Ryan Breuer

Standardizing postoperative PICU handovers improves handover metrics and patient outcomes.

Objectives: To improve handover communication and patient outcomes for postoperative admissions to a multidisciplinary PICU. Design: Prospective cohort study. Setting: Multidisciplinary PICU in a university hospital. Subjects: The multidisciplinary team responsible for postoperative PICU admissions and patient care, including attending, fellow, house staff physicians, and nurses from pediatric critical care medicine, surgery, and anesthesia. Interventions: An online survey distributed to PICU, surgery, and anesthesia providers identified existing barriers and challenges to effective postoperative PICU handovers and guided the formation of a standard protocol. Handovers for postoperative PICU admissions were then directly observed for 3 months pre- and postimplementation of the protocol, with data collected on communication, metrics, and patient outcomes. Observations and data collection, as well as the online provider survey, were repeated approximately 1 year after handover protocol implementation. Measurements and Main Results: Survey data demonstrated increases in provider ratings of handover attendance, communication, and quality after implementation of the handover protocol (p < 0.001). Surgical report errors were eliminated (p = 0.03), and the prevalence of provider attendance for the handover duration increased from 39.3% to 68.2% (p = 0.01). Following protocol implementation, fewer patients experienced antibiotic delays (34.5% to 13.9%; p = 0.03) or required hemodynamic or respiratory interventions within the first 6 hours of PICU admission (24.6% to 9.1%; p = 0.04). Patients received their first dose of analgesia (62.3 to 17.4 min; p = 0.01) and had their admission laboratory studies sent (42.3 to 32.9 min; p = 0.04) more quickly. Data collected at 12 months postimplementation demonstrated sustained reductions in analgesia timing, antibiotic delays, and handover barriers. Conclusions: Postoperative communication and patient outcomes can be improved and sustained over time with implementation of a standardized handover protocol.

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes

Objective: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality. Study Design: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%. Setting: PICUs participating in NEAR4KIDS. Patients: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed. Measurements and Main Results: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58–229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1–7 yr and 18% for 8–17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4–21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24–2.60; p = 0.002), after adjusted for patient confounders. Conclusions: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

Trend and Outcomes of Video Laryngoscope Use Across Picus.

Objective: Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs. Design: Retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from July 2010 to June 2015. Setting: Thirty-six PICUs/cardiac ICUs across the United States, Canada, Japan, New Zealand, and Singapore. Patients: Any patient admitted to a PICU or a pediatric cardiac ICU and undergoing tracheal intubation. Interventions: Use of direct laryngoscopy versus video laryngoscopy for tracheal intubation. Measurements and Main Results: There were 8,875 tracheal intubations reported in the National Emergency Airway Registry for Children database, including 7,947 (89.5%) tracheal intubations performed using direct laryngoscopy and 928 (10.5%) tracheal intubations performed using video laryngoscopy. Wide variability in video laryngoscopy use exists across PICUs (median, 2.6%; range, 0–55%). Video laryngoscopy was more often used in older children (p < 0.001), in children with history of a difficult airway (p = 0.01), in children intubated for ventilatory failure (p < 0.001), and to facilitate the completion of an elective procedure (p = 0.048). After adjusting for patient-level covariates, a secular trend, and site-level variance, the use of video laryngoscopy significantly increased over a 5-year period compared with fiscal year 2011 (odds ratio, 6.7; 95% CI, 1.7–26.8 for fiscal year 2014 and odds ratio, 11.2; 95% CI, 3.2–38.9 for fiscal year 2015). The use of video laryngoscopy was independently associated with a lower occurrence of tracheal intubation adverse events (adjusted odds ratio, 0.57; 95% CI, 0.42–0.77; p < 0.001) but not with a lower occurrence of severe tracheal intubation adverse events (adjusted odds ratio, 0.86; 95% CI, 0.56–1.32; p = 0.49) or fewer multiple attempts at endotracheal intubation (adjusted odds ratio, 0.93; 95% CI, 0.71–1.22; p = 0.59). Conclusions: Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children

Objectives: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. Design: A retrospective observational study using a multicenter emergency airway quality improvement registry. Setting: Thirty-five PICUs within general and children’s hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). Patients: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. Measurements and Main Results: Propensity score–matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62–0.75; p < 0.001). In propensity score–matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90–0.95; p < 0.001). Conclusions: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Identifying Hesitation and Discomfort with Diagnosing Sepsis: Survey of a Pediatric Tertiary Care Center

Objective: Pediatric sepsis remains a significant cause of morbidity and mortality despite the development of strategies proven to improve diagnosis and treatment. Specifically, early recognition and urgent therapy initiation are consistently associated with improved outcomes. However, providers bring these principles inconsistently to the bedside. The objective of this study was to describe practitioner knowledge of, and attitudes toward, sepsis as a means of identifying potentially modifiable factors delaying life-saving treatment. We hypothesized there would be difficulties with sepsis recognition and self-reported discomfort with making the diagnosis among all provider groups in a pediatric tertiary care center. Methods: Emergency department and inpatient pediatric physicians, nurses, and respiratory therapists in a single, freestanding children’s hospital received an electronic survey. Likert scales permitted anonymous self-reporting of comfort and diagnostic delays. Seven clinical vignettes assessed diagnostic knowledge. Independent sample t tests and Chi-square compared responses. Results: Three hundred two staff participated (73% response rate), 41% of whom had at least 10 years of clinical experience. One in 5 was uncomfortable alerting coworkers to a patient with suspected sepsis or septic shock, and almost half were uncomfortable doing so in cases of compensated shock. Every role self-reported diagnostic delays, including faculty physicians. On average, physicians answered a greater percentage of vignette questions correctly (66%), compared with nurses (58%; P = 0.013) and respiratory therapists (52%; P = 0.005). Conclusions: Sepsis knowledge deficits, provider discomfort, and diagnostic delays are prevalent within a tertiary care children’s hospital. Their presence and scale suggest areas for future research and targeted intervention.

Negative-Pressure Ventilation in Pediatric Acute Respiratory Failure

BACKGROUND: The objective of this work was to describe the use of negative-pressure ventilation (NPV) in a heterogeneous critically ill, pediatric population. METHODS: A retrospective chart review was conducted of all patients admitted to a pediatric ICU with acute respiratory failure supported with NPV from January 1, 2012 to May 15, 2015. RESULTS: Two hundred thirty-three subjects at a median age of 15.5 months were supported with NPV for various etiologies, most commonly bronchiolitis (70%). Median (interquartile range) duration of support was 18.7 (8.7–34.3) h. The majority were NPV responders (70%), defined as not needing escalation to any form of positive-pressure ventilation. In non-responders, escalation occurred at a median (interquartile range) of 6.9 (3.3–16.6) h. More NPV non-responders had upper-airway obstruction (P = .02), and fewer had bronchiolitis (P = .008) compared with responders. A bedside scoring system developed on these data was 98% specific in predicting NPV failure by 4 h after NPV start (area under the curve 0.759, 95% CI 0.675–0.843, P < .001). Complications from NPV were rare (3%); however, delayed enteral nutrition (33%) and continuous intravenous sedation use (51%) in children while receiving NPV were more frequent. The annual percentage of pediatric ICU admissions requiring intubation declined by 28% in the 3 y after NPV introduction, compared with the 3 y prior. CONCLUSIONS: NPV is a noninvasive respiratory support for pediatric acute respiratory failure from all causes with few complications and a 70% response rate. Children receiving NPV often required intravenous sedation for comfort, and one third received delayed enteral nutrition. Those who required escalation from NPV worsened within 6 h; this may be predictable with a bedside scoring system.

Effect of Location on Tracheal Intubation Safety in Cardiac Disease—Are Cardiac ICUs Safer?

Objectives: Evaluate differences in tracheal intubation–associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. Design: Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). Setting: Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. Patients: Children with medical or surgical cardiac disease who underwent intubation in an ICU. Interventions: None. Measurements and Main Results: Our primary outcome was the rate of any adverse tracheal intubation–associated event. Secondary outcomes were severe tracheal intubation–associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0–6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1–11 mo]; p < 0.001). Tracheal intubation–associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54–1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52–0.97; p = 0.033). Rates of severe tracheal intubation–associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04–1.15; p = 0.002). Conclusions: In children with underlying cardiac disease, rates of adverse tracheal intubation–associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

1885: BIPHASIC CUIRASS VENTILATOR USE DURING SPECIAL CIRCUMSTANCES IN THE PEDIATRIC ICU

Learning Objectives: Several drugs that are not FDA approved in the US are used worldwide for cosmetic soft tissue augmentation. Young women often travel outside of the US to have procedures performed by non-medical lay practitioners and end up with fatal complications. We describe the case of hemorrhagic pneumonitis causing acute respiratory failure in a young healthy female due to Anicoll injection. Methods: A healthy 29-year-old woman was admitted with history of sudden onset of shortness of breath, cough productive of blood tinged sputum, chest pain, headache and altered mental status for 2 days. She was febrile and hypotensive. She was intubated, resuscitated and started on vasopressors, antimicrobials and hydrocortisone. Labs showed elevated WBC count, anemia and thrombocytopenia. Toxicology screen was negative. CT chest showed extensive infiltrates, predominantly in bilateral lower lobes and ground glass opacities within the middle and upper lobes. Bilateral breast implants were noted to be intact. CT pelvis showed dense infiltration within the subcutaneous fat of bilateral buttocks. Diagnostic bronchoscopy was suggestive of diffuse alveolar hemorrhage. Lumbar puncture was negative for infection. Upon obtaining further history from family, it was revealed that she had received injections in her gluteal region at a local beauty salon in Mexico 1 day prior to her symptoms. The salon in Mexico was contacted which revealed that she received Anicoll injection for gluteal enhancement. The composition of Anicoll was found to be polymethyl methacrylate (PMMA) microspheres suspended in purified collagen (30%) and silicone (70%). Extensive workup for infection and autoimmune conditions was negative. Bronchoalveolar fluid showed reactive alveolar macrophages, blood, inflammatory cells and negative cytology. Antimicrobials were discontinued and the patient received high dose intravenous methylprednisolone. Her hemodynamic and respiratory status gradually improved. Results: Silicone, more commonly than PMMA, enters the blood stream when inappropriately injected and can cause pneumonitis and an emboli syndrome