Jane Di Gennaro

Use and Effect of Vasopressors after Pediatric Traumatic Brain Injury

Background: Vasopressors are commonly used to increase mean arterial blood pressure (MAP) and cerebral perfusion pressure (CPP) after traumatic brain injury (TBI), but there are few data comparing vasopressor effectiveness after pediatric TBI. Objective: To determine which vasopressor is most effective at increasing MAP and CPP in children with moderate-to-severe TBI. Methods: After institutional review board approval, we performed a retrospective cohort study of children 0–17 years old admitted to a level 1 trauma center (Harborview Medical Center, Seattle, Wash., USA) between 2002 and 2007 with moderate-to-severe TBI who received a vasopressor to increase blood pressure. Baseline demographic and physiologic characteristics and hourly physiologic monitoring for 3 h after having started a vasopressor were abstracted. We evaluated differences in MAP and CPP at 3 h after initiation of therapy between phenylephrine, dopamine and norepinephrine among patients who did not require a second vasopressor during this time. Multivariate linear regression was used to adjust for age, gender, injury severity score and baseline MAP or CPP and to cluster by subject. Results: Eighty-two patients contributed data to the entire dataset. The most common initial medication was phenylephrine for 47 (57%). Patients receiving phenylephrine and norepinephrine tended to be older than those receiving dopamine and epinephrine. Thirteen (16%) of the patients received a second vasopressor during the first 3 h of treatment and were thus not included in the regression analyses; these patients received more fluid resuscitation and exhibited higher in-hospital mortality (77 vs. 32%; p = 0.004) compared to patients receiving a single vasopressor. The norepinephrine group exhibited a 5 mm Hg higher MAP (95% CI: –4 to 13; p = 0.31) and a 12 mm Hg higher CPP (95% CI: –2 to 26; p = 0.10) than the phenylephrine group, and a 5 mm Hg higher MAP (95% CI: –4 to 15; p = 0.27) and a 10 mm Hg higher CPP (95% CI: –5 to 25; p = 0.18) than the dopamine group. However, in post hoc analysis, after adjusting for time to start of vasopressor, hypertonic saline and pentobarbital, the effect on MAP was lost, but the CPP was 8 mm Hg higher (95% CI: –10 to 25; p = 0.39) than in the phenylephrine group, and 5 mm Hg higher (95% CI: –14 to 24; p = 0.59) than in the dopamine group. Conclusions: Vasopressor use varied by age. While there was no statistically significant difference in MAP or CPP between vasopressor groups, norepinephrine was associated with a clinically relevant higher CPP and lower intracranial pressure at 3 h after start of vasopressor therapy compared to the other vasopressors examined.

Pediatric Critical Care Resource Use by Children with Medical Complexity

OBJECTIVES To examine the proportionate use of critical care resources among children of differing medical complexity admitted to pediatric intensive care units (ICUs) in tertiary-care childrens hospitals. STUDY DESIGN This is a retrospective, cross-sectional study of all children (<19 years of age) admitted to a pediatric ICU between January 1, 2012, and December 31, 2013, in the Pediatric Health Information Systems database. Using the Pediatric Medical Complexity Algorithm, we assigned patients to 1 of 3 categories: no chronic disease, noncomplex chronic disease (NC-CD), or complex chronic disease (C-CD). Baseline demographics, hospital costs, and critical care resource use were stratified by these groups and summarized. RESULTS Of 136 133 children with pediatric ICU admissions, 53.0% were categorized as having C-CD. At the individual-encounter level, ICU resource use was greatest among patients with C-CD compared with children with NC-CD and no chronic disease. At the hospital level, patients with C-CD accounted for more than 75% of all examined ICU resources, including ventilation days, ICU costs, extracorporeal membrane oxygenation runs, and arterial and central venous catheters. Children with a progressive condition accounted for one-half of all ICU resources. In contrast, patients with no chronic disease and NC-CD accounted for less than one-quarter of all ICU therapies. CONCLUSION Children with medical complexity disproportionately use the majority of ICU resources in childrens hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.

An Elevated Low Cardiac Output Syndrome Score Is Associated With Morbidity in Infants After Congenital Heart Surgery.

Objectives: To evaluate an empirically derived Low Cardiac Output Syndrome Score as a clinical assessment tool for the presence and severity of Low Cardiac Output Syndrome and to examine its association with clinical outcomes in infants who underwent surgical repair or palliation of congenital heart defects. Design: Prospective observational cohort study. Setting: Cardiac ICU at Seattle Children’s Hospital. Patients: Infants undergoing surgical repair or palliation of congenital heart defects. Interventions: None. Measurements and Main Results: Clinical and laboratory data were recorded hourly for the first 24 hours after surgery. A Low Cardiac Output Syndrome Score was calculated by assigning one point for each of the following: tachycardia, oliguria, toe temperature less than 30°C, need for volume administration in excess of 30 mL/kg/d, decreased near infrared spectrometry measurements, hyperlactatemia, and need for vasoactive/inotropes in excess of milrinone at 0.5 &mgr;g/kg/min. A cumulative Low Cardiac Output Syndrome Score was determined by summation of Low Cardiac Output Syndrome Score on arrival to cardiac ICU, and 8, 12, and 24 hours postoperatively. Scores were analyzed for association with composite morbidity (prolonged mechanical ventilation, new infection, cardiopulmonary arrest, neurologic event, renal dysfunction, necrotizing enterocolitis, and extracorporeal life support) and resource utilization. Fifty-four patients were included. Overall composite morbidity was 33.3%. Median peak Low Cardiac Output Syndrome Score and cumulative Low Cardiac Output Syndrome Score were higher in patients with composite morbidity (3 [2–5] vs 2 [1–3]; p = 0.003 and 8 [5–10] vs 2.5 [1–5]; p < 0.001)]. Area under the receiver operating characteristic curve for cumulative Low Cardiac Output Syndrome Score versus composite morbidity was 0.83, optimal cutoff of greater than 6. Patients with cumulative Low Cardiac Output Syndrome Score greater than or equal to 7 had higher morbidity, longer duration of mechanical ventilation, cardiac ICU, and hospital length of stay (all p ⩽ 0.001). After adjusting for other relevant variables, peak Low Cardiac Output Syndrome Score and cumulative Low Cardiac Output Syndrome Score were independently associated with composite morbidity (odds ratio, 2.57; 95% CI, 1.12–5.9 and odds ratio, 1.35; 95% CI, 1.09–1.67, respectively). Conclusion: Higher peak Low Cardiac Output Syndrome Score and cumulative Low Cardiac Output Syndrome Score were associated with increased morbidity and resource utilization among infants following surgery for congenital heart defects and might be a useful tools in future cardiac intensive care research. Independent validation is required.

Identifying High-Risk Children in the Emergency Department

Purpose: Early warning scores (EWS) identify high-risk hospitalized patients prior to clinical deterioration; however, their ability to identify high-risk pediatric patients in the emergency department (ED) has not been adequately evaluated. We sought to determine the association between modified pediatric EWS (MPEWS) in the ED and inpatient ward-to-pediatric intensive care unit (PICU) transfer within 24 hours of admission. Methods: This is a case–control study of 597 pediatric ED patients admitted to the inpatient ward at Seattle Children’s Hospital between July 1, 2010, and December 31, 2011. Cases were children subsequently transferred to the PICU within 24 hours, whereas controls remained hospitalized on the inpatient ward. The association between MPEWS in the ED and ward-to-PICU transfer was determined by chi-square analysis. Results: Fifty children experienced ward-to-PICU transfer within 24 hours of admission. The area under the receiver–operator characteristic curve was 0.691. Children with MPEWS > 7 in the ED were more likely to experience ward-to-PICU transfer (odds ratio 8.36, 95% confidence interval 2.98-22.08); however, the sensitivity was only 18.0% with a specificity of 97.4%. Using MPEWS >7 for direct PICU admission would have led to 167 unnecessary PICU admissions and identified only 9 of 50 patients who required PICU care. Conclusions: Elevated MPEWS in the ED is associated with increased risk of ward-to-PICU transfer within 24 hours of admission; however, an MPEWS threshold of 7 is not sufficient to identify more than a small proportion of ward-admitted children with subsequent clinical deterioration.

12: DELIRIUM RISK FACTORS AND OUTCOMES IN CRITICALLY ILL CHILDREN AT A TERTIARY CHILDREN'S HOSPITAL.

Learning Objectives: Delirium is increasingly recognized as a problem in critically ill patients, including children. In 2013, Seattle Children’s adopted the Cornell Assessment of Pediatric Delirium (CAP-D) to screen for delirium. We hypothesized that children with delirium have longer length of stay (LOS) and are more likely to suffer a decline in Pediatric Cerebral Performance Category (PCPC) from baseline to ICU discharge. Methods: We studied all patients with a 1st PICU admission from 3/1/2014 to 2/28/2015, including all PICU data from that hospitalization. A CAP-D score ≥9 indicated delirium, excluding deeply sedated or comatose patients (RASS -4 or -5). Statistical analyses used chi2 test, 2-sample t-test, logistic and linear regression. Results: 1353 patients had 10,622 delirium assessments (49.1% female, median age 5.5 y (IQR 1.2 – 13.5), 74.1% with normal baseline PCPC (=1)). Delirium occurred in 46.4% of patients; it was least common in those with baseline PCPC=1 (38.5%) and increased with each PCPC category (RR=1.5, 1.9, and 2.3 for PCPC=2, 3, and 4; p<.0005); 89.5% of children with PCPC=4 had delirium. Among patients with delirium, the % of scores positive for delirium also increased with PCPC category, from 57% (PCPC=1) to 93.6% (PCPC=4), p<.0005. In univariate analyses in patients with baseline PCPC=1, delirium was associated with younger age (mean 4.4 vs. 8.8 y, p=<.0005), comorbidity (RR=1.4, p<.0005), >1 PICU admission within the hospitalization (RR=1.8, p<.0005), mechanical ventilation within 24h of ICU admission (RR=2.6, p<.0005), post-op status (RR=.8, p=.006), and severity of illness (mean PRISM 4.1 vs. 2.6, p<.0005). In multivariable analysis controlling for those factors, delirium was associated with decline in PCPC at discharge (p=.025), longer PICU (157% increase, p<.0005) and hospital LOS (115% increase, p<.0005). Conclusions: Rates of delirium increase markedly with baseline PCPC category. Among patients with normal baseline cerebral function, delirium is associated with poorer short-term outcomes, including longer length of stay and a decline in cerebral functional status at ICU discharge.

498: PEDIATRIC DELIRIUM IS ASSOCIATED WITH DECREASED POST-DISCHARGE HEALTH-RELATED QUALITY OF LIFE

Learning Objectives: Delirium is increasingly recognized as a problem in critically ill patients, but little is known about its impact beyond hospital discharge in children. In 2013, Seattle Children’s adopted the Cornell Assessment of Pediatric Delirium (CAP-D) to screen for delirium. We hypothesized that delirium is associated with a decline in health-related quality of life (HRQL) after hospital discharge. Methods: We studied all children with a 1st PICU admission from 3/1/2014 to 2/28/2015, restricted to those undergoing HRQL assessment by our hospital’s Outcomes Assessment Program (an ongoing QI program). HRQL was assessed by Pediatric Quality of Life Inventory v.4 (PedsQL). Surveys were obtained on hospital admission (to estimate baseline HRQL) and 2 to 8 weeks post-discharge. A CAP-D score ≥9 indicated delirium, excluding deeply sedated or comatose patients (RASS -4 or -5). Statistical analysis used Fisher’s exact test, two-sample t-test, and logistic regression. We built a multivariable model for decline in HRQL, testing variables with p<.2 on univariate analyses, and retaining those with p<.1 in the final model. Results: 138 patients completed postdischarge HRQL assessment. They were not representative of the entire PICU population, with lower admission PRISM scores (mean 2.3 vs. 3.4, p=.001) and receipt of mechanical ventilation within 24 h of ICU admission (29% vs. 35%, p=.046). However, they had similar baseline Pediatric Cerebral Performance Category (PCPC) (81.1% vs. 73.6% with PCPC=1), and a similar proportion had delirium (46.2% vs. 46.6%). N=43 (32.1%) had a decline in HRQL at followup. Those with delirium trended towards a decline in HRQL at follow-up (40.4% vs. 24.7%, p=.05). In multivariable analysis accounting for age (the only other qualifying variable), delirium was independently associated with a decline in HRQL at follow-up (OR=2.4, p=.04).Conclusions: The presence of delirium during an intensive care admission is independently associated with decreased HRQL at 2-8 weeks post-discharge compared to baseline.

364: RACE IS AN INDEPENDENT RISK FACTOR FOR MORTALITY DURING ECMO FOR RESPIRATORY SUPPORT

equipment, and radiographic resources will cause the Berlin definition of ARDS to underestimate ARDS incidence in a resource-poor setting. Methods:This single-center prospective observational study screened every adult patient admitted to a public referral hospital in Rwanda for hypoxemia for four weeks. For every patient with an oxygen saturation <90% or receiving oxygen, we collected data on demographics and ARDS risk factors. We evaluated these patients for ARDS using pulse oximetry, ultrasound, and chest radiograph when available. ARDS was defined by modified Berlin criteria using a validated estimate of the PaO2/FiO2 ratio based on oxygen saturation, waiver of the positive end expiratory pressure (PEEP) requirement, and bilateral opacities defined as “B lines” or consolidation by ultrasound. We performed testing for agreement between ultrasound and radiograph findings. Results: 1046 adults were admitted to the hospital in one month. 126 (12.0%) screened positive for hypoxemia. Using our modified Berlin criteria, 56 of 1046 patients (5.4%) met criteria for ARDS. ARDS risk factors were: infection 44.3%, trauma 23.7%, surgery 22.7%, and stroke 9.3%. Hospital mortality for ARDS patients was 59.3%. Since only 47.9% of all hypoxemic patients had a chest radiograph at any time during the study, confining the criteria to bilateral opacities on chest radiograph led to an ARDS incidence of only 2.7%. Requiring a minimum PEEP level reduced the incidence to 1.1%. Of the 158 patient-days in which both a chest radiograph and ultrasound examination were available, there was agreement in 101 (63.9%). Conclusions: Our survey of a referral hospital in Rwanda suggests that ARDS is a common and fatal syndrome. Use of modified Berlin criteria is necessary to capture all affected patients in resource-constrained settings. These criteria need to be validated in a resource-rich setting with gold standard comparisons.