Rambod Amirnovin

790: IMPLEMENTATION OF A WITHDRAWAL PREVENTION PROTOCOL IN A PEDIATRIC CARDIAC ICU

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) pulmonary embolism (PE) were listed in the complication or diagnosis field, or prophylactic if neither DVT nor PE was indicated in either field. Results: Of the 1,970,117 patients identified, 23,558 (1.2%) received an IVC filter. Overall use of IVC filters decreased significantly from 2010–2012, sliding from 1.3% to 1.1% (P<0.001). This was not due to variation in venous thromboembolism (VTE) incidence, which remained constant at 1.1% for the yr examined. Likewise, therapeutic use of IVC filters remained constant at ~0.3% for each year of the study. However, use of prophylactic IVC filters significantly decreased from 1.0% to 0.8% (P<0.001) during the study period, which is nearly half of the previously reported 1.4% (Dossett et al. 2011. J of Trauma). Conclusions: In the US, prophylactic use of IVC filters has significantly decreased in recent years, suggesting widespread changes in practice patterns. This is a dramatic shift away from the upsurge in usage observed from 1993–2007. This reduction may be partially attributable to the 2008 CHEST guidelines which strongly recommend against IVC filters as thromboprophylaxis and starkly contrast the earlier and more liberal guidelines of both EAST and CHEST.

Analysis of a Pediatric Home Mechanical Ventilator Population

BACKGROUND: The population of children requiring home mechanical ventilation has evolved over the years and has grown to include a variety of diagnoses and needs that have led to changes in the care of this unique population. The purpose of this study was to provide a descriptive analysis of pediatric patients requiring home mechanical ventilation after hospitalization and how the evolution of this technology has impacted their care. METHODS: A retrospective, observational, longitudinal analysis of 164 children enrolled in a university-affiliated home mechanical ventilation program over 26 years was performed. Data included each childs primary diagnosis, date of tracheostomy placement, duration of mechanical ventilation during hospitalization that consisted of home mechanical ventilator initiation, total length of pediatric ICU stay, ventilator settings at time of discharge from pediatric ICU, and disposition (home, facility, or died). Univariate, bivariate, and regression analysis was used as appropriate. RESULTS: The most common diagnosis requiring the use of home mechanical ventilation was neuromuscular disease (53%), followed by chronic pulmonary disease (29%). The median length of stay in the pediatric ICU decreased significantly after the implementation of a ventilator ward (70 d [30–142] vs 36 d [18–67], P = .02). The distribution of subjects upon discharge was home (71%), skilled nursing facility (24%), and died (4%), with an increase in the proportion of subjects discharged on PEEP and those going to nursing facilities over time (P = 0.02). CONCLUSIONS: The evolution of home mechanical ventilation has allowed earlier transition out of the pediatric ICU and with increasing disposition to skilled nursing facilities over time. There has also been a change in ventilator management, including increased use of PEEP upon discharge, possibly driven by changes in ventilators and in-patient practice patterns.

Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit

Objective: Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. Design: A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. Patients: Pediatric patients with congenital or acquired cardiac disease. Setting: Twenty-four-bed cardiothoracic intensive care unit in a tertiary children’s hospital. Interventions: Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. Results: There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001). Conclusion: The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.

Implementation of a risk-stratified opioid weaning protocol in a pediatric intensive care unit

Purpose: Opioids are important in the care of critically ill children. However, their use is associated with complications including delirium, dependence, withdrawal, and bowel dysfunction. Our aim was to implement a risk‐stratified opioid weaning protocol to reduce the duration of opioids without increasing the incidence of withdrawal. Methods: A pre‐ and post‐interventional prospective study was undertaken in a large childrens hospital pediatric ICU where we implemented a risk‐stratified opioid weaning protocol. Patients were included if exposed to ≥7 days of scheduled opioids. The primary outcome was duration of opioids and secondary outcome was hospital LOS. Results: One hundred seven critically ill children met the inclusion criteria (68 pre‐, 39 post‐intervention). Demographics, risk factors, and confounders did not differ between groups. Patients in the post‐intervention group had shorter duration of opioids (17 vs. 22.5 days, p = 0.01) and opioid wean (12 vs. 18 days, p = 0.01). Despite the shorter duration of opioid wean, there was no increase in withdrawal incidence. There was no difference in the LOS (29 vs. 33 days, p = 0.06). Conclusions: We implemented a risk‐stratified opioid weaning protocol for critically ill children that resulted in reduction in opioid exposure without an increase in withdrawal. There was no difference in the LOS. Highlights:We implemented a risk‐stratified opioid weaning protocol in critically ill children.We reduced the length of opioid exposure without an increase in withdrawal.This is the largest study of an opioid weaning protocol in critically ill children.

86: INTER-RATER RELIABILITY OF PERIPHERAL PERFUSION ASSESSMENTS IN NEONATES AFTER CARDIAC SURGERY

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) ratio between the standard deviation and the mean of all glucose measurements during the cooling period (32–34°C during 24 hr).Patient-specific clinically validated model-based insulin sensitivity (IS,L/mU∙min) was identified from patientspecific clinical data and describes the overall whole-body effect of insulin, using concentration of BG (mmol/L), based on the total glucose and insulin doses, model-estimated plasma and interstitial insulin concentrations. Results: We studied 213 patients: male 81%, median age 61 [51–71] yr, diabetics patients 82 (38%). BG on admission was 10.3 [8.1–13.8] mmol/L and median blood glucose 7.8 [7.1–9.2] mmol/L. Median GV was 0.22 [0.14–0.33]. In a multivariable analysis, the only predictor of GV was BG on admission, although the correlation was poor (r2=0.19; p=0.01). GV was similar in diabetic and non-diabetic patients. There was no correlation between GV and IS (r2=-0.008; p=0.98). Conclusions: GV is higher than 20% during TTM after CA, and its intensity can hardly be predicted (except for a high BG on admission). Insulin sensitivity plays no important role. Thus, frequent measurements and a more patient-specific management would be necessary for glucose management of CA survivors treated with TTM.