Yu Inata

Inter-shift variation in unscheduled intensive care unit transfers at a children's hospital

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ped.13536 This article is protected by copyright. All rights reserved. DR. YU INATA (Orcid ID : 0000-0002-2180-9517)The early detection of clinical deterioration and the prompt escalation of care is important but may be limited in the general ward, especially at night. Identifying variations between work shifts in the number of unscheduled in‐hospital intensive care unit (ICU) transfers and emergency transfers involving life‐threatening conditions may help implement targeted interventions to reduce delayed transfers and improve patient safety and outcomes.

Outcomes of ‘unrecognised situation awareness failures events’ in intensive care unit transfer of children in a Japanese children's hospital: Outcomes of emergent internal transfer

To demonstrate that unrecognised situation awareness failures events (UNSAFE) transfers are associated with poorer outcomes in the intensive care unit (ICU) at a Japanese childrens hospital lacking a rapid response system.

Ventilator auto-triggering by cardiac electrical activity during noninvasive ventilation with neurally adjusted ventilatory assist

Neurally adjusted ventilatory assist (NAVA), by capturing the electrical activity of the diaphragm, improves patient‐ventilator synchrony. It is, however, not completely immune from auto‐triggering by cardiac electrical activity as illustrated in this case. Stringent observation of respiratory rate and vigilance for this phenomenon is warranted when using NAVA.

Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit

Background: Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU. Methods: We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group). Results: Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group. Conclusions: Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.

Ventilator-Induced Hiccups

A male infant born at 36 weeks of gestation with cervical lymphangioma was admitted to the pediatric intensive care unit. He was mechanically ventilated while awaiting elective tracheostomy. Two days after birth, he was found to have hiccups, with each one occurring invariably at the end of inspiration (Figure). Neither sedatives nor decompressing the stomach by nasogastric tube suppressed the hiccups. They continued for an hour until the pressure control (PC) of the ventilator was decreased from 12 to 10 cm H2O, which immediately terminated the hiccups After cessation, increasing the PC instantaneously triggered hiccups; they were again terminated by dropping the PC to the baseline (Video; available at www.jpeds.com). The afferent limb of the hiccup reflex arch includes the phrenic, vagus, and sympathetic nerves. We speculate the hiccups in this case were triggered by the stimulation of phrenic or vagus nerves via the stretch of the respiratory system. Although hypercapnia reduces hiccup frequency, hypo/hypercapnia should not be the cause of onset or cessation of hiccups in this case because their response to the change of PC was instantaneous. Although positive pressure ventilation and supramaximal inspiration are reported as a treatment for hiccups, “ventilator-induced hiccups” have not been described in the literature. ■

Complex effects of high-flow nasal cannula therapy on hemodynamics in the pediatric patient after cardiac surgery

BackgroundThe high-flow nasal cannula (HFNC) system has been widely used for children in various clinical settings. However, the physiological and clinical impact of HFNC therapy on the pediatric patient with respiratory distress after cardiac surgery has not been thoroughly investigated.Main body of the abstractIt seems logical to use HFNC as a primary therapy for post-extubation respiratory failure after congenital heart surgery, in which low cardiac output syndrome and upper airway obstruction are commonly encountered; the HFNC therapy alleviates the work of breathing and large negative swings of intrathoracic pressure, which in turn helps to decrease the systemic ventricular afterload. When applying HFNC to patients after congenital heart surgery, however, consideration must be given to its diverse effects on hemodynamics because of the complex respiratory and cardiac pathophysiology in these patients. The positive pressure generated by HFNC can exert different effects on pulmonary vascular resistance depending on the lung condition, while its impact on cardiac output may also differ depending on the cardiac physiology. The hemodynamic effects of HFNC may become even more complex in a patient with a single ventricle. To better assess its physiologic effects in patients after cardiac surgery, future studies could utilize various modalities including esophageal balloon catheters, electrical impedance tomography, and near-infrared spectroscopy. At the same time, studies should focus on specific types of cardiac pathophysiology or surgery when evaluating the effects of HFNC, since it may exert various effects, depending on the cardiac physiology or preoperative pulmonary hemodynamics. Lastly, the optimal flow rate at which the benefit of HFNC is maximized through favorable cardiopulmonary interactions should be determined in future studies.Short conclusionFurther studies are needed to better understand the effect of HFNC in different cardiac and respiratory physiologies, given their complexity in pediatric patients after cardiac surgery.