An international effort and use of social media to save a young girl.

BACKGROUND AND OBJECTIVES: A 2-year-old female with neuroblastoma needed In(b-), E- red blood cells (RBCs). No units were available at the blood centre (BC) nor in the rare donor programme member's inventories. BC's Immunohematology Reference Laboratory (IRL) and its marketing department concentrated on recruiting and testing those donors more likely to be antigen negative based on ethnicity. MATERIALS AND METHODS: The BC's communication plan utilized social and traditional media to assist in the search for In(b-) blood. Media strategies directed donors in the United States (US) and Canada to go to their nearest BC for collection, tagging and testing of units. Two segments from each donation were shipped overnight to the BC's IRL (associated with the patient) for testing. Diluted anti-Inb sera was tested by microtechniques to conserve resources. Additionally, the American Rare Donor Program (ARDP) facilitated the international searches and acted as a liaison to the Food and Drug Administration (FDA). RESULTS: More than 25 000 people responded to the appeal. Seventy-seven BCs submitted segments from 4197 units. Two donors were In(b-) but E+ and thus not compatible with the patient but were submitted to ARDP for future needs. The prevalence of In(b-) units identified in the search was 0·048%. In total, five known In(b-) donors, two from the US and three from international sources, provided units for this patient. CONCLUSION: Social media sparked a viral response to the rare blood need. While a match was not found among the units tested, domestic and international searches were able to meet the patient's blood needs.

Reducing Albuterol Use in Children With Bronchiolitis.

OBJECTIVES: In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting. METHODS: A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention. RESULTS: The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged. CONCLUSIONS: Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children's hospital without impacting other outcome measures.

High-Flow Nasal Cannula in Pediatric Patients: A Survey of Clinical Practice.

BACKGROUND: High-flow nasal cannula (HFNC) use has greatly increased in recent years. In non-neonatal pediatric patients, there are limited data available to guide HFNC use, and clinical practice may vary significantly. The goal of this study was to evaluate current HFNC practice by surveying practicing pediatric respiratory therapists. METHODS: A survey instrument was posted on the American Association for Respiratory Care's AARConnect online social media platform in March 2017. Paper versions of the survey were also distributed at the annual Children Hospitals Association meeting. RESULTS: There were 63 responses, of which 98% used HFNC. HFNC was defined as any heated gas delivered by nasal cannula by 49% of respondents, whereas 21% defined HFNC as heated gas delivered via nasal cannula at flow greater than or equal to the patient's inspiratory demand, and 16% defined HFNC as any gas delivered via nasal cannula above predefined thresholds. Initial flow was set per provider orders by 34% of respondents, per respiratory therapist-driven protocol by 28%, per patient weight by 15%, per patient age by 15%; 5% of respondents used other methods. Noninvasive ventilation or CPAP was used by 88% of respondents as the next step for patients who failed HFNC, with 7% opting for intubation and 5% using other interventions. Aerosol therapy was delivered by 75% of respondents during HFNC, with 77% of these respondents delivering aerosol via vibrating mesh nebulizer. During aerosol therapy, 13% of respondents decreased HFNC flow, while 23% removed patients from HFNC. CONCLUSION: There was no consensus on the definition of HFNC, how to set initial flow, or how to make adjustments. Aerosols were delivered by 75% of respondents, predominantly via a vibrating mesh nebulizer placed on the dry side of the humidifier. The definition of HFNC, how to set flow, and aerosolized medication delivery are areas in which more research is needed.

Transfusion of blood and blood products: indications and complications.

Red blood cell transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues. Transfusion of red blood cells should be based on the patient's clinical condition. Indications for transfusion include symptomatic anemia (causing shortness of breath, dizziness, congestive heart failure, and decreased exercise tolerance), acute sickle cell crisis, and acute blood loss of more than 30 percent of blood volume. Fresh frozen plasma infusion can be used for reversal of anticoagulant effects. Platelet transfusion is indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects. Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy. Transfusion-related infections are less common than noninfectious complications. All noninfectious complications of transfusion are classified as noninfectious serious hazards of transfusion. Acute complications occur within minutes to 24 hours of the transfusion, whereas delayed complications may develop days, months, or even years later.

Does change in thoracic impedance measured via defibrillator electrode pads accurately detect ventilation breaths in children?

INTRODUCTION: Resuscitation guidelines recommend rescue ventilations consist of tidal volumes 7-10 ml/kg. Changes in thoracic impedance (ΔTI) measured using defibrillator electrode pads to detect and guide rescue ventilations have not been studied in children. AIM: We hypothesized that ΔTI measured via standard anterior-apical (AA) position can accurately detect ventilations with volume > 7 ml/kg in children. We also compared standard AA position with alternative anterior-posterior (AP) position. METHODS: IRB-approved, prospective, observational study of sedated, subjects (6 months to 17 years) on conventional mechanical ventilation. Thoracic impedance (TI) was obtained via Philips MRx defibrillator with standard electrode pads for 5 min each in AA and AP positions. Ventilations were simultaneously measured by pneumotachometer (Novametrix CO(2)SMO Plus). RESULTS: Twenty-eight subjects (median 4 years, IQR 1.7-9 years; median 16.3 kg, IQR 10.5-39 kg) were enrolled. Data were available for 21 episodes in AA position and 22 episodes in AP position, with paired AA and AP data available for 18. For ventilations with volume < 7 ml/kg, the defibrillator algorithm detected 80.0% for both AA and AP (p=0.99). For ventilations ≥ 7 ml/kg, detection was 95.1% for AA and 95.7% for AP (p=0.38). CONCLUSIONS: Changes in thoracic impedance obtained via defibrillator pads can accurately detect ventilations above 7 ml/kg in stable, mechanically ventilated children, corresponding to rescue ventilations recommended during CPR. Both AA and AP pad positions were less sensitive to detect smaller volumes (< 7 ml/kg) than higher volumes (≥ 7 ml/kg), suggesting that shallow ventilations during CPR might be missed. There were no differences in impedance measurements between standard AA pad position and commonly used alternative AP pad position.

High-dose continuous nebulized levalbuterol for pediatric status asthmaticus: a randomized trial.

OBJECTIVE: To assess the use of high-dose continuous levalbuterol (LEV), the single active (R)-enantiomer of racemic albuterol (RAC), in the treatment of status asthmaticus. STUDY DESIGN: Children age 6 to 18 years with severe asthma exacerbation were enrolled in this randomized, double-blind trial if they failed initial emergency department (ED) therapy with RAC and systemic steroids. Subjects received equipotent doses of RAC (20 mg/hour) or LEV (10 mg/hour) within a standardized inpatient protocol. Blood samples for measurements of albuterol enantiomer, potassium, and glucose levels were obtained from the first 40 subjects. The median time until discontinuation of continuous therapy was compared using the rank-sum test, and other outcomes were compared using general linear mixed models. RESULTS: A total of 81 subjects (40 in the RAC group and 41 in the LEV group) were enrolled; the 2 groups were similar at baseline. Both groups tolerated continuous therapy with similar changes in heart rate and serum potassium and glucose levels but higher serum (S)-albuterol concentrations in the subjects treated with RAC. The median time for continuous therapy was similar in the RAC and LEV groups (18.3 hours vs 16.0 hours), as were the other clinical measures. CONCLUSIONS: Substituting high-dose continuous LEV for RAC did not reduce the time on continuous therapy and had similar adverse effects in children who had failed initial treatment with RAC.

Plasmapheresis and intravenous immune globulin for the treatment of D alloimmunization in pregnancy.

The alloimmunized pregnancy can result in fetal and newborn mortality due to fetal anemia. Control of fetal anemia has not been possible until recently, and management consists of following the degree of fetal anemia during gestation until intrauterine transfusion is feasible to support the fetus until delivery. Cordocentesis and intrauterine transfusion have potential complications that have been well documented. Control of fetal anemia via immune modulation utilizing plasmapheresis and intravenous immune globulin administration has been attempted alone and in combination with varying results. We present a case report of an Rh(D) alloimmunized pregnancy, in which successful management consisted of initial therapeutic plasmapheresis (TPE) followed by intravenous immunoglobulin (IVIG) administration until delivery at 37 weeks gestation without the need for intrauterine transfusion.

Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant simulation model.

OBJECTIVE: Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator. METHODS: A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded. RESULTS: Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001). CONCLUSIONS: In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.

Significance of margin and extent of dysplasia in loop electrosurgery excision procedure biopsies performed for high-grade squamous intraepithelial lesion in predicting persistent disease.

CONTEXT: High-grade squamous intraepithelial lesions (cervical intraepithelial neoplasia 2 and 3) are commonly treated with loop electrosurgery excision procedure (LEEP) biopsies. OBJECTIVE: To highlight the significance of positive margins and extent of positive margins of the cervical LEEP biopsies in predicting the persistence of high-grade squamous intraepithelial lesion and to provide suggestions for reporting margins in cervical LEEP biopsies. DESIGN: The pathology files at the University of Arkansas for Medical Sciences were searched for cervical intraepithelial neoplasia 2 and 3 treated by LEEP biopsy from 1990 to 2001. RESULTS: A total of 489 LEEP biopsy specimens were retrieved and reviewed; 270 patients had follow-up within 1 year. The biopsy specimens of 110 patients showed positive endocervical margins. One hundred sixty specimens had negative ectocervical-endocervical margins. Follow-up of 54% of the cases with initial positive margins showed residual high-grade squamous intraepithelial lesions. This association was even greater when multiple blocks showed positive endocervical margins and in cases with positive deep margins. On the other hand, a negative margin predicted ability to completely remove the lesion in 95% of patients. CONCLUSION: This study reiterates the significance of the evaluation of the margin, even in samples that were received as multiple fragments. Reporting of LEEP biopsy findings should include the extent of the dysplasia, the status of the ectocervical-endocervical margin, and the status of the deep margin.

Analysis of promoter hypermethylation of death-associated protein kinase and p16 tumor suppressor genes in actinic keratoses and squamous cell carcinomas of the skin.

Death-associated protein kinase is a serine/threonine protein kinase implicated in promoting apoptosis and tumor suppression, whereas p16 is a tumor suppressor gene that inhibits cyclin-dependent kinase 4 and 6 activity and arrests the cell cycle in the G1 phase. Hypermethylation of death-associated protein kinase or p16 gene with resultant gene inactivation has been described in a wide variety of human cancers. Promoter methylation of the death-associated protein kinase and p16 gene has been found in about 55% and 30% cases of head and neck squamous cell carcinoma respectively but has not yet been analyzed in cutaneous premalignant and malignant lesions. A total of 33 cases were examined for evidence of death-associated protein kinase and p16 hypermethylation and these consist of 9 cases of spongiotic dermatitis as nonneoplastic skin control, 9 cases of actinic keratosis, 8 cases of squamous cell carcinoma in situ, and 7 cases of invasive squamous cell carcinoma. Death-associated protein kinase promoter methylation was detected in 1 case of squamous cell carcinoma in situ and 1 case of nonneoplastic skin control but none of the cases of invasive squamous cell carcinoma or actinic keratosis. P16 promoter methylation was detected in 1 case of invasive squamous cell carcinoma and 1 case of nonneoplastic skin control but none of the cases of squamous cell carcinoma in situ or actinic keratosis. Promoter hypermethylation of the death-associated protein kinase and p16 genes does not appear to play an important role in the development of cutaneous squamous cell carcinoma. The data thus suggest that the mechanisms of ultraviolet-induced cutaneous carcinomas differ from those involved in the development of head and neck squamous cell carcinoma, a malignant disease induced by tobacco and alcohol exposure.