Pub Date : 2024-10-01Epub Date: 2024-06-24DOI: 10.1097/PCC.0000000000003559
Stefanie Gauguet
Recently, we took care of a teenage boy in our PICU who had been struggling with a lifelong chronic illness and accompanied him and his parents during the last few days of his life. We had the privilege of getting to know him and his parents quite well during the last few years, as he required hospitalization several times during this time. We saw how extremely dedicated his parents had been to him and his care, how they left no stone unturned and sacrificed everything they could to help him have the best quality of life possible. I happened to not be on service, nor know about the moment when he passed away. I also missed when his funeral took place. I wanted to reach out to his parents, to express how much his life and their love for him had meant to me, too, and to find some closure. So I wrote this short poem for them, and for all the other parents, who have to go through the most difficult time a parent can ever go through-as a pediatric intensivist, a Mom who has never been where they had to go, a fellow human being, and a grieving friend.
{"title":"To the Parents of the Boy We Lost.","authors":"Stefanie Gauguet","doi":"10.1097/PCC.0000000000003559","DOIUrl":"10.1097/PCC.0000000000003559","url":null,"abstract":"<p><p>Recently, we took care of a teenage boy in our PICU who had been struggling with a lifelong chronic illness and accompanied him and his parents during the last few days of his life. We had the privilege of getting to know him and his parents quite well during the last few years, as he required hospitalization several times during this time. We saw how extremely dedicated his parents had been to him and his care, how they left no stone unturned and sacrificed everything they could to help him have the best quality of life possible. I happened to not be on service, nor know about the moment when he passed away. I also missed when his funeral took place. I wanted to reach out to his parents, to express how much his life and their love for him had meant to me, too, and to find some closure. So I wrote this short poem for them, and for all the other parents, who have to go through the most difficult time a parent can ever go through-as a pediatric intensivist, a Mom who has never been where they had to go, a fellow human being, and a grieving friend.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141443169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01Epub Date: 2024-07-18DOI: 10.1097/PCC.0000000000003579
Kelly M Liesse, Lakshmee Malladi, Tu C Dinh, Brendan M Wesp, Brittni N Kam, Benjamin A Turturice, Kimberly A Pyke-Grimm, Danton S Char, Seth A Hollander
Objective: Pediatric deaths often occur within hospitals and involve balancing aggressive treatment with minimization of suffering. This study first investigated associations between clinical/demographic features and the level of intensity of various therapies these patients undergo at the end of life (EOL). Second, the work used these data to develop a new, broader spectrum for classifying pediatric EOL trajectories.
Setting: Four hundred sixty-one bed tertiary, stand-alone children's hospital with 112 ICU beds.
Patients: Patients of age 0-26 years old at the time of death.
Interventions: None.
Measurements and main results: Of 1111 included patients, 85.7% died in-hospital. Patients who died outside the hospital were older. Among the 952 in-hospital deaths, most occurred in ICUs (89.5%). Clustering analysis was used to distinguish EOL trajectories based on the presence of intensive therapies and/or an active resuscitation attempt at the EOL. We identified five simplified categories: 1) death during active resuscitation, 2) controlled withdrawal of life-sustaining technology, 3) natural progression to death despite maximal therapy, 4) discontinuation of nonsustaining therapies, and 5) withholding/noninitiation of future therapies. Patients with recent surgical procedures, a history of organ transplantation, or admission to the Cardiovascular ICU had more intense therapies at EOL than those who received palliative care consultations, had known genetic conditions, or were of older age.
Conclusions: In this retrospective study of pediatric EOL trajectories based on the intensity of technology and/or resuscitation discontinued at the EOL, we have identified associations between these trajectories and patient characteristics. Further research is needed to investigate the impact of these trajectories on families, patients, and healthcare providers.
{"title":"Trajectories in Intensity of Medical Interventions at the End of Life: Clustering Analysis in a Pediatric, Single-Center Retrospective Cohort, 2013-2021.","authors":"Kelly M Liesse, Lakshmee Malladi, Tu C Dinh, Brendan M Wesp, Brittni N Kam, Benjamin A Turturice, Kimberly A Pyke-Grimm, Danton S Char, Seth A Hollander","doi":"10.1097/PCC.0000000000003579","DOIUrl":"10.1097/PCC.0000000000003579","url":null,"abstract":"<p><strong>Objective: </strong>Pediatric deaths often occur within hospitals and involve balancing aggressive treatment with minimization of suffering. This study first investigated associations between clinical/demographic features and the level of intensity of various therapies these patients undergo at the end of life (EOL). Second, the work used these data to develop a new, broader spectrum for classifying pediatric EOL trajectories.</p><p><strong>Design: </strong>Retrospective, single-center study, 2013-2021.</p><p><strong>Setting: </strong>Four hundred sixty-one bed tertiary, stand-alone children's hospital with 112 ICU beds.</p><p><strong>Patients: </strong>Patients of age 0-26 years old at the time of death.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Of 1111 included patients, 85.7% died in-hospital. Patients who died outside the hospital were older. Among the 952 in-hospital deaths, most occurred in ICUs (89.5%). Clustering analysis was used to distinguish EOL trajectories based on the presence of intensive therapies and/or an active resuscitation attempt at the EOL. We identified five simplified categories: 1) death during active resuscitation, 2) controlled withdrawal of life-sustaining technology, 3) natural progression to death despite maximal therapy, 4) discontinuation of nonsustaining therapies, and 5) withholding/noninitiation of future therapies. Patients with recent surgical procedures, a history of organ transplantation, or admission to the Cardiovascular ICU had more intense therapies at EOL than those who received palliative care consultations, had known genetic conditions, or were of older age.</p><p><strong>Conclusions: </strong>In this retrospective study of pediatric EOL trajectories based on the intensity of technology and/or resuscitation discontinued at the EOL, we have identified associations between these trajectories and patient characteristics. Further research is needed to investigate the impact of these trajectories on families, patients, and healthcare providers.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141634119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01Epub Date: 2024-10-03DOI: 10.1097/PCC.0000000000003586
Lindsay N Shepard, Akira Nishisaki
{"title":"Cardiopulmonary Resuscitation: Push Hard, Push Fast, But Where to Push?","authors":"Lindsay N Shepard, Akira Nishisaki","doi":"10.1097/PCC.0000000000003586","DOIUrl":"10.1097/PCC.0000000000003586","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11451562/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142366091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01Epub Date: 2024-06-05DOI: 10.1097/PCC.0000000000003535
Dana Singer Harel, Yiqun Lin, Carl Y Lo, Adam Cheng, Jennifer Davidson, Todd P Chang, Clyde Matava, Michael Buyck, Guylaine Neveu, Natasha Collia, Jabeen Fayyaz, Keya Manshadi, Arielle Levy, Stephanie Pellerin, Jonathan Pirie
Objectives: An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use.
Design: Simulation-based randomized trial, conducted from May to December 2021.
Setting: Four pediatric simulation centers.
Subjects: Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box).
Interventions: Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales.
Measurements and main results: A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the "low" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand ( p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales ( p < 0.05).
Conclusions: The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the "low" range, and there was no significant difference between airway provider and assistant.
{"title":"Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY) Study: Secondary Workload and Provider Outcomes in a Simulation-Based Trial.","authors":"Dana Singer Harel, Yiqun Lin, Carl Y Lo, Adam Cheng, Jennifer Davidson, Todd P Chang, Clyde Matava, Michael Buyck, Guylaine Neveu, Natasha Collia, Jabeen Fayyaz, Keya Manshadi, Arielle Levy, Stephanie Pellerin, Jonathan Pirie","doi":"10.1097/PCC.0000000000003535","DOIUrl":"10.1097/PCC.0000000000003535","url":null,"abstract":"<p><strong>Objectives: </strong>An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use.</p><p><strong>Design: </strong>Simulation-based randomized trial, conducted from May to December 2021.</p><p><strong>Setting: </strong>Four pediatric simulation centers.</p><p><strong>Subjects: </strong>Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box).</p><p><strong>Interventions: </strong>Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales.</p><p><strong>Measurements and main results: </strong>A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the \"low\" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand ( p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales ( p < 0.05).</p><p><strong>Conclusions: </strong>The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the \"low\" range, and there was no significant difference between airway provider and assistant.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141247985","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01Epub Date: 2024-06-25DOI: 10.1097/PCC.0000000000003563
Kitman Wai, Murray M Pollack, Sonali Basu
Objectives: To examine career trajectory and academic profile of Pediatric Critical Care Medicine (PCCM) physicians, with special focus on gender differences.
Design: Observational cross-sectional study of PCCM fellowship graduates using publicly available data.
Setting: Publicly available databases including National Provider Identifier registry, American Board of Pediatrics, Doximity, official hospital websites, and Scopus.
Subjects: Two thousand one hundred twenty-nine PCCM fellowship graduates employed in clinical positions in U.S. practice locations.
Intervention: None.
Measurements and main results: Physician demographic characteristics included gender and time since fellowship completion. Current career and academic characteristics included employment data, publication productivity (h-index), and academic rank. Data from 2129 career PCCM physicians was included, with recent graduates showing a notable increase in female representation. Workplace characteristics revealed that most PCCM physicians worked in university-affiliated hospitals, with higher percentages of female physicians working in university-affiliated hospitals compared with male physicians. The study also highlighted significant gender disparities in academic metrics, with male physicians having higher h-indices (3 vs. 2; p < 0.001) and more publications (6 vs. 4; p < 0.001) than their female counterparts across various career phases. Additionally, the analysis showed gender differences in academic rank, with a higher proportion of female faculty holding assistant and associate professor ranks (58.2% vs. 47.5%; p < 0.001), while a greater percentage of male faculty held the rank of professor (20.2% vs. 11.1%; p < 0.001). Multiple variable regression analysis identified both male gender and time since fellowship graduation as independently associated with a physician's h-index, while only time since fellowship graduation was linked to current academic rank.
Conclusions: This is the first analysis of career and academic characteristics of practicing PCCM physicians, additionally studying the association of gender and career trajectory. Gender discrepancy was seen in employment hospital characteristics, h-indices, and academic rank. Additional studies are required to further explore the impact of gender on career trajectory.
{"title":"Evolution of Pediatric Critical Care Medicine Physicians Clinical and Academic Profile by Gender.","authors":"Kitman Wai, Murray M Pollack, Sonali Basu","doi":"10.1097/PCC.0000000000003563","DOIUrl":"10.1097/PCC.0000000000003563","url":null,"abstract":"<p><strong>Objectives: </strong>To examine career trajectory and academic profile of Pediatric Critical Care Medicine (PCCM) physicians, with special focus on gender differences.</p><p><strong>Design: </strong>Observational cross-sectional study of PCCM fellowship graduates using publicly available data.</p><p><strong>Setting: </strong>Publicly available databases including National Provider Identifier registry, American Board of Pediatrics, Doximity, official hospital websites, and Scopus.</p><p><strong>Subjects: </strong>Two thousand one hundred twenty-nine PCCM fellowship graduates employed in clinical positions in U.S. practice locations.</p><p><strong>Intervention: </strong>None.</p><p><strong>Measurements and main results: </strong>Physician demographic characteristics included gender and time since fellowship completion. Current career and academic characteristics included employment data, publication productivity (h-index), and academic rank. Data from 2129 career PCCM physicians was included, with recent graduates showing a notable increase in female representation. Workplace characteristics revealed that most PCCM physicians worked in university-affiliated hospitals, with higher percentages of female physicians working in university-affiliated hospitals compared with male physicians. The study also highlighted significant gender disparities in academic metrics, with male physicians having higher h-indices (3 vs. 2; p < 0.001) and more publications (6 vs. 4; p < 0.001) than their female counterparts across various career phases. Additionally, the analysis showed gender differences in academic rank, with a higher proportion of female faculty holding assistant and associate professor ranks (58.2% vs. 47.5%; p < 0.001), while a greater percentage of male faculty held the rank of professor (20.2% vs. 11.1%; p < 0.001). Multiple variable regression analysis identified both male gender and time since fellowship graduation as independently associated with a physician's h-index, while only time since fellowship graduation was linked to current academic rank.</p><p><strong>Conclusions: </strong>This is the first analysis of career and academic characteristics of practicing PCCM physicians, additionally studying the association of gender and career trajectory. Gender discrepancy was seen in employment hospital characteristics, h-indices, and academic rank. Additional studies are required to further explore the impact of gender on career trajectory.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141446647","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-26DOI: 10.1097/PCC.0000000000003624
Wesley Boland, Dibyadyuti Datta, Ruth Namazzi, Caitlin Bond, Andrea L Conroy, Kagan A Mellencamp, Robert O Opoka, Chandy C John, Michael Lintner Rivera
Objectives: Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality.
Design: Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017.
Setting: Two referral hospitals in Central and Eastern Uganda.
Patients: Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children.
Interventions: None.
Measurements and main results: PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%.
Conclusions: In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.
目的:连续、无创的外周灌注监测工具(如灌注指数(PI))可检测血液动力学异常,并有助于重症疟疾住院患儿的治疗。在这项针对重症疟疾住院患儿的研究中,我们旨在评估灌注指数是否与临床灌注指标相关,并确定将灌注指数与这些临床指标相结合是否能更好地识别死亡率较高的患儿:对2014年至2017年间进行的一项前瞻性多中心队列研究进行事后分析:乌干达中部和东部的两家转诊医院:600名5岁以下的重症疟疾患儿和120名无症状的社区儿童:测量和主要结果在住院的头 24 小时内,每隔 6 小时测量一次 PI。我们将 PI 与毛细血管再充盈时间、外周肢体是否冰冷或温度梯度等标准临床灌注测量指标进行了比较。入院 PI 与临床灌注测量结果高度相关。与无症状的社区儿童相比,重症疟疾患儿入院时的血流灌注指数较低;在重症疟疾患儿中,有血流灌注不良临床特征或重症疟疾并发症(如休克和高乳酸血症)的患儿的血流灌注指数较低(均 p <0.02)。在重症疟疾患儿中,在对年龄、性别和重症疟疾标准进行调整后,较低的入院 PI 与较高的死亡几率相关(调整后的几率比,PI 每下降 1 个对数,死亡几率为 2.4 [95% CI,1.0-5.9];P = 0.045)。在诊断上,连续两次出现低 PI(< 1%)可预测死亡率,灵敏度为 50%,特异度为 76%:结论:在重症疟疾中,PI 与临床并发症(包括休克和血清乳酸升高)相关,可作为一个客观、连续的解释变量,与较高的后期院内死亡率相关。
{"title":"Peripheral Perfusion Index in Ugandan Children With Plasmodium falciparum Severe Malaria: Secondary Analysis of Outcomes in a 2014-2017 Cohort Study.","authors":"Wesley Boland, Dibyadyuti Datta, Ruth Namazzi, Caitlin Bond, Andrea L Conroy, Kagan A Mellencamp, Robert O Opoka, Chandy C John, Michael Lintner Rivera","doi":"10.1097/PCC.0000000000003624","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003624","url":null,"abstract":"<p><strong>Objectives: </strong>Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality.</p><p><strong>Design: </strong>Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017.</p><p><strong>Setting: </strong>Two referral hospitals in Central and Eastern Uganda.</p><p><strong>Patients: </strong>Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%.</p><p><strong>Conclusions: </strong>In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142351488","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1097/PCC.0000000000003612
Anna E McCormick, Stuart H Friess, Kimberly S Quayle, John C Lin, Arushi Manga
Objectives: To assess the skill of bag-tube manual ventilation with the flow-inflating bag in multiprofessional PICU team members using a mobile simulation unit.
Design: Prospective observational study from January 2022 to April 2022.
Setting: In situ mobile simulation using the flow-inflating bag in an academic PICU.
Subjects: Multiprofessional PICU team members including nurses, respiratory therapists, nurse practitioners, fellows, and attendings.
Interventions: None.
Measurements and main results: We enrolled 129 participants who twice completed 1-minute tasks performing bag-tube manual ventilation with a flow-inflating bag. Sessions were video recorded; four could not be analyzed. Only 30% of participants reported being very to extremely confident, and the majority (62%) reported infrequent skill performance. Task success was defined as achieving target pressure ranges during 80% of the delivered breaths, respiratory rate (RR) of 25-35 breaths/min, and successful pop-off valve engagement. Only five of 129 participants (4%) achieved successful ventilation as defined. Overall, participants were more likely to deliver lower pressures and faster rate. Maintaining target positive end-expiratory pressure (PEEP) was least likely to be achieved (19% success), followed by RR (52%), pop-off valve (64%), then peak inspiratory pressure (71%). Nurses were less likely to achieve target pressures compared with all other professions.
Conclusions: Multiprofessional PICU team members have highly variable self-confidence with bag-tube manual ventilation using a flow-inflating bag. Observed performance demonstrates rare success with achieving targeted ventilation parameters, in particular maintenance of PEEP. Future research should focus on developing mobile simulation units to facilitate profession-specific, real-time coaching to teach high-quality manual ventilation that can be translated to the bedside.
{"title":"Pediatric Resuscitation Skill of Bag-Tube Manual Ventilation: Developing and Using a Mobile Simulation Program to Assess Competency of a Multiprofessional PICU Team.","authors":"Anna E McCormick, Stuart H Friess, Kimberly S Quayle, John C Lin, Arushi Manga","doi":"10.1097/PCC.0000000000003612","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003612","url":null,"abstract":"<p><strong>Objectives: </strong>To assess the skill of bag-tube manual ventilation with the flow-inflating bag in multiprofessional PICU team members using a mobile simulation unit.</p><p><strong>Design: </strong>Prospective observational study from January 2022 to April 2022.</p><p><strong>Setting: </strong>In situ mobile simulation using the flow-inflating bag in an academic PICU.</p><p><strong>Subjects: </strong>Multiprofessional PICU team members including nurses, respiratory therapists, nurse practitioners, fellows, and attendings.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We enrolled 129 participants who twice completed 1-minute tasks performing bag-tube manual ventilation with a flow-inflating bag. Sessions were video recorded; four could not be analyzed. Only 30% of participants reported being very to extremely confident, and the majority (62%) reported infrequent skill performance. Task success was defined as achieving target pressure ranges during 80% of the delivered breaths, respiratory rate (RR) of 25-35 breaths/min, and successful pop-off valve engagement. Only five of 129 participants (4%) achieved successful ventilation as defined. Overall, participants were more likely to deliver lower pressures and faster rate. Maintaining target positive end-expiratory pressure (PEEP) was least likely to be achieved (19% success), followed by RR (52%), pop-off valve (64%), then peak inspiratory pressure (71%). Nurses were less likely to achieve target pressures compared with all other professions.</p><p><strong>Conclusions: </strong>Multiprofessional PICU team members have highly variable self-confidence with bag-tube manual ventilation using a flow-inflating bag. Observed performance demonstrates rare success with achieving targeted ventilation parameters, in particular maintenance of PEEP. Future research should focus on developing mobile simulation units to facilitate profession-specific, real-time coaching to teach high-quality manual ventilation that can be translated to the bedside.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142471873","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1097/PCC.0000000000003621
Ashleigh E Butler, Florencia Krall, Alexis Shinewald, Joseph C Manning, Karen Choong, Karen Dryden-Palmer
{"title":"Family-Centered Care in the PICU: Strengthening Partnerships in Pediatric Critical Care Medicine.","authors":"Ashleigh E Butler, Florencia Krall, Alexis Shinewald, Joseph C Manning, Karen Choong, Karen Dryden-Palmer","doi":"10.1097/PCC.0000000000003621","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003621","url":null,"abstract":"","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142471872","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objectives: In this study, we have reviewed the association between esophageal pressure-guided positive end-expiratory pressure (PEEP) setting and oxygenation and lung mechanics with a conventional mechanical ventilation (MV) strategy in patient with moderate to severe pediatric acute respiratory distress syndrome (PARDS).
Design: Retrospective cohort, 2018-2021.
Setting: Tertiary PICU.
Patients: Moderate to severe PARDS patients who required MV with PEEP of greater than or equal to 8 cm H2O.
Measurements and main results: We identified 26 PARDS cases who were divided into those who had been managed with PTP-guided MV (PTP group) and those managed with conventional ventilation strategy (non-PTP). Oxygenation and lung mechanics were compared between groups at baseline (0 hr) and 24, 48, and 72 hours of MV. There were 13 patients in each group in the first 24 hours. At 48 and 72 hours, there were 11 in PTP group and 12 in non-PTP group. On comparing these groups, first, use of PTP monitoring was associated with higher median (interquartile range) mean airway pressure at 24 hours (18 hr [18-20 hr] vs. 15 hr [13-18 hr]; p = 0.01) and 48 hours (19 hr [17-19 hr] vs. 15 hr [13-17 hr]; p = 0.01). Second, use of PTP was associated with higher PEEP at 24, 48, and 72 hours (all p < 0.05). Third, use of PTP was associated with lower Fio2 and greater Pao2 to Fio2 ratio at 72 hours. Last, there were 18 of 26 survivors, and we failed to identify an association between use of PTP monitoring and survival.
Conclusions: In this cohort of moderate to severe PARDS cases undergoing MV with PEEP greater than or equal to 8 cm H2O, we have identified some favorable associations of oxygenation status when PTP-guided MV was used vs. not. Larger studies are required.
{"title":"Transpulmonary Pressure-Guided Mechanical Ventilation in Severe Acute Respiratory Distress Syndrome in PICU: Single-Center Retrospective Study in North India, 2018-2021.","authors":"Anil Sachdev, Anil Kumar, Bharat Mehra, Neeraj Gupta, Dhiren Gupta, Suresh Gupta, Parul Chugh","doi":"10.1097/PCC.0000000000003609","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003609","url":null,"abstract":"<p><strong>Objectives: </strong>In this study, we have reviewed the association between esophageal pressure-guided positive end-expiratory pressure (PEEP) setting and oxygenation and lung mechanics with a conventional mechanical ventilation (MV) strategy in patient with moderate to severe pediatric acute respiratory distress syndrome (PARDS).</p><p><strong>Design: </strong>Retrospective cohort, 2018-2021.</p><p><strong>Setting: </strong>Tertiary PICU.</p><p><strong>Patients: </strong>Moderate to severe PARDS patients who required MV with PEEP of greater than or equal to 8 cm H2O.</p><p><strong>Interventions: </strong>Esophageal pressure (i.e., transpulmonary pressure [PTP]) guided MV vs. not.</p><p><strong>Measurements and main results: </strong>We identified 26 PARDS cases who were divided into those who had been managed with PTP-guided MV (PTP group) and those managed with conventional ventilation strategy (non-PTP). Oxygenation and lung mechanics were compared between groups at baseline (0 hr) and 24, 48, and 72 hours of MV. There were 13 patients in each group in the first 24 hours. At 48 and 72 hours, there were 11 in PTP group and 12 in non-PTP group. On comparing these groups, first, use of PTP monitoring was associated with higher median (interquartile range) mean airway pressure at 24 hours (18 hr [18-20 hr] vs. 15 hr [13-18 hr]; p = 0.01) and 48 hours (19 hr [17-19 hr] vs. 15 hr [13-17 hr]; p = 0.01). Second, use of PTP was associated with higher PEEP at 24, 48, and 72 hours (all p < 0.05). Third, use of PTP was associated with lower Fio2 and greater Pao2 to Fio2 ratio at 72 hours. Last, there were 18 of 26 survivors, and we failed to identify an association between use of PTP monitoring and survival.</p><p><strong>Conclusions: </strong>In this cohort of moderate to severe PARDS cases undergoing MV with PEEP greater than or equal to 8 cm H2O, we have identified some favorable associations of oxygenation status when PTP-guided MV was used vs. not. Larger studies are required.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142292812","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-18DOI: 10.1097/PCC.0000000000003610
Kevin S Gochenour, Melissa H Ross, Heidi R Flori, Joseph G Kohne
Objectives: To examine the clinical characteristics, outcomes, and resource use of adolescents and young adults (AYAs) admitted to PICUs in the United States with respiratory failure.
Design: Retrospective cohort study.
Setting: De-identified data from 48 U.S. children's hospitals contributing to the Pediatric Health Information System (PHIS) database.
Patients: All patients older than 30 days old with respiratory failure, defined as encounters with clinical transaction codes for noninvasive or invasive mechanical ventilation, admitted to PHIS database PICUs from January 2011 to December 2022. Patients were categorized into five cohorts (< 15, 15-18, 19-21, 22-25, and > 25 yr old).
Interventions: None.
Measurements and main results: A total of 430,238 patients were identified. AYA (≥ 15 yr old) accounted for 15% (65,740) of all PICU admissions with respiratory failure. Forty-nine percent (32,232/65,740) of AYA older than 25 years had medical technology dependence compared with 39% in those younger than 15 years (p < 0.001). Sixty-one percent of AYA older than 25 years had a cardiovascular comorbidity compared with 35% of those younger than 15 years (p < 0.001). Forty percent of AYA older than 25 years had a neurologic comorbidity, and 27% a gastrointestinal comorbidity, compared with 27% and 31%, respectively, in those younger than 15 years (all p < 0.001). Compared with those younger than 15 years, AYA median hospital crude mortality rate was higher at 7.7% compared with 5.2%, as were median hospital charges per encounter at $163K (interquartile range [IQR], $77K-$350K) vs. $121K (IQR, $53K-$278K; all p < 0.001). Median ventilator days and hospital length of stay in survivors were similar for all age cohorts.
Conclusions: AYA represent a substantial proportion of patients admitted to the PICU with respiratory failure. These individuals have unique comorbidities and are at risk for increased mortality and resource utilization compared with younger patients during hospitalization. Medical complexity and sequelae of pediatric illness may delay the transition of AYA to adult care, necessitating collaboration between adult and pediatric critical care physicians to increase research across the age spectrum and develop and implement appropriate evidence-based guidelines.
{"title":"Adolescents and Young Adults With Respiratory Failure in U.S. PICUs: A Pediatric Health Information System Database Study, 2011-2022.","authors":"Kevin S Gochenour, Melissa H Ross, Heidi R Flori, Joseph G Kohne","doi":"10.1097/PCC.0000000000003610","DOIUrl":"https://doi.org/10.1097/PCC.0000000000003610","url":null,"abstract":"<p><strong>Objectives: </strong>To examine the clinical characteristics, outcomes, and resource use of adolescents and young adults (AYAs) admitted to PICUs in the United States with respiratory failure.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>De-identified data from 48 U.S. children's hospitals contributing to the Pediatric Health Information System (PHIS) database.</p><p><strong>Patients: </strong>All patients older than 30 days old with respiratory failure, defined as encounters with clinical transaction codes for noninvasive or invasive mechanical ventilation, admitted to PHIS database PICUs from January 2011 to December 2022. Patients were categorized into five cohorts (< 15, 15-18, 19-21, 22-25, and > 25 yr old).</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>A total of 430,238 patients were identified. AYA (≥ 15 yr old) accounted for 15% (65,740) of all PICU admissions with respiratory failure. Forty-nine percent (32,232/65,740) of AYA older than 25 years had medical technology dependence compared with 39% in those younger than 15 years (p < 0.001). Sixty-one percent of AYA older than 25 years had a cardiovascular comorbidity compared with 35% of those younger than 15 years (p < 0.001). Forty percent of AYA older than 25 years had a neurologic comorbidity, and 27% a gastrointestinal comorbidity, compared with 27% and 31%, respectively, in those younger than 15 years (all p < 0.001). Compared with those younger than 15 years, AYA median hospital crude mortality rate was higher at 7.7% compared with 5.2%, as were median hospital charges per encounter at $163K (interquartile range [IQR], $77K-$350K) vs. $121K (IQR, $53K-$278K; all p < 0.001). Median ventilator days and hospital length of stay in survivors were similar for all age cohorts.</p><p><strong>Conclusions: </strong>AYA represent a substantial proportion of patients admitted to the PICU with respiratory failure. These individuals have unique comorbidities and are at risk for increased mortality and resource utilization compared with younger patients during hospitalization. Medical complexity and sequelae of pediatric illness may delay the transition of AYA to adult care, necessitating collaboration between adult and pediatric critical care physicians to increase research across the age spectrum and develop and implement appropriate evidence-based guidelines.</p>","PeriodicalId":19760,"journal":{"name":"Pediatric Critical Care Medicine","volume":null,"pages":null},"PeriodicalIF":4.0,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142292811","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}