Objectives:
Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1mg, which corresponds to a weight of 100kg. Actual practice patterns are unknown.
Design:
Multi-center cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in pediatric intensive care units (PICUs). Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher’s exact test.
Setting:
Internet-based survey.
Subjects:
U.S. PICU representatives (one per institution) involved in resuscitation systems of care.
Interventions:
None.
Measurements and main results:
Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children’s hospitals or dedicated children’s hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%) and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 (94%) respondents report using patient weight, 23 (34%) patient age and 5 (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to <60kg, 17 (27%) at 60 to <80kg, 5 (8%) at 80 to <100kg and 8 (12%) at ≥100kg. Among those reporting using age, 4 (17%) switch at 14 to <16 years, 5 (22%) at 16 to <18 and 6 (26%) at ≥18. Twenty-nine (43%) respondents report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require ACLS certification for some/all code team responders compared to institutions that do not require ACLS certification (52% vs 22%, p = 0.02).
Conclusions:
The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.
INTRODUCTION: Pediatric severe sepsis (PSS) continues to be a major health problem. Extracorporeal therapies (ETs), defined as extracorporeal membrane oxygenation (ECMO) and RRenal replacement therapyenal replacement therapy (RRT), are becoming more available for utilization in a variety of health conditions. We aim to describe (1) rates of utilization of ET in PSS, (2) outcomes for PSS patients receiving ET, and (3) epidemiologic characteristics of patients receiving ET. METHODS: We conducted a retrospective review of a prospectively collected database. Data from the Pediatric Health Information System (PHIS) database collected by the Children's Hospital Association (CHA) from 2004-2012 from 43 US children's hospitals' pediatric intensive care units (PICUs) were used. Patients with PSS were defined by (1) International Classification of Diseases, 9th Revision (ICD-9) codes reflecting severe sepsis and septic shock and (2) ICD-9 codes of infection and organ dysfunction as defined by updated Angus criteria. Among the patients with PSS, those with a PHIS flag of ECMO or RRT were identified further as our main cohort. RESULTS: From 2004 to 2012, 636,842 patients were identified from 43 hospitals, and PSS prevalence was 7.7 % (49,153 patients). Nine point eight percent (4795 patients) received at least one form of ET, and the associated mortality rate was 39 %. Mortality rates were 47.8 % for those who received ECMO, 32.3 % in RRT, and 58.0 % in RRT + ECMO. Underlying co-morbidities were found in 3745 patients (78.1 %) who received ET (81 % for ECMO, 77.9 % in RRT, and 71.2 % in those who received both). There was a statistically significant increase in ECMO utilization in patients with at least three organ dysfunctions from 2004 to 2012 (6.9 % versus 10.3 %, P < 0.001) while RRT use declined (24.5 % versus 13.2 %, P < 0.001). After 2009, there was a significant increase in ECMO utilization (3.6 % in 2004-2008 versus 4.0 % in 2009-2012, P = 0.004). ECMO and RRT were used simultaneously in only 500 patients with PSS (1 %). CONCLUSIONS: ETs were used in a significant portion of PSS patients with multiple organ dysfunction syndrome (MODS) during this time period. Mortality was significant and increased with increasing organ failure. ECMO use in PSS patients with MODS increased from 2004 to 2012. Further evaluation of ET use in PSS is warranted.
Critically ill populations incur high levels of oxidative stress and commonly present with vitamin D deficiency. This study aimed to investigate the relationship between vitamin D status and plasma markers of glutathione (GSH) and cysteine (Cys) redox and immunity in critically ill children. This was a cross-sectional study of n = 50 PICU patients. Subjects were categorized according to their plasma 25-hydroxyvitamin D [25(OH)D] concentrations: (<20, 20–30, and ≥30 ng/dL). Plasma GSH, glutathione disulfide (GSSG), Cys, and cystine (CySS) were measured with high-performance liquid chromatography, and their associated redox potentials determined (EhGSSG and EhCySS, respectively). Plasma LL-37, an indicator of innate immune function, was assayed with ELISA. Data were analyzed using general linear regression before and after adjustment for age, sex, and race. Results showed that EhCySS was more reduced in subjects with plasma 25(OH)D concentrations ≥30 ng/mL compared to those with 25(OH)D concentrations <20 ng/mL (P = 0.009). Plasma GSH, GSSG, and total GSH decreased with increasing 25(OH)D category (P = 0.06, 0.03, and 0.01, respectively), and plasma glutamine levels were lowest in subjects with plasma 25(OH)D concentrations ≥30 ng/mL (P = 0.004). Plasma LL-37 concentrations did not significantly differ by vitamin D status (P = 0.08). In conclusion, vitamin D sufficiency was associated with more reduced plasma EhCySS, indicative of lower oxidative stress in critically ill children. Plasma GSH, GSSG, and glutamine, however, were lower in the vitamin D sufficient group. The role of vitamin D in maintaining redox status during pediatric critical illness requires further study.
Background
Oxidative stress is known to play a role in critical illness due to an imbalance in reactive oxygen species and reactive nitrogen species, and the body’s ability to detoxify pro-oxidants using small molecule anti-oxidants and anti-oxidant enzymes.
Objective
To compare the concentrations of plasma redox metabolites and redox potentials for the Cys/CySS and GSH/GSSG thiol/disulfide pairs in critically ill children with healthy control children.
Methods
We performed a prospective clinical observational study of children ages ≤18 years and weight ≥6 kg, who were hospitalized between January 2010 and April 2012 in a 30-bed multidisciplinary medical-surgical pediatric intensive care unit (PICU). We measured the plasma concentrations of Cys, CySS, GSH, and GSSG within the first 24 h of PICU arrival, and we calculated the redox potential for the Cys/CySS (Eh Cys/CySS) and GSH/GSSG (Eh GSH/GSSG) thiol/disulfide pairs in the plasma of 61 critically ill children and 16 healthy control children.
Results
Critically ill children have less Cys (p = 0.009), less CySS (p = 0.011), less Total Cys ([Cys] + 2[CySS], p = 0.01), more GSSG (p < 0.001), and more oxidized Eh GSH/GSSG (p < 0.001) compared to healthy children.
Conclusion
Our results demonstrate that in the presence of pediatric critical illness, the Total Cys/CySS thiol pool decreases while GSH is likely one component of the cellular redox system that reduces CySS back to Cys, thus maintaining Eh Cys/CySS. The Total Cys pool is more abundant than the Total GSH pool in the plasma of children. Further investigation is needed to elucidate the differences in redox potentials in subgroups of critically ill children, and to determine whether differences in redox metabolite concentrations and redox potentials correlate with severity of critical illness and clinical outcomes.
Introduction: The built environment may impact safety and decisions made during the design phases can have unintended downstream effects that lead to patient harm. These flaws within the system are latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) provides a clinical context to examine the environment for safety threats postconstruction. Integration of Failure Mode Effect Analysis (FMEA) with SbCST provides a framework to identify, categorize, and prioritize LSTs before patient exposure. Methods: We implemented SbCST in a newly constructed pediatric subspecialty outpatient center before opening. We used in-situ simulations to evaluate both routine and high-risk clinical scenarios pertinent to each clinical area. FMEA was used as a methodology to assign risk, prioritize, and categorize LSTs identified during the simulation. Results: Over 3 months, we conducted 31 simulated scenarios for 15 distinct subspecialty clinics involving 150 participants and 151 observers. We identified a total of 334 LSTs from 15 distinct clinics. LSTs were further classified into process/workflow, facility, resource, or clinical performance issues. Conclusions: Integration of SbCST and FMEA risk assessment is effective in evaluating a new space for safety threats, workflow, and process inefficiencies in the postconstruction environment, providing a framework for prioritizing issues with the greatest risk for harm.
Healthcare systems are urged to build facilities that support safe and efficient delivery of care. Literature demonstrates that the built environment impacts patient safety. Design decisions made early in the planning process may introduce flaws into the system, known as latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) has successfully been incorporated in the post-construction evaluation process in order to identify LSTs prior to patient exposure and promote preparedness, easing the transition into newly built facilities. As the application of simulation in healthcare extends into the realm of process and systems testing, there is a need for a standardized approach by which to conduct SbCST in order to effectively evaluate newly built healthcare facilities. This paper describes a systemic approach by which to conduct SbCST and provides documentation and evaluation tools in order to develop, implement, and evaluate a newly built environment to identify LSTs and system inefficiencies prior to patient exposure.
Behavioral and mental health (BMH) crises are rapidly growing in pediatric hospitals. These concerns are addressed within quality initiatives for improving safety culture, such as the integration of team principles to optimize performance and improve patient outcomes. Simulation methodologies support these goals through the application of an evidence-based team training framework in a safe learning environment. Performance is further enhanced through the identification of latent safety threats (LST) within processes to mitigate safety concerns. Simulation-based team training was conducted for the new Behavioral Emergency Response Team (BERT). This interdisciplinary team is trained to respond to pediatric behavioral and mental health crises and is composed of BMH nurses, security officers, and house supervisors.
The National Emergency Airway Registry for Children (NEAR4KIDS) Airway Safety Quality Improvement (QI) Bundle is a QI tool to improve the safety of tracheal intubations. The ability to achieve targeted compliance with bundle adherence is a challenge for centers due to competing QI initiatives, lack of interdisciplinary involvement, and time barriers. We applied translational simulations to identify safety and performance gaps contributing to poor compliance and remediate barriers by delivering simulation-based interventions. METHODS: This was a single-center retrospective review following translational simulations to improve compliance with the NEAR4KIDS bundle . The simulation was implemented between March 2018 and December 2018. Bundle adherence was assessed 12 months before simulation and 9 months following simulation. Primary outcomes were compliance with the bundle and utilization of apneic oxygenation. The secondary outcome was the occurrence of adverse tracheal intubation-associated events. RESULTS: Preintervention bundle compliance was 66%, and the application of apneic oxygenation was 27.9%. Following the simulation intervention, bundle compliance increased to 93.7% (P < 0.001) and adherence to apneic oxygenation increased to 77.9% (P < 0.001). There was no difference in the occurrence of tracheal intubation-associated events. CONCLUSIONS: Translational simulation was a safety tool that improved NEAR4KIDS bundle compliance and elucidated factors contributing to successful implementation. Through simulation, we optimized bundle customization through process improvement, fostered a culture of safety, and effectively engaged multidisciplinary teams in this quality initiative to improve adherence to best practices surrounding tracheal intubations.
Objective: To describe clinical factors associated with mortality and causes of death in tracheostomy-dependent (TD) children.
Methods: A retrospective study of patients with a new or established tracheostomy requiring hospitalization at a large tertiary children's hospital between 2009 and 2015 was conducted. Patient groups were developed based on indication for tracheostomy: pulmonary, anatomic/airway obstruction, and neurologic causes. The outcome measures were overall mortality rate, mortality risk factors, and causes of death.
Results: A total of 187 patients were identified as TD with complete data available for 164 patients. Primary indications for tracheostomy included pulmonary (40%), anatomic/airway obstruction (36%), and neurologic (24%). The median age at tracheostomy and duration of follow up were 6.6 months (IQR 3.5–19.5 months) and 23.8 months (IQR 9.9–46.7 months), respectively. Overall, 45 (27%) patients died during the study period and the median time to death following tracheostomy was 9.8 months (IQR 6.1–29.7 months). Overall survival at 1- and 5-years following tracheostomy was 83% (95% CI: 76–88%) and 68% (95% CI: 57–76%), respectively. There was no significant difference in mortality based on indication for tracheostomy (p = 0.35), however pulmonary indication for tracheostomy was associated with a shorter time to death (HR: 1.9; 95% CI: 1.04–3.4; p = 0.04). Among the co-morbid medical conditions, children with seizure disorder had higher mortality (p = 0.04).
Conclusion: In this study, TD children had a high mortality rate with no significant difference in mortality based on indication for tracheostomy. Pulmonary indication for tracheostomy was associated with a shorter time to death and neurologic indication was associated with lower decannulation rates.
Introduction The potential role for vitamin D in infection has been well described in adults. The objective of our study was to determine the prevalence of vitamin D insufficiency and to evaluate the relationship between vitamin D status and markers of innate immunity and infection in critically ill children. Hypothesis Vitamin D deficiency is highly prevalent in children with critical illness and correlates with the severity of illness and dysfunction in innate immunity.Methods We performed a prospective clinical observational study with both case and control groups in the pediatric intensive care unit (PICU). Vitamin D status was defined as vitamin D sufficient (25-hydroxyvitamin D (25(OH)D ≤ 20 ng/mL), vitamin D insufficient (25(OH)D 10-20 ng/mL), and vitamin D deficient (25(OH)D <10 ng/mL). Vitamin D status, severity of illness scores, and cathelicidin, and other clinical data were collected.Results Sixty-one PICU patients and 46 control patients were enrolled. Over 60% of the PICU cases were found to be vitamin D insufficient while less than 1/3 of the controls were insufficient (p < 0.0001). No significant correlation was seen between plasma 25(OH)D and any severity of illness scores. Cases with asthma had a significantly lower median level 25(OH)D (16.9 ng/mL) than cases without asthma (18.7 ng/mL). Over 50% of patients hospitalized during the fall and winter were considered vitamin D deficient or insufficient whereas in the sunnier seasons (spring and summer) the prevalence of vitamin D deficiency/insufficiency decreased to about 30% (p = 0.003).Conclusions Vitamin D deficiency is common in the pediatric critical care population. Significant seasonal differences were noted even in the critically ill. The role of vitamin D in certain diseases like asthma in critically ill children merit further study.