Anne Stormorken

Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia-Outside the Operating Room for Esophagogastroduodenoscopy and Colonoscopy in Children: Age Is an Independent Predictor of Outcomes.

Objectives: Procedural sedation/anesthesia outside the operating room for a variety of procedures is well described with an overall low adverse event rate in certain settings. Adverse event associated with procedural sedation/anesthesia outside the operating room for gastrointestinal procedures have been described, albeit in small, single-center studies with wide variance in outcomes. Predictors of such outcomes are unclear. We aimed to estimate the prevalence of adverse event in children undergoing procedural sedation/anesthesia outside the operating room for esophagogastroduodenoscopy, colonoscopy, or both to identify predictors of adverse event. Design/Setting/Patients: Retrospective analysis of Pediatric Sedation Research Consortium database, a large data repository of pediatric patients aged 21 years old or younger undergoing procedural sedation/anesthesia outside the operating room during September 2007 to November 2011. Twenty-two of the 40 centers provided data pertaining to the procedure of interest. Interventions: None. Measurements and Main Results: Primary outcome variable is any adverse event. Independent variables include: age (five groups), sex, American Societyof Anaesthesiologists status, procedure (esophagogastroduodenoscopy, colonoscopy, or both), provider responsible, medication used, location, and presence of coexisting medical conditions. Descriptive statistics used to summarize the data. Using multivariablelogistic regression model, odds ratio, 95% CI) were computed. A total of 12,030 procedures were performed (esophagogastroduodenoscopy, 7,970; colonoscopy, 1,378; and both, 2,682). A total of 96.9% of patients received propofol. Eighty-three percent were performed in a sedation unit. Prevalence of adverse event was 4.8%. The most common adverse event were persistent desaturations (1.5%), airway obstruction (1%), cough (0.9%), and laryngospasm (0.6%). No deaths or CPR occurred. Infants and children aged 5 years old or younger had a higher adverse event rate than older children (15.8%, 7.8% vs 4%). Regression analysis revealed age 5 years old or younger, American Society of Anaesthesiologists greater than or equal to 2, esophagogastroduodenoscopy ± colonoscopy, and coexisting medical conditions of obesity and lower airway disease were independent predictors of higher adverse event. Conclusions: Overall prevalence of any adverse event was 4.8%. Independent predictors of adverse events in procedural sedation/anesthesia outside the operating room in pediatric esophagogastroduodenoscopy/colonoscopy onoscopy were identified. Recognition of such risk factors may enable optimization of procedural sedation.

Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium

Objective: Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events. Design: Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium. Setting: Sedation services from academic, community, free-standing children’s hospitals and pediatric wards within general hospitals. Patients: Children from birth to 21 years old or younger. Interventions: None. Measurements and Main Results: Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92–7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60–1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm. Conclusions: This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.

Development, implementation, and initial participant feedback of a pediatric sedation provider course.

Background: No standardized educational curriculum exists for pediatric sedation practitioners. We sought to describe the curriculum and implementation of a pediatric sedation provider course and assess learner satisfaction with the course curriculum. Description: The course content was determined by formulating a needs assessment using published sedation guidelines, reports of sedation related adverse events, and a survey of sedation practitioners. Students provided feedback regarding satisfaction with the course immediately following the course and 6 months later. Evaluation: The course consisted of 5 didactic lectures, 1 small-group session, 6 simulation scenarios, a course syllabus, and a written examination. The course was conducted over 1 day at 3 different locations. Sixty-nine students completed the course and were uniformly satisfied with the course curriculum. Conclusions: A standardized pediatric sedation provider course was developed for sedation practitioners and consisted of a series of lectures and simulation scenarios. Overall satisfaction with the course was positive.

Pediatric procedural sedation using the combination of ketamine and propofol outside of the emergency department: A report from the pediatric sedation research consortium

Objectives: Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. Design: Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007–2015. Setting: Procedural sedation services from academic, community, free-standing children’s hospitals, and pediatric wards within general hospitals. Patients: Children from birth to less than or equal to 21 years old. Interventions: None. Measurements and Main Results: A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ⩽ 21 yr; interquartile range, 36–144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12–10.49%) and 3.47% (95% CI, 3.07–3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. Conclusions: Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

468: THE EFFECT OF POVERTY ON CHILDREN PRESENTING WITH DIABETIC KETOACIDOSIS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) risks such as thrombophlebitis, volume overload, and bloodstream infections. This study assessed appropriateness of PPN prescribing practices and the incidence of selected adverse effects at an academic medical center. Methods: Single-center, retrospective cohort study of adult patients admitted to Johns Hopkins Hospital from August to November 2015 who received PPN. PPN use was evaluated for appropriateness using definitions derived from SCCM and ASPEN clinical practice guidelines and standard of practice. Adverse events, including phlebitis and bacteremia, were examined. A subgroup analysis was performed on patients who had PPN initiated in the intensive care unit. Results: Of the 159 patients included, 51 (32.1%) met all criteria for appropriate PPN therapy. One hundred twenty eight patients (80.5%) had an appropriate indication, 85 (53.5%) had appropriate time to PPN initiation, 157 (98.7%) had an appropriate duration of therapy, and 112 (70.4%) achieved an appropriate percentage of goal daily calories. ICU and surgical subgroup analyses were examined, with appropriate therapy received in 41.4% and 32.1% of patients respectively. The safety analysis revealed 69 (43.4%) of patients had documented phlebitis, and bacteremia occurred in 5 (3.1%) of patients. Conclusions: PPN was appropriately utilized in only onethird of the patients in this study. PPN was prescribed for appropriate indications in the majority of patients, but the time to initiation was often too early. PPN therapy initiated in the ICU had a higher incidence of appropriate use compared to the entire study population, but was still low overall. Phlebitis was a common adverse effect associated with PPN. Based on our findings, development of restrictions for PPN use is recommended to ensure that the appropriate route of nutrition delivery is utilized and minimize the incidence of inappropriate PPN use.

981: POVERTY IS ASSOCIATED WITH UNFAVORABLE CLINICAL OUTCOMES FOR CHILDREN WITH BRONCHIOLITIS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) as age 60 vs 61, sex, APACHE2 28 vs 25, SOFA score 9 vs 8). According to the comparison analysis, awake ECMO group may show shorter length of stay in ICU (13.6 vs 21.7 days) and hospital (41.9 vs 60.0 days), improve the selfambulate rate at discharge (70% vs 38.5%), reduce the total cost (

518: POVERTY IS ASSOCIATED WITH LONGER HOSPITAL LENGTH OF STAY FOR CHILDREN WITH CRITICAL ASTHMA.

673,000 vs

Nutrition and High-Flow Nasal Cannula Respiratory Support in Children With Bronchiolitis

814,000). However, there was not significantly different between the two group. Conclusions: There are no significant differences between awake-ECMO and non-awake ECMO. Awake ECMO and active rehabilitation to venovenous ECMO as a bridge to recovery can potentially improve physical function and reduce the length of stay in ICU and hospital, reduce the total cost. Further observation and verification is necessary.

Nutrition and High Flow Nasal Cannula Respiratory Support in Children with Bronchiolitis

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) accurate quantitative hemodynamic information for critically ill patients including pulmonary capillary wedge pressure and cardiac output [1]. Using a robust database, we sought to determine the incidence of SGC of patients in the United States and the impact of an institution’s teaching status on these trends. Methods: Utilizing the Nationwide Inpatient Sample database, we identified the discharges involving Swan-Ganz catheterization (SGC) from 1997 to 2013 in United States. Year-wise distribution of number and rate of patients who underwent SGC at teaching and non-teaching hospitals was described. Z-test statistic was used to compare the two groups. Results: During the study period, the total annual number of patients who received SGC at all institutions decreased significantly overall and ranged from 169,724 to 37,507 (P <0.0001). The rate of patients who underwent catheterization at all institutions decreased significantly as well and ranged from 62.3 to 12.1 per 100,000 patients (Fig. 1, P<0.0001). Notably, from 2004 to 2013, the number of patients who received SGC was consistently and significantly higher for patients treated at teaching hospitals as opposed to those treated at nonteaching hospitals (P<0.0001). However, from 1997 to 2003, there was no significant difference between the number of catheterizations performed by these two types of institutions. Conclusions: The usage of SGC has been decreasing in United States during the past two decades. Teaching status of institutions has an impact on the use of Swan-Ganz catheterization (SGC) in critically ill patients. Future research should attempt to define these aspects of SGC and make a recommendation regarding populations in which use of SGC will have a positive impact on mortality.