Search

Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.

ObjectiveTo describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs.DesignRetrospective cohort study using prospectively collected clinical registry data.SettingPediatric Cardiac Critical Care Consortium registry.PatientsAll patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals.InterventionsNone.Measurements and main resultsAnalysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001).ConclusionsThough extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.

Purpose: Studies in adult and neonatal intensive care units (ICUs) report a high prevalence of epileptic seizures in comatose patients. The prevalence of seizures in pediatric ICUs is variably reported in a few retrospective studies using different electroencephalography (EEG) methods. We aimed to determine prospectively the prevalence of epileptic seizures (clinical and subclinical) in comatose children in the pediatric ICU using continuous video-EEG (v-EEG) monitoring. Methods: We performed v-EEG in consecutive children aged 2 months to 17 years admitted to the pediatric ICU with sustained depressed consciousness over a period of 15 months. Results: We monitored 100 comatose children, 69% within 24 h of ICU admission. Median length of ICU stay was 5 days. Median duration of v-EEG was 20 h. Epileptic seizures were identified in only seven patients, of whom six had a history of epilepsy with witnessed seizures immediately prior to v-EEG. All epileptic seizures were recorded in the first 3 h of v-EEG. Seizures were suspected by ICU staff in 18 monitored patients, only four of whom had confirmed epileptic seizures. Discussion: The lower prevalence of epileptic seizures and the shorter length of ICU stay in children compared to adults and neonates suggest a different spectrum of disease and neurologic response. Short-duration v-EEG in patients with a history of prior seizures, epilepsy, or clinical events suspected to be seizures seems more appropriate than routine v-EEG in all comatose children in the pediatric ICU. [ABSTRACT FROM AUTHOR]

The article presents two case studies of drug exposure including first of a 17-year-old male, who presented following smoking synthetic cannabinoids for recreational use and the second of a 12-month-old Hispanic male, who was referred to hospital with complaint of excessive drowsiness. The first patient medical history revealed bipolar disorder while second patient's father was smoker of synthetic cannabinoids. The article discusses complexity of diagnosing drug exposure.

Objective: Veno-venous extracorporeal membrane oxygenation (ECMO) is an established therapy for the treatment of respiratory failure. Traditionally ECMO has been used to support patients with an acute, reversible disease process, with a predictable outcome. We report the successful use of veno-venous ECMO for an unusual indication.Patient: A 10-year old girl was admitted to intensive care with severe, hypoxic respiratory failure on the background of a 2-month history of worsening respiratory symptoms. She required high levels of conventional positive pressure ventilation, and high frequency oscillation. Lung biopsy confirmed a non-specific interstitial pneumonia, and the patient was commenced on immune suppressive therapy. Her clinical course was further complicated by pulmonary haemorrhage and severe air leak.Interventions: On day 20 after admission the patient was placed on veno-venous ECMO for lung rest while awaiting a response to continued medical treatment. She required ECMO for 20 days, during which time sedation was reduced, and she was able to interact with those around her. The patient's ventilatory requirements after decannulation were minimal, and she subsequently made a steady clinical recovery.Conclusions: ECMO was safely and successfully used to provide a period of lung rest and time for medical therapy to take effect in a child with an unusual indication for support: a rare disease with an uncertain outcome on the background of prolonged mechanical ventilation. [ABSTRACT FROM AUTHOR]

Background: There has been a growing impetus for developing pediatric neurocritical care (PNCC) programs to improve care delivery for children with critical neurological conditions. We sought to develop a unique PNCC program using the concept of Community of Practice (CoP).Methods: This is a process improvement project in an academic Children's Hospital. Using CoP framework (domain, community, practice), we created a domain of PNCC with a stated vision and formal organizational structure, a core community of intensivists and neurologists interested in PNCC, and a standardized practice approach by establishing core competencies for PNCC and implementing practice guidelines.Results: We evaluated the program through the Four-Frame Model of Organizational Theory and Behavior (structural, human resource, political, symbolic) and by the Neurocritical Care Society's (NCS's) standards for a Level I Neurocritical Care Unit (Neuro-ICU). Structural frame included opening a pediatric Neuro-ICU, identifying PNCC leaders across specialties, and developing a multidisciplinary care delivery model. Human resource frame included forming physician and nurse groups with a primary role in PNCC and ongoing education through workshops, lecture series, and certification. Politically, program implementation was tailored to each department gaining institution-wide support for program initiatives. Symbolically, the PNCC program highlighted the vision to advance knowledge and best practices. Our program met 232 of 252 (92%) proposed NCS standards.Conclusions: The CoP as the foundation for program development has enabled us to achieve the majority of standards proposed by NCS for a Level I Neuro-ICU. The generalizability of these frameworks may facilitate the development of a PNCC program for other institutions. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the impact of public health interventions on the volume and characteristics of admissions to the PICU.Design: Multicenter retrospective cohort study.Setting: Six U.S. referral PICUs during February 15, 2020-May 14, 2020, compared with the same months during 2017-2019 (baseline).Patients: PICU admissions excluding admissions for illnesses due to severe acute respiratory syndrome coronavirus 2 and readmissions during the same hospitalization.Interventions: None.Measurements and Main Results: Primary outcome was admission volumes during the period of stay-at-home orders (March 15, 2020-May 14, 2020) compared with baseline. Secondary outcomes were hospitalization characteristics including advanced support (e.g., invasive mechanical ventilation), PICU and hospital lengths of stay, and mortality. We used generalized linear mixed modeling to compare patient and admission characteristics during the stay-at-home orders period to baseline. We evaluated 7,960 admissions including 1,327 during March 15, 2020-May 14, 2020. Daily admissions and patients days were lower during the period of stay-at-home orders compared with baseline: median admissions 21 (interquartile range, 17-25) versus 36 (interquartile range, 30-42) (p < 0.001) and median patient days 93.0 (interquartile range, 55.9-136.7) versus 143.6 (interquartile range, 108.5-189.2) (p < 0.001). Admissions during the period of stay-at-home orders were less common in young children and for respiratory and infectious illnesses and more common for poisonings, endocrinopathies and for children with race/ethnicity categorized as other/unspecified. There were no differences in hospitalization characteristics except fewer patients received noninvasive ventilation during the period of stay-at-home orders.Conclusions: Reductions in PICU admissions suggest that much of pediatric critical illness in younger children and for respiratory and infectious illnesses may be preventable through targeted public health strategies. [ABSTRACT FROM AUTHOR]