Pediatric Critical Care Unit Research Articles

Perioperative Assessment of Cerebral Oxygen Metabolism in Infants With Functionally Univentricular Hearts Undergoing the Bidirectional Cavopulmonary Connection.

The transition from single-ventricle lesions with surgically placed systemic-to-pulmonary artery shunt to the circulation following a bidirectional cavopulmonary connection results in higher pressure in the superior vena cava when compared with the preceding circulation. The aim of this study was to evaluate the impact of this transition on the perioperative cerebral oxygen metabolism. Prospective observational cohort study. Pediatric critical care unit of a tertiary referral center. Sixteen infants after bidirectional cavopulmonary connection. Cardiac surgery (bidirectional cavopulmonary connection). We measured regional cerebral oxygen saturation, amount of hemoglobin, blood flow velocity, and microperfusion immediately before, 12-24 hours, and 36-48 hours following bidirectional cavopulmonary connection. Based on these measurements, we calculated cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen. Mean pressure in the superior vena cava increased significantly (8 vs 17 mm Hg; p < 0.001) following bidirectional cavopulmonary connection. Mean cerebral oxygen saturation increased from 49.0% (27.4-61.0) to 56.9% (39.5-64.0) (p = 0.008), whereas mean cerebral blood flow velocity decreased from 80.0 arbitrary units (61.9-93.0) to 67.3 arbitrary units (59.0-83.3) (p < 0.001). No change was found in the cerebral amount of hemoglobin and in the cerebral microperfusion. Mean cerebral fractional tissue oxygen extraction (0.48 [0.17-0.63] vs 0.30 [0.19-0.56]; p = 0.006) and approximated cerebral metabolic rate of oxygen (5.82 arbitrary units [2.70-8.78] vs 2.27 arbitrary units [1.19-7.35]; p < 0.001) decreased significantly. Establishment of bidirectional cavopulmonary connection is associated with postoperative improvement in cerebral oxygen metabolism. Cerebral amount of hemoglobin did not increase, although creation of the bidirectional cavopulmonary connection results in significant elevation in superior vena cava pressure. Improvement in cerebral oxygen metabolism was due to lower cerebral blood flow velocity and stable microperfusion, which may indicate intact cerebral autoregulation.

Effect of a Blood-Borne Diseases Prevention Program on Nurses' Performance in Pediatric Critical Care Units

Background: Prevention of percutaneous injuries and other blood exposures is an important step in preventing the transmission of blood-borne viruses to healthcare personnelAim of Study was to assess the effect of a prevention program for blood-borne diseases on nurses' performance for infection control standard precautions. Research Design: A quasi-experimental design was utilized. Study settings: the study conducted at Critical area (Neonatal Intensive Care Unit, Pediatric Intensive Care Unit in Children's Hospital affiliated to Ain Shams University Hospitals. Research Subject: included 45 nurses selected by simple random sample working in the previously mentioned settings. Tools of the data collection: A predesigned questionnaire sheet, Observational Checklists were used pre and post program implementation Results: revealed that there was a statistical significant difference between nurses' performance pre and post program for blood-born diseases. Conclusion a prevention program for blood-borne diseases had significant effect on nurses' performance for infection control. Recommendation it could be recommended that implement the designed prevention program for blood-borne diseases to all nursing staff in all pediatric settings

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Children in Neonatal and Pediatric Intensive Care Units.

Over the past several years, pediatric critical care units increasingly count on the expert advisement of palliative care specialists. Given the limited availability of pediatric palliative care specialists, all palliative care clinicians may be required to care for pediatric patients and their families. Special considerations in caring for these patients include the relative importance of prognosis, involvement of child life, music and pet therapy, incorporation of parents in end-of-life rituals, care for siblings, use of medical technology, and prolonged duration of stay. The following top 10 tips provide recommendations for caring for seriously ill infants, children, adolescents, and the families of these critically ill pediatric patients. They are written by pediatric intensive care providers to address common issues around palliative care in intensive care units.

Impact of Deferring Critically Ill Children Away from Their Designated Pediatric Critical Care Unit: A Population-Based Retrospective Cohort Study.

Background:The impact of deferring critically ill children in referral hospitals away from their designated pediatric critical care unit (PCCU) on patients and the healthcare system is unknown. We aimed to identify factors associated with deferrals and patient outcomes and to study the impact of a referral policy implemented to balance PCCU bed capacity with regional needs.Methods:We conducted a population-based retrospective cohort study of admissions to a PCCU following inter-facility transport from 2004 to 2016 in Ontario, Canada.Results:Of 10,639 inter-facility transfers, 24.8% (95% confidence interval [CI]: 23.5–26.1%) were deferred during pre-implementation and 16.0% (95% CI: 15.1–16.9%) during post-implementation of a referral policy. Several factors, including previous intensive care unit admissions, residence location, presenting hospital factors, patient co-morbidities, specific designated PCCUs and winter (versus summer) season, were associated with deferral status. Deferrals were not associated with increased mortality.Conclusions:Deferral from a designated PCCU does not confer an increased risk of death. Implementation of a referral policy was associated with a consistent referral pattern in 84% of transfers.

Performance of Pediatric Index of Mortality-2 in a Pediatric Intensive Care Unit of a Tertiary Care Hospital of Nepal

Various scoring system have been developed and are becoming essential part of Pediatric and other critical care units. The Pediatric department wants to introduce Pediatric Index of Mortality-2 (PIM 2) as a predictive scoring system in Pediatric critical care unit of Nepal Medical College Teaching Hospital (NMCTH). This was a prospective cohort study done in Pediatric Intensive Care Unit (PICU) of NMCTH. Study was done from August 2017 to December 2018. All cases admitted in ICU were taken consecutively from term newborn to 14 yrs of age. PIM 2 scoring system was done in all patients. PIM 2 performed well in terms of discrimination with area under curve for PIM 2 scor e was 0.809 with 95% Confidence Interval of 0.0709 to 0.910 and Standard Error of 0.051. Good calibration was observed across deciles of risk as measured by Hosmer-Lemeshow goodness of fit test with P value of 0.163, chi-square value of 11.752 (8). Mortality observed in our PICU was 28.4% with standardized mortality ratio of 1. PIM 2 scoring system performed well in our PICU.

The importance of bioelectrical impedance in the critical pediatric patient

Sepsis is still a significant cause of death in the Intensive Care Unit and its early diagnosis is vital. Changes in cell permeability have been observed early in sepsis. Lower values of bioelectrical impedance (BIA) such as reactance adjusted by height (Xc/H) and phase angle (PA) have already been studied as a prognostic biomarker for many diseases and may indicate cell injury. BIA is a low cost, practical, noninvasive method that can be measured at bedside. This study investigated the utility of PA and Xc/H raw values in the pediatric critical care unit as predictors of progression to septic shock, as a clinical monitoring tool and to support the diagnosis of septic shock. We prospectively analyzed bioelectrical impedance in 145 children aged between one month and six years who were not in septic shock on admission to the intensive care unit Serial bioelectrical impedance analysis (BIA) measures were analyzed to determine the sensitivity and specificity of accurately identifying children who subsequently developed septic shock. Kaplan-Meier septic shock-free survival curves modeled by Xc/H and PA were done. The free-septic shock survival curve analysis showed that patients with the lowest median values of Xc/H and PA were associated with the highest percentage of occurrence of septic shock (p=0.0001 for Xc/H and <0.0006 for PA) and longest length of stay in the intensive care unit (p<0.0011 for Xc/H and p<0.004 for PA). Values of Xc/H below 48.63Ohm/m at admission showed statistically significant odds ratio (OR) of 3.72 for developing septic shock any time during the hospitalization period, with a 87% sensitivity, 35% specificity and an area under the curve (AUC) of 0.62. The PA at admission did not show significant results. During hospitalization, patients with Xc/H below 35.72 Ohm/m were 3.38 times more likely to develop septic shock in the next day, with a sensitivity of 66.7%, a specificity of 62.3% and AUC of 0.65. PA values below 3.27 had an OR of 9.58 for a septic shock the next day with a sensitivity of 95.8%, specificity of 29.4% and AUC of 0.62. The presence of a value of Xc/H below 33 Ohm/m showed a strong association with the occurrence of septic shock on the same day of the measurement, with an OR of 11.7, as well as a value of PA below 2.64, showed an OR of 14.2. The bioelectrical parameters Xc/H and phase angle have limitations in predicting septic shock as isolated biomarkers, but have a potential role as a monitoring tool in the pediatric intensive care unit. The comparative value with other biomarkers remains to be elucidated.

Blood Components Management: An Analysis on the Blood Transfusion Medicine in Zabol, Sistan and Baluchistan Province of Iran

Introduction: Blood components are commonly used during surgical operations; however, limited sources are globally available in this regard. The present study aimed to assess blood product usage and wastage in Amir-Almomenin hospital, Zabol, Iran. Methods: A total of3883 ordered blood components were retrospectively analyzed in AmirAlmomenin hospital, Zabol, Iran (January) 2017-(July)2018. The data were analyzed using the SPSS software, version 18. Results: The results demonstrated that the most frequent ordered blood products included packed red blood cells (PRBCs, 2097 units, 54%), followed by fresh frozen plasma (823 units, 21.2%), platelet concentrates (757 units, 19.5%), and cryoprecipitate (206 units, 5.2%), respectively. Intensive care unit department had the highest records of orders (34.2%) and the ratio of crossmatched blood to transfused blood (C/T) was 1.73. In addition, based on the results, the total amount of component wastage was 2.03% with the highest and lowest percentage for PRBCs (59.6%) and cryoprecipitate (4.35%), respectively. The highest rate of wastage was related to the delivery ward (8.23%). There was no return from pediatrics, dialysis, pediatric critical care unit, critical care unit, and gastroenterology wards. Further, a significant difference was observed between the returned rates of D-positive and D-negative blood components with higher rates belonging to D-negative products (P=0.001). Conclusion: In general, due to the 2.03% wastage rate, there is an indispensable need regarding implementing sufficient supervision and assigning vigilant policies on the hospital-based transfusion policies in order to optimize the blood product management.

Evaluation of healthcare associated infections at pediatric critical care units

Amac: Hastane enfeksiyonlari (HE), hastalarda hastaneye basvuru aninda veya inkubasyon doneminde olmayan, hastaneye basvurularindan 48-72 saat sonra gelisen enfeksiyonlar olarak tanimlanmaktadir. Bu calismada cocuk yogun bakim unitemizin HE acisindan lokal surveyans verilerinin elde edilmesi, HE sikliginin azaltilmasi ve uygun tedavinin gecikmeden uygulanabilmesi amaclanmistir. Yontem: Sivas Cumhuriyet Universitesi Hastanesi Cocuk Yogun Bakim(CYB) servisine Ocak2014-Aralik2018 tarihleri arasinda yatan hastalarin geriye donuk dosyalari incelendi. HE tanimlamalari “Centers for Disease Control and Prevention” kriterlerine gore degerlendirildi. Bulgular: Calisma suresince yatmis olan 1566 hastanin (7651 yogun bakim yatis gunu) toplam 56’sinda, 71 HE saptandi (enfeksiyon hizi:%4.5). Ortanca yas 15 ay (2ay-17yas), E/K:1.43 olarak gozlendi. Solunum sikintisi ve ponomoni en sik basvuru sikâyetini ve yatis tanisini olusturdu (%48.5,%35.7). HE yeri olarak, azalan siklikla VIO (26/71, %36.6), KDE (18/71, %25.4), USE (18/71, %25.4), CAE (7/71, %9.9), SVK-KDE (2/71, %2.8) goruldu. Gram negatif bakteri enfeksiyonlarinin belirgin oldugu calismada (54/71, %77.1), Acinetobacter baumanii ve Klebsiella pneumonia en sik bakteriyel etkenlerdi (%25.3, %14.1). Calismamizda funguslar HE’nin %12.6’sindan sorumlu bulundu. Antibiyotik direncinin 30 kultur uremesinde var oldugu (%42.2), karbapenem direnci (%21.1) ile ESBL (%12.7) pozitif bakteri oraninin en sik iki antibiyotik direncini olusturdugu gozlendi. On iki hasta enfeksiyona ikincil sebeplerden eksitus oldu (HE mortalite orani: %21.4). Eksitus olan hastalarin 5 yasindan kucuk, yuksek PRISM skoruna, uzun entubasyon suresine, sik nazogastrik sonda uygulamasina, uzun yogun bakim ve hastane yatis surelerine sahip olduklari goruldu (sirasiyla p=0. 004, p<0.001, p=0.007, p=0.001, p=0.010, p=0.045). Sonuc: Hastane enfeksiyonlari, hastane yatis suresini uzatan, tedavi maliyetleri ile morbidite ve mortalitesi yuksek olan enfeksiyonlardir. Invazif girisimlerin yogun oldugu, kritik hasta takibinin yapildigi cocuk yogun bakim servislerinde ise, diger risk faktorlerinin de eklenmesi ile HE riski ve sikligi belirgin olarak artar. Bu nedenle yogun bakim unitelerinde surveyans calismalari yapilarak uygun tedavinin baslanmasi saglanmali ve gereksiz invaziv girisimleri azaltarak hastane enfeksiyonu nedeniyle olusan morbidite ve mortalite azaltilmalidir.

Risk factors associated with resolution of diabetic ketoacidosis in pediatric critical care units

Objective: Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type-I Diabetes Mellitus. The goals of therapy are to correct dehydration, resolution of acidosis and fading of ketosis. Such serious complications necessitate closed monitoring of DKA patients with delicate, balanced therapy, probably at an intensive care facility. Regarding the fact that, each facility shoul determine the clinical profile of their own patient population, we aimed to investigate the risk factors for consequences and determine the timing of DKA resolution by analyzing the demographic and epidemiologic data, clinical outcome and the prognosis of diabetic ketoacidotic children admitted to PICU. Method: This descriptive, retrospective study was conducted in 105 children admitted to PICU with the complaints of DKA between January 2014 and December 2108. Demograhic data including age, gender, weight, height, body mass index (BMI), initial compliants with clinical findings and level of consciousness were recorded. Children were categorized into two groups depending on the timing of DM diagnosis (new onset of diabetes and established diabetes mellitus). DKA severity was determined by the degree of metabolic acidosis (mild, moderate, severe). SPSS-23 was used for statictics. Descriptive analyses were expressed as percentages, mean±standart deviation (SD), median with minimum and maximum values. Chi square and Fischer exact test were used for comparison of categorical variables. Student’s t-test, Mann Whitney U test and Wilcoxon rank sum test were assessed for continous variables. Pearson correlation coefficient and logistic regressions were used for correlations and to determine the risk factors. P-value < 0.05 was considered significant. Results: The patient demographics presented the mean age as 11.31±4.18 years, female/male ratio 1/1.4 and body mass index 18.48±4.48. Children were classified as mild DKA (29.5%), moderate DKA (35.2%) and severe DKA (35.2%) based on the acidosis severity. 48.6% of the patients had Kusmaull respiration; 30.5% had manifested altered consciousness. One patient had tomography-proven brain edema and had required mechanical ventilation due to neurological incapability to sustain airway Children with new onset of diabetes accounted for 51.4% of the study population. The mean age was 9.70±4.47 years; this group constituted a younger population compared the established DM patients (p<0.001). Altered mental state and kusmaull respiration also occurred at a higher rate and the major complaint seemed ae weight loss within two weeks (p=0.006, p=0.002, p<0.001 respectively). Children with established diabetes mellitus presented significant biochemical abnormalities in terms of elevated BUN and serum potassium levels (p<0.001, p<0.001); infections occurred as the major triggering factor for DKA at a rate of 80.4% at this group. We observed a positive correlation with DKA resolution with serum creatinine, calculated osmolality, anion gap (r=0.242, r=0.215, r=0.302) and a negative correlation with blood gas pH and HCO3 (r= -0.704, r= -0.694). In the multivariable regression model including age, gender, body mass index, PRISM-3 score, BUN, serum potassium, phosphate and chloride, only blood gas pH and new onset of diabetes appeared to be the independent risk factors for DKA resolution. 0.1 unit decrement in blood gas pH elongated the resolution by 3.76 hours (p<0.001, adjusted ratio: 0.743). New onset of diabetes mellitus also increased the length of resolution by 5.30 hours (p<0.001). Conclusions: Inıtial blood gas pH and presence of new onset of diabetes are the major risk factors in resolution of ketoacidosis.

Effect of an Educational Training Program for Nurses about Infection Control Precautions in Their Practice in the Pediatric Critical Care

Background and study aim: Infection control is essentially a clinical service directly related to improving and maintaining the quality of patient care. The aim of the present study was to identify the impact of an educational training program for nurses about infection control precautions in their practice in the pediatric critical care units. Materials and methods: A quasi-experimental study was conducted on sample of 70 nurses. The present study was conducted at pediatric Intensive care unit & Hemodialysis unit at pediatric hospital as well as, operation rooms at pediatric surgery department in Zagazig University Hospital. Two tools were used; first a questionnaire sheet to assess nurses' knowledge and the second tool was an observational checklist used to assess nurses' practice. In addition, an educational program about infection control to improve nurses' knowledge and practice related to infection control precaution. Results: The results showed that nurses had unsatisfactory knowledge about infection control before implementation of educational program. Nurses' knowledge and practice had been improved significantly after implementation of educational program either immediately or 2 months later. Conclusion: It can be concluded that educational program had improved nurses' practice about infection control. Based on the results of the present study, In-service, training program for nurses about infection control precautions should be done. In addition, the development of infection control guidelines is essential, to be followed and available for all nurses.

3439 Role of the Airway Microbiome in Viral Bronchiolitis Associated Respiratory Failure

OBJECTIVES/SPECIFIC AIMS: This study aims to determine if a bronchiolitis specific microbiome exists and how it evolves through disease course. Objective 1. Determine the microbiome profile of the airway in virus induced bronchiolitis-associated respiratory failure. Objective 2. Identify changes in the airway microbiome profile through the course of virus induced bronchiolitis associated respiratory failure, and the relationship between microbiome composition and clinical respiratory status. Objective 3. Determine the impact of rhinovirus infection on the lung and stool microbiome in a murine asthma model. METHODS/STUDY POPULATION: Objectives 1 &amp;2: We are conducting a single-center prospective case-control study of patients admitted to the Komansky - Weill Cornell Pediatric Critical Care Unit. Infants less than two years of age with a diagnosis of bronchiolitis requiring intubation and mechanical ventilation are enrolled as subjects. Infants less than two years of age intubated and requiring mechanical ventilation without primary lung pathology are enrolled as controls. To evaluate our primary objective, tracheal aspirates will be collected from both subjects and controls on the day of intubation. We will perform 16s RNA sequencing on the tracheal aspirate samples and compare the resulting microbiomes. To evaluate secondary objective, we will collect tracheal aspirates of our study population on a daily basis and map the microbiome in parallel with objective measures of respiratory status including oxygen index and successful extubation. Both subjects and controls are being enrolled as a convenience sample. Objective 3: Mice, heterozygous for the sptlc2 gene (Spltc2 +/−) demonstrate reduced de-novo sphingolipids and increased airway hyperresponsiveness with methacholine challenge. Airway hyper-responsiveness is a cardinal feature of asthma. This airway hyperresponsiveness is exacerbated in the setting of rhinovirus (Figure 1). Using 16s sequencing, we will examine the lung microbiome of Sptlc2 +/− ad Sptlc2 +/+ at 1- and 7-days following rhinovirus infection. RESULTS/ANTICIPATED RESULTS: This clinical study is currently IRB approved and enrollment is ongoing. We have enrolled 12 subjects and 5 controls. Sample analysis will begin following the 2018-2019 respiratory season, with an anticipated cohort of 20 subjects and 20 controls. With regards to the murine studies, we have demonstrated that the lung microbiome of Sptlc2 +/− and Sptlc2 +/+ mice is similar at baseline (Figure 2) and remains similar following 1-day infection with rhinovirus. We do however, see a distinct change in the microbiome profile of the stool of Sptlc2 +/− mice following rhinovirus infection (Figure 3). Lung analysis at day 7 post infection is pending. DISCUSSION/SIGNIFICANCE OF IMPACT: These studies will lay the groundwork for detailing the functional role of the airway microbiome in bronchiolitis, with the objective of developing new modalities for disease treatment and prevention. In addition our murine studies allow us to view the microbiome in the context of sphingolipid deficiency, providing a potential mechanistic link to rhinovirus and ORMDL3 associated asthma.

Agitated behavior scale in pediatric traumatic brain injury

ABSTRACTAgitation following TBI commonly occurs during the acute recovery phase. The ABS is a valid measure of agitation in adults following TBI. The objective of the study was to determine if ABS scores accurately measure acute agitation in pediatric patients recovering from TBI. The ABS was completed twice daily for 4 days and mean ABS scores were calculated. Physicians assessed patients’ agitation daily using a VAS. In addition, interventions for agitation were recorded. The association between ABS and VAS scores was assessed using Spearman’s correlation. The relationship between the number of medication classes taken for agitation (0, 1–2, or ≥3) and ABS scores was assessed using one-way analysis of variance. Finally, the association between the use of hand restraints and ABS scores was examined using an unpaired two-sample t-test. Twenty-six pediatric patients with acute TBI were included. ABS scores significantly associated with VAS scores. Patients that required interventions for agitation (hand restraints or ≥3 medication classes) had higher ABS scores than patients that did not receive any intervention. The study supports the use of ABS scoring to measure agitation in pediatric patients with TBI. However, additional studies are warranted to further support the validity of this scale.Abbreviations: TBI: Traumatic brain injury; ABS: Agitated Behaviour Scale; VAS: visual analog scale; PCCU: Pediatric Critical Care Unit

2104. Impact of a Supervision and Education Directed Bundle in Ventilator-Associated Pneumonia (VAP) on a Pediatric Critical Care Unit of a Teaching Hospital

BackgroundProven measures to prevent VAP include 35–45¡ inclination of the head, prompt extubation, hand hygiene prior to intubation, oral hygiene with clorhexidine, minimize secretion pooling above the endothraqueal tube cuff. Adherence to these methods remains an angular point in preventing VAP’s. Increasing rates of VAP in the pediatric critical care unit (PICU) of a reference teaching hospital in Guatemala, led the Hospital Infection Prevention and Control (HIPC) team to implement a bundle to control VAP’s.MethodsA daily active surveillance to identify cases of VAP according to the Center for Disease Control (CDC) definition was done for 10 months before the HIPC intervention. The HAI implemented a bundle defined as: (1) head elevation (35¡ degree inclination), (2) hand hygiene, (3) oral hygiene with clorhexidine, (4) minimize secretion pooling, (5) daily evaluation of extubation, (6) daily surveillance, (7) continuous education of personnel, (8) adequate supplies distribution analysis. After the intervention rates and trends of VAP where analyzed for 30 months.ResultsIn the pre-intervention observational period the rates of VAP increased from 18 (September 2014) to 28 cases per 1,000 ventilator-days (June 2015). The first month after the bundle implementation (July 2015) a 50% VAP rate decreased was evidenced. A constant decrease in VAP rates was reported in the 24 months after the implementation of the bundle, reaching the lowest rate in August 2017 (five cases per 1,000 ventilator-days). For administrative reasons adherence to oral hygiene with clorhexidine was sub-optimal due to a lack of supplies from August 2017 to December 2017 which coincided with an increase in VAP rates from five to 14 per cases 1,000 ventilator-days.ConclusionA notable and constant reduction of VAP rates in the PICU was achieved after the implementation of the bundle. Even though many of the measures included in the bundle were already protocoled in the PICU, a probable lack of adherence could explain the high rates observed pre-intervention. By adding the continuous education and supervision of the personnel by a member of the HIPC team, to previously proven methods, the VAP rates decreased in almost 80%. This makes a strong case for the idea that protocols without continuous enforcement might not be enough to control infections.Disclosures All authors: No reported disclosures.

262. Pediatric Antibiotic Use in the Duke Antimicrobial Stewardship Outreach Network

BackgroundThe Duke Antimicrobial Stewardship Outreach Network (DASON) was established in 2013 to provide antimicrobial stewardship resources to community hospitals in the Southeast. Pediatric patients in community hospitals may benefit from antimicrobial stewardship program (ASP) activities.MethodsAntibacterial use (AU) was reviewed using the DASON Antimicrobial Stewardship Assessment Portal, which includes filters for National Healthcare Safety Network (NHSN) unit types. We performed a retrospective review of AU in pediatric units from January 1 to December 31, 2017. AU was summarized by days of therapy (DOT) and percent of total DOT for specific unit types and agents. AU rates were reported by DOT/1,000 patient-days.ResultsA total of 41 pediatric units were included from the 28 hospital DASON cohort: 11 Neonatal Critical Care or Step Down Nurseries, eight Pediatric Medical/Surgical Wards, and 22 Well Baby Units. There were no pediatric (non-neonatal) critical care or oncology units. A total of 21,731 antibiotic DOT were attributable to pediatric units, accounting for 1.6% of all AU in the cohort. These include 5,585 (26%) DOT in Neonatal Critical Care (level II/III) Units, 4,898 (23%) in Pediatric Medical/Surgical Units, 3,910 (18%) in Well Baby Units, 3,307 (15%) in Neonatal Critical Care (level III) Units, 3,217 (15%) in Step Down Neonatal Nurseries (level II), and 814 (4%) in Pediatric Medical Wards. Ampicillin (7,229 DOT, 33%), gentamicin (6,320 DOT, 29%), ceftriaxone (1,750 DOT, 8%), and vancomycin (1,462, 7%) were the most common antibiotics administered.AU rates were 219 DOT/1,000 patient-days in children when compared with 979 in adults. Unit-specific rates ranged from 65 (Well Baby Units) to 1,081 DOT/1,000 patient-days (Pediatric Medical/Surgical Units). Rates in level II and III nurseries ranged from 302 to 697 DOT/1,000 patient-days.ConclusionPediatric patients accounted for a small proportion of AU in community hospitals. AU rates on pediatric medical/surgical units were comparable with adult units. Although rates were lower in neonatal units, these units accounted for 75% of pediatric AU. Antibiotic exposure in the neonatal period has been associated with short- and long-term outcomes, including necrotizing enterocolitis, obesity, and atopy. This population would benefit from a dedicated focus from community hospital ASPs.Disclosures All authors: No reported disclosures.

Abstract 160: End-Tidal Carbon Dioxide &gt; 20mmHg During Pediatric In-Hospital Cardiopulmonary Resuscitation is not Associated With Survival

Introduction: Based on laboratory CPR investigations and limited adult data, the American Heart Association Consensus Statement on CPR Quality recommends titrating end-tidal carbon dioxide (ETCO2) to &amp;gt; 20 mmHg during CPR. Hypothesis: ETCO2 &amp;gt; 20 mmHg during pediatric in-hospital CPR is associated with survival to hospital discharge. Methods: Children &amp;gt; 37 weeks gestation in Collaborative Pediatric Critical Care Research Network intensive care units with chest compressions for &amp;gt; 1 minute and ETCO2 monitoring prior to and during CPR between July 1, 2013 and June 31, 2016 were included. ETCO2 and Utstein-style cardiac arrest data were collected. Multivariable Poisson regression models with robust error estimates were used to estimate relative risk of outcomes. Results: Investigators blinded to outcome analyzed ETCO2 waveforms from 43 children for the first (up to) 10 minutes of CPR. During CPR, the median ETCO2 was 23 mmHg (quartiles, 16 and 28 mmHg), median ventilation rate was 29 breaths/minute (quartiles, 24 and 35 bpm), and median duration of CPR was 5 minutes [quartiles, 2 and 16 minutes]. Return of spontaneous circulation occurred after 71% of CPR events and 37% of patients survived to hospital discharge. For children with mean ETCO2 during CPR &amp;gt; 20 mmHg, the adjusted relative risk for return of spontaneous circulation was 1.32 (0.89, 1.95), p= 0.16 and for survival to hospital discharge was 0.92 (0.41, 2.08), p= 0.84. Further sensitivity analyses were unable to demonstrate an association between mean ETCO2 &amp;gt; 25 mmHg or &amp;gt; 30 mmHg and ROSC or survival to hospital discharge. The median mean ETCO2 among children who survived to hospital discharge was 20 mmHg [quartiles; 15, 28 mmHg] versus 23 mmHg [16, 28 mmHg] among non-survivors. Conclusion: Mean ETCO2 &amp;gt; 20 mmHg during pediatric in-hospital CPR was not associated with ROSC or survival to hospital discharge. ETCO2 was not demonstrably different among survivors versus non-survivors.

The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department

BackgroundRespiratory distress is a common presenting complaint in children brought to the Emergency Department (ED). The Clinical Respiratory Score (CRS) has shown promise as a screen for severe illness in High Income Countries. We aimed to validate the admission CRS in children presenting to the ED of a Low-to Middle Income Country.MethodsChildren (1 month to 16 years) presenting with respiratory distress to the ED of the Aga Khan University Hospital, Karachi, Pakistan, between November 2015 to March 2016, were enrolled. The CRS was measured at initial presentation, prior to any management and 2 h after treatment was started. The predictive value for admission to the paediatric critical care units for a variety of cut offs for CRS at presentation were derived.ResultsA total of 112 children (70% male) of median age 12 months (IQR 2, 34.5 months) were enrolled. Patients with severe CRS (score 8–12) at presentation were more likely to be admitted to paediatric critical care (90% vs. 23% with mild-moderate CRS; OR: 5.7; 95% CI: 2.2–15.3, p < 0.001). The sensitivity and specificity of CRS > 3 in predicting outcome were 94% (95% CI 79.8–99.3) and 40% (95% CI 35–45), respectively, with a positive likelihood ratio of 1.6 (95% CI 1.31–1.98) and negative predictive value of 94% (95% CI 81–98).ConclusionAn admission CRS of > 3 in the ED of a Low-to Middle Income Country had excellent predictive value for disease severity, and it should be considered for incorporation into ED triage protocols.

A retrospective observational study of acquired subglottic stenosis using low‐pressure, high‐volume cuffed endotracheal tubes

The safety of cuffed endotracheal tubes in the neonatal and critically ill pediatric population continues to be questioned due to the theoretical risk of acquired subglottic stenosis. The incidence of acquired subglottic stenosis in the high-risk mixed surgical and medical critically ill pediatric cohort using high-volume, low-pressure cuffed endotracheal tube policy has not yet been described. The aim of our study was to describe and evaluate the use and complication rate of cuffed ETT's in our unit over a 5-year period. We defined clinically significant subglottic stenosis as a positive stenotic finding of endotracheal tube-related pathology on a microlaryngoscopy within 6months of invasive ventilation. All patients admitted through our pediatric critical care unit from January 10, 2012 to January 25, 2017 were matched against our theater management system database for the same period. We reviewed all matching patients' baseline demographics, comorbidities, intubation/endotracheal tube history, and subsequent surgical management. Of 5309 pediatric critical care unit admissions (61% ventilated) and 1251 microlaryngoscopies, 23 children had endoscopic findings of clinically significant endotracheal tube-related pathology, reflecting 0.68% of all intubated patients. Eight patients developed acquired subglottic stenosis. All those requiring major surgical correction were ex-premature neonates initially intubated with uncuffed tubes in an external neonatal intensive care. No patient initially intubated with a cuffed endotracheal tube developed subglottic stenosis requiring surgical correction. We report no single case of acquired subglottic stenosis in our cohort that required major surgical correction from a cuffed endotracheal tube during a 5-year period. The introduction of a policy of appropriate placement and maintenance of low-pressure, high-volume cuffed endotracheal tubes in the pediatric critical care unit was not associated with an increased rate of endotracheal tube-related subglottic trauma.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review.

Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

Red cell distribution width as a prognostic marker in mechanically ventilated children admitted in pediatric critical care unit of tertiary care centre, India

Background: Paediatric population is a vulnerable group necessitating standard care for medically and surgically ill children. Red cell distribution width (RDW) is a simple and low-cost measure that denotes the variability in red blood cell size. Any process that releases reticulocytes in the circulation will result in an increase in RDW. RDW may also be useful as a biomarker of disease severity and clinical outcomes in critically ill patients. Methods: Retrospective cohort study of all patients between 1month-12yrs of age, mechanically ventilated in Paediatric intensive care unit. Those patients with RDW on admission and complete data for PIM3 (Paediatric Index of Mortality 3) were included. Analyses included correlation, logistic regression analysis, and receiver operating characteristic (ROC) curves.Results: Retrospective analysis of data on 93 consecutive critically ill children admitted in PICU was done between Jan 2015- June 2016. We noted statistically significant correlation between mortality and anemia (10.24 g/dL, SD 2.26; 8.78 g/dL, SD 2.60.p = 0.009), LOS on MV (p = 0.008), RDW (p = 0.002), shock (p = 0.004) and ventilator associated Pneumonia (p = 0.024). Mortality increased as length of stay on mechanical ventilation increased (4.13 days, SD 2.125 versus 6.94 days, SD 7.603 p = 0.008). The cut-off of 18.10 was chosen as Mean RDW. Based on AUROC, RDW is independently associated with high risk of mortality.Conclusions: RDW measured within 24 hours of PICU admission was independently associated with length of stay on mechanical ventilation and mortality in a general PICU population. We recommend the need for multicentric, prospective longitudinal studies to determine the optimum utility of RDW to enhance decision making in PICU.

Cycling related traumatic brain injury requiring intensive care: association with non-helmet wearing in young people

IntroductionTraumatic injury is the leading cause of death in children after infancy. Almost 25% of all cyclists killed in the UK are children, and two thirds of these will die because of their head injuries. We compared the population of young people wearing helmets whilst cycling, to those admitted with serious post cycling head injuries to our paediatric critical care unit. MethodAll children aged 0–18 years admitted to our intensive care following a bicycle accident between the years January 2011–June 2018 were identified and information on the mechanism of injury, and both immediate and long term clinical data were collected. For comparison data, helmet wearing on a random morning was observed from six schools. All pupils arriving at school by bicycle were observed. Data collected included the school year and sex of the child, and whether each child was wearing a helmet or not. ResultsOf 28 cases, 22 were admitted due to head injuries. None wore a helmet. 23/133 school pupils wore a helmet. The intensive care population were significantly less likely to be wearing helmets than the general population (p = 0.044, Fisher’s exact test). A Chi-Square test for helmet wearing by school year showed a reduction in helmet wearing with increasing school year with a p value of 0.0026. There was no association between helmet wearing and abdominal injury. ConclusionYoung people admitted to a Critical Care Unit with cycling related head trauma are statistically significantly less likely to wear a helmet than the general, age matched cycling population. Helmet wearing decreases as children get older. Outcomes were mixed, but in the head trauma group only 3/18 recovered with no neurological deficit