Clinical Practice Guideline: Maintenance Intravenous Fluids in Children.

Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).

Pediatrics Residents' Confidence and Performance Following a Longitudinal Quality Improvement Curriculum.

BACKGROUND: Quality improvement (QI) training is an integral part of residents' education. Understanding the educational value of a QI curriculum facilitates understanding of its impact. OBJECTIVE: The purpose of this study was to evaluate the effects of a longitudinal QI curriculum on pediatrics residents' confidence and competence in the acquisition and application of QI knowledge and skills. METHODS: Three successive cohorts of pediatrics residents (N = 36) participated in a longitudinal curriculum designed to increase resident confidence in QI knowledge and skills. Key components were a succession of progressive experiential projects, QI coaching, and resident team membership culminating in leadership of the project. Residents completed precurricular and postcurricular surveys and demonstrated QI competence by performance on the pediatric QI assessment scenario. RESULTS: Residents participating in the Center for Advancing Pediatric Excellence QI curriculum showed significant increases in pre-post measures of confidence in QI knowledge and skills. Coaching and team leadership were ranked by resident participants as having the most educational value among curriculum components. A pediatric QI assessment scenario, which correlated with resident-perceived confidence in acquisition of QI skills but not QI knowledge, is a tool available to test pediatrics residents' QI knowledge. CONCLUSIONS: A 3-year longitudinal, multimodal, experiential QI curriculum increased pediatrics residents' confidence in QI knowledge and skills, was feasible with faculty support, and was well-accepted by residents.

Pediatric approach to hypertension.

The prevalence of pediatric hypertension (HTN) has increased over the past several decades, bringing with it increased numbers of children with hypertensive sequelae such as left ventricular hypertrophy as well as greater numbers of hypertensive adults. This growing public health concern calls for vigilant screening, diagnosis, evaluation, and treatment of HTN in children. Although primary HTN has become more common in childhood and adolescence, it still should be considered a diagnosis of exclusion. As such, a diagnostic work-up should be conducted to rule out secondary causes of HTN for any child with a confirmed diagnosis of HTN. Important secondary causes of pediatric HTN include renal parenchymal, renovascular, and endocrine etiologies, and secondary HTN becomes more likely the younger the child is and the more severe the blood pressure elevation is at diagnosis. In addition, several genetic disorders have been identified in which one aberrant gene results in severe HTN, often early in life. All hypertensive children, regardless of the cause of their HTN, should be prescribed therapeutic lifestyle changes, and children with symptomatic, secondary, or severe HTN; HTN resistant to lifestyle changes; or children with evidence of end-organ damage also should be prescribed antihypertensive medications.

Model for improvement - Part 1: A framework for health care quality.

The Model for Improvement is a rigorous and reasonable method for busy health care practitioners to use to improve patient outcomes. The use of this model requires practice for clinicians to be comfortable, but mastery is critical to develop the necessary skills to participate in quality improvement initiatives. The future of health care in the United States depends on every practitioner delivering safe, effective, and efficient care. The case study demonstrates how this methodology can be applied in any busy health care setting. Incorporating this approach to quality improvement into daily work will improve clinical outcomes and advance health care delivery and design.