Breaking barriers in establishing simulation in India-A collaborative approach by pediatric simulation training and research society (PediSTARS).

Simulation based training (SBT) plays a pivotal role in quality improvement and patient safety. Simulation is not only for training health care professionals but also an excellent tool for systems and facility changes which will potentially improve patient safety and ultimately outcomes. SBT is already established both as a training modality, and as a quality improvement tool in high income countries. It's use in low and middle-income countries (LMIC), including India, however, is sporadic and variable because of multiple barriers. The barriers for establishment of simulation are lack of knowledge about benefits of simulation, psychological resistance, cost, and lack of trained faculty. PediSTARS (Pediatric Simulation Training and Research Society), a simulation society was founded in August 2013 to spread the simulation across India and thus improve the quality and safety of health care using SBT. In this article we discuss various barriers for healthcare simulation in India and also our attempts to overcome some of these barriers by collaborative practice.

What you see may not be what you get! Simulate towards effective planning of pediatric intensive care unit.

Aims and objectives: This study aimed to describe the application of low-cost inter-professional simulation over 4 phases in identifying structural and design issues, latent safety threats as well as test systems, processes, including facilitated team training during the design of a new pediatric intensive care unit (PICU). Materials and methods: The four-phase inter-professional simulation sessions involving clinical and non-clinical teams were conducted over a 3-month period in a corporate hospital during the designing of a new PICU. Low-cost resources, such as floor tapes, low-tech manikins, reused sterilized consumables, and actual patient beds and equipment, were used for the in situ simulation sessions. A plus-delta method of debriefing was done, and changes agreed on consensus were implemented after each simulated session. Results: There were 10 simulation sessions conducted over 4 phases during the 3-month period of designing the PICU. The participants included 10 doctors from PICU and adult critical care, 25 critical care nurses, 12 members from the project team, and 2 hospital administrators in various combinations. The first phase led to the re-design of workspace and clinical areas for better space utilization. The second phase required further revision to facilitate better mobility and facilities. In the third phase, the number of beds was reduced to 6 beds following the simulated drills involving the actual placement of patient cots and equipment. The fourth phase had thematic 5 simulated exercises involving the newly recruited clinical teams that enabled the identification of systems and process issues. Cognitive aids and video orientation of the setup, team training, and human factors training were addressed, and the unit was open for patient care in a week. Conclusion: A phased inter-professional simulation exercise with low-cost resources can enable the identification of structural challenges, design issues, latent safety threats, test systems, processes, patient flow, and facilitated team training during the design of a new PICU. Further studies are needed to understand the generalization of the study findings into designing PICU.

Simulathon 2020: Integrating Simulation Period Prevalence Methodology Into the COVID-19 Disaster Management Cycle in India.

SUMMARY STATEMENT: The disaster management cycle is an accepted model that encompasses preparation for and recovery from large-scale disasters. Over the past decade, India's Pediatric Simulation Training and Research Society has developed a national-scale simulation delivery platform, termed the Simulathon , with a period prevalence methodology that integrates with core aspects of this model. As an exemplar of the effectiveness of this approach, we describe the development, implementation, and outcomes of the 2020 Simulathon, conducted from April 20 to May 20 in response to the nascent COVID-19 pandemic disaster. We conclude by discussing how aspects of the COVID-19 Simulathon enabled us to address key aspects of the disaster management cycle, as well as challenges that we encountered. We present a roadmap by which other simulation programs in low- and middle-income countries could enact a similar process.

Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events.

OBJECTIVES: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. DESIGN: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. SETTING: Forty international PICUs participating in the National Emergency Airway Registry for Children. PATIENTS: Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. CONCLUSIONS: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.

Tracheal Intubation Practice and Safety Across International PICUs: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: It is unknown if variation in tracheal intubation practice and outcomes exist across PICUs in different geographical regions. We hypothesized there would be differences in the process of care and adverse outcomes for tracheal intubation across PICUs in six different geographical regions (New Zealand, Japan, Singapore, Germany, India, and North America). DESIGN: Prospective multicenter pediatric tracheal intubation database (National Emergency Airway Registry for Children) SETTING:: Six non-North American (International) and 36 North American PICUs. EVENTS: All PICU tracheal intubation encounters from July 2014 to June 2017 MEASUREMENTS AND MAIN RESULTS:: Adverse tracheal intubation-associated events and desaturation occurrence (oxygen saturation < 80%) were evaluated. A total of 1,134 and 9,376 TIs from International and North American PICUs were reported, respectively: primary tracheal intubation 9,060, endotracheal tube change 1,450. The proportion of tracheal intubations for endotracheal tube change was greater in International PICUs (37% vs 11%; p < 0.001). Median age for International tracheal intubations was younger compared with North America (0 yr [interquartile range, 0-2 yr] vs 1 yr (0-7 yr); p < 0.001). Among primary tracheal intubations, the most common indication was respiratory (International 67%, North American 63%; p = 0.049). Direct laryngoscopy was the most common device in both International (86%) and North American (74%) tracheal intubations. Occurrence of any adverse tracheal intubation-associated event was New Zealand 8%, Japan 17%, Singapore 9%, Germany 17%, and India 6%; International 11% versus North American 14%; p value equals to 0.003. Desaturation was reported less commonly in International PICUs: 13% versus North American 17%; p equals to 0.001. International PICUs used cuffed endotracheal tube less often (52% vs 95%; p < 0.001). Proportion of cuffed endotracheal tube use per PICU was inversely correlated with the rate of tube change (r = -0.67; p < 0.001). CONCLUSIONS: There were both similarities and differences in tracheal intubation practice and outcomes across international PICUs. Fewer adverse tracheal intubation-associated events were reported from International versus North American PICUs. International PICUs used cuffed endotracheal tube less often and had higher proportion of endotracheal tube change.

Simulation in pediatrics: Is it about time?

Pediatrics is a challenging field where "Time is Essence" and the interplay of time-bound dynamics has a huge influence on the outcomes, particularly in an acutely ill child. In this context, simulation based training appears to play a major role in training young Paediatricians to develop critical decision making skills and learning in a risk-free environment. In present times and in future, it is expected that simulation is used by practically every healthcare provider at some or multiple points in the training and certification process.

Highly non-planar dendritic porphyrin for pH sensing: observation of porphyrin monocation.

Metal-free porphyrin-dendrimers provide a convenient platform for the construction of membrane-impermeable ratiometric probes for pH measurements in compartmentalized biological systems. In all previously reported molecules, electrostatic stabilization (shielding) of the core porphyrin by peripheral negative charges (carboxylates) was required to shift the intrinsically low porphyrin protonation pK(a)'s into the physiological pH range (pH 6-8). However, binding of metal cations (e.g., K(+), Na(+), Ca(2+), Mg(2+)) by the carboxylate groups on the dendrimer could affect the protonation behavior of such probes in biological environments. Here we present a dendritic pH nanoprobe based on a highly non-planar tetraaryltetracyclohexenoporphyrin (Ar(4)TCHP), whose intrinsic protonation pK(a)'s are significantly higher than those of regular tetraarylporphyrins, thereby eliminating the need for electrostatic core shielding. The porphyrin was modified with eight Newkome-type dendrons and PEGylated at the periphery, rendering a neutral water-soluble probe (TCHpH), suitable for measurements in the physiological pH range. The protonation of TCHpH could be followed by absorption (e.g., ε(Soret)(dication)∼270,000 M(-1) cm(-1)) or by fluorescence. Unlike most tetraarylporphyrins, TCHpH is protonated in two distinct steps (pK(a)'s 7.8 and 6.0). In the region between the pK(a)'s, an intermediate species with a well-defined spectroscopic signature, presumably a TCHpH monocation, could be observed in the mixture. The performance of TCHpH was evaluated by pH gradient measurements in large unilamellar vesicles. The probe was retained inside the vesicles and did not pass through and/or interact with vesicle membranes, proving useful for quantification of proton transport across phospholipid bilayers. To interpret the protonation behavior of TCHpH we developed a model relating structural changes on the porphyrin macrocycle upon protonation to its basicity. The model was validated by density functional theory (DFT) calculations performed on a planar and non-planar porphyrin, making it possible to rationalize higher protonation pK(a)'s of non-planar porphyrins as well as the easier observation of their monocations.

Efficient preparation of photoswitchable dithienylethene-linker-conjugates by palladium-catalyzed coupling reactions of terminal alkynes with thienyl chlorides and other aryl halides.

Three photochromic dithienylethene-linker-conjugates with an adamantane core containing different spacer lengths and footprint areas with carboxylic anchoring groups are synthesized. The synthetic routes start either from the ethynylene-linker 5 or the iodo-substituted linker 8. Reaction conditions for the final Sonogashira coupling step between ethynylene-linker 5 with the chloro-substituted dithienylethene 4 in the presence of [PdCl(2)(CH(3)CN)(2)]/X-Phos and Cs(2)CO(3) or K(3)PO(4) are optimized using 2-chloro-5-methylthiophene (9) and triethylsilylacetylene or triisopropylsilylacetylene (10a,b) as model compounds. Experimental conditions are found to suppress the activation of the C(sp)-Si bond in TIPS-acetylene 10b, a reaction leading to a subsequent cross-coupling reaction to form by-product 12. Furthermore, activation of the C(sp)-Si bond in the presence of the fluorinated backbone of the chloro-substituted dithienylethene 4 can also be prevented. The photochromic properties of the conjugate 3 and its precursor dithienylethene 7b are also investigated.

Large footprint pyrene chromophores anchored to planar and colloidal metal oxide thin films.

Sensitization and binding of a large footprint pyrene chromophore to planar (sapphire) and colloidal metal oxide films (TiO2 and ZrO2) is investigated. The model compound combines a 1-pyrenyl-ethynylenephenylene unit with a new adamantane-tripodal linker that binds to the surface. The linker design, combining a large footprint (approximately 2 nm2) of the tripodal linker with the meta position of the COOH anchoring groups, was suggested from atomistic models, and it aims to provide improved spacing control. The pyrene chromophore unit provides a probe of sensitizer-sensitizer interactions through its propensity to form excimers, unless neighboring pyrene units are sufficiently spaced (>or=3.5 A). Absorption and fluorescence studies, and a comparison with a pyrene-rigid rod model compound, suggest that the new tripodal anchor group allows spacing control on planar surfaces. On colloidal films, the linker provides spacing control at low surface coverage but sensitizer-sensitizer interactions are still observed on colloidal films at high surface coverage. Implications for the functionalization of metal oxide films in hybrid molecule-metal oxide semiconductor material systems are discussed.