Variation in Anticonvulsant Selection and Electroencephalographic Monitoring Following Severe Traumatic Brain Injury in Children-Understanding Resource Availability in Sites Participating in a Comparative Effectiveness Study. (Williams)

Kurz JE, et al. Variation in Anticonvulsant Selection and Electroencephalographic Monitoring Following Severe Traumatic Brain Injury in Children-Understanding Resource Availability in Sites Participating in a Comparative Effectiveness Study. Pediatr Crit Care Med. 2016 Jul; 17(7):649-657.

OBJECTIVES: Early posttraumatic seizures may contribute to worsened outcomes after traumatic brain injury. Evidence to guide the evaluation and management of early posttraumatic seizures in children is limited. We undertook a survey of current practices of continuous electroencephalographic monitoring, seizure prophylaxis, and the management of early posttraumatic seizures to provide essential information for trial design and the development of posttraumatic seizure management pathways.

DESIGN: Surveys were sent to site principal investigators at all 43 sites participating in the Approaches and Decisions in Acute Pediatric TBI trial at the time of the survey. Surveys consisted of 12 questions addressing strategies to 1) implement continuous electroencephalographic monitoring, 2) posttraumatic seizure prophylaxis, 3) treat acute posttraumatic seizures, 4) treat status epilepticus and refractory status epilepticus, and 5) monitor antiseizure drug levels.

SETTING: Institutions comprised a mixture of free-standing children’s hospitals and university medical centers across the United States and Europe.

SUBJECTS: Site principal investigators of the Approaches and Decisions in Acute Pediatric TBI trial.


MEASUREMENTS AND MAIN RESULTS: Continuous electroencephalographic monitoring was available in the PICU in the overwhelming majority of clinical sites (98%); however, the plans to operationalize such monitoring for children varied considerably. A similar majority of sites report that administration of prophylactic antiseizure medications is anticipated in children (93%); yet, a minority reports that a specified protocol for treatment of posttraumatic seizures is in place (43%). Reported medication choices varied substantially between sites, but the majority of sites reported pentobarbital for refractory status epilepticus (81%). The presence of treatment protocols for seizure prophylaxis, early posttraumatic seizures, posttraumatic status epilepticus, and refractory status epilepticus was associated with decreased reported medications (all p < 0.05).

CONCLUSIONS: This study reports the current management practices for early posttraumatic seizures in select academic centers after pediatric severe traumatic brain injury. The substantial variation in continuous electroencephalographic monitoring implementation, choice of seizure prophylaxis medications, and management of early posttraumatic seizures across institutions was reported, signifying the areas of clinical uncertainty that will help provide focused design of clinical trials. Although sites with treatment protocols reported a decreased number of medications for the scenarios described, completion of the Approaches and Decisions in Acute Pediatric TBI trial will be able to determine if these protocols lead to decreased variability in medication administration in children at the clinical sites.

Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation. (Williams)

Nasr VG, Faraoni D, DiNardo JA, Thiagarajan RR. Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. 2016 Jul;17(7):684-91.

OBJECTIVES: Extracorporeal membrane oxygenation is increasingly utilized to provide cardiopulmonary support to critically ill children. Although life-saving in many instances, extracorporeal membrane oxygenation support is associated with considerable morbidity and mortality. This study evaluates the effect of extracorporeal membrane oxygenation complications and extracorporeal membrane oxygenation hospital characteristics on mortality in neonates and children supported with extracorporeal membrane oxygenation.

DESIGN: Retrospective analysis of administrative data.

SETTING: Data from 31 U.S. states included in 2012 Healthcare Cost and Utilization Project Kids’ Inpatient Database.

PATIENTS: Children treated with extracorporeal membrane oxygenation.


MEASUREMENTS AND MAIN RESULTS: Study subject were identified using International Classification of Diseases, 9th Edition Clinical Modification code 39.65 and classified into six diagnostic categories: 1) cardiac surgery, 2) non-surgical heart disease, 3) congenital diaphragmatic hernia, 4) neonatal respiratory failure, 5) pediatric respiratory failure, and 6) sepsis. Demographics, hospital characteristics, and outcome information were used in a multivariate logistic regression analysis to determine factors associated with mortality. We identified 1,465 children treated with extracorporeal membrane oxygenation. Overall mortality was 40% (591/1,465). Mortality was independently associated with diagnosis (heart disease: odds ratio, 1.7; p = 0.01; congenital diaphragmatic hernia: odds ratio, 5.1; p < 0.001; and sepsis odds ratio: 2.4; p = 0.003 compared with neonatal respiratory failure) time from hospital admission to extracorporeal membrane oxygenation of more than 10 days (odds ratio, 4.5; p < 0.001) and extracorporeal membrane oxygenation complications (renal [odds ratio: 5; p < 0.001] and neurologic [odds ratio, 1.4; p = 0.03] injury). In addition, hospitals with bed size less than 400 had higher mortality (odds ratio, 1.4; p = 0.02). In patients with any extracorporeal membrane oxygenation complication, probability of mortality was lower for extracorporeal membrane oxygenation patients in larger hospitals, 38% (95% CI, 37-39) versus 44% (95% CI, 43-46) with p value of less than 0.001.

CONCLUSIONS: Extracorporeal membrane oxygenation mortality was significantly associated with patient diagnosis, time to extracorporeal membrane oxygenation initiation, extracorporeal membrane oxygenation complications, and extracorporeal membrane oxygenation hospital bed size. Improved survival in larger hospitals supports centralization of extracorporeal membrane oxygenation services to larger centers.

Does Simulation Improve Recognition and Management of Pediatric Septic Shock, and If One Simulation Is Good, Is More Simulation Better? (Williams)

Dugan MC, McCracken CE, Hebbar KB. Does Simulation Improve Recognition and Management of Pediatric Septic Shock, and If One Simulation Is Good, Is More Simulation Better? Pediatr Crit Care Med. 2016 Jul;17(7):605-14.

OBJECTIVES: Determine whether serial simulation training sessions improve resident recognition and initial septic shock management in a critically ill simulated septic shock patient, and to determine whether serial simulations further improve resident task performance when compared with a single simulation session.

DESIGN: Prospective observational cohort study with a live expert review of trainee simulation performance. Expert reviewers blinded to prior trainee performance.

SETTING: A PICU room in a quaternary-care children’s hospital, featuring a hi-fidelity pediatric patient simulator.

SUBJECTS: Postgraduate year-2 and postgraduate year-3 pediatric residents who rotate through the PICU.

INTERVENTIONS: Postgraduate year-3 residents as the control cohort, completing one simulation near the start of their third residency year. Postgraduate year-2 residents as the intervention cohort, completing two simulations during their second residency year and one near the start of their third residency year.

MEASUREMENTS AND MAIN RESULTS: Resident objective performance was measured using a validated 27-item checklist (graded 0/1) related to monitoring, data gathering, and interventions in the diagnosis and management of pediatric septic shock. The intervention cohort had a higher mean performance percentage score during their third simulation than the control cohort completing their single simulation (87% vs 77%; p < 0.001). Septic shock was correctly diagnosed more often in the intervention cohort at the time of their third simulation (100% vs 78%; p < 0.001). Appropriate broad-spectrum antibiotics were administered correctly more often in the intervention cohort (83% vs 50%; p < 0.001).

CONCLUSIONS: Simulations significantly improved resident performance scores in the management of septic shock with repetitive simulation showing significant ongoing improvements. Further studies are needed to determine long-term impact on knowledge and skill retention and whether results attained in a simulation environment are translatable into clinical practice in improving bedside care.

Hemodynamic Bedside Ultrasound Image Quality and Interpretation After Implementation of a Training Curriculum for Pediatric Critical Care Medicine Providers. (Williams)

Conlon TW, Ishizuka M, Himebauch AS, Cohen MS, Berg RA, Nishisaki A. Hemodynamic Bedside Ultrasound Image Quality and Interpretation After Implementation of a Training Curriculum for Pediatric Critical Care Medicine Providers. Pediatr Crit Care Med. 2016 Jul;17(7):598-604.

OBJECTIVE: Bedside ultrasound for hemodynamic evaluation in critically ill children is increasingly recognized as an important skill for pediatric critical care medicine providers. Our institution implemented a training curriculum leading to institutional credentialing for pediatric critical care providers in nonprocedural bedside ultrasound core applications. We hypothesized that hemodynamic studies performed or supervised by credentialed providers (credentialed providers group) have better image quality and greater accuracy in interpretation than studies performed by non-credentialed providers without supervision (non-credentialed providers group).

DESIGN: Retrospective descriptive study.

SETTING: Single-center tertiary non-cardiac 55-bed PICU in a children’s hospital.

PATIENTS: Patients from October 2013 to January 2015, with hemodynamic bedside ultrasound performed and interpreted by pediatric critical care providers exposed to bedside ultrasound training.

INTERVENTIONS: A cardiologist blinded to performer scored hemodynamic bedside ultrasound image quality for five core cardiac views (excellent = 3, good = 2, fair = 1, unacceptable = 0; median = quality score) and interpretation within 5 hemodynamic domains (agreement = 3, minor disagreement = 2, major disagreement = 1; median = interpretation score), as well as a global assessment of interpretation.

MEASUREMENTS AND MAIN RESULTS: Eighty-one studies (45 in the credentialed providers group and 36 in the non-credentialed providers group) were evaluated. There was no statistically significant difference in quality score between groups (median: 1.4 [interquartile range: 0.8-1.8] vs median: 1.2 [interquartile range: 0.75-1.6]; p = 0.14]. Studies in the credentialed providers group had higher interpretation score than those in the non-credentialed providers group (median: 3 [interquartile range: 2.5-3) vs median: 2.67 [interquartile range: 2.25-3]; p = 0.04). Major disagreement between critical care provider and cardiology review occurred in 25 of 283 hemodynamic domains assessed (8.8%), with no statistically significant difference between credentialed providers and non-credentialed providers groups (6.1% vs 11.9%; p = 0.12).

CONCLUSION: Hemodynamic bedside ultrasound performed or supervised by credentialed pediatric critical care providers had more accurate interpretation than studies performed by unsupervised non-credentialed providers. A rigorous pediatric critical care medicine bedside ultrasound credentialing program can train intensivists to attain adequate images and interpret those images appropriately.

Association Between Uropathogen and Pyuria. (Emrath)

Shaikh N, Shope TR, Hoberman A, Vigliotti A, Kurs-Lasky M, Martin JM. Association Between Uropathogen and Pyuria. Pediatrics. 2016 Jul;138(1). pii: e20160087.

OBJECTIVE: We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen.

METHODS: We obtained data on children evaluated at the Children’s Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures.

RESULTS: There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization.

CONCLUSIONS: We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.

The Fecal Microbiota Profile and Bronchiolitis in Infants. (Emrath)

Hasegawa K, Linnemann RW, Mansbach JM, Ajami NJ, Espinola JA, Petrosino JF,
Piedra PA, Stevenson MD, Sullivan AF, Thompson AD, Camargo CA Jr. The Fecal Microbiota Profile and Bronchiolitis in Infants. Pediatrics. 2016 Jul;138(1). pii: e20160218.

BACKGROUND: Little is known about the association of gut microbiota, a potentially modifiable factor, with bronchiolitis in infants. We aimed to determine the association of fecal microbiota with bronchiolitis in infants.

METHODS: We conducted a case-control study. As a part of multicenter prospective study, we collected stool samples from 40 infants hospitalized with bronchiolitis. We concurrently enrolled 115 age-matched healthy controls. By applying 16S rRNA gene sequencing and an unbiased clustering approach to these 155 fecal samples, we identified microbiota profiles and determined the association of microbiota profiles with likelihood of bronchiolitis.

RESULTS: Overall, the median age was 3 months, 55% were male, and 54% were non-Hispanic white. Unbiased clustering of fecal microbiota identified 4 distinct profiles: Escherichia-dominant profile (30%), Bifidobacterium-dominant profile (21%), Enterobacter/Veillonella-dominant profile (22%), and Bacteroides-dominant profile (28%). The proportion of bronchiolitis was lowest in infants with the Enterobacter/Veillonella-dominant profile (15%) and highest in the Bacteroides-dominant profile (44%), corresponding to an odds ratio of 4.59 (95% confidence interval, 1.58-15.5; P = .008). In the multivariable model, the significant association between the Bacteroides-dominant profile and a greater likelihood of bronchiolitis persisted (odds ratio for comparison with the Enterobacter/Veillonella-dominant profile, 4.24; 95% confidence interval, 1.56-12.0; P = .005). In contrast, the likelihood of bronchiolitis in infants with the Escherichia-dominant or Bifidobacterium-dominant profile was not significantly different compared with those with the Enterobacter/Veillonella-dominant profile.

CONCLUSIONS: In this case-control study, we identified 4 distinct fecal microbiota profiles in infants. The Bacteroides-dominant profile was associated with a higher likelihood of bronchiolitis.

Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU. (Emrath)

Bechard LJ, et al. Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU. Crit Care Med. 2016 Aug;44(8):1530-7.

OBJECTIVE: To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.

DESIGN: Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.

SETTING: Ninety PICUs from 16 countries with eight or more beds.

PATIENTS: Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.

MEASUREMENTS AND MAIN RESULTS: Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p < 0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p < 0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p < 0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p < 0.001) fewer ventilator-free days than normal weight and overweight, respectively.

CONCLUSIONS: Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

A Time-Motion Study of ICU Workflow and the Impact of Strain. (Emrath)

Hefter Y, Madahar P, Eisen LA, Gong MN. A Time-Motion Study of ICU Workflow and the Impact of Strain. Crit Care Med. 2016 Aug;44(8):1482-9.

OBJECTIVE: Understanding ICU workflow and how it is impacted by ICU strain is necessary for implementing effective improvements. This study aimed to quantify how ICU physicians spend time and to examine the impact of ICU strain on workflow.

DESIGN: Prospective, observational time-motion study.

SETTING: Five ICUs in two hospitals at an academic medical center.

SUBJECTS: Thirty attending and resident physicians.


MEASUREMENTS AND MAIN RESULTS: In 137 hours of field observations, the most time-84 hours (62% of total observation time)-was spent on professional communication. Reviewing patient data and documentation occupied a combined 52 hours (38%), whereas direct patient care and education occupied 24 hours (17%) and 13 hours (9%), respectively. The most frequently used tool was the computer, used in tasks that occupied 51 hours (37%). Severity of illness of the ICU on day of observation was the only strain factor that significantly impacted work patterns. In a linear regression model, increase in average ICU Sequential Organ Failure Assessment was associated with more time spent on direct patient care (β = 4.3; 95% CI, 0.9-7.7) and education (β = 3.2; 95% CI, 0.7-5.8), and less time spent on documentation (β = -7.4; 95% CI, -11.6 to -3.2) and on tasks using the computer (β = -7.8; 95% CI, -14.1 to -1.6). These results were more pronounced with a combined strain score that took into account unit census and Sequential Organ Failure Assessment score. After accounting for ICU type (medical vs surgical) and staffing structure (resident staffed vs physician assistant staffed), results changed minimally.

CONCLUSION: Clinicians spend the bulk of their time in the ICU on professional communication and tasks involving computers. With the strain of high severity of illness and a full unit, clinicians reallocate time from documentation to patient care and education. Further efforts are needed to examine system-related aspects of care to understand the impact of workflow and strain on patient care.