Practice Patterns in Pediatric Critical Care Medicine: Results of a Workforce Survey.

OBJECTIVE: To obtain current data on practice patterns of the U.S. pediatric critical care medicine workforce. DATA SOURCES: Membership of the American Academy of Pediatrics Section on Critical Care and individuals certified by the American Board of Pediatrics in pediatric critical care medicine. STUDY SELECTION: All active members of the American Academy of Pediatrics Section on Critical Care, and nonduplicative individuals certified by the American Board of Pediatrics in pediatric critical care medicine, were classified as eligible to participate in this electronically administered workforce survey. DATA EXTRACTION: Data were extracted by a doctorate-level research professional. Extracted data included demographic information, work environment, number of hours worked, training, clinical responsibilities, work satisfaction and burnout, and plans to leave the practice of pediatric critical care medicine. DATA SYNTHESIS: Of 1,857 individuals contacted, 923 completed the survey (49.7%). The majority of respondents were white, male, non-Hispanic, university-employed, and taught residents. Respondents who worked full time were on clinical intensive care service for a median of 15 wk/yr and responsible for a median of 13 ICU beds, working a median of 60 hr/wk. Total night call responsibility was a median of 60 nights/yr; about half of respondents indicated night call was in-hospital. Fewer than half were engaged in basic science or clinical research. Compared with earlier data, there was minimal change in work hours and proportion of time devoted to research, but there was an increase in the proportion of female pediatric critical care medicine physicians. CONCLUSIONS: These data provide a description of the typical intensivist and a snapshot of the current pediatric critical care medicine workforce, which may be experiencing a mild-to-moderate undersupply. The results are useful for assessing the current workforce and valuable for future planning.

Extracorporeal membrane oxygenation for pediatric respiratory failure: Survival and predictors of mortality.

OBJECTIVE: The last multicentered analysis of extracorporeal membrane oxygenation in pediatric acute respiratory failure was completed in 1993. We reviewed recent international data to evaluate survival and predictors of mortality. DESIGN: Retrospective case series review. SETTING: The Extracorporeal Life Support Organization Registry, which includes data voluntarily submitted from over 115 centers worldwide, was queried. The work was completed at the Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Medical Center, University of Utah, Salt Lake City, UT. SUBJECTS: Patients aged 1 month to 18 yrs supported with extracorporeal membrane oxygenation for acute respiratory failure from 1993 to 2007. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 3,213 children studied. Overall survival remained relatively unchanged over time at 57%. Considerable variability in survival was found based on pulmonary diagnosis, ranging from 83% for status asthmaticus to 39% for pertussis. Comorbidities significantly decreased survival to 33% for those with renal failure (n = 329), 16% with liver failure (n = 51), and 5% with hematopoietic stem cell transplantation (n = 22). The proportion of patients with comorbidities increased from 19% during 1993 to 47% in 2007. Clinical factors associated with mortality included precannulation ventilatory support longer than 2 wks and lower precannulation blood pH. CONCLUSIONS: Although the survival of pediatric patients with acute respiratory failure treated with extracorporeal membrane oxygenation has not changed, this treatment is currently offered to increasingly medically complex patients. Mechanical ventilation in excess of 2 wks before the initiation of extracorporeal membrane oxygenation is associated with decreased survival.

A Systematic Review of the Relationship Between In-Training Examination Scores and Specialty Board Examination Scores.

BACKGROUND: In-training examinations (ITEs) are intended for low-stakes, formative assessment of residents' knowledge, but are increasingly used for high-stake purposes, such as to predict board examination failures. OBJECTIVE: The aim of this review was to investigate the relationship between performance on ITEs and board examination performance across medical specialties. METHODS: A search of the literature for studies assessing the strength of the relationship between ITE and board examination performance from January 2000 to March 2019 was completed. Results were categorized based on the type of statistical analysis used to determine the relationship between ITE performance and board examination performance. RESULTS: Of 1407 articles initially identified, 89 articles underwent full-text review, and 32 articles were included in this review. There was a moderate-strong relationship between ITE and board examination performance, and ITE scores significantly predict board examination scores for the majority of studies. Performing well on an ITE predicts a passing outcome for the board examination, but there is less evidence that performing poorly on an ITE will result in failing the associated specialty board examination. CONCLUSIONS: There is a moderate to strong correlation between ITE performance and subsequent performance on board examinations. That the predictive value for passing the board examination is stronger than the predictive value for failing calls into question the "common wisdom" that ITE scores can be used to identify "at risk" residents. The graduate medical education community should continue to exercise caution and restraint in using ITE scores for moderate to high-stakes decisions.

Critical appraisal of: triaging pediatric critical care resources during a pandemic: ethical and medical considerations.

OBJECTIVE: To identify the ethical norms that should govern the allocation of pediatric critical care resources during a pandemic. DESIGN: Narrative review. METHODS: Review the literature on triage and pandemics. FINDINGS: When care that is functionally equivalent to usual patient care practices can no longer be maintained, resources should be allocated primarily on the basis of medical need and/or benefit. Unequal treatment may be justified to increase the supply of available resources and thereby save more lives. When ethically relevant distinctions can no longer be made between patients, resources should be distributed by chance. Allocation on the basis of quality of life, general contributions to society, or age are potentially problematic. Existing triage protocols inconsistently articulate the relationship between these ethical norms and their specific recommendations. In addition, they have limited applicability in pediatrics principally because of the lack of a simple validated global scoring system, which predicts mortality and/or resource utilization. CONCLUSIONS: Although research to develop such scoring systems is ongoing, clinicians will need to rely more heavily on individual diagnoses of acute illnesses with high mortality rates and underlying conditions with short life expectancies and on random allocation methods.

Always ready, always prepared-preparing for the next pandemic.

A future global pandemic is likely to occur and planning for the care of critically ill children is less robust than that for adults. This review covers the current state of federal and regional resources for pediatric care in pandemics, a strategy for pandemic preparation in pediatric intensive care units and regions focusing on stuff, space, staff and systems, considerations in developing surge capacity and triage protocols, special circumstances such as highly infectious and highly lethal pandemics, and a discussion of ethics in the setting of pediatric critical care in a pandemic.

Use of High-Frequency Ventilation in the Pediatric Intensive Care Unit.

Objective To evaluate the clinical characteristics, ventilator settings, and gas exchange indices of patients placed on high-frequency percussive ventilation (HFPV) and high-frequency oscillatory ventilation (HFOV). Methods Retrospective observation of all consecutive patients aged 0 to 18 years with acute respiratory failure managed with high-frequency ventilation from the institution's introduction of HFPV on May 1, 2012, until July 10, 2013. Measurements and Main Results Twenty-seven patients underwent HFPV as a first mode of high-frequency ventilation and 16 patients underwent HFOV first. HFPV was used more frequently in patients with acute respiratory illnesses (p < 0.01), lower Pediatric Index of Mortality 2 scores (rank-sum p < 0.04), higher Spo 2/Fio 2 (SF) ratios (p < 0.01), and lower oxygen saturation indices (p < 0.01). HFPV patients showed increased SF ratios (p < 0.01) and decreased Paco 2 levels (p = 0.02) 6 hours after initiation, and HFOV patients showed no significant differences. Peak inspiratory pressures (HFPV) and mean airway pressures (HFOV) remained at or below 30 cm H2O at each time point. HFPV and HFOV patients had an average of 2.8 and 2.9 mode changes, respectively. Mortality was 15% in the HFPV group and 50% in the HFOV group. Conclusions HFPV is associated with rapid improvement in oxygenation and ventilation at acceptable airway pressures in patients with acute respiratory failure of various etiologies, primarily for those with difficulties of ventilation or secretion management. In our institution, HFOV appears to be initiated first in children with higher severity of illness.

Inhaled nitric oxide prevents the increase in pulmonary vascular permeability caused by hydrogen peroxide.

Given the interest in using inhaled nitric oxide (NO.) to treat acute lung injury and the importance of oxygen radicals in its pathogenesis, we studied the effects, in buffer-perfused isolated rabbit lungs, of inhaled NO. (24 ppm) on the injury caused by generating hydrogen peroxide with glucose and glucose oxidase (GOX). Experiments were performed at a constant pulmonary arterial pressure. GOX substantially augmented vascular permeability, as demonstrated by an increase in the lung-to-perfusate 125I-labeled albumin ratio, lavage-to-perfusate 125I-albumin ratio, wet-to-dry lung weight ratio, and pulmonary vascular filtration coefficient. Lungs treated with inhaled NO. before perfusion with GOX had lung-to-perfusate and lavage-to-perfusate 125I-albumin ratios that were not significantly different from control values and intermediate between the control and GOX groups. Inhaled NO. also prevented the increase in wet-to-dry lung weight ratio and pulmonary vascular filtration coefficient caused by GOX.. Thus inhaled NO. substantially reduced in the isolated lung the increase in pulmonary vascular permeability produced by the intravascular generation of hydrogen peroxide.

Braided bronchus: a previously undescribed airway anomaly.

Infants with congenital heart disease frequently experience recurrent atelectasis, in many cases associated with anomalous branching of the bronchial tree. The bridging bronchus has been well described and has been associated with both left-sided obstructive lesions and a sling-like left pulmonary artery. We describe a similar, though distinct airway anomaly, the "braided bronchus," associated with a bridging bronchus in a child with coarctation of the aorta and recurrent atelectasis. Methods used to delineate the "braided bronchus" are described.

Isoflurane therapy for status asthmaticus in children: A case series and protocol.

OBJECTIVE: To describe the use of inhaled isoflurane by using a standardized protocol in the treatment of respiratory failure secondary to status asthmaticus in a series of pediatric patients. DESIGN: Case series. SETTING: Pediatric intensive care unit of a tertiary care military medical facility. PATIENTS: Six pediatric patients ranging in age from 14 months to 15 yrs who were treated with isoflurane in our pediatric intensive care unit for status asthmaticus from 1995 to 1998. INTERVENTION: Inhaled isoflurane therapy was initiated by using the treatment protocol after the patients had failed conventional medical management in the treatment of their asthma. MEASUREMENTS AND MAIN RESULTS: All patients tolerated isoflurane therapy well by using our standardized protocol in conjunction with careful hemodynamic monitoring and support. The administration of inhaled isoflurane resulted in measurable improvements in the subject patients, as evidenced by statistically significant decreases in Paco2 and peak inspiratory pressures, as well as a significant increase in pH. All six patients were successfully extubated and were discharged from the hospital without apparent sequelae. CONCLUSIONS: We conclude isoflurane may be a safe, effective treatment modality in the management of status asthmaticus refractory to aggressive medical therapy, although further study is warranted. We emphasize this mode of therapy should be instituted only after traditional treatment modalities have failed and appropriate intensive care support is available.

A randomized, blinded comparison of chloral hydrate and midazolam sedation in children undergoing echocardiography.

The objective of this prospective, randomized, and blinded study was to compare the use of chloral hydrate versus oral midazolam sedation in children undergoing echocardiography. No adverse effects (nausea, vomiting, paradoxical agitation, or significant deviations from baseline vital signs) were noted with either medication. No differences were noted in onset of sedation between the 2 groups, however, the time to complete recovery was significantly shorter with midazolam than with chloral hydrate. The children in the chloral hydrate group had a significantly deeper level of sedation and were more likely to receive a more nearly comprehensive echocardiographic evalation.

Transport of the mechanically ventilated pediatric patient.

Children deserve quality care when they are critically ill or injured. Specialized pediatric services may be limited outside major medical centers. Transport by specialized pediatric and neonatal transport teams may be required to deliver patients to tertiary pediatric medical centers. In addition, in the past decade a cost-effective, organized, systematic approach to health care management has assumed greater importance, leading to the concept of the so-called medical home. In this model, a child with a complex medical problem is cared for in the environment in which he or she will receive the best care, with emphasis on providing rehabilitative and long-term care near the child's home. It is likely, then, that the field of pediatric transport medicine will assume greater importance in the coming decade.

The pediatric critical care experience at Naval Hospital Guam: suggestions for critical care training during residency.

OBJECTIVES: To determine the critical care experience encountered by three recently graduated military pediatricians at an overseas military hospital and present one model of maximizing allowable critical care training time during residency. METHOD: Retrospective reviews of all admissions to the special care nursery and intensive care unit at U.S. Naval Hospital Guam were performed for a 3-year and a 2-year period, respectively. Age, diagnosis, birth weight (if applicable), level of nursery care, invasive procedures performed in the nursery (endotracheal tube, umbilical artery, and umbilical venous catheter placement), patient outcome, and the need for medical transport were recorded. RESULTS: During a 3-year period, there were 122 admissions to the special care nursery (7.1% of all deliveries). In addition, pediatricians performed a total of 53 invasive procedures on these patients, and 29 infants required medical transport to an off-island neonatal intensive care unit for additional care. During a 2-year period, 70 pediatric patients were admitted to the adult intensive care unit, representing 10.2% of all intensive care unit admissions during this period. Fourteen of these patients required medical transport to an off-island referral hospital. CONCLUSION: Graduating military pediatric residents may be faced with caring for a wide range of critically ill neonatal and pediatric patients depending on their assignment. Residency training programs, with the recent increased emphasis on primary pediatric care, will need to streamline instruction in pediatric critical care to provide maximal benefit to the resident while maintaining compliance with Residency Review Committee guidelines.

Development of a pediatric critical care transport team: experience at a military medical center.

INTRODUCTION: A pediatric critical care transport program was initiated and organized at Naval Medical Center San Diego in January 1994. The primary goal of the program was to formally train military pediatric residents in the early stabilization and transport of the critically ill neonatal and pediatric patient. It was also felt that such a program would generate significant cost savings to the Department of Defense. We present the statistics, training protocol, and the cost savings. In addition, we surveyed previous residents who had been involved with this program to determine its perceived benefit. METHODS: In the first phase of this project, the pediatric critical care transport program database from January 1994 to December 1997 was reviewed. The number and types of transports were recorded. Next, we determined cost savings for the transport program for fiscal year 1996-1998 (the period for which fiscal data were available). In the second phase of this project, we sent surveys to the 23 graduating residents who had participated in the pediatric critical care transport program. The survey sought to determine the perceived value of the transport training experience and the degree to which that training is now being used. All investigators were blinded to the responses. Statistical analysis consisted of determining the percentage of each response. RESULTS: During the 4-year period reviewed, 404 transports were performed (198 neonatal and 206 pediatric). During fiscal year 1996-1998, there was a cost avoidance of $1,962 per transport. In the second phase, 91% of the surveys were returned and analyzed. The majority of residents were practicing in overseas or isolated communities. All respondents rated their experience in the pediatric critical care transport program as worthwhile and educational, and they complemented their training in the neonatal and pediatric intensive care units. Seventy-one percent of the respondents had transported a critically ill neonate or child to another facility within the last year. CONCLUSIONS: In summary, we report our experience with the development of a pediatric critical care transport program. The program was developed to provide military pediatric residents instruction and experience in the stabilization and transport of critically ill children. In addition, we were able to demonstrate a significant cost avoidance.

Risk factors for poor outcomes and therapeutic strategies for seasonal and pandemic influenza.

Seasonal influenza is a leading cause of morbidity and mortality worldwide annually while pandemic influenza, a unique entity, poses distinct challenges. The pediatric population is the primary vector for epidemics and the main focus of this article. While primary prevention with universal influenza vaccination is the best protection against significant illness, the antigenic shift and drift unique to influenza viruses leave a large population at risk even with universal vaccination. Early in an epidemic various diagnostic tests are available and discussed here. However, once an epidemic is established, testing is no longer necessary for diagnosis. Groups with particular vulnerability to serious illness include those <6 mo of age, children with underlying neuromuscular disease, pulmonary disorders, or other comorbid conditions. Early treatment with neuraminidase inhibitors is recommended for those with influenza infection requiring hospitalization. Respiratory failure and need for mechanical ventilation are the leading indications for intensive care unit admission among children. Complications of influenza such as pneumonia, empyema, myocarditis and neurologic involvement increase risk for intensive care unit admission and will be discussed as will the use of extracorporeal membrane support. An overview of the epidemiology of influenza with an emphasis on risk factors for critical illness and poor patient outcomes in the pediatric population as well as treatment strategies for critically ill children will be presented. Additionally, we will address some of the unique challenges posed by pandemic influenza and mitigation strategies.

The evolving model of pediatric critical care delivery in North America.

The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.

Comparison of severity of illness scores to physician clinical judgment for potential use in pediatric critical care triage.

OBJECTIVE: A pediatric triage tool is needed during times of resource scarcity to optimize critical care utilization. This study compares the modified sequential organ failure assessment score (M-SOFA), the Pediatric Early Warning System (PEWS) score, the Pediatric Risk of Admission Score II (PRISA-II), and physician judgment to predict the need for pediatric intensive care unit (PICU) interventions. METHODS: This retrospective cohort study evaluates three illness severity scores for all non-neonatal pediatric patients transported and admitted to a single center in 2006. The outcome of interest was receipt of a PICU intervention (mechanical ventilation, acute dialysis, depressed consciousness, or persistent hypotension). Predictive ability was assessed using receiver operating curves (ROCs). RESULTS: Of 752 patients admitted to the hospital, 287 received a PICU intervention. Median scores for all tools were significantly higher for children receiving an intervention than for those who did not. ROCs showed PEWS had the least discriminatory ability, followed by PRISA-II and pediatric M-SOFA. No value of the pediatric M-SOFA produced both positive and negative predictive values better than clinician judgment. CONCLUSIONS: No score had a clinically acceptable discriminate ability to predict patients who required a PICU intervention from those who did not. Physician judgment outperformed all three triage scores.

Surgical ligation of a residually patent arterial duct following failed occlusion using transcatheter coils.

Transcatheter techniques for occlusion of the persistently patent arterial duct using coils have become standard therapy at many centers for pediatric cardiology, and in selected patients have demonstrated comparable efficacy to surgical ligation. Surgical ligation may still be required in many cases, including premature infants or those born with low weight, those with ducts of large diameter, those with associated structural heart disease, and in circumstances of unsuccessful occlusion subsequent to attempted closure using coils. We report on the successful surgical ligation of an arterial duct of moderate size that exhibited residual patency despite two separate attempts at occlusion using coils.