Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU.

OBJECTIVES: To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN: Prospective multicenter interventional quality improvement study. SETTING: Ten PICUs in North America. PATIENTS: Patients undergoing tracheal intubation in the PICU. INTERVENTIONS: VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS: The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS: Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.

Cyanosis in a Newborn Immediately after Birth.

Cyanosis in a Newborn Immediately after BirthA male neonate, weighing 3.9 kg, was delivered via Cesarean section at 39 weeks of gestation. He cried immediately after birth, but his whole body appeared blue and he had low muscle tone that did not improve with suctioning and stimulation. Blow-by with 100% oxygen was initiated, and pulse oximetry on his left hand measured 40%. What is the diagnosis?

Operations and outcomes of a Hospital-wide Emergency Airway Response Team (HEART) in a quaternary academic children's hospital.

BACKGROUND: To improve pediatric airway management outside of the operating room, a Hospital-wide Emergency Airway Response Team (HEART) program composed of anesthesiology, otorhinolaryngology, and respiratory therapy clinicians was developed. AIMS: To report processes and outcomes of HEART activations in a quaternary academic children's hospital. METHODS: A retrospective observational cohort study between January 2017 and December 2019. Local airway emergency database was reviewed for HEART activations. Additional safety data was obtained from patients' electronic health records. PRIMARY OUTCOME: Adverse airway outcomes, either adverse tracheal intubation-associated events or oxygen desaturation (SpO2 <80%). We compared airway management by primary teams before HEART arrival and by HEART after arrival. RESULTS: Of 96 HEART activations, 36 were from neonatal intensive care unit, 35 from pediatric and cardiac intensive care units, 14 from emergency department, and 11 from inpatient wards. 56 (62%) children had airway anomalies and 41/96 (43%) were invasively ventilated. Median HEART arrival time was 5 min (interquartile range, 3-5). 56/96 (58%) required insertion of an advanced airway (supra/extra-glottic airway, endotracheal tube, tracheostomy tube). HEART succeeded in establishing a definitive airway in 53/56 (94%). Adverse airway outcomes were more common before (56/96, 58%) versus after HEART arrival (28/96, 29%; absolute risk difference 29%; 95% confidence interval 16, 41%; p < .001). Oxygen desaturation occurred more frequently before (46/96, 48%) versus after HEART arrival (24/96, 25%; absolute risk difference 23%; 95% confidence interval 11, 35%; p = .02). Cardiac arrests were more common before (9/96, 9%) versus after HEART arrival (3/96, 3%). Multiple (≥3) intubation attempts were more frequent before (14/42, 33%) versus after HEART arrival (9/46, 20%; absolute risk difference -14%; 95% confidence interval -32, 5%; p = .15). CONCLUSIONS: A multidisciplinary emergency airway response team plays an important role in pediatric airway management outside of the operating room. Adverse airway outcomes were more frequent before compared to after HEART arrival.

Atrioventricular block after congenital heart surgery: Analysis from the Pediatric Cardiac Critical Care Consortium.

OBJECTIVES: Our primary aims were to describe the contemporary epidemiology of postoperative high-grade atrioventricular block (AVB), the timing of recovery and permanent pacemaker (PPM) placement, and to determine predictors for development of and recovery from AVB. METHODS: Patients who underwent congenital heart surgery from August 2014 to June 2017 were analyzed for AVB using the Pediatric Cardiac Critical Care Consortium registry. Predictors of AVB with or without PPM were identified using multinomial logistic regression. We used these predictors to model the probability of PPM for the subgroup of patients with intraoperative complete AVB. RESULTS: We analyzed 15,901 surgical hospitalizations; 422 (2.7%) were complicated by AVB and 162 (1.0%) patients underwent PPM placement. In patients with transient AVB, 50% resolved by 2 days, and 94% resolved by 10 days. In patients who received a PPM, 50% were placed by 8 days and 62% were placed by 10 days. Independent risk factors associated with PPM compared with resolution of AVB were longer duration of cardiopulmonary bypass (relative risk ratio, 1.04; P = .023) and a high-risk operation (relative risk ratio, 2.59; P < .001). Among patients with complete AVB originating in the operating room, those with the highest predicted probability of PPM had a PPM placed only 77% of the time. CONCLUSIONS: In this cohort, postoperative AVB complicated almost 3% of congenital heart surgery cases and 1% of patients underwent PPM placement. Because almost all patients (94%) with transient AVB had resolution by 10 days, our results suggest there is limited benefit to delaying PPM placement beyond that time frame.

Initial presentation and management of pediatric heart failure.

PURPOSE OF REVIEW: Heart failure is a rare but morbid diagnosis in the pediatric patient presenting to the emergency department (ED). Familiarity of the ED physician with the presentation, work-up, and management of pediatric heart failure is essential as accurate diagnosis is reliant on a high degree of suspicion. RECENT FINDINGS: Studies evaluating pediatric heart failure are limited by its rarity and the heterogeneity of underlying conditions. However, recent reports have provided new data on the epidemiology, presentation, and outcomes of children with heart failure. SUMMARY: The recent studies reviewed here highlight the significant diagnostic and management challenges that pediatric heart failure presents given the variety and lack of specificity of its presenting signs, symptoms, and diagnostic work-up. This review provides the ED physician with a framework for understanding of pediatric heart failure to allow for efficient diagnosis and management of these patients. The primary focus of this review is heart failure in structurally normal hearts.

Depot medroxyprogesterone acetate use is not associated with risk of incident sexually transmitted infections among adolescent women.

PURPOSE: To determine whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of acquisition of sexually transmitted infections (STIs) in a cohort of healthy adolescents, for whom prospective evidence is sparse. METHODS: Adolescent women aged 14-17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing. During alternating 3-month periods, participants also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs. Data collected through 2009 (median follow-up length = 42.2 months) were analyzed. Univariable and multivariable tests of association between STI acquisition during the 3-month diary period and covariates were calculated, using nonlinear mixed-effect logistic regression models to control for repeated measurements. RESULTS: In multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The number of total or unprotected sexual events during the diary period was not associated with the risk of STI. Older age was a protective factor for the development of Chlamydia trachomatis (odds ratio = .85; 95% confidence interval = .76-.96). The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period (odds ratio, range = 1.91-2.62). CONCLUSIONS: In this U.S.-based cohort of adolescent women, we found no evidence that DMPA use was associated with increased STI risk. Efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.

Building trust through communication in the intensive care unit: HICCC.

OBJECTIVE: The goal of this study was to explore the role of communication in building trust between intensivists and parents in the pediatric intensive care unit. METHODS: Semistructured qualitative interviews were administered to English-speaking parents of children who were admitted to the pediatric intensive care unit for at least 48 hrs. Parents were asked about the factors impacting trust and communication in the pediatric intensive care unit. Qualitative data were managed with NVIVO software (QSR International, Southport, UK) and analyzed for themes. RESULTS: Participants were 122 parents (41% black, 40% white). Most parents articulated that communication is integral to building trust. Specifically, parents described that they wanted healthcare workers to communicate in ways that were Honest, Inclusive, Compassionate, Clear and Comprehensive, and Coordinated, which can be summarized using the acronym, HICCC. In addition, nonwhite parents were more likely than white parents to report instances when they felt doctors did not listen to them (p = 0.0083). Parents from minority groups reported instances of self-experienced or observed discrimination in healthcare with greater frequency than white parents. When asked to identify their pediatric intensive care unit doctor, 46% of parents were either unable to do so or named doctors from other hospital departments. CONCLUSIONS: Communication is vital to building trust in the pediatric intensive care unit. Developed from parents' own observations and perspectives, HICCC is an accessible framework that can help doctors to remember what parents value in communication in the acute care setting. In addition, pediatric intensivists would benefit from targeted cultural competency training to reduce physician bias.