Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes.

BACKGROUND: Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS: This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS: A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS: Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.

Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction.

BACKGROUND: Cryoextraction via flexible bronchoscopy (FB) can be used to alleviate airway obstruction due to blood clots, casts, mucus, and foreign bodies. There is limited literature regarding the utility of cryoextraction to restore airway patency in critically ill children, especially on extracorporeal membrane oxygenation (ECMO). The aims of this study were to describe the clinical course and outcomes of children who underwent cryoextraction via FB. METHODS: A singlecenter retrospective review of children who underwent cryoextraction via FB between 2017 and 2021 was conducted. The analyzed data included diagnoses, indications for cryoextraction, respiratory support modalities, FB and chest imaging results, and outcomes. RESULTS: Eleven patients aged 3-17 years underwent a total of 33 cryoextraction sessions via FB. Patients required ECMO (n = 9) or conventional mechanical ventilation (CMV) for pneumonia, pulmonary hemorrhage, pulmonary embolism, asthma exacerbation, and cardiorespiratory failure following cardiac surgery. One patient underwent elective FB and cryoextraction for plastic bronchitis. Indications for cryoextraction included airway obstruction due to tracheobronchial thrombi (n = 8), mucus plugs (n = 1), or plastic bronchitis (n = 2). Cryoextraction via FB was performed on patients on ECMO (n = 9) and CMV (n = 2) with 6 patients requiring ≥3 cryoextraction sessions for airway obstruction. There were no complications related to cryoextraction. Patient outcomes included partial (n = 5) or complete (n = 6) restoration of airway patency with ECMO decannulation (n = 5) and death (n = 4) due to critical illness. CONCLUSIONS: Cryoextraction via FB is an effective intervention that can be utilized in critically ill children with refractory tracheobronchial obstruction to restore airway patency and to facilitate liberation from ECMO.

Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium.

BACKGROUND: Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists. PURPOSE: Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI. STUDY TYPE: Retrospective analysis of prospectively collected data. SUBJECTS: The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017. ASSESSMENT: Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined. STATISTICAL TESTS: Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method. RESULTS: A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time. DATA CONCLUSIONS: Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 5.

Management of esophageal button battery ingestions: resource utilization and outcomes.

PURPOSE: Institutions are adopting the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines for pediatric esophageal button battery ingestion (EBBI). Our objective was to evaluate the guidelines' impact on in-hospital resource utilization and short-term clinical outcomes in hemodynamically stable patients after endoscopic battery removal. METHODS: A single-center retrospective review of all EBBI admissions from 2010 to 2020. Patients were divided into two groups based on adoption of national guidelines: pre-guideline (2010-2015) and post-guideline (2016-2020). RESULTS: Sixty-five patients were studied (pre-guideline n = 23; post-guideline n = 42). Compared with pre-guideline, post-guideline use of magnetic resonance imaging (MRI) increased (2/23 [8.7%]; 30/42 [71.4%]; p < 0.001). Post-guideline increases resulted for median days (IQR) receiving antibiotics (0 [0, 4]; 6 [3, 8]; p = 0.01), total pediatric intensive care unit admission (0 [0, 1]; 3 [0, 6]; p < 0.001), and total hospital length of stay (5 [2, 11]; 11.5 [4, 17]; p = 0.02). Two patients in the post-guideline group had delayed presentations despite normal imaging: one with TEF and one with aorto-esophageal fistula. All survived to discharge. CONCLUSION: In EBBI cases managed using the consensus based NASPHAGN guidelines, we report increased resource utilization without improved patient outcomes. Further research should evaluate post-guideline costs and resource utilization.

Long-term evidence of neonatal anaesthesia neurotoxicity linked to behavioural phenotypes in monkeys: where do we go from here?

Whether anaesthesia exposure early in life leads to brain damage with long-lasting structural and behavioural consequences in primates has not been conclusively determined. A study in the British Journal of Anaesthesia by Neudecker and colleagues found that 2 yr after early anaesthesia exposure, monkeys exhibited signs of chronic astrogliosis which correlate with behavioural deficits. Given the increasing frequency of exposure to anaesthetics in infancy in humans, clinical trials are greatly needed to understand how sedative/anaesthetic agents may be impacting brain and behaviour development.

"Difficult to Sedate": Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children.

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08-0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

Sedatives used in children to obtain head CT in the emergency department.

OBJECTIVES: Children in the emergency department who require computerized tomography (CT) of the head often are given sedative medications to facilitate completion of the study with adequate imaging. A prior study found the two most common medications used to obtain head CT in children were pentobarbital and chloral hydrate; however, these medications have become less popular. We hypothesized that there was variability in medication choice amongst providers in the emergency department and there has been a change in the preferred sedatives used in the last decade. METHODS: We conducted a retrospective multicenter cross-sectional study of children 0-18 years old who received a medication with sedative properties and underwent head CT while in the emergency department from 2007 to 2018, using the Pediatric Health Information System (PHIS) database. The primary outcome measure was the frequency of administration of drugs within an individual sedative class. RESULTS: We analyzed 24,418 patient encounters, of whom 53% received an opioid and 41% received a benzodiazepine. There were statistically significant decreases in the use of barbiturates, chloral hydrate, anti-emetic sedatives, and opioids, while increases in barbiturate combination drugs, benzodiazepines and dexmedetomidine were observed over the study period. The majority of medications were administered parenterally. CONCLUSION: There is wide variability in sedatives used in children to obtain head CT and the preferred drugs have shifted over the last decade.

Trends in Outpatient Procedural Sedation: 2007-2018.

BACKGROUND: Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. METHODS: Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. RESULTS: A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). CONCLUSIONS: We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.

Critical care resource use, cost, and mortality associated with firearm-related injuries in US children's hospitals.

BACKGROUND/PURPOSE: To assess trends and resource use attributable to firearm-related injuries in US pediatric intensive care units (PICUs). METHODS: Retrospective data from Pediatric Health Information Systems (PHIS) database from 2004 to 2017. RESULTS: Of 5,984,938 admissions to 28 children's hospitals, 3707 were for firearm injuries. A total of 1088 of 3707 hospitalizations (29.9%) required PICU admission. Median PICU length of stay was 2 days (IQR, 1-6 days), and the median cost for PICU patients was $37,569.31 (IQR, $19,243.83-$77,856.32). Use of mechanical ventilation (674/1088 admissions [61.9%]), surgical procedures (744/1088 admissions [68.3%]), blood transfusions (429/1088 admissions [39.9%]), and intracranial pressure monitoring devices (30/1088 admissions [2.8%]) increased in PICU patients. Computed tomography showed an overall increase (197/287 [68.6%] to 138/177 [78%], P = .037) from 2004 to 2007 to 2016-2017. Mortality among PICU patients (140/1058 [13.23%]) attributable to firearm-related injuries increased insignificantly (34/285 (11.93%] to 25/172 [14.53%], P = .746). CONCLUSIONS: Using PHIS data, we found a significant increase in median cost per hospitalization and an increase in critical care resource use, including the frequency of invasive mechanical ventilatory assistance, neuromonitoring, operations performed, and transfusion of blood products. Further research is needed to continue to characterize the burden of pediatric critical firearm injury. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

Analysis of 207,543 children with acute opioid poisonings from the United States National Poison Data System.

Introduction: Previous studies using administrative data have demonstrated that the United States opioid epidemic is harming both adults and children, and is straining health care systems. Our objective is to describe the outcomes and trends in resource use among children with acute opioid ingestions using patient-level case report data.Materials and Methods: This study was a retrospective analysis of prospectively collected data from the 55 poison control centers in the United States which comprise the National Poison Data System (NPDS). Children under 19 years of age with a primary opioid ingestion between 1 January 2005 and 31 December 2018 were included in the analysis. Trends over three eras (2005-2009, 2010-2014, 2015-2018) were assessed using a Cochran-Armitage Trend Test. Yearly trends in the proportion of cases were calculated using generalized linear models. Multi-variable logistic regression analysis was used to calculate the adjusted odds of variables associated with having at least one Pediatric Intensive Care Unit (PICU) level intervention.Results: Children were involved in 207,543 (27.54%) of a total of 1,002,947 primary exposure-related opioid poisoning cases reported to US poison centers. The percentage of patients admitted to a critical care unit from these exposures increased in each era (6.6%, 8.5%, 9.6%). Suicidal intent increased in each era (14.0%, 15.3%, 21.2%), and was associated with increased adjusted odds of receiving a PICU procedure (OR 9.68, CI 7.97-11.76). Fentanyl (OR 12, CI 9.2-15.7), heroin (OR 11.1, CI 9.4-13.1), and methadone (OR 15, CI 13-17.3) were the opioids most associated with having a PICU procedure.Discussion and Conclusions: The severity of admissions for acute opioid ingestions, especially following attempted suicide, has increased over the studied time frame. Efforts focused on reducing access, especially to synthetic and illicit opioids, and addressing adolescent suicidality are needed to reduce these serious consequences of the opioid epidemic on children in the United States.

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center.

BACKGROUND: Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS. OBJECTIVE: To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization. METHODS: Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded. RESULTS: A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed. CONCLUSION: Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

Prospective evaluation of a clinical decision tool to reduce childhood admissions to PICUs for poisoning: ReCAP2.

Aim: To prospectively validate a pediatric clinical prediction model to identify children at low risk of clinically significant ingestions to prevent unnecessary pediatric intensive care unit (PICU) admissions.Methods: Calls received by the Georgia Poison Center about children for acute ingestions between May 25, 2017 and May 17, 2018 were scored in real time using the full, age-stratified, and simplified clinical scoring tool to reduce childhood admissions to PICUs for poisoning (RECAP2). Clinically significant ingestions with a poison center recommendation of PICU admission are defined in the simple RECAP2 model as ingestion of clonidine, ethanol, an oral anti-hyperglycemic agent, or exposure to carbon monoxide, as well as the presence of symptoms occurring within 2 h for an immediate release, or 4 h for an extended release, medication exposure. Model statistics and percent reduction in PICU admissions were computed.Results: There were 886 children admitted after ingestions, of which 454 (51.2%) children were admitted to intensive care. At the time of the initial poison center call to report the ingestion, 44 cases (5%) were incomplete using the full, age-stratified model compared to the complete scoring using the simple scoring model. Seventy-two children (8.1%) required monitoring or interventions performed only in a PICU. Real-time application of the full model compared with the simple model would have reduced PICU admissions by 33.3 and 31.7%, respectively.Conclusions: The simple RECAP2 clinical scoring model is a sensitive prediction tool to identify children at very low risk for clinically significant ingestions for whom PICU admission can be avoided. Clinical implementation of the simple RECAP2 model and recommendation for admission to an inpatient unit versus PICU should be further evaluated, to reduce unnecessary PICU admissions following acute ingestions.

Procedural Sedation Outside the Operating Room and Potential Neurotoxicity: Analysis of an At-Risk Pediatric Population.

OBJECTIVES: To determine the characteristics of children who met the risk criteria for potential neurotoxicity defined by the US Food and Drug Administration (FDA; 2016 warning) in a procedural sedation (PS) service. STUDY DESIGN: A single-center retrospective review of all infants and children aged <3 years receiving PS outside the operating room from 2014 to 2016. Demographics, duration of, and the reason for PS were analyzed. RESULTS: A total of 2950 patients with 3653 sedation encounters were included. Median age was 19 (range, 11-26) months. Most PS (86.4%) were for magnetic resonance imaging (MRI). The median number of sedation procedures per patient was 1 (25th-75th: 1-7), and median duration of sedation was 72 minutes (25th-75th: 55-98 minutes). Forty patients (1.4%) required prolonged sedations >3 hours, in a single encounter (median, [25th-75th] of 196 minutes [185-214 minutes]), and 298 patients (10.1%) had multiple sedation exposures during the study period. Overall, 327 patients, 11.1% (95% confidence interval, 10.0%-12.3%) required repeated and/or prolonged sedation. The most common reasons for repeated or prolonged sedation were MRI of the brain and neurologic concerns. CONCLUSIONS: Multiple and prolonged PS commonly occurs outside the operating room in this young and potentially vulnerable population. Although certain imaging cannot be avoided, other cases may have the potential to be delayed until the child is >3 years old or to have alternate imaging that may not require prolonged PS. Family and provider awareness of the FDA warnings regarding potential neurotoxicity of sedation in all settings, both inside and outside the operating room, is critical.

Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship.

OBJECTIVES: Pediatric procedural sedation has been increasingly performed by pediatric intensivists over the past decade. Pediatric Critical Care Medicine fellowship guidelines do not specify how fellows obtain proficiency in pediatric procedural sedation. We sought to survey the state of pediatric procedural sedation training during fellowship and whether fellows thought it was sufficient. DESIGN: A 21-question survey gathered data on pediatric procedural sedation training provided to Pediatric Critical Care Medicine fellows. Surveys were sent to fellowship directors with instructions to distribute to second- and third-year fellows or recent graduates. Over 2 months, up to three e-mail reminders were sent to fellowship directors whose program had not completed at least one survey. SUBJECTS: Senior fellows and graduates of 65 active Accreditation Council for Graduate Medical Education Pediatric Critical Care Medicine fellowship programs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-five percent of fellowship programs (42/65) returned at least one response. Ninety senior fellows and 27 recent graduates responded. Of respondents, 38% received pediatric procedural sedation training during the fellowship, and 32% reported mandatory training. Nine percent of programs used simulation. Although 61% who received training felt adequately prepared to perform pediatric procedural sedation, 25% needed additional preceptorship to sedate independently. Nearly one third (31%) reported that completion of a predetermined number of cases was required to sedate independently. Forty-eight percent reported a minimum number of cases was required for hospital credentialing. Nearly 45% were allowed to perform pediatric procedural sedation off the unit after receiving credentials. When asked if inadequate pediatric procedural sedation training would be a deterrent to applying for a position that included pediatric procedural sedation, 8.6% replied yes, 52.6% replied no, and 38.8% replied they were unsure. CONCLUSIONS: Pediatric procedural sedation lacks a clearly defined training pathway. Most fellows find pediatric procedural sedation a valuable skill set. We propose that all Pediatric Critical Care Medicine fellows receive training that includes pediatric procedural sedation critical incident simulation and cases performed outside the PICU to establish proficiency.

Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members.

BACKGROUND: Children with autism spectrum disorder are challenging to sedate because of communication, sensory, and behavioral challenges. AIMS: The aim of this survey was to determine how procedural sedation is provided to children with autism spectrum disorders and whether sedation programs have specialized protocols for procedural sedation of these children. METHODS: We surveyed physician Medical Directors of sedation programs who are members of the Society for Pediatric Sedation, asking about practice characteristics and resource utilization during procedural sedation of children with autism spectrum disorders. RESULTS: Of 58 directors, 47 (81%) responded. Of the programs surveyed, 53% were either a large university medical center and 40% were a freestanding children's hospital. Only (12/47, 25.5%) of the programs used an individualized autism coping plan. To accomplish procedural sedation in this study cohort, 36% of the programs used additional nurses, whereas a child life specialist was used in 55% of the programs surveyed. Only 28% of the centers allotted additional time to accommodate children with autism spectrum disorders. Distraction methods were used in 80% whereas restrains were used in 45% programs for were used most commonly for i.v. catheter placement. Propofol was the preferred agent for 70% of programs for imaging, while propofol + fentanyl was used by 66% of programs for painful procedures. Although 57% of directors reported that their program staff was extremely comfortable providing procedural sedation for children with autism spectrum disorder, 79% of the directors wanted more education about behavioral management strategies for procedural sedation of these children. CONCLUSION: Among the Society for Pediatric Sedation programs, significant institutional variation exists on the delivery of procedural sedation to children with autism spectrum disorders. A better understanding of resources required, standardization of behavioral management strategies and pharmacologic approaches, and protocol development may help optimize care to this vulnerable population.