Background/Aims: Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. Methods: We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. Results: A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). Conclusions: More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.

Letter to the editor.

Objectives: To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders. Design: Mixed methods. Setting: Thirteen PICUs of the National Emergency Airway Registry for Children network. Intervention: Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks. Measurements and Main Results: Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182-781). Five sites were early (median, 153 d; interquartile range, 146-267) and eight sites were late adopters (median, 783 d; interquartile range, 773-845). Focus groups identified common "promoter" themes - interdisciplinary approach, influential champions, and quality improvement bundle customization - and "barrier" themes - time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention. Conclusions: Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

Objective: Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events. Design: Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium. Setting: Sedation services from academic, community, free-standing children's hospitals and pediatric wards within general hospitals. Patients: Children from birth to 21 years old or younger. Interventions: None. Measurements and Main Results: Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92-7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60-1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm. Conclusions: This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.

Objective: To derive and validate clinical prediction models to identify children at low risk of clinically significant intoxications for whom intensive care admission is unnecessary. Design: Retrospective review of data in the National Poison Data Systems from 2011 to 2014 and Georgia Poison Center cases from July to December 2016. Setting: United States PICUs and poison centers participating in the American Association of Poison Control Centers from 2011 to 2016. Patients: Children 18 years and younger admitted to a United States PICU following an acute intoxication. Interventions: None. Measurements and Main Results: The primary study outcome was the occurrence of clinically significant intoxications defined a priori as organ system-based clinical effects that require intensive care monitoring and interventions. We analyzed 70,364 cases. Derivation (n = 42,240; 60%) and validation cohorts (n = 28,124; 40%) were randomly selected from the eligible population and had similar distributions of clinical effects and PICU interventions. PICU interventions were performed in 1,835 children (14.1%) younger than 6 years, in 374 children (15.4%) 6-12 years, and in 4,446 children (16.5%) 13 years and older. We developed highly predictive models with an area under the receiver operating characteristic curve of 0.834 (< 6 yr), 0.771 (6-12 yr), and 0.786 (≥13 yr), respectively. For predicted probabilities of less than or equal to 0.10 in the validation cohorts, the negative predictive values were 95.4% (< 6 yr), 94.9% (6-12 yr), and 95.1% (≥ 13 yr). An additional 700 patients from the Georgia Poison Center were used to validate the model and would have reduced PICU admission by 31.4% (n = 110). Conclusions: These validated models identified children at very low risk of clinically significant intoxications for whom pediatric intensive care admission can be avoided. Application of this model using Georgia Poison Center data could have resulted in a 30% reduction in PICU admissions following intoxication.

Objective: Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs. Design: Retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from July 2010 to June 2015. Setting: Thirty-six PICUs/cardiac ICUs across the United States, Canada, Japan, New Zealand, and Singapore. Patients: Any patient admitted to a PICU or a pediatric cardiac ICU and undergoing tracheal intubation. Interventions: Use of direct laryngoscopy versus video laryngoscopy for tracheal intubation. Measurements and Main Results: There were 8,875 tracheal intubations reported in the National Emergency Airway Registry for Children database, including 7,947 (89.5%) tracheal intubations performed using direct laryngoscopy and 928 (10.5%) tracheal intubations performed using video laryngoscopy. Wide variability in video laryngoscopy use exists across PICUs (median, 2.6%; range, 0-55%). Video laryngoscopy was more often used in older children (p < 0.001), in children with history of a difficult airway (p = 0.01), in children intubated for ventilatory failure (p < 0.001), and to facilitate the completion of an elective procedure (p = 0.048). After adjusting for patient-level covariates, a secular trend, and site-level variance, the use of video laryngoscopy significantly increased over a 5-year period compared with fiscal year 2011 (odds ratio, 6.7; 95% CI, 1.7-26.8 for fiscal year 2014 and odds ratio, 11.2; 95% CI, 3.2-38.9 for fiscal year 2015). The use of video laryngoscopy was independently associated with a lower occurrence of tracheal intubation adverse events (adjusted odds ratio, 0.57; 95% CI, 0.42-0.77; p < 0.001) but not with a lower occurrence of severe tracheal intubation adverse events (adjusted odds ratio, 0.86; 95% CI, 0.56-1.32; p = 0.49) or fewer multiple attempts at endotracheal intubation (adjusted odds ratio, 0.93; 95% CI, 0.71-1.22; p = 0.59). Conclusions: Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.

Objectives: Acute intoxications in children account for 4.6% of annual admissions to the PICU. We aimed to describe the interventions and monitoring required for children admitted to the PICU following intoxications with the ultimate goal of determining patient and intoxication characteristics associated with the need for PICU interventions. Design: Retrospective review of prospectively collected data from Virtual Pediatric Systems, LLC. Setting: United States PICUs participating in the Virtual Pediatric Systems database from 2011 to 2014. Patients: Less than or equal to 18 years old admitted to a PICU with a diagnostic code for poisoning, ingestion, intoxication, or overdose. Interventions: None. Measurements and Main Results: In total, 12,021 patients were included with a median PICU length of stay of 0.97 days (interquartile range, 0.67-1.60). Seventy-eight percent of the intoxications were intentional. The top five classes of medications ingested were unknown substances (21.6%), antidepressants (11.5%), other chemicals (10.7%), analgesics (7.3%), and antihypertensives (6.2%). Seventy-six (0.61%) patients died. Any of the interventions reported in the Virtual Pediatric Systems database were performed in only 29.1% of the total cases. Conclusions: The majority of cases (70.9%) admitted to the PICU following an intoxication did not undergo any significant intervention. Future studies should focus on distinguishing patient and intoxication characteristics associated with need for PICU intervention to optimize patient safety and minimize resource burden.

Objectives: Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. Design: Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. Setting: Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. Patients: Children from birth to less than or equal to 21 years old. Interventions: None. Measurements and Main Results: A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. Conclusions: Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.