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.

Cell-Free Plasma Hemoglobin and Male Gender Are Risk Factors for Acute Kidney Injury in Low Risk Children Undergoing Cardiopulmonary Bypass.

OBJECTIVES: To determine the relationship between the production of cell-free plasma hemoglobin and acute kidney injury in infants and children undergoing cardiopulmonary bypass for cardiac surgery. DESIGN: Prospective observational study. SETTING: Twelve-bed cardiac ICU in a university-affiliated children's hospital. PATIENTS: Children were prospectively enrolled during their preoperative outpatient appointment with the following criteria: greater than 1 month to less than 18 years old, procedures requiring cardiopulmonary bypass, no preexisting renal dysfunction. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Plasma and urine were collected at baseline (in a subset), the beginning and end of cardiopulmonary bypass, and 2 hours and 24 hours after cardiopulmonary bypass in 60 subjects. Levels of plasma hemoglobin increased during cardiopulmonary bypass and were associated (p < 0.01) with cardiopulmonary bypass duration (R = 0.22), depletion of haptoglobin at end and 24 hours after cardiopulmonary bypass (R = 0.12 and 0.15, respectively), lactate dehydrogenase levels at end cardiopulmonary bypass (R = 0.27), and change in creatinine (R = 0.12). Forty-three percent of patients developed acute kidney injury. There was an association between plasma hemoglobin level and change in creatinine that varied by age (overall [R = 0.12; p < 0.01]; in age > 2 yr [R = 0.22; p < 0.01]; and in < 2 yr [R = 0.03; p = 0.42]). Change in plasma hemoglobin and male gender were found to be risk factors for acute kidney injury (odds ratio, 1.02 and 3.78, respectively; p < 0.05). CONCLUSIONS: Generation of plasma hemoglobin during cardiopulmonary bypass and male gender are associated with subsequent renal dysfunction in low-risk pediatric patients, especially in those older than 2 years. Further studies are needed to determine whether specific subgroups of pediatric patients undergoing cardiopulmonary bypass would benefit from potential treatments for hemolysis and plasma hemoglobin-associated renal dysfunction.

Clinician Attitudes Toward Adoption of Pediatric Emergency Telemedicine in Rural Hospitals.

OBJECTIVE: Although there is growing evidence regarding the utility of telemedicine in providing care for acutely ill children in underserved settings, adoption of pediatric emergency telemedicine remains limited, and little data exist to inform implementation efforts. Among clinician stakeholders, we examined attitudes regarding pediatric emergency telemedicine, including barriers to adoption in rural settings and potential strategies to overcome these barriers. METHODS: Using a sequential mixed-methods approach, we first performed semistructured interviews with clinician stakeholders using thematic content analysis to generate a conceptual model for pediatric emergency telemedicine adoption. Based on this model, we then developed and fielded a survey to further examine attitudes regarding barriers to adoption and strategies to improve adoption. RESULTS: Factors influencing adoption of pediatric emergency telemedicine were identified and categorized into 3 domains: contextual factors (such as regional geography, hospital culture, and individual experience), perceived usefulness of pediatric emergency telemedicine, and perceived ease of use of pediatric emergency telemedicine. Within the domains of perceived usefulness and perceived ease of use, belief in the relative advantage of telemedicine was the most pronounced difference between telemedicine proponents and nonproponents. Strategies identified to improve adoption of telemedicine included patient-specific education, clinical protocols for use, decreasing response times, and simplifying the technology. CONCLUSIONS: More effective adoption of pediatric emergency telemedicine among clinicians will require addressing perceived usefulness and perceived ease of use in the context of local factors. Future studies should examine the impact of specific identified strategies on adoption of pediatric emergency telemedicine and patient outcomes in rural settings.

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.

Neurological sequelae of 2009 influenza A (H1N1) in children: a case series observed during a pandemic.

OBJECTIVE: To outline a series of cases demonstrating neurologic complications in children with Influenza infection. The ongoing 2009 influenza A (H1N1) presents significant challenges to the field of pediatric critical care and requires increased awareness of new presentations and sequelae of infection. Since World Health Organization declared a H1N1 pandemic, much attention has been focused on its respiratory manifestations of the illness, but limited information regarding neurologic complications has been reported. DESIGN: Case series. SETTING: Pediatric intensive care unit of a tertiary care medical facility. PATIENTS: Four children admitted to the pediatric intensive care unit between March and November 2009 at the Children's Hospital of Pittsburgh with altered mental status and influenza infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The clinical course was extracted by chart review and is summarized. All children demonstrated a coryzal prodrome, fever, and altered level of consciousness at admission, and one child presented with clinical seizures. Diagnostic studies performed to establish a diagnosis are summarized. All children had abnormal electroencephalograms early in their intensive care unit course and 50% had abnormal imaging studies. All children survived but 50% had neurologic deficits at hospital discharge. CONCLUSION: We conclude that 2009 influenza A (H1N1) can cause significant acute and residual neurologic sequelae. Clinicians should consider Influenza within a comprehensive differential diagnosis in children with unexplained mental status changes during periods of pandemic influenza.

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.

Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.