Diaphragmatic Thickening Fraction by Ultrasound in Mechanically Ventilated Pediatric Patients: Pilot Observations During Spontaneous Breathing Trials.

OBJECTIVES: In critically ill, mechanically ventilated adults, diaphragmatic atrophy and reduced diaphragmatic thickening fraction (DTF) has been associated with poor extubation outcomes. Diaphragmatic ultrasound assessment in critically ill pediatric patients shows similar results, though studies are on-going. We sought to explore the feasibility and utility of using DTF, obtained during a spontaneous breathing trial (SBT) in predicting weaning outcomes. METHODS: We conducted a prospective, observational study in a single-center tertiary noncardiac pediatric intensive care unit (PICU) in a children's hospital. Mechanically ventilated pediatric patients were included except for those with preexisting conditions of neuromuscular weakness, diaphragm paresis, or chronic respiratory failure requiring non-invasive or invasive mechanical ventilation at baseline. A convenience sample of 38 patients were included in the study. RESULTS: Weaning failure occurred in 10/38 (26%) instances with 9/38 (24%) occurring due to failed SBT and 1/38 (2%) due to failed extubation requiring reintubation. Median DTF was 24% (IQR: 12-33). DTF was significantly lower in instances of failed SBT, 12% compared to 27% (P < .01). The odds ratio (OR) of SBT failure utilizing: TF < 25% is 12 (CI: 1.33-108.0, Z-score: 2.22, P = .027), TV <5 mL/kg was 10.4 (CI: 1.76-61.67, Z-score: 2.58, P = .01), and combined TV <5 mL/kg and TF < 25% is 17.6 (CI: 1.19-259.61, Z-score: 2.09, P = .04). CONCLUSIONS: Our preliminary study suggests that ultrasound measurements of diaphragm thickening fraction during spontaneous breaths in mechanically ventilated pediatric patients may be a useful addition in predicting weaning readiness.

Implementation of a Pediatric Delirium Screening Program in a Pediatric Intensive Care Unit.

BACKGROUND: Knowledge of and screening for delirium are important to patient care. As bedside caregivers, nurses are in a strategic position to observe changes that may indicate delirium. OBJECTIVE: To institute a delirium screening protocol in a pediatric intensive care unit using the Cornell Assessment of Pediatric Delirium. METHODS: Implementation strategies included cycles of education and repeated, timed compliance and accuracy assessments. Surveys administered before and 6 months after implementation were used to identify nurses' perceptions of screening. Compliance with and accuracy of screening were measured over 3 years. During the second and third years, text messages to bedside nurses' telephones served as screening reminders. RESULTS: Responses on the nursing surveys before (n = 89) and after (n = 74) implementation were compared. After implementation, time to complete the assessment, medical providers, and procedures were less likely to be perceived as obstacles to screening. Nurses' confidence in delirium screening improved over time. Accuracy increased from 60% during the first year to 100% during the second and third years (P < .05). Unit-wide compliance with delirium screening was 68% in the first year, 51% in the second year, and 72% in the third year, a trend toward improvement that was statistically significant (P < .05). CONCLUSIONS: Although unit-wide compliance with the screening protocol decreased without regular monitoring, it subsequently improved after the institution of reminders and reeducation of nursing staff. Nursing perceptions evolved to view screening as an important component of patient care that did not disrupt daily workflow.

Point-of-Care Ultrasound Assessment of the Inferior Vena Cava in Mechanically Ventilated Critically Ill Children.

OBJECTIVES: The objective of this study was to compare the ultrasound-measured inferior vena cava distensibility index (IVCdi), inferior vena cava distensibility variability (IVCdv), and inferior vena cava-to-aorta ratio (IVC/Ao) to other common methods to assess fluid status in mechanically ventilated pediatric critically ill patients. These methods include central venous pressure (CVP), percent fluid overload by weight (%FOw), and percent fluid overload by volume (%FOv). METHODS: This was a prospective observational study of a convenience sample of 50 mechanically ventilated pediatric patients. Ultrasound measurements of the inferior vena cava and aorta were obtained, and the IVCdi, IVCdv, and IVC/Ao were calculated and compared to CVP, %FOw, and %FOv. RESULTS: The median %FOw was 5%, and the median %FOv was 10%. The mean CVP ± SD was 8.6 ± 4 mm Hg. The CVP had no significant correlation with %FOw or %FOv. There was no significant correlation of the IVCdi with CVP (r = -0.145; P = .325) or %FOv (r = 0.119; P = .420); however, the IVCdi had a significant correlation with %FOw (P = .012). There was also no significant relationship of the IVCdv with CVP (r = -0.135; P = .36) or %FOv (r = 0.128; P = .385); however, there was a significant correlation between the IVCdv and %FOw (P = .012). There was no relationship between the IVC/Ao and any other measures of fluid status. CONCLUSIONS: In this cohort of mechanically ventilated pediatric intensive care unit patients, many commonly used markers of fluid status showed weak correlations with each other. The IVCdi and IVCdv significantly correlated with %FOw and may have potential as markers for fluid overload in this patient population.

Medical missions for the provision of paediatric cardiac surgery in low- and middle-income countries.

This review will outline the role of visiting cardiac surgical teams in low- and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.