Andrew Beardsley

Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections.

Objectives: A catheter thrombosis and the presence of a catheter-associated bloodstream infection (CBSI) often occur simultaneously, but it is unclear if or to what degree the two complications relate. Several animal and adult studies indicate a relationship between fibrin sheaths and thrombi in the development of CBSIs. To date, there has been limited human investigation in the pediatric population to determine a clear link between the presence of a thrombus and bacteremia. The use of alteplase for malfunctioning central venous catheter may indicate the formation of intraluminal thrombus or fibrin sheath. A catheter that requires alteplase is at higher risk of a CBSI. Design: A retrospective chart review from July 2008 to December 2010. Setting: PICU. Patients: All patients with central catheters admitted to the PICU. Interventions: No interventions performed with the retrospective study. Measurements: Number of total central venous catheters, number of central venous catheters that received treatment with alteplase, and number of CBSIs. Main Results: Preliminary data during the study period identified 3,289 central venous catheters. Twelve percent of these catheters required at least one dose of alteplase. There were 40 CBSIs during this same time period of which 28% received alteplase during the 5 days preceding the positive blood culture. The odds ratio for getting a CBSI when alteplase is administered is 2.87 (confidence interval 1.42–5.80; p = 0.002). The average age of the central venous catheters at time of infection was not statistically different, 16.1 days in the alteplase catheters compared with 25.6 days for the catheters that did not receive alteplase (p = 0.6). Conclusions: There is a positive correlation between the use of alteplase for malfunctioning central venous catheters and the development of a CASBI. This is likely associated with the presence of an intraluminal fibrin sheath or thrombus. This study adds evidence linking thrombus formation to CBSI.

Devastating Ischemic Stroke Following Selective Arterial Embolization of a Large Chest Wall Aneurysmal Bone Cyst.

Aneurysmal bone cysts (ABC) are benign bone lesions found in children and young adults. Rarely, these lesions can arise from ribs, and there is disagreement on the best treatment because of proximity to vital structures. Frequently, surgeons remove ABC with en bloc resection. Selective arterial embolization has been used as an adjunct to surgery, or rarely as the primary treatment. We report a case of embolic stroke complicating embolization of a rib ABC, likely from the presence of collateral circulation between the mass and vertebral artery. Caution should be taken when performing embolization of lesions in this location because of potential complications.

1323: AN INTERPROFESSIONAL WEANING PROTOCOL FOR CONTINUOUS ALBUTEROL IN THE PICU

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Endotracheal intubation remains a lifesaving intervention performed in pediatric intensive care units. However, it is associated with risks such as increased rate of infection, prolonged hospitalizations and worse clinical outcomes. Thus successful extubation is critical to minimizing the duration of mechanical ventilation. Previous studies have reported extubation failure (defined as requiring reintubation within 24 to 48 hours following extubation) rates, of 5–9%. Many studies have attempted to improve assessments of extubation readiness, but it is unclear if extubation failure rates have improved over time. Knowing the timing of extubation failure may also further improve failure rates. Methods: We performed a retrospective, observational analysis of 25 regional PICUs (size range 842 beds) using Virtual PICU Systems (VPS, LLC) Database. All consecutive patients that received invasive mechanical ventilation from January 1, 2015 through December 31, 2015 were included. Patients with tracheostomy tubes, altered code status, ventilation < 4hrs, or death prior to extubation were excluded. Extubation failure was defined as reintubation within 48hrs following extubation. The number of reintubations within specific time threshold was analyzed. The ratio of extubation failures to the total number of intubations during the specific time period (Example: within 1, 6, 12, 24, and 48hrs of extubation) defined the extubation failure rate. Results: A total of 22,342 consecutive patients were identified. There were 3264 extubations and 156 “extubation failures”. The overall extubation failure rate was 4.8% (156/3264). When analyzed by time from extubation, the failure rates were: 1 hr1.5%; 6 hr-2.8%; 12 hr3.2%; 24 hr4.1%; 48 hr4.8%). The patients who failed extubation were most likely to have the primary diagnosis of respiratory disease (33.1%), cardiovascular disease (22%), and neurologic disease (16%). Conclusions: Extubation failure remains relatively uncommon. •The current failure rate (4.8%) is consistent with previous studies (5–9%). •Nearly two-thirds of extubation failures occur within the first 12 hours after extubation (86% failed within 24hrs). •This study, using a national clinical registry, demonstrates the ability to add a time element to the analysis of clinical outcomes. Future studies will attempt to identify the patients at highest risk for extubation failure, the role of noninvasive respiratory support after extubation, and estimate the timing of failure.

1159: RISK FACTORS, OUTCOMES, AND TIMING OF VENTILATOR-ASSOCIATED INFECTIONS IN PEDIATRIC TRAUMA PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) expected response to successful SBT in an already established, structured handoff tool as a contingency plan; and designation of a MICU provider to respond to notices of successful SBTs occurring during work rounds, allowing assessment of the patient and order entry without interruption. An uncontrolled beforeafter study design was employed, and medical records were reviewed from two cohorts: six months preand post-intervention. Results: Early post-intervention analysis was conducted at four months. The pre(n=59) and post-intervention (n=33) cohorts were not statistically different in baseline characteristics except for prevalence of obstructive sleep apnea. The percentage of patients extubated within 45 minutes of successful completion of a SBT increased significantly from 33.9% to 51.5% (RR = 1.52, p < 0.05). The mean time to extubation after successful completion of SBT decreased significantly from 86.9 to 57.1 minutes (p = 0.02). Conclusions: Improving communication regarding extubation of patients who have passed a SBT can lead to early liberation from MV. This initiative suggests, with limitation, that a bundled intervention that formalizes communication about extubation plans through development of a new system is a possible solution to this issue.