Utilizing a Pediatric Disaster Coalition Model to Increase Pediatric Critical Care Surge Capacity in New York City.

A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).

An Updated Therapeutic Intervention Scoring System for Critically Ill Children Enables Nursing Workload Assessment With Insight Into Potential Untoward Events.

BACKGROUND: To introduce an updated version of the original Therapeutic Intervention Scoring System (TISS) applicable to critically ill children (TISS-C). This version was designed to assess patient acuity and nursing workload (NW) and to determine a relationship between such assessment and the incidence of adverse events. METHODS: Reviewing previous versions of TISS, an updated TISS-C was developed. Items inapplicable to pediatric critical care were eliminated; items current to critical care were added; and items still valid were edited. The point system accounts for the wide range of care provided. Random patients from a predetermined period had TISS-C scores calculated. The TISS-C scores were also calculated on patients with documented adverse events. Baseline scores were compared with scores of patients in whom adverse events had occurred. We determined the pediatric intensive care unit (PICU) NW to be the product of the TISS-C score and the patient-nurse ratio (PNR). RESULTS: One hundred twenty-five random patients had a mean TISS-C of 14.6 ± 11.8. Patients with any adverse event (98) had a TISS-C of 19.9 ± 11.6 (P < .05). Using our PICU mean PNR of 1.4 (20 patients/14 nurses), the NW for patients with more severe events was 33.6 ± 15.9. CONCLUSIONS: Critically ill pediatric patients are more vulnerable to experience adverse events when their derived NW values are high. It is postulated that a critical NW exists, where adverse events are more likely to occur.

Early administration of terbutaline in severe pediatric asthma may reduce incidence of acute respiratory failure.

BACKGROUND: Severe pediatric asthma, if not immediately and aggressively treated, may progress to acute respiratory failure requiring mechanical ventilation in the pediatric intensive care unit (PICU). Intravenous (IV) terbutaline, a ß2 agonist, is dispensed when the initial treatment does not improve the clinical condition. OBJECTIVE: To investigate the influence of early initiation of IV terbutaline on the incidence of acute respiratory failure requiring mechanical ventilation in severe pediatric asthma. METHODS: A retrospective chart review was conducted of 120 subjects (35 patients from an outside hospital emergency department [ED] with late start of terbutaline and 85 patients from the authors' hospital ED with early initiation of IV terbutaline) admitted to the PICU with severe asthma treated with continuous IV terbutaline. Responses to terbutaline treatment and outcomes were evaluated. RESULTS: Patients transported from outlying hospital EDs had shorter pre-PICU mean durations of IV terbutaline than those transferred from the authors' ED (0.69 ± 1.38 and 2.91 ± 2.47 hours, respectively, P = .001). Twenty-one of 35 patients (60%) from outlying EDs required mechanical ventilation compared with 14 of 85 patients (16%) from the authors' ED (P = .001). Durations of pre-PICU terbutaline infusion for patients requiring mechanical ventilation were significantly shorter than those with no such requirement (P = .015). CONCLUSION: The results of the present study, conducted in the largest number of subjects to date, suggest that early administration of continuous terbutaline in the ED may decrease acute respiratory failure and the need for mechanical respiratory (invasive and noninvasive) support in severe pediatric asthma.

Definitions and pathophysiology of sepsis.

Mortality rates for sepsis and septic shock have not improved in the past decade. The Surviving Sepsis Campaign (SSC) guidelines released in 2012 emphasize early recognition and treatment of sepsis, in an effort to reduce the burden of sepsis worldwide. This series of review articles will discuss the pathophysiology of sepsis; comorbidities, such as multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and endocrine issues; and finally, management of sepsis and septic shock.

Pediatric residents experience a significant decline in their response capabilities to simulated life-threatening events as their training frequency in cardiopulmonary resuscitation decreases.

OBJECTIVE: To determine the frequency of cardiopulmonary resuscitation education using high-fidelity patient simulators during pediatric residency training. DESIGN: Randomized controlled trial. SETTING: Suburban tertiary care children's hospital residency training program. SUBJECTS: Twenty-four second year pediatric residents. INTERVENTIONS: Twenty-four second year pediatric residents were randomized into two study groups, 12 residents in each. Both groups completed a formal resuscitation training course utilizing lectures, skill stations, and six scenarios on high-fidelity patient stimulators. Group A was retested on three scenarios 4 months after training and group B was similarly retested 8 months after training. MEASUREMENTS AND MAIN RESULTS: Time intervals from induction of a clinical problem to its definitive management were recorded for each resident. Residents were also asked to complete surveys following each episode of training and testing. The mean time intervals, for group A, to start effective bag mask ventilation and chest compressions in response to apnea and cardiac arrest were 17.75 secs (± 3.39 secs) and 23.42 secs (± 9.33 secs), respectively. These were significantly shorter than 32.7 secs (± 18.6 secs) and 81.2 secs (± 74.9 secs), for group B, respectively (p < .05). Residents in group A provided higher survey scores for their level of confidence in using cardiopulmonary resuscitation pharmacology than residents in group B did (p < .05). The two groups were no different in their response time to defibrillate or to start anti-arrhythmia medications for life-threatening arrhythmias and in their endotracheal intubation skills. CONCLUSIONS: Pediatric residents show a significantly slower response time to effectively manage episodes of apnea and cardiac arrest 8 months after their initial resuscitation training, when compared to 4 months after training. These results may indicate that residents require more frequent training than currently recommended.

Continuous renal replacement therapy results in respiratory and hemodynamic beneficial effects in pediatric patients with severe systemic inflammatory response syndrome and multiorgan system dysfunction.

BACKGROUND: Proinflammatory mediators have been implicated in the pathogenesis of systemic inflammatory response syndrome and multiorgan system dysfunction. These mediators are of molecular weights that render them amenable to clearance by the hemodiafiltration mode of continuous renal replacement therapy. OBJECTIVE: To determine whether a period of 48 hrs of continuous renal replacement therapy in patients with multiorgan system dysfunction secondary to systemic inflammatory response syndrome improves their degree of anasarca as well as their cardiovascular and respiratory systems performances. DATA SOURCE: Retrospective chart review. STUDY DESIGN: Charts of patients diagnosed with systemic inflammatory response syndrome, who were mechanically ventilated in the pediatric intensive care unit and at the same time were receiving continuous renal replacement therapy, from 2004 to 2008, were reviewed. Patients with preexisting renal failure and/or received extracorporeal membrane oxygenation were excluded. Changes in the patients' body weights, oxygenation indices, and vasopressor scores were used as markers for responsiveness to continuous renal replacement therapy. DATA ANALYSIS AND MAIN RESULTS: Data from twenty-two patients with systemic inflammatory response syndrome and with three to five concomitantly diagnosed organ system dysfunctions, at the time continuous renal replacement therapy was initiated, were analyzed. None of the six patients who had five organ system dysfunctions survived to be discharged from the pediatric intensive care unit. Of the remaining 16 patients with three or four organ system dysfunctions, eight (50%) survived and eight (50%) died. The patients' weight, oxygenation indices, and vasopressor scores did not significantly change with 48 hrs of continuous renal replacement therapy. CONCLUSIONS: Mechanically ventilated patients with systemic inflammatory response syndrome and multiorgan system dysfunction demonstrated a precarious and insignificant response to 48 hrs of continuous renal replacement therapy in a hemodiafiltration mode. However, the patients' overall clinical status did not deteriorate during this therapy. More prospective studies are necessary to determine the effectiveness of continuous renal replacement therapy in patients with multiorgan system dysfunction.

Severity assessment of obstructive sleep apnea syndrome (OSAS) in pediatric patients.

OBJECTIVE: To assess obstructive sleep apnea syndrome (OSAS) severity among pediatric patients. Design. A retrospective review of charts and polysomnography (PSG) results. MEASUREMENTS AND MAIN RESULTS: Apnea-hypopnea index (AHI) and the cumulative duration of sleep while O(2)SAT was <91% were determined in 389 patients with OSAS. Patients with AHI ranging <5, 5 to 15, 16 to 30, and >30, had mean lowest observed O(2)SAT values of 88% +/- 8%, 85% +/- 9%, 78% +/- 12%, and 69% +/- 13%, respectively. The patients spent a mean of 3.5% +/- 9.2 % of their sleep time with O(2)SAT < 91%. AHI values showed a poor linear correlation with the lowest measured O(2)SAT values. Body mass index percentiles showed no significant linear correlation with AHI values or with the lowest measured values of O(2)SAT. CONCLUSION: Values of AHI cannot accurately predict severity of oxyhemoglobin desaturation in pediatric OSAS and vice versa. No significant correlation between body mass index percentiles and severity of OSAS was established.

Pressure characteristics of mechanical ventilation and incidence of pneumothorax before and after the implementation of protective lung strategies in the management of pediatric patients with severe ARDS.

OBJECTIVE: To compare pressure characteristics of mechanical ventilation and their impact on pediatric patients with severe ARDS in the pre-protective lung strategy (PLS) and post-PLS eras. METHODS: Medical records of 33 patients admitted to our pediatric ICU with ARDS from 1992 through 1994 (pre-PLS) and 52 patients with ARDS admitted from 2000 through 2003 (post-PLS) were retrospectively reviewed. RESULTS: Patient age and gender distribution were identical in both eras. Fifty-five percent of the patients in the pre-PLS era had pneumothorax, compared to 17% in the post-PLS era (p < 0.05). Overall mortality rates for patients in the pre-PLS and post-PLS eras were 42% and 25%, respectively (p = 0.09; not significant). Mean duration of exposure to peak inspiratory pressure (PIP) values > 40 cm H2O was significantly longer in the pre-PLS era than in the post-PLS era. Pre-PLS patients with pneumothorax received mean maximum PIP of 72 +/- 17 cm H2O, mean maximum positive end-expiratory pressure (PEEP) of 20 +/- 5 cm H2O, and maximum mean airway pressure (MAP) of 46 +/- 8 cm H2O, while patients in the post-PLS era required mean maximum PIP of 42 +/- 2 cm H2O, mean maximum PEEP of 14 +/- 2 cm H2O, and maximum MAP of 30 +/- 6 cm H2O, respectively (p < 0.05 for all pressure parameters). There were no significant differences in mechanical ventilation pressure characteristics among patients who did not have pneumothorax during their course of management in both eras. CONCLUSIONS: A significantly more aggressive use of ventilator pressure characteristics distinguished the pre-PLS era from the post-PLS era, and was found to be associated with a markedly higher incidence of pneumothorax. Outcome in both eras did not differ significantly, presumably due to insufficient statistical power.

Concomitant assessment of depth of sedation by changes in bispectral index and changes in autonomic variables (heart rate and/or BP) in pediatric critically ill patients receiving neuromuscular blockade.

OBJECTIVE: We evaluated whether or not changes in bispectral index (BIS) are associated with concomitant changes in autonomic variables that are in agreement with the different level of sedation that the changes in BIS indicate. DESIGN: A retrospective chart review. SETTING: A pediatric ICU of a children's hospital. METHODS AND MAIN RESULTS: Charts of patients who were receiving mechanical ventilation and IV sedation, neuromuscular blockade, and continuous BIS monitoring were enrolled in the study. Changes in BIS values > or = 30% from previous readings were evaluated to determine whether or not concomitant changes of > or = 10% in autonomic variables, in the same direction, coexisted. Forty-seven patients (35 male and 12 female) were enrolled in our study; ages ranged from 10 days to 18 years (mean, 4.2 +/- 6.2 years [+/- SD]). Twenty-five patients were < 1 year of age (53%). All patients were sedated and pharmacologically paralyzed. Overall, 387 BIS readings (15%) showed a > or = 30% change from the previously documented BIS number. These BIS changes were in agreement with heart rate (HR) changes, mean arterial pressure (MAP) changes, and both HR and MAP changes in 10.6%, 23.8%, and 5.7% of the time, respectively. The same analysis of agreement was done for patients < or = 1 year old, and results were no different from those of older patients. Among 21 patients who were not receiving any vasoactive drugs (alpha- and/or beta-adrenergic agonists) during the study period, 157 BIS recordings (15%) showed a > or = 30% change from the previously documented BIS number. The percents of agreement with HR, MAP, and HR and MAP for these patients were 14.6%, 17.2%, and 7.6%, respectively. In 26 patients who were receiving vasoactive medications during the study, 230 BIS recordings (15%) showed a > or = 30% change from the previously documented BIS number. For these patients, the percentages of agreement were 7.8%, 28.3%, and 4.3%, respectively. Agreement with MAP was significantly better than with HR for this group of patients (p < 0.05; Fisher Exact Test). SUMMARY: While significant changes in BIS are thought to reflect significant changes in depth of sedation, they have a very low rate of agreement with changes in vital signs. In the absence of BIS, the level of sedation of chemically paralyzed pediatric patients can be better guided by changes in MAP than in HR, particularly in patients receiving vasoactive drug treatment.

Prone positioning of pediatric patients with ARDS results in improvement in oxygenation if maintained > 12 h daily.

OBJECTIVES: To evaluate changes in oxygenation index (OI) in pediatric patients with ARDS during the first 24 h of prone positioning (PP), and to determine whether or not longer periods of PP (> 12 h) result in a more pronounced improvement in oxygenation. DESIGN: A retrospective chart review of patients with ARDS who had been placed in PP for their management. SETTING: Pediatric ICU of a children's hospital. MEASUREMENTS AND MAIN RESULTS: We retrieved the charts of patients with ARDS who had been admitted to our pediatric ICU over a 3-year period and placed in PP for their management. The patients received mechanical ventilation, were sedated and pharmacologically paralyzed, and underwent arterial blood gas analysis, with concomitant documentation of ventilator settings, at a frequency of once every 4 h or more often. We divided the first 24 h of PP into two periods, brief and prolonged. The brief period was defined as duration of PP between 6 h and 10 h, and the prolonged period was between 18 h and 24 h. We compared pre-PP OI values to values after brief periods and prolonged periods of PP. Values of the PaO(2)/fraction of inspired oxygen (P/F) ratio and the mean airway pressure (MAP) were similarly evaluated. We also evaluated the degree of OI fluctuations during 24 h of PP by identifying the time points at which the best OI and the worst OI were observed. Data from a total of 40 pediatric patients with ARDS were evaluated. Twenty-one of the patients were male, and 19 were female; their ages ranged from 1 month to 18 years (mean +/- SD, 6.22 +/- 6.27 years). Thirty-two patients received conventional mechanical ventilation, and 8 patients received high-frequency oscillatory ventilation. Thirty-three patients survived, and 7 patients (21%) died. The mean duration of PP was 67 +/- 64 h (2.8 +/- 2.7 days), the mean number of ventilator days was 32 +/- 32, and the mean interval between endotracheal intubation and placing the patients in PP was 107 +/- 108 h (4.5 +/- 4.5 days). Thirty-seven patients completed 20 h of PP or more. The mean post-PP time points at which OI values were actually evaluated for these patients were 8 +/- 2 h (brief) and 21 +/- 4 h (prolonged), respectively. Overall, the OI decreased from a pre-PP value of 24.8 +/- 13.0 to 16.7 +/- 13.7 after a brief period of PP (p < 0.05 when compared to baseline) and 11.4 +/- 6.3 after prolonged period (p < 0.05 when compared to baseline and brief period values). This improvement in OI followed the improvement seen in the P/F ratio, whereas the MAP remained unchanged. The best mean OI value, with patients in PP, was 11 +/- 9 (p < 0.05 when compared to baseline) that occurred at 16 +/- 6 h, and the worst was 22 +/- 15 (p = not significant when compared to baseline) that occurred at 9 +/- 7 h. CONCLUSIONS: PP of pediatric patients with ARDS for prolonged periods (18 to 24 h) results in a more pronounced and more stable reduction in their OI values than those observed after brief periods (6 to 10 h). This improvement in OI was not associated with changes in MAP during the first 24 h of mechanical ventilation. OI values tend to fluctuate more during the first 12 h of PP then they do during the subsequent 12 h.

Cephalad movement of endotracheal tubes caused by prone positioning pediatric patients with acute respiratory distress syndrome.

OBJECTIVE: To test the hypothesis that prone positioning of patients with acute respiratory distress syndrome results in significant cephalad movement of their endotracheal tubes (ETT). DESIGN: A retrospective review of chest radiographs and patient information. SETTING: Pediatric intensive care unit of a children's hospital. MEASUREMENTS AND MAIN RESULTS: Patients with acute respiratory distress syndrome had digital chest radiographs performed before and immediately after prone positioning as per our routine practice. Based on measurements of the length of the thoracic trachea and the length of the thoracic segment of the ETT, the movement of the ETT subsequent to prone positioning was calculated. Fifteen pairs of radiographs of 14 consecutive patients were evaluated. There were seven girls and seven boys, with ages ranging from 2 months to 18 yrs. All patients had a cephalad movement of their ETT ranging from 10% to 57% of their thoracic tracheal length (p < .001) associated with prone positioning. The mean amplitude of this movement was 34% +/- 16%, indicating that if the tip of the ETT is not deeper than one third of the thoracic tracheal length before prone positioning, it might slide into the cervical trachea as a result of this procedure. CONCLUSIONS: Prone positioning results in cephalad movement of ETT within the trachea. The tip of the ETT should be deeper than one third of the total length of the thoracic trachea before prone positioning to prevent it from moving into the cervical trachea. When prone positioning is done with an ETT originally not deeper than one third of the thoracic trachea, obtaining a chest radiograph immediately after prone positioning is important to determine whether the ETT remained safely situated in the trachea.