Faculty Bibliography

Introduction/Aim: NYU Langone Health's first neonatal ECMO patient was in March 2015, marking the start of the Pediatric and Neonatal ECMO Program within the institution. Since then, our program averages 5 ECMO patients per fiscal year (September 1 to August 31). A core ECMO Team, consisting of a Medical Director, a Surgical Director, an ECMO coordinator, 2 Chiefs of Perfusion, and 3 ECMO Intensivists, was identified to establish a reservoir of ECMO expertise within our new, low volume ECMO program. When a patient requires ECMO support, the core ECMO Team collaborates with the multidisciplinary ICU team to optimize both patient and circuit management. The teams provide concurrent care with the ECMO Team overseeing all ECMO-related decision making. Despite having the core ECMO Team as a resource during each ECMO case, a low volume of ECMO patients per year augments slower institutional learning and highlights the need for more frequent educational opportunities. The core ECMO Team worked together to create a recurring multidisciplinary Pediatric ECMO In-situ Simulation to bridge the educational gap in a new, low volume ECMO center. Material and Methods: The goal of establishing Pediatric ECMO In-Situ Simulation was to have either a real life patient on ECMO support or have a simulated ECMO patient once a month to establish routine ECMO exposure and promote multidisciplinary learning and competency. The first simulation session took place in September 2017. For 9 consecutive months, we achieved this goal with 4 real life ECMO patients and 5 simulated ECMO patients. Each simulation session took place over 4 hours and included a complete critical care team, consisting of an ICU Attending Physician, an Advanced Practice Provider, a Resident, 2 Critical Care Nurses, a Perfusionist, and a Respiratory Therapist. Pre-and postsimulation, participants completed self-assessments and knowledge tests, which were then, analyzed using the Wilcoxon Signed-rank test. Simulation logistics included a high fidelity simulation mannequin that was connected to a running ECMO circuit, as well as IV infusions and a mechanical ventilator. Simulation medications, fluids, blood products, and bedside supplies were readily available for the participants. Contact information to simulated ancillary departments, such as Inpatient STAT Lab, Blood Bank and Radiology, was distributed. We also collaborated with Hospital Informatics to create a virtual medical record for the simulated patient, which allowed the participants to view the ECMO order set, lab values, imaging results, vital signs, etc. The participants could also place orders in real time and document in the "patient's" medical record. The primary learning objective of the simulation was to improve competency in the daily management of an ECMO patient with less emphasis on ECMO circuit troubleshooting and emergency management. Scenarios included routine ECMO practices, such as conducting multidisciplinary ECMO rounds, adhering to programmatic processes, completing hourly patient assessments and documentation requirements, and monitoring patient fluid volume status. Results: 27 participants took pre-and post-course tests to assess their ECMO knowledge. They also filled out pre-and post-course selfassessments to determine their level of self-confidence in caring for an ECMO patient. One participant was excluded from the data analysis due to incomplete test scores and survey responses. Using the Wilcoxon Signed-rank test, we found a statistically significant improvement in the self-assessment scores (p=0.00001284). There was also a trend towards improvement in the knowledge scores (p=0.09). Conclusions: High fidelity in-situ simulation targeting various learner groups is effective with improvement in self-confidence and written knowledge. Recurring simulation opportunities in a new, low volume ECMO Center promotes continued familiarity and experience in caring for ECMO patients. Next steps include conducting multiple simulation sessions throughout a longer time span, such as over a 12 to 24 hour period

Introduction/Aim: Our Pediatric ECMO Program was launched in March of 2015. Based on historical volumes and projections we anticipated a low volume center. Per ELSO Guidelines, ECMO centers require institutional structure and organization for effective use of ECMO therapy. Also, literature review of pediatric ECMO patient outcomes imply that high volume ECMO centers are associated with improved survival rates in pediatric ECMO patients. Our goal was to implement a formal Pediatric ECMO Program, along with a structured educational course, to demonstrate that successful patient survival rates are obtainable in a low volume ECMO center. Material and Methods: A comprehensive review was completed to identify gaps and areas for improvement within the current state of ECMO at the institution with the goal of establishing an ECMO Program, per ELSO Guidelines, that ensures safe use of ECMO, improved patient outcomes, and optimized programmatic processes. Interventions implemented to formalize the ECMO Program included establishment of clinical practice guidelines and protocols, creation of an ECMO credentialing process, standardization of intrahospital processes related to ECMO, and organization of patient data collection. To assure reasonable use of this resource all cannulation and decannulation decisions required agreement of both the Medical and Surgical ECMO Directors. Formalization of the interprofessional collaboration with the critical care teams and ancillary departments was established with structured morning and evening rounds. Collaboration continued through implementation of formal multidisciplinary team meetings, including patient case reviews and quality assurance meetings. Last, a primary intervention in formalization of an ECMO Program was the establishment of an ECMO education course that was required for all providers who would be involved in the care of ECMO patients. The course was geared towards frontline critical care physicians and advanced practice providers caring for pediatric ECMO patients. The course included didactic learning and simulation training with a high fidelity simulation mannequin and a running ECMO circuit. Pre-and postcourse, participants completed self-assessments and knowledge tests. Results: Since March 2015, our Pediatric ECMO Program averages 5 ECMO patients per fiscal year (September 1 to August 31). In the first fiscal year (FY) 2015, our survival from ECMO rate was 33% with 0% of our patients surviving to discharge. Our hemorrhagic and neurologic complication rates were 67%. The formalization of our ECMO Program and implementation of ECMO education occurred in April 2016, mid FY 2016. Our survival from ECMO rate for FY 2016 improved from 33% to 86%, showing a 160.6% increase. Subsequently, our survival from ECMO rates continued to improve with FY 2017 having 100% survival rate and FY 2018 having 80% survival rate. We also observed a notable decrease in hemorrhagic and neurologic complications per FY. These complications decreased by 40.3% and 70.1%, respectively. Along with tracking our ECMO patient outcomes and complications, our program closely monitors our ECMO consults. Since March 2015, we average 23 ECMO consults per FY with an average of 5 patients (20%) placed on ECMO and 18 patients (80%) denied from ECMO. Out of the patients who were denied ECMO support, 30% of patients expired and 70% of patients recovered and survived to discharge, emphasizing the importance of strict patient selection criteria and centralized ECMO decision-making. For our ECMO course results, our team has held seven courses since August 2016. Among the first time participants (n=82), 84% showed improvement, 10% did worse, and 6% had incomplete data in their post-test written knowledge test. Conclusions: Despite a low institutional case volume of ECMO patients, creation of a structured ECMO Program with a recurring comprehensive ECMO course, promotes both self-confidence and clinical abilities of the multidisciplinary critical care team, as well as improves patient outcomes. Ongoing data collection and quality improvement will be essential to maintain this high level of performance

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity characterized by variable associations of headaches, encephalopathy, seizures, vomiting, visual disturbance, and focal neurological signs. Neuroimaging shows cerebral edema of different patterns, classically involving the parieto-occipital white matter. PRES has been associated with several conditions predominantly hypertension, eclampsia, and immunosuppressive therapy. However, constipation has not been previously described in association with the development of PRES. In this report, we describe an 11-year-old child with history of severe functional constipation who developed PRES, as a consequence of renovascular hypertension from severe fecal impaction. Both hypertension and neurologic dysfunction resolved after resolution of fecal impaction. CONCLUSION: Severe functional constipation is a previously unrecognized cause of severe acute hypertension, resulting in life-threatening neurologic dysfunction. We highlight this unrecognized complication of severe functional constipation with fecal impaction that is potentially preventable if managed appropriately. WHAT IS KNOWN: * Posterior reversible encephalopathy syndrome (PRES) is a life-threatening disorder * PRES has been associated with multiple conditions, including hypertension and immunosuppressive therapy What is New: * Constipation with severe fecal impaction may cause severe renovascular hypertension and PRES * Severe functional constipation is a previously unrecognized cause of severe symptomatic hypertension that could result in acute brain dysfunction, such as PRES.

We report an interesting case of a child with new-onset malignant hypertension (HTN) associated with facial paralysis. A review of the medical literature on this association and discussion of diagnostic and management aspects are included.

OBJECTIVE: To test the hypothesis that telemedicine can reliably be used for many aspects of circulatory and neurologic examinations of children admitted to a pediatric intensive care unit (PICU). STUDY DESIGN: A prospective, randomized study in a 14-bed PICU in a tertiary care, academic-affiliated institution. Eligible patients were >2 months or <19 years of age, not involved in a concurrent study, had parents/guardian able to sign an informed consent form, were not at end-of-life, and had an attending who not only deemed them medically stable, but also felt that the study would not interrupt their care. Other than the Principal Investigator, 6 pediatric intensivists and 7 pediatric critical care fellows were eligible study providers. Two physician providers were randomly assigned to perform circulatory and neurologic examinations according to the American Heart Association/Pediatric Advanced Life Support guidelines in-person and via telemedicine. Findings were recorded on a standardized data collection form and compared. RESULTS: One hundred ten data collection forms were completed. For many aspects of the circulatory and neurologic examinations, outcomes showed substantial to perfect agreement between the in-person and telemedical care providers (kappa = 0.64-1.00). However, assessments of muscle tone had a kappa = 0.23, with a kappa = 0.37 for skin color. CONCLUSIONS: Telemedicine can reliably identify normal and abnormal findings of many aspects of circulatory and neurologic examinations in PICU patients. This finding opens the door to further studies on the use of telemedicine across other disciplines.