Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS:Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS:We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS:Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

IMPORTANCE:Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections (LRTIs) and infant hospitalization worldwide. OBJECTIVE:To evaluate the characteristics and outcomes of RSV-related critical illness in US infants during peak 2022 RSV transmission. DESIGN, SETTING, AND PARTICIPANTS:This cross-sectional study used a public health prospective surveillance registry in 39 pediatric hospitals across 27 US states. Participants were infants admitted for 24 or more hours between October 17 and December 16, 2022, to a unit providing intensive care due to laboratory-confirmed RSV infection. EXPOSURE:Respiratory syncytial virus. MAIN OUTCOMES AND MEASURES:Data were captured on demographics, clinical characteristics, signs and symptoms, laboratory values, severity measures, and clinical outcomes, including receipt of noninvasive respiratory support, invasive mechanical ventilation, vasopressors or extracorporeal membrane oxygenation, and death. Mixed-effects multivariable log-binomial regression models were used to assess associations between intubation status and demographic factors, gestational age, and underlying conditions, including hospital as a random effect to account for between-site heterogeneity. RESULTS:The first 15 to 20 consecutive eligible infants from each site were included for a target sample size of 600. Among the 600 infants, the median (IQR) age was 2.6 (1.4-6.0) months; 361 (60.2%) were male, 169 (28.9%) were born prematurely, and 487 (81.2%) had no underlying medical conditions. Primary reasons for admission included LRTI (594 infants [99.0%]) and apnea or bradycardia (77 infants [12.8%]). Overall, 143 infants (23.8%) received invasive mechanical ventilation (median [IQR], 6.0 [4.0-10.0] days). The highest level of respiratory support for nonintubated infants was high-flow nasal cannula (243 infants [40.5%]), followed by bilevel positive airway pressure (150 infants [25.0%]) and continuous positive airway pressure (52 infants [8.7%]). Infants younger than 3 months, those born prematurely (gestational age <37 weeks), or those publicly insured were at higher risk for intubation. Four infants (0.7%) received extracorporeal membrane oxygenation, and 2 died. The median (IQR) length of hospitalization for survivors was 5 (4-10) days. CONCLUSIONS AND RELEVANCE:In this cross-sectional study, most US infants who required intensive care for RSV LRTIs were young, healthy, and born at term. These findings highlight the need for RSV preventive interventions targeting all infants to reduce the burden of severe RSV illness.

OBJECTIVES/OBJECTIVE:We aimed to critically evaluate the effectiveness of a designated ECMO team in our ECMO selection process and patient outcomes in the first 3 years of our low-volume pediatric ECMO program. METHODS:We conducted a retrospective chart review of patients who received an ECMO consultation between the start of our program in March 2015 and May 2018. We gathered clinical and demographic information on patients who did and did not receive ECMO, and described our selection process. We reflected on the processes used to initiate our program and our outcomes in the first 3 years. RESULTS:, lactate, and pH between the patients who went on ECMO and who did not. We improved our outcomes from 0% survival to discharge in 2015, to 60% in 2018, with an average of 63% survival to discharge over the first 3 years of our program. CONCLUSIONS:In a low-volume pediatric ECMO center, having a designated team to assist in the patient selection process and management can help provide safe and efficient care to these patients, and improve patient outcomes. Having a strict management protocol and simulation sessions involving all members of the medical team yields comfort for the providers and optimal care for patients. This study describes our novel structure, processes, and outcomes, which we hope will be helpful to others seeking to develop a new pediatric ECMO program.

OBJECTIVES:Extracorporeal membrane oxygenation (ECMO) has been used successfully to support adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiac or respiratory failure refractory to conventional therapies. Comprehensive reports of children and adolescents with SARS-CoV-2-related ECMO support for conditions, including multisystem inflammatory syndrome in children (MIS-C) and acute COVID-19, are needed. DESIGN:Case series of patients from the Overcoming COVID-19 public health surveillance registry. SETTING:Sixty-three hospitals in 32 U.S. states reporting to the registry between March 15, 2020, and December 31, 2021. PATIENTS:Patients less than 21 years admitted to the ICU meeting Centers for Disease Control criteria for MIS-C or acute COVID-19. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The final cohort included 2,733 patients with MIS-C ( n = 1,530; 37 [2.4%] requiring ECMO) or acute COVID-19 ( n = 1,203; 71 [5.9%] requiring ECMO). ECMO patients in both groups were older than those without ECMO support (MIS-C median 15.4 vs 9.9 yr; acute COVID-19 median 15.3 vs 13.6 yr). The body mass index percentile was similar in the MIS-C ECMO versus no ECMO groups (89.9 vs 85.8; p = 0.22) but higher in the COVID-19 ECMO versus no ECMO groups (98.3 vs 96.5; p = 0.03). Patients on ECMO with MIS-C versus COVID-19 were supported more often with venoarterial ECMO (92% vs 41%) for primary cardiac indications (87% vs 23%), had ECMO initiated earlier (median 1 vs 5 d from hospitalization), shorter ECMO courses (median 3.9 vs 14 d), shorter hospital length of stay (median 20 vs 52 d), lower in-hospital mortality (27% vs 37%), and less major morbidity at discharge in survivors (new tracheostomy, oxygen or mechanical ventilation need or neurologic deficit; 0% vs 11%, 0% vs 20%, and 8% vs 15%, respectively). Most patients with MIS-C requiring ECMO support (87%) were admitted during the pre-Delta (variant B.1.617.2) period, while most patients with acute COVID-19 requiring ECMO support (70%) were admitted during the Delta variant period. CONCLUSIONS:ECMO support for SARS-CoV-2-related critical illness was uncommon, but type, initiation, and duration of ECMO use in MIS-C and acute COVID-19 were markedly different. Like pre-pandemic pediatric ECMO cohorts, most patients survived to hospital discharge.

INTRODUCTION/BACKGROUND:Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. METHODS:After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. RESULTS:82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. CONCLUSION/CONCLUSIONS:ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

BACKGROUND/UNASSIGNED:Delirium is a common complication of critical illness, with a prevalence of 25% among pediatric intensive care unit (ICU) patients. Pharmacological treatment options for ICU delirium are limited to off-label use of antipsychotics, but their benefit remains uncertain. OBJECTIVE/UNASSIGNED:The purpose of this study was to evaluate quetiapine effectiveness for the treatment of delirium in critically ill pediatric patients and to describe the safety profile of quetiapine. METHODS/UNASSIGNED:A single-center, retrospective review of patients aged ≤ 18 years who screened positive for delirium via the Cornell Assessment of Pediatric Delirium (CAPD ≥ 9) and received ≥ 48 hours of quetiapine therapy was conducted. The relationship between quetiapine and deliriogenic medication doses was evaluated. RESULTS/UNASSIGNED:This study included 37 patients who received quetiapine for the treatment of delirium. The change in sedation requirements before quetiapine initiation to 48 hours after the highest quetiapine dose demonstrated a downward trend; 68% of patients had a decrease in opioid requirements and 43% of patients had a decrease in benzodiazepine requirements. The median CAPD score at baseline was 17 and the median CAPD score at 48 hours after the highest dose was 16. Three patients experienced QTc prolongation (defined as a QTc ≥ 500), although none developed dysrhythmias. CONCLUSION AND RELEVANCE/UNASSIGNED:Quetiapine did not have a statistically significant impact on deliriogenic medication doses. There were minimal changes in QTc and dysrhythmias were not identified. Therefore, quetiapine can be safe to use in our pediatric patients but further studies are needed to find an effective dose.

INTRODUCTION: Extra-corporeal membrane oxygenation (ECMO) is a treatment modality known to alter drug pharmacokinetics (PK). The PK changes can result from drug binding to the oxygenator, alterations in clearance, and drug adsorption or sequestration. Levels of drug absorption by polymers, silicone rubber and other materials have been linked to the drugs' lipophilicity and the published literature is mostly outdated. Additionally, there is limited data regarding the impact of the oxygenator on drug changes in ECMO circuits in comparison to the other components of the ECMO circuit. The purpose of this study was to determine the impact of the Quadrox-i pediatric and adult oxygenators on the PK of remdesivir (RDV) in contemporary ECMO circuits.
METHOD(S): One 1/4-in. and one 3/8-in. closed loop ECMO circuits were prepared using custom tubing with polyvinylchloride and superTygon (Medtronic Inc., Minneapolis, MN) and a Quadrox-i adult or pediatric oxygenator (Maquet). Additionally, one 1/4-in. and one 3/8- in. closed loop ECMO circuits were assembled without an oxygenator in series. RDV was added to the circuit and levels were obtained pre-and post-oxygenator at the following time intervals; 5 mins, 1, 2, 3, 4, 5, 6, 8, 12, and 24 hrs. RDV was also maintained in a glass vial and samples obtained at the same time periods for control purposes. RDV samples were analyzed by liquid chromatography tandem mass spectrometry.
RESULT(S): For the 3/8-in. circuit with and without an oxygenator, there was a 60-70% RDV loss during the study period. For the 1/4-in. circuits with an oxygenator, there was a 35-60% RDV loss during the study period. For the 1/4-in. circuits without an oxygenator, there was a 5-20% RDV loss during the study period.
CONCLUSION(S): There was RDV loss within the circuit during the study period and the RDV loss was more pronounced with the larger 3/8-in circuit when compared with the 1/4-in. circuit. This preliminary data suggests RDV dosing may need to be adjusted for concern of drug loss via the ECMO circuit. Additional single and multiple dose studies are needed to validate these findings

INTRODUCTION: High rates of burnout and depression in pediatric residents negatively impacts quality of care. These rates may be heightened during PICU rotations, which serve as a primary source of exposure to end of life events. Consistent debriefings after significant events can reduce the risk of burnout and increase one's ability to manage grief. The aim of this study is to assess the baseline level of resident burnout and resilient coping prior to implementing a standardized resident debrief in the PICU.
METHOD(S): A survey based, cohort study was conducted at a single-center academic PICU. All pediatric residents rotating in the PICU were eligible to participate. Participants completed a survey at the start of the academic year (July 2022). The survey included demographic questions, the Maslach Burnout Inventory (MBI) which consists of three domains (emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA)), and the Brief Resilient Coping Scale (BRCS), which captures adaptive tendencies to cope with stress.
RESULT(S): Forty-six percent of eligible residents (18/39) completed the survey (PGY-2: 55%; PGY-3: 45%). Demographics were representative of the study population with the majority being female (83%), Caucasian (77%), and Non-Hispanic (89%). Although 33% of respondents had never participated in a formal debrief, 100% were interested in participating in a formal debriefing. The mean MBI results were averaged by domain and compared to the standardized scales for healthcare workers in medicine (EE 22, DP 7, PA 36). The average EE (32), DP (12), and PA (33) scores of participants demonstrated higher EE and DP and lower PA scores in the study population, demonstrating high levels of burnout. The BRCS results revealed 94% of participants were low (50%) or medium (44%) copers, while only 6% demonstrated high resilient coping.
CONCLUSION(S): This study identified high levels of burnout and low levels of resilient coping in pediatric residents, as well as minimal exposure to formal debrief sessions despite a high level of interest in participating in such opportunities. The results highlight the need for standardized resident debrief sessions during high stress PICU rotations

INTRODUCTION: The distinct clinical entity known as Hyperosmolar Diabetic Ketoacidosis (H-DKA) is increasing in incidence without simultaneous advances in treatment. There are limited reports of an associated fatal syndrome characterized by a Malignant Hyperthermia-like (MH-L) picture with persistent fever, rhabdomyolysis and cardiac compromise. Evidence supports the use of empiric treatment with Dantrolene to decrease mortality in these cases. This report highlights a case of patient survival with early, empiric Dantrolene administration. DESCRIPTION: A 15-year-old male with ADHD and obesity presented to the hospital after being found unresponsive at home. He was intubated with succinylcholine and started on an insulin drip and maintenance fluids. He was admitted with fluid-refractory, hypovolemic shock secondary to H-DKA and new onset Type II Diabetes Mellitus. He was afebrile at presentation, but developed high fevers within hours of insulin initiation which persisted, despite use of scheduled acetaminophen and cooling blankets. He then developed rhabdomyolysis (CK: 9,680 U/L), pancreatitis (lipase: 2,103 U/L) and severe AKI (Creatinine: 5.4 mg/dL). High fevers persisted, blood and urine cultures remained negative, thus given concern for MH-L picture, Dantrolene 2.5mg/kg (240mg) was administered and he defervesced to 37 degreeC. He then developed significant cardiac dysfunction with ST elevations on ECG, high troponin levels (Troponin: 21,534 ng/L), and depressed LV function (EF: 35%), thought to be secondary to Myopericarditis given normal cardiac catheterization. Ultimately, fevers persisted without an identified source, but inflammatory markers downtrended and cultures remained negative. DISCUSSION: H-DKA with associated rhabdomyolysis, cardiac dysfunction, and MH-L picture is rarely reported and associated with significant mortality. This case demonstrates the effective use of Dantrolene administration with transient improvement in the patient's fever curve and patient survival. Evolving evidence supports the entity referred to as "awake- MH" in which there is no triggering anesthetic agent, but a possible underlying genetic cause due to a variant in the RYR1 gene. Genetic testing may be considered in patients with H-DKA, rhabdomyolysis and persistent fever without a source