Impact of Helium-Oxygen Administered via High Velocity Nasal Insufflation on Delivery of Inhaled Nitric Oxide.

Inhaled nitric oxide (iNO) may be continued during the transition from invasive to noninvasive respiratory support. Upper airway obstruction from laryngeal edema following extubation and lower airway obstruction from asthma and bronchiolitis may be managed with inhaled helium. The coadministration of helium with iNO and the impact on delivered amounts of iNO have not been extensively studied. A bench model simulating a spontaneously breathing infant received iNO at varying preset doses delivered with either helium-oxygen or nitrogen-oxygen via a Vapotherm unit. iNO levels were measured at the simulated trachea. Results from the two conditions were compared using t-tests. When nitrogen-oxygen was used, there was no difference between preset and measured iNO levels. A significant difference was present when helium-oxygen was used, with a 10-fold increase in measured iNO levels compared with preset values. The use of helium resulted in a significant increase in measured iNO at the level of the simulated trachea. Clinicians must be aware that iNO will not be delivered at prescribed doses when used with helium under the conditions used in this study.

Occupational-Induced Secondary Traumatic Stress and Posttraumatic Stress Disorder in Respiratory Therapists.

BACKGROUND: Secondary traumatic stress (STS) may occur in the caretakers of individuals who have experienced traumatic events or are suffering and, when severe, may be associated with posttraumatic stress disorder (PTSD) at a diagnostic level due to STS. For respiratory therapists (RTs), the incidence of STS and PTSD at a diagnostic level due to STS has not been examined. We assessed the prevalence of self-reported STS and PTSD at a diagnostic level due to STS in licensed RTs. METHODS: Licensed RTs who were members of the American Association for Respiratory Care completed the Secondary Traumatic Stress Scale (STSS) based on feelings experienced over the preceding 30 days and 12 months. Results were evaluated on the basis of primary patient population (neonatal/pediatric vs adult), years of experience, and usual work location (ambulatory care, acute care, or ICU) using the McNemar chi-square analysis and the Fisher exact test. RESULTS: 201 licensed and practicing RTs completed the survey. 92% of the respondents worked ≥ 30 h/week, 75% worked in ICUs, 67% worked primarily with adults, and 89% had been in practice ≥ 6 years. PTSD at a diagnostic level due to STS was common in all respondents, occurring in 36% based on experiences from the prior 30 days and in 32% based on experiences from the prior 12 months. CONCLUSIONS: No difference in PTSD at a diagnostic level due to STS was noted between RTs caring for neonatal/pediatric versus adult patients or between RTs based on years of work experience or based on work environment. STS and PTSD at a diagnostic level due to STS was common in RTs.

Virtual Reality Simulation for Pediatric Airway Intubation Readiness Education.

Background The objective of this study was to provide education to inexperienced trainees regarding preparation for airway intubation using virtual reality (VR) tutorial and comparison of performance with that of experienced trainees without VR training. We hypothesized that after the VR tutorial, junior fellows and residents will have comparable recall of the proper steps as experienced trainees. Methods This project was initiated in the pediatric intensive care unit from July 1, 2019, to July 30, 2019. Volunteer residents and pediatric critical care medicine fellows participated. The VR group completed a 19-minute immersive tutorial and then demonstrated learned skills with a traditional manikin. Non-VR group fellows listed steps to prepare for airway intubation from memory with scoring on a 24-point timed checklist. Results Seventeen subjects participated; two residents were excluded. The VR group had seven trainees (47%) and scored similarly to the other group based on checklist items (50.5% vs 50.8%, P=1). Conclusion VR technologies can be used for education in preparation for pediatric airway intubation. There was no difference in the performance accuracy between the two groups. Larger studies are essential to study benefits of VR in preparation and performance of airway intubation.

Application of Telemedicine Technology to Facilitate Diagnosis of Pediatric Postintensive Care Syndrome.

Background: Postintensive care syndrome (PICS) is well-defined in the adult literature but has not received much attention in pediatrics. Introduction: We sought to use a telemedicine platform for the characterization of PICS by creating a convenient and effective virtual follow-up clinic. Materials and Methods: Prospective single-center study in a pediatric intensive care unit (ICU) of patients aged 4-17 years who underwent any invasive procedures while admitted to the ICU. Parents completed the Weiss Functional Impairment Rating Scale (WFIRS) based on baseline behaviors before ICU admission, with the scale readministered at 1 week, 1 month, and 3 months postdischarge via secure telehealth platform. Patients with a WFIRS baseline raw score of 10 or an interval increase of 2 were referred to psychiatry for evaluation and treatment. Results: Fifty patients were enrolled. Risk factors for PICS included number of procedural interventions, length of pediatric ICU stay, number of specialty consults, sex, race, and duration of sedation/airway instrumentation. In univariate analysis, age appeared to be the only statistically significant factor associated with the development of PICS. Variables associated with a higher change in WFIRS score showed a statistically significant correlation with the number of procedures completed, the number of specialists involved, and the need for a psychiatric referral. Only 34% of total telemedicine follow-ups were completed. Discussion: There is an association between age and the development of PICS and between change in WFIRS score and number of procedures, specialist involved, and psychiatric referral. Conclusions: The use of telemedicine did not result in an improved follow-up rate when compared to outpatient clinic studies.

Real-World Evaluation of the Eko Electronic Teleauscultation System.

Heart murmur evaluation is the most common cause of referral to cardiology, and auscultation of heart sounds with a stethoscope remains a key component of the initial cardiovascular exam. Adoption of telecardiology has been limited by challenges in teleauscultation. We set out to compare in-person auscultatory findings with heart sounds recorded by the Core stethoscope (Eko, Berkeley, CA) in patients with normal heart sounds, innocent heart murmurs, and a variety of pathologic findings. Our study demonstrates that Eko recordings had a high percent of agreement with in-person auscultation findings and echocardiogram findings, with moderate inter-rater reliability. It was useful in identifying patients with pathologic murmurs who would benefit from further assessment. It was able to discern major types of pathological murmurs. Certain qualitative differences in the recorded sounds as compared to in-person auscultation were identified by the reading cardiologists. They were able to acclimate to these subtle differences. The system was felt to be easy to use, and most cardiologists in the study would consider using it in clinical settings. The Eko Core system may be a useful screening tool for murmur evaluation.

The Incidence and Nature of Allergic and Anaphylactic Reactions During Pediatric Procedural Sedation: A Report From the Pediatric Sedation Research Consortium.

BACKGROUND AND OBJECTIVES: Anaphylaxis is rare but life-threatening. Its incidence during pediatric procedural sedation outside of the operating room is unknown. We used data from the Pediatric Sedation Research Consortium (PSRC) to determine the incidence and nature of allergic and anaphylactic reactions in this practice. METHODS: A retrospective observational study of prospectively collected information in the PSRC's multicenter database was performed. Cases of allergic reaction were identified. Because anaphylaxis is not a listed complication in the PSRC database, all cases for which allergic reaction was noted were reviewed for the occurrence of other complications or interventions that would suggest at least 2 organ system derangements consistent with anaphylaxis as well as for practitioner commentary stating the occurrence of anaphylaxis. Descriptive analyses of demographic information and summary statistics were performed, and multiple logistic regression analysis was used to evaluate associations between the occurrence of allergic reactions and medications. RESULTS: During the study period, 227 833 cases were entered into the PSRC database. There were 54 cases of allergic reaction (incidence 1:4219); 6 were consistent with anaphylaxis (incidence 1:37 972). A significant association between the development of allergic reaction and 4 sedative and/or analgesic medications was noted: midazolam (odds ratio [OR] 2.2; confidence interval [CI] 1.2-3.9), ketamine (OR 3.8; CI 2.1-7.1), methohexital (OR 48.8; CI 14.9-159.9), and morphine (OR 4.4; CI 1.04-18.2). There were no mortalities. CONCLUSIONS: Allergic reactions and anaphylaxis during pediatric procedural sedation are rare. In this study, the development of allergic reactions was significantly associated with the use of midazolam, ketamine, methohexital, and morphine.

Impact of Interfacility Transport Method and Specialty Teams on Outcomes of Pediatric Trauma Patients.

OBJECTIVE: The aim of the study was to evaluate the impact of ground versus air transport and use of pediatric specialty versus generalist transport teams on outcomes of pediatric trauma victims requiring interfacility transport. METHODS: A retrospective review of our hospital's trauma registry database was performed. Children with traumatic injuries who were transported from a referring hospital by either our pediatric specialty transport team or an outside generalist transport team were included in the analysis. Comparisons were made by mode of transport (air vs ground), team type (specialty vs generalist), and by transport mode and team type combined. RESULTS: Total transport time was significantly shorter for generalist air transport than other modes. Severity of injury as determined by Pediatric Trauma Score (PTS) was equivalent for all patients at the referring hospital, but there was a statistically significant greater decrease (worsening) in PTS from referral to arrival for generalist team air transports versus all other transport modes. Similarly, there was a statistically significant greater decrease (worsening) in Glasgow Coma Score from referral to arrival for generalist team air transport versus all other transport modes. Hospital discharge disposition to home was greater for all ground teams versus air teams and for specialty team air versus generalist team air. CONCLUSIONS: In our system, air transport by a generalist team occurred more rapidly than ground or air transport by a specialty team. However, generalist air transport is associated with significant worsening in patients' PTS and Glasgow Coma Score despite similar severity of injury at referral, and differences in hospital discharge disposition were present.

A Prospective Pilot Study of the Use of Telemedicine During Pediatric Transport: A High-Quality, Low-Cost Alternative to Conventional Telemedicine Systems.

OBJECTIVE: Few trials address the use of telemedicine during pediatric transport. We believe that video conferencing has equivalent quality, connectivity, and ease of operation, can be done economically, and will improve evaluation. METHODS: Prospective randomized pilot study was used to examine video versus cellular communication between the medical command officer (MCO) and pediatric transport team (TT) for children with moderate to severe illness undergoing interhospital transport. Twenty-five patients were randomized to cellular communication, and 25 patients were randomized to video. The MCO completed a Likert scale to evaluate connection, quality, and ease of operation. Call durations were recorded. A Likert scale to evaluate the communication mode on patient care was completed. RESULTS: Connection and audio quality were equivalent and there were no dropped calls. Average call duration in the phone group was 186 versus 139 seconds in the video group (P = 0.055). The MCO survey results were the following: 100% found video intuitive, 92% felt that disposition based on phone report was difficult, 80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used for transport. The iPad system offers a significant savings when compared with conventional telemedicine. CONCLUSIONS: Video conferencing seems as easy to complete as phone with equivalent quality and connectivity. Duration of video was equivalent to phone conferencing. Surveyed MCOs believed that video conferencing improved assessment and disposition. The iPad-based conferencing provided significant savings when compared with conventional cart-based or robotic units. Further evaluation of video conferencing during interhospital transport is warranted.

Use of insulin to decrease septic shock-induced myocardial depression in a porcine model.

Insulin is known to attenuate septic shock-induced myocardial depression. Possible mechanisms include an anti-inflammatory or inotropic effect of insulin. The objective of this study was to determine whether the mechanism of action of insulin in attenuating septic shock-induced myocardial depression is through an immunomodulatory effect. Fourteen pigs were assigned to one of two groups. Both groups received a 4-h infusion of lipopolysaccharide endotoxin from Escherichia coli 0111:B4. Group 2 additionally received insulin at 1.5 U/kg/h with infusions of D50 normal saline and KCl to maintain normal serum glucose and potassium levels. Cardiac function was measured with shortening fraction using transthoracic echocardiogram. Plasma TNF-α, IL-1ß, and IL-6 levels were obtained every 30 min. Postmortem cytokine analysis and histomorphology were performed on the heart tissue. Although insulin attenuated septic shock-induced myocardial depression, this was not due to an anti-inflammatory effect and, therefore, likely resulted from an inotropic effect of insulin.

Surfactant administration prior to one lung ventilation: physiological and inflammatory correlates in a piglet model.

OBJECTIVES: To test the hypothesis that surfactant, when given prophylactically during one lung ventilation (OLV), improves physiological stability and reduces inflammation. METHODS: Prospective controlled animal study. After 30 min of mechanical ventilation, surfactant was administered to the left lung of the treatment group. Right lung mechanical ventilation continued for 3 hr, after which the left lung was unblocked. Bilateral mechanical ventilation was continued for 30 min thereafter. Physiological parameters and biomarkers of inflammation in plasma, lung tissue homogenates, and bronchoalveolar lavage (BAL) were measured. MEASUREMENTS AND MAIN RESULTS: Oxygenation improved in the surfactant group, reaching statistical significance at 3 hr of OLV and again after 30 min of bilateral mechanical ventilation following the OLV. Plasma levels of interleukin (IL)-1 ß, IL-6, and tumor necrosis factor (TNF)-α showed a trend for reduction. The lung homogenates from the ventilated lungs had significantly lower levels of IL-1 ß (P < 0.01) and IL-6 (P < 0.01). The BAL specimen showed an overall reduction in the cytokine levels; IL-1 ß was significantly lower in the ventilated lungs (P < 0.01). CONCLUSIONS: Surfactant administration improves oxygenation and decreases inflammation, as evidenced by a decrease in several inflammatory cytokines both in the plasma and lungs of a piglet model of OLV.

Conversion disorder mimicking serotonin syndrome in an adolescent taking sertraline.

We present the case of a 15-year-old-boy on sertraline (Zoloft) who presented to the Emergency Department with palpitations, tremor, and weakness after starting erythromycin. Upon admission to the hospital, he developed syncopal-like episodes of unresponsiveness associated with body-wide jerking and stiffening as well as tachycardia and hypertension. He was initially believed to have serotonin syndrome and was transferred to a pediatric Intensive Care Unit where the diagnosis of conversion disorder was made. We discuss the salient features of serotonin syndrome and conversion disorder and emphasize the importance of making either diagnosis.

An unusual case of button battery-induced traumatic tracheoesophageal fistula.

BACKGROUND: Much of pediatric medicine is focused on prevention of disease and injury. Although accidental ingestions of various household chemicals and medicines are well described and the treatment is supported by local poison control hotlines, the ingestion of button batteries by children is less publicized, and the dangers are less understood by both parents and health care providers. METHODS: We describe a case report of a 17-month-old girl with no significant medical history who presented with respiratory distress, cough, and fever and subsequently was discovered to have ingested a button battery. RESULTS: The formation of a traumatic tracheoesophageal fistula required intensive management that escalated to cardiopulmonary bypass and eventual pericardial patch closure of the tracheal defect after the failure of conventional mechanical ventilation. CONCLUSIONS: Esophageal button battery impaction places the patient at high risk for full-thickness damage to the esophagus and tracheal structures with fistula formation in as little as a few hours. The key to successful therapy is prompt diagnosis and removal, but in nonverbal pediatric patients, this often is not achievable. Because of the complications associated with this disease (tracheoesophageal fistula) and subsequent difficulties associated with oxygenation and ventilation, these patients should be managed at an institution with the skilled capability of providing cardiopulmonary bypass quickly as a potentially lifesaving therapy.

Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children.

AIM: Mechanically ventilated patients are at risk for aspiration of gastric contents. The aim of this observational study was to determine the prevalence of micro-aspiration in children with cuffed and uncuffed endotracheal (ET) tubes and with tracheostomies and to assess the effect of feeding status on aspiration. Micro-aspiration was determined by measuring gastric pepsin in tracheal aspirates. METHODS: We studied 27 children on ventilators in paediatric intensive care unit (PICU) and 10 children undergoing elective surgeries for various indications. Tracheal aspirates were collected from children on ventilatory support in the intensive care unit during medically indicated suctioning and from the group of children undergoing elective surgery in the operation room. Pepsin was detected by enzymatic assay. RESULTS: Overall 70% of cases in PICU were positive for pepsin in at least one of the aspirates. Pepsin positivity was significantly lower in the cuffed group than in the uncuffed and tracheostomy groups. Tube feedings did not significantly influence the prevalence of pepsin positivity. CONCLUSIONS: Measurement of gastric pepsin in tracheobronchial fluid is a sensitive tool to detect aspirations in mechanically ventilated children and to assess the efficacy of preventive measures in PICU settings.

Genome-level longitudinal expression of signaling pathways and gene networks in pediatric septic shock.

We have conducted longitudinal studies focused on the expression profiles of signaling pathways and gene networks in children with septic shock. Genome-level expression profiles were generated from whole blood-derived RNA of children with septic shock (n=30) corresponding to day one and day three of septic shock, respectively. Based on sequential statistical and expression filters, day one and day three of septic shock were characterized by differential regulation of 2,142 and 2,504 gene probes, respectively, relative to controls (n=15). Venn analysis demonstrated 239 unique genes in the day one dataset, 598 unique genes in the day three dataset, and 1,906 genes common to both datasets. Functional analyses demonstrated time-dependent, differential regulation of genes involved in multiple signaling pathways and gene networks primarily related to immunity and inflammation. Notably, multiple and distinct gene networks involving T cell- and MHC antigen-related biology were persistently downregulated on both day one and day three. Further analyses demonstrated large scale, persistent downregulation of genes corresponding to functional annotations related to zinc homeostasis. These data represent the largest reported cohort of patients with septic shock subjected to longitudinal genome-level expression profiling. The data further advance our genome-level understanding of pediatric septic shock and support novel hypotheses.

Genome-level expression profiles in pediatric septic shock indicate a role for altered zinc homeostasis in poor outcome.

Human septic shock involves multiple genome-level perturbations. We have conducted microarray analyses in children with septic shock within 24 h of intensive care unit admission, using whole blood-derived RNA. Based on sequential statistical and expression filters, there were 2,482 differentially regulated gene probes (1,081 upregulated and 1,401 downregulated) between patients with septic shock (n = 42) and controls (n = 15). Both gene lists encompassed several biologically relevant gene ontologies and canonical pathways. Notably, many of the genes downregulated in the patients with septic shock, relative to the controls, participate in gene ontologies related to metal or zinc homeostasis. Comparison of septic shock survivors (n = 33) and nonsurvivors (n = 9) demonstrated differential regulation of 63 gene probes. Among the 63 gene probes differentially regulated between septic shock survivors and nonsurvivors, two isoforms of metallothionein (MT) demonstrated increased expression in the nonsurvivors. Consistent with the ability of MT to sequester zinc in the intracellular compartment, nonsurvivors had lower serum zinc levels compared with survivors. In a corroborating study of murine sepsis, MT-null mice demonstrated a survival advantage compared with wild-type mice. These data represent the largest reported cohort of pediatric patients with septic shock that has undergone genome-level expression profiling based on microarray. The data are biologically plausible and demonstrate that genome-level alterations of zinc homeostasis may be prevalent in clinical pediatric septic shock.

Intussusception in a child with respiratory syncytial virus: a new association.

Intussusception is known to be associated with childhood viral illnesses. Respiratory syncytial virus (RSV) has not, to our knowledge, been previously reported in association with intussusception. We report a case of a 4-month-old boy admitted with RSV bronchiolitis, who subsequently developed an intussusception during the hospital course, necessitating laparotomy and resection.

Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes.

OBJECTIVE: To determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure. DESIGN: Twelve-month prospective, observational, clinical study. SETTING: Sixteen diverse PICUs in the United States. PATIENTS: Patients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3-7.1). Patient features associated with extubation failure (p <.05) included age < or =24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, SD +/- 207.8 vs. success, 107.9 hrs, SD +/- 171.3; p <.001), longer PICU length of stay (17.5 days, SD +/- 15.6 vs. 7.6 days, SD +/- 11.1; p <.001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%; p <.001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not. CONCLUSION: A variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.

A model of determining a fair market value for teaching residents: who profits?

CONTEXT: Centers for Medicare & Medicaid Services (CMS) Health Resources and Services Administration Children's Hospitals Graduate Medical Education (GME) Payment Program now supports freestanding children's teaching hospitals. OBJECTIVE: To analyze the fair market value impact of GME payment on resident teaching efforts in our pediatric intensive care unit (PICU). DESIGN: Cost-accounting model, developed from a 1-year retrospective, descriptive, single-institution, longitudinal study, applied to physician teachers, residents, and CMS. SETTING: Sixteen-bed PICU in a freestanding, university-affiliated children's teaching hospital. PARTICIPANTS: Pediatric critical care physicians, second-year residents. MAIN OUTCOME MEASURES: Cost of physician opportunity time; CMS investment return; the teaching physicians' investment return; residents' investment return; service balance between CMS and teaching service investment margins; economic balance points; fair market value. RESULTS: GME payments to our hospital increased 4.8-fold from 577 886 dollars to 2 772 606 dollars during a 1-year period. Critical care physicians' teaching opportunity cost rose from 250 097 dollars to 262 215 dollars to provide 1523 educational hours (6853 relative value units). Residents' net financial value for service provided to the PICU rose from 245 964 dollars to 317 299 dollars. There is an uneven return on investment in resident education for CMS, critical care physicians, and residents. Economic balance points are achievable for the present educational efforts of the CMS, critical care physicians, and residents if the present direct medical education payment increases from 29.38% to 36%. CONCLUSIONS: The current CMS Health Resources and Services Administration Children's Hospitals GME Payment Program produces uneven investment returns for CMS, critical care physicians, and residents. We propose a cost-accounting model, based on perceived production capability measured in relative value units and available GME funds, that would allow a clinical service to balance and obtain a fair market value for the resident education efforts of CMS, physician teachers, and residents.