Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS

OBJECTIVE

Describe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes.

DESIGN

Retrospective analysis of TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS).

SETTING

Thirteen academic NICUs.

PATIENTS

Infants undergoing TI between October 2014 and December 2017.

MAIN OUTCOME MEASURES

Association of family presence with TI processes and outcomes including first attempt success (primary outcome), success within two attempts, adverse TI-associated events (TIAEs) and severe oxygen desaturation ≥20% from baseline.

RESULTS

Of the 2570 TIs, 242 (9.4%) had family presence, which varied by site (median 3.6%, range 0%-33%; p<0.01). Family member was more often present for older infants and those with chronic respiratory failure. Fewer TIs were performed by residents when family was present (FP 10% vs no FP 18%, p=0.041). Among TIs with family presence versus without family presence, the first attempt success rate was 55% vs 49% (p=0.062), success within two attempts was 74% vs 66% (p=0.014), adverse TIAEs were 18% vs 20% (p=0.62) and severe oxygen desaturation was 49% vs 52%, (p=0.40). In multivariate analyses, there was no independent association between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

CONCLUSION

Family are present in less than 10% of TIs, with variation across NICUs. Even after controlling for important patient, provider and site factors, there were no significant associations between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

Impact of Physician Training Level on Neonatal Tracheal Intubation Success Rates and Adverse Events: A Report from National Emergency Airway Registry for Neonates (NEAR4NEOS)

INTRODUCTION

Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed.

METHODS

Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference).

RESULTS

Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11-0.30) for residents and 0.80 (95% CI: 0.51-1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation.

CONCLUSION

Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.

Left Ventricular Diastolic Dysfunction in Pediatric Sepsis: Outcomes in a Single-Center Retrospective Cohort Study

OBJECTIVES

Left ventricular diastolic dysfunction is associated with difficulty in ventilator weaning and increased mortality in septic adults. We evaluated the association of left ventricular diastolic dysfunction with outcomes in a cohort of children with severe sepsis and septic shock.

DESIGN

Retrospective cohort study.

SETTING

Single-center noncardiac PICU.

PATIENTS

Age greater than 1 month to less than 18 years old with severe sepsis or septic shock from January 2011 to June 2017 with echocardiogram within 48 hours of sepsis onset.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Echocardiograms were retrospectively assessed for mitral inflow E (early) and A (atrial) velocity and e' (early mitral annular motion) septal and lateral velocity. Left ventricular diastolic dysfunction was defined as E/e' greater than 10, E/A less than 0.8, or E/A greater than 1.5. Left ventricular diastolic dysfunction was present in 109 of 204 patients (53%). The data did not demonstrate an association between the presence of left ventricular diastolic dysfunction and the proportion of children requiring invasive mechanical ventilation at the time of echocardiogram (difference in proportion, +5% [72% vs 67%; 95% CI, -8% to 17%]; p = 0.52). The duration of mechanical ventilation was median 192.9 hours (interquartile range, 65.0-378.4 hr) in the left ventricular diastolic dysfunction group versus 151.0 hours (interquartile range, 45.7-244.3 hr) in the group without left ventricular diastolic dysfunction. The presence of left ventricular diastolic dysfunction was not significantly associated with ICU length of stay or mortality. Exploratory analyses revealed that an alternative definition of left ventricular diastolic dysfunction, solely defined by E/e' greater than 10, was found to have an association with mechanical ventilation requirement at the time of echocardiogram (difference in proportion, +15%; 95% CI, 3-28%; p = 0.02) and duration of mechanical ventilation (median, 207.3 vs 146.9 hr).

CONCLUSIONS

The data failed to show an association between the presence of left ventricular diastolic dysfunction defined by both E/e' and E/A and the primary and secondary outcomes. When an alternative definition of left ventricular diastolic dysfunction with E/e' alone was used, there was a significant association with respiratory outcomes.

Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators

OBJECTIVES

To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs.

DESIGN

Multicenter time-series study.

SETTING

PICUs in the United States.

PATIENTS

All patients received tracheal intubations in ICUs.

INTERVENTIONS

We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001).

CONCLUSIONS

Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

Associations of Stylet Use during Neonatal Intubation with Intubation Success, Adverse Events, and Severe Desaturation: A Report from NEAR4NEOS

INTRODUCTION

Intubations are frequently performed procedures in neonatal intensive care units (NICU) and delivery rooms (DR). Unsuccessful first attempts are common as are tracheal intubation-associated events (TIAEs) and severe desaturations. Stylets are often used during intubation, but their association with intubation outcomes is unclear.

OBJECTIVE

To compare intubation success, rate of relevant TIAEs, and severe desaturations in neonates intubated with and without stylets.

METHODS

Tracheal intubations of neonates in the NICU or DR from 16 centers between October 2014 and December 2018, performed by neonatology or pediatric providers, were collected from the NEAR4NEOs international registry. Primary oral intubations with a laryngoscope were included in the analysis. First-attempt success, the occurrence of relevant TIAEs, and severe oxygen desaturation (≥20% saturation drop from baseline) were compared between intubations performed with versus without a stylet. Logistic regression with generalized estimate equations was used to control for covariates and clustering by sites.

RESULTS

Out of 5,292 primary oral intubations, 3,877 (73%) utilized stylets. Stylet use varied considerably across the centers with a range between 0.5 and 100%. Stylet use was not associated with first-attempt intubation success, esophageal intubation, mainstem intubation, or severe desaturations after controlling for confounders. Patient size was associated with these outcomes and much more predictive of success.

CONCLUSIONS

Stylet use during neonatal intubation was not associated with higher first-attempt intubation success, fewer relevant TIAEs, or less severe desaturations. These data suggest that stylets can be used based on individual preference, but stylet use may not be associated with better intubation outcomes.

First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial

BACKGROUND

Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy.

METHODS

In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432.

FINDINGS

Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028).

INTERPRETATION

Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications.

FUNDING

Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

Objectives

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

Design

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

Methods

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, “in our practice” statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

Results

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, “in our practice” statements were provided. In addition, 52 research priorities were identified.

Conclusions

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Team Stress and Adverse Events during Neonatal Tracheal Intubations: A Report from NEAR4NEOS

OBJECTIVE

This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations.

STUDY DESIGN

TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated.

RESULT

In this study, 208 of 2,009 TIs (10%) had high stress levels (score < 4). Oxygenation failure, hemodynamic instability, and family presence were associated with high stress level. Video laryngoscopy and premedication were associated with lower stress levels. High stress level TIs were associated with adverse TI-associated event rates (31 vs. 16%, p < 0.001), which remained significant after adjusting for potential confounders including patient, provider, and practice factors associated with high stress (odds ratio: 1.90, 96% confidence interval: 1.36-2.67, p < 0.001).

CONCLUSION

High team stress levels during TI were more frequently reported among TIs with adverse events.

Supervised Machine Learning Applied to Automate Flash and Prolonged Capillary Refill Detection by Pulse Oximetry

Objective

Develop an automated approach to detect flash (<1.0 s) or prolonged (>2.0 s) capillary refill time (CRT) that correlates with clinician judgment by applying several supervised machine learning (ML) techniques to pulse oximeter plethysmography data.

Materials and Methods

Data was collected in the Pediatric Intensive Care Unit (ICU), Cardiac ICU, Progressive Care Unit, and Operating Suites in a large academic children’s hospital. Ninety-nine children and 30 adults were enrolled in testing and validation cohorts, respectively. Patients had 5 paired CRT measurements by a modified pulse oximeter device and a clinician, generating 485 waveform pairs for model training. Supervised ML models using gradient boosting (XGBoost), logistic regression (LR), and support vector machines (SVMs) were developed to detect flash (<1 s) or prolonged CRT (≥2 s) using clinician CRT assessment as the reference standard. Models were compared using Area Under the Receiver Operating Curve (AUC) and precision-recall curve (positive predictive value vs. sensitivity) analysis. The best performing model was externally validated with 90 measurement pairs from adult patients. Feature importance analysis was performed to identify key waveform characteristics.

Results

For flash CRT, XGBoost had a greater mean AUC (0.79, 95% CI 0.75–0.83) than logistic regression (0.77, 0.71–0.82) and SVM (0.72, 0.67–0.76) models. For prolonged CRT, XGBoost had a greater mean AUC (0.77, 0.72–0.82) than logistic regression (0.73, 0.68–0.78) and SVM (0.75, 0.70–0.79) models. Pairwise testing showed statistically significant improved performance comparing XGBoost and SVM; all other pairwise model comparisons did not reach statistical significance. XGBoost showed good external validation with AUC of 0.88. Feature importance analysis of XGBoost identified distinct key waveform characteristics for flash and prolonged CRT, respectively.

Conclusion

Novel application of supervised ML to pulse oximeter waveforms yielded multiple effective models to identify flash and prolonged CRT, using clinician judgment as the reference standard.

Tweet

Supervised machine learning applied to pulse oximeter waveform features predicts flash or prolonged capillary refill.

Exhaled nitric oxide measurement before pediatric adenotonsillectomy: A feasibility study

BACKGROUND

Exhaled nitric oxide (eNO) is a known biomarker for the diagnosis and monitoring of bronchial hyperreactivity in adults and children.

AIMS

To investigate the potential role of eNO measurement for predicting perioperative respiratory adverse events in children, we sought to determine its feasibility and acceptability before adenotonsillectomy.

METHODS

We attempted eNO testing in children, 4-12 years of age, immediately prior to admission for outpatient adenotonsillectomy. We used correlations between eNO levels and postoperative adverse respiratory events to make sample size predictions for future studies that address the predictability of the device.

RESULTS

One hundred and three (53%) of 192 children were able to provide an eNO sample. The success rate increased with age from 23% (9%-38%) at age 4 to over 85% (54%-98%) after age 9. Using the eNO normal value (<20 ppb) as a cutoff, an expected sample size to detect a significant difference between children with and without adverse events is 868, assuming that respiratory adverse events occur in 29% of children.

CONCLUSIONS

eNO testing on the day of surgery has limited feasibility in children younger than 7 years of age. The most common reason for failure was inadequate physical performance while interacting with the testing device. The role of this respiratory biomarker in the context of perioperative outcomes for pediatric adenotonsillectomy remains unknown and should be further studied with improved technologies.

Respiratory Therapist Intubation Practice in Pediatric ICUs: A Multicenter Registry Study

BACKGROUND

Tracheal intubation by respiratory therapists (RTs) is a well-established practice that has been described primarily in adult and neonatal patients. However, minimal data exist regarding RTs' intubation performance in pediatric ICUs. The purpose of this study was to describe the current landscape of intubations performed by RTs in pediatric ICUs.

METHODS

A multicenter quality improvement database, the National Emergency Airway Registry for Children (NEAR4KIDS) was queried from 2015 to 2018. We performed a retrospective analysis of prospectively collected data on subject demographics, indication for intubation, difficult airway history and feature presence, provider discipline, medications, and device. Intubation outcomes included first-attempt and overall success rates, adverse events, and oxygen desaturation (ie, [Formula: see text] < 80%). Overall intubation success was defined as intubation achieved in ≤ 2 attempts.

RESULTS

There were 12,056 initial intubation encounters from 46 ICUs, with 109 (0.9%) first attempts performed by RTs. Nine (20%) ICUs reported at least one intubation encounter by RTs. The number of intubations performed by RTs at individual centers ranged from 1 to 46 (RT participation rate: 0.3% to 19.6%). RTs utilized video laryngoscopy more often than other providers (53.2% for RTs vs 28.1% for others, P < .001). RTs' first attempt success (RT 60.6% vs other 69.2%, P = .051), overall success (RT 76.2 % vs other 82.4%, P = .09), and oxygen desaturation [Formula: see text] < 80% (RT 16.5% vs other 16.9%, P = .91) were similar to other providers. Adverse events were more commonly reported in intubations by RTs versus by other providers (22.9% vs 13.8%, P = .006).

CONCLUSIONS

RTs infrequently intubate in pediatric ICUs, with success rates similar to other providers but higher adverse event rates. RTs were more likely to use video laryngoscopy than other providers. RTs' intubation participation, success, and adverse event rates varied greatly across pediatric ICUs.

Normal and difficult airways in children: "What's New"-Current evidence

BACKGROUND

Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit.

METHODS

Expert review of the recent literature.

RESULTS

Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation-associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration.

CONCLUSION

Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Comparison of Neonatal Intubation Practice and Outcomes between the Neonatal Intensive Care Unit and Delivery Room

BACKGROUND

Characteristics of neonatal tracheal intubations (TI) may vary between the neonatal intensive care unit (NICU) and delivery room (DR). The impact of the setting on TI outcomes is not well characterized.

OBJECTIVE

The aim of this study was to define variation in neonatal TI practice between settings, and identify the association between setting and TI success and safety outcomes.

DESIGN

This was a retrospective cohort study of TIs in the National Emergency Airway Registry for Neonates from October 2014 to September 2017. The setting (NICU vs. DR) was the exposure of interest. The outcomes were first attempt success, course success, success within 4 attempts, adverse TI-associated events, severe desaturation, and bradycardia. We compared TI characteristics and outcomes between settings in univariable analysis. Factors significant in univariable analysis (p < 0.1) were included in a logistic regression model, with adjustment for clustering by center, to identify the independent impact of the setting on TI outcomes.

RESULTS

There were 3,145 TI encounters (2279 NICU, 866 DR) in 9 centers. Almost all baseline characteristics significantly varied between settings. First attempt success rates were 48% (NICU) and 46% (DR). In multivariable analysis, the setting was not associated with first attempt success. DR was associated with a higher adjusted OR (aOR) of success within 4 attempts (1.48, 95% CI 1.06-2.08) and a lower aOR for bradycardia (0.43, 95% CI 0.26-0.71).

CONCLUSION

Significant differences in patient, provider, and practice characteristics exist between NICU and DR TIs. There is substantial room for improvement in first attempt success rates. These results suggest interventions to improve safety and success need to be targeted to the distinct setting.

Standardising communication to improve in-hospital cardiopulmonary resuscitation

AIM

Recommendations for standardised communication to reduce chest compression (CC) pauses are lacking. We aimed to achieve consensus and evaluate feasibility and efficacy using standardised communication during cardiopulmonary resuscitation (CPR) events.

METHODS

Modified Delphi consensus process to design standardised communication elements. Feasibility was pilot tested in 16 simulated CPR scenarios (8 scenarios with physician team leaders and 8 with chest compressors) randomized (1:1) to standardised [INTERVENTION] vs. closed-loop communication [CONTROL]. Adherence and efficacy (duration of CC pauses for defibrillation, intubation, rhythm check) was assessed by audiovisual recording. Mental demand and frustration were assessed by NASA task load index subscales.

RESULTS

Consensus elements for standardised communication included: 1) team preparation 15-30 s before CC interruption, 2) pre-interruption countdown synchronized with last 5 CCs, 3) specific action words for defibrillation, intubation, and interrupting/resuming CCs. Median (Q1,Q3) adherence to standardised phrases was 98% (80%,100%). Efficacy analysis showed a median [Q1,Q3] peri-shock pause of 5.1 s. [4.4; 5.8] vs. 7.5 s. [6.3; 8.8] seconds, p < 0.001, intubation pause of 3.8 s. [3.6; 5.0] vs. 6.9 s. [4.8; 10.1] seconds, p = 0.03, rhythm check pause of 4.2 [3.2,5.7] vs. 8.6 [5.0,10.5] seconds, p < 0.001, median frustration index of 10/100 [5,20] vs. 35/100 [25,50], p < 0.001, and median mental demand load of 55/100 [30,70] vs. 65/100 [50,85], p = 0.41 for standardised vs. closed loop communication.

CONCLUSION

This pilot study demonstrated feasibility of using consensus-based standardised communication that was associated with shorter CC pauses for defibrillation, intubation, and rhythm checks without increasing frustration index or mental demand compared to current best practice, closed loop communication.

Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice

Diagnostic point-of-care ultrasound (POCUS) is a growing field across all disciplines of pediatric practice. Machine accessibility and portability will only continue to grow, thus increasing exposure to this technology for both providers and patients. Individuals seeking training in POCUS should first identify their scope of practice to determine appropriate applications within their clinical setting, a few of which are discussed within this article. Efforts to build standardized POCUS infrastructure within specialties and institutions are ongoing with the goal of improving patient care and outcomes.

Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates

OBJECTIVE

To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU).

DESIGN

Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates.

SETTING

Ten academic NICUs.

PATIENTS

Neonates intubated in the NICU at each of the sites between October 2014 and March 2017.

MAIN OUTCOME MEASURES

Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation.

RESULTS

Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53).

CONCLUSIONS

Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.

[Point-of-care ultrasound: Is it time to include it in the paediatric specialist training program?]

Point-of-care ultrasound (POCUS) has become an essential tool for clinical practice in recent years. It should be considered as an extension of the standard physical examination, which complements and enriches it without substituting it. POCUS enables the physician to answer specific clinical questions about the diagnosis, to understand better the pathophysiological context, to orientate the treatment, and to perform invasive procedures more safely. Despite its current use in many centres, and in most paediatric sub-specialties, there are currently no specific recommendations addressing educational aims in the different training areas, as well as methodology practice and the certification process in paediatrics. These ingredients are essential for POCUS implementation in daily practice, with a quality guarantee in terms of efficiency and safety. Several POCUS experts in different paediatric medicine environments performed a non-systematic review addressing the main paediatric POCUS applications in paediatrics. The lack of educational programs in POCUS in Spain is also discussed, and the experience in the United States of America in this topic is provided. Considering the current situation of POCUS in paediatrics, we strongly believe that it is urgent to establish evidence-based recommendations for POCUS training that should be the base to develop educational programs and to include POCUS in the paediatric residency training.

Getting to know a familiar face: Current and emerging focused ultrasound applications for the perioperative setting

Ultrasound technology is available in many pediatric perioperative settings. There is an increasing number of ultrasound applications for anesthesiologists which may enhance clinical performance, procedural safety, and patient outcomes. This review highlights the literature and experience supporting focused ultrasound applications in the pediatric perioperative setting across varied disciplines including anesthesiology. The review also suggests strategies for building educational and infrastructural systems to translate this technology into clinical practice.

Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States

IMPORTANCE

Guidelines for declaration of brain death in children were revised in 2011 by the Society of Critical Care Medicine, American Academy of Pediatrics, and Child Neurology Society. Despite widespread medical, legal, and ethical acceptance, ongoing controversies exist with regard to the concept of brain death and the procedures for its determination.

OBJECTIVES

To determine the epidemiology and clinical characteristics of pediatric patients declared brain dead in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This study involved the abstraction of all patient deaths from the Virtual Pediatric Systems national multicenter database between January 1, 2012, and June 30, 2017. All patients who died in pediatric intensive care units (PICUs) were included.

MAIN OUTCOMES AND MEASURES

Patient demographics, preillness developmental status, severity of illness, cause of death, PICU medical and physical length of stay, and organ donation status, as well as comparison between patients who were declared brain dead vs those who sustained cardiovascular or cardiopulmonary death.

RESULTS

Of the 15 344 patients who died, 3170 (20.7%) were declared brain dead; 1861 of these patients (58.7%) were male, and 1401 (44.2%) were between 2 and 12 years of age. There was a linear association between PICU size and number of patients declared brain dead per year, with an increase of 4.27 patients (95% CI, 3.46-5.08) per 1000-patient increase in discharges (P < .001). The median (interquartile range) of patients declared brain dead per year ranged from 1 (0-3) in smaller PICUs (defined as those with <500 discharges per year) to 10 (7-15) for larger PICUs (those with 2000-4000 discharges per year). The most common causative mechanisms of brain death were hypoxic-ischemic injury owing to cardiac arrest (1672 of 3170 [52.7%]), shock and/or respiratory arrest without cardiac arrest (399 of 3170 [12.6%]), and traumatic brain injury (634 of 3170 [20.0%]). Most patients declared brain dead (681 of 807 [84.4%]) did not have preexisting neurological dysfunction. Patients who were organ donors (1568 of 3144 [49.9%]) remained in the PICU longer after declaration of brain death compared with those who were not donors (median [interquartile range], 29 [6-41] hours vs 4 [1-8] hours; P < .001).

CONCLUSIONS AND RELEVANCE

Brain death occurred in one-fifth of PICU deaths. Most children declared brain dead had no preexisting neurological dysfunction and had an acute hypoxic-ischemic or traumatic brain injury. Brain death determinations are infrequent, even in large PICUs, emphasizing the importance of ongoing education for medical professionals and standardization of protocols to ensure diagnostic accuracy and consistency.

Comparison of Methods for Identification of Pediatric Severe Sepsis and Septic Shock in the Virtual Pediatric Systems Database

OBJECTIVES

To compare the performance of three methods of identifying children with severe sepsis and septic shock from the Virtual Pediatric Systems database to prospective screening using consensus criteria.

DESIGN

Observational cohort study.

SETTING

Single-center PICU.

PATIENTS

Children admitted to the PICU in the period between March 1, 2012, and March 31, 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, all PICU patients were prospectively screened daily for sepsis, and those meeting consensus criteria for severe sepsis or septic shock on manual chart review were entered into the sepsis registry. Of 7,459 patients admitted to the PICU during the study period, 401 met consensus criteria for severe sepsis or septic shock (reference standard cohort). Within Virtual Pediatric Systems, patients identified using "Martin" (n = 970; κ = 0.43; positive predictive value = 34%; F1 = 0.48) and "Angus" International Classification of Diseases, 9th Edition, Clinical Modification codes (n = 1387; κ = 0.28; positive predictive value = 22%; F1 = 0.34) showed limited agreement with the reference standard cohort. By comparison, explicit International Classification of Diseases, 9th Edition, Clinical Modification codes for severe sepsis (995.92) and septic shock (785.52) identified a smaller, more accurate cohort of children (n = 515; κ = 0.61; positive predictive value = 57%; F1 = 0.64). PICU mortality was 8% in the reference standard cohort and the cohort identified by explicit codes; age, illness severity scores, and resource utilization did not differ between groups. Analysis of discrepancies between the reference standard and Virtual Pediatric Systems explicit codes revealed that prospective screening missed 66 patients with severe sepsis or septic shock. After including these patients in the reference standard cohort as an exploratory analysis, agreement between the cohort of patients identified by Virtual Pediatric Systems explicit codes and the reference standard cohort improved (κ = 0.73; positive predictive value = 70%; F1 = 0.75).

CONCLUSIONS

Children with severe sepsis and septic shock are best identified in the Virtual Pediatric Systems database using explicit diagnosis codes for severe sepsis and septic shock. The accuracy of these codes and level of clinical detail available in the Virtual Pediatric Systems database allow for sophisticated epidemiologic studies of pediatric severe sepsis and septic shock in this large, multicenter database.