Atul Vats

Use of hypertonic saline for the treatment of altered mental status associated with diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) occurs in 25% to 40% of children with newly diagnosed type 1 diabetes mellitus (1). Clinically apparent cerebral edema, which occurs in approximately 1% of episodes of DKA in children, is associated with a mortality rate of 40% to 90% (2–4). It is responsible for 50% to 60% of diabetes-related deaths in children (5, 6). In addition, asymptomatic cerebral swelling is thought to occur more frequently in children with DKA (7, 8). The traditional therapy for cerebral edema in DKA has been the use of 20% mannitol. However, the brisk diuresis caused by this drug may lead to intravascular dehydration, hypokalemia, hypotension, prerenal azotemia, and even decreased cerebral blood flow. A small amount may also be converted to glycogen in the liver, thus further disturbing the glucose homeostasis (9). Hypertonic saline (HS, 3%) has recently been examined as a treatment for intracranial hypertension and cerebral edema in trauma patients. Its use has been shown to reduce raised intracranial pressure while augmenting intravascular volume and increasing mean arterial pressure (10). We report a case series of pediatric patients with DKA in whom HS was used to control apparent intracranial hypertension. All four patients had good clinical outcome, without apparent side effects.

The impact of a lean rounding process in a pediatric intensive care unit

Introduction/Objective: Poor workflow associated with physician rounding can produce inefficiencies that decrease time for essential activities, delay clinical decisions, and reduce staff and patient satisfaction. Workflow and provider resources were not optimized when a pediatric intensive care unit increased by 22,000 square feet (to 33,000) and by nine beds (to 30). Lean methods (focusing on essential processes) and scenario analysis were used to develop and implement a patient-centric standardized rounding process, which we hypothesize would lead to improved rounding efficiency, decrease required physician resources, improve satisfaction, and enhance throughput. Design: Human factors techniques and statistical tools were used to collect and analyze observational data for 11 rounding events before and 12 rounding events after process redesign. Actions included: 1) recording rounding events, times, and patient interactions and classifying them as essential, nonessential, or nonvalue added; 2) comparing rounding duration and time per patient to determine the impact on efficiency; 3) analyzing discharge orders for timeliness; 4) conducting staff surveys to assess improvements in communication and care coordination; and 5) analyzing customer satisfaction data to evaluate impact on patient experience. Setting: Thirty-bed pediatric intensive care unit in a childrens hospital with academic affiliation. Patients/Subjects: Eight attending pediatric intensivists and their physician rounding teams. Interventions: Eight attending physician-led teams were observed for 11 rounding events before and 12 rounding events after implementation of a standardized lean rounding process focusing on essential processes. Measurements and Main Results: Total rounding time decreased significantly (157 ± 35 mins before vs. 121 ± 20 mins after), through a reduction in time spent on nonessential (53 ± 30 vs. 9 ± 6 mins) activities. The previous process required three attending physicians for an average of 157 mins (7.55 attending physician man-hours), while the new process required two attending physicians for an average of 121 mins (4.03 attending physician man-hours). Cumulative distribution of completed patient rounds by hour of day showed an improvement from 40% to 80% of patients rounded by 9:30 AM. Discharge data showed pediatric intensive care unit patients were discharged an average of 58.05 mins sooner (p < .05). Staff surveys showed a significant increase in satisfaction with the new process (including increased efficiency, improved physician identification, and clearer understanding of process). Customer satisfaction scores showed improvement after implementing the new process. Conclusions: Implementation of a lean-focused, patient-centric rounding structure stressing essential processes was associated with increased timeliness and efficiency of rounds, improved staff and customer satisfaction, improved throughput, and reduced attending physician man-hours.

Cost of extracorporeal life support in pediatric patients with acute respiratory failure.

OBJECTIVES To determine the impact of extracorporeal life support (ECLS) on mortality in pediatric patients with acute hypoxemic respiratory failure (AHRF) at our institution; and to calculate the hospital charges associated with the use of ECLS. DESIGN Retrospective review of medical records and hospital charges. SETTING Pediatric intensive care unit (ICU) of a university-affiliated childrens hospital. PATIENTS Twenty patients admitted to the pediatric ICU between 1991 and 1995 for AHRF who received ECLS as a part of their hospital course. INTERVENTIONS Predicted mortality was calculated using the Pediatric Respiratory Failure score and was compared with survival at the time of hospital discharge. Hospital charges were used as a proxy for resource utilization. Cost-per-life-year-saved calculations were performed based on a normal life expectancy for survivors. MEASUREMENTS AND MAIN RESULTS Twenty patients were identified. The median age was 4.83 yrs. The median duration of ECLS was 9 days, with 19.5 days in the pediatric ICU and 23.5 days for the entire hospital length of stay. The observed mortality rate for these patients was 20%. Median predicted mortality rate based on the Pediatric Respiratory Failure score calculation was 83%. The hospital charges incurred by these patients was a median of

Invasive intracranial pressure monitoring is a useful adjunct in the management of severe hepatic encephalopathy associated with pediatric acute liver failure

199,096. Based on a normal life expectancy for survivors, this results in a cost of

Lean analysis of a pediatric intensive care unit physician group rounding process to identify inefficiencies and opportunities for improvement.

4,190/life-year. CONCLUSIONS ECLS for the pediatric patient with AHRF is done at a considerable cost. However, ECLS affects survival favorably, and compares favorably when considering cost/life-year calculations. The data presented in this study may serve as a benchmark for comparison with newer therapies (i.e., liquid ventilation, nitric oxide). These data also provide a framework for cost-based analyses at other ECLS institutions.

Tricycle injuries presenting to US emergency departments, 2012-2013

Objective: Pediatric acute liver failure is often accompanied by hepatic encephalopathy, cerebral edema, and raised intracranial pressure. Elevated intracranial pressure can be managed more effectively with intracranial monitoring, but acute-liver-failure-associated coagulopathy is often considered a contraindication for invasive monitoring due to risk for intracranial bleeding. We reviewed our experience with use of early intracranial pressure monitoring in acute liver failure in children listed for liver transplantation. Design and Patients: Retrospective review of all intubated pediatric acute liver failure patients with grade III and grade IV encephalopathy requiring intracranial pressure monitoring and evaluated for potential liver transplant who were identified from an institutional liver transplant patient database from 1999 to 2009. Interventions: None. Measurements and Main Results: A total of 14 patients were identified who met the inclusion criteria. Their ages ranged from 7 months to 20 yrs. Diagnoses of acute liver failure were infectious (three), drug-induced (seven), autoimmune hepatitis (two), and indeterminate (two). Grade III and IV encephalopathy was seen in ten (71%) and four (29%) patients, respectively. Computed tomography scans before intracranial pressure monitor placement showed cerebral edema in five (35.7%) patients. Before intracranial pressure monitor placement, fresh frozen plasma, vitamin K, and activated recombinant factor VIIa were given to all 14 patients, with significant improvement in coagulopathy (p < .04). The initial intracranial pressure ranged from 5 to 50 cm H2O; the intracranial pressure was significantly higher in patients with cerebral edema by computed tomography (p < .05). Eleven of 14 (78%) patients received hypertonic saline, and three (22%) received mannitol for elevated intracranial pressure. Eight of 14 (56%) monitored patients were managed to liver transplant, with 100% surviving neurologically intact. Four of 14 (28%) patients had spontaneous recovery without liver transplant. Two of 14 (14%) patients died due to multiple organ failure before transplant. One patient had a small 9-mm intracranial hemorrhage but survived after receiving a liver transplant. No patient developed intracranial infection. Conclusions: In our series of patients, intracranial pressure monitoring had a low complication rate and was associated with a high survival rate despite severe hepatic encephalopathy and cerebral edema in the setting of pediatric acute liver failure. In our experience, monitoring of intracranial pressure allowed interventions to treat increased intracranial pressure and provided additional information regarding central nervous system injury before liver transplant. Further study is warranted to confirm if monitoring allows more directed intracranial pressure therapy and improves survival in pediatric acute liver failure.

Physician Scheduling for Continuity: An Application in Pediatric Intensive Care

Objective: A physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency. Design: Human factor (observational data collection) techniques were used to capture >60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds. Setting: Thirty-bed pediatric intensive care unit in a childrens hospital with academic affiliation. Patients or Subjects: Eight attending pediatric intensivists and their physician rounding teams. Interventions: Eight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts. Measurements and Main Results: Large variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a “lean process.” Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins). Conclusions: In a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.

Is Hypertonic Saline an Effective Alternative to Mannitol in the Treatment of Elevated Intracranial Pressure in Pediatric Patients?: Vats A, Chambliss CR, Anand KJS, Pettignano R Is Hypertonic Saline an Effective Alternative to Mannitol in the Treatment of Elevated Intracranial Pressure in Pediatric Patients? J Intensive Care Med 1999,14 184-188

OBJECTIVE: To investigate the characteristics of tricycle-related injuries in children presenting to US emergency departments (EDs). METHODS: Data regarding tricycle injuries in children younger than 18 years of age were obtained from the National Electronic Injury Surveillance System for calendar years 2012 and 2013. Data included body regions injured, ED disposition, and demographics. RESULTS: There were an estimated 9340 tricycle-related injuries treated in US EDs from 2012 to 2013. The average age was 3 years. Children 2 years of age had the highest frequency of injuries. Boys accounted for 63.6% of all injuries. Children 1 to 2 years of age represented 51.9% of all injuries. Lacerations were the most common type of injury. Internal organ damage was the most common type of injury in 3- and 5-year-olds. Contusions were the most common type of injury in 1- and 7-year-olds. The head was the most commonly injured region of the body and the most common region to endure internal damage. The elbows were the most commonly fractured body part. The upper extremity was more frequently fractured than the lower extremity. Approximately 2.4% of all injured children were admitted to the hospital. CONCLUSIONS: The upper extremity of children, particularly the elbow, was more frequently fractured than the lower extremity. The head was the most common body part to endure internal damage. By elucidating the characteristics of tricycle-related injuries, preventive measures can be implemented to decrease the incidence of tricycle-related injuries and ED visits.

Extracorporeal life support in pediatric acute respiratory failure: we can afford it AND need it.

A physician schedule that maximizes continuity i.e., reduces instances of patients being treated by multiple physicians could improve the efficiency of handoffs-the transfer of patients from the care of one physician to another. We present a modeling and solution approach for assigning physicians to service and call shifts in the pediatric intensive care unit PICU at Childrens Healthcare of Atlanta at Egleston Childrens. We developed the handoff continuity score HCS for measuring the continuity of a schedule. We combined the HCS with a mixed-integer programming model MIP with the objective of maximizing the HCS, while minimizing violations of physician preferences. For a 51-week horizon and a physician pool of 16 physicians, no feasible solution to this MIP is found within 48 hours using CPLEX 12.4. However, an iterative heuristic incorporating modified versions of the MIP produces a schedule 3.42 percent optimality gap for the scheduling instance faced by Childrens for this period. Our solution approach facilitates resource optimization, and automated scheduling requires less time than manually constructing such a schedule. We generated six-month schedules that were implemented in the PICU at Childrens in 2011, 2012, and 2013. Such automated schedule construction allows for creation of schedules that maximize continuity.

Risk Factors for Seizures Among Young Children Monitored With Continuous Electroencephalography in Intensive Care Unit: A Retrospective Study

ous study has compared the effectiveness of HS to mannitol. Using a concurrent cohort design, we propose that HS and mannitol are similarly effective in controlling intracranial hypertension. Twenty-five patients received a total of 82 doses of HS at a dose of 5 ml/kg for the treatment of elevated ICR Significant reductions in ICP were noted at 30 (p < 0.05), 60, and 120 (p < 0.01) minutes following the administration of HS, and cerebral perfusion pressure (CPP) increased significantly at 60 and 120 minutes (p < 0.05). There