Epinephrine Dosing Use During Extracorporeal Cardiopulmonary Resuscitation: Single-Center Retrospective Cohort.

OBJECTIVES: During pediatric cardiac arrest, contemporary guidelines recommend dosing epinephrine at regular intervals, including in patients requiring extracorporeal membrane oxygenation (ECMO). The impact of epinephrine-induced vasoconstriction on systemic afterload and venoarterial ECMO support is not well-defined. DESIGN: Nested retrospective observational study within a single center. The primary exposure was time from last dose of epinephrine to initiation of ECMO flow; secondary exposures included cumulative epinephrine dose and arrest time. Systemic afterload was assessed by mean arterial pressure and use of systemic vasodilator therapy; ECMO pump flow and Vasoactive-Inotrope Score (VIS) were used as measures of ECMO support. Clearance of lactate was followed post-cannulation as a marker of systemic perfusion. SETTING: PICU and cardiac ICU in a quaternary-care center. PATIENTS: Patients 0-18 years old who required ECMO cannulation during resuscitation over the 6 years, 2014-2020. Patients were excluded if ECMO was initiated before cardiac arrest or if the resuscitation record was incomplete. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 92 events in 87 patients, with 69 events having complete data for analysis. The median (interquartile range) of total epinephrine dosing was 65 mcg/kg (37-101 mcg/kg), with the last dose given 6 minutes (2-16 min) before the initiation of ECMO flows. Shorter interval between last epinephrine dose and ECMO initiation was associated with increased use of vasodilators within 6 hours of ECMO ( p = 0.05), but not with mean arterial pressure after 1 hour of support (estimate, -0.34; p = 0.06). No other associations were identified between epinephrine delivery and mean arterial blood pressure, vasodilator use, pump speed, VIS, or lactate clearance. CONCLUSIONS: There is limited evidence to support the idea that regular dosing of epinephrine during cardiac arrest is associated with increased in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.

Implementation of a Critical Asthma Protocol in a Pediatric ICU.

BACKGROUND: Protocol-driven therapy has been successful in managing patients with asthma on pediatric wards, but there is wide variability in ICU-level management that is often provider-dependent. This study aimed to determine if a standardized protocol for critical asthma treatment could improve clinical outcomes. METHODS: A pre-intervention cohort consisting of subjects age 2-18 y, excluding patients with airway obstruction that was not felt to be due to asthma, who were admitted to the ICU for critical asthma. Demographics and data along with medication administration information were gathered using the hospital electronic medical record. A post-intervention cohort was obtained over 13 months in an identical manner. The primary end point was time on continuous albuterol. Subjects adhering to the protocol were examined as a subset. RESULTS: 71 post-intervention subjects were compared with a historical cohort of 52 pre-intervention subjects over a similar time frame. There were no significant differences in demographic characteristics. Median time on continuous albuterol (14.4 h vs 8.1 h, P = .14) and secondary end points of median ICU length of stay (LOS), hospital LOS, and time from discontinuing continuous albuterol to transfer out of ICU were not significantly reduced in the post-intervention cohort. Overall adherence to the clinical protocol through completion was 42%. When comparing the pre-intervention cohort with the protocol-adherent subjects, significant reductions were seen in time on continuous albuterol (14.4 h vs 3.0 h, P < .001), ICU LOS (38.7 h vs 21.0 h, P < .001), and hospital LOS (2.8 d vs 1.7 d, P = .005). CONCLUSIONS: Implementation of an asthma protocol in the pediatric ICU did not result in significant improvements in time on continuous albuterol or hospital and pediatric ICU LOS, likely due to low adherence to the protocol. However, in subjects who did adhere to the protocol there were significant reductions in the outcome measures.

3-Dimensional nature-based therapeutics in pediatric patients with total pancreatectomy and islet auto-transplant.

BACKGROUND: Virtual Reality (VR) has been increasingly employed as a therapeutic means to help patients reduce stress, anxiety, and pain. While it has been shown to be effective in multiple settings, there is still scant literature referencing its use in the pediatric intensive care unit (ICU) and none using VR longitudinally as a vehicle for mindful focus utilizing natural environments. OBJECTIVES: This proof of concept study aims to demonstrate that the use of 3-D Nature-Based Therapy (NBT) glasses will lead to a reduction in pain, nausea, and anxiety in children and adolescents undergoing Total Pancreatectomy Islet Auto-Transplant (TPIAT). METHODS: Six pediatric patients (8-18 yr.) scheduled to receive TPIAT were recruited over a one-year period. Patients rated their symptoms using various scoring methods, including a novel nature-based anxiety scale. If VR was used prior to a physical therapy session, this was also noted. Patients then utilized the Oculus ™ VR device and re-scored their symptoms. Interviews were performed at entry to study, post-ICU, and at hospital discharge. RESULTS: Four of six recruited patients utilized the VR device, three of whom completed pre- and post-use scores during 11 encounters, though many other encounters occurred without scoring. Of the two patients not utilizing the device, one chose to use other means of distraction and the other reported nausea and chose not to use device. Of the patients who utilized the device, there was a net decrease in symptom scores after use, including the use of the nature-based scale which mimicked both validated scales. On survey results, all patients who utilized the device found it to be "enjoyable" and "helpful", either "would" or "might use" it again, and "would recommend it to others" for use. CONCLUSIONS: In this proof of concept study, children in a critical care setting were able to utilize VR devices for NBT after extensive surgical procedures. Initial quantitative scoring systems suggest overall improvement in symptom management, and reactions by both patients and their parents were overall positive.