassification of initial rhythm and neurologically intact survival to hospital discharge using multivariable logistic regression. RESULTS: A total of 863 OHCA cases were available for analysis with 1,756 shocks delivered during 542 (63%) resuscitation attempts. Eleven percent of shocks were delivered to pulseless electrical activity (PEA). Sensitivity and specificity for paramedic initial rhythm interpretation were 176/197 (0.89, 95% CI 0.84-0.93) and 463/504 (0.92, 95% CI 0.89-0.94) respectively. No patient survived to hospital discharge when paramedics misclassified the initial rhythm. CONCLUSIONS: Paramedics achieved high sensitivity for shock delivery to shockable rhythms, but with an 11% shock delivery rate to PEA. Misclassification of initial rhythm was associated with poor survival. Technologies that assist in rhythm identification during CPR, rapid shock delivery, and minimal hands-off time may improve outcomes.

The State of Neonatal and Pediatric Interfacility Transport During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has altered the provision of health care, including interfacility transport of critically ill neonatal and pediatrics patients. Transport medicine faces unique challenges in the care of persons infected with the severe acute respiratory syndrome coronavirus 2. In particular, the multitude of providers, confined spaces for prolonged time periods, varying modes (ground, rotor wing, and fixed wing) of transport, and the need for frequent aerosol-generating procedures place transport personnel at high risk. This study describes the clinical practices, personal protective equipment, and potential exposure risks of a large cohort of neonatal and pediatric interfacility transport teams. METHODS: Data for this study came from a survey distributed to members of the American Academy of Pediatrics Section on Transport Medicine. RESULTS: Fifty-four teams responded, and 47 reported transporting COVID-19-positive patients. Among the 47 teams, 25% indicated having at least 1 team member convert to COVID-19 positive. A small percentage of teams (40% ground, 40% fixed wing, and 18% rotor wing) reported allowing parental accompaniment during transport. There was no difference in teams with a positive team member among those that do (26%) and do not (25%) allow parents. There was a higher percentage of teams with a positive team member among teams that intubate (32% vs. 0%) and place laryngeal mask airways (34% vs. 0%) during transport. CONCLUSION: Our study shows that exceptional care during interfacility transport, including a family-centered approach, can continue during the COVID-19 pandemic. Teams must take steps to protect themselves, as well as the patients and families they serve, in order to mitigate the transmission of the SARS-CoV-2 virus.

Barriers and facilitators to screening and treating malnutrition in older adults living in the community: a mixed-methods synthesis.

BACKGROUND: Malnutrition (specifically undernutrition) in older, community-dwelling adults reduces well-being and predisposes to disease. Implementation of screen-and-treat policies could help to systematically detect and treat at-risk and malnourished patients. We aimed to identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care, which barriers have been addressed and which facilitators have been successfully incorporated in existing interventions. METHOD: A data-base search was conducted using MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews from 2012 to June 2016 to identify relevant qualitative and quantitative literature from primary/community care. Studies were included if participants were older, community-dwelling adults (65+) or healthcare professionals who would screen and treat such patients. Barriers and facilitators were extracted and mapped onto intervention features to determine whether these had addressed barriers. RESULTS: Of a total of 2182 studies identified, 21 were included (6 qualitative, 12 quantitative and 3 mixed; 14 studies targeting patients and 7 targeting healthcare professionals). Facilitators addressing a wide range of barriers were identified, yet few interventions addressed psychosocial barriers to screen-and-treat policies for patients, such as loneliness and reluctance to be screened, or healthcare professionals' reservations about prescribing oral nutritional supplements. CONCLUSION: The studies reviewed identified several barriers and facilitators and addressed some of these in intervention design, although a prominent gap appeared to be psychosocial barriers. No single included study addressed all barriers or made use of all facilitators, although this appears to be possible. Interventions aiming to implement screen-and-treat approaches to malnutrition in primary care should consider barriers that both patients and healthcare professionals may face. REVIEW REGISTRATIONS: PROSPERO: CRD42017071398 . The review protocol was registered retrospectively.

The relationship between working memory and the dual-target cost in visual search guidance.

Searching for two targets produces a dual-target cost compared with single-target search, with reduced attentional guidance toward targets (Stroud, Menneer, Cave, & Donnelly, 2012). We explore the effect of holding a color in working memory (WM) on guidance in single-target search. In Experiments 1 and 2, participants searched for a T of a specific color while holding one of the following in WM: a color patch, a letter, a dot pattern, or an oriented bar. Only when holding a color in WM was guidance in single-target search affected as strongly as it is in dual-target search. In Experiment 3, the target changed color from trial to trial. A color in WM reduced guidance, but not to the extent of dual-target search. However, search and WM error rates were high, suggesting interference and incomplete engagement with the combined task. We conclude that the guidance cost in dual-target search is not solely due to attentional capture by the WM-color, because the WM-color can be effectively separated from search color, with little confusion between the two. However, WM load does cause substantial interference in guidance when both tasks involve color. These results illustrate the complex interactions between WM and attentional guidance. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

We can guide search by a set of colors, but are reluctant to do it.

For some real-world color searches, the target colors are not precisely known, and any item within a range of color values should be attended. Thus, a target representation that captures multiple similar colors would be advantageous. If such a multicolor search is possible, then search for two targets (e.g., Stroud, Menneer, Cave, and Donnelly, Journal of Experimental Psychology: Human Perception and Performance, 38(1): 113-122, 2012) might be guided by a target representation that included the target colors as well as the continuum of colors that fall between the targets within a contiguous region in color space. Results from Stroud, Menneer, Cave, and Donnelly, Journal of Experimental Psychology: Human Perception and Performance, 38(1): 113-122, (2012) suggest otherwise, however. The current set of experiments show that guidance for a set of colors that are all from a single region of color space can be reasonably effective if targets are depicted as specific discrete colors. Specifically, Experiments 1-3 demonstrate that a search can be guided by four and even eight colors given the appropriate conditions. However, Experiment 5 gives evidence that guidance is sometimes sensitive to how informative the target preview is to search. Experiments 6 and 7 show that a stimulus showing a continuous range of target colors is not translated into a search target representation. Thus, search can be guided by multiple discrete colors that are from a single region in color space, but this approach was not adopted in a search for two targets with intervening distractor colors.

Antarctica eye study: a prospective study of the effects of overwintering on ocular parameters and visual function.

BACKGROUND: In 2013 five polar explorers attempted to complete the first Trans-Antarctic Winter Traverse (TAWT). This study presents the ophthalmological findings for this group, who overwintered in Antarctica as part of the White Mars Human Science Protocol. Antarctic crews are exposed to extreme cold, chronic hypoxia and altered day-night cycles. Previous studies of Antarctic explorers have focused on the prolonged effect of ultraviolet radiation including the development of ultraviolet keratitis and accelerated cataract formation. This is the first study of its kind to investigate the effect of overwintering in Antarctica on the human eye. METHODS: Pre and post-expedition clinical observations were made including visual acuity, contrast sensitivity, colour vision, auto-refraction, subjective refraction, retinal examination, retinal autofluoresence and retinal thickness, which were graded for comparison. During the expedition additional observations were made on a monthly basis including LogMAR visual acuity, autorefraction and intraocular pressure. RESULTS: No significant differences between pre and post-expedition observations were found, including visual acuity, contrast sensitivity, colour vision, refraction, visual fields, intraocular pressure and retinal examination. There was a small but statistically significant decrease in retinal thickness across all regions of the retina, except for the macular and fovea, in all explorers. Intra-expedition observations remained within normal limits. CONCLUSION: Reassuringly, the human eye remains largely unchanged by exposure to the extreme conditions encountered during the Antarctic winter, however, further research is needed to investigate changes in retinal thickness. This may have implications for scientists who spend prolonged periods of time in the polar regions, as well as those who have prolonged exposure to the extreme cold or chronic hypoxia in other settings.

Dual Target Search is Neither Purely Simultaneous nor Purely Successive.

Previous research shows that visual search for two different targets is less efficient than search for a single target. Stroud, Menneer, Cave and Donnelly (2012) concluded that two target colours are represented separately based on modeling the fixation patterns. Although those analyses provide evidence for two separate target representations, they do not show whether participants search simultaneously for both targets, or first search for one target and then the other. Some studies suggest that multiple target representations are simultaneously active, while others indicate that search can be voluntarily simultaneous, or switching, or a mixture of both. Stroud et al.'s participants were not explicitly instructed to use any particular strategy. These data were revisited to determine which strategy was employed. Each fixated item was categorised according to whether its colour was more similar to one target or the other. Once an item similar to one target is fixated, the next fixated item is more likely to be similar to that target than the other, showing that at a given moment during search, one target is generally favoured. However, the search for one target is not completed before search for the other begins. Instead, there are often short runs of one or two fixations to distractors similar to one target, with each run followed by a switch to the other target. Thus, the results suggest that one target is more highly weighted than the other at any given time, but not to the extent that search is purely successive.

Does hypoxia play a role in the development of sarcopenia in humans? Mechanistic insights from the Caudwell Xtreme Everest Expedition.

OBJECTIVES: Sarcopenia refers to the involuntary loss of skeletal muscle and is a predictor of physical disability/mortality. Its pathogenesis is poorly understood, although roles for altered hypoxic signaling, oxidative stress, adipokines and inflammatory mediators have been suggested. Sarcopenia also occurs upon exposure to the hypoxia of high altitude. Using data from the Caudwell Xtreme Everest expedition we therefore sought to analyze the extent of hypoxia-induced body composition changes and identify putative pathways associated with fat-free mass (FFM) and fat mass (FM) loss. METHODS: After baseline testing in London (75m), 24 investigators ascended from Kathmandu (1300m) to Everest base camp (EBC 5300m) over 13 days. Fourteen investigators climbed above EBC, eight of whom reached the summit (8848m). Assessments were conducted at baseline, during ascent and after one, six and eight week(s) of arrival at EBC. Changes in body composition (FM, FFM, total body water, intra- and extra-cellular water) were measured by bioelectrical impedance. Biomarkers of nitric oxide and oxidative stress were measured together with adipokines, inflammatory, metabolic and vascular markers. RESULTS: Participants lost a substantial, but variable, amount of body weight (7.3±4.9kg by expedition end; p<0.001). A progressive loss of both FM and FFM was observed, and after eight weeks, the proportion of FFM loss was 48% greater than FM loss (p<0.008). Changes in protein carbonyls (p<0.001) were associated with a decline in FM whereas 4-hydroxynonenal (p<0.001) and IL-6 (p<0.001) correlated with FFM loss. GLP-1 (r=-0.45, p<0.001) and nitrite (r=-0.29, p<0.001) concentration changes were associated with FFM loss. In a multivariate model, GLP-1, insulin and nitrite were significant predictors of FFM loss while protein carbonyls were predicted FM loss. CONCLUSIONS: The putative role of GLP-1 and nitrite as mediators of the effects of hypoxia on FFM is an intriguing finding. If confirmed, nutritional and pharmacological interventions targeting these pathways may offer new avenues for prevention and treatment of sarcopenia.

Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport.

OBJECTIVES: Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport. METHODS: Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL. RESULTS: Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL. CONCLUSIONS: The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.

Casual Video Games as Training Tools for Attentional Processes in Everyday Life.

Three experiments examined the attentional components of the popular match-3 casual video game, Bejeweled Blitz (BJB). Attentionally demanding, BJB is highly popular among adults, particularly those in middle and later adulthood. In experiment 1, 54 older adults (Mage = 70.57) and 33 younger adults (Mage = 19.82) played 20 rounds of BJB, and completed online tasks measuring reaction time, simple visual search, and conjunction visual search. Prior experience significantly predicted BJB scores for younger adults, but for older adults, both prior experience and simple visual search task scores predicted BJB performance. Experiment 2 tested whether BJB practice alone would result in a carryover benefit to a visual search task in a sample of 58 young adults (Mage = 19.57) who completed 0, 10, or 30 rounds of BJB followed by a BJB-like visual search task with targets present or absent. Reaction times were significantly faster for participants who completed 30 but not 10 rounds of BJB compared with the search task only. This benefit was evident when targets were both present and absent, suggesting that playing BJB improves not only target detection, but also the ability to quit search effectively. Experiment 3 tested whether the attentional benefit in experiment 2 would apply to non-BJB stimuli. The results revealed a similar numerical but not significant trend. Taken together, the findings suggest there are benefits of casual video game playing to attention and relevant everyday skills, and that these games may have potential value as training tools.

Goal-Directed Resuscitative Interventions During Pediatric Interfacility Transport.

OBJECTIVES: This article reports results of the first National Institutes of Health-funded prospective interfacility transport study to determine the effect of goal-directed therapy administered by a specialized pediatric team to critically ill children with the systemic inflammatory response syndrome. We hypothesized that goal-directed therapy during interfacility transport would decrease hospital length of stay, prevent multiple organ dysfunction, and reduce subsequent ICU interventions. DESIGN: Before-and-after intervention trial. SETTING: During interfacility transport of critically ill patients by a specialized pediatric transport team, back to a tertiary care children's hospital. PATIENTS: Before-and-after intervention trial. DESIGN: Interfacility pediatric transport patients, age 1 month to 17 years, with systemic inflammatory response syndrome. INTERVENTIONS: Prospective data were collected on all pediatric interfacility transport patients with systemic inflammatory response syndrome transported by the Angel One Transport team at Arkansas Children's Hospital. A 10-month data collection period was followed by institution of a goal-directed resuscitation protocol. Data were subsequently collected for 10 additional months followed by comparison of pre- and postintervention groups. All transport personnel underwent training with didactics and high-fidelity simulation until mastery with goal-directed resuscitation was achieved. MEASUREMENTS AND MAIN RESULTS: All transport patients were screened for systemic inflammatory response syndrome using established variables and 235 (123 preintervention and 112 postintervention) were enrolled. Univariate analysis revealed shorter hospital stay (11 ± 15 d vs 7 ± 10 d; p = 0.02) and fewer required therapeutic ICU interventions in the postintervention group (Therapeutic Intervention Scoring System-28 Scores, 19.4 ± 6.8 vs 17.3 ± 6.6; p = 0.04). ICU stay and prevalence of organ dysfunction were not statistically different. Multivariable analysis showed a 1.6-day (95% CI, 1.3-2.03; p = 0.02) decrease in hospital stay in the postintervention group. CONCLUSIONS: This study suggests that goal-directed therapy administered by a specialized pediatric transport team has the potential to impact the outcomes of critically ill children. Findings from this study should be confirmed across multiple institutions, but have the potential to impact the clinical outcomes of critically ill children with systemic inflammatory response syndrome.

Discrepancies between autopsy and clinical findings among patients requiring extracorporeal membrane oxygenator support.

Discrepancy between clinical and autopsy diagnosis in children supported on extracorporeal membrane oxygenation (ECMO) has not been previously described. To assess the utility of autopsy examination in children supported on ECMO and assess discrepancies between premortem and postmortem diagnosis in these patients. Retrospective chart review. General pediatric and cardiac intensive care units (ICUs) in a tertiary children's hospital. The hospital's ECMO database was queried for patients supported on ECMO from 2000 through 2010 who died and underwent autopsy examination. Fifty-four autopsies were performed in 139 nonsurvivors (28%) who required ECMO support in the pediatric and cardiac ICU. Major discrepancies between premortem and postmortem diagnoses were found in 29 patients (53.7%). The commonest missed diagnosis was myocardial infarction that occurred in 16 patients, followed by adrenal hemorrhage in three patients. Five patients with a cardiac diagnosis had both major (type 1 discrepancy) and minor (type 2 discrepancy) discrepancies. Surgical complications were noted in four postmortem study with three of them being class 1 discrepancy. We report significant discrepancy between autopsy and clinical findings among ECMO-supported pediatric patients. Our findings underscore the need for enhanced premorbid surveillance in patients supported on ECMO.

Extracorporeal membrane oxygenation support among children with adenovirus infection: a review of the Extracorporeal Life Support Organization registry.

Overwhelming adenovirus infection requiring extracorporeal membrane oxygenation (ECMO) support carries a high mortality in pediatric patients. The objective of this study was to retrospectively review data from the Extracorporeal Life Support Organization (ELSO) registry for pediatric patients with adenovirus infection and define for this patient cohort: 1) clinical characteristics, 2) survival to hospital discharge, and 3) factors associated with mortality before hospital discharge. In this retrospective registry study, pediatric patients with adenovirus infection requiring ECMO support identified in an international ECMO registry from 1998 to 2009 were compared for clinical characteristics (demographics, pre-ECMO variables, and complications on ECMO) between survivors and nonsurvivors to hospital discharge. Descriptive statistics and univariate and multivariate logistic analysis were used to compare clinical characteristics among survivors and nonsurvivors. For children requiring ECMO support for adenovirus, the survival at hospital discharge is 38% (62/163). Among neonates (<31 days of age), the survival at hospital discharge was only 11% (6/54). Among patient factors, neonatal age (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.62-10.87), a decrease of 0.1 unit in pre-ECMO pH (OR, 1.77; 95% CI, 1.3-2.42), the presence of sepsis (OR, 4.55; 95% CI, 1.47-14.15), and increased peak inspiratory pressures (OR, 1.04; 95% CI, 1.01-1.08) were all independently associated with in-hospital mortality. ECMO complications independently associated with in-hospital mortality were presence of pneumothorax (OR, 3.57; 95% CI, 1.19-10.7), pH less than 7.2 (OR, 5.94; 95% CI, 1.04-34.1), and central nervous system hemorrhage (OR, 25.36; 95% CI, 1.47-436.7). In this retrospective cohort study of pediatric patients with adenovirus infection supported on ECMO, survival to hospital discharge was 38% but was much lower in neonates. Neonatal presentation, degree of acidosis, sepsis, and increased PIP are factors present before decisions are made regarding a trial of ECMO, whereas pneumothorax and brain hemorrhage were ECMO-related complications independently associated with mortality.

Prolonged extracorporeal membrane oxygenator support among neonates with acute respiratory failure: a review of the Extracorporeal Life Support Organization registry.

The objective of this study was to identify types of neonatal diseases associated with prolonged (≥21 days) extracorporeal membrane oxygenation (ECMO), characteristics of survivors and nonsurvivors among those requiring prolonged ECMO, and factors associated with mortality. Data were obtained from the Extracorporeal Life Support Organization registry over the period from January 1, 1998, through December 31, 2011, for all neonates (age <31 days), with respiratory failure as the indication for ECMO. The primary outcome was survival to hospital discharge. Survivors and nonsurvivors were compared for 1) patient demographics, 2) primary diagnosis, 3) pre-ECMO clinical course and therapies, and 4) ECMO course and associated complications. The most common diagnosis associated with prolonged ECMO support in neonates is congenital diaphragmatic hernia (CDH; 69%). Infants with meconium aspiration syndrome had the highest survival rate (71%) compared with other diagnoses analyzed (26.3%; p < 0.001). Nonsurvivors were more likely to experience complications on ECMO, and multivariate analysis showed that the need for inotropes while on ECMO support (odds ratio, 2.2 [95% confidence interval, 1.3-3.7]; p = 0.003) was independently associated with mortality. Neonates requiring prolonged ECMO support have a 24% survival to discharge. Many of these cases involve CDH. Complications are common with prolonged ECMO, but only receipt of inotropes was shown to be independently associated with mortality. This report may help guide clinical decision making and family counseling for neonates requiring prolonged ECMO support.

Pediatric and neonatal interfacility transport: results from a national consensus conference.

The practice of pediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile ICUs capable of delivering state-of-the-art critical care during pediatric and neonatal transport. The most recent document regarding the practice of pediatric/neonatal transport is more than a decade old. The following article details changes in the practice of interfacility transport over the past decade and expresses the consensus views of leaders in the field of transport medicine, including the American Academy of Pediatrics' Section on Transport Medicine.

Introduction of a rounding sticker improves care and reduces infection rates in the Pediatric Intensive Care Unit (PICU).

As part of our plan to decrease infection rates, we instituted a rounding sticker used during daily rounds. This sticker is a checklist that serves as a reminder of interventions known to improve quality of care in the PICU. It is completed daily and placed in the bedside chart of all patients in the Pediatric Intensive Care Unit (PICU) at Arkansas Children's Hospital. Date was collected on central venous catheter days, foley catheter days, arterial line days, infection rates, GI prophylaxis use, neuromuscular blocker use, and changes in medications before and after institution of the rounding sticker. Following rounding sticker use, there was a 56% reduction in urinary tract infections [4.13/1000 device days vs 1.8/1000 device days; p = 0.027], as well as an increase in GI prophylaxis (1846 vs 2399) and enoxaparin (119 vs 151) use.