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Objective: Sedation may be needed for safe, effective completion of pediatric dental procedures. Procedural sedation is performed in a children's hospital based dental office. The three sedation approaches: a propofolonly (P-O) approach (2–3mg/kg titrated to the needed level of sedation), an approach that includes either IV ketamine (K+P) (0.25 or 0.5mg/kg) or IV fentanyl (F+P) (0.5–1mcg/kg) prior to propofol administration. We sought to determine safety and efficacy of various propofol based sedation protocols. Study Design: Retrospective review of 222 patients receiving a propofol-only (P-O), ketamine+propofol (K+P) or fentanyl+propofol (F+P) approach. Results: There were 44 patients in P-O group, 154 in K+P group and 24 in F+P group with mean age (4.8±3.4y) and mean weight (19.7±6.7kg). All the patients completed procedures successfully. Mild hypoxemia occurred in 24% of cases and resolved with nasal cannula. Mean total dose of propofol was similar in all groups (P-O 8.2mg/kg, K+P 9.5mg/kg, F+P 9.6mg/kg, p=0.15). Although procedure and recovery times were similar in all groups, discharge times in K+P group were significantly shorter than P-O group and F+P group respectively (K+P 9.35±8.93.min, P-O 13.57±10.42min, F+P 10.42±4.40 p= 0.002). Conclusion: Sedation can be accomplished safely and effectively in a children's hospital based dental office using propofol-based sedation.

Objective:To describe characteristics and overlap associated with various ventilator-associated infection criteria in the PICU.Design:Retrospective observational study.Setting:A quaternary care children’s hospital PICU.Patients:Children ventilated more than 48 hours, excluding patients with tracheos

Rowan CM, Vianna RM, Speicher RH, Mangus RS, Tector AJ, Nitu ME. Post-transplant critical care outcomes for pediatric multivisceral and intestinal transplant patients. Abstract: This study reviews the post-operative management of pediatric intestinal transplant patients at a single center with reporting of standard PICU benchmarks for quality of care. It is a retrospective, descriptive, chart review describing our institution’s experience between 2006 and 2010. Twenty patients were included. Median age at transplant was 1.6 yr. Median length of PICU stay was 12 days. Median ventilation time was two days. Median time for continuous sedation infusion was two days, with median continuous pain medication infusion of three days. All patients were placed on parental nutrition and started on enteral feedings between days 3 and 4. Forty percent of patients required hemodynamic support. Only 35% of patients required insulin therapy. Diuretics were frequently used in this patient population. There were no episodes of early rejection. The survival rate to PICU discharge was 95%. Our institution’s experience over the past four yr has been very successful with a short duration of mechanical ventilation, limited use of pain and sedation drips, early initiation of enteral feedings, minimal hemodynamic support, and a low mortality rate to PICU discharge despite a preponderance of complex MVTx recipients.

The mortality in the ICU for pediatric HSCT recipients remains high. Early pulmonary complications continue to be an obstacle to the survival. We hypothesize OI is a predictor for mortality in critically ill pediatric HSCT recipients. Retrospective review of pediatric HSCT recipients between 2002 and 2010 who required intensive care during the same hospital admission as their transplant. Twenty-eight patients accounted for 31 ICU admissions. Twenty-six (84%) admissions required mechanical ventilation. Ten (38%) mechanically ventilated admissions were placed on HFOV. Mortality of those mechanically ventilated was 70%. An OI ≥ 20 at any point during ventilation was associated with 94% mortality, while an OI ≥ 25 had 100% mortality. There was a significant association between maximum OI at any point during mechanical ventilation and ICU mortality, with the odds of dying increasing by 13% for each unit increase of max OI (OR = 1.13, 95% CI = 1.01-1.26, p = 0.03). An OI of 20 had a sensitivity of 0.89 and specificity of 0.83 for predicting mortality. OI has a strong association with ICU mortality among pediatric stem cell recipients.

1. Mara Nitu, MD* 2. Greg Montgomery, MD† 3. Howard Eigen, MD§ 1. *Associate Professor of Clinical Pediatrics, Section of Pediatric Pulmonology, Critical Care and Allergy; Medical Director, PICU/Riley Hospital for Children; Medical Co-Director of Lifeline Transport Team, Indianapolis, IN. 2. †Assistant Professor of Clinical Pediatrics, Section of Pulmonology, Critical Care and Allergy; Medical Director, Pediatric Bronchoscopy Laboratory, James Whitcomb Riley Hospital for Children, Indianapolis, IN. 3. §Billie Lou Wood Professor of Pediatrics, Associate Chairman for Clinical Affairs; Director, Section of Pediatric Pulmonology, Critical Care and Allergy, James Whitcomb Riley Hospital for Children, Indianapolis, IN. After completing this article, readers should be able to: 1. Understand the mechanisms for regulating acid-base physiology. 2. Know the differential diagnosis of metabolic acidosis associated with high anion gap and plan for initial management. 3. Know the differential diagnosis of normal anion gap metabolic acidosis. 4. Describe pulmonary compensatory changes in metabolic acidosis and alkalosis. 5. Understand how various diuretics can lead to acid-base imbalance. 6. Describe renal compensatory changes in respiratory acidosis and alkalosis. A 16-year-old girl who has no significant previous medical history presents to the emergency department with a 4-day history of nausea, vomiting, fever, chills, diarrhea, leg cramps, abdominal pain, and headaches. She is finishing her menstrual period and arrives with a tampon in place, which she reports that she inserted yesterday. Her vital signs include a heart rate of 165 beats/min, respiratory rate of 28 breaths/min, blood pressure 65/30 mm Hg, and oxygen saturation of 100% on 4 L/min of oxygen. The most likely diagnosis for this patient is toxic shock syndrome, which was later confirmed with a positive antibody test. The initial arterial blood gas (ABG) values are: Such findings are suggestive of metabolic acidosis with respiratory compensation. Further laboratory results are

Objective The aim of this article is to determine whether dexmedetomidine or propofol is better for MRI sedation in children. Design This study is a retrospective review of patients sedated with dexmedetomidine or propofol for MRI between July 2007 and July 2015. Dexmedetomidine group (group D) was administered a bolus of 2 µg/kg over 10 minutes followed by a 1 ug/kg/hour infusion. Propofol group (group P) received a bolus of 2 mg/kg over 2 minutes followed by 83 µg/kg/minute infusion. Results Of the 996 cases completed, 452 were in group P and 544 were in group D. Patients in group P were heavier and older than those in group D. All the patients except one in group D completed the procedures. Hypotension occurred in 59% in group P versus 4% in group D (89 ± 11.4 SBP vs. 103.80 ± 19.4; p

Background: Evaluate patterns in existing cost data for patients with respiratory illness managed in a large academic Pediatric Intensive Care Unit (PICU), with the goal to identify targets for potential cost-management strategies. Methods: Retrospective, observational study of patients admitted to a 34-bed multidisciplinary PICU from October 2011 to September 2012. Study design: Variable direct costs (VDC) for each All Patient Refined Diagnosis Related Group (APR DRG) were obtained from the Decision Support Group and detailed analysis was performed for top respiratory APR DRGs. Results: During the study period, 1,999 patients were admitted to the PICU equating to 17,053 PICU days. Medical critical care patients accounted for 54% of all admissions and 46% PICU days. The top 5 respiratory-related APR DRGs accounted for almost 45% of all PICU medical admissions. Non-asthma respiratory-related APR DRGs accounted for 23% of medical admission and 18% of medical PICU days. Of the total VDC for this subgroup, 54% and 20% was attributed to nursing and respiratory care respectively, with a significant minority (

Objectives A catheter thrombosis and the presence of a catheter-associated bloodstream infection (CBSI) often occur simultaneously, but it is unclear if or to what degree the two complications relate. Several animal and adult studies indicate a relationship between fibrin sheaths and thrombi in the development of CBSIs. To date, there has been limited human investigation in the pediatric population to determine a clear link between the presence of a thrombus and bacteremia. The use of alteplase for malfunctioning central venous catheter may indicate the formation of intraluminal thrombus or fibrin sheath. A catheter that requires alteplase is at higher risk of a CBSI. Design A retrospective chart review from July 2008 to December 2010. Setting PICU. Patients All patients with central catheters admitted to the PICU. Interventions No interventions performed with the retrospective study. Measurements Number of total central venous catheters, number of central venous catheters that received treatment with alteplase, and number of CBSIs. Main results Preliminary data during the study period identified 3,289 central venous catheters. Twelve percent of these catheters required at least one dose of alteplase. There were 40 CBSIs during this same time period of which 28% received alteplase during the 5 days preceding the positive blood culture. The odds ratio for getting a CBSI when alteplase is administered is 2.87 (confidence interval 1.42-5.80; p = 0.002). The average age of the central venous catheters at time of infection was not statistically different, 16.1 days in the alteplase catheters compared with 25.6 days for the catheters that did not receive alteplase (p = 0.6). Conclusions There is a positive correlation between the use of alteplase for malfunctioning central venous catheters and the development of a CASBI. This is likely associated with the presence of an intraluminal fibrin sheath or thrombus. This study adds evidence linking thrombus formation to CBSI.

The objective of the study is to review a single institution's experience with high-frequency oscillatory ventilation (HFOV) and compare patient characteristics, outcomes, and complications with other reported studies of HFOV use in burn patients with acute respiratory distress syndrome and respiratory failure. This study is a retrospective chart review of the burn patients treated with HFOV in Pediatric Burn Unit at Riley Hospital for Children from October 1996 to April 2007. Patient data were collected, including demographics, percentage of TBSA burn, percentage of full-thickness burn, mechanisms of burn, settings on conventional mechanical ventilation and HFOV, and blood gas data before initiation of HFOV and at 1, 3, 6, 12, 24, 72 (3 days), 120 (5 days), 168 (7 days), 240 (10 days), and 336 hours (14 days). Length of stay, mortality, and complications were also included. HFOV was used 24 times in 21 patients between October 1996 and April 2007 with a mean age of 10 ± 11 years. At initiation of HFOV, the PaO2/FiO2 and oxygenation index values were 109 ± 26 and 36 ± 12, respectively. At stop, the PaO2/FiO2 improved to 166 ± 24 with an average increase from before HFOV of 57 ± 39 (P < .002). At 5 days of HFOV, oxygenation index improved to 14.1 ± 1.7 (P < .02) but did not significantly improve at discontinuation of HFOV at 28.8 ± 6.2 (P = .11). The mortality rate during admission to the burn unit was 29%. Barotrauma occurred in 38% of patients during HFOV. Severe hypercapnea was present briefly in 49% of patients, and this was refractory to standard treatment in 19%. In our experience, HFOV in severe burn patients has significant, early, and sustained improvement in oxygenation. Earlier institution of HFOV seems to significantly lower rates of barotraumas.

Diazoxide is commonly used in the treatment of neonatal hyperinsulinism. We describe a one month-old infant who was treated with diazoxide for prolonged neonatal hyperinsulinism. Shortly after starting diazoxide, she was admitted to the hospital for tachypnea with hypoxemia, and was subsequently diagnosed with laryngomalacia and obstructive apnea. During hospitalization, her clinical course worsened due to the development of severe pulmonary hypertension, presumed due to diazoxide toxicity. Lung biopsy revealed a probable toxic vascular drug reaction. After discontinuing diazoxide, her clinical status improved and eventually returned to baseline.

Introduction: In critical illness, hyperglycemia is associated with organ dysfunction and failure, morbidity and mortality. Although not thoroughly evaluated in children, evidence from existing randomized controlled trials contradictory. Most trials in adults suggest that strict glycemic control res

Resolution of Apnea of Prematurity (AOP) in 24-28 Week Gestational Age (GA) Infants Is No Different from Preterms 31-34 Weeks GA

Apnea Of Prematurity, Length Of Stay and NICU Admission in 31-34 Weeks Gestational Age Multiple Births † 994