Academic Pediatric Intensive Care Unit Research Articles

Identifying high-risk central lines in critically ill children: a novel nurse-driven screening and mitigation intervention to reduce CLABSI

BackgroundDespite strong adherence to central line associated bloodstream infection (CLABSI) infection prevention bundles, the CLABSI rate in our academic pediatric intensive care unit (PICU) and pediatric cardiac intensive unit (PCICU) remained high. MethodsWe developed a novel screening tool that stratified patients' risk for CLABSI and considered risk-mitigation strategies. ResultsOf 1583 screenings, 30% were classified as high-risk, 27% as moderate-risk, and 43% as low-risk. With accurate screening, the tool was 100% sensitive to patients who developed CLABSI, with a negative predictive value of 100% for low-risk screens. The CLABSI rate declined from 1.83 per 1000 catheter-days to 0.98 and 1.02 in 2021 and 2022, respectively, with unprecedented consecutive months CLABSI free. Device utilization was stable across both units, declining by 22% in the PICU and rising in the PCICU with increased cardiac surgeries. Clinicians expressed increased awareness of patient CLABSI risk factors and mitigation strategies in surveys. DiscussionsThis novel screening tool effectively identified high-risk patients to target resources and promoted improvements in CLABSI-prevention processes in the PICU and PCICU. ConclusionsA novel nurse-driven CLABSI risk factor screening tool identified and focused resources on patients at high-risk for CLABSI, and increased awareness and proactive risk mitigation by clinicians.

Effect of Targeted Single-Dose Antibiotics to Reduce the Occurrence of Pediatric Central Line–Associated Bloodstream Infections Post Alteplase Administration

OBJECTIVE Previous studies have shown an association between alteplase for line clearance and central line–associated bloodstream infections (CLABSIs). The objective of this study was to evaluate the use of post-alteplase antibiotics as a CLABSI reduction strategy in pediatric intensive care unit (PICU) patients. METHODS This was a single center, retrospective, observational study evaluating PICU patients from ­January 1, 2014, through August 1, 2021, conducted at a tertiary academic PICU. Included in this study were critically ill patients who had 1 or more central venous lines (CVLs) requiring alteplase for line clearance. The primary objective was incidence of CLABSI occurrence post alteplase administration for CVL clearance, with or without targeted single-dose antibiotics (piperacillin-tazobactam or vancomycin) post alteplase. Secondary outcomes included evaluation of total alteplase administrations and risk factors associated with CLABSI occurrence. RESULTS Two hundred fifty patients were included, with 156 receiving alteplase only, 82 piperacillin-­tazobactam, and 12 vancomycin, and with median ages of 2.8, 3.8, and 3.8 years, respectively. Seven ­CLABSIs occurred in the alteplase-only group, with 0 incidences in both the piperacillin-tazobactam (exact OR, 0.12; exact 95% CI, <0.01–0.59; p < 0.01) and vancomycin (exact OR, 1.20; exact 95% CI, 0.03–9.80; p = 1.00) groups. Patients in the piperacillin-tazobactam group achieved statistical significance for CLABSI risk factors that may benefit by decreasing CLABSI incidence (p values <0.01–0.02). CONCLUSIONS Alteplase use has been associated with CLABSIs. Providing a single dose of post-alteplase antibiotics targeting the most likely site-specific pathogens may reduce the incidence of CLABSIs.

Development and testing of a deep learning algorithm to detect lung consolidation among children with pneumonia using hand-held ultrasound.

Severe pneumonia is the leading cause of death among young children worldwide, disproportionately impacting children who lack access to advanced diagnostic imaging. Here our objectives were to develop and test the accuracy of an artificial intelligence algorithm for detecting features of pulmonary consolidation on point-of-care lung ultrasounds among hospitalized children. This was a prospective, multicenter center study conducted at academic Emergency Department and Pediatric inpatient or intensive care units between 2018-2020. Pediatric participants from 18 months to 17 years old with suspicion of lower respiratory tract infection were enrolled. Bedside lung ultrasounds were performed using a Philips handheld Lumify C5-2 transducer and standardized protocol to collect video loops from twelve lung zones, and lung features at both the video and frame levels annotated. Data from both affected and unaffected lung fields were split at the participant level into training, tuning, and holdout sets used to train, tune hyperparameters, and test an algorithm for detection of consolidation features. Data collected from adults with lower respiratory tract disease were added to enrich the training set. Algorithm performance at the video level to detect consolidation on lung ultrasound was determined using reference standard diagnosis of positive or negative pneumonia derived from clinical data. Data from 107 pediatric participants yielded 117 unique exams and contributed 604 positive and 589 negative videos for consolidation that were utilized for the algorithm development process. Overall accuracy for the model for identification and localization of consolidation was 88.5%, with sensitivity 88%, specificity 89%, positive predictive value 89%, and negative predictive value 87%. Our algorithm demonstrated high accuracy for identification of consolidation features on pediatric chest ultrasound in children with pneumonia. Automated diagnostic support on an ultraportable point-of-care device has important implications for global health, particularly in austere settings.

Repositioning Guidelines to Decrease Pressure Injury in the Pediatric Intensive Care Unit: A Quality Improvement Project.

The purpose of this quality improvement (QI) project was to develop and implement repositioning guidelines that reduce pressure injury (PI) in hemodynamically unstable pediatric intensive care unit (PICU) patients. All PICU patient ages 0 to 36months who required sedation for invasive mechanical ventilation and had a Braden Q score≤18 were eligible for inclusion. The project was implemented in 116 patients preimplementation and 100 postimplementation. Their median t age was 5months (interquartile range 2-13months). The QI project setting was an academic hospital PICU with a Level I trauma center located in the Mid-Atlantic Region of the United States. A pre-post observational design was used to compare the at-risk population for 21weeks before (August-December 2018) and after (August-December 2019) implementing repositioning guidelines. Turn attempts were undertaken every 2hours. Repositioning attempts were defined as (1) full (30°); (2) partial (15°); (3) unable to turn owing to hemodynamic instability; or (4) noncompliance. The primary outcome was incidence of Stage II or higher PI. We found a significant reduction in the incidence of PI before and after implementation of the repositioning intervention (16.4% vs 2.0%, P =.0003). A structured intervention for repositioning hemodynamically unstable PICU patients has the potential to significantly lower PI incidence in a group of hemodynamically unstable children.

An evaluation of the outcomes associated with peritoneal catheter use in neonates undergoing cardiac surgery: A multicenter study

ObjectiveThe study objective was to determine if intraoperative peritoneal catheter placement is associated with improved outcomes in neonates undergoing high-risk cardiac surgery with cardiopulmonary bypass. MethodsThis propensity score–matched retrospective study used data from 22 academic pediatric cardiac intensive care units. Consecutive neonates undergoing Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery category 3 to 5 cardiac surgery with cardiopulmonary bypass at centers participating in the NEonatal and Pediatric Heart Renal Outcomes Network collaborative were studied to determine the association of the use of an intraoperative placed peritoneal catheter for dialysis or passive drainage with clinical outcomes, including the duration of mechanical ventilation. ResultsAmong 1490 eligible neonates in the NEonatal and Pediatric Heart Renal Outcomes Network dataset, a propensity-matched analysis was used to compare 395 patients with peritoneal catheter placement with 628 patients without peritoneal catheter placement. Time to extubation and most clinical outcomes were similar. Postoperative length of stay was 5 days longer in the peritoneal catheter placement cohort (17 vs 22 days, P = .001). There was a 50% higher incidence of moderate to severe acute kidney injury in the no-peritoneal catheter cohort (12% vs 18%, P = .02). Subgroup analyses between specific treatments and in highest risk patients yielded similar associations. ConclusionsThis study does not demonstrate improved outcomes among neonates with placement of a peritoneal catheter during cardiac surgery. Outcomes were similar apart from longer hospital stay in the peritoneal catheter cohort. The no-peritoneal catheter cohort had a 50% higher incidence of moderate to severe acute kidney injury (12% vs 18%). This analysis does not support indiscriminate peritoneal catheter use, although it may support the utility for postoperative fluid removal among neonates at risk for acute kidney injury. A multicenter controlled trial may better elucidate peritoneal catheter effects.

Assessing the health literacy of caregivers in the pediatric intensive care unit: a mixed-methods study.

Limited health literacy is associated with increased hospitalizations, emergency visits, health care costs, and mortality. The health literacy levels of caregivers of critically ill children are unknown. This mixed-methods study aims to quantitatively assess the health literacy of caregivers of children admitted to the pediatric intensive care unit (PICU) and qualitatively describe facilitators and barriers to implementing health literacy screening from the provider perspective. Caregivers of patients admitted to our large, academic PICU (between August 12, 2022 and March 31, 2023) were approached to complete a survey with the Newest Vital Sign (NVS), which is a validated health literacy screener offered in English and Spanish. We additionally conducted focus groups of interdisciplinary PICU providers to identify factors which may influence implementation of health literacy screening using the Consolidated Framework for Implementation Research (CFIR) framework. Among 48 surveyed caregivers, 79% demonstrated adequate health literacy using the Newest Vital Sign screener. The majority of caregivers spoke English (96%), were mothers (85%), and identified as White (75%). 83% of caregivers were able to attend rounds at least once and 98% believed attending rounds was helpful. Within the PICU provider focus groups, there were 11 participants (3 attendings, 3 fellows, 2 nurse practitioners, 1 hospitalist, 2 research assistants). Focus group participants described facilitators and barriers to implementation, which were mapped to CFIR domains. Timing of screening and person administering screening were identified as modifiable factors to improve future implementation. We found the health literacy levels of PICU caregivers in our setting is similar to prior assessments of parental health literacy. Participation in morning rounds was helpful for developing understanding of their child's illness, regardless of health literacy status. Qualitative feedback from providers identified barriers across all CFIR domains, with timing of screening and person administering screening as modifiable factors to improve future implementation.

Comfort and Coordination among Interprofessional Care Providers Involved in Intubations in the Pediatric Intensive Care Unit.

Successful execution of invasive procedures in acute care settings, including tracheal intubation, requires careful coordination of an interprofessional team. The stress inherent to the intensive care unit (ICU) environment may threaten the optimal communication and planning necessary for the safe execution of this complex procedure. The objective of this study is to characterize the perceptions of interprofessional team members surrounding tracheal intubations in the pediatric ICU (PICU). This is a single-center survey-based study of staff involved in the intubation of pediatric patients admitted to a tertiary level academic PICU. Physicians, nurses, and respiratory therapists (RT) involved in tracheal intubations were queried via standardized, discipline-specific electronic surveys regarding their involvement in procedural planning and overall awareness of and comfort with the intubation plan. Qualitative variables were assessed by both Likert scales and free-text comments that were grouped and analyzed thematically. One hundred and eleven intubation encounters were included during the study time period, of which 93 (84%) had survey responses from at least 2 professional teams. Among those included in the analysis, the survey was completed 244 times by members of the PICU teams including 86 responses from physicians, 76 from nurses, and 82 from RTs. Survey response rates were >80% from each provider team. There were significant differences in interprofessional team comfort with nurses feeling less well informed and comfortable with the intubation plan and process compared to physicians and RTs (p < 0.001 for both). Qualitative themes including clear communication, adequate planning and preparation prior to procedure initiation, and clear definition of roles emerged among both affirmative and constructive comments. Exploration of provider perceptions and emergence of constructive themes expose opportunities for teamwork improvement strategies involving intubations in the PICU. The use of a preintubation checklist may improve organization and communication amongst team members, increase provider morale, decrease team stress levels, and, ultimately, may improve patient outcomes during this high stakes, coordinated event.

Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients.

This study aimed to determine if a respiratory therapist (RT)-driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma. This was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of an RT-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. After PDSA 2, mean HFNC duration decreased (26.8-18.1 h). Mean PICU LOS decreased (41-31.8 h). Mean hospital LOS also decreased (86.5-68 h). These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use were unchanged, while IMV use decreased. An RT-driven HFNC protocol led to decreased length of HFNC and PICU and hospital LOS for pediatric patients with critical asthma without an increase in adverse events.

Heart Rate Variability in Children with Moderate and Severe Traumatic Brain Injury: A Prospective Observational Study

AbstractThe aim of this study was to assess the feasibility of continuous monitoring of heart rate variability (HRV) in children with traumatic brain injury (TBI) hospitalized in a pediatric intensive care unit (PICU) and collect preliminary data on the association between HRV, neurological outcome, and complications. This is a prospective observational cohort study in a tertiary academic PICU. Children admitted to the PICU ≤24 hours after moderate or severe TBI were included in the study. Children suspected of being brain dead at PICU entry or with a pacemaker were excluded. Children underwent continuous monitoring of electrocardiographic (ECG) waveforms over 7 days post-TBI. HRV analysis was performed retrospectively, using a standardized, validated HRV analysis software (CIMVA). The occurrence of medical complications (“event”: intracranial hypertension, cerebral hypoperfusion, seizure, and cardiac arrest) was prospectively documented. Outcome of children 6 months post-TBI was assessed using the Glasgow Outcome Scale – Extended Pediatric (GOS-E Peds). Fifteen patients were included over a 20-month period. Thirteen patients had ECG recordings available and 4 had &gt;20% of missing ECG data. When ECG was available, HRV calculation was feasible (average 88%; range 70–97%). Significant decrease in overall HRV coefficient of variation and Poincaré SD2 (p &lt; 0.05) at 6 hours post–PICU admission was associated with an unfavorable outcome (defined as GOS-E Peds ≥ 3, or a deterioration of ≥2 points over baseline score). Several HRV metrics exhibited significant and nonsignificant variation in HRV during event. This study demonstrates that it is feasible to monitor HRV in the PICU provided ECG data are available; however, missing ECG data are not uncommon. These preliminary data suggest that altered HRV is associated with unfavorable neurological outcome and in-hospital medical complications. Larger prospective studies are needed to confirm these findings and to explore if HRV offers reliable and clinically useful prediction data that may help clinical decision making.

843: VIDEO LARYNGOSCOPY AND TEAM DYNAMICS DURING INTUBATION

Introduction: Intubation in the pediatric intensive care unit (PICU) involves teamwork between a proceduralist and team leader. Improved team dynamics may minimize harm to patients during this high-risk procedure. Video laryngoscopy (VL) allows multiple team members to view the glottic anatomy. Although VL use has increased, little is known about its influence on team dynamics. Our aim was to compare cognitive load, team member stress, and provision of feedback during VL versus direct laryngoscopy (DL) intubations. Methods: We prospectively studied intubations performed by the critical care team for children < 18 years old in an academic PICU from November 2021 to May 2022. Proceduralists and team leaders completed brief surveys after each intubation. We defined cognitive load using the validated Paas scale (range: 0-9) and the NASA Task Load Index (NASA-TLX, range: 0-100 on each of six domains). Team members were also queried regarding stress levels, perceptions of feedback, and confidence in endotracheal tube placement. Chi squared analysis was used to compare DL and VL. Results: Among 45 intubations during the study period, 41 surveys were completed by the proceduralist and 39 surveys were completed by the team leader. When measured using the Paas scale, cognitive load did not differ between VL and DL for the proceduralist or the team leader (P>0.05). When measured using NASA-TLX, cognitive load only differed for the proceduralist in 2 domains: increased effort (62.7 with VL vs. 49.4 with DL, P=0.017) and reduced performance (41.9 with VL vs. 17.4 with DL, P=0.044). Stress levels did not differ between VL and DL (P>0.05). The proceduralist received feedback more often with VL than DL (100% vs. 68%, p=0.005), however the team lead did not perceive a difference in ease of giving feedback with VL versus DL (P>0.05). The team leader had increased confidence in correct endotracheal tube placement using VL versus DL (3 vs. 2.84, p = 0.04). Conclusions: Although VL allows for a shared mental model during intubation by projecting glottic anatomy onto a screen, its use does not reduce team stress or cognitive load. Furthermore, the proceduralist finds VL to require more effort and decrease performance compared to DL. This may be due to less familiarity with VL or use of VL in more clinically stressful situations.

970: PHYSIOLOGY-BASED VENTILATOR COMPUTER DECISION SUPPORT OUTPERFORMS CLINICIANS IN AN IN SILICO TRIAL

Introduction: Intensivists are routinely required to titrate alveolar minute ventilation based on blood gas information. Survey data show that intensive care trainees feel insufficiently trained in ventilator management. Bedside decision support has the potential to facilitate more efficient ventilator titration and serve as a teaching tool for trainees. Methods: We developed an online ventilator calculator based upon arterial partial pressure of carbon dioxide (PaCO2) and Henderson-Hasselbalch equations, allowing clinicians to input ventilator parameters as well as current and desired blood gas information. We validated predictions among arterial blood gas (ABG) values from a single quaternary academic pediatric intensive care unit (PICU). We included all ABG values obtained between 1/1/2010 and 12/31/2020 among PICU patients receiving invasive pressure control, volume control, or volume targeted ventilation and concurrent pharmacologic muscle relaxation with a repeat blood gas analysis within 1-24 hours. We excluded ABGs from patients on extracorporeal support. We subsequently performed a retrospective in-silico trial on a subset of ABGs meeting criteria for ventilator weaning (pCO2 < 30 and pH > 7.35 or pCO2 < 50 and pH > 7.50) or escalation (pCO2 > 50 and pH < 7.30 or pCO2 > 45 and pH < 7.20), excluding patients with traumatic brain injury. Clinician behavior was compared against calculator recommendations, with a goal of achieving an ABG value that met neither weaning nor escalation criteria. Results: There were 16,835 included ABGs among 664 patients, with a median (IQR) time between ABGs of 3.8 (2.2-4.4) hours. The median (IQR) difference between predicted and actual PaCO2 values was 0.00 (-3.06-3.00) mmHg. 11,460/16,835 (68.1%) PaCO2 values were within 5 mmHg of predicted, and 14,902/16,835 (88.5%) were within 10 mmHg. There were 2,433 ABGs among 350 patients included in the in-silico trial. Calculator recommendations were preferable to clinician behavior in 1,149/1,534 (74.9%) weaning scenarios and 605/899 (67.3%) escalation scenarios. Conclusions: Computer decision support outperformed clinician actions in this retrospective in-silico trial and may provide a useful teaching tool for trainees. Prospective study is needed to determine feasibility and user satisfaction.

607: IMPLEMENTING A HIGH-FLOW NASAL CANNULA HOLIDAY AND DISCHARGE CRITERIA FOR BRONCHIOLITIS PATIENTS

Introduction: Costs for bronchiolitis have risen over the years. Previous studies have shown that respiratory therapist (RT) driven high flow nasal cannula (HFNC) management protocols can decrease length of HFNC as well as pediatric intensive care unit (PICU) and hospital length of stay (LOS). The aim of this study was to determine if modifications to an existing RT-driven HFNC management protocol could further safely decrease length of HFNC and PICU and hospital LOS. Methods: This is a quality improvement project performed at a quaternary academic PICU. This study included patients less than 24 months of age admitted to the PICU with an admission diagnosis of bronchiolitis requiring HFNC. After initial implementation of a (RT)-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. Duration of HFNC was used as the primary outcome measure and PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use and 7-day PICU and hospital readmission rates were used as balancing measures. Results: A total of 1,310 patients were included. Patients in PDSA 2, PDSA 3&4 groups were older compared to pre-intervention and PDSA 1 (median of 9 and 10 months compared to 8 months, p=0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2 and 1.5 days after PDSA 3&4. Hospital LOS decreased from 5.7 days to 4.5 days after PDSA 1, 3.1 days after PDSA 2 and 2.7 days after PDSA 3&4. The use of non-invasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at end of the project. The 7-day PICU and hospital readmission rates did not increase. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. Conclusions: Modifications to an existing RT-driven HFNC protocol and standardized discharge criteria led to an improvement in bronchiolitis patients’ outcomes without an increase in adverse events.

Adverse Childhood Experiences and Patient-Reported Outcome Measures in Critically Ill Children.

Adverse childhood experiences (ACEs) are linked to adverse health outcomes for adults and children in the United States. The prevalence of critically ill children who are exposed to ACEs is not known. Our objective was to compare the frequency of ACEs of critically ill children with that of the general pediatric population of Georgia and the United States using publicly available National Survey of Children’s Health (NSCH) data. The impact of ACEs on patient-reported outcome measures of emotional, social, and physical health in critically ill children is not known. We sought to determine whether a higher total number of ACEs was associated with poorer patient-reported measures of emotional, social, and physical health. We conducted a prospective cross-sectional study of children < 18 years of age who were admitted to a 36-bed free-standing, quaternary academic pediatric intensive care unit in Atlanta, Georgia from June 2020—December 2021. Parents of patients who were admitted to the pediatric intensive care unit completed a survey regarding their child’s ACEs, health care use patterns, and patient-reported outcome measures (PROMIS) of emotional, social, and physical health. Prevalence estimates of ACEs were compared with national and state data from the NSCH using Rao-Scott Chi-square tests. PROMIS measures reported within the PICU cohort were compared with population normed T-scores. The association of cumulative ACEs within the PICU cohort with patient-reported outcomes of emotional, social, and physical health were evaluated with a t-test. Among the 84 participants, 54% had ≥ 1 ACE, 29% had ≥ 2 ACEs, and 10% had ≥ 3 ACEs. Children with ≥ 2 ACEs had poorer anxiety and family relationship T-scores compared to those with ≤ 1 ACE. Given the high burden of ACEs in critically ill children, screening for ACEs may identify vulnerable children that would benefit from interventions and support to mitigate the negative effects of ACEs and toxic stress on emotional, social, and physical health.

Italian Version of the Cornell Assessment of Pediatric Delirium: Evaluation of the Scale Reliability and Ability to Detect Delirium Compared to Pediatric Intensive Care Unit Physicians Clinical Evaluation

BackgroundDelirium is an acute brain dysfunction associated with increased length of hospitalization, mortality, and high healthcare costs especially in patients admitted to the pediatric intensive care unit (PICU). The Cornell Assessment of Pediatric Delirium (CAPD) is a screening tool for evaluating delirium in pediatric patients. This tool has already been used and validated in other languages but not in Italian.ObjectivesTo test the reliability of the Italian version of the CAPD to screen PICU patients for delirium and to assess the agreement between CAPD score and PICU physician clinical evaluation of delirium.MethodsProspective double-blinded observational cohort study of patients admitted to a tertiary academic center PICU for at least 48 h from January 2020 to August 2021. We evaluated intra- and inter-rater agreement using the Intraclass Correlation Coefficient (ICC). The ability of the scale to detect delirium was evaluated by comparing the nurses’ CAPD assessments with the clinical evaluation of a PICU physician with expertise in analgosedation using the area under the ROC curve (AUC).Measurements and Main ResultsSeventy patients were included in the study. The prevalence of pediatric delirium was 54% (38/70) when reported by a positive CAPD score and 21% (15/70) when diagnosed by the PICU physician. The CAPD showed high agreement levels both for the intra-rater (ICC 1 0.98, 95% CI: 0.97–0.99) and the inter-rater (ICC 2 0.93, 95% CI: 0.89–0.96) assessments. In patients with suspected delirium according to the CAPD scale, the observed sensitivity and specificity of the scale were 0.93 (95% CI: 0.68–1.00) and 0.56 (95% CI: 0.42–0.70), respectively. The AUC observed was 0.75 (95% CI: 0.66–0.8490).ConclusionThe Italian version of the CAPD seems a reliable tool for the identification of patients at high risk of developing delirium in pediatric critical care settings. Compared to the clinical evaluation of the PICU physician, the use of the CAPD scale avoids a possible underestimation of delirium in the pediatric population.

Simulation-Facilitated Education for Pediatric Critical Care Nurse Practitioners' Airway Management Skills: A 10-Year Experience

AbstractThis study aimed to describe the process of the development and implementation with report of our 10-year experience with a simulation-facilitated airway management curriculum for pediatric acute care nurse practitioners in a large academic pediatric intensive care unit. This is a retrospective observational study. The study was conducted at a single-center quaternary noncardiac pediatric intensive care unit in an urban children's hospital in the United States. A pediatric critical care airway management curriculum for nurse practitioners consisting 4 hours of combined didactic and simulation-facilitated education followed by hands-on experience in the operating room. Tracheal intubations performed by nurse practitioners in the pediatric intensive care unit were tracked by a local quality improvement database, NEAR4KIDS from January 2009 to December 2018. Since curriculum initiation, 39 nurse practitioners completed the program. Nurse practitioners functioned as the first provider to attempt intubation in 473 of 3,128 intubations (15%). Also, 309 of 473 (65%) were successful at first attempt. Implementation of a simulation-facilitated pediatric airway management curriculum successfully supported the ongoing airway management participation and first attempt intubation success by nurse practitioners in the pediatric intensive care unit over the 10-year period.

Temperature Trajectory Sub-phenotypes and the Immuno-Inflammatory Response in Pediatric Sepsis.

Heterogeneity has hampered sepsis trials, and sub-phenotyping may assist with enrichment strategies. However, biomarker-based strategies are difficult to operationalize. Four sub-phenotypes defined by distinct temperature trajectories in the first 72 h have been reported in adult sepsis. Given the distinct epidemiology of pediatric sepsis, the existence and relevance of temperature trajectory-defined sub-phenotypes in children is unknown. We aimed to classify septic children into de novo sub-phenotypes derived from temperature trajectories in the first 72 h, and compare cytokine, immune function, and immunometabolic markers across subgroups. This was a secondary analysis of a prospective cohort of 191 critically ill septic children recruited from a single academic pediatric intensive care unit. We performed group-based trajectory modeling using temperatures over the first 72 h of sepsis to identify latent profiles. We then used mixed effects regression to determine if temperature trajectory-defined sub-phenotypes were associated with cytokine levels, immune function, and mitochondrial respiration. We identified four temperature trajectory-defined sub-phenotypes: hypothermic, normothermic, hyperthermic fast-resolvers, and hyperthermic slow-resolvers. Hypothermic patients were less often previously healthy and exhibited lower levels of pro- and anti-inflammatory cytokines and chemokines. Hospital mortality did not differ between hypothermic children (17%) and other sub-phenotypes (3-11%; P = 0.26). Critically ill septic children can be categorized into temperature trajectory-defined sub-phenotypes that parallel adult sepsis. Hypothermic children exhibit a blunted cytokine and chemokine profile. Group-based trajectory modeling has utility for identifying subtypes of clinical syndromes by incorporating readily available longitudinal data, rather than relying on inputs from a single timepoint.

Sepsis-Related Brain MRI Abnormalities Are Associated With Mortality and Poor Neurological Outcome in Pediatric Sepsis

BackgroundIt is not known whether brain magnetic resonance imaging (MRI) abnormalities in pediatric sepsis are associated with clinical outcomes. Study objectives were to (1) determine the prevalence and type of sepsis-related neuroimaging abnormalities evident on clinically indicated brain MRI in children with sepsis and (2) test the association of these abnormalities with mortality, new disability, length of stay (LOS), and MRI indication. MethodsRetrospective cohort study of 140 pediatric patients with sepsis and a clinically indicated brain MRI obtained within 60 days of sepsis onset at a single, large academic pediatric intensive care unit (PICU). Two radiologists systematically reviewed the first post-sepsis brain MRI and determined which abnormalities were sepsis-related. Outcomes compared in patients with versus without sepsis-related MRI abnormalities. ResultsPICU mortality was 7%. Thirty patients had one or more sepsis-related MRI abnormality, yielding a prevalence of 21% (95% confidence interval 15%, 28%). Among those, 53% (16 of 30) had sepsis-related white matter signal abnormalities; 53% (16 of 30) sepsis-related ischemia, infarction, or thrombosis; and 27% (eight of 30) sepsis-related posterior reversible encephalopathy. Patients with one or more sepsis-related MRI abnormality had increased mortality (17% vs 5%; P = 0.04), new neurological disability at PICU discharge (32% vs 11%; P = 0.03), and longer PICU LOS (median 18 vs 11 days; P = 0.04) compared with patients without. ConclusionsIn children with sepsis and a clinically indicated brain MRI, 21% had a sepsis-related MRI abnormality. Sepsis-related MRI abnormalities were associated with increased mortality, new neurological disability, and longer PICU LOS.

Patterns of Delirium in a Pediatric Intensive Care Unit and Associations With Noise Pollution.

Objective: Delirium is a common problem in the Pediatric Intensive Care Unit (PICU) and is associated with increased length of stay, cost and mortality. This study evaluated the relationship between noise pollution and delirium risk. Design: This is a Quality Improvement (QI) initiative at an academic PICU. Sound levels were monitored and patients were screened for delirium using the Cornell Assessment of Pediatric Delirium (CAPD). Setting PICU Patients: All PICU patients Interventions: None Measurements and Main Results: Over the 83-week study period (2015-2017), the median [IQR] CAPD score was 8 [3 to 14]. Nursing compliance with the CAPD was 72.2%. The proportion of patients screening positive for delirium (CAPD ≥ 9) was 45.9%. A total of 329 711 hly decibel (dB) measurements were collected and reported. Occupied rooms were louder than unoccupied rooms (51.8 [51.6-51.9] dB vs. 49.8 [49.7-49.9] dB, respectively, p < 0.001). Days (10 AM to 4 PM) were louder than nights (11 PM to 5 AM) (52.8 [52.7-53.0] dB vs. 50.7 [49.9-51.5] dB, respectively p < 0.001) in occupied rooms. Winter (Nov-Feb) months were louder than summer (May-Aug) months (52.0 [51.8-52.3] dB vs. 51.5 [51.3-51.7] dB, respectively, p < 0.002) in occupied rooms. Median weekly nighttime noise levels and CAPD scores demonstrated a correlation coefficient of 0.6 (p < 0.001). Median weekly risk of mortality (ROM) and CAPD scores demonstrated a correlation coefficient of 0.15 (p < 0.01). Conclusions: Significant noise pollution exists in the PICU with a moderate correlation between nighttime noise levels and CAPD scores. This could potentially implicate noise pollution as a risk factor for the development of delirium.

Early Prediction of Multiple Organ Dysfunction in the Pediatric Intensive Care Unit.

Objective: The objective of the study is to build models for early prediction of risk for developing multiple organ dysfunction (MOD) in pediatric intensive care unit (PICU) patients.Design: The design of the study is a retrospective observational cohort study.Setting: The setting of the study is at a single academic PICU at the Johns Hopkins Hospital, Baltimore, MD.Patients: The patients included in the study were <18 years of age admitted to the PICU between July 2014 and October 2015.Measurements and main results: Organ dysfunction labels were generated every minute from preceding 24-h time windows using the International Pediatric Sepsis Consensus Conference (IPSCC) and Proulx et al. MOD criteria. Early MOD prediction models were built using four machine learning methods: random forest, XGBoost, GLMBoost, and Lasso-GLM. An optimal threshold learned from training data was used to detect high-risk alert events (HRAs). The early prediction models from all methods achieved an area under the receiver operating characteristics curve ≥0.91 for both IPSCC and Proulx criteria. The best performance in terms of maximum F1-score was achieved with random forest (sensitivity: 0.72, positive predictive value: 0.70, F1-score: 0.71) and XGBoost (sensitivity: 0.8, positive predictive value: 0.81, F1-score: 0.81) for IPSCC and Proulx criteria, respectively. The median early warning time was 22.7 h for random forest and 37 h for XGBoost models for IPSCC and Proulx criteria, respectively. Applying spectral clustering on risk-score trajectories over 24 h following early warning provided a high-risk group with ≥0.93 positive predictive value.Conclusions: Early predictions from risk-based patient monitoring could provide more than 22 h of lead time for MOD onset, with ≥0.93 positive predictive value for a high-risk group identified pre-MOD.

Implementation of a Follow-Up System for Pediatric Sepsis Survivors in a Large Academic Pediatric Intensive Care Unit.

Background: Survivors of pediatric sepsis often develop new morbidities and deterioration in quality of life after sepsis, leading to a need for improved follow-up for children who survive sepsis.Objective: To implement a follow-up system for pediatric sepsis survivors in a pediatric health system.Methods: We performed a retrospective case series of patients treated for sepsis from October 2018 through October 2019 in a pediatric intensive care unit in a quaternary children's hospital, and describe implementation of a follow-up system for sepsis survivors. Program planning started in 2017 with multidisciplinary meetings including physical, occupational, and speech therapists, teachers, neuropsychologists, and coordinators from other survivorship programs (neonatology, stroke, and oncology). In 2018, a workshop was held to consult with local and national experts. The Pediatric Sepsis Survivorship Program launched in October 2018 led by a nurse coordinator who met with families to educate about sepsis and offer post-discharge follow-up. Patients with high pre-existing medical complexity or established subspecialty care were referred for follow-up through existing care coordination or subspecialty services plus guidance to monitor for post-sepsis morbidity. For patients with low-moderate medical complexity, the nurse coordinator administered a telephone-based health-assessment 2–3 months after discharge to screen for new physical or psychosocial morbidity. Patients flagged with concerns were referred to their primary physician and/or to expedited neuropsychological evaluation to utilize existing medical services.Results: Of 80 sepsis patients, 10 died, 20 were referred to care coordination by the program, and 13 had subspecialty follow-up. Five patients were followed in different health systems, four were adults not appropriate for existing follow-up programs, four remained hospitalized, and four were missed due to short stay or unavailable caregivers. The remaining 20 patients were scheduled for follow-up with the Pediatric Sepsis Program. Nine patients completed the telephone assessment. Four patients were receiving new physical or occupational therapy, and one patient was referred for neuropsychology evaluation due to new difficulties with attention, behavior, and completion of school tasks.Conclusions: Implementation of an efficient, low-cost pediatric sepsis survivorship program was successful by utilizing existing systems of care, when available, and filling a follow-up gap in screening for select patients.