Robert J. Dimand

Neonatal Intensive Care Unit Antibiotic Use

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS: In a retrospective cohort study of 52 061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report.

Objective: Injured pediatric patients in remote communities are often cared for at trauma centers that may be underserved with respect to pediatric specialty services. The objective of this study is to describe a pilot telemedicine project that allows a remote trauma center’s adult intensive care unit to obtain nontrauma, nonsurgical-related pediatric critical care consultations for acutely injured children. Design: Nonconcurrent cohort design. Setting: A remote, level II trauma center’s shock-trauma intensive care unit and a tertiary care children’s hospital pediatric intensive care unit. Patients: Analyses were conducted on cohorts of pediatric trauma patients (<16 yrs) consecutively admitted to the remote adult intensive care unit, including historical control patients and patients who received and did not receive telemedicine consultations. Interventions: Telemedicine consultations were obtained at the discretion of the remote intensive care unit provider for nontrauma, nonsurgical medical issues. Measurements and Results: The Injury Severity Score and Trauma and Injury Severity Score were used to assess severity of injury and predicted mortality rates, respectively, for the patient cohorts. Parental and provider satisfaction with the telemedicine consultations was also described. Thirty-nine consultations were conducted on 17 patients from the 97 pediatric patients admitted during the 2-yr study. Patients who received consultations were younger (5.5 yrs vs. 13.3 yrs, p < .01) and were more severely injured (mean Injury Severity Score = 18.3 vs. 14.7, p = .07). Severity-adjusted mortality rates were consistent with Trauma and Injury Severity Score expectations. Satisfaction surveys suggested a high level of provider and parental satisfaction. Conclusions: Our report of a trauma intensive care unit based pediatric critical care telemedicine program demonstrates that telemedicine consultations to a remote intensive care unit are feasible and suggests a high level of satisfaction among providers and parents.

Children with Cancer, Fever, and Treatment-Induced Neutropenia: Risk Factors Associated with Illness Requiring the Administration of Critical Care Therapies

Objectives: To identify clinical and laboratory characteristics of pediatric patients with cancer, fever, and treatment-induced neutropenia, available at initial presentation, that are independently associated with the development of illnesses requiring administration of critical care therapies. Methods: We retrospectively collected historical, clinical, and laboratory data on initial presentation for all pediatric (younger than18 years) cancer patients admitted for fever and treatment-induced neutropenia at our institution over a 5-year period. The outcome variable was the need for administration of a critical care therapy within 24 hours of admission. A multivariable analysis was performed and internally validated using bootstrap analysis. Results: We identified 303 events in 143 patients, of which 36 (11.9%) received a critical care therapy. Higher temperature at presentation and capillary filling time (CFT) of >3 seconds retained significance in the multivariable analysis and were validated by the bootstrap analysis. The positive and negative predictive values of the presence of either temperature of ≥39.5°C or CFT of >3 seconds were 35% and 91%, respectively. Conclusions: Pediatric patients with cancer, fever, and treatment-induced neutropenia who present with higher fever or prolonged CFT are at increased risk of developing life-threatening illnesses requiring administration of critical care therapies, independent of hematologic factors, type of cancer, or other physiologic signs of sepsis.

Adipose tissue abnormalities in cystic fibrosis: noninvasive determination of mono- and polyunsaturated fatty acids by carbon-13 topical magnetic resonance spectroscopy.

ABSTRACT: Natural abundance in vivo carbon-13 topical magnetic resonance (TMR) spectroscopy was used to assess human adipose tissue stores of essential (polyunsaturated) fatty acids. TMR spectra were obtained from 17 normal volunteers and nine cystic fibrosis patients using an Oxford TMR-32 with a surface coil that sampled tissue less than 1 cm below the surface of an extremity. Spectra were taken of lower leg adipose tissue. Polyunsaturated fatty acid content was determined by comparing peak heights of the polyunsaturated peak (internal unsaturated carbons, 128 ppm) to C-l carboxyl groups (173 ppm). Monounsaturated fatty acid content was determined by subtracting the polyunsaturated peak from the peak observed for all unsaturated carbons (external unsaturated carbon, 130 ppm) and dividing this ratio by the carboxyl peak. In vivo TMR of normal volunteers resulted in observed polyunsaturated fatty acid content of 17.8 ± 2.1% and a monounsaturated content of 44.8 ± 3.8%. The polyunsaturated and monounsaturated fatty acid content of adipose tissue from the cystic fibrosis patients was 15.0 ± 2.0% (p < 0.005 versus normal volunteers) and 47.8 ± 6.5% (NS), respectively. One cystic fibrosis patient without fat malabsorption had decreased adipose polyunsaturateds, whereas another patient on high calorie gastrostomy feeds had normal levels. Carbon-13 TMR spectroscopy is a sensitive, noninvasive technique for determining essential fatty acid status in subcutaneous adipose tissue of patients with cystic fibrosis.

Bedside Placement of pH-Guided Transpyloric Small Bowel Feeding Tubes in Critically III Infants and Small Children

BACKGROUND AND METHODS The small bowel of critically ill infants and small children was cannulated using a soft feeding tube with a pH sensor at the distal tip. By monitoring pH, the tubes were guided through the stomach into the small bowel. RESULTS Successful placements were performed in 36 of 37 (97%) attempts in 29 critically ill patients whose age was 7.9 +/- 6.3 months and weight was 5.9 +/- 2.6 kg. Continuous jejunal feedings were administered for 3.7 +/- 3.1 weeks without difficulties or complications in all but one patient. CONCLUSION pH-guided jejunal tube placement provides a safe, easy bedside alternative to fluoroscopic, endoscopic or surgical placement in critically ill infants and small children.

Impact of a pediatric palliative care program on the caregiver experience

California’s pediatric palliative care program Partners for Children uses family-centered care coordination to offer hospice-like therapeutic, respite, and pain management services for children delivered concurrently with curative care and regardless of the child’s life expectancy. As an early implementer of concurrent care for children, the program provides evidence of the impact of concurrent care on children and their families. Program impact on caregivers’ perceptions of their levels of stress and worry was measured using random effect growth curve models that included survey wave, caregivers’ perceived family support, and the child’s age and disease severity. All other data were descriptive and subject to univariate analysis. Worry and stress improved in the overall study population between the baseline and follow-up surveys. Family support was predictive of reductions in stress and worry. Disease severity was predictive of stress. Family-centered care coordination is a promising tool to enhance care for children with life-threatening health conditions and reduce caregiver stress and worry. Program strategies, including individualized care planning, access to a 24/7 nurse line, and a focus on the entire family, can be a model for other states as the need for integration of pediatric palliative care for seriously ill children becomes a national public health priority.

Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity

Importance Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission. Objectives To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care. Design, Setting, and Participants Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity. Exposures Live birth at GA of 34 weeks or more. Main Outcomes and Measures Inborn NICU admission rate. Results Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman &rgr; = −0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman &rgr; = −0.21, P = .41). Conclusions and Relevance Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

THE EFFECT OF SEVERE HYPOXIA/REOXYGENATION ON SUBSTRATE SELECTION IN THE ISOLATED 4-DAY-OLD RABBIT HEART: USE OF 13 C ISOTOPOMER ANALYSIS.• 142

THE EFFECT OF SEVERE HYPOXIA/REOXYGENATION ON SUBSTRATE SELECTION IN THE ISOLATED 4-DAY-OLD RABBIT HEART: USE OF 13 C ISOTOPOMER ANALYSIS.• 142

THE EFFECT OF ACIDOSIS ON CATECHOLAMINE RESPONSIVENESS IN ISOLATED INFANT RABBIT HEART. † 260

THE EFFECT OF ACIDOSIS ON CATECHOLAMINE RESPONSIVENESS IN ISOLATED INFANT RABBIT HEART. † 260