Division Of Critical Care Medicine Research Articles

I Make a Lap.

Department of Pediatrics, Division of Critical Care Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Dr. Wolf has disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected]

Consent for the Apnea Test: Asking the Wrong Question.

1 Division of Critical Care Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada. 2 John Dossetor Health Ethics Center, University of Alberta, Edmonton, AB, Canada. *See also p. 399. Dr. Joffe has disclosed that he does not have any potential conflicts of interest.

Models for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine

HomeCirculationVol. 147, No. 3Models for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine No AccessArticle CommentaryRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessFull TextModels for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine Patrick R. Lawler, MD, MPH Patrick R. LawlerPatrick R. Lawler Correspondence to: Patrick R. Lawler, MD, MPH, Peter Munk Cardiac Center, Toronto General Hospital, RFE3-410, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4. Email: E-mail Address: [email protected] https://orcid.org/0000-0001-5155-5071 Peter Munk Cardiac Centre, Toronto General Hospital; and Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada. Search for more papers by this author Originally published17 Jan 2023https://doi.org/10.1161/CIRCULATIONAHA.122.061231Circulation. 2023;147:187–189FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at www.ahajournals.org/journal/circFor Sources of Funding and Disclosures, see page 189.Correspondence to: Patrick R. Lawler, MD, MPH, Peter Munk Cardiac Center, Toronto General Hospital, RFE3-410, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4. Email: patrick.[email protected]ca

What Are Adaptive Platform Clinical Trials and What Role May They Have in Cardiovascular Medicine?

HomeCirculationVol. 145, No. 9What Are Adaptive Platform Clinical Trials and What Role May They Have in Cardiovascular Medicine? No AccessArticle CommentaryRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessFull TextWhat Are Adaptive Platform Clinical Trials and What Role May They Have in Cardiovascular Medicine? Patrick R. Lawler, MD, MPH, Judith S. Hochman, MD, MA and Ryan Zarychanski, MD, MSc Patrick R. LawlerPatrick R. Lawler Correspondence to: Patrick R. Lawler, MD, MPH, Peter Munk Cardiac Centre, Toronto General Hospital, RFE3-410, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5155-5071 Peter Munk Cardiac Centre, Toronto General Hospital, Canada (P.R.L.). Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.). Search for more papers by this author , Judith S. HochmanJudith S. Hochman https://orcid.org/0000-0002-5889-5981 Cardiovascular Clinical Research Center and Division of Cardiology, New York University Langone Health, New York University Grossman School of Medicine (J.S.H.). Search for more papers by this author and Ryan ZarychanskiRyan Zarychanski University of Manitoba, Max Rady College of Medicine, Department of Internal Medicine, Sections of Hematology/Medical Oncology and Critical Care, Winnipeg, Canada (R.Z). CancerCare Manitoba, Department of Medical Oncology and Hematology, Winnipeg, Canada (R.Z.). Search for more papers by this author Originally published28 Feb 2022https://doi.org/10.1161/CIRCULATIONAHA.121.058113Circulation. 2022;145:629–632FootnotesCirculation is available at www.ahajournals.org/journal/circThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 632.Correspondence to: Patrick R. Lawler, MD, MPH, Peter Munk Cardiac Centre, Toronto General Hospital, RFE3-410, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4. Email patrick.[email protected]ca

Quality Improvement Studies in Pediatric Critical Care Medicine.

1 Division of Neonatology, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH 2 John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality and Safety; Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected]

In Response.

Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Patient Blood Management Program, Mayo Clinic, Rochester, Minnesota, [email protected] Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Funding: M.A.W. is supported by the Clinical and Translational Sciences Award (CTSA) grant number KL2 TR002379 from the National Center for Advancing Translational Science (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

Reducing Mortality From Motor Vehicle Crashes in Rural Communities.

Injuries are the leading cause of pediatric mortality, and motor vehicle crashes are the most common cause of injury.1 Efforts to ameliorate morbidity and mortality from these crashes have been focused on both prevention and optimizing care for those who are injured. Although preventive measures in the United States have decreased the number of pediatric deaths, our rate of improvement is lower than that of 19 comparable industrialized nations.2 In addition, although the advent of regional trauma centers has improved outcomes after an injury, the systems of care are not yet leveraged to their full potential and often are not readily accessible to those in rural areas. In this issue of Pediatrics , Mokdad et al3 highlight the disparities in outcomes between children injured in motor vehicle crashes in urban versus rural areas using the Fatality Analysis Reporting System database (years 2010–2017). The authors document higher mortality rates in rural counties and demonstrate lower mortality rates in counties with a regional trauma center. These findings are consistent with decades of literature revealing similar results from the United States and internationally.4–6 It is well known that children … Address correspondence to John Holcroft, MD, Division of Critical Care Medicine, Department of Pediatrics, University of California, Davis, 2556 Stockton Blvd, Sacramento, CA 95827. E-mail: jholcroft{at}ucdavis.edu

The authors reply

Mayo Clinic, Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Rochester, MN; Mayo Clinic, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rochester, MN The authors have disclosed that they do not have any potential conflicts of interest.

Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation.

The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists. An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists. Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models. Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review. Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records. Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

397: ASSOCIATION BETWEEN ETHNICITY AND GOALS OF CARE: ANALYSIS OF INTERHOSPITAL VARIABILITY

1MD, Toronto, ON 2University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Canada 3Programme in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Ce, Toronto, Ontario 4Sunnybrook Hospital, University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, ON

Nutritional Status and Outcomes in Pediatric Severe Sepsis-Size Matters.

Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital; and Harvard Medical School, Boston, MA *See also p. e1029. Dr. Mehta receives royalties for textbooks Pediatric Critical Care Nutrition and Roger’s Textbook of Pediatric Intensive Care.

Lessons From the 2013 Boston Marathon: Incorporating Residents Into Institutional Emergency Plans

* Abbreviations: BCH — : Boston Children’s Hospital BMC — : Boston Medical Center EPP — : emergency preparedness plan When 2 pressure-cooker bombs exploded during the 2013 Boston Marathon, first responders and hospitals across the city coordinated a swift and effective response, caring for 264 patients across 26 local hospitals.1 Residents from the Boston Combined Residency Program were staffing 3 of these hospitals, whereas others were watching or running the marathon. Shortly after the bombings, overwhelmed by call volumes, cellular service went down across Boston. Our program was challenged by hampered communication with residents. Beyond difficulties with communication, the residents’ role in the disaster response was unclear. Well-intentioned residents wanted to help out, but didn’t know how, which added a layer of confusion that is common in disaster scenarios. Would residents be expected to provide surge staffing, and who would make that determination? Would all residents participate or just the most experienced? Later in the week, a citywide manhunt led to “shelter in place” orders, with all civilians mandated to remain inside while law enforcement worked to locate the bombing suspects. With this development, a new set of questions arose. What was the best way to find a balance between patient safety and residents’ personal safety? Could trainees be asked to work beyond scheduled shifts? Should trainees be asked to commute to work during … Address correspondence to Katherine R. Schlosser, MD, Division of Critical Care Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: katherine.schlosser{at}childrens.harvard.edu

Conventional Versus Video Laryngoscopy for Tracheal Tube Exchange

*Department of Anesthesiology and Division of Critical Care Medicine (Surgery), Hartford Hospital, Hartford, CT; and †Biostatistics Center, George Washington University, Rockville, MD.

Detection Versus Infection; What Is the Difference?*

Division of Critical Care Medicine, Children’s National Health System, Washington, DC See also p. e201. Dr. Spaeder received support for travel from the Society of Critical Care Medicine (Travel accommodations for faculty presentation at SCCM Current Concepts in Pediatric Critical Care [1/18/13]) and from The National Center for the Study of Preparedness and Catastrophic Event Response (Travel accommodations for Expert Panel on Pediatric Surge Capacity and Reverse Triage [4/29/13]).

709

1Keenan Research Center for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada 2Beatrix Children’s Hospital/ University Medical Center, Groningen, Netherlands 3Critical Care, Anesthesiology, Peri-operative medicine & Emergency medicine, the University of Groningen, Groningen, Netherlands 4University of Toronto, Toronto, ON, Canada 5Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada 6St. Michael’s Hospital, Toronto, ON, Canada

The authors reply

Department of Intensive Care Medicine, Raymond Poincaré Hospital, Garches, France; Division of Critical Care Medicine, Cooper Medical School of Rowan University, Cooper Health Systems, Camden, NJ The authors have disclosed that they do not have any potential conflicts of interest.

New concepts in predicting, evaluating, and managing neurodevelopmental outcomes in children with congenital heart disease

Over the last two decades advances in congenital heart surgery, pediatric cardiology, and pediatric intensive care have dramatically increased the survival of infants with critical congenital heart disease (CHD). Survivors often experience neurodevelopmental deficits and behavioral and emotional problems. These complications often have a profound impact on quality of life in this high-risk population. This review will focus on the most significant and innovative studies that have been published over the last 18 months that focus on predicting, evaluating, and managing neurodevelopmental outcomes in children with CHD. Recent reports demonstrate new potential predictors of worse neurodevelopmental outcome, including abnormal fetal cerebrovascular resistance, brain biomarkers, and abnormalities in electroencephalogram (EEG) during the perioperative period, and new stratification schemata. In addition, a new evidence-based scientific statement from the American Heart Association (AHA) and American Academy of Pediatrics (AAP) describing how to evaluate and manage neurodevelopmental outcomes in children and adolescents with CHD and novel interventions to improve neurodevelopmental outcomes will be reviewed. The literature reviewed reveals new intervention opportunities to improve neurodevelopmental outcome in the fetus (cerebrovascular resistance), during the perioperative period (brain biomarkers and EEG), and through the utilization of new stratification schemata. The new AHA/AAP guidelines on the evaluation and management of neurodevelopmental outcomes create the opportunity to identify and treat a significant population of survivors with neurodevelopmental deficits with novel interventions.

Paralytics Use Should be Cautioned in the Prediction for Prognosis After Hypoxic Injury

Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pediatrics, Division of Critical Care Medicine and Neonatology, Taipei City Hospital-Branch for Women and Children, Taipei, Taiwan; Department of Pediatrics, Division of Critical Care Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan The authors have disclosed that they do not have any potential conflicts of interest.

The Blind Physicians and the Elephant on Extracorporeal Membrane Oxygenation*

Translational Research Program, Division of Critical Care Medicine, Department of Pediatrics, Washington University in St Louis, St Louis Children’s Hospital, St Louis, MO *See also p. e77. Dr. Spinella receives support, with research material only, from Haemonetics and Roche.

Acute kidney injury: We’ve got the diagnosis, now what?

In 2004, our understanding of the impact of kidney injury on patient outcome received a huge fillip with the publication of the Risk, Injury, Failure, Loss, and End-stage renal disease (RIFLE) criteria. A multinational group of experts calling themselves the Acute Dialysis Quality Initiative (ADQI) created a new diagnostic classification that pulled together terms such as acute renal dysfunction and acute renal failure into one category, i.e., acute kidney injury (AKI). Based on changes in renal function that occurred over one week, three categories of AKI (Risk, Injury, and Failure) were defined by a) an incremental increase or threshold serum creatinine (SCr) or a decrease in the estimated glomerular filtration rate (eGFR) calculated from SCr; and b) the degree and duration of oliguria. Two additional categories (Loss and End-stage renal disease) were defined by the presence of established AKI for four weeks or three months, respectively. Subsequently, the ADQI coalesced into the Acute Kidney Injury Network (AKIN), and in 2007, published a new, simpler, three-stage definition known as the AKIN criteria (Table 1). These criteria are defined over 48 hr, making them more pertinent to the rapid diagnosis of AKI. The eGFR was discarded in favour of SCr alone, and definitions related to the duration of established AKI were dropped completely. Based on more recent evidence of the adverse impact on outcome of even slight increases in SCr, Stage 1 AKI is defined by as little as a 26.4 lmol L (0.3 mg dL) increase in SCr. The oliguria criteria in AKIN remain virtually unchanged from the RIFLE criteria, except for shorter and stricter thresholds in Stage 3. Subsequently, the AKIN criteria have achieved widespread acceptance in clinical medicine as well as outcomes research. In this issue of the Journal, Odutayo et al. publish the results of a prospective epidemiologic 30-day study on the impact of AKI in 603 patients admitted to intensive care units (ICUs) in five Canadian hospitals. This compelling study highlights the extraordinarily adverse effect that AKI has on patient outcomes. Using AKIN criteria, the authors found that a little more than a quarter of ICU patients developed AKI, which was associated with an almost fourfold increase in 30-day mortality (29.2% vs 8.6% in patients without AKI). About 60% of patients had Stage 1 AKI, with an equal distribution of Stage 2 and 3 AKI between the remaining 40%. Mortality increased significantly with the severity of AKI (Stage 1, 19.2%; Stage 2, 37.9%; Stage 3, 51.5%). The authors also evaluated the risk factors associated with AKI in the ICU population that they studied. Perhaps unsurprisingly, there were significant associations of AKI with increasing age, male sex, and cardiovascular and metabolic disease (hypertension, diabetes, coronary artery disease). Patients who developed AKI were more likely to be on mechanical ventilation or vasopressor therapy, with higher SCr, blood urea nitrogen (BUN), and white blood cell count, and lower pH, serum bicarbonate, and hemoglobin. Finally, the authors found that the BUN and serum bicarbonate values at the time of AKI diagnosis were significant predictors of mortality, with an area under the receiver-operating characteristic curve (AUC) of 0.79. However, Odutayo et al. themselves acknowledge that ‘‘...their ability to identify, with any reliability, those patients who will die is modest.’’ R. N. Sladen, MBChB (&) Division of Critical Care Medicine, Department of Anesthesiology, College of Physicians & Surgeons of Columbia University, PH 527-B, 630 West 168th St, New York, NY 10032, USA e-mail: rs543@columbia.edu