Jeanine M. Graf

Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

BACKGROUND: Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation. OBJECTIVE: To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines. PATIENTS AND METHODS: Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions. RESULTS: To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001). CONCLUSIONS: The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.

Pediatric tracheostomies: a recent experience from one academic center.

Objectives: To describe the indications, surgical timing, length of stay, hospital charges, and discharge disposition of pediatric tracheostomy patients. Design: Retrospective case series. Setting: Large urban academic pediatric hospital. Patients: Seventy children and adolescents undergoing tracheostomy placement over a 24-month period. Interventions: None. Measurements and Main results: Hospital database records were used to determine demographics and readmission rates, tabulate charges, and confirm deaths. Indications for tracheostomies included airway obstruction, inadequate airway protection, chronic lung disease, neuromuscular weakness, and central hypoventilation. Surgical timing of the tracheostomy was grouped into three categories: prolonged mechanical ventilation, elective, or emergent. The overall median hospital stay was 46 days (range 14–254) with a median hospital charge of

Fulminant pertussis: a multi-center study with new insights into the clinico-pathological mechanisms.

136,718 (range

Derivation of a clinical prediction rule for pediatric abusive head trauma

36,237–

Children With New Tracheostomies : Planning for Family Education and Common Impediments to Discharge

913,934). The prolonged mechanical ventilation group underwent a tracheostomy after a median of 26 days (mean 37.5 days) on the ventilator. Eighty-one percent of children were discharged home; 63% of children were readmitted within 6 months, with 11% requiring four or more admissions. The six-month mortality rate was 13%; no deaths were related to the tracheostomy. Conclusions: Children with tracheostomies are a heterogeneous population. Children who require tracheostomy for long-term mechanical ventilation have longer hospital stays than children who receive a tracheotomy on an elective or emergent basis. Hospital readmissions should be anticipated in this complex group of patients.

Test characteristics of an automated age- and temperature-adjusted tachycardia alert in pediatric septic shock.

Pertussis carries a high risk of mortality in very young infants. The mechanism of refractory cardio‐respiratory failure is complex and not clearly delineated. We aimed to examine the clinico‐pathological features and suggest how they may be related to outcome, by multi‐center review of clinical records and post‐mortem findings of 10 patients with fulminant pertussis (FP). All cases were less than 8 weeks of age, and required ventilation for worsening respiratory symptoms and inotropic support for severe hemodynamic compromise. All died or underwent extra corporeal membrane oxygenation (ECMO) within 1 week. All had increased leukocyte counts (from 54 to 132 × 109/L) with prominent neutrophilia in 9/10. The post‐mortem demonstrated necrotizing bronchitis and bronchiolitis with extensive areas of necrosis of the alveolar epithelium. Hyaline membranes were present in those cases with viral co‐infection. Pulmonary blood vessels were filled with leukocytes without well‐organized thrombi. Immunodepletion of the thymus, spleen, and lymph nodes was a common feature. Other organisms were isolated as follows; 2/10 cases Para influenza type 3, 2/10 Moraxella catarrhalis, 1/10 each with respiratory syncytial virus (RSV), a coliform organism, methicillin‐resistant Staphylococcus aureus (MRSA), Haemophilus influenzae, Stenotrophomonas maltophilia, methicillin‐sensitive Staphylococcus aureus (MSSA), and candida tropicalis. We postulate that severe hypoxemia and intractable cardiac failure may be due to the effects of pertussis toxin, necrotizing bronchiolitis, extensive damage to the alveolar epithelium, tenacious airway secretions, and possibly leukostasis with activation of the immunological cascade, all contributing to increased pulmonary vascular resistance. Cellular apoptosis appeared to underlay much of these changes. The secondary immuno‐compromise may facilitate co‐infection. Pediatr Pulmonol. 2009; 44:970–980. ©2009 Wiley‐Liss, Inc.

Resuscitation Bundle in Pediatric Shock Decreases Acute Kidney Injury and Improves Outcomes

Objectives: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that—if validated—can inform pediatric intensivists’ early decisions to launch (or forego) an evaluation for abuse. Design: Prospective, multicenter, cross-sectional, observational. Setting: Fourteen PICUs. Patients: Acutely head-injured children less than 3 years old admitted for intensive care. Interventions: None. Measurements and Main Results: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity—to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. Conclusions: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform—not dictate—their early decisions to launch (or forego) an evaluation for abuse.

Munchausen syndrome by proxy: a case report

To describe an educational program and timeline for the discharge of children with a new tracheostomy and identify common impediments to the education and discharge process.

Speed isn't everything in pediatric medical transport.

Objectives This study aimed to create and analyze the performance of an automated triage tool alerting triage nursing staff and physicians to an abnormal heart rate consistent with septic shock in a pediatric emergency department. Methods A computerized best-practice alert (BPA) triage system corrected heart rate for temperature (5 beats per minute for each 1°F above 100°F or 9.6–10 beats per minute for each 1°C > 36°C) and alarmed on tachycardia. If patients appeared ill and/or had medical comorbidities predisposing them to sepsis, a “shock protocol” was activated. Sensitivity was calculated for patients clinically diagnosed with shock during the study period. Results During the study period (February to August 2010), the BPA was triggered in 4552 (11.5%) of 39,697 visits. Mean age was 5.4 years (range, 18 days to 18 years); 53% were female. The tool was 81% sensitive in identifying the 210 patients with shock. Missed patients were more likely to be previously healthy (odds ratio, 2.7; 95% confidence interval, 1.2–6.2), younger (5.7 vs 8.7 years, P = 0.004), and less likely to have a malignancy (odds ratio, 0.38; 95% confidence interval, 0.2–0.8). The tool was 89% specific; positive and negative predictive values were 4% and 99.9%, respectively. Conclusions The BPA-automated sensitive triage tool, based solely on initial temperature and heart rate, led to the identification of most children with septic shock, even before clinical acumen and laboratory values were incorporated into the diagnostic algorithm.

The Centers for Disease Control and Prevention's New Definitions for Complications of Mechanical Ventilation Shift the Focus of Quality Surveillance and Predict Clinical Outcomes in a PICU.

OBJECTIVE To investigate the impact of an early emergency department (ED) protocol-driven resuscitation (septic shock protocol [SSP]) on the incidence of acute kidney injury (AKI). STUDY DESIGN This was a retrospective pediatric cohort with clinical sepsis admitted to the pediatric intensive care unit (PICU) from the ED before (2009, PRE) and after (2010, POST) implementation of the SSP. AKI was defined by pRIFLE (pediatric version of the Risk of renal dysfunction; Injury to kidney; Failure of kidney function; Loss of kidney function, End-stage renal disease creatinine criteria). RESULTS A total of 202 patients (PRE, n = 98; POST, n = 104) were included (53% male, mean age 7.7 ± 5.6 years, mean Pediatric Logistic Organ Dysfunction [PELOD] 8.9 ± 12.7, mean Pediatric Risk of Mortality score 5.3 ± 13.9). There were no differences in demographics or illness severity between the PRE and POST groups. POST was associated with decreased AKI (54% vs 29%, P < .001), renal-replacement therapy (4 vs 0, P = .04), PICU, and hospital lengths of stay (LOS) (1.9 ± 2.3 vs 4.5 ± 7.6, P < .01; 6.3 ± 5.1 vs 15.3 ± 16.9, P < .001, respectively), and mortality (10% vs 3%, P = .037). The SSP was independently associated with decreased AKI when we controlled for age, sex, and PELOD (OR 0.27, CI 0.13-0.56). In multivariate analyses, the SSP was independently associated with shorter PICU and hospital LOS when we controlled for AKI and PELOD (P = .02, P < .001, respectively). CONCLUSION A protocol-driven implementation of a resuscitation bundle in the pediatric ED decreased AKI and need for renal-replacement therapy, as well as PICU and hospital LOS and mortality.