Faculty Bibliography

Introduction: Abdominal compartment syndrome (ACS) in children carries a mortality rate of 40% to 60%. Definitive treatment for ACS traditionally involves decompressive laparotomy. Although percutaneous catheter drainage (PCD) is an accepted therapy for neonates with intestinal perforation, its adoption for ACS remains low, due to uncertainty concerning its efficacy and concerns about complications. We explored whether PCD safely and successfully reversed ACS physiology in a cohort of children with intra-abdominal fluid.
Method(s): We reviewed records of all children undergoing PCD for ACS from 2014 to 2018 at a single institution. Bedside sonogram-guided PCD was performed by the surgical service using the Seldinger technique, with catheters removed on resolution of ACS physiology and fluid output of <10 mL/d. Clinical variables were explored using descriptive statistics and reported as median with interquartile range (IQR). Physiologic improvements over 24 hours were compared using paired Wilcoxon signed-rank tests.
Result(s): A total of 11 infants with a median age of 11 days (IQR 4 to 273 days) and weight of 4.2 kg (IQR 2.3 to 9.2 kg) underwent PCD for ACS secondary to ascites (n = 6), hemoperitoneum (n = 4), and pneumoperitoneum with ascites (n = 1). Catheters remained in place for a median of 8 days (IQR 5 to 9 days), with a median of 359 mL of fluid (IQR 165 to 1,588 mL) drained in the first 24 hours. Percutaneous catheter drainage resulted in significant physiologic improvement across multiple variables (Table). No catheter-related complications occurred, with only 1 patient requiring subsequent laparotomy.
Conclusion(s): Percutaneous catheter drainage is efficacious in reversing ACS physiology in children with intra-abdominal fluid, and should be considered a safe intervention that can obviate decompressive laparotomy. [Figure presented]
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Since March 2015, our Pediatric ECMO team has cared for 31 patients. Of these, 16 patients are still living today (53%). Patient & family support are necessary during ECMO, as well as post-ECMO and hospital discharge. Recent studies show that not only patients who required ECMO fulfill post-traumatic stress disorder diagnostic criteria, but also their close relatives are at risk to develop PTSD. Minimal peer to peer resources exist in the community for these patients and families. We found this to be a gap in ECMO care and an area of opportunity for us to provide additional support to this patient population. Our team explored options for engaging and decided to host our first Pediatric ECMO Reunion. The reunion included both patients & families and multidisciplinary staff members who cared for our prior ECMO patients. This venue provided an opportunity for sharing patient stories, for ECMO providers to reconnect with survivors and staff to experience the positive outcomes from their work. This allowed for a first step for families to understand their experience and help decrease burnout in providers and staff. We provided families the option to stay in touch with the ECMO Program through different family work groups. We also interviewed families and distributed surveys for direct feedback on their experience working with our team while their child was on ECMO. Next steps include creating an ECMO Family Work Group by partnering with families to develop new ways to support future ECMO families and improve the ECMO family experience

The majority of neonatal and pediatric patients require emergent cannulations at the bedside in the intensive care unit (ICU). To accomplish a bedside cannulation, multidisciplinary teams need to work together and perform tasks that may be different from the usual practices in the ICU. The complexity of the many tasks that need to be completed can lead to significant delay if not well choreographed. Our project goal was to streamline the pre-cannulation process to decrease the time from ECMO mobilization to procedure start. The initiative was implemented in September 2016. Interventions included formalization of ECMO Program policies & procedures and multidisciplinary education, as well as implementation of formal patient case reviews & quality assurance meetings. Our team collaborated with ancillary departments to ensure timeliness and efficiency with orders & processes related to ECMO initiation. We also created a detailed precannulation checklist which defines each team members' role and their responsibilities in the pre-cannulation process. The checklist is reviewed prior to the procedure time out as a final check to ensure all required tasks are completed. Upon retrospective chart review, the pre- & post-initiative data revealed a 54% decrease in time from ECMO mobilization to cannulation procedure start. The post-initiative average time of 65 minutes showed successful improvement from the pre-initiative average time of 136 minutes. We concluded that a structured process for pre-cannulation preparedness, role definition, multidisciplinary education, and team debriefs maximize efficiency in team readiness for a bedside ECMO cannulation procedure

Infants with meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension of newborn (PPHN) have the most favorable outcomes among infants requiring extracorporeal membrane oxygenation (ECMO). Early term (ET) infants have been shown to have higher morbidities when compared with term infants. It is not known if ET infants requiring ECMO for MAS and/or PPHN have higher morbidities and mortality than term infants. Objective of our study was to compare morbidity and mortality in ET infants with MAS and/or PPHN requiring ECMO in comparison to their term counterparts. A total of 3831 neonatal ECMO runs for MAS and/or PPHN were reviewed from the de-identified ELSO registry patient dataset from 2007- 2017. Neonates born at ET (37+0/7 - 38+6/7 weeks) and term (39+0/7 - 40+6/7 weeks) were further classified as two study groups. Both groups were compared using chi-square test. Of 2529 infants who were included in the study, there were 799 ET and 1730 term infants. ET infants when compared with term infants had higher mortality (9.6% vs 6%, P=0.002), lower survival to discharge (80.4% vs 87.7%, P<0.001), higher neurologic complications (14.8% vs 11.5%, P=0.024), and increased need for hemofiltration (32.9% vs 28.7%, P=0.033). There were no statistically significant differences between both groups in hemorrhagic, infectious, metabolic and cardiovascular complications. ET infants with MAS and/or PPHN have higher morbidities and mortality than term infants on ECMO. Caregivers should be informed of higher risks associated with use of ECMO in ET infants when compared to full term newborns

The past two decades have witnessed an alarming expansion of staphylococcal disease caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). The factors underlying the epidemic expansion of CA-MRSA lineages such as USA300, the predominant CA-MRSA clone in the United States, are largely unknown. Previously described virulence and antimicrobial resistance genes that promote the dissemination of CA-MRSA are carried by mobile genetic elements, including phages and plasmids. Here, we used high-resolution genomics and experimental infections to characterize the evolution of a USA300 variant plaguing a patient population at increased risk of infection to understand the mechanisms underlying the emergence of genetic elements that facilitate clonal spread of the pathogen. Genetic analyses provided conclusive evidence that fitness (manifest as emergence of a dominant clone) changed coincidently with the stepwise emergence of (i) a unique prophage and mutation of the regulator of the pyrimidine nucleotide biosynthetic operon that promoted abscess formation and colonization, respectively, thereby priming the clone for success; and (ii) a unique plasmid that conferred resistance to two topical microbiocides, mupirocin and chlorhexidine, frequently used for decolonization and infection prevention. The resistance plasmid evolved through successive incorporation of DNA elements from non-S. aureus spp. into an indigenous cryptic plasmid, suggesting a mechanism for interspecies genetic exchange that promotes antimicrobial resistance. Collectively, the data suggest that clonal spread in a vulnerable population resulted from extensive clinical intervention and intense selection pressure toward a pathogen lifestyle that involved the evolution of consequential mutations and mobile genetic elements.

PURPOSE/OBJECTIVE:The purpose of this study was to reduce radiation exposure during pediatric central venous line (CVL) placement by implementing a radiation safety process including a radiation safety briefing and a job-instruction model with a preradiation time-out. METHODS:We reviewed records of all patients under 21 who underwent CVL placement in the operating room covering 22 months before the intervention through 10 months after 2013-2016. The intervention consisted of a radiation safety briefing by the surgeon to the intraoperative staff before each case and a radiation safety time-out. We measured and analyzed the dose area product (DAP), total radiation time pre- and postintervention, and the use of postprocedural chest radiograph. RESULTS:, P < 0.001) and a 73% decrease in the median radiation time (28 vs 7.6 s, P < 0.001). Additionally, there was a significant reduction in use of confirmatory CXR (95% vs 15%, P < 0.01). CONCLUSION/CONCLUSIONS:A preoperative radiation safety briefing and a radiation safety time-out supported by a job-instruction model were effective in significantly lowering the absorbed doses of radiation in children undergoing CVL insertion. TYPE OF STUDY/METHODS:Case-control study. LEVEL OF EVIDENCE/METHODS:Level III.

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