Exploratory factor analysis yields grouping of brain injury biomarkers significantly associated with outcomes in neonatal and pediatric ECMO.

In this two-center prospective cohort study of children on ECMO, we assessed a panel of plasma brain injury biomarkers using exploratory factor analysis (EFA) to evaluate their interplay and association with outcomes. Biomarker concentrations were measured daily for the first 3 days of ECMO support in 95 participants. Unfavorable composite outcome was defined as in-hospital mortality or discharge Pediatric Cerebral Performance Category > 2 with decline ≥ 1 point from baseline. EFA grouped 11 biomarkers into three factors. Factor 1 comprised markers of cellular brain injury (NSE, BDNF, GFAP, S100ß, MCP1, VILIP-1, neurogranin); Factor 2 comprised markers related to vascular processes (vWF, PDGFRß, NPTX1); and Factor 3 comprised the BDNF/MMP-9 cellular pathway. Multivariable logistic models demonstrated that higher Factor 1 and 2 scores were associated with higher odds of unfavorable outcome (adjusted OR 2.88 [1.61, 5.66] and 1.89 [1.12, 3.43], respectively). Conversely, higher Factor 3 scores were associated with lower odds of unfavorable outcome (adjusted OR 0.54 [0.31, 0.88]), which is biologically plausible given the role of BDNF in neuroplasticity. Application of EFA on plasma brain injury biomarkers in children on ECMO yielded grouping of biomarkers into three factors that were significantly associated with unfavorable outcome, suggesting future potential as prognostic instruments.

Higher levels of brain injury biomarker tau are associated with unfavorable outcomes in patients supported with ECMO following cardiac arrest.

Aim: We sought to determine if higher plasma levels of brain injury biomarkers neurofilament light (NfL), phosphorylated tau 181 (pT181), tau, and ubiquitin C-terminal hydrolase L1 (UCHL1) were associated with unfavorable outcomes in children supported on extracorporeal membrane oxygenation (ECMO) with and without preceding cardiac arrest. Methods: We conducted a secondary analysis of a two-center prospective observational study of ECMO patients 0-<18 years. Plasma concentrations of NfL, pT181, tau, and UCHL1 were measured on ECMO days 1, 2 and 3. Unfavorable outcome was defined as in-hospital mortality or discharge Pediatric Cerebral Performance Category (PCPC) >2 with decline from baseline PCPC among survivors. Results: Among 88 children on ECMO, mean tau levels were significantly higher on each of the first three ECMO days in children who underwent extracorporeal cardiopulmonary resuscitation (ECPR) compared to those with non-ECPR cardiac arrest or with no cardiac arrest preceding ECMO. Higher ECMO day 1 tau levels were significantly associated with increased hazard of unfavorable outcome in unadjusted (HR, 1.35, 95% CI 1.09-1.66) and adjusted (HR, 1.42; 95% CI 1.13-1.79) models. Higher levels of NfL or pT181 were not associated with increased hazard for unfavorable outcome in multivariable models. UCHL1 values were outside of detectable limits and thus deferred from analysis. Conclusions: Levels of tau were significantly associated with increased hazard of death or unfavorable neurologic outcome in unadjusted and adjusted models. Biomarkers of brain injury, particularly tau, may aid in detection of neurologic injury and neuroprognostication in patients on ECMO with and without preceding cardiac arrest.

Coaching to Improve Individual and Team Performance in Anesthesiology.

In addition to medical knowledge and psychomotor skills, anesthesiology practice requires the ability to work within a complex system, navigate social situations, manage conflict, and lead teams. Coaching has foundations in psychology and adult learning theory and uses a process of inquiry, reflection, and shared discernment to discover values, goals, and solutions. There is increasing use and evidence for coaching in medicine and anesthesiology to support personal and professional growth. Individual and group coaching for anesthesiologists may improve anesthesiologists' ability to communicate, collaborate and solve problems, improving well-being, culture, and plausibly, patient outcomes.

Evaluating the Women's Empowerment and Leadership Initiative: Supporting mentorship, career satisfaction, and well-being among pediatric anesthesiologists.

The Society for Pediatric Anesthesia launched the Women's Empowerment and Leadership Initiative (WELI) in 2018 to empower highly productive women pediatric anesthesiologists to achieve equity, promotion, and leadership. WELI is focused on six career development domains: promotion and leadership, networking, conceptualization and completion of projects, mentoring, career satisfaction, and sense of well-being. We sought feedback about whether WELI supported members' career development by surveys emailed in November 2020 (baseline), May 2021 (6 months), and January 2022 (14 months). Program feedback was quantitatively evaluated by the Likert scale questions and qualitatively evaluated by extracting themes from free-text question responses. The response rates were 60.5% (92 of 152) for the baseline, 51% (82 of 161) for the 6-month, and 52% (96 of 185) for the 14-month surveys. Five main themes were identified from the free-text responses in the 6- and 14-month surveys. Members reported that WELI helped them create meaningful connections through networking, obtain new career opportunities, find tools and projects that supported their career advancement and promotion, build the confidence to try new things beyond their comfort zone, and achieve better work-life integration. Frustration with the inability to connect in-person during the coronavirus-19 pandemic was highlighted. Advisors further stated that WELI helped them improve their mentorship skills and gave them insight into early career faculty issues. Relative to the baseline survey, protégés reported greater contributions from WELI at 6 months in helping them clarify their priorities, increase their sense of achievement, and get promoted. These benefits persisted through 14 months. Advisors reported a steady increase in forming new meaningful relationships and finding new collaborators through WELI over time. All the members reported that their self-rated mentoring abilities improved at 6 months with sustained improvement at 14 months. Thus, programs such as WELI can assist women anesthesiologists and foster gender equity in career development, promotion, and leadership.

Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation.

BACKGROUND: Inflammatory and endothelial activation responses during extracorporeal membrane oxygenation (ECMO) support in children are poorly understood. In this study, we aimed to determine if circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and with neurologic outcomes in children on ECMO. METHODS: We conducted a secondary analysis of a two-center prospective observational study of 99 neonatal and pediatric ECMO patients. Inflammatory (interferon gamma [IFNγ], interleukin-6 [IL-6], IL-1ß, tumor necrosis factor alpha [TNFα]), endothelial activation (E-selectin, P-selectin, intercellular adhesion molecule-3 [ICAM-3], thrombomodulin [TM]), and fibrinolytic markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1]) were measured in plasma on days 1, 2, 3, 5, 7, and every third day thereafter during the ECMO course. RESULTS: All ECMO day 1 inflammatory biomarkers were significantly elevated in children with abnormal vs. normal neuroimaging. ECMO day 1 and peak levels of IL-6 and PAI-1 were significantly elevated in children who died compared to those who survived to hospital discharge. Tested biomarkers showed no significant association with long-term neurobehavioral outcomes measured using the Vineland Adaptive Behavioral Scales, Second Edition. CONCLUSIONS: High levels of circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and abnormal neuroimaging in children on ECMO. IMPACT: The inflammatory, endothelial activation, and fibrinolytic profile of children on ECMO differs by primary indication for extracorporeal support. Proinflammatory biomarkers on ECMO day 1 are associated with abnormal neurologic imaging in children on ECMO in univariable but not multivariable models. In multivariable models, a pronounced proinflammatory and prothrombotic biomarker profile on ECMO day 1 and longitudinally was significantly associated with mortality. Further studies are needed to identify inflammatory, endothelial, and fibrinolytic profiles associated with increased risk for neurologic injury and mortality through potential mediation of bleeding and thrombosis.

Cyclohexanone Exposure in Children on Extracorporeal Membrane Oxygenation Support.

The aim of this study was to determine if plasma cyclohexanone and metabolites are associated with clinical outcomes of children on extracorporeal membrane oxygenation (ECMO) support. We performed a secondary analysis of a prospective observational study of children on ECMO support at two academic centers between July 2010 and June 2015. We measured plasma cyclohexanone and metabolites on the first and last days of ECMO support. Unfavorable outcome was defined as in-hospital death or discharge Pediatric Cerebral Performance Category score > 2 or decline ≥ 1 from baseline. Among 90 children included, 49 (54%) had unfavorable outcome at discharge. Cyclohexanediol, a cyclohexanone metabolite, was detected in all samples and at both time points; concentrations on the first ECMO day were significantly higher in those with unfavorable versus favorable outcome at hospital discharge (median, 5.7 ng/µl; interquartile range [IQR], 3.3-10.6 ng/µl vs. median, 4.2 ng/µl; IQR, 1.7-7.3 ng/µl; p = 0.04). Twofold higher cyclohexanediol concentrations on the first ECMO day were associated with increased risk of unfavorable outcome at hospital discharge (multivariable-adjusted hazard ratio [HR], 1.24 [95% CI, 1.05-1.48]). Higher cyclohexanediol concentrations on the first ECMO day were not significantly associated with new abnormal neuroimaging or 1-year Vineland Adaptive Behavior Scales-II score < 85 or death among survivors.

Empowering Women as Leaders in Pediatric Anesthesiology: Methodology, Lessons, and Early Outcomes of a National Initiative.

Research has shown that women have leadership ability equal to or better than that of their male counterparts, yet proportionally fewer women than men achieve leadership positions and promotion in medicine. The Women's Empowerment and Leadership Initiative (WELI) was founded within the Society for Pediatric Anesthesia (SPA) in 2018 as a multidimensional program to help address the significant career development, leadership, and promotion gender gap between men and women in anesthesiology. Herein, we describe WELI's development and implementation with an early assessment of effectiveness at 2 years. Members received an anonymous, voluntary survey by e-mail to assess whether they believed WELI was beneficial in several broad domains: career development, networking, project implementation and completion, goal setting, mentorship, well-being, and promotion and leadership. The response rate was 60.5% (92 of 152). The majority ranked several aspects of WELI to be very or extremely valuable, including the protégé-advisor dyads, workshops, nomination to join WELI, and virtual facilitated networking. For most members, WELI helped to improve optimism about their professional future. Most also reported that WELI somewhat or absolutely contributed to project improvement or completion, finding new collaborators, and obtaining invitations to be visiting speakers. Among those who applied for promotion or leadership positions, 51% found WELI to be somewhat or absolutely valuable to their application process, and 42% found the same in applying for leadership positions. Qualitative analysis of free-text survey responses identified 5 main themes: (1) feelings of empowerment and confidence, (2) acquisition of new skills in mentoring, coaching, career development, and project implementation, (3) clarification and focus on goal setting, (4) creating meaningful connections through networking, and (5) challenges from coronavirus disease 2019 (COVID-19) and the inability to sustain the advisor-protégé connection. We conclude that after 2 years, the WELI program has successfully supported career development for the majority of protégés and advisors. Continued assessment of whether WELI can meaningfully contribute to attainment of promotion and leadership positions will require study across a longer period. WELI could serve as a programmatic example to support women's career development in other subspecialties.

Using the ImPAACT program with preschoolers with Down syndrome: a hybrid service-delivery model.

Three parents of preschool-aged children with Down syndrome using mobile augmentative and alternative communication (AAC) technologies to communicate participated indirect, systematic communication-partner instruction. Intervention featured an adaptation of the ImPAACT Program (Improving Partner Applications of Augmentative Communication Techniques; Kent-Walsh, Binger, & Malani, 2010) that included six face-to-face and three telepractice sessions. Parents learned to use the evidence-based Read-Ask-Answer (RAA) instructional strategy (Kent-Walsh, Binger, & Hasham, 2010) during shared storybook reading with their children. A single-case, multiple-probe across participants design was used to assess parents' accurate implementation of the instructional strategy and children's multimodal communicative turns. All three parents increased their use of the RAA strategy and maintained strategy use over time, and all three children increased their frequency of communicative turns taken and maintained higher turn-taking rates. Results support the use of the ImPAACT Program with parents of children with complex communication needs, including the integration of hybrid learning as part of the instructional approach.

Grow and Advance through Intentional Networking: A pilot program to foster connections within the Women's Empowerment and Leadership Initiative in the Society for Pediatric Anesthesia.

BACKGROUND: The Women's Empowerment and Leadership Initiative in the Society for Pediatric Anesthesia was established to support women's efforts to achieve promotion, leadership positions, and equity in pediatric anesthesiology through coaching, mentoring, sponsorship, and networking. Career advancement relies on the establishment of mentoring relationships within institutions and at regional and national levels. Prior to the SARS-CoV-2 (COVID-19) pandemic, networking was primarily conducted at large national meetings. AIMS: When national meetings were canceled by the COVID-19 pandemic, the Women's Empowerment and Leadership Initiative sought to reduce networking barriers by creating a pilot program called "Grow and Advance through Intentional Networking" (GAIN). MATERIALS & METHODS: Monthly 1-h virtual GAIN sessions were developed based on topics requested by the Women's Empowerment and Leadership Initiative members. Faculty facilitated psychologically safe small-group discussions to maximize engagement. RESULTS: We present an overview of our pilot GAIN program, which has been well received by the Women's Empowerment and Leadership Initiative members and met with continuous demand for more sessions. DISCUSSION: Professional networking is critical for career advancement and for developing and maintaining a sense of community and well-being. Early- and mid-career physicians depend on these relationships to facilitate academic productivity and promotion. CONCLUSION: Programs like the Women's Empowerment and Leadership Initiative GAIN are critical for advancing our specialty and supporting the well-being of pediatric anesthesiologists. GAIN addresses barriers to professional networking, including during the COVID-19 pandemic.

Coaching for the pediatric anesthesiologist: Becoming our best selves.

Anesthesiologists must balance demanding clinical workloads with career development goals. Leadership, conflict management, and other skills can improve medical outcomes, reduce stress at work, and increase career satisfaction. However, Medicine in general and Anesthesiology in particular have not traditionally emphasized physician growth in these areas. Coaching utilizes concepts from psychology, adult learning, and adult development theory to support an individual in personal and professional growth through inquiry, reflection, and shared discovery. This manuscript reviews the history and evidence basis for coaching, differentiates coaching from traditional mentorship, and presents some constructs of coaching and working with a coach. An example of a successful pilot program to disseminate coaching skills and support leadership growth among anesthesiologists, the Women's Empowerment and Leadership Initiative within the Society for Pediatric Anesthesia, is described.

Pediatric Safety Restraint Use in Motor Vehicle Crashes at a Level I Safety-Net Trauma Center.

BACKGROUND: Adherence to child passenger safety recommendations is essential to prevent death and injury in children involved in motor vehicle crashes. Parents may not undertake the proper safety measures, which can lead to increase injury. METHODS: A safety net, level I trauma center's database was used to identify admitted children (age<15 y/o) involved in motor vehicle crashes over a 2-y period to investigate safety restraint device use and compliance with state recommendations. Variables evaluated were crash characteristics, presence and method of passenger restraint, demographics, Glasgow Coma Scale, and Injury Severity Score. Excluded were patients where restraint characteristics could not be identified and those discharged from the trauma center. RESULTS: Eighty patients met inclusion criteria. Thirty-two (40%) children were unrestrained. Safety restraint device was noted in 48 (60%) children with 13 (27.1%) patients improperly restrained. The most common method of improper restraint (6, 46.2%) was traveling in the front seat before the age state law recommends. With respect to proper, improper, and no restraint, age (7.31 ± 14.26, 5.76 ± 3.24, P = 0.36), female sex (17, 8, 13, P = 0.32), low-income status (14, 5, 24, P = 0.28), and race (P = 0.08) did not differ between the groups. The unrestrained children had statistically lower initial Glasgow Coma Scale and higher Injury Severity Score and were more often involved in high-risk mechanism of Injury motor vehicle crashes. CONCLUSIONS: Despite recommendations and regulations regarding child passenger safety measures, there are a significant number of children that remain suboptimally restrained who are admitted to a safety-net trauma center. Further research is needed to understand the barriers to increase the compliance with recommendations along with targeted educational campaigns in low-compliance populations.

Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness.

There is a growing population of children with prolonged intensive care unit (ICU) hospitalization. These children with chronic critical illness (CCI) have a high health care utilization. Emerging data suggest a mismatch between the ICU acute care models and the daily care needs of these patients. Clinicians and parents report that the frequent treatment alterations typical for ICU care may be interrupting and jeopardizing the slow recoveries typical for children with CCI. These frequent treatment titrations could therefore be prolonging ICU stays even further. The aim of this study is to evaluate and summarize existing literature regarding pace and consistency of ICU care for patients with CCI. We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (of September 2018). PubMed (biomedical and life sciences literature), Excerpta Medica database (EMBASE), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language studies with data about CCI, care models, and pacing of clinical management. Four unique papers were identified. Our most important finding was that quality data on chronic ICU management, particularly for children, is sparse. All papers in this review confirmed the unique needs of chronic patients, particularly related to respiratory management, which is a common driver of ICU length of stay. Taken together, the papers support the hypothesis that protocols to reduce interdisciplinary management variability and to allow for slower management pacing should be studied for their impact on patient and health system outcomes. Optimizing value in ICU care requires mapping of resources to patient needs, particularly for patients with the most intense resource utilization. For children with CCI, parents and clinicians report that rapid treatment changes undermine recovery and prolong ICU stays. This review highlights the lack of quality pediatric research in this area and supports further investigation of a "slow and steady" approach to ICU management for children with CCI.

Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs.

We describe the process converting half of our 40-bed PICU into a negative-pressure biocontainment ICU dedicated to adult coronavirus disease 2019 patients within a 1,003-bed academic quaternary hospital. We outline the construction, logistics, supplies, provider education, staffing, and operations. We share lessons learned of working with a predominantly pediatric staff blended with adult expertise staff while maintaining elements of family-centered care typical of pediatric critical care medicine. Critically ill coronavirus disease 2019 adult patients may be cared for in a PICU and care may be augmented by implementing elements of holistic, family-centered PICU practice.

Applying Pediatric Brain Injury Guidelines at a Level I Adult/Pediatric Safety-Net Trauma Center.

BACKGROUND: Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC. METHODS: A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included. RESULTS: Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I. CONCLUSIONS: Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

OBJECTIVES: To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. DESIGN: Single-center, prospective, observational trial. SETTING: Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. PATIENTS: Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. CONCLUSIONS: On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

The Use of Bivalirudin in Pediatric Cardiac Surgery and in the Interventional Cardiology Suite.

Anticoagulation is an essential component for patients undergoing cardiopulmonary bypass or extracorporeal membrane oxygenation and for those with ventricular assist devices. However, thrombosis and bleeding are common complications. Heparin continues to be the agent of choice for most patients, likely owing to practitioners' comfort and experience and the ease with which the drug's effects can be reversed. However, especially in pediatric cardiac surgery, there is increasing interest in using bivalirudin as the primary anticoagulant. This drug circumvents certain problems with heparin administration, such as heparin resistance and heparin-induced thrombocytopenia, but it comes with additional challenges. In this manuscript, the authors review the literature on the emerging role of bivalirudin in pediatric cardiac surgery, including its use with cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, ventricular assist devices, and interventional cardiology. Moreover, they provide an overview of bivalirudin's pharmacodynamics and monitoring methods.

Neurologic Outcomes in a Two-Center Cohort of Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation.

Contemporary studies of long-term outcomes in children supported on extracorporeal membrane oxygenation (ECMO) in the United States are limited. We enrolled 99 ECMO patients between July 2010 and June 2015 in a two-center prospective observational study that included neurologic and neuropsychologic evaluation at 6 and 12 months, using standardized outcome measures. Pre-ECMO, 20 (20%) had a pre-existing neurologic diagnosis, 40 (40%) had cardiac arrest, and 10 of 47 (21%) children with neuroimaging had acute abnormal findings. Of 50 children eligible for follow-up at 6 or 12 months, 40 (80%) returned for at least one visit. At the follow-up visit of longest interval from ECMO, the median Vineland Adaptive Behavior Scales-II (VABS-II) score was 91 (interquartile range [IQR], 81-98), the median Pediatric Stroke Outcome Measure (PSOM) score was 1 (IQR, 0-2), and the median Mullen Scales of Early Learning composite score was 85 (IQR, 72-96). Presence of new neuroimaging abnormalities during ECMO or within 6 weeks post-ECMO was associated with VABS-II score <85 or death within 12 months after ECMO. The Pediatric Cerebral Performance Category at hospital discharge showed a strong relationship with unfavorable VABS-II and PSOM scores at 6 or 12 months after ECMO. In this study, we report a higher prevalence of pre-ECMO neurologic conditions than previously described. In survivors to hospital discharge, median scores for adaptive behavior and cognitive, neurologic, and quality of life assessments were all below the general population means, but most deficits would be considered minor within each of the domains tested.