A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19.

BACKGROUND: Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES: To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19. METHODS: A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values. RESULTS: At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked. CONCLUSIONS: Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.

The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation.

BACKGROUND: Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI. METHODS: This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct. RESULTS: Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm). CONCLUSIONS: Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.

Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success.

BACKGROUND: Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. METHODS: This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. RESULTS: Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). CONCLUSIONS: In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.

Worse Hospital Outcomes for Children and Adults with COVID-19 and Congenital Heart Disease.

The aim of the current study is to investigate hospitalization outcomes of COVID-19 positive children and adults with moderate or severe congenital heart disease to children and adults without congenital heart disease. Retrospective review using the Vizient Clinical Data Base for admissions of patients with an ICD-10 code for COVID-19 from April 2020 to March 2021. Admissions with COVID-19 and with and without moderate or severe congenital heart disease (CHD) were stratified into pediatric (< 18 years) and adult (≥ 18 years) and hospital outcomes were compared. There were 9478 pediatric COVID-19 admissions, 160 (1.7%) with CHD, and 658,230 adult COVID-19 admissions, 389 (0.06%) with CHD. Pediatric admissions with COVID-19 and CHD were younger (1 vs 11 years), had longer length of stay (22 vs 6 days), higher complication rates (6.9 vs 1.1%), higher mortality rates (3.8, 0.8%), and higher costs ($54,619 vs 10,731; p < 0.001 for all). Adult admissions with COVID-19 and CHD were younger (53 vs 64 years, p < 0.001), had longer length of stay (12 vs 9 days, p < 0.001), higher complication rates (8 vs 4.8%, p = 0.003), and higher costs ($23,551 vs 13,311, p < 0.001). This appears to be the first study to report the increased hospital morbidities and costs for patients with CHD affected by COVID-19. Our hope is that these findings will help counsel patients moving forward during the pandemic.

Coronary artery spasm in a 15-year-old male in diabetic ketoacidosis.

Coronary artery disease and myocardial infarction are known complications of long-standing diabetes mellitus in adults, but coronary artery spasm is far more rare and has not been reported in children. We present a 15-year-old male in diabetic ketoacidosis who developed diffuse ST segment elevations and elevated troponin with normal coronary arteries on coronary angiography and no signs of pericarditis that was due to coronary artery spasm.

Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period.

OBJECTIVE: There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED. METHODS: This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age. RESULTS: During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]). CONCLUSIONS: In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.

Pediatric Ventilator Management in the Emergency Department.

Pediatric mechanical ventilation is first initiated by emergency physicians when performing active airway management in a critically ill or injured child. When initiating and adjusting mechanical ventilation, the child has unique anatomy and physiology to consider. The EP is the first to respond to ventilator alarm triggers, and the initial medical provider to resuscitate the ventilated pediatric patient who is deteriorating while in the emergency department. This article uses cases to provide a framework to initiate and troubleshoot mechanical ventilation of pediatric patients in the emergency department.

Emergency Department Management of Pediatric Shock.

Shock, a state of inadequate oxygen delivery to tissues resulting in anaerobic metabolism, lactate accumulation, and end-organ dysfunction, is common in children in emergency department. Shock can be divided into 4 categories: hypovolemic, distributive, cardiogenic, and obstructive. Early recognition of shock can be made with close attention to historical clues, physical examination and vital sign abnormalities. Early and aggressive treatment can prevent or reverse organ dysfunction and improve morbidity and mortality.

Paediatric chest wall trauma causing delayed presentation of ventricular arrhythmia.

This report describes a paediatric patient presenting with haemodynamically stable non-sustained ventricular tachycardia 1 day after minor blunt chest trauma. Initial laboratory studies, chest X-ray and echocardiography were normal; however, cardiac MRI revealed precordial haematoma, myocardial contusion and small pericardial effusion. Throughout her hospital course, she remained asymptomatic aside from frequent couplets and triplets of premature ventricular contractions. Ectopy was controlled with oral verapamil. This case highlights how significant cardiac injury may be missed with standard diagnostic algorithms.

Targeted Temperature Management in Pediatric Central Nervous System Disease.

Acute central nervous system conditions due to hypoxic-ischemic encephalopathy, traumatic brain injury (TBI), status epilepticus, and central nervous system infection/inflammation, are a leading cause of death and disability in childhood. There is a critical need for effective neuroprotective therapies to improve outcome targeting distinct disease pathology. Fever, defined as patient temperature > 38°C, has been clearly shown to exacerbate brain injury. Therapeutic hypothermia (HT) is an intervention using targeted temperature management that has multiple mechanisms of action and robust evidence of efficacy in multiple experimental models of brain injury. Prospective clinical evidence for its neuroprotective efficacy exists in narrowly-defined populations with hypoxic-ischemic injury outside of the pediatric age range while trials comparing hypothermia to normothermia after TBI have failed to demonstrate a benefit on outcome but consistently demonstrate potential use in decreasing refractory intracranial pressure. Data in children from prospective, randomized controlled trials using different strategies of targeted temperature management for various outcomes are few but a large study examining HT versus controlled normothermia to improve neurological outcome in cardiac arrest is underway.

Expression of mTOR signaling pathway markers in prostate cancer progression.

BACKGROUND: The PI3K/AKT/mTOR pathway is central to prostate cancer progression. A preliminary investigation of immuno-histochemical expression of mammalian target of rapamycin (mTOR) pathway markers was undertaken to identify patterns of expression in prostate tissue. METHODS: Immunohistochemistry was performed on a custom-made prostate tissue array. Mean long scores and variability of long scores for each marker were recorded for normal lumenal cells, prostate intraepithelial neoplasia (PIN), and cancer. RESULTS: Expression of PTEN decreased and mTOR signaling pathway markers increased in PIN and in cancer as compared to normal cells in the majority of samples. Overexpression of 4E-BP1 and p-4E-BP1 was observed in PIN and cancer. However, in cancer, the overexpression of 4E-BP1 was significantly higher than with any other marker. DISCUSSION: Results suggest that 4E-BP1 overexpression is strongly associated with prostate cancer, especially when combined with PTEN and mTOR expression data. Hierarchical clustering analysis utilizing PTEN, mTOR, and 4E-BP1 separated normal from cancer cell populations in most cases.

Cómo mejorar la calidad del servicio en las instituciones de cuidados prolongados a las personas de edad

An investigation into the quality of service in nine Israel institutions for the long-term care of the elderly revealed many shortcomings. Two government ministries have adopted an experimental programme to upgrade the quality of care by improving the regulatory system. Instruments have been prepared and tested, supervisors and institutional staff have been trained, and baseline data have been gathered for use in programme evaluation. Advances have been made in the enforcement of regulations and in the identification of deficiencies. Both government supervisors and institutional administrators have welcomed the opportunity to participate in the programme and to contribute to the betterment of life in old-age homes