Outcomes of Children With Firearm Injuries Admitted to the PICU in the United States.

OBJECTIVES: Firearm-related injury is the second leading cause of injury and death for children 1-18 years old in United States. The objective of our study was to analyze the outcomes of children admitted to the PICU with firearm injuries. DESIGN: Retrospective study. SETTING: PICUs in United States contributing data to Virtual Pediatric Systems, LLC, from January 2009 to December 2017. PATIENTS: Children age 1 month to 18 years old admitted to the PICU with firearm injury, identified by external cause of injury E-codes and International Classification of Diseases, 9th Edition, and International Classification of Diseases, 10th Edition, codes were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,447 cases identified of which 175 (12%) died in the PICU. Unintentional firearm injury (67.7%) and assault with a firearm injury (20%) comprised 90% of the cases. Males comprised 78% of the cohort (1,122) and race distribution included 45% Black (646), 27% White (390), and 12% Hispanic (178). Among the children who died in the PICU, 55% were 13-18 years old. Children attempting suicide with a firearm were more likely to die in the PICU as compared to the other causes of firearm injury. Based on their Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores at discharge, there is high morbidity in children with firearm injuries. CONCLUSIONS: Mortality rate of children with firearm injury admitted to the PICU is high. Children admitted to the PICU with suicide attempt with a firearm carried the highest mortality. Further studies may help further define the epidemiology of firearm injuries in children and plan interventions to minimize these unnecessary deaths.

Characteristics and outcomes of children with congenital heart disease needing diaphragm plication.

BACKGROUND: Diaphragm dysfunction following surgery for congenital heart disease is a known complication leading to delays in recovery and increased post-operative morbidity and mortality. We aimed to determine the incidence of and risk factors associated with diaphragm plication in children undergoing cardiac surgery and evaluate timing to repair and effects on hospital cost and length of stay. METHODS: We conducted a multi-institutional retrospective observational cohort study. Forty-three hospitals from the Pediatric Health Information System database were included, and a total of 112,110 patients admitted between January 2004 and December 2014 were analysed. RESULTS: Patients less than 18 years of age who underwent cardiac surgery were included. Risk Adjustment for Congenital Heart Surgery was utilized to determine procedure complexity. The overall incidence of diaphragm dysfunction was 2.2% (n = 2513 out of 112,110). Of these, 24.0% (603 patients) underwent diaphragm plication. Higher complexity cardiac surgery (Risk Adjustment for Congenital Heart Surgery 5-6) and age less than 4 weeks were associated with a higher likelihood of diaphragm plication (p-value < 0.01). Diaphragmatic plication was associated with increased hospital length of stay (p-value < 0.01) and increased medical cost. CONCLUSIONS: Diaphragm plication after surgery for congenital heart disease is associated with longer hospital length of stay and increased cost. There is a strong correlation of prolonged time to plication with increased length of stay and medical cost. The likelihood of plication increases with younger age and higher procedure complexity. Methods to improve early recognition and treatment of diaphragm dysfunction should be developed.

Optimizing Team Dynamics: An Assessment of Physician Trainees and Advanced Practice Providers Collaborative Practice.

OBJECTIVES: The presence of advanced practice providers has become increasingly common in many ICUs. The ideal staffing model for units that contain both advanced practice providers and physician trainees has not been described. The objectives of this study were to evaluate ICU staffing models that include physician trainees and advanced practice providers and their effects on patient outcomes, resident and fellow education, and training experience. A second aim was to assess strategies to promote collaboration between team members. DATA SOURCES: PubMed, CINAHL, OVID MEDLINE, and Cochrane Review from 2002 to 2015. STUDY SELECTION: Experimental study designs conducted in an ICU setting. DATA EXTRACTION: Two reviewers screened articles for eligibility and independently abstracted data using the identified search terms. DATA SYNTHESIS: We found 21 articles describing ICU team structure and outcomes. Four articles were found describing the impact of advanced practice providers on resident or fellow education. Two articles were found discussing strategies to promote collaboration between advanced practice providers and critical care fellows or residents. CONCLUSIONS: Several articles were identified describing the utilization of advanced practice providers in the ICU and the impact of models of care on patient outcomes. Limited data exist describing the impact of advanced practice providers on resident and fellow education and training experience. In addition, there are minimal data describing methods to enhance collaboration between providers. Future research should focus on determining the optimal ICU team structure to improve patient outcomes, education of trainees, and job satisfaction of team members and methods to promote collaboration between advanced practice providers and physicians in training.

The use of near-infrared spectroscopy during an extubation readiness trial as a predictor of extubation outcome.

OBJECTIVES: To determine whether the measurement of cerebral and somatic regional oxygen saturation during an extubation readiness trial predicts extubation failure in postoperative cardiac patients. DESIGN: Prospective observational study. SETTING: Tertiary care center cardiac ICU. PATIENTS: Pediatric patients 1 day to 21 years old following cardiac surgery for congenital heart disease. Patients were included if they were intubated for greater than 12 hours and were undergoing an extubation readiness trial. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data collection included patient demographic, procedural, laboratory, and physiologic variables. Regional oxygen saturation values were recorded using near-infrared spectroscopy at baseline, during a 2-hour extubation readiness trial, and in the first 2 hours postextubation. Ninety-nine extubation readiness trials were conducted in 79 patients. Adjusting for baseline somatic regional oxygen saturation, logistic regression analysis demonstrated that patients with a decline in their minimum somatic regional oxygen saturation of at least 10% during an extubation readiness trial had a 6-time increased odds of extubation failure (p = 0.02; 95% CI, 1.26-29.8). Receiver-operating characteristic curve analysis demonstrated that a 12% decline in the minimum regional oxygen saturation best predicted extubation failure with 54% sensitivity and 82% specificity. CONCLUSIONS: A 12% decline in somatic regional oxygen saturation during an extubation readiness trial is associated with an increased risk of extubation failure following a successful extubation readiness trial. The addition of somatic regional oxygen saturation measurements to an extubation readiness trial may improve our ability to predict extubation outcome.

The Impact of Dedicated Cardiac Intensive Care Units on Outcomes in Pediatric Cardiac Surgery: A Virtual Pediatric Systems Database Analysis.

Care of children undergoing cardiac surgery occurs in dedicated cardiac intensive care units (CICU) or mixed intensive care units. In this article, we analyzed data from Virtual Pediatric Systems (VPS, LLC) database (2009-2014) for children < 18 years of age undergoing cardiac surgery, classified according to Society of Thoracic Surgery-European Association of Cardiothoracic Surgery (STS-EACTS) risk category. We had 25,052 (52%) patients in 53 mixed units (mortality rate, 2.99%), and 22,762 (48%) patients in 19 dedicated CICUs (mortality rate, 2.62%). There was a direct relationship between STS-EACTS risk category and death rate in both units. By multivariable logistic and linear regression, there was no difference in mortality between mixed unit and CICU death rates within STS-EACTS risk categories. We found no difference in outcomes for children undergoing cardiac surgery based on the unit type (dedicated CICU or mixed unit).

High-dose Dexamethasone in a Child With Enteric Encephalopathy Caused by Salmonella enterica serovar Typhi.

Increased antimicrobial resistance to Salmonella species threatens successful treatment of typhoid and other infectious diseases. Consequently, rare complications arising from incompletely treated typhoid could increase in frequency. We describe a case of enteric encephalopathy caused by Salmonella enterica serovar Typhi and the utility of adjunct treatment with corticosteroids.

Growth hormone as a rescue treatment in maple syrup urine disease with lessons from pediatric burn literature, case report and brief literature review.

Maple Syrup Urine Disease (MSUD) is a rare inherited disorder of branched chain amino acid metabolism characterized by cerebral edema and death in uncorrected metabolic crisis. It is conventionally treated with intensive nutritional therapy to prevent and correct metabolic crisis. This paper reports the use of growth hormone as a pharmacologic rescue agent in the case of an 11-year-old male with MSUD and metabolic crisis refractory to standard interventions. The initiation of short courses of growth hormone correlated with corrected mental status, resolution of metabolic acidosis, and improvement in plasma leucine levels on two occasions during an admission to the pediatric intensive care unit. This is the first known case report of the use of growth hormone in MSUD since contemporary dietary management became available. The discussion includes a literature review of the use of growth hormone in inherited diseases of amino acid metabolism and a brief discussion of protein anabolic pharmacotherapeutic agents shown to improve net protein balance in pediatric burn patients. We propose that growth hormone and other protein anabolic agents may be valuable adjuvants to standard therapy in children with inherited metabolic disease.

Pediatric Anti-N-Methyl-d-Aspartate Receptor Encephalitis: A Review with Pooled Analysis and Critical Care Emphasis.

PURPOSE: Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is being recognized with increasing frequency among children. Given the paucity of evidence to guide the critical care management of these complex patients, we provide a comprehensive review of the literature with pooled analysis of published case reports and case series. METHODS: We performed a comprehensive literature search using PubMed, Scopus, EMBASE, and Web of Science for relevant published studies. The literature search was conducted using the terms NMDA, anti-NMDA, Anti-N-methyl-d-aspartate, pediatric encephalitis, and anti-NMDAR and included articles published between 2005 and May 1, 2016. RESULTS: Forty-eight references met inclusion criteria accounting for 373 cases. For first-line treatments, 335 (89.8%) received high-dose corticosteroids, 296 received intravenous immunoglobulin (79.3%), and 116 (31%) received therapeutic plasma exchange. In these, 187 children (50.1%) had a full recovery with only minor deficits, 174 patients (46.7%) had partial recovery with major deficits, and 12 children died. In addition, 14 patients were reported to require mechanical ventilation. CONCLUSION: Anti-NMDA encephalitis is a formidable disease with great variation in clinical presentation and response to treatment. With early recognition of this second most common cause of pediatric encephalitis, a multidisciplinary approach by physicians may provide earlier access to first- and second-line therapies. Future studies are needed to examine the efficacy of these current therapeutic strategies on long-term morbidity.