Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk.

This study aimed to create a pediatric sedation scoring system independent of the American Society of Anesthesiology Physical Status (ASA-PS) classification that is predictive of adverse events, facilitates objective stratification, and resource allocation. Multivariable regression and machine learning algorithm analysis of 134,973 sedation encounters logged in to the Pediatric Sedation Research Consortium (PSRC) database between July 2007 and June 2011. Patient and procedure variables were correlated with adverse events with resultant ß -regression coefficients used to assign point values to each variable. Point values were then summed to create a risk assessment score. Validation of the model was performed with the 2011 to 2013 PSRC database followed by calculation of ROC curves and positive predictive values. Factors identified and resultant point values are as follows: 1 point: age ≤ 6 months, cardiac diagnosis, asthma, weight less than 5th percentile or greater than 95 th , and computed tomography (CT) scan; 2 points: magnetic resonance cholangiopancreatography (MRCP) and weight greater than 99th percentile; 4 points: magnetic resonance imaging (MRI); 5 points: trisomy 21 and esophagogastroduodenoscopy (EGD); 7 points: cough at the time of examination; and 18 points: bronchoscopy. Sum of patient and procedural values produced total risk assessment scores. Total risk assessment score of 5 had a sensitivity of 82.69% and a specificity of 26.22%, while risk assessment score of 11 had a sensitivity of 12.70% but a specificity of 95.29%. Inclusion of ASA-PS value did not improve model sensitivity or specificity and was thus excluded. Higher risk assessment scores predicted increased likelihood of adverse events during sedation. The score can be used to triage patients independent of ASA-PS with site-specific cut-off values used to determine appropriate sedation resource allocation.

Barriers to Communication in a PICU: A Qualitative Investigation of Family and Provider Perceptions.

OBJECTIVES: Family and medical provider perceptions of communication barriers within the PICU are poorly understood. We designed a qualitative study to characterize the perspective of families and medical providers of critically ill children regarding communication barriers. The identified barriers may be used to direct efforts to improve communication. DESIGN: Semi-structured interviews were conducted from August 2017 to January 2018. Interviews were audio recorded and professionally transcribed verbatim. SETTING: A PICU at a tertiary care academic center. PATIENTS: Forty-two families whose children were admitted to the PICU (excluding patients receiving end-of-life care or with protective services involvement) and 12 PICU staff members, including nurses, residents, fellows, and attending's. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: An interprofessional team of a physician, nurse manager, and medical student coded the transcripts. Interviewing continued until thematic saturation was reached. Codes were organized into common themes using a modified constant comparative method. The families interviewed represented 16 previously healthy children, and 26 children with a chronic health condition. Staff interviewed included three residents, three fellows, three attending intensivists, and three nurses. Participants' perceptions and experiences of barriers to communication included the following: 1) Communication breakdowns related to coordination of care among several services, 2) Family-centered rounds are insufficient for effective communication, 3) Undervaluing the knowledge of families of children with chronic health conditions or special needs, and 4) Communication breakdowns occur across provider hand-offs. Theme 3 was identified by families, but not by providers. CONCLUSIONS: Families and medical providers both identified several barriers to communication. However, only families identified the barrier "Undervaluing the knowledge of families with chronically ill children." Future work should explore these barriers and the discrepancy in perception between providers and families to determine if there are interventions that improve both family satisfaction and patient care.

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.

Use of Simulation to Improve Cardiopulmonary Resuscitation Performance and Code Team Communication for Pediatric Residents.

INTRODUCTION: Cardiorespiratory events are infrequent in pediatric teaching hospitals but can lead to significant morbidity and mortality. Clear communication within the response team prevents delays in action and allows all team members to contribute to providing optimum management. This resource was developed to simulate high-acuity and low-frequency events for pediatric residents. The scenario options are recurrent supraventricular tachycardia, prolonged QT syndrome, myocarditis, and respiratory syncytial virus bronchiolitis. METHODS: The simulation is best performed in a simulation center with audio- and video-recording capabilities but could also be performed in situ in the pediatric intensive care unit or emergency room. Necessary personnel include a simulation technician and two instructors. A code cart, mock medications, and defibrillator with hands-free pads appropriate for the mannequin are necessary supplies. Critical actions include initial survey and intervention, rhythm recognition, cardiopulmonary resuscitation (CPR), use of defibrillator, and administration of anti-arrhythmic medications when needed. At the conclusion of the scenario, a formal debriefing with learners using structured feedback is performed. RESULTS: These cases have been used with groups of pediatric or emergency medicine residents approximately 16 times over the past 3 years. Learners have reported that participation increased their confidence and comfort with management of cardiorespiratory events and that communication technique practice improved their teamwork and sign-out skills. Rhythm recognition and CPR performance scores during the simulation scenarios improved, with subjective improvement during actual cardiorespiratory events. DISCUSSION: This resource advances learner knowledge of Pediatric Advanced Life Support algorithms and teamwork communication and identifies learner knowledge and management deficits.

Relationship between Interdialytic Weight Gain and Blood Pressure in Pediatric Patients on Chronic Hemodialysis.

Overhydration is reported to be the main cause of hypertension (HTN) as well as to have no association with HTN in hemodialysis (HD) population. This is the first report of the relationship between interdialytic weight gain (IDWG) and pre-HD blood pressure (BP) in pediatric patients in relation to residual urine output (RUO). We studied 170 HD sessions and interdialytic periods performed during a 12-week period in 5 patients [age 4-17 years, weight 20.8-66 kg, 3 anuric (102 HD sessions), and 2 nonanuric (68 HD sessions)]. BP is presented as systolic BP index (SBPI) and diastolic BP index (DBPI), calculated as systolic or diastolic BP/95th percentile for age, height, and gender. IDWG did not differ (P > 0.05) between anuric and nonanuric pts. There was a positive but not significant correlation between IDWG and both pre-HD SBPI (r = 0.833, P = 0.080) and pre-HD DBPI (r = 0.841, P = 0.074). Pre-HD SBPI (1.01 ± 0.12 versus 1.13 ± 0.18) and DBPI (0.92 ± 0.16 versus 1.01 ± 0.24) were higher in nonanuric patents (P < 0.001 and P < 0.01, resp.). Pre-HD HTN may not be solely related to IDWG and therapies beyond fluid removal may be needed. Individualized approach to HTN management is necessary in pediatric dialysis population.

Discontinuation of Antimicrobial Prophylaxis (AP) in Children With Spina Bifida: A Case Series Analysis.

BACKGROUND: Spina bifida increases the risk for urinary tract infections (UTI). Antimicrobial prophylaxis (AP) reduces symptomatic UTI's but selects resistant organisms. Measures to ensure regular and complete emptying of the bladder combined with treatment of constipation reduce the risk for UTI. OBJECTIVES: Demonstrate that close adherence to a catheterization regimen in children with spina bifida (Selective Treatment - ST) reduces the need for antimicrobial prophylaxis. METHODS: Case series analysis of pediatric spina bifida clinic patients where routine antimicrobial prophylaxis was replaced by clean-catch catheterization and daily bowel regimen (ST). Retrospective chart review of 67 children (mean entry age: 24 months, median age: 4 months; 32 Males, 35 Females) enrolled between 1986 - 2004. Mean follow-up was 128.6 months (range 3 - 257 months). Asymptomatic and symptomatic UTI incidences were noted on AP and ST protocols. Creatinine clearance at study entry and follow-up was calculated by the age appropriate method. A multivariable regression model with delta Glomerular Filtration Rate (GFR) as the dependent variable, independent sample t-test and Wilcoxon rank sum were performed with SAS v. 9.2. RESULTS: The mean number of infections while on AP was 8.7 (95% CI 5.72, 11.68) and was 1.0 on ST (95% CI 0.48, 1.43). 5 infections on the AP protocol required intravenous (IV) antibiotics due to resistance to oral therapy, but none on ST. Comparing change in GFR between both protocols (AP vs. ST) found a significant difference in the change of GFR by treatment protocol. CONCLUSIONS: AP did not prevent UTIs and resulted in more resistant organisms requiring IV antibiotics. Discontinuing AP allowed the return of susceptibility to oral antimicrobials and significantly improved GFR in those children who had previously been on AP. Adherence to a catheterization regimen with prompt treatment of symptomatic UTI conserved renal function and prevented selection of resistant organisms.

Effect of the decrease in dialysate sodium in pediatric patients on chronic hemodialysis.

Optimal dialysate sodium (dNa) is unknown, with both higher and lower values suggested in adult studies to improve outcomes. Similar studies in pediatric hemodialysis (HD) population are missing. This is the first report of the effect of two constant dNa concentrations in pediatric patients on chronic HD. 480 standard HD sessions and interdialytic periods were studied in 5 patients (age 4-17 years, weight 20.8-66 kg) during a period of 6-11 months per patient. dNa was 140 mEq/L during the first half, and 138 mEq/L during the second half of the study period for each patient. Lowering dNa was associated with improved preHD hypertension, decreased interdialytic weight gain, decreased need for ultrafiltration, lower sodium gradient and was well tolerated despite lack of concordance with predialysis sNa, that was variable. Further studies are needed to verify our findings and to investigate if an even lower dNa may be more beneficial in the pediatric HD population.

Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia-Outside the Operating Room for Esophagogastroduodenoscopy and Colonoscopy in Children: Age Is an Independent Predictor of Outcomes.

OBJECTIVES: Procedural sedation/anesthesia outside the operating room for a variety of procedures is well described with an overall low adverse event rate in certain settings. Adverse event associated with procedural sedation/anesthesia outside the operating room for gastrointestinal procedures have been described, albeit in small, single-center studies with wide variance in outcomes. Predictors of such outcomes are unclear. We aimed to estimate the prevalence of adverse event in children undergoing procedural sedation/anesthesia outside the operating room for esophagogastroduodenoscopy, colonoscopy, or both to identify predictors of adverse event. DESIGN/SETTING/PATIENTS: Retrospective analysis of Pediatric Sedation Research Consortium database, a large data repository of pediatric patients aged 21 years old or younger undergoing procedural sedation/anesthesia outside the operating room during September 2007 to November 2011. Twenty-two of the 40 centers provided data pertaining to the procedure of interest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome variable is any adverse event. Independent variables include: age (five groups), sex, American Societyof Anaesthesiologists status, procedure (esophagogastroduodenoscopy, colonoscopy, or both), provider responsible, medication used, location, and presence of coexisting medical conditions. Descriptive statistics used to summarize the data. Using multivariablelogistic regression model, odds ratio, 95% CI) were computed. A total of 12,030 procedures were performed (esophagogastroduodenoscopy, 7,970; colonoscopy, 1,378; and both, 2,682). A total of 96.9% of patients received propofol. Eighty-three percent were performed in a sedation unit. Prevalence of adverse event was 4.8%. The most common adverse event were persistent desaturations (1.5%), airway obstruction (1%), cough (0.9%), and laryngospasm (0.6%). No deaths or CPR occurred. Infants and children aged 5 years old or younger had a higher adverse event rate than older children (15.8%, 7.8% vs 4%). Regression analysis revealed age 5 years old or younger, American Society of Anaesthesiologists greater than or equal to 2, esophagogastroduodenoscopy ± colonoscopy, and coexisting medical conditions of obesity and lower airway disease were independent predictors of higher adverse event. CONCLUSIONS: Overall prevalence of any adverse event was 4.8%. Independent predictors of adverse events in procedural sedation/anesthesia outside the operating room in pediatric esophagogastroduodenoscopy/colonoscopy onoscopy were identified. Recognition of such risk factors may enable optimization of procedural sedation.

Hyperkalemia and ventricular tachycardia after outpatient ureteral valve reimplantation: a case report.

OBJECTIVE: This study aimed to report on a toddler who presented with progressively worsening abdominal pain and obstructive uropathy 1 week after ureteral valve reimplantation. Acute renal failure resulted in critical hyperkalemia. METHODS: Chart review of presentation, physical examination, laboratory tests, and treatment. RESULTS: Initial potassium level was 10 mEq/L; ventricular tachycardia was observed and treated. CONCLUSIONS: More commonly, hyperkalemia results from overuse/overdose of supplementation or in patients with known renal failure. Although less common, obstructive uropathy should be considered in any patient with recent instrumentation of the urinary tract and coincident complications can be significant.

Analysis of procedural sedation provided by pediatricians.

BACKGROUND: Pediatric procedural sedation outside of the operating room is performed by a variety of pediatric specialists. Using the database from the Pediatric Sedation Research Consortium (PSRC), patient demographics, medications used, diagnoses, complications, and procedures involved when pediatricians provided sedation in this cohort, were described. 'Pediatrician' was defined as a general pediatrician, cardiologist, endocrinologist, gastroenterologist, hematologist/oncologist, neurologist, pulmonologist or hospitalist. METHODS: Data were collected by the PSRC, a group of 35 institutions dedicated to improving sedation care for children. Members prospectively enrolled consecutive patients who received sedation or anesthesia for diagnostic or therapeutic procedures. Data on demographics, primary diagnoses, procedures, medications, interventions, and complications were collected and stored on a Web-based data collection tool. RESULTS: A total of 12 113 sedations performed by pediatricians were submitted from 1 July 2004 to 31 December 2008, compared to 119 665 cases performed by non-pediatricians. Pediatrician patients were more frequently non-emergency American Society of Anesthesiologists (ASA) class I or II, aged 2-8 years old, with a neurologic primary diagnosis, being sedated for a radiologic procedure with a sedative. Distraction techniques were used more frequently in the pediatrician group (11.9% vs 3.1%). The most common complication encountered was inadequate sedation, which occurred 2.2% of the time. CONCLUSIONS: Pediatricians sedate for a variety of patients within the PSRC, but the patients tended to be younger, predominately ASA class I or II, non-emergency, and undergoing non-painful procedures when compared to non-pediatrician providers. The patient demographics, medications used, diagnoses, complications, and procedures involved varied between the groups significantly. Complication rates were similar between the groups.

Impact of provider specialty on pediatric procedural sedation complication rates.

OBJECTIVE: To determine if pediatric procedural sedation-provider medical specialty affects major complication rates when sedation-providers are part of an organized sedation service. METHODS: The 38 self-selected members of the Pediatric Sedation Research Consortium prospectively collected data under institutional review board approval. Demographic data, primary and coexisting illness, procedure, medications used, outcomes, airway interventions, provider specialty, and adverse events were reported on a self-audited, Web-based data collection tool. Major complications were defined as aspiration, death, cardiac arrest, unplanned hospital admission or level-of-care increase, or emergency anesthesia consultation. Event rates per 10 000 sedations, 95% confidence intervals, and odds ratios were calculated using anesthesiologists as the reference group and were then adjusted for age, emergency status, American Society of Anesthesiologists physical status > 2, nil per os for solids, propofol use, and clustering by site. RESULTS: Between July 1, 2004, and December 31, 2008, 131 751 pediatric procedural sedation cases were recorded; there were 122 major complications and no deaths. Major complication rates and 95% confidence intervals per 10 000 sedations were as follows: anesthesiologists, 7.6 (4.6-12.8); emergency medicine, 7.8 (5.5-11.2); intensivist, 9.6 (7.3-12.6); pediatrician, 12.4 (6.9-20.4); and other, 10.2 (5.1-18.3). There was no statistical difference (P > .05) among provider's complication rates before or after adjustment for potential confounding variables. CONCLUSIONS: In our sedation services consortium, pediatric procedural sedation performed outside the operating room is unlikely to yield serious adverse outcomes. Within this framework, no differences were evident in either the adjusted or unadjusted rates of major complications among different pediatric specialists.

Proteinuria in children with sickle cell disease.

BACKGROUND: Sickle cell nephropathy is characterized by proteinuria that starts in childhood and may lead to renal failure. Microalbuminuria is used as a marker of glomerular damage. There are no data on the extent and type of proteinuria other than microalbuminuria in children with sickle cell disease (SCD). Our goal was characterization of glomerular permselectivity and tubular proteinuria in children with SCD. The improved characterization will allow earlier recognition and prevention of renal damage. METHODS: Thirty-two stable patients with haemoglobin SS (HbSS) (15 boys and 17 girls, age 9.57 +/- 5.45 years, 8 months to 19 years) were investigated. All patients had normal renal function and tested negative for proteinuria with a dipstick method. Markers of glomerular permselectivity used were albumin (marker of charge selectivity and less severe pore-size selectivity) and immunoglobulin G (IgG, marker of more severe pore-size selectivity). The marker of tubular injury used was retinol-binding protein (RBP, marker of proximal tubular dysfunction). These proteins were measured in urine spot samples using nephelometry. We did not include a control group as values in healthy subjects were previously published. RESULTS: Total protein excretion was elevated in 41% (13/32) of all patients and, of these 13 patients, 38.5% (5/13) had increased microalbuminuria, 15% (2/13) had increased excretion of RBP and 23% (3/13) had increased excretion of IgG. Increased total proteinuria that was not detected by testing for microalbuminuria was found in 61.5% (8/13) of patients. The youngest patient was 3 years old. Increased microalbuminuria was present in 25% (8/32) of all patients and was detected as early as 4 years of age. Of these, 62% (5/8) also had increased total protein excretion and 62% (5/8) also had increased IgG excretion. A total of 62.5% were older than 10 years. RBP excretion was elevated in 16% (5/32) of patients, all of whom were 7-14 years old. None of these patients had increased microalbuminuria or increased excretion of IgG. IgG excretion was elevated in 16% (5/32) of patients and was accompanied by increased microalbuminuria. All patients with increased IgG excretion were > or = 13 years old. We found a weak positive correlation between microalbuminuria and age (0.323, P = 0.07). We did not find a significant correlation between any type of proteinuria and disease morbidity. Ten of the thirty-two patients received hydroxyurea treatment and 60% (6/10) had no proteinuria. Twelve of the thirty-two patients received chronic exchange transfusions and 42% (5/12) had no proteinuria. CONCLUSION: We found early glomerular selectivity damage in children with SCD, which is secondary to both size-selectivity and charge-selectivity impairment. Microalbuminuria alone does not adequately detect early renal damage in children with SCD. Proximal tubular dysfunction is seen in younger children and is independent of glomerular damage. We suggest that children with SCD be tested for both total protein and IgG excretion in the urine in addition to albumin. Knowing the extent and type of renal damage may allow earlier recognition of renal injury and prompt earlier initiation of preventive therapies.