Factors Associated With Post-Extubation Stridor in Infants Intubated in the Pediatric ICU.

BACKGROUND: Post-extubation stridor (PES) is a common problem in the pediatric intensive care unit (PICU) and is associated with extubation failure, longer length of stay, and increased mortality. Infants represent a large proportion of PICU admissions and are at higher risk for PES, making identification and mitigation of factors associated with PES important in this age group. RESEARCH QUESTION: What factors are associated with PES in infants (age less than 1 year) intubated in the PICU? STUDY DESIGN & METHODS: The primary outcome was PES as defined by the need for racemic epinephrine within 6 h of extubation. Secondary outcomes were heliox administration and reintubation. Statistical analyses were performed with Fisher's exact test for univariate analyses and multivariate logistic regression. RESULTS: 518 patient charts were retrospectively reviewed. 24.1% of patients developed PES. Duration of mechanical ventilation greater than 48 h was associated with increased risk of PES (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.13-2.71, P = .01), as was nonelective intubation (OR = 2.92, 95% CI 1.91-4.46, P < .01). The presence of a cuff, gastroesophageal reflux disease, prematurity, and known upper airway abnormality had no association with PES. 4.0 endotracheal tubes (ETTs) had an increased association with PES compared to 3.5 ETTs (OR = 1.96, 95% CI 1.18-3.27, P < .01). There was no difference in risk of PES between 3.5 and 3.0 ETTs. INTERPRETATION: In infants intubated in the PICU, mechanical ventilation greater than 48 h and nonelective intubation were associated with PES. 4.0 ETTs were associated with higher risk of PES compared to 3.5 ETTs. These findings may help providers in ETT selection and to identify infants that may be at increased risk of PES.

Who Speaks First? Promoting Senior Resident Autonomy on Family-Centered Rounds: A QI Initiative.

BACKGROUND AND OBJECTIVES: Graduated autonomy is fundamental as trainees transition to independent practice. Family-centered rounds (FCR), the leading model of inpatient rounding in pediatrics, is an opportunity for trainees to demonstrate their competence in leading a health care team, which is an entrustable professional activity for all pediatric residents. At our institution, senior residents (SRs) at baseline performed at a novice level on the basis of the Senior Resident Empowerment Actions 21 (SREA-21), a validated tool that is used to assess SR autonomy during FCR. Our objective for this study was to increase the median percentage of SREA-21 domains in which SRs perform at a competent level from 38% to 75% within 6 months. METHODS: Researchers observed 4 FCR encounters weekly and calculated SREA-21 scores after 2 weeks on the basis of actions promoting SR autonomy performed by the SR-hospitalist dyad. The primary outcome measure was the percentage of SREA-21 domains in which the SR achieved a competent score on the SREA-21. We used the model for improvement to identify key drivers and test proposed interventions using serial plan-do-study-act cycles. Interventions included creation of unified inpatient SR expectations, introduction of a SR-hospitalist pre-FCR huddle, auditing of FCR interruptions, and direct feedback to the SR-hospitalist dyad after FCR. Run charts were used to track SR and hospitalist scores on the SREA-21. RESULTS: After multiple plan-do-study-act cycles, there was special cause improvement with a desirable shift upward in the centerline to 100%, which correlated with the project's interventions and surpassed our goal. CONCLUSIONS: Using quality improvement methodology, we improved SR autonomy during FCR, as measured by the SREA-21.

Hyperosmolality, High Blood Pressure, and Decreased Estimated Glomerular Filtration Rate in US Adolescents, National Health and Nutrition Examination Survey 1999-2012.

BACKGROUND: Experimental evidence suggests that hyperosmolality may be a causative factor in the development of both salt-sensitive hypertension and chronic kidney disease (CKD). There are no population-wide studies in young persons to assess the relationships among these factors. OBJECTIVE: To determine the association of serum osmolality and serum sodium with high systolic blood pressure (SBP) and decreased estimated glomerular filtration rate (eGFR) among a nationally representative population of adolescents. METHOD: Relevant data among participants ages 12-14 were obtained from the National Health and Nutrition Examination Survey cycles 1999-2012. Serum osmolality was calculated using the Worthley equation. eGFR was calculated using the Counahan-Barratt equation, and values < 90 mL/min/1.73 m2 were considered decreased. High SBP was defined as SBP ≥95th percentile for age, height, and sex. RESULTS: A total of 4,168 adolescents were analyzed (representative population: 10,464,592). Adolescents with serum osmolality ≥290 mOsm/kg and/or serum sodium ≥143 mmol/L had increased odds for both high SBP (serum osmolality ≥290 mOsm/kg: OR 2.04; 95% CI 1.03-4.02; sodium ≥143 mmol/L: OR 4.36; 95% CI 1.58-12.04) and decreased eGFR (serum osmolality ≥290 mOsm/kg: OR 1.61; 95% CI 1.18-2.21; sodium ≥143 mmol/L: OR 3.27; 95% CI 1.77-6.03) when compared to participants with values below these thresholds. These thresholds remained significant even after multivariable adjustment. CONCLUSION: Among adolescents in a nationally representative survey, hypernatremia and hyperosmolality were associated with high SBP and decreased eGFR. These findings may support the hypothesis that an imbalance of salt and water contribute to hypertension and CKD.

Caffeine exposure and acute kidney injury in premature infants with necrotizing enterocolitis and spontaneous intestinal perforation.

BACKGROUND: Acute kidney injury (AKI) is common in preterm infants, but specific therapies remain scarce. Recent studies have demonstrated an association between caffeine exposure and less frequent AKI in the first 7-10 days after birth. We hypothesized that patients with necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) would provide a better natural model of AKI to evaluate this association. METHODS: We reviewed all premature patients diagnosed with NEC or SIP at our institution from 2008 to 2014. AKI was defined by change in serum creatinine using the neonatal Kidney Disease: Improving Global Outcomes definition. Caffeine was prescribed for apnea of prematurity and caffeine exposure was determined by chart review. RESULTS: A total of 146 patients with NEC/SIP were reviewed. Of these, 119 (81.5%) received caffeine, and 91 (62.3%) developed AKI. AKI occurred less frequently in patients who received caffeine than in those who did not (55.5% vs. 92.6%; odds ratio (OR) 0.10; 95% confidence interval (CI) 0.02-0.44). This association persisted in multivariable models after adjustment for potential confounders (adjusted OR 0.08; 95% CI 0.01-0.42; number needed to be exposed to caffeine to prevent one case of AKI = 2.6). Although baseline serum creatinine did not differ by caffeine exposure, patients receiving caffeine had lower peak creatinine (median 1.0 mg/dl vs. 1.5 mg/dl; p = 0.008) and absolute creatinine change (median 0.42 mg/dl vs. 0.68 mg/dl; p = 0.003) than those who did not. CONCLUSIONS: Caffeine exposure in preterm infants with NEC/SIP is associated with decreased incidence and severity of AKI.

Prevalence of chronic kidney disease risk factors among low birth weight adolescents.

BACKGROUND: By adulthood, low birth weight infants have an increased risk for chronic kidney disease (CKD). The extent to which objective CKD risk factors are present at earlier ages is unclear. METHODS: We analyzed 5352 participants aged 12-15 years in the National Health and Nutrition Examination Survey, 1999-2012. Participants were classified as low birth weight (LBW; < 2500 g), very low birth weight (VLBW; < 1500 g), or normal (2500-4000 g) by parental/proxy recall. Albuminuria (albumin/creatinine 30 - <300 mg/g), decreased estimated glomerular filtration rate (eGFR; < 90 ml/min/1.73 m(2); Counahan-Barratt), and elevated systolic blood pressure (BP; ≥ 95th percentile for age, height, and sex) were considered CKD risk factors. RESULTS: While albuminuria did not vary by birth weight, elevated blood pressure (BP) and decreased eGFR occurred more frequently in LBW/VLBW adolescents (elevated BP: LBW 6.0 %, VLBW 11.2 %, normal 2.4 %; decreased eGFR: LBW 23.2 %, VLBW 32.5 %, normal 16.1 %). After multivariable adjustment, LBW/VLBW adolescents had greater odds for both elevated BP (LBW: OR 2.90, 95 % CI 1.48-5.71; VLBW: 5.23; 1.11-24.74) and decreased eGFR (LBW: 1.49, 95 % CI 1.06-2.10; VLBW 2.49, 95 % CI 1.20-5.18). CONCLUSIONS: In the U.S. population, both decreased eGFR and elevated systolic BP occur frequently among adolescents with history of LBW/VLBW.