Faculty Bibliography

OBJECTIVES/OBJECTIVE:With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers. DESIGN/METHODS:National 2-day point prevalence study. SETTING/METHODS:Eighty-two PICUs in 65 hospitals across the United States. PATIENTS/METHODS:All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day. INTERVENTIONS/METHODS:None. MEASUREMENTS AND MAIN RESULTS/RESULTS:The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs < 3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6). CONCLUSIONS:Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.

The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line-associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.

Mobilizing patients during an intensive care unit admission results in improved clinical and functional outcomes. The goal of this quality improvement project was to increase the percentage of patients in the pediatric intensive care unit (PICU) mobilized early from 62% to 80%. Early mobilization was within 18 hours of admission for nonmechanically ventilated (non-MV) patients and 48 hours for mechanically ventilated (MV) patients.

Well-known causes of zinc deficiency, also referred to as acrodermatitis enteropathica (AE), include defects in intestinal zinc transporters and inadequate intake, but a rare cause of acquired zinc deficiency discussed here is an iatrogenic nutritional deficiency caused by parenteral nutrition administered without trace elements. While zinc-depleted parenteral nutrition causing dermatosis of acquired zinc deficiency was first reported in the 1990s, it is now again relevant due to a national vitamin and trace element shortage. A high index of suspicion may be necessary to diagnose zinc deficiency, particularly because early clinical findings are nonspecific. We present this case of acquired zinc deficiency in a patient admitted to a pediatric intensive care unit for respiratory distress and atypical pneumonia, who subsequently developed a severe bullous eruption due to iatrogenic zinc deficiency but was treated effectively with enteral and parenteral zinc supplementation, allowing for rapid re-epithelialization of previously denuded skin.

Objectives/UNASSIGNED:Our aim was to describe the pharmacokinetics of cefazolin in paediatric patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) who received cefazolin for peri-operative surgical prophylaxis in addition to having cefazolin added to the CPB circuit priming solution. Secondary aims were to determine the pharmacodynamic exposure associated with the addition of cefazolin to the CPB priming solution and to assess whether a target cefazolin concentration range for the CPB priming solution could be identified. Methods/UNASSIGNED:A multicentre, prospective, open-label pharmacokinetic study was carried out in children from birth to 16 years of age undergoing cardiac surgery. Results/UNASSIGNED:Forty-one patients met the inclusion criteria and accounted for 492 samples for analysis. Cefazolin concentrations were best described by a one-compartment model with weight as a covariate on the volume of distribution (Vd) with allometric scaling. The mean ± standard deviation (SD) total body CL for the birth-6 month cohort was 0.009 ± 0.006 mL/min/kg with a mean ± SD Vd of 0.59 ± 0.26 L/kg, the mean ± SD total body CL for the 7 month-3 year cohort was 0.01 ± 0.005 mL/min/kg with a mean ± SD Vd of 0.79 ± 0.15 L/kg, and the mean ± SD total body CL for the 4-16 year cohort was 0.007 ± 0.004 mL/min/kg with a mean ± SD Vd of 3.4 ± 0.94 L/kg. The median cefazolin loss in the CPB circuit ranged from 78% to 95% and the median patient cefazolin concentration after CPB circuit detachment ranged from 92 to 197 mg/L. Conclusions/UNASSIGNED:These data demonstrate that mixing cefazolin in the CPB circuit priming solution was effective in maintaining cefazolin serum concentrations during surgery. If this practice is utilized, re-dosing of cefazolin during the CPB run and upon CPB circuit detachment is most probably not needed. Larger pharmacokinetic studies are warranted.

Objective/UNASSIGNED:Evidence for successful and sustainable models that systematically identify and address family stress in the pediatric intensive care unit (PICU) remains scarce. Using an integrated improvement science and family engagement framework, we implemented a standardized family stress screening tool and response protocol to improve family experience and reduce family crises through the timely coordination of parent support interventions. Methods/UNASSIGNED:We conducted this improvement initiative in the 12-bed PICU of a children's hospital within a large, urban academic medical center. Our team, which included 2 family advisors, adapted a validated Distress Thermometer for use in pediatric intensive care. A co-designed family stress screening tool and response protocol were iteratively tested, refined, and implemented in 2015-2017. Process and outcome measures included screening and response reliability, parent satisfaction, and security calls for distressed families. Results/UNASSIGNED:< 0.01; 95% CI). The number of security calls for distressed families decreased by 50%. Conclusions/UNASSIGNED:The successful implementation of a co-designed family stress screening tool and response protocol led to the timely coordination of parent support interventions, the improved family perception of emotional support, and reduced family crises in the PICU.

Invasive community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections disproportionately affect children, but there are few pediatric reports of pericarditis and mediastinitis caused by CA-MRSA in previously healthy children. Here we report a severe case of CA-MRSA pericarditis with extension to the mediastinum and carotid sheath in a previously healthy 8-month-old infant who was successfully treated with surgical interventions and with a combination of daptomycin and vancomycin. The relatively indolent clinical course in this patient was notable given the significant extent of infection. This case highlights the potential virulence of CA-MRSA in previously healthy children and the importance of early diagnosis, prompt drainage, and appropriate antibiotic coverage.

Learning Objectives: 1. Assess the impact and feasibility of an early mobilization program in the Pediatric Intensive Care Unit (PICU). 2. Increase percent of PICU patients mobilized within recommended time frame to 80% (from 56%) -timeframe defined as 18 hours for non-mechanically ventilated (MV) patients and 48 hours for MV patients. 3. Decrease PICU LOS Methods: Design: Quality improvement (QI) project with preand post-intervention groups. Setting: 12 bedded PICU in an academic medical center Patients: 73 patients in the pre-intervention group and 110 patients in the post-intervention group. Interventions: A survey was developed to identify barriers to mobilization. An algorithm was created to help identify children appropriate for mobilization. Education and training was completed on the benefits of early mobilization and techniques to safely mobilize critically ill children. Family advisors assisted in incorporating patient and family feedback into staff education. Measurements: Mobilization rate; incidence of safety events, Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP) orders, ICU and hospital LOS, discharge disposition Results: Percent of patients mobilized within allotted time frame increased from 56% to 82%. Percent of patients with PT, OT, and SLP orders increased by 7%, 10% and 1% respectively. For the non-MV group, hospital length of stay decreased from 6.1 to 4.2 days, PICU LOS decreased from 3.5 to 2.4 days and percent of patients discharged home increased from 85% to 95% versus discharge to facility. For non-MV patients the average PICU LOS decreased from 3.5 to 2.4 days (p = .012). Length of stay was correlated with early mobilization (r =-.20, p = .008), as measured across the pre-and post-intervention time periods. The total LOS decreased from 6.1 to 4.2 days. The correlation between LOS and mobilization, r =-.20, was maintained whether considering total hospital length of stay or length of stay in the PICU only. For MV patients, the average PICU LOS increased from 12.1 to 12.5 days (3% increase) and the overall average hospital LOS decreased from 15.3 to 14.8 days (3% decrease). Conclusions: Early mobilization in the PICU is safe and effective and can increase percentage of patients mobilized, and percent of patients with PT and OT orders. Early mobilization is associated with decreased PICU and floor LOS and increased percent of patients discharged to home in non-mechanically ventilated patients