Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future.

BACKGROUND: The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes. METHODS: The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership. RESULTS: Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges. CONCLUSIONS: Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.

Healthcare-associated infection in pediatric patients on extracorporeal life support: The role of multidisciplinary surveillance.

OBJECTIVE: To describe the use of a multidisciplinary approach to sepsis surveillance and evaluate impact on outcome. DESIGN: Prospective clinical study or clinical audit cycle. SETTING: Tertiary pediatric extracorporeal membrane oxygenation (ECMO) center. PATIENTS: Patients were 215 children supported with ECMO January 1999 to December 2004. INTERVENTIONS: A multidisciplinary team met monthly to evaluate cases of bloodstream infection and mediastinitis, review trends, and update unit policies. Changes in practice were made at the end of 2001 in order to address a perceived high rate of sepsis: a) reeducation; b) introduction of electively preprimed ECMO circuits; and c) preference for neck rather than chest cannulation in cardiac patients. Prophylactic antibiotics were used from preprocedure for 24 hrs only throughout the study. MEASUREMENTS AND MAIN RESULTS: Over the entire study period, 39 children had 47 septic episodes, with a rate of 24.9 per 1000 ECMO days. Multiple logistic regression analyses indicated that infection was associated with duration of ECMO support (odds ratio 1.24; 95% confidence interval 1.15, 1.35 per day) and case type: Closed vs. open chest was protective in cardiac patients (odds ratio 0.08; 95% confidence interval 0.01, 0.50). Infection increased the odds of death by 2.01 (95% confidence interval 1.00, 4.05), but this effect was less important than case type and ECMO days. After policy changes were implemented, there was a reduction in sepsis from 29.3 to 20.1 episodes per 1000 ECMO days. There was reduced sepsis in respiratory patients: neonates from 28.0 to 6.6 and pediatric patients from 42.4 to 16.9 episodes per 1000 ECMO days. Despite policy changes, sepsis remained a problem in cardiac patients with open sternum: 65.1 per 1000 ECMO days. CONCLUSIONS: ECMO support is a high-risk setup for nosocomial infection, in particular for cardiac patients with open sternum for whom antibiotic prophylaxis is justified. Multidisciplinary surveillance offers an excellent approach for quality improvement in this challenging field.

The role of imaging during extracorporeal membrane oxygenation in pediatric respiratory failure.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is increasingly widely used in pediatric respiratory failure. Despite playing a key part in patient management during ECMO, the role of radiology is not widely reported. We discuss the principles of ECMO support and the normal imaging appearances. Radiologic findings arising from the complications of ECMO are highlighted. CONCLUSION: Radiology has a central role in establishing well-designed imaging protocols and vigilant reporting of ECMO apparatus positions and complications.