Myke Federman

Refractory Metabolic Acidosis as a Complication of High-dose Midazolam Infusion for Pediatric Status Epilepticus

Background: The use of midazolam for the treatment of status epilepticus in children has generally been shown to be well tolerated and safe. Furthermore, encouraging efficacy has been observed when pediatric patients with status epilepticus have received continuous intravenous infusions of midazolam. Case Presentation: A 9-year-old girl was treated with high-dose, continuous intravenous infusion of midazolam for the management of refractory status epilepticus. The patient developed a severe hyperchloremic, non-anion gap metabolic acidosis and resultant hemodynamic compromise, necessitating significant inotropic support and the initiation of a vasopressor infusion. We speculate that this complication was due to the preparation of parenteral midazolam with hydrochloric acid. The midazolam infusion was stopped, and, in less than 5 hours, the patients metabolic acidosis resolved. The patients inotropic and vasopressor infusions could only be weaned after discontinuing the use of high-dose midazolam. Conclusions: Although this complication was observed in only 1 pediatric patient with cortical dysplasia, caution and close clinical and laboratory surveillance should be exercised when administering continuous intravenous infusions of midazolam to pediatric patients.

The Effect of Gender and Gender Match on Mortality in Pediatric Heart Transplantation

The effect of organ–recipient gender match on pediatric heart transplant mortality is unknown. We analyzed the effects of gender and donor–recipient gender matching. Based on Organ Procurement and Transplant Network data, we performed a historical cohort study in a population of 3630 heart transplant recipients less than 18 years old. We compared unadjusted and adjusted mortality by recipient gender, donor gender and between gender‐matched and gender‐mismatched recipients. Female recipients had decreased survival compared to male recipients (unadjusted hazard ratio [HR] 1.16, confidence interval [CI] 1.02–1.31; p = 0.020). Organ–recipient gender mismatch did not affect mortality for either male or female recipients, though gender‐mismatched females had the worst survival compared to gender‐matched males, who had the best survival (unadjusted HR 1.26, CI 1.07–1.49; p = 0.005). After adjustment for other risk factors affecting transplant mortality, female recipients had decreased survival compared to male recipients (HR 1.27, CI 1.12–1.44; p = 0.020) and gender matching had no effect. In conclusion, gender mismatch alone did not increase long‐term mortality for pediatric heart transplant recipients. However, there may be additive effects of gender and gender matching affecting survival. There are insufficient data at this time to support that recipient and donor gender should affect heart allocation in children.

Understanding communication among health care professionals regarding death and dying in pediatrics

OBJECTIVE Effective communication regarding death and dying in pediatrics is a vital component of any quality palliative care service. The goal of the current study is to understand communication among health care professionals regarding death and dying in children. The three hypotheses tested were: (1) hospital staff (physicians of all disciplines, nurses, and psychosocial clinicians) that utilize consultation services are more comfortable communicating about death and dying than those who do not use such services, (2) different disciplines of health care providers demonstrate varying levels of comfort communicating about a range of areas pertaining to death and dying, and (3) health care staff that have had some type of formal training in death and dying are more comfortable communicating about these issues. METHODS A primary analysis of a survey conducted in a tertiary care teaching childrens hospital. RESULTS Health care professionals who felt comfortable discussing options for end of life care with colleagues also felt more comfortable: initiating a discussion regarding a childs impending death with his/her family (r = 0.42), discussing options for terminal care with a family (r = 0.58), discussing death with families from a variety of ethnic/cultural backgrounds (r = 0.51), guiding parents in developmentally age-appropriate discussions of death with their children (r = 0.43), identifying and seeking advice from a professional role model regarding management concerns (r = 0.40), or interacting with a family following the death of a child (r = 0.51). Among all three disciplines, physicians were more likely to initiate discussions with regards to a childs impending death (F = 13.07; p = 0.007). Health care professionals that received formal grief and bereavement training were more comfortable discussing death. Significance of the results: The results demonstrated that consultation practices are associated with a higher level of comfort in discussing death and dying in pediatrics.

Novel techniques in the use of bivalirudin for cardiopulmonary bypass anticoagulation in a child with heparin-induced thrombocytopenia:

Heparin-induced thrombocytopenia (HIT) occurs in both the pediatric and adult populations after exposure to heparin. Bivalirudin has been used as an alternative to heparin for adults undergoing cardiac surgery and cardiopulmonary bypass, but has only been used minimally in children for this purpose. We report the successful use of bivalirudin for anticoagulation during cardiopulmonary bypass in a small child with HIT, using novel techniques not previously described.

Identification of Risk Factors for Poor Feeding in Infants with Congenital Heart Disease and a Novel Approach to Improve Oral Feeding

&NA; Many infants with complex congenital heart disease (CHD) do not develop the skills to feed orally and are discharged home on gastrostomy tube or nasogastric feeds. We aimed to identify risk factors for failure to achieve full oral feeding and evaluate the efficacy of oral motor intervention for increasing the rate of discharge on full oral feeds by performing a prospective study in the neonatal and cardiac intensive care units of a tertiary childrens hospital. 23 neonates born at ≥ 37 weeks gestation and diagnosed with single‐ventricle physiology requiring a surgical shunt were prospectively enrolled and received oral motor intervention therapy. 40 historical controls were identified. Mean length of stay was 53.7 days for the control group and 40.9 days for the study group (p = 0.668). 13/23 patients who received oral motor intervention therapy (56.5%) and 18/40 (45.0%) controls were on full oral feeds at discharge, a difference of 11.5% (95% CI − 13.9% to 37.0%, p = 0.378). Diagnosis of hypoplastic left heart syndrome, longer intubation and duration of withholding enteral feeds, and presence of gastroesophageal reflux disease were predictors of poor oral feeding on univariate analysis. Although we did not detect a statistically significant impact of oral motor intervention, we found clinically meaningful differences in hospital length of stay and feeding tube requirement. Further research should be undertaken to evaluate methods for improving oral feeding in these at‐risk infants. Highlights:Infants with complex congenital heart disease are at risk for poor oral feeding.Specific factors associated with poor oral feeding are identified.Oral motor intervention may decrease hospital length of stay.Oral motor intervention may decrease feeding tube requirements.Screening bedside laryngoscopy may identify vocal cord dysfunction.

Who Is Responsible for Work-Life Balance?

The problem with the concept of work–life balance is that most of the onus of achieving such clarity and satisfaction is left to the employee. As a pediatric intensivist and mother of two, I am ruled by the demands and requirements imposed both by my employer and academic position and by my beautiful children. It is the culture around and perception of working mothers that needs to change – both at work and in life. This would finally allow women to find balance and promote their success in all aspects of their lives. It seems every day there are new articles, blogs, and reports, you name it, which discuss work–life balance. Everyone has their “secrets” on how you too can achieve the perfect distribution of time, effort, and success between work and life. A quick Internet search will tell you to “Drop activities that sap your time and energy!”, “Rethink your errands!” (1), “Leave work at work!” (2), or, my favorite, “Rethink your idea of clean!” (3). Yes, a messy house is just the thing that will make me feel more balanced. Of course, there are small things each of us can do to prioritize the things that are important to us, but in order for us all, particularly working mothers, to find this elusive “balance” in our lives, it is our work environment and culture around work and life that needs to change. There are many aspects of the general work environment in the United States that do not support the working mother. The sad state of maternity leave in this country is one of the clearest examples of how poorly we support women trying to balance work and family. The United States currently ranks 20th out of the 21 high income countries in terms of the length of protected maternity leave at only 12 weeks and, along with Oman, is one of the only two countries that does not provide paid maternity leave (4). Of course, there are exceptions in this country: Netflix recently announced it would offer unlimited paid maternity leave to its employees, but only those on its digital side, not the lower paid, more easy to replace line workers (5). Unfortunately, this minimalist approach to maternity leave and pregnancy does not stop with employee policies. One of my colleagues, a neonatologist, planned an all too brief maternity leave, but was asked 2 weeks in when she would be returning from “vacation.” Or what about the fact that our own ruling board, The American Board of Pediatrics, would not let me take the critical care board exam locally when I was 39 weeks pregnant? They insisted the pregnancy was not a disability and I would have to travel hundreds of miles away to take my exam endangering myself and my unborn daughter. The return to work is not all that welcoming either. Exhausted, emotional and forced back to work too early, many women long to continue breastfeeding, but we find ourselves hidden in dirty bathrooms pumping in secrecy since pump rooms are not always made available for employees. Returning to work also requires finding an affordable, high quality, loving environment for the new little one who, if we were kangaroos, would not even have left the pouch yet. Finding this type of care, whether it be daycare or nanny care, is quite challenging. The cost of high quality child care is astronomical in this country and infant care is even more expensive and difficult to find. I am incredibly fortunate to have phenomenal care for my children on the campus which I work, but I could pay in-state tuition for three children here at UCLA for the same price I pay for daycare for two. In addition to the logistical difficulty of coming back to work, most women face questions and opinions regarding their ability to commit to both work and family. In a study where fake resumes that differed only by the sex and parental status of the applicant were evaluated, women with children were seen as less competent than women without children, though men with children were seen as equally competent and more warm than men without children. These assessments led to less interest in hiring, promoting, and educating working mothers when compared to working fathers or employees without children (6). In a similar study using fake resumes in a “laboratory” setting as well as sending fake resumes to actual potential employers, mothers were rated as less competent and less committed than non-mothers, but fathers were actually seen as being more committed and were offered higher starting salaries than non-fathers (7). This aptly named phenomenon, the “Motherhood penalty” is supported by countless other studies and has been documented in many countries outside of the United States. Women face increasingly negative perceptions about their commitment and ability as they have more children, whereas men are seen in a more positive light as their family grows. Mothers need to be supported better at work. The United States used to rank seventh in terms of the proportion of women in the workplace, but we have recently dropped to 20th, just behind Japan. The disappearance of women from the work force has the potential of reducing family standards of living and negatively affects the economy. In addition, there is mounting evidence that having a working mother has economic, educational, and social benefits for children of both sexes (8). A recent study by Kathleen McGinn from Harvard Business School showed that daughters of working mothers were more likely to be employed, had higher incomes, and were more likely to have supervisory positions than daughters of non-working mothers (9). As a start, we need to have comprehensive policies to better support maternity leave and breastfeeding at work. Large employers should consider providing on-site daycare that is affordable and convenient. These efforts along with other initiatives to encourage work–life balance have been shown to benefit not only the employee, but the employer as well. Organizations with strong, well-established work policies demonstrate higher organizational performance, market performance, and profit-sales growth (10) and employees of such organizations have higher job satisfaction, are more likely to stay at their job and have greater pride in their organization (11). Employer efforts would go a long way to change the perception of working mothers by recognizing the challenges of balancing work and family and having policies in place to support them. However, this likely would not be enough. Women (and men) who find themselves in leadership roles need to take advantage of their position to support other women, particularly working mothers. One study of a large law firm showed that female attorneys were more likely to be promoted and stay at the law firm if they had female partners as mentors and role models (12). Leaders should be mindful of how organizing meetings and committees may put more stress on working mothers by scheduling meetings, for example, at 7:00 a.m. or 6:00 p.m. I was once invited to join the “Women in Science” Committee in a discussion of the challenges of women in academic medicine, but the meeting was scheduled from 5:00 p.m. to 7:00 p.m. This forces working mothers to make difficult choices and to limit their involvement in committees or meetings that may be meaningful for their careers. It also forces them to make excuses as to why they cannot participate, which is often negatively perceived. As a working mother oncologist has quoted saying, “Women need to stop apologizing for wanting and needing to be with their kids in addition to fulfilling their careers and playing a role in society” (13).

Improving outcomes after pediatric cardiac arrest – the ICU-Resuscitation Project: study protocol for a randomized controlled trial

BackgroundQuality of cardiopulmonary resuscitation (CPR) is associated with survival, but recommended guidelines are often not met, and less than half the children with an in-hospital arrest will survive to discharge. A single-center before-and-after study demonstrated that outcomes may be improved with a novel training program in which all pediatric intensive care unit staff are encouraged to participate in frequent CPR refresher training and regular, structured resuscitation debriefings focused on patient-centric physiology.Methods/designThis ongoing trial will assess whether a program of structured debriefings and point-of-care bedside practice that emphasizes physiologic resuscitation targets improves the rate of survival to hospital discharge with favorable neurologic outcome in children receiving CPR in the intensive care unit. This study is designed as a hybrid stepped-wedge trial in which two of ten participating hospitals are randomly assigned to enroll in the intervention group and two are assigned to enroll in the control group for the duration of the trial. The remaining six hospitals enroll initially in the control group but will transition to enrolling in the intervention group at randomly assigned staggered times during the enrollment period.DiscussionTo our knowledge, this is the first implementation of a hybrid stepped-wedge design. It was chosen over a traditional stepped-wedge design because the resulting improvement in statistical power reduces the required enrollment by 9 months (14%). However, this design comes with additional challenges, including logistics of implementing an intervention prior to the start of enrollment. Nevertheless, if results from the single-center pilot are confirmed in this trial, it will have a profound effect on CPR training and quality improvement initiatives.Trial registrationClinicalTrials.gov, NCT02837497. Registered on July 19, 2016.

Heparin-Coated Grafts Reduce Mortality in Pediatric Patients Receiving Systemic-to-Pulmonary Shunts

We aimed to evaluate the outcomes of systemic-to-pulmonary (SP) shunt procedures utilizing heparin-coated (HC) polytetrafluoroethylene (PTFE) vascular grafts compared to uncoated (non-HC) grafts, in order to observe any benefits in pediatric patients. Our institution switched from using non-HC grafts to HC grafts in March 2011. We conducted a retrospective review of consecutive pediatric patients receiving SP shunts from May 2008 to December 2015. Perioperative variables including baseline characteristics, morbidity, mortality, and blood product utilization were evaluated between the HC and non-HC groups. A total of 142 pediatric patients received SP shunts during the study period: 69 patients received HC shunts and 73 patients received non-HC shunts. The HC group had significantly fewer desaturation or arrest events (P < 0.01), fewer shunt occlusions/thromboses (P < 0.01). There was no statistically significant difference in unplanned reoperations between groups (P = 0.18). The HC group demonstrated significantly lower overall 30-day mortality (P < 0.01), as well as shunt-related mortality (P < 0.01). The HC group had significantly lower postoperative packed red blood cell utilization as compared to the non-HC group (P < 0.01). In this study, pediatric patients receiving HC PTFE grafts in SP shunts demonstrated significantly lower shunt-related mortality. The majority of HC grafts remained patent. These findings suggest that HC grafts used in SP shunt procedures may benefit pediatric patients in terms of efficacy and outcomes.