Katherine Slain

The Dose Makes the Poison: Comparing Epinephrine With Dopamine in Pediatric Septic Shock.

e308 www.ccmjournal.org May 2016 • Volume 44 • Number 5 company-sponsored lectures on high-frequency oscillatory ventilation); Vapotherm (received honoraria for the development of educational materials and company-sponsored lectures on high-flow nasal cannula therapy); and Elsevier (receives royalties for the role of associate editor in a pediatric critical care textbook). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Neurologic and Functional Morbidity in Critically Ill Children with Bronchiolitis

Objectives: Neurologic and functional morbidity occurs in ~30% of PICU survivors, and young children may be at particular risk. Bronchiolitis is a common indication for PICU admission among children less than 2 years old. Two single-center studies suggest that greater than 10–25% of critical bronchiolitis survivors have neurologic and functional morbidity but those estimates are 20 years old. We aimed to estimate the burden of neurologic and functional morbidity among more recent bronchiolitis patients using two large, multicenter databases. Design: Analysis of the Pediatric Health Information System and the Virtual Pediatric databases. Setting: Forty-eight U.S. children’s hospitals (Pediatric Health Information System) and 40 international (mostly United States) children’s hospitals (Virtual Pediatric Systems). Patients: Previously healthy PICU patients less than 2 years old admitted with bronchiolitis between 2009 and 2015 who survived and did not require extracorporeal membrane oxygenation or cardiopulmonary resuscitation. Interventions: None. Neurologic and functional morbidity was defined as a Pediatric Overall Performance Category greater than 1 at PICU discharge (Virtual Pediatric Systems subjects), or a subsequent hospital encounter involving developmental delay, feeding tubes, MRI of the brain, neurologist evaluation, or rehabilitation services (Pediatric Health Information System subjects). Measurements and Main Results: Among 3,751 Virtual Pediatric Systems subjects and 9,516 Pediatric Health Information System subjects, ~20% of patients received mechanical ventilation. Evidence of neurologic and functional morbidity was present at PICU discharge in 707 Virtual Pediatric Systems subjects (18.6%) and more chronically in 1,104 Pediatric Health Information System subjects (11.6%). In both cohorts, neurologic and functional morbidity was more common in subjects receiving mechanical ventilation (27.5% vs 16.5% in Virtual Pediatric Systems; 14.5% vs 11.1% in Pediatric Health Information System; both p < 0.001). In multivariate models also including demographics, use of mechanical ventilation was the only variable that was associated with increased neurologic and functional morbidity in both cohorts. Conclusions: In two large, multicenter databases, neurologic and functional morbidity was common among previously healthy children admitted to the PICU with bronchiolitis. Prospective studies are needed to measure neurologic and functional outcomes using more precise metrics. Identification of modifiable risk factors may subsequently lead to improved outcomes from this common PICU condition.

Temporal Changes in Prescription of Neuropharmacologic Drugs and Utilization of Resources Related to Neurologic Morbidity in Mechanically Ventilated Children With Bronchiolitis

Objectives: Critically ill children with bronchiolitis may require neuropharmacologic medications and support for neuro-functional sequelae, but current practices are not well described. We aimed to describe recent trends in neuropharmacology and utilization of neuro-rehabilitation resources in mechanically ventilated children with bronchiolitis. Design: Analysis of the multicenter Pediatric Health Information System database. Setting: Forty-seven U.S. children’s hospitals. Patients: PICU patients less than 2 years old with bronchiolitis undergoing mechanical ventilation between 2006 and 2015. Interventions: None. Annual rates of utilization of neuropharmacologic medications (sedatives, analgesics, etc) and of neuro-rehabilitation services (physical therapy, neurologic consultation, etc) over the 10-year study period were compared. Measurements and Main Results: Neuropharmacologic medications prescribed on greater than or equal to 2 days were extracted. Utilization of MRI of the brain, neurologic consultation, swallow evaluation, occupational therapy, and physical therapy was also extracted. Among 12,508 subjects, the median age was 2.8 months, ~50% had comorbid conditions, and the median duration of mechanical ventilation was 7 days. The percentage of children prescribed greater than or equal to five drugs/drug classes increased over the study period from 36.5% to 55.8% (p < 0.001). There were significant increases over time in utilization of 10 of the 15 individual drugs/drug classes analyzed. More than half of subjects (6,294 [50.3%]) received at least one service that evaluates/treats neurologic morbidity. There were significant increases in the use of greater than or equal to one service (36.3% in 2006 to 59.6% in 2015; p < 0.001) and in the use of greater than or equal to two services (20.8% to 34.8%; p < 0.001). Utilization of each of the five individual resources increased significantly during the study period, but use of vasoactive medications and mortality did not. Conclusions: Prescription of neuropharmacologic agents increased over time using metrics of both overall drug burden and specific drug usage. Concurrently, the utilization of services that evaluate and/or treat neurologic morbidity was common and also increased over time.

1140: EXTUBATION FAILURE RATES AND POST-LIBERATION SUPPORT MODALITY AMONG BRONCHIOLITIS PATIENTS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: High-flow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NPPV) may be used to support children following liberation from invasive mechanical ventilation. Evidence comparing extubation failure rates between subjects supported by HFNC and NPPV is available for adult and neonatal patients, but pediatric data are lacking. We employed a quality controlled, multicenter Pediatric ICU database to test the hypothesis that NPPV is associated with higher extubation failure rates among bronchiolitis patients. Methods: With IRB approval, data provided by Virtual Pediatric Systems (VPS, LLC) were queried for invasively ventilated patients < 24 months old with bronchiolitis admitted to one of 124 PICUs from 1/2009 to 9/2015 who received HFNC or NPPV support immediately following extubation. Tracheal intubation within 48hrs of extubation defined extubation failure. Statistical methods included Chi-squared and Mann-Whitney U tests. Variables that were near significant (p < 0.10) were included in a logistic regression model. Data are shown as n (%), median (IQR) and OR (95% CI). Results: Among 758 patients, median age was 2.4 (1.3 – 5.4) months, 41.2% were female, 39.6% had ≥1 co-morbid condition, and 43.7% were Caucasian. Median PICU length of stay was 8.8 (5.8 – 13.8) days. Median duration of intubation was 5.5 (3.4– 9.1) days and 62 patients (8.1%) had extubation failure. Most subjects (656 [86.5%]) were supported by HFNC following extubation. Extubation failure was more common among NPPV patients (15.7% vs. 7.0%, p = 0.005). NPPV was associated with extubation failure after adjusting for age, weight, and gender [OR 2.39 [1.294.45]), and in a second model that also included co-morbid status and Pediatric Index of Mortality scores (OR 2.36 [1.26 – 4.40]). Conclusions: In this multicenter database study, extubation of children with bronchiolitis to HFNC was associated with a lower incidence of reintubation when compared to children supported by NPPV, even after adjusting for confounding variables. Prospective studies are needed to delineate specific risk factors associated with extubation failure and better determine if post-extubation support modality can mitigate the risk of extubation failure.

1134: POVERTY AND CLINICAL OUTCOMES IN CRITICALLY ILL CHILDREN WITH PNEUMONIA

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Based on US Census data, over 40% of children live in or near poverty. There are well established associations between adverse health outcomes and poverty in children. However, little is known regarding the effects of childhood poverty on outcomes in critically ill children. We hypothesized that poverty would be associated with unfavorable outcomes in children with acute respiratory failure and pneumonia. Methods: With IRB approval, children ≤ 18 years old with a primary diagnosis of pneumonia associated with acute respiratory failure requiring high flow nasal cannula (HFNC), non-invasive positive pressure ventilation (CPAP or BiPAP), or invasive mechanical ventilation (MV) admitted to our PICU from 10/2013 through 12/2015 were identified using local Virtual PICU (VPS, LLC) data and the electronic medical record. Demographics and length of stay (LOS) were collected. Median household income was estimated from patient zip codes and 2015 US Census Bureau data. Patients were classified as living below the 200% federal poverty threshold (< 200FPT) or above the 200% FPT (> 200FPT). Statistical methods included descriptive statistics and Wilcoxon rank-sum. Data shown as n (%) or median (interquartile range). Results: There were 76 children included in this study. The median age was 42.5 (14.0–149.3) months; 45 (59%) were Caucasian, and 29 (38%) were African American. PICU LOS was 5.584 (2.586–11.967) days. In this cohort, 16 (21%) were living in poverty (<

1026: OUTCOMES OF HIGH-FLOW NASAL CANNULA AND NONINVASIVE POSITIVE PRESSURE VENTILATION IN BRONCHIOLITIS

24,036/year for a family of 4) and 41 (54%) were living < 200FPT. There was no difference in PICU LOS (7.076 days [2.71612.979] vs. 5.309 [2.314–11.990], p = 0.662) between those children living below or above the 200% FPT. Conclusions: In this cohort of critically ill children with pneumonia, greater poverty was not associated with longer PICU length of stay.

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

Learning Objectives: Bronchiolitis is a common indication for invasive mechanical ventilation (IMV) during infancy. High-flow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NPPV) may reduce the need for IMV in some populations, but robust data comparing HFNC and NPPV in bronchiolitis are lacking. We hypothesize that rates of IMV of will be similar between bronchiolitis patients initiated on HFNC vs those initiated on NPPV. Methods: With IRB approval, VPS data was provided by Virtual Pediatric Systems (VPS, LLC) and queried for bronchiolitis patients <2yo admitted to one of 124 PICUs from 1/09-9/15 who received HFNC or NPPV prior to IMV. Statistical methods included Chi-squared, Fischer’s exact, Mann-Whitney U and Student’s t-test. Variables that were near significant (p<0.1) were included in regression models. Data are shown as N(%), median(IQR) and OR(95% CI). Results: Among 6,379 patients, median age was 3.9 (1.7–9.4) months, 40.4% were female and 39.5% were Caucasian. Median PICU length of stay (LOS) was 2.9 (1.8–4.9) days and mortality was 0.3%. Patients started on HFNC (5460 [86%]) had lower mortality risk by PIM2 (Pediatric Index of Mortality) score than patients initiated on NPPV (0.2% [0.2–0.3] vs 0.7% [0.6–0.9], p<0.001). Patients initiated on NPPV vs HFNC had higher rates of IMV (19.5% vs 10.9%) even after controlling for age, weight, and PIM2 scores (OR 1.5 [1.2–1.8]). NPPV was also associated with longer PICU LOS (3.8 [2.2–6.5] vs 2.8 [1.8–4.7] days, p<0.001) and increased mortality (1.1% vs 0.2%; OR 4.8 [1.9–12.0]). Compared to those receiving HFNC alone, HFNC followed by NPPV (475 [8.7%]) was associated with a higher rate of IMV (29.3% vs 9.2%, OR 3.5 [2.8–4.4]), longer PICU LOS (6.1 [4.1–9.9] vs 2.7 [1.8–4.2] days, p<0.001) and increased mortality (0.6% vs 0.1%, OR 4.5 [1.1–17.6]). Conclusions: In this multicenter database, NPPV in bronchiolitis patients is associated with unfavorable outcomes vs HFNC. Prospective studies are needed to evaluate causality, identify risk factors associated with treatment failure, and characterize patients that may benefit from a particular modality.

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

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.

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

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 (

782: HYPONATREMIA AND IVF TONICITY ARE ASSOCIATED WITH UNFAVORABLE OUTCOMES IN CRITICAL BRONCHIOLITIS

673,000 vs