Diffuse alveolar hemorrhage after hematopoietic cell transplantation- response to treatments and risk factors for mortality.

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.

Transport Medical Control Education for Pediatric Critical Care Fellows: A National Needs Assessment Study.

OBJECTIVES: Characterize transport medical control education in Pediatric Critical Care Medicine fellowship. DESIGN: Cross-sectional survey study. SETTING: Pediatric Critical Care Medicine fellowship programs in the United States. SUBJECTS: Pediatric Critical Care Medicine fellowship program directors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We achieved a 74% (53/72) response rate. A majority of programs (85%) require fellows to serve as transport medical control, usually while carrying out other clinical responsibilities and sometimes without supervision. Fellows at most programs (80%) also accompany the transport team on patient retrievals. Most respondents (72%) reported formalized transport medical control teaching, primarily in a didactic format (76%). Few programs (25%) use a standardized assessment tool. Transport medical control was identified as requiring all six Accreditation Council for Graduate Medical Education competencies, with emphasis on professionalism and interpersonal and communication skills. CONCLUSIONS: Transport medical control responsibilities are common for Pediatric Critical Care Medicine fellows, but training is inconsistent, assessment is not standardized, and supervision may be lacking. Fellow performance in transport medical control may help inform assessment in multiple domains of competencies. Further study is needed to identify effective methods for transport medical control education.

A Survey Assessing Pediatric Transport Team Composition and Training.

OBJECTIVE: The aim of this study was to assess national pediatric/neonatal specialty transport teams' composition and training requirements to determine if any current standardization exists. METHODS: This was a survey of the transport teams listed with the American Academy of Pediatrics via SurveyMonkey. RESULTS: While most of the teams maintain internal criteria for team competency and training, there is large variation across team compositions. The vast majority of the teams have a nurse-led team with the addition of another nurse, medic, and/or respiratory therapist regardless of mode of transport. Many of the teams report adjusting team composition based on acuity. Fewer than 15% of teams have a physician as a standard team member. More than 80% required a minimum number of supervised intubations prior to independent practice; however, the number varied largely from as little as 3 to as many as 30. Eighty-eight percent of the teams report using simulation as part of their education program, but again there were marked differences between teams as to how it was used. CONCLUSIONS: There is tremendous variability nationally among pediatric/neonatal transport teams regarding training requirements, certifications, and team composition. The lack of standardization regarding team member qualifications or maintenance of competency among specialized transport teams should be looked at more closely, and evidence-based guidelines may help lead to further improved outcomes in the care of critically ill pediatric patients in the prehospital setting.

Assessing Competence in Central Venous Catheter Placement by Pediatric Critical Care Fellows: A National Survey Study.

OBJECTIVES: To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required. DESIGN: Cross-sectional internet-based survey with deliberate sampling. SETTING: United States pediatric critical care medicine fellowship programs. SUBJECTS: Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important. CONCLUSIONS: Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors' abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.

Simulation-Based Palliative Care Communication for Pediatric Critical Care Fellows.

BACKGROUND: Pediatric palliative care (PPC) education is lacking in pediatric critical care medicine (PCCM) fellowships, despite the desire of many program directors and fellows to expand difficult conversation training. Simulation-based training is an experiential method for practicing challenging communication skills such as breaking bad news, disclosing medical errors, navigating goals of care, and supporting medical decision-making. METHODS: We describe a simulation-based PPC communication series for PCCM fellows, including presimulation session, simulation session, debriefing, and evaluation methods. From 2011 to 2017, 28 PCCM fellows participated in a biannual half-day simulation session. Each session included 3 scenarios (allowing for participation in up to 18 scenarios over 3 years). Standardized patients portrayed the child's mother. PCCM and interprofessional PPC faculty cofacilitated, evaluated, and debriefed the fellows after each scenario. Fellows were evaluated in 4 communication categories (general skills, breaking bad news, goals of care, and resuscitation) using a 3-point scale. A retrospective descriptive analysis was conducted. RESULTS: One hundred sixteen evaluations were completed for 18 PCCM fellows. Median scores for general communication items, breaking bad news, and goals of care ranged from 2.0 to 3.0 (interquartile range [IQR]: 0-1) with scores for resuscitation lower at 1.0 (IQR: 1.5-2). DISCUSSION: This experiential simulation-based PPC communication curriculum taught PCCM fellows valuable palliative communication techniques although revealed growth opportunities within more complex communication tasks. The preparation, methods, and lessons learned for an effective palliative simulation curriculum can be expanded upon by other pediatric training programs, and a more rigorous research program should be added to educational series.

A Novel Weaning Protocol for High-Flow Nasal Cannula in the PICU.

OBJECTIVE: High-flow nasal cannula use in the PICU continues to increase; however, a protocol for weaning patients has yet to be published. This study aimed to create an efficient and safe protocol for weaning high-flow nasal cannula. DESIGN: A Respiratory Assessment Score was created using two validated scoring systems. A protocol was established for set "holidays" off high-flow nasal cannula, where nasal cannula flow was reduced to age-based low-flow nasal cannula rates if Respiratory Assessment Scores met certain criteria. SETTING: The PICU at Children's Healthcare of Atlanta at Egleston, a quaternary level hospital affiliated with Emory University. PATIENTS: Patients treated in the PICU with high-flow nasal cannula from August 2013 to March 2014. Exclusions included apnea, heliox therapy, oxygen saturations less than 92% with a FIO2 greater than 50%, admitted to PICU less than 6 hours, progression to intubation prior to scoring, or those ordered by physician to not receive holidays based on clinical status. INTERVENTIONS: Patients who qualified for a "holiday" based on Respiratory Assessment Score were trialed off high-flow nasal cannula and rescored afterwards to assess tolerance. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-three patients were treated with high-flow nasal cannula, with the most common diagnosis being bronchiolitis (43%). Of these 133 patients, 119 (89.5%) successfully weaned to low-flow nasal cannula within four holiday attempts. Eighty-three patients (70%) weaned with only one attempt. Fourteen patients (10.5%) failed to wean. Reasons for failure were reintubation, increasing flow on high-flow nasal cannula, too high of Respiratory Assessment Score to meet weaning criteria, or slow weaning after failed attempts. Holidays did not precipitate clinical deterioration or lead to immediate intubation. CONCLUSIONS: Our study suggests that a high-flow nasal cannula "holiday" protocol is a safe and effective way to successfully wean PICU patients off high-flow nasal cannula. Additional investigation including validation of the scoring system used is warranted.

Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.

BACKGROUND: Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework. METHODS: A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English-language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE. RESULTS: Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias. CONCLUSIONS: In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophylaxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pediatric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.

Developing a Tool to Assess Placement of Central Venous Catheters in Pediatrics Patients.

BACKGROUND: Pediatric critical care medicine requires the acquisition of procedural skills, but to date no criteria exist for assessing trainee competence in central venous catheter (CVC) insertion. OBJECTIVE: The goal of this study was to create and demonstrate validity evidence for a direct observation tool for assessing CVC insertion. METHODS: Ten experts used the modified Delphi technique to create a 15-item direct observation tool to assess 5 scripted and filmed simulated scenarios of CVC placement. The scenarios were hosted on a dedicated website from March to May 2013, and respondents recruited by e-mail completed the observation tool in real time while watching the scenarios. The goal was to obtain 50 respondents and a total of 250 scenario ratings. RESULTS: A total of 49 pediatrics intensive care faculty physicians (6.3% of 780 potential subjects) responded and generated 188 scenario observations. Of these, 150 (79.8%) were recorded from participants who scored 4 or more on the 5 scenarios. The tool correctly identified the expected reference standard in 96.8% of assessments with an interrater agreement kappa (standard error) = 0.94 (0.07) and receiver operating characteristic = 0.97 (95% CI 0.94-0.99). CONCLUSIONS: This direct observation assessment tool for central venous catheterization demonstrates excellent performance in identifying the reference standard with a high degree of interrater reliability. These assessments support a validity construct for a pediatric critical care medicine faculty member to assess a provider placing a CVC in a pediatrics patient.

Adrenal insufficiency and response to corticosteroids in hypotensive critically ill children with cancer.

BACKGROUND: Assessment and treatment of adrenal axis function in critically ill pediatric patients with oncologic disorders have not been well elucidated. Critically ill children with oncologic disorders may be at increased risk for adrenal insufficiency (AI). OBJECTIVE: The aim of the present study was to evaluate the incidence of AI in a cohort of hypotensive patients with oncologic disorders and the correlation of AI with hemodynamic response to corticosteroids. DESIGN/METHODS: This is a retrospective review of pediatric oncology patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and steroid supplementation. Vasopressor dose requirements were evaluated before and after the initiation of corticosteroids. Absolute AI (AAI) was defined as baseline cortisol less than 18 µg/dL. Relative AI (RAI) was defined as δ-cortisol less than 9 µg/dL. RESULTS: Twenty patients received adrenocorticotropin testing; primary diagnoses were 13 hematologic malignancies and 7 solid tumors. The median age was 132 months (range, 4-224 months). The median fluid resuscitation was 80 mL/kg (range, 60-120 mL/kg), with 10 (50%) of 20 patients requiring mechanical ventilation for a median of 12 days. Overall, 10 (50%) of 20 patients met the definition for RAI, 15 (75%) of 20 met the definition for AAI, and 18 (90%) of 20 had either AAI or RAI. All patients received steroids: 18 (90%) of 20 on dopamine and 17 (85%) of 20 on norepinephrine. After the introduction of steroids, dosage of norepinephrine and dopamine was significantly reduced in 4 hours (P = .0001). CONCLUSIONS: Both RAI and AAI were common in this cohort of critically ill pediatric patients with oncologic disorders. Introduction of steroids was associated with a significant reduction in vasopressors dose.

Enteral nutrition and cardiovascular medications in the pediatric intensive care unit.

BACKGROUND: Enteral nutrition has multiple benefits for critically ill patients. However, the administration of enteral nutrition to patients requiring medications for cardiovascular support is controversial secondary to concerns of altered splanchnic perfusion. The objective of this study is to evaluate the tolerance of enteral nutrition in pediatric patients receiving cardiovascular medications. METHODS: This was a retrospective chart review of patients admitted to the pediatric intensive care unit at Children's Healthcare of Atlanta at Egleston in a 1-year period. Patients were eligible for the study if they received enteral nutrition during or within 24 hours of requiring continuous infusion of dopamine, dobutamine, epinephrine, norepinephrine, or neosynephrine. RESULTS: Fifty-five admissions (52 patients) met study criteria. Patients ranged in age from 1 month to 20 years old. Although a large number (71%) of patients experienced at least 1 feeding interruption, the majority (70%) of reasons cited for stopping or slowing feedings were not related to gastrointestinal (GI) tolerance. Only 29% of patients had feedings held for perceived intolerance. Vomiting was the most often-cited reason for these interruptions. Constipation was reported in 36% of patients but cited only 4 times as a reason for feeding interruption. Four patients exhibited evidence of GI bleeding. This bleeding was considered clinically insignificant in 2 patients and appeared unrelated to enteral feedings in the others. CONCLUSIONS: This study suggests that many pediatric patients receiving cardiovascular medications tolerate enteral nutrition without adverse events. Further prospective studies are needed to determine whether enteral nutrition can consistently benefit these critically ill pediatric patients.