Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU.

OBJECTIVES: To examine the impact of an ICU bundle on delirium screening and prevalence and describe characteristics of delirium cases. DESIGN: Quality improvement project with prospective observational analysis. SETTING: Nineteen-bed PICU in an urban academic medical center. PATIENTS: All consecutive patients admitted from December 1, 2013, to September 30, 2015. INTERVENTIONS: A multidisciplinary team implemented an ICU bundle consisting of three clinical protocols: delirium, sedation, and early mobilization using the Plan-Do-Study-Act cycles as part of a quality improvement project. The delirium protocol implemented in December 2013 consisted of universal screening with the Cornell Assessment of Pediatric Delirium revised instrument, prevention and treatment strategies, and case conferences. The sedation protocol and early mobilization protocol were implemented in October 2014 and June 2015, respectively. MEASUREMENTS AND MAIN RESULTS: One thousand eight hundred seventy-five patients were screened using the Cornell Assessment of Pediatric Delirium revised tool. One hundred forty patients (17%) had delirium (having Cornell Assessment of Pediatric Delirium revised scores ≥ 9 for 48 hr or longer). Seventy-four percent of delirium positive patients were mechanically ventilated of which 46% were younger than 12 months and 59% had baseline developmental delays. Forty-one patients had emerging delirium (having one Cornell Assessment of Pediatric Delirium revised score ≥ 9). Statistical process control was used to evaluate the impact of three ICU bundle process changes on monthly delirium rates over a 22-month period. The delirium rate decreased with the implementation of each phase of the ICU bundle. Ten months after the delirium protocol was implemented, the mean delirium rate was 19.3%; after the sedation protocol and early mobilization protocols were implemented, the mean delirium rate was 11.84%. CONCLUSIONS: Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and treatment and is associated with decreased delirium prevalence.

Comparison of Antithrombin III Products in Pediatric Patients Receiving Extracorporeal Membrane Oxygenation.

The study investigated the safety and efficacy of two antithrombin III (ATIII) products in pediatric patients receiving extracorporeal membrane oxygenation (ECMO) by performing a retrospective analysis of patients who received either recombinant ATIII (rATIII) or human-derived ATIII (hATIII). Twenty-two patients were included in the study from January 2014 to September 2015 and all received unfractionated heparin (UFH) as anticoagulation during ECMO. In total, 86 doses of ATIII were included in the analysis in which 37 doses (43%) were rATIII and 49 doses (57%) were hATIII. Unfractionated heparin rates were also evaluated for all cases (n = 86) at 24 hours post-ATIII supplementation. The UFH rate decreased after the administration of both types of ATIII. However, neither the reduction in UFH rate between the two ATIII products (p = 0.52) nor the UFH rates pre- and post-ATIII supplementation at 24 hours (p = 0.08) reached statistical significance. There was a significant difference in cost favoring the rATIII product (p < 0.0001). An ad-hoc estimation of waste associated with ATIII supplementation showed >$100,000 in financial loss of unused drug. Future studies are warranted to evaluate the efficacy of ATIII supplementation in pediatric ECMO.

Extracorporeal Membrane Oxygenation for Neonates with Congenital Renal and Urological Anomalies and Pulmonary Hypoplasia: A Case Report and Review of the Extracorporeal Life Support Organization Registry.

Objective Congenital anomalies of the kidney and urinary tract constitute up to 30% of anomalies identified in the neonatal period. In utero oligohydramnios is often associated with pulmonary hypoplasia and respiratory failure in the neonate who may not be responsive to mechanical ventilation. Placement of these neonates on extracorporeal membrane oxygenation (ECMO) remains controversial and is considered in most centers to be a relative contraindication. The objective of this study is to use the Extracorporeal Life Support Organization (ELSO) database to describe the outcomes and complications of patients with congenital renal and urogenital anomalies with pulmonary hypoplasia who underwent ECMO in the neonatal period. Data Sources Data from the ELSO registry were retrospectively reviewed for all patients with congenital renal and urogenital anomalies with pulmonary hypoplasia treated with ECMO support between 1990 and November 2014 using ICD-9 diagnosis codes. Data Synthesis We identified 45 patients. The average age of the patient at the time of ECMO was 1.7 days (range: 0-14 days) and weight was 3.1 kg (interquartile range [IQR]: 2.5-3.3). Patients spent an average of 162 hours on ECMO (IQR: 81-207). The majority of patients were managed with venoarterial ECMO (60%), and the overall survival of this cohort was 42%. Survivors had higher weights (3.4 vs. 2.8 kg; p < 0.019) and were more likely to be male (90 vs. 44%; p < 0.002). Patients with obstructive urogenital lesions had an overall survival of 71 versus 16.6% in patients with a primary intrinsic renal diagnosis ( p = 0.004). Renal replacement therapy was required in 51% of the patients during their ECMO support. Conclusion Neonates with renal or urogenital disease and pulmonary hypoplasia have an overall survival rate of 42%. Patients with a diagnosis of urogenital obstruction have much more favorable outcomes when compared with those with intrinsic renal disease such as polycystic kidney 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.

Effects of Clonidine on Withdrawal From Long-term Dexmedetomidine in the Pediatric Patient.

OBJECTIVE: To compare withdrawal symptoms among pediatric intensive care patients receiving clonidine to those not receiving clonidine while being weaned from long-term dexmedetomidine. METHODS: This retrospective analysis evaluated Withdrawal Assessment Tool-1 (WAT-1) scores and hemodynamic parameters in pediatric patients on dexmedetomidine for 5 days or longer between January 1, 2009, and December 31, 2012. The primary objective was to compare withdrawal symptoms based on the number of elevated WAT-1 scores among patients on clonidine to those not on clonidine, while being weaned from long-term dexmedetomidine. The secondary objective was to describe withdrawal symptoms associated with long-term dexmedetomidine use. RESULTS: Nineteen patients (median age, 1.5 years; interquartile range [IQR], 0.67-3.3) received 20 treatment courses of dexmedetomidine for at least 5 days. Clonidine was received by patients during 12 of the treatment courses. The patients in the clonidine group had an average of 0.8 (range, 0-6) elevated WAT-1 scores 24 hours post wean compared to an average of 3.2 (0-8) elevated WAT-1 scores in the no clonidine group (p = 0.49). There were no significant difierences between prewean and postwean systolic or diastolic blood pressures among the 2 groups. The average heart rate during the postwean period was 112 beats per minute (bpm) (range, 88.5-151.5) in the clonidine group compared to 138.4 bpm (range, 117.8-168.3) in the no clonidine group (p = 0.003). In the clonidine group, the mean change in heart rate postwean compared to prewean was an increase of 3.6 bpm (range, -39.6 to 47.5), compared to a mean increase of 29.9 bpm (range, 5.5-74.7) in the no clonidine group (p = 0.042). CONCLUSIONS: There was no difierence in WAT-1 scores between groups, with the clonidine group displaying a trend towards fewer elevated WAT-1 scores during the 24 hours post dexmedetomidine wean. Patients who received clonidine had significantly lower heart rates than the no clonidine group.