1
|
McNevin K, Nicassio L, Rice-Townsend SE, Katz CB, Goldin A, Avansino J, Calkins CM, Durham MM, Page K, Ralls MW, Reeder RW, Rentea RM, Rollins MD, Saadai P, Wood RJ, van Leeuwen KD, Smith CA. Comparison of the PCPLC Database to NSQIP-P: A Patient Matched Comparison of Surgical Complications Following Repair of Anorectal Malformation. J Pediatr Surg 2024; 59:997-1002. [PMID: 38365475 DOI: 10.1016/j.jpedsurg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/27/2023] [Accepted: 01/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Anorectal malformations (ARM) are rare and heterogenous which creates a challenge in conducting research and offering recommendations for best practice. The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) was formed in 2016 to address this challenge and created a shared national data registry to collect information about pediatric colorectal patients. There has been no external validation of the data collected. We sought to evaluate the database by performing a patient matched analysis comparing 30-day outcomes identified in the PCPLC registry with the NSQIP-P database for patients undergoing surgical repair of ARM. METHODS Patients captured in the PCPLC database from 2016 to 2021 at institutions also participating in NSQIP-P who underwent ARM repair younger than 12 months old were reviewed for 30-day complications. These patients were matched to their NSQIP-P record using their hospital identification number, and records were compared for concordance in identified complications. RESULTS A total of 591 patient records met inclusion criteria in the PCPLC database. Of these, 180 patients were also reviewed by NSQIP-P. One hundred and fifty-six patient records had no complications recorded. Twenty-four patient records had a complication listed in one or both databases. There was a 91 % concordance rate between databases. When excluding complications not tracked in the PCPLC registry, this agreement improved to 93 %. CONCLUSION Including all patients evaluated for this subpopulation, a 91 % concordance rate was observed when comparing PCPLC collected complications to NSQIP-P. Future efforts can focus on further validating the data within the PCPLC for other patient populations. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Kathryn McNevin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
| | - Lauren Nicassio
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Samuel E Rice-Townsend
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Cindy B Katz
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Adam Goldin
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Jeffrey Avansino
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, 999 N 92 St Suite 320, Milwaukee, WI 53226, USA
| | - Megan M Durham
- Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E Hospital Drive Level 4, Ann Arbor, MI 48109, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Dr., Ste 3800 Salt Lake City, UT 84112, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, 2521 Stockton Blvd, 4th Floor Suite 4100, Sacramento, CA 95817, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kathleen D van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, 1919 E. Thomas Rd, Phoenix, AZ 85016, USA
| | - Caitlin A Smith
- Department of General Surgery, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA 98105, USA
| |
Collapse
|
2
|
Yates AR, Naim MY, Reeder RW, Ahmed T, Banks RK, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yeh J, Zuppa AF, Sutton RM, Meert KL. Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021). Pediatr Crit Care Med 2024; 25:312-322. [PMID: 38088765 PMCID: PMC10994777 DOI: 10.1097/pcc.0000000000003423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients. DESIGN Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497). SETTING Eighteen ICUs participated in ICU-RESUS. PATIENTS There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation. CONCLUSIONS We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.
Collapse
Affiliation(s)
- Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Justin Yeh
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| |
Collapse
|
3
|
Frazier AH, Topjian AA, Reeder RW, Morgan RW, Fink EL, Franzon D, Graham K, Harding ML, Mourani PM, Nadkarni VM, Wolfe HA, Ahmed T, Bell MJ, Burns C, Carcillo JA, Carpenter TC, Diddle JW, Federman M, Friess SH, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Meert KL, Naim MY, Notterman D, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Yates AR, Sutton RM, Berg RA. Association of Pediatric Post-Cardiac Arrest Ventilation and Oxygenation with Survival Outcomes. Ann Am Thorac Soc 2024. [PMID: 38507645 DOI: 10.1513/annalsats.202311-948oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/18/2024] [Indexed: 03/22/2024] Open
Abstract
RATIONALE Adult and pediatric studies provide conflicting data whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia and/or hypocapnia are associated with worse outcomes. OBJECTIVES Determine if post-arrest hypoxemia or post-arrest hyperoxemia are associated with lower rates of survival to hospital discharge compared to post-arrest normoxemia, and if post-arrest hypocapnia or hypercapnia are associated with lower rates of survival compared to post-arrest normocapnia. METHODS Embedded prospective observational study during a multi-center interventional cardiopulmonary resuscitation trial from 2016-2021. Patients ≤18 years and ≥37 weeks corrected gestational age who received chest compressions for cardiac arrest in one of 18 ICUs were included. Exposures during the first 24 hours post-arrest were hypoxemia, hyperoxemia, or normoxemia defined as lowest PaO2 <60mmHg, highest PaO2 ≥200mmHg, or every PaO2 60-199mmHg, respectively, and hypocapnia, hypercapnia, or normocapnia defined as lowest PaCO2 <30mmHg, highest PaCO2 ≥50mmHg, or every PaCO2 30-49mmHg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. MEASUREMENTS AND MAIN RESULTS The hypoxemia group was less likely to survive to hospital discharge compared with the normoxemia group (aRR 0.71, 0.58-0.87), whereas the hyperoxemia group survival did not differ from the normoxemia group (aRR 1.0, 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge compared with the normocapnia group (aRR 0.74, 0.64-0.84), whereas the hypocapnia group survival did not differ from the normocapnia group (aRR 0.91, 0.74-1.12). CONCLUSIONS Post-arrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.
Collapse
Affiliation(s)
- Aisha H Frazier
- Nemours Children's Hospital Delaware, 25401, Cardiac Center, Wilmington, Delaware, United States
- Thomas Jefferson University Sidney Kimmel Medical College, 12313, Pediatrics, Philadelphia, Pennsylvania, United States
| | - Alexis A Topjian
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Ron W Reeder
- University of Utah, Department of Pediatrics, Salt Lake City, Utah, United States
| | - Ryan W Morgan
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States
| | - Ericka L Fink
- Children's Hospital of Pittsburgh of UPMC, 6619, Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States
| | - Deborah Franzon
- UCSF Benioff Children's Hospital, 21642, Department of Pediatrics, San Francisco, California, United States
| | - Kathryn Graham
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States
| | - Monica L Harding
- University of Utah, Department of Pediatrics, Salt Lake City, Utah, United States
| | - Peter M Mourani
- University of Arkansas for Medical Sciences, 12215, Pediatrics, Critical Care Medicine, Little Rock, Arkansas, United States
- Arkansas Childrens Research Institute, 366944, Little Rock, Arkansas, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Heather A Wolfe
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Tageldin Ahmed
- Children's Hospital of Michigan, 2969, Department of Pediatrics , Detroit, Michigan, United States
| | - Michael J Bell
- Children's National Hospital, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Candice Burns
- Washington University School of Medicine in Saint Louis, 12275, Department of Pediatrics, St Louis, Missouri, United States
| | - Joseph A Carcillo
- Children's Hospital of Pittsburgh of UPMC Department of Pediatric Critical Care Medicine, 549368, Pittsburgh, Pennsylvania, United States
| | - Todd C Carpenter
- University of Colorado School of Medicine, 12225, Aurora, Colorado, United States
- Children's Hospital Colorado, 2932, Department of Pediatrics, Aurora, Colorado, United States
| | - J Wesley Diddle
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Myke Federman
- University of California Los Angeles, 8783, Los Angeles, California, United States
- UCLA Mattel Children's Hospital, 21785, Department of Pediatrics, Los Angeles, California, United States
| | - Stuart H Friess
- Washington University School of Medicine in Saint Louis, 12275, Department of Pediatrics, St Louis, Missouri, United States
| | - Mark Hall
- Nationwide Children's Hospital, 2650, Department of Pediatrics, Columbus, Ohio, United States
- The Ohio State University, 2647, Columbus, Ohio, United States
| | - David A Hehir
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Christopher M Horvat
- Children's Hospital of Pittsburgh of UPMC, 6619, Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States
- University of Pittsburgh, 6614, Pittsburgh, Pennsylvania, United States
| | - Leanna L Huard
- University of California Los Angeles, 8783, Los Angeles, California, United States
- UCLA Mattel Children's Hospital, 21785, Department of Pediatrics, Los Angeles, California, United States
| | - Tensing Maa
- Nationwide Children's Hospital, 2650, Department of Pediatrics , Columbus, Ohio, United States
- The Ohio State University, 2647, Columbus, Ohio, United States
| | - Kathleen L Meert
- Children's Hospital of Michigan, 2969, Department of Pediatrics, Detroit, Michigan, United States
- Central Michigan University, 5649, Mount Pleasant, Michigan, United States
| | - Maryam Y Naim
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Daniel Notterman
- Princeton University, 6740, Department of Molecular Biology, Princeton, New Jersey, United States
| | - Murray M Pollack
- Children's National Hospital, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Carleen Schneiter
- University of Colorado School of Medicine, 12225, Aurora, Colorado, United States
- Children's Hospital Colorado, 2932, Department of Pediatrics , Aurora, Colorado, United States
| | - Matthew P Sharron
- Children's National Medical Center, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Neeraj Srivastava
- UCLA Mattel Children's Hospital, 21785, Department of Pediatrics, Los Angeles, California, United States
- University of California Los Angeles, 8783, Los Angeles, California, United States
| | - Shirley Viteri
- Nemours Children's Hospital Delaware, 25401, Department of Pediatrics, Wilmington, Delaware, United States
- Thomas Jefferson University Sidney Kimmel Medical College, 12313, Philadelphia, Pennsylvania, United States
| | - David Wessel
- Children's National Hospital, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Andrew R Yates
- Nationwide Children's Hospital, 2650, Pediatrics, Columbus, Ohio, United States
- The Ohio State University, 2647, Pediatrics, Columbus, Ohio, United States
| | - Robert M Sutton
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States;
| |
Collapse
|
4
|
Ullrich S, Austin K, Avansino JR, Badillo A, Calkins CM, Crady RC, Durham MM, Fuller MK, Rana A, Reeder RW, Rentea RM, Rollins MD, Saadai P, Speck KE, Wood RJ, van Leeuwen K, Frischer JS. Does Delayed Diagnosis of Hirschsprung Disease Impact Post-operative and Functional Outcomes? A Multi-Center Review From the Pediatric Colorectal and Pelvic Learning Consortium. J Pediatr Surg 2024:S0022-3468(24)00186-6. [PMID: 38677965 DOI: 10.1016/j.jpedsurg.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Hirschsprung Disease (HD) is a rare cause of functional bowel obstruction in children. Patients are typically diagnosed in the neonatal period and undergo pull-through (PT) soon after diagnosis. The optimal management and post-operative outcomes of children who present in a delayed fashion are unknown. METHODS A multi-center retrospective review of children with HD was performed at participating Pediatric Colorectal and Pelvic Learning Consortium sites. Children were stratified by age at diagnosis (neonates <29 days; infants 29 days-12 months; toddler 1 year-5 years and child >5 years). RESULTS 679 patients with HD from 14 sites were included; Most (69%) were diagnosed in the neonatal period. Age at diagnosis was not associated with differences in 30-day complication rates or need for PT revision. Older age at diagnosis was associated with a greater likelihood of undergoing fecal diversion after PT (neonate 10%, infant 12%, toddler 26%, child 28%, P < 0.001) and a greater need for intervention for constipation or incontinence postoperatively (neonate 56%, infant 62%, toddler 78%, child 69%, P < 0.001). CONCLUSION Delayed diagnosis of HD does not impact 30-day post-operative outcomes or need for revision surgery but, delayed diagnosis is associated with increased need for fecal diversion after pull-through. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Sarah Ullrich
- Colorectal Center, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Kelly Austin
- Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Avansino
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel C Crady
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Megan M Durham
- Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Megan K Fuller
- Department of Surgery, Boys Town National Research Hospital, University of Nebraska Medical Center, Boys Town, NE, USA
| | - Ankur Rana
- Department of Surgery and Perioperative Care, Dell Children's Medical Center, University of Texas Austin, Austin, TX, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, Davis, CA, USA
| | - K Elizabeth Speck
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Kathleen van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, Phoenix, AZ, USA
| | - Jason S Frischer
- Colorectal Center, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA.
| |
Collapse
|
5
|
Verhey LH, Kulkarni AV, Reeder RW, Riva-Cambrin J, Jensen H, Pollack IF, Rocque BG, Tamber MS, McDonald PJ, Krieger MD, Pindrik JA, Hauptman JS, Browd SR, Whitehead WE, Jackson EM, Wellons JC, Hankinson TC, Chu J, Limbrick DD, Strahle JM, Kestle JRW. A re-evaluation of the Endoscopic Third Ventriculostomy Success Score: a Hydrocephalus Clinical Research Network study. J Neurosurg Pediatr 2024:1-11. [PMID: 38335514 DOI: 10.3171/2023.12.peds23401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/06/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVE The Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study 1) to determine if a new, better-performing version of the Endoscopic Third Ventriculostomy Success Score (ETVSS) could be developed, 2) to explore the performance characteristics of the original ETVSS in a modern endoscopic third ventriculostomy (ETV) cohort, and 3) to determine if the addition of radiological variables to the ETVSS improved its predictive abilities. METHODS From April 2008 to August 2019, children (corrected age ≤ 17.5 years) who underwent a first-time ETV for hydrocephalus were included in a prospective multicenter HCRN study. All children had at least 6 months of clinical follow-up and were followed since the index ETV in the HCRN Core Data Registry. Children who underwent choroid plexus cauterization were excluded. Outcome (ETV success) was defined as the lack of ETV failure within 6 months of the index procedure. Kaplan-Meier curves were constructed to evaluate time-dependent variables. Multivariable binary logistic models were built to evaluate predictors of ETV success. Model performance was evaluated with Hosmer-Lemeshow and Harrell's C statistics. RESULTS Seven hundred sixty-one children underwent a first-time ETV. The rate of 6-month ETV success was 76%. The Hosmer-Lemeshow and Harrell's C statistics of the logistic model containing more granular age and etiology categorizations did not differ significantly from a model containing the ETVSS categories. In children ≥ 12 months of age with ETVSSs of 50 or 60, the original ETVSS underestimated success, but this analysis was limited by a small sample size. Fronto-occipital horn ratio (p = 0.37), maximum width of the third ventricle (p = 0.39), and downward concavity of the floor of the third ventricle (p = 0.63) did not predict ETV success. A possible association between the degree of prepontine adhesions on preoperative MRI and ETV success was detected, but this did not reach statistical significance. CONCLUSIONS This modern, multicenter study of ETV success shows that the original ETVSS continues to demonstrate good predictive ability, which was not substantially improved with a new success score. There might be an association between preoperative prepontine adhesions and ETV success, and this needs to be evaluated in a future large prospective study.
Collapse
Affiliation(s)
- Leonard H Verhey
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Michigan State University, Grand Rapids, Michigan
| | - Abhaya V Kulkarni
- 2Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Ron W Reeder
- 3Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jay Riva-Cambrin
- 4Division of Neurosurgery, Alberta Children's Hospital, University of Calgary, Alberta, Canada
| | - Hailey Jensen
- 3Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ian F Pollack
- 5Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania
| | - Brandon G Rocque
- 6Department of Neurosurgery, Children's of Alabama, University of Alabama, Birmingham, Alabama
| | - Mandeep S Tamber
- 7Division of Neurosurgery, UBC Department of Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Patrick J McDonald
- 8Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mark D Krieger
- 9Department of Neurosurgery, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jonathan A Pindrik
- 10Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jason S Hauptman
- 11Department of Neurological Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Samuel R Browd
- 11Department of Neurological Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - William E Whitehead
- 12Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Eric M Jackson
- 13Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - John C Wellons
- 14Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd C Hankinson
- 15Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Jason Chu
- 9Department of Neurosurgery, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - David D Limbrick
- 16Department of Neurosurgery, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Missouri; and
| | - Jennifer M Strahle
- 16Department of Neurosurgery, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Missouri; and
| | - John R W Kestle
- 17Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| |
Collapse
|
6
|
Srinivas S, Knaus ME, Avansino JR, Badillo A, Calkins CM, Dickie BH, Durham MM, Fuller MK, Ralls MW, Reeder RW, Rentea RM, Rollins MD, van Leeuwen K, Wood RJ. Outcomes From Colonic Pull-Through for Cloacal Exstrophy Differ by Colon Length: A Multi-Institutional Study. J Pediatr Surg 2024; 59:225-229. [PMID: 37968156 DOI: 10.1016/j.jpedsurg.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/11/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Cloacal exstrophy (CE) represents a rare sub-group of anorectal malformations. Traditionally managed with a permanent colostomy, colonic pull-through (PT) has emerged to allow cleanliness without a life-long stoma. We sought to understand outcomes of PT in a large multi-center CE population. METHODS We performed a retrospective study involving eleven pediatric hospitals. We gathered data on demographics, outcomes, and anatomical factors including colon length. Continuous variables were analyzed with Wilcoxon rank-sum tests and categorial variables with Fisher's exact tests. RESULTS There were 98 patients, of which the majority (n = 70, 71.4 %) never underwent PT. There were no differences in exstrophy type, demographics, or associated anomalies. Median age at PT was 1.3 years (IQR 0.3-3.7). Of the cohort that continue to use their PT, the majority (n = 16, 69.6 %) are not clean. In total, 7.1 % (n = 7) of the cohort is clean with a PT, and only one patient is continent. Clean patients have a longer colon length than those who are not clean or opt for re-do ostomy (64.0 cm [IQR 46.0-82.0] vs 26.5 cm [IQR 11.6-41.2], p = 0.005). CONCLUSION Overall, we demonstrate that most children born with CE will keep their stoma. Only a small percentage who elect to undergo colonic PT are clean for stool. Greater colon length correlates with success. This suggests that multiple factors, including colon length, are important when considering PT in a child with CE. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Shruthi Srinivas
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
| | - Maria E Knaus
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Jeffrey R Avansino
- Department of Surgery, Seattle Children's, University of Washington, Seattle, WA, USA
| | - Andrea Badillo
- Department of Surgery, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Megan M Durham
- Department of Surgery, Emory + Children's Pediatric Institute, Atlanta, GA, USA
| | - Megan K Fuller
- Department of Surgery, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Michael D Rollins
- Division of Pediatric Surgery, Primary Children's Hospital, University of Utah Health, Salt Lake City, UT, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
| |
Collapse
|
7
|
Morgan RW, Reeder RW, Bender D, Cooper KK, Friess SH, Graham K, Meert KL, Mourani PM, Murray R, Nadkarni VM, Nataraj C, Palmer CA, Srivastava N, Tilford B, Wolfe HA, Yates AR, Berg RA, Sutton RM. Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival. Circulation 2024; 149:367-378. [PMID: 37929615 PMCID: PMC10841728 DOI: 10.1161/circulationaha.123.066659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that "specific values to guide therapy have not been established in children." METHODS This prospective observational cohort study was a National Heart, Lung, and Blood Institute-funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate). RESULTS Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00-1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups. CONCLUSIONS In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.
Collapse
Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City (R.W.R., C.A.P.)
| | - Dieter Bender
- Villanova Center for Analytics of Dynamic Systems, Villanova University, PA (D.B., C.N.)
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (S.H.F.)
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit (K.L.M., B.T.)
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (P.M.M.)
| | - Robert Murray
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (R.M., A.R.Y.)
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Chandrasekhar Nataraj
- Villanova Center for Analytics of Dynamic Systems, Villanova University, PA (D.B., C.N.)
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City (R.W.R., C.A.P.)
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles (N.S.)
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit (K.L.M., B.T.)
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (R.M., A.R.Y.)
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| |
Collapse
|
8
|
Zinna SS, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Cooper KK, Michael Dean J, Wesley Diddle J, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Hehir DA, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis. Resuscitation 2024; 194:110068. [PMID: 38052273 PMCID: PMC10843614 DOI: 10.1016/j.resuscitation.2023.110068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
AIM Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes. METHODS AND RESULTS Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes. CONCLUSIONS Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.
Collapse
Affiliation(s)
- Shairbanu S Zinna
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
9
|
Federman M, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Kirkpatrick T, Maa T, Maitoza LA, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Naim MY. Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease. Pediatr Crit Care Med 2024; 25:4-14. [PMID: 37678381 PMCID: PMC10843749 DOI: 10.1097/pcc.0000000000003368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease. DESIGN Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021). SETTING Eighteen PICUs. PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups. CONCLUSIONS In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.
Collapse
Affiliation(s)
- Myke Federman
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children’s Hospital, Delaware, Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, St. Louis, MO, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Theresa Kirkpatrick
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Laura A Maitoza
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Murray M Pollack
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children’s Hospital, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
10
|
Osborne CM, Langelier C, Kamm J, Williamson K, Ambroggio L, Reeder RW, Locandro C, Kirk Harris J, Wagner BD, Maddux AB, Caldera S, Lyden A, Soesanto V, Simões EAF, Leroue MK, Carpenter TC, Hall MW, Zuppa AF, Carcillo JA, Meert KL, Pollack MM, McQuillen PS, Notterman DA, DeRisi J, Mourani PM. Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection. Pediatr Crit Care Med 2024; 25:e1-e11. [PMID: 37732845 PMCID: PMC10756702 DOI: 10.1097/pcc.0000000000003336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs). DESIGN This is an analysis of of a seven-center prospective cohort study. SETTING Seven PICUs within academic children's hospitals in the United States. PATIENTS Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours. INTERVENTIONS We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement. MEASUREMENTS AND MAIN RESULTS Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001). CONCLUSIONS Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.
Collapse
Affiliation(s)
- Christina M Osborne
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Charles Langelier
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, CA
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Lilliam Ambroggio
- Department of Epidemiology, University of Colorado School of Medicine, Aurora, CO
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - J Kirk Harris
- Department of Pediatrics, Section of Pulmonary Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Eric A F Simões
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew K Leroue
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Todd C Carpenter
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Athena F Zuppa
- Anesthesiology and Critical Care, Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joseph A Carcillo
- Department of Anesthesia and Critical Care Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kathleen L Meert
- Department of Pediatrics, Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Murray M Pollack
- Department of Pediatrics, Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | | | | | - Peter M Mourani
- Department of Pediatrics, Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR
| |
Collapse
|
11
|
Workman JK, Reeder RW, Banks RK, Zimmerman JJ, Meert KL, Keenan HT. Change in Functional Status During Hospital Admission and Long-Term Health-Related Quality of Life Among Pediatric Septic Shock Survivors. Pediatr Crit Care Med 2023; 24:e573-e583. [PMID: 37346003 PMCID: PMC10739609 DOI: 10.1097/pcc.0000000000003312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVES To investigate whether change in functional status from pre-hospitalization baseline to hospital discharge is associated with long-term health-related quality of life (HRQL) among children surviving septic shock. DESIGN Secondary analysis of Life After Pediatric Sepsis Evaluation (LAPSE), a prospective cohort study of children with community-acquired septic shock, enrolled from January 2014 to June 2017. SETTING Twelve U.S. academic PICUs. PATIENTS Children, 1 month to 18 years, who survived to hospital discharge and had follow-up data for HRQL at 3 and/or 12 months. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Functional Status Scale (FSS) was assessed around enrollment to ascertain baseline status (pre-hospitalization) and at 28 days or hospital discharge. Two measures of HRQL were utilized: children with significant development delay were measured with the Functional Status II-R (FSII-R); typically, developing children were measured with the Pediatric Quality of Life Inventory (PedsQL). Each group was analyzed separately with multivariable regression modeling to determine the association between change in FSS from baseline to day 28 and HRQL at 3 and 12 months from PICU admission. Of the original 389 LAPSE participants, 224 (58%) are included. Among children with developmental delay ( n = 88), worsened FSS was associated with lower FSII-R at 3 months from PICU admission (-2.02; 95% CI, -3.34 to -0.0.71; p = 0.003), but not 12 months. Among developmentally typical children ( n = 136), worsened FSS was associated with lower PedsQL at both 3 and 12 months. Developmentally typical children with a neurologic insult during the PICU stay had the largest decrement in PedsQL at 12 months (-14.04 mo; 95% CI, -22.15 to -5.94 mo; p < 0.001). However, worsened FSS remained associated with poor HRQL-PedsQL at 3 and 12 months, after controlling for neurologic events (both p < 0.001). CONCLUSIONS Change in FSS during hospitalization for septic shock is associated with long-term reductions in HRQL and could serve as a useful tool for identifying children at risk for this sequela.
Collapse
Affiliation(s)
- Jennifer K. Workman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Ron W. Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Russell K Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Jerry J. Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathleen L. Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI
| | - Heather T. Keenan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
12
|
Killien EY, Watson RS, Banks RK, Reeder RW, Meert KL, Zimmerman JJ. Predicting functional and quality-of-life outcomes following pediatric sepsis: performance of PRISM-III and PELOD-2. Pediatr Res 2023; 94:1951-1957. [PMID: 37185949 PMCID: PMC10860342 DOI: 10.1038/s41390-023-02619-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Illness severity scores predict mortality following pediatric critical illness. Given declining PICU mortality, we assessed the ability of the Pediatric Risk of Mortality-III (PRISM) and Pediatric Logistic Organ Dysfunction-2 (PELOD) scores to predict morbidity outcomes. METHODS Among 359 survivors <18 years in the Life After Pediatric Sepsis Evaluation multicenter prospective cohort study, we assessed functional morbidity at hospital discharge (Functional Status Scale increase ≥3 points from baseline) and health-related quality of life (HRQL; Pediatric Quality of Life Inventory or Functional Status II-R) deterioration >25% from baseline at 1, 3, 6, and 12 months post-admission. We determined discrimination of admission PRISM and admission, maximum, and cumulative 28-day PELOD with functional and HRQL morbidity at each timepoint. RESULTS Cumulative PELOD provided the best discrimination of discharge functional morbidity (area under the receive operating characteristics curve [AUROC] 0.81, 95% CI 0.76-0.87) and 3-month HRQL deterioration (AUROC 0.71, 95% CI 0.61-0.81). Prediction was inferior for admission PRISM and PELOD and for 6- and 12-month HRQL assessments. CONCLUSIONS Illness severity scores have a good prediction of early functional morbidity but a more limited ability to predict longer-term HRQL. Identification of factors beyond illness severity that contribute to HRQL outcomes may offer opportunities for intervention to improve outcomes. IMPACT Illness severity scores are commonly used for mortality prediction and risk stratification in pediatric critical care research, quality improvement, and resource allocation algorithms. Prediction of morbidity rather than mortality may be beneficial given declining pediatric intensive care unit mortality. The PRISM and PELOD scores have moderate to good ability to predict new functional morbidity at hospital discharge following pediatric septic shock but limited ability to predict health-related quality of life outcomes in the year following PICU admission. Further research is needed to identify additional factors beyond illness severity that may impact post-discharge health-related quality of life.
Collapse
Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
- Harborview Injury Prevention & Research Center, Seattle, WA, USA.
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| |
Collapse
|
13
|
Gardner MM, Hehir DA, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Topjian AA. Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study. Crit Care 2023; 27:388. [PMID: 37805481 PMCID: PMC10559632 DOI: 10.1186/s13054-023-04662-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge. METHODS We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes. RESULTS Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001). CONCLUSIONS Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.
Collapse
Affiliation(s)
- Monique M Gardner
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| |
Collapse
|
14
|
Stenson EK, Banks RK, Reeder RW, Maddux AB, Zimmerman J, Meert KL, Mourani PM. Fluid Balance and Its Association With Mortality and Health-Related Quality of Life: A Nonprespecified Secondary Analysis of the Life After Pediatric Sepsis Evaluation. Pediatr Crit Care Med 2023; 24:829-839. [PMID: 37260317 PMCID: PMC10689573 DOI: 10.1097/pcc.0000000000003294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To evaluate the association between fluid balance (FB) and health-related quality of life (HRQL) among children at 1 month following community-acquired septic shock. DESIGN Nonprespecified secondary analysis of the Life After Pediatric Sepsis Evaluation. FB was defined as 100 × [(cumulative PICU fluid input - cumulative PICU fluid output)/PICU admission weight]. Three subgroups were identified: low FB (< 5%), medium FB (5%-15%), and high FB (> 15%) based on cumulative FB on days 0-3 of ICU stay. HRQL was measured at ICU admission and 1 month after using Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales or the Stein-Jessop Functional Status Scale. The primary outcome was a composite of mortality or greater than 25% decline in HRQL 1 month after admission compared with baseline. SETTING Twelve academic PICUs in the United States. PATIENTS Critically ill children between 1 month and 18 years, with community-acquired septic shock who survived to at least day 4. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred ninety-three patients were included of whom 66 (23%) had low FB, 127 (43%) had medium FB, and 100 (34%) had high FB. There was no difference in Pediatric Risk of Mortality Score 3 (median 11 [6, 17]), age (median 5 [1, 12]), or gender (47% female) between FB groups. After adjusting for potential confounders and comparing with medium FB, higher odds of mortality or greater than 25% HRQL decline were seen in both the low FB (odds ratio [OR] 2.79 [1.20, 6.57]) and the high FB (OR 2.16 [1.06, 4.47]), p = 0.027. Compared with medium FB, low FB (OR 4.3 [1.62, 11.84]) and high FB (OR 3.29 [1.42, 8.00]) had higher odds of greater than 25% HRQL decline. CONCLUSIONS Over half of the children who survived septic shock had low or high FB, which was associated with a significant decline in HRQL scores. Prospective studies are needed to determine if optimization of FB can improve HRQL outcomes.
Collapse
Affiliation(s)
- Erin K. Stenson
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO
| | - Russell K Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W. Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aline B. Maddux
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathleen L. Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M. Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR
| |
Collapse
|
15
|
Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest. Resuscitation 2023; 191:109939. [PMID: 37625580 PMCID: PMC10528057 DOI: 10.1016/j.resuscitation.2023.109939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
AIM To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest. METHODS This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status. RESULTS Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites. CONCLUSIONS Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.
Collapse
Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Robert Bishop
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Heather A Wolfe
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
| |
Collapse
|
16
|
Cheung C, Kernan KF, Berg RA, Zuppa AF, Notterman DA, Pollack MM, Wessel D, Meert KL, Hall MW, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Banks RK, Reeder RW, Holubkov R, Carcillo JA, Fink EL. Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study. Pediatr Crit Care Med 2023; 24:840-848. [PMID: 37314247 PMCID: PMC10719421 DOI: 10.1097/pcc.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure. DESIGN Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS). SETTING Nine tertiary care PICUs in the United States. PATIENTS Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC. CONCLUSIONS One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.
Collapse
Affiliation(s)
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F. Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Rick E. Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| |
Collapse
|
17
|
Rappold TE, Morgan RW, Reeder RW, Cooper KK, Weeks MK, Widmann NJ, Graham K, Berg RA, Sutton RM. The association of arterial blood pressure waveform-derived area duty cycle with intra-arrest hemodynamics and cardiac arrest outcomes. Resuscitation 2023; 191:109950. [PMID: 37634859 PMCID: PMC10829972 DOI: 10.1016/j.resuscitation.2023.109950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
AIM Develop a novel, physiology-based measurement of duty cycle (Arterial Blood Pressure-Area Duty Cycle [ABP-ADC]) and evaluate the association of ABP-ADC with intra-arrest hemodynamics and patient outcomes. METHODS This was a secondary retrospective study of prospectively collected data from the ICU-RESUS trial (NCT02837497). Invasive arterial waveform data were used to derive ABP-ADC. The primary exposure was ABP-ADC group (<30%; 30-35%; >35%). The primary outcome was systolic blood pressure (sBP). Secondary outcomes included intra-arrest physiologic goals, CPR quality targets, and patient outcomes. In an exploratory analysis, adjusted splines and receiver operating characteristic (ROC) curves were used to determine an optimal ABP-ADC associated with improved hemodynamics and outcomes using a multivariable model. RESULTS Of 1129 CPR events, 273 had evaluable arterial waveform data. Mean age is 2.9 years + 4.9 months. Mean ABP-ADC was 32.5% + 5.0%. In univariable analysis, higher ABP-ADC was associated with lower sBP (p < 0.01) and failing to achieve sBP targets (p < 0.01). Other intra-arrest physiologic parameters, quality metrics, and patient outcomes were similar across ABP-ADC groups. Using spline/ROC analysis and clinical judgement, the optimal ABP-ADC cut point was set at 33%. On multivariable analysis, sBP was significantly higher (point estimate 13.18 mmHg, CI95 5.30-21.07, p < 0.01) among patients with ABP-ADC < 33%. Other intra-arrest physiologic and patient outcomes were similar. CONCLUSIONS In this multicenter cohort, a lower ABP-ADC was associated with higher sBPs during CPR. Although ABP-ADC was not associated with outcomes, further studies are needed to define the interactions between CPR mechanics and intra arrest patient physiology.
Collapse
Affiliation(s)
- Tommy E Rappold
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - M Katie Weeks
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Nicholas J Widmann
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
18
|
Morgan RW, Reeder RW, Ahmed T, Bell MJ, Berger JT, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Himebauch AS, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial. Resuscitation 2023; 190:109897. [PMID: 37406760 PMCID: PMC10530491 DOI: 10.1016/j.resuscitation.2023.109897] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes. METHODS This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR. RESULTS Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups. CONCLUSIONS In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.
Collapse
Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - John T Berger
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA; Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
19
|
Prout AJ, Banks RK, Reeder RW, Zimmerman JJ, Meert KL. Association of Sex and Age with Mortality and Health-Related Quality of Life in Children with Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation. J Intensive Care Med 2023; 39:8850666231190270. [PMID: 37529851 DOI: 10.1177/08850666231190270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Introduction: Sepsis is more common in males than females, but whether outcomes differ by sex in various pediatric age groups is unclear. The Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter prospective cohort study that evaluated health-related quality of life (HRQL) in children after community-acquired septic shock. In this secondary analysis, we evaluated whether male children are at increased risk of mortality or long-term decline in HRQL than female children by age group. Methods: Children (1 month-18 years) with community-acquired septic shock were recruited from 12 pediatric intensive care units in the U.S. Data included sex, age group (<1 year, 1-<13 years, 13-18 years), acute illness severity (acute organ dysfunction and inflammation), and longitudinal assessments of HRQL and mortality. Persistent decline in HRQL was defined as a 10% decrease in HRQL comparing baseline to 3 months following admission. Male and female children were stratified by age group and compared to evaluate the difference in the composite outcome of death or persistent decline in HRQL using the Cochran-Mantel-Haenszel test. Results: Of 389 children, 54.2% (n = 211) were male. Overall, 10% (21/211) of males and 12% (22/178) of females died by 3 months (p = 0.454). Among children with follow-up data, 41% (57/138) of males and 44% (48/108) of females died or had persistent decline in HRQL at 3 months (p = 0.636), with no observed difference by sex when stratified by age group. There was no significant difference in acute illness severity between males and females overall or stratified by age group. Conclusions: In this secondary analysis of the LAPSE cohort, HRQL, and mortality were not different between male and female children when stratified by age group. There were no significant differences by sex across multiple measures of illness severity or treatment intensity.
Collapse
Affiliation(s)
- Andrew J Prout
- Section of Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Department of Pediatrics, Central Michigan University School of Medicine, Mt. Pleasant, MI, USA
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jerry J Zimmerman
- Section of Pediatric Critical Care, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Kathleen L Meert
- Section of Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Department of Pediatrics, Central Michigan University School of Medicine, Mt. Pleasant, MI, USA
| |
Collapse
|
20
|
Leroue MK, Williamson KM, Curtin PC, Sontag MK, Wagner BD, Ambroggio L, Bixby M, Busgang SA, Murphy SE, Peterson LA, Vevang KR, Sipe CJ, Kirk Harris J, Reeder RW, Locandro C, Carpenter TC, Maddux AB, Simões EAF, Osborne CM, Robertson CE, Langelier C, Carcillo JA, Meert KL, Pollack MM, McQuillen PS, Mourani PM. Tobacco smoke exposure, the lower airways microbiome and outcomes of ventilated children. Pediatr Res 2023; 94:660-667. [PMID: 36750739 PMCID: PMC9903281 DOI: 10.1038/s41390-023-02502-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/18/2022] [Accepted: 01/16/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Tobacco smoke exposure increases the risk and severity of lower respiratory tract infections in children, yet the mechanisms remain unclear. We hypothesized that tobacco smoke exposure would modify the lower airway microbiome. METHODS Secondary analysis of a multicenter cohort of 362 children between ages 31 days and 18 years mechanically ventilated for >72 h. Tracheal aspirates from 298 patients, collected within 24 h of intubation, were evaluated via 16 S ribosomal RNA sequencing. Smoke exposure was determined by creatinine corrected urine cotinine levels ≥30 µg/g. RESULTS Patients had a median age of 16 (IQR 568) months. The most common admission diagnosis was lower respiratory tract infection (53%). Seventy-four (20%) patients were smoke exposed and exhibited decreased richness and Shannon diversity. Smoke exposed children had higher relative abundances of Serratia spp., Moraxella spp., Haemophilus spp., and Staphylococcus aureus. Differences were most notable in patients with bacterial and viral respiratory infections. There were no differences in development of acute respiratory distress syndrome, days of mechanical ventilation, ventilator free days at 28 days, length of stay, or mortality. CONCLUSION Among critically ill children requiring prolonged mechanical ventilation, tobacco smoke exposure is associated with decreased richness and Shannon diversity and change in microbial communities. IMPACT Tobacco smoke exposure is associated with changes in the lower airways microbiome but is not associated with clinical outcomes among critically ill pediatric patients requiring prolonged mechanical ventilation. This study is among the first to evaluate the impact of tobacco smoke exposure on the lower airway microbiome in children. This research helps elucidate the relationship between tobacco smoke exposure and the lower airway microbiome and may provide a possible mechanism by which tobacco smoke exposure increases the risk for poor outcomes in children.
Collapse
Affiliation(s)
- Matthew K Leroue
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
| | - Kayla M Williamson
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Paul C Curtin
- CHEAR Data Center, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marci K Sontag
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Brandie D Wagner
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Lilliam Ambroggio
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Moira Bixby
- CHEAR Data Center, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stefanie A Busgang
- CHEAR Data Center, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sharon E Murphy
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Lisa A Peterson
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Karin R Vevang
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | | | - J Kirk Harris
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron W Reeder
- Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Todd C Carpenter
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Eric A F Simões
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Christina M Osborne
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles E Robertson
- Medicine, Division of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles Langelier
- Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | | | - Kathleen L Meert
- Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | | | | | - Peter M Mourani
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
- Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, USA
| |
Collapse
|
21
|
Ortmann LA, Reeder RW, Raymond TT, Brunetti MA, Himebauch A, Bhakta R, Kempka J, di Bari S, Lasa JJ. Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records. Resuscitation 2023; 188:109855. [PMID: 37257678 PMCID: PMC10890910 DOI: 10.1016/j.resuscitation.2023.109855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children. METHODS This was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes). RESULTS A total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36-1.69), p = 0.53]. CONCLUSIONS Survivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.
Collapse
Affiliation(s)
- Laura A Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital, Dallas, TX, USA
| | - Marissa A Brunetti
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adam Himebauch
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rupal Bhakta
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica Kempka
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Shauna di Bari
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Critical Care, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
22
|
Winder MM, Schwartz S, Buckley JR, Fogg KL, Matiasek M, Lyman A, Tortorich A, Holmes K, Frank DU, Nasworthy M, Vichayavilas PE, Bertrandt RA, Kasmai C, Kuester JC, Raymond TT, Greiten LE, Reeder RW, Bailly DK. Optimal Fat-modified Diet Duration for the Treatment of Postoperative Chylothorax in Children. Ann Thorac Surg 2023:S0003-4975(23)00581-7. [PMID: 37308065 DOI: 10.1016/j.athoracsur.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/12/2023] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Dietary modification is the mainstay of treatment for postoperative chylothorax in children. However, optimal fat-modified diet (FMD) duration to prevent recurrence is unknown. Our aim was to determine the association between FMD duration and chylothorax recurrence. METHODS Retrospective cohort study conducted across six pediatric cardiac intensive care units within the United States. Patients <18 years who developed chylothorax within 30 days following cardiac surgery between January 2020 and April 2022 were included. Patients with a Fontan palliation or who died or were lost to follow-up or within 30 days of resuming a regular diet were excluded. FMD duration was defined as the first day of a FMD when chest tube output was <10 mL/kg/day without increasing until the resumption of a regular diet. Patients were classified into three groups (< 3 weeks, 3-5 weeks, >5 weeks) based on FMD duration. RESULTS 105 patients were included; <3 weeks (n=61) 3-5 weeks (n=18), and >5 weeks (n=26). Demographic, surgical, and hospitalization characteristics were not different across groups. In the >5 weeks group, chest tube duration was longer compared to the <3 weeks and 3-5 weeks groups (median: 17.5 days (IQR: 9, 31) vs 10 and 10.5 days; p=0.04). There was no recurrence of chylothorax within 30 days once chylothorax was resolving regardless of FMD duration. CONCLUSIONS FMD duration was not associated with recurrence of chylothorax, suggesting FMD duration can safely be shortened to at least < 3 weeks from time of resolving chylothorax.
Collapse
Affiliation(s)
- Melissa M Winder
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah.
| | - Stephanie Schwartz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of North Carolina
| | - Jason R Buckley
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina
| | | | - Megan Matiasek
- Department of Pediatrics, Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Alissa Lyman
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Science University
| | - Alisa Tortorich
- Department of Pediatrics, Division of Pediatric Gastroenterology, Oregon Health and Science University
| | - Kathy Holmes
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Science University
| | - Deborah U Frank
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Virginia
| | - Mandy Nasworthy
- Department of Pediatrics, Division of Pediatric Cardiology, University of Virginia
| | | | - Rebecca A Bertrandt
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin/Children's Wisconsin
| | - Cam Kasmai
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin/Children's Wisconsin
| | - Jill C Kuester
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin/Children's Wisconsin
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital
| | - Lawrence E Greiten
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Arkansas Children's Hospital
| | - Ron W Reeder
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Utah
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Utah
| |
Collapse
|
23
|
Shepard LN, Reeder RW, O'Halloran A, Kienzle M, Dowling J, Graham K, Keim GP, Topjian AA, Yehya N, Sutton RM, Morgan RW. Pediatric in-hospital cardiac arrest: respiratory failure characteristics and association with outcomes. Resuscitation 2023:109856. [PMID: 37257679 PMCID: PMC10402637 DOI: 10.1016/j.resuscitation.2023.109856] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/05/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
AIMS To characterize respiratory failure prior to pediatric in-hospital cardiac arrest (IHCA) and to associate pre-arrest respiratory failure characteristics with survival outcomes. METHODS This is a single-center, retrospective cohort study from a prospectively identified cohort of children <18 years in intensive care units (ICUs) who received cardiopulmonary resuscitation (CPR) for ≥ 1 minute between January 1, 2017 and June 30, 2021, and were receiving invasive mechanical ventilation (IMV) in the hour prior to IHCA. Patient characteristics, ventilatory support and gas exchange immediately pre-arrest were described and their association with the return of spontaneous circulation (ROSC) was measured. RESULTS In the 187 events among 154 individual patients, the median age was 0.9 [0.2, 2.4] years, and CPR duration was 7.5 [3, 29] minutes. Respiratory failure was acute prior to 106/187 (56.7%) events, and the primary indication for IMV was respiratory in nature in 107/187 (57.2%) events. Immediately pre-arrest, the median positive end-expiratory pressure was 8 [5,10] cmH2O; mean airway pressure was 13 [10,18] cmH2O; peak inspiratory pressure was 28 [24, 35] cmH2O; and fraction of inhaled oxygen (FiO2) was 0.40 [0.25, 0.80]. Pre-arrest FiO2 was lower in patients with ROSC vs. without ROSC (0.30 vs 0.99; p<0.001). Patients without ROSC had greater severity of pre-arrest oxygenation failure (p<0.001) as defined by oxygenation index, oxygen saturation index, P/F ratio or S/F ratio. CONCLUSIONS There was substantial heterogeneity in respiratory failure characteristics and ventilatory requirements pre-arrest. Higher pre-arrest oxygen requirement and greater degree of oxygenation failure were associated with worse survival outcomes.
Collapse
Affiliation(s)
- Lindsay N Shepard
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania.
| | - Ron W Reeder
- Department of Pediatrics University of Utah Salt Lake City, Utah
| | - Amanda O'Halloran
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Martha Kienzle
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Jameson Dowling
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Garrett P Keim
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania
| |
Collapse
|
24
|
Dewan MC, Isaacs AM, Cools MJ, Yengo-Kahn A, Naftel RP, Jensen H, Reeder RW, Holubkov R, Haizel-Cobbina J, Riva-Cambrin J, Jafrani RJ, Pindrik JA, Jackson EM, Judy BF, Kurudza E, Pollack IF, Mcdowell MM, Hankinson TC, Staulcup S, Hauptman J, Hall K, Tamber MS, Cheong A, Warsi NM, Rocque BG, Saccomano BW, Snyder RI, Kulkarni AV, Kestle JRW, Wellons JC. Treatment of hydrocephalus following posterior fossa tumor resection: a multicenter collaboration from the Hydrocephalus Clinical Research Network. J Neurooncol 2023; 163:123-132. [PMID: 37129738 DOI: 10.1007/s11060-023-04316-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Persistent hydrocephalus following posterior fossa brain tumor (PFBT) resection is a common cause of morbidity in pediatric brain tumor patients, for which the optimal treatment is debated. The purpose of this study was to compare treatment outcomes between VPS and ETV in patients with persistent hydrocephalus following surgical resection of a PFBT. METHODS A post-hoc analysis was performed of the Hydrocephalus Clinical Research Network (HCRN) prospective observational study evaluating VPS and ETV for pediatric patients. Children who experienced hydrocephalus secondary to PFBT from 2008 to 2021 were included. Primary outcomes were VPS/ETV treatment failure and time-to-failure (TTF). RESULTS Among 241 patients, the VPS (183) and ETV (58) groups were similar in age, extent of tumor resection, and preoperative ETV Success Score. There was no difference in overall treatment failure between VPS and ETV (33.9% vs 31.0%, p = 0.751). However, mean TTF was shorter for ETV than VPS (0.45 years vs 1.30 years, p = 0.001). While major complication profiles were similar, compared to VPS, ETV patients had relatively higher incidence of minor CSF leak (10.3% vs. 1.1%, p = 0.003) and pseudomeningocele (12.1% vs 3.3%, p = 0.02). No ETV failures were identified beyond 3 years, while shunt failures occurred beyond 5 years. Shunt infections occurred in 5.5% of the VPS cohort. CONCLUSIONS ETV and VPS offer similar overall success rates for PFBT-related postoperative hydrocephalus. ETV failure occurs earlier, while susceptibility to VPS failure persists beyond 5 years. Tumor histology and grade may be considered when selecting the optimal means of CSF diversion.
Collapse
Affiliation(s)
- Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, Vanderbilt Children's Hospital, 2200 Children's Way, 9226 Doctors Office Tower, Nashville, TN, 37232-9557, USA.
| | - Albert M Isaacs
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J Cools
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseline Haizel-Cobbina
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Ryan J Jafrani
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University, St. Louis, MO, USA
| | - Jonathan A Pindrik
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elena Kurudza
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael M Mcdowell
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Susan Staulcup
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jason Hauptman
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Koko Hall
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alex Cheong
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Nebras M Warsi
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Benjamin W Saccomano
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Rita I Snyder
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
25
|
Garvey EM, Fuller M, Frischer J, Calkins CM, Rentea RM, Ralls M, Wood R, Rollins MD, Avansino J, Reeder RW, Durham MM. Multi-Institutional Review From the Pediatric Colorectal and Pelvic Learning Consortium of Minor Spinal Cord Dysraphism in the Setting of Anorectal Malformations: Diagnosis, Treatment, and Outcomes. J Pediatr Surg 2023:S0022-3468(23)00251-8. [PMID: 37248140 DOI: 10.1016/j.jpedsurg.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND/RATIONALE Anorectal malformations (ARM) are associated with congenital anomalies of the spine, but the impact of a minor spinal cord dysraphism (mSCD) on fecal continence in the setting of ARM remains unclear. MATERIALS/METHODS A retrospective review was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry. The patient cohort was reviewed for ARM type, mSCD screening/incidence/neurosurgical intervention and age-based BMP utilization. RESULTS 987 patients with ARM were categorized into mild (38%), moderate (32%) or complex (19%). 694 (70%) had normal spinal (NS) status. 271 (27.5%) patients had mSCD. MRI alone (49%) was the most common screening test for mSCD. US screening had a positive predictive value of 86.3% and a negative predictive value of 67.1%. Surgical intervention rates for mSCD ranged between 13% and 77% at a median age of 0.6-5.2 years. 726 (73.6%) patients were prescribed BMP (74.4% NS, 77.5% mSCD). Laxatives were most utilized BMP in all groups <5yo. ≥5yo, enema utilization increased with ARM complexity independent of spine status (with or without neurosurgical intervention). Neurosurgical intervention did not affect BMP utilization at any age or with any ARM when mSCD was identified. CONCLUSIONS MSCD influence on bowel function in the setting ARM remains unclear. No significant impact of mSCD was noted on ARM patient bowel management program utilization. Variability exists within PCPLC site with screening and intervention for mSCD in patients with ARM. Future studies with standardized care may be needed to elucidate the true impact of mSCD on long term patient outcomes in ARM patients. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Erin M Garvey
- Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85106, USA
| | - Megan Fuller
- Boys Town National Research Hospital, 14040 Boys Town Hospital Rd, Omaha, NE, 68010, USA
| | | | - Casey M Calkins
- Children's Hospital of Wisconsin, 999 N. 92nd Street, Milwaukee, WI, 53226, USA
| | - Rebecca M Rentea
- Children's Mercy Kansas City, University of Missouri- Kansas City, Kansas City, MO, 64108, USA
| | - Matthew Ralls
- C.S. Mott Children's Michigan University of Michigan, 1540 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - Richard Wood
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Michael D Rollins
- Primary Children's Hospital, University of Utah, 100 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Jeffrey Avansino
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Ron W Reeder
- Data Coordinating Center, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Megan M Durham
- Division of Pediatric Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, 1405 Clifton Road NE, 3rd Floor, Tower 1, Pediatric Surgical Suite, Atlanta, GA, 30322, USA.
| |
Collapse
|
26
|
Iantorno SE, Rollins MD, Austin K, Avansino JR, Badillo A, Calkins CM, Crady RC, Dickie BH, Durham MM, Frischer JS, Fuller MK, Grabowski JE, Ralls MW, Reeder RW, Rentea RM, Saadai P, Wood RJ, van Leeuwen KD, Short SS. Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management. J Pediatr Surg 2023:S0022-3468(23)00252-X. [PMID: 37173214 DOI: 10.1016/j.jpedsurg.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined. METHODS A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse. RESULTS A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17). CONCLUSION Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Stephanie E Iantorno
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA.
| | - Michael D Rollins
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Kelly Austin
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Avansino
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Casey M Calkins
- Department of Surgery, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel C Crady
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Megan M Durham
- Emory + Children's Pediatric Institute, Atlanta, GA, USA
| | - Jason S Frischer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Megan K Fuller
- Department of Surgery, Boys Town Research Hospital-Children's of Omaha, University of Nebraska Medical Center, Boys Town, NE, USA
| | - Julia E Grabowski
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Matthew W Ralls
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Payam Saadai
- Department of Surgery, UC Davis Children's Hospital, University of California Davis, Davis, CA, USA
| | - Richard J Wood
- Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Kathleen D van Leeuwen
- Department of Surgery, Phoenix Children's Hospital, University of Arizona, Phoenix, AZ, USA
| | - Scott S Short
- Department of Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
27
|
Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Michael Dean J, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, KirkpatrickN T, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Qunibi D, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes. Resuscitation 2023; 185:109673. [PMID: 36565948 PMCID: PMC10065910 DOI: 10.1016/j.resuscitation.2022.109673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
AIM To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit. METHODS This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses. RESULTS Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency. CONCLUSIONS Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.
Collapse
Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Theresa KirkpatrickN
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Danna Qunibi
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
| |
Collapse
|
28
|
Rice-Townsend SE, Nicassio L, Glazer D, Avansino J, Durham MM, Frischer J, Calkins C, Rentea RM, Ralls M, Fuller M, Wood RJ, Rollins M, Lee J, Lewis KE, Reeder RW, Smith CA. Fecal continence outcomes and potential disparities for patients with anorectal malformations treated at referral institutions for pediatric colorectal surgery. Pediatr Surg Int 2023; 39:157. [PMID: 36952009 DOI: 10.1007/s00383-023-05447-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Fecal incontinence is a problem for many patients born with an anorectal malformation (ARM) that can impact quality of life. It is unknown if racial, ethnic, and socioeconomic disparities relate to fecal continence in these children. We sought to examine outcomes and potential disparities in care. METHODS We performed a multicenter retrospective study of children > 3y with ARM evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The primary outcome was fecal continence. We evaluated for associations between fecal continence and race, sex, age, and insurance status. RESULTS 509 patients with ARM from 11 institutions were included. Overall, 24% reported complete fecal continence, and fecal continence was associated with older age (p < .001). For school-aged children, 27% reported complete continence, while 53% reported none. On univariate analysis, patients with combined private and public insurance showed lower rates of continence when compared to those with private insurance (23 vs. 12%; p = 0.02). Age was associated with continence on univariate and multivariable analyses. CONCLUSION Rates of complete fecal continence in this population are low. Differences based on payor status may exist. There were no observed disparities related to sex and race. Further investigation is warranted to improve care for this patient population. LEVEL OF EVIDENCE III. TYPE OF STUDY Multi-institutional retrospective comparative study.
Collapse
Affiliation(s)
- Samuel E Rice-Townsend
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA.
| | - Lauren Nicassio
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Deb Glazer
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Jeffrey Avansino
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | - Megan M Durham
- Children's Healthcare of Atlanta, Emory University Pediatric Institute, Atlanta, GA, USA
| | | | - Casey Calkins
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | | | | - Justin Lee
- Phoenix Children's Hospital, Phoenix, AZ, USA
| | | | | | - Caitlin A Smith
- Seattle Children's Hospital, University of Washington, OA.9.220, PO Box 5371, Seattle, WA, 98145-5005, USA
| | | |
Collapse
|
29
|
Morgan RW, Berg RA, Reeder RW, Carpenter TC, Franzon D, Frazier AH, Graham K, Meert KL, Nadkarni VM, Naim MY, Tilford B, Wolfe HA, Yates AR, Sutton RM. The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes. Crit Care 2023; 27:105. [PMID: 36915182 PMCID: PMC10012560 DOI: 10.1186/s13054-023-04399-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC. METHODS This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders." RESULTS Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline). CONCLUSIONS The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.
Collapse
Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA.
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | | |
Collapse
|
30
|
Bailly DK, Reeder RW, Muszynski JA, Meert KL, Ankola AA, Alexander PM, Pollack MM, Moler FW, Berg RA, Carcillo J, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Dalton H, Zuppa AF. Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis. Perfusion 2023; 38:363-372. [PMID: 35220828 DOI: 10.1177/02676591211056562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.
Collapse
Affiliation(s)
- David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, 14434University of Utah, Salt Lake, UT, USA
| | - Jennifer A Muszynski
- Division of Critical Care, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Center for Clinical and Translational Research, 2650The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen L Meert
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Cardiology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Peta Ma Alexander
- Department of Pediatrics, 14434Harvard Medical School, Boston, MA, USA
| | - Murray M Pollack
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Frank W Moler
- Department of Pediatrics and Communicable Diseases, 1259University of Michigan, Ann Arbor, MI, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Critical Care Medicine, 6619Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Berger
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Michael J Bell
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - J M Dean
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Carol Nicholson
- Trauma and Critical Illness Branch, 35040National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA.,35040National Institutes of Health, Bethesda, MD, USA
| | - Pamela Garcia-Filion
- Department of Biomedical Informatics, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David Wessel
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Sabrina Heidemann
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Allan Doctor
- Department of Pediatrics and Center for Blood Oxygen Transport and Hemostasis, 12264University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Rick Harrison
- Department of Pediatrics, 21785Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Heidi Dalton
- Department of Pediatrics and Heart and Vascular Institute, 3313Inova Fairfax Hospital, Fall Church, VA, USA
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
31
|
Ahmad H, Wood RJ, Avansino JR, Calkins CM, Dickie BH, Durham MM, Frischer J, Fuller M, Ralls M, Reeder RW, Rentea RM, Rollins MD, Saadai P, Oelschlager AMEA, Breech LL, Hewitt GD, Kluivers K, van Leeuwen KD, McCracken KA. Does presence of a VACTERL anomaly predict an associated gynecologic anomaly in females with anorectal malformations?: A Pediatric Colorectal and Pelvic Learning Consortium Study. J Pediatr Surg 2023; 58:471-477. [PMID: 35879143 DOI: 10.1016/j.jpedsurg.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND VACTERL association is defined by the presence of 3 or more anomalies in any of the following systems: vertebral, anorectal, cardiac, trachea-esophageal, renal, or limb. This study hypothesized that the presence of VACTERL association would correlate with an increased risk of gynecologic anomalies in patients with anorectal malformation (ARM). METHODS This study is a cross-sectional, retrospective analysis from the prospectively collected, multicenter registry of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The 834 female patients with ARM who were enrolled in the registry by January 1, 2020 were included in this study. The relationship of VACTERL association with presence of a gynecologic anomaly was evaluated with Fisher's exact test. The relationship of each VACTERL system with presence of a gynecologic anomaly was assessed in patients with cloaca, rectovestibular fistulas and rectoperineal fistulas. P-values reported were based on a 2-sided alternative and considered significant when less than 0.05. RESULTS 834 patients with ARM underwent VACTERL screening and gynecologic evaluation with the three most common subtypes being cloaca (n = 215, 25.8%), rectovestibular fistula (n = 191, 22.9%) and rectoperineal fistula (n = 194, 23.3%). A total of 223 (26.7%) patients with ARM had gynecologic anomalies. VACTERL association was seen in 380 (45.6%) of patients with ARM. Gynecologic anomalies were present in 149 (39.1%) vs. 74 (16.3%) of subjects with vs. without VACTERL association (p < 0.001). VACTERL association did not significantly increase the risk of gynecologic anomaly in patients with cloaca and VACTERL (n = 88, 61.5%) vs. cloaca without VACTERL (n = 39, 54.2% p = 0.308). VACTERL association increased the risk of gynecologic anomalies in patients with rectoperineal fistulas (n = 7, 14.9% vs n = 9, 6.1% p = 0.014) and rectovestibular fistulas (n = 19, 31.1% vs. n = 13, 10.0% p<0.001). In patients with ARM who had a VACTERL association, when one of the associated anomalies was renal, there was an even higher risk of having an associated gynecologic anomaly (n = 138, 44.2% vs. n = 85, 16.3% p<0.001). CONCLUSIONS VACTERL association in patients with rectoperineal and rectovestibular fistulas correlates with an increased risk of gynecologic anomalies. The presence of VACTERL associated findings, especially renal, should prompt a thorough evaluation of the gynecologic system. LEVEL OF EVIDENCE III. Retrospective comparative study.
Collapse
Affiliation(s)
- Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, FOB 6B, Columbus, OH 43205, United States; Seattle Children's Hospital, Seattle, WA, United States.
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, FOB 6B, Columbus, OH 43205, United States
| | | | - Casey M Calkins
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | | | - Megan M Durham
- Emory-CHOA Pediatric Institute, Atlanta, GA, United States
| | - Jason Frischer
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | | | - Matt Ralls
- University of Michigan, Ann Arbor, MI, United States
| | - Ron W Reeder
- University of Utah School of Medicine, Salt Lake City, UT, United States
| | | | - Michael D Rollins
- Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Payam Saadai
- University of California Davis, Davis, CA, United States
| | | | - Lesley L Breech
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Geri D Hewitt
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, FOB 6B, Columbus, OH 43205, United States
| | - Kirsten Kluivers
- Radboud University Medical Centre Nijmegen, Nijmegen, the Netherlands
| | | | - Katherine A McCracken
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, FOB 6B, Columbus, OH 43205, United States
| |
Collapse
|
32
|
Miya TR, Furlong-Dillard JM, Sizemore JM, Meert KL, Dalton HJ, Reeder RW, Bailly DK. Association Between Mortality and Ventilator Parameters in Children With Respiratory Failure on ECMO. Respir Care 2023; 68:592-601. [PMID: 36787913 PMCID: PMC10171354 DOI: 10.4187/respcare.10107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND In refractory respiratory failure, extracorporeal membrane oxygenation (ECMO) is a rescue therapy to prevent ventilator-induced lung injury. Optimal ventilator parameters during ECMO remain unknown. Our objective was to describe the association between mortality and ventilator parameters during ECMO for neonatal and pediatric respiratory failure. METHODS We performed a secondary analysis of the Bleeding and Thrombosis on ECMO dataset. Ventilator parameters included breathing frequency, tidal volume, peak inspiratory pressure, PEEP, dynamic driving pressure, pressure support, mean airway pressure, and FIO2 . Parameters were evaluated before cannulation, on the calendar day of ECMO initiation (ECMO day 1), and the day before ECMO separation. RESULTS Of 237 included subjects analyzed, 64% were neonates, of whom 36% had a congenital diaphragmatic hernia. Of all the subjects, 67% were supported on venoarterial ECMO. Overall in-hospital mortality was 35% (n = 83). The median (interquartile range) PEEP on ECMO day 1 was 8 (5.0-10.0) cm H2O for neonates and 10 (8.0-10.0) cm H2O for pediatric subjects. By multivariable analysis, higher PEEP on ECMO day 1 in neonates was associated with lower odds of in-hospital mortality (odds ratio 0.77, 95% CI 0.62-0.92; P = .01), with a further amplified effect in neonates with congenital diaphragmatic hernia (odds ratio 0.59, 95% CI 0.41-0.86; P = .005). No ventilator type or parameter was associated with mortality in pediatric subjects. CONCLUSIONS Avoiding low PEEP on ECMO day 1 for neonates on ECMO may be beneficial, particularly those with a congenital diaphragmatic hernia. No additional ventilator parameters were associated with mortality in either neonatal or pediatric subjects. PEEP is a modifiable parameter that may improve neonatal survival during ECMO and requires further investigation.
Collapse
Affiliation(s)
- Tadashi R Miya
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah.
| | - Jamie M Furlong-Dillard
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Johnna M Sizemore
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - David K Bailly
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| |
Collapse
|
33
|
Berg RA, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM. Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study. Crit Care Med 2023; 51:91-102. [PMID: 36519983 PMCID: PMC9970166 DOI: 10.1097/ccm.0000000000005715] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort. DESIGN Prospective observational study. SETTING Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020. PATIENTS Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051). CONCLUSIONS These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.
Collapse
Affiliation(s)
- Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
34
|
Smith CA, Kwon EG, Nicassio L, Glazer D, Avansino J, Durham MM, Frischer J, Calkins C, Rentea RM, Ralls M, Saadai P, Badillo A, Fuller M, Wood RJ, Rollins MD, Van Leeuwen K, Reeder RW, Lewis KE, Rice-Townsend SE. Fecal continence disparities in patients with idiopathic constipation treated at referral institutions for pediatric colorectal surgery. J Pediatr Surg 2023; 58:56-63. [PMID: 36283846 DOI: 10.1016/j.jpedsurg.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Fecal continence is a concern for many patients with idiopathic constipation and can significantly impact quality of life. It is unknown whether racial, ethnic, and socioeconomic disparities are seen in fecal continence within the idiopathic constipation population. We aimed to evaluate fecal continence and associated demographic characteristics in children with idiopathic constipation referred for surgical evaluation. METHODS A multicenter retrospective study of children with idiopathic constipation was performed at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). All patients >3y of age with idiopathic constipation diagnosis were included. The primary outcome was fecal continence, categorized as complete (no accidents ever), daytime (no accidents during the day), partial (occasional incontinence day/night), and none (incontinent). We evaluated for associations between fecal continence and race, sex, age, insurance status, and other patient-level factors, employing Kruskal-Wallis and trend tests. RESULTS 458 patients with idiopathic constipation from 12 sites were included. The median age of diagnosis was 4.1 years. Only 25% of patients referred for surgical evaluation were completely continent. Age at the visit was significantly associated with fecal continence level (p = 0.002). In addition, patients with public and mixed public and private insurance had lower levels of continence (p<0.001). Patients with developmental delay were also more likely to have lower continence levels (p = 0.009) while diagnoses such as anxiety, ADD/ADHD, autism, depression, obsessive-compulsive disorder were not associated. Approximately 30% of patients had an ACE operation (antegrade continence enema) at a median age of 9.2 years at operation. Black patients were significantly less likely to undergo ACE operation (p = 0.016) when compared to white patients. CONCLUSION We observed data that suggest differences in fecal incontinence rates based on payor status. Further investigation is needed to characterize these potential areas of disparate care. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
| | - Eustina G Kwon
- Seattle Children's Hospital, Seattle, WA, United States.
| | | | - Deb Glazer
- Seattle Children's Hospital, Seattle, WA, United States
| | | | - Megan M Durham
- Emory + Children's Pediatric Institute, Atlanta, GA, United States
| | - Jason Frischer
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Casey Calkins
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | | | - Matthew Ralls
- C.S. Mott Children's Michigan, Ann Arbor, MI, United States
| | | | | | - Megan Fuller
- Boys Town National Research Hospital, Boys Town, NE, United States
| | - Richard J Wood
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Michael D Rollins
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, United States
| | | | - Ron W Reeder
- University of Utah, Salt Lake City, UT, United States
| | | | | | | |
Collapse
|
35
|
Horvat CM, Fabio A, Nagin DS, Banks RK, Qin Y, Park HJ, Kernan KF, Canna SW, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Reeder RW, Sward K, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Mortality Risk in Pediatric Sepsis Based on C-reactive Protein and Ferritin Levels. Pediatr Crit Care Med 2022; 23:968-979. [PMID: 36178701 PMCID: PMC9722561 DOI: 10.1097/pcc.0000000000003074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Interest in using bedside C-reactive protein (CRP) and ferritin levels to identify patients with hyperinflammatory sepsis who might benefit from anti-inflammatory therapies has piqued with the COVID-19 pandemic experience. Our first objective was to identify patterns in CRP and ferritin trajectory among critically ill pediatric sepsis patients. We then examined the association between these different groups of patients in their inflammatory cytokine responses, systemic inflammation, and mortality risks. DATA SOURCES A prospective, observational cohort study. STUDY SELECTION Children with sepsis and organ failure in nine pediatric intensive care units in the United States. DATA EXTRACTION Two hundred and fifty-five children were enrolled. Five distinct clinical multi-trajectory groups were identified. Plasma CRP (mg/dL), ferritin (ng/mL), and 31 cytokine levels were measured at two timepoints during sepsis (median Day 2 and Day 5). Group-based multi-trajectory models (GBMTM) identified groups of children with distinct patterns of CRP and ferritin. DATA SYNTHESIS Group 1 had normal CRP and ferritin levels ( n = 8; 0% mortality); Group 2 had high CRP levels that became normal, with normal ferritin levels throughout ( n = 80; 5% mortality); Group 3 had high ferritin levels alone ( n = 16; 6% mortality); Group 4 had very high CRP levels, and high ferritin levels ( n = 121; 11% mortality); and Group 5 had very high CRP and very high ferritin levels ( n = 30; 40% mortality). Cytokine responses differed across the five groups, with ferritin levels correlated with macrophage inflammatory protein 1α levels and CRP levels reflective of many cytokines. CONCLUSIONS Bedside CRP and ferritin levels can be used together to distinguish groups of children with sepsis who have different systemic inflammation cytokine responses and mortality risks. These data suggest future potential value in personalized clinical trials with specific targets for anti-inflammatory therapies.
Collapse
Affiliation(s)
- Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Fabio
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S. Nagin
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | | | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A. Berg
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI., Central Michigan University, Mt Pleasant MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital Immune Surveillance Laboratory, and Nationwide Children’s Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Rick E. Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F. Zuppa
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
36
|
Cashen K, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fink EL, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Meert KL. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatr Crit Care Med 2022; 23:784-792. [PMID: 35880872 PMCID: PMC9529841 DOI: 10.1097/pcc.0000000000003045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). DESIGN Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. SETTING Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621). CONCLUSIONS In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.
Collapse
Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Aisha H Frazier
- Department of Pediatrics, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| |
Collapse
|
37
|
Kamps NN, Banks R, Reeder RW, Berg RA, Newth CJ, Pollack MM, Meert KL, Carcillo JA, Mourani PM, Sorenson S, Varni JW, Cengiz P, Zimmerman JJ. The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock. Pediatr Crit Care Med 2022; 23:687-697. [PMID: 35695852 PMCID: PMC9444900 DOI: 10.1097/pcc.0000000000003009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes. DESIGN Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity. SETTING Twelve academic PICUs in the United States. PATIENTS Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212). CONCLUSIONS This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.
Collapse
Affiliation(s)
- Nicole N Kamps
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Russell Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Murray M Pollack
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Peter M Mourani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Samuel Sorenson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - James W Varni
- Department of Pediatrics, Texas A&M University, College Station, TX
| | - Pelin Cengiz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
38
|
Short SS, Reeder RW, Lewis KE, Dickie B, Grabowski J, Sepuha T, Durham MM, Frischer J, Badillo A, Calkins CM, Rentea RM, Ralls M, Wood RJ, Fuller MK, van Leeuwen K, Avansino JR, Austin K, Rollins MD. The presence of a neurodiverse disorder is associated with increased use of antegrade enema therapy in children with severe constipation: A study from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). J Pediatr Surg 2022; 57:1676-1680. [PMID: 35597676 DOI: 10.1016/j.jpedsurg.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas. MATERIALS AND METHODS Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's. RESULTS 372 patients requiring a BMP were identified. 95 patients (58 autism spectrum, 54 developmental delay) were neurodiverse, and 277 patients were not. Neurodiverse patients had a higher prevalence of enema therapy 62.1% (59/95) vs. 54.9% (152/273) and use of antegrade enema therapy 33.7% (32/95) vs. 21.2% (58/273), p = 0.126. Neurodiverse patients were older 37.9% (36/95) > 12 years vs. 23.1% (63/273), p = 0.001 and 47.6% (10/21) were changed from laxative to enema therapy over time. 80% (8/10) of those changed from laxatives to enemas used antegrade therapy. 67.3% (35/52) of neurodiverse patients followed over time were on enema therapy at the most recent visit with 80% (28/35) requiring antegrade therapy. CONCLUSION A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Scott S Short
- Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, USA.
| | | | | | | | | | | | | | | | | | | | | | - Matt Ralls
- C.S. Mott Children's Hospital/Univ. of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | | | - Michael D Rollins
- Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, USA
| |
Collapse
|
39
|
Salud D, Reeder RW, Banks RK, Meert KL, Berg RA, Zuppa A, Newth CJ, Hall MW, Quasney M, Sapru A, Carcillo JA, McQuillen PS, Mourani PM, Varni JW, Zimmerman JJ. Association of Pathogen Type With Outcomes of Children Encountering Community-Acquired Pediatric Septic Shock. Pediatr Crit Care Med 2022; 23:635-645. [PMID: 35687094 PMCID: PMC9529775 DOI: 10.1097/pcc.0000000000003001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the association of pathogen type with mortality, functional status, and health-related quality of life (HRQL) among children at hospital discharge/1 month following hospitalization for septic shock. DESIGN Secondary database analysis of a prospective, descriptive cohort investigation. SETTING Twelve academic PICUs in the United States. PATIENTS Critically ill children, 1 month to 18 years old, enrolled from 2013 to 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Association of clinical outcomes with pathogen type was assessed for all patients and separately for surviving patients enrolled in the primary Life After Pediatric Sepsis Evaluation (LAPSE) investigation. For this secondary analysis, we predicted that age would be associated with pathogen type and outcomes, and accordingly, it was incorporated as a confounding variable in primary analyses. Among 389 children enrolled with septic shock, at 1 month/hospital discharge, we observed no statistically significant differences in relation to pathogen types for the composite outcome mortality or substantial new functional morbidity: no causative organism identified (27% [28/103]), pure viral infections (26% [24/91]), pure bacterial/fungal infections (25% [31/125]), and bacterial/fungal+viral coinfections (33% [23/70]). Similarly, we observed no statistically significant differences in relation to pathogen types for the composite outcome, mortality, or persistent serious deterioration of HRQL: no causative organism identified (43% [44/103]), pure viral infections (33% [30/91]), pure bacterial/fungal infections (46% [57/125]), and bacterial/fungal+viral coinfections (43% [30/70]). However, we did identify statistically significant associations between pathogen type and the outcome ventilator-free days ( p = 0.0083) and PICU-free days (0.0238). CONCLUSIONS This secondary analysis of the LAPSE database identified no statistically significant association of pathogen type with composite mortality and morbidity outcomes. However, pathogen type may be associated with PICU resources employed to treat sepsis organ dysfunction. Ultimately, pediatric septic shock was frequently associated with adverse patient-centered, clinically meaningful outcomes regardless of infectious disease pathogen type.
Collapse
Affiliation(s)
- Derek Salud
- Touro College of Osteopathic Medicine, New York, NY
| | | | | | - Kathleen L Meert
- Children’s Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI
| | - Robert A Berg
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Athena Zuppa
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Mark W Hall
- Nationwide Children’s Hospital, Columbus, OH
| | - Michael Quasney
- CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A Carcillo
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | | | | | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
| | | |
Collapse
|
40
|
Tham SW, Rollins MD, Reeder RW, Lewis KE, Calkins CM, Avansino JR, Palermo TM. Health-related quality of life in children with Hirschsprung disease and children with functional constipation: Parent-child variability. J Pediatr Surg 2022; 57:1694-1700. [PMID: 35491270 PMCID: PMC9296600 DOI: 10.1016/j.jpedsurg.2022.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Health-related quality of life (HRQOL) is an important outcome among children with Hirschsprung Disease (HD), but there are challenges in interpreting findings in previous studies owing to the choice of a comparator group and informant. We compared parent-proxy versus child self-report HRQOL in children with HD to children with functional constipation (FC) and examined predictors of HRQOL. METHODS Data of 126 children (5-18 years, 60.3% male, HD: n = 52, FC: n = 74) were acquired from the Pediatric Colorectal and Pelvic Learning Consortium. Demographics, clinical variables, HRQOL (Pediatric Quality of Life Inventory parent-proxy; child self-report) and functional outcomes (Baylor Continence Scale, Cleveland Clinic Constipation Scoring System) were collected. RESULTS Parent and child HRQOL was similar for both cohorts, with higher scores on physical functioning and lower scores on emotional and school functioning. For children with HD, demographics and clinical variables did not predict HRQOL in multivariable regression models. For children with FC, greater severity of constipation predicted lower HRQOL (parent-proxy: B = -2.14, p < 0.001; child: B = -1.75, p = 0.001). Parent-child agreement on HRQOL scores was poor to moderate in the HD group (intraclass correlations (ICC)=0.38-0.74), but moderate to excellent in the FC group (ICC=0.63-0.84). Furthermore, parents of children with FC and ≤10 years overestimated children's HRQOL (proportional OR 4.59 (1.63, 13.85); p = 0.004). CONCLUSION Clinical symptoms and demographic factors did not predict HRQOL among children with HD, highlighting the need to examine other biopsychosocial factors to understand long term HRQOL. Low parent-child HRQOL agreement in children with HD demonstrates the importance of obtaining parent and child perspectives. LEVEL OF EVIDENCE III. TYPE OF STUDY Prognosis study.
Collapse
Affiliation(s)
- See Wan Tham
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA; Seattle Children's Research Institute, M/S CURE-3, PO Box 5371, Seattle, WA 98145, USA.
| | - Michael D Rollins
- University of Utah Health, Salt Lake City, UT, USA,Division of Pediatric Surgery, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Ron W Reeder
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Katelyn E Lewis
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Casey M Calkins
- Division of Pediatric Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Jeffrey R Avansino
- Department of Surgery, University of Washington School of Medicine, Division of Pediatric General and Thoracic Surgery, Seattle Children’s, Seattle, WA USA
| | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA,Seattle Children’s Research Institute, Seattle, WA, USA
| |
Collapse
|
41
|
Rocque BG, Jensen H, Reeder RW, Kulkarni AV, Pollack IF, Wellons JC, Naftel RP, Jackson EM, Whitehead WE, Pindrik JA, Limbrick DD, McDonald PJ, Tamber MS, Hankinson TC, Hauptman JS, Krieger MD, Chu J, Simon TD, Riva-Cambrin J, Kestle JRW, Rozzelle CJ. Endoscopic third ventriculostomy in previously shunt-treated patients. J Neurosurg Pediatr 2022; 30:1-9. [PMID: 35907200 PMCID: PMC9884313 DOI: 10.3171/2022.6.peds22177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Endoscopic third ventriculostomy (ETV) is an option for treatment of hydrocephalus, including for patients who have a history of previous treatment with CSF shunt insertion. The purpose of this study was to report the success of postshunt ETV by using data from a multicenter prospective registry. METHODS Prospectively collected data in the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (i.e., HCRN Registry) were reviewed. Children who underwent ETV between 2008 and 2019 and had a history of previous treatment with a CSF shunt were included. A Kaplan-Meier survival curve was created for the primary outcome: time from postshunt ETV to subsequent CSF shunt placement or revision. Univariable Cox proportional hazards models were created to evaluate for an association between clinical and demographic variables and subsequent shunt surgery. Postshunt ETV complications were also identified and categorized. RESULTS A total of 203 children were included: 57% male and 43% female; 74% White, 23% Black, and 4% other race. The most common hydrocephalus etiologies were postintraventricular hemorrhage secondary to prematurity (56, 28%) and aqueductal stenosis (42, 21%). The ETV Success Score ranged from 10 to 80. The median patient age was 4.1 years. The overall success of postshunt ETV at 6 months was 41%. Only the surgeon's report of a clear view of the basilar artery was associated with a lower likelihood of postshunt ETV failure (HR 0.43, 95% CI 0.23-0.82, p = 0.009). None of the following variables were associated with postshunt ETV success: age at the time of postshunt ETV, etiology of hydrocephalus, sex, race, ventricle size, number of previous shunt operations, ETV performed at time of shunt infection, and use of external ventricular drainage. Overall, complications were reported in 22% of patients, with CSF leak (8.6%) being the most common complication. CONCLUSIONS Postshunt ETV was successful in treating hydrocephalus, without subsequent need for a CSF shunt, in 41% of patients, with a clear view of the basilar artery being the only variable significantly associated with success. Complications occurred in 22% of patients. ETV is an option for treatment of hydrocephalus in children who have previously undergone shunt placement, but with a lower than expected likelihood of success.
Collapse
Affiliation(s)
- Brandon G. Rocque
- Department of Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham, Alabama
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ian F. Pollack
- Department of Neurosurgery, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania
| | - John C. Wellons
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Robert P. Naftel
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Eric M. Jackson
- Department of Neurosurgery, The Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland
| | | | - Jonathan A. Pindrik
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - David D. Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Patrick J. McDonald
- Division of Neurosurgery, British Columbia Children’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mandeep S. Tamber
- Division of Neurosurgery, British Columbia Children’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Todd C. Hankinson
- Department of Neurosurgery, Children’s Hospital Colorado, Colorado Springs, Colorado
| | - Jason S. Hauptman
- Department of Neurosurgery, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Mark D. Krieger
- Department of Neurosurgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Jason Chu
- Department of Neurosurgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Tamara D. Simon
- Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Jay Riva-Cambrin
- Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, Canada
| | - John R. W. Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis J. Rozzelle
- Department of Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham, Alabama
| | | |
Collapse
|
42
|
Maddux AB, Zimmerman JJ, Banks RK, Reeder RW, Meert KL, Czaja AS, Berg RA, Sapru A, Carcillo JA, Newth CJL, Quasney MW, Mourani PM. Health Resource Use in Survivors of Pediatric Septic Shock in the United States. Pediatr Crit Care Med 2022; 23:e277-e288. [PMID: 35250001 PMCID: PMC9203867 DOI: 10.1097/pcc.0000000000002932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate postdischarge health resource use in pediatric survivors of septic shock and determine patient and hospitalization factors associated with health resource use. DESIGN Secondary analyses of a multicenter prospective observational cohort study. SETTING Twelve academic PICUs. PATIENTS Children greater than or equal to 1 month and less than 18 years old hospitalized for community-acquired septic shock who survived to 1 year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For 308/338 patients (91%) with baseline and greater than or equal to one postdischarge survey, we evaluated readmission, emergency department (ED) visits, new medication class, and new device class use during the year after sepsis. Using negative binomial regression with bidirectional stepwise selection, we identified factors associated with each outcome. Median age was 7 years (interquartile range, 2-13), 157 (51%) had a chronic condition, and nearly all patients had insurance (private [n = 135; 44%] or government [n = 157; 51%]). During the year after sepsis, 128 patients (42%) were readmitted, 145 (47%) had an ED visit, 156 (51%) started a new medication class, and 102 (33%) instituted a new device class. Having a complex chronic condition was independently associated with readmission and ED visit. Documented infection and higher sum of Pediatric Logistic Organ Dysfunction--2 hematologic score were associated with readmission, whereas younger age and having a noncomplex chronic condition were associated with ED visit. Factors associated with new medication class use were private insurance, neurologic insult, and longer PICU stays. Factors associated with new device class use were preadmission chemotherapy or radiotherapy, presepsis Functional Status Scale score, and ventilation duration greater than or equal to 10 days. Of patients who had a new medication or device class, most had a readmission (56% and 61%) or ED visit (62% and 67%). CONCLUSIONS Children with septic shock represent a high-risk cohort with high-resource needs after discharge. Interventions and targeted outcomes to mitigate postdischarge resource use may differ based on patients' preexisting conditions.
Collapse
Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Jerry J. Zimmerman
- Seattle Children’s Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA
| | | | | | - Kathleen L. Meert
- Children’s Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI
| | - Angela S. Czaja
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Anil Sapru
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christopher J. L. Newth
- Department of Pediatrics, Section of Critical Care, University of Southern California, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Michael W. Quasney
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, AR
| |
Collapse
|
43
|
Qin Y, Kernan KF, Fan Z, Park HJ, Kim S, Canna SW, Kellum JA, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Michael Dean J, Carcillo JA. Machine learning derivation of four computable 24-h pediatric sepsis phenotypes to facilitate enrollment in early personalized anti-inflammatory clinical trials. Crit Care 2022; 26:128. [PMID: 35526000 PMCID: PMC9077858 DOI: 10.1186/s13054-022-03977-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy-induced thrombocytopenia-associated multiple organ failure and hyperinflammatory macrophage activation syndrome are important causes of late pediatric sepsis mortality that are often missed or have delayed diagnosis. The National Institutes of General Medical Science sepsis research working group recommendations call for application of new research approaches in extant clinical data sets to improve efficiency of early trials of new sepsis therapies. Our objective is to apply machine learning approaches to derive computable 24-h sepsis phenotypes to facilitate personalized enrollment in early anti-inflammatory trials targeting these conditions. METHODS We applied consensus, k-means clustering analysis to our extant PHENOtyping sepsis-induced Multiple organ failure Study (PHENOMS) dataset of 404 children. 24-hour computable phenotypes are derived using 25 available bedside variables including C-reactive protein and ferritin. RESULTS Four computable phenotypes (PedSep-A, B, C, and D) are derived. Compared to all other phenotypes, PedSep-A patients (n = 135; 2% mortality) were younger and previously healthy, with the lowest C-reactive protein and ferritin levels, the highest lymphocyte and platelet counts, highest heart rate, and lowest creatinine (p < 0.05); PedSep-B patients (n = 102; 12% mortality) were most likely to be intubated and had the lowest Glasgow Coma Scale Score (p < 0.05); PedSep-C patients (n = 110; mortality 10%) had the highest temperature and Glasgow Coma Scale Score, least pulmonary failure, and lowest lymphocyte counts (p < 0.05); and PedSep-D patients (n = 56, 34% mortality) had the highest creatinine and number of organ failures, including renal, hepatic, and hematologic organ failure, with the lowest platelet counts (p < 0.05). PedSep-D had the highest likelihood of developing thrombocytopenia-associated multiple organ failure (Adj OR 47.51 95% CI [18.83-136.83], p < 0.0001) and macrophage activation syndrome (Adj OR 38.63 95% CI [13.26-137.75], p < 0.0001). CONCLUSIONS Four computable phenotypes are derived, with PedSep-D being optimal for enrollment in early personalized anti-inflammatory trials targeting thrombocytopenia-associated multiple organ failure and macrophage activation syndrome in pediatric sepsis. A computer tool for identification of individual patient membership ( www.pedsepsis.pitt.edu ) is provided. Reproducibility will be assessed at completion of two ongoing pediatric sepsis studies.
Collapse
Affiliation(s)
- Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Zhenjiang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Soyeon Kim
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott W Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Russell Banks
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Ron W Reeder
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Holubkov
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel A Notterman
- University of Utah, Salt Lake City, UT, USA
- Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
| |
Collapse
|
44
|
Arynchyna-Smith A, Rozzelle CJ, Jensen H, Reeder RW, Kulkarni AV, Pollack IF, Wellons JC, Naftel RP, Jackson EM, Whitehead WE, Pindrik JA, Limbrick DD, McDonald PJ, Tamber MS, O’Neill BR, Hauptman JS, Krieger MD, Chu J, Simon TD, Riva-Cambrin J, Kestle JRW, Rocque BG. Endoscopic third ventriculostomy revision after failure of initial endoscopic third ventriculostomy and choroid plexus cauterization. J Neurosurg Pediatr 2022; 30:1-10. [PMID: 35453104 PMCID: PMC9587128 DOI: 10.3171/2022.3.peds224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Primary treatment of hydrocephalus with endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC) is well described in the neurosurgical literature, with wide reported ranges of success and complication rates. The purpose of this study was to describe the safety and efficacy of ETV revision after initial ETV+CPC failure. METHODS Prospectively collected data in the Hydrocephalus Clinical Research Network Core Data Project registry were reviewed. Children who underwent ETV+CPC as the initial treatment for hydrocephalus between 2013 and 2019 and in whom the initial ETV+CPC was completed (i.e., not abandoned) were included. Log-rank survival analysis (the primary analysis) was used to compare time to failure (defined as any other surgical treatment for hydrocephalus or death related to hydrocephalus) of initial ETV+CPC versus that of ETV revision by using random-effects modeling to account for the inclusion of patients in both the initial and revision groups. Secondary analysis compared ETV revision to shunt placement after failure of initial ETV+CPC by using the log-rank test, as well as shunt failure after ETV+CPC to that after ETV revision. Cox regression analysis was used to identify predictors of failure among children treated with ETV revision. RESULTS The authors identified 521 ETV+CPC procedures that met their inclusion criteria. Ninety-one children underwent ETV revision after ETV+CPC failure. ETV revision had a lower 1-year success rate than initial ETV+CPC (29.5% vs 45%, p < 0.001). ETV revision after initial ETV+CPC failure had a lower success rate than shunting (29.5% vs 77.8%, p < 0.001). Shunt survival after initial ETV+CPC failure was not significantly different from shunt survival after ETV revision failure (p = 0.963). Complication rates were similar for all examined surgical procedures (initial ETV+CPC, ETV revision, ventriculoperitoneal shunt [VPS] placement after ETV+CPC, and VPS placement after ETV revision). Only young age was predictive of ETV revision failure (p = 0.02). CONCLUSIONS ETV revision had a significantly lower 1-year success rate than initial ETV+CPC and VPS placement after ETV+CPC. Complication rates were similar for all studied procedures. Younger age, but not time since initial ETV+CPC, was a risk factor for ETV revision failure.
Collapse
Affiliation(s)
- Anastasia Arynchyna-Smith
- Department of Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Curtis J. Rozzelle
- Department of Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ian F. Pollack
- Department of Neurosurgery, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania
| | - John C. Wellons
- Department of Neurosurgery, Vanderbilt University Medical Center; and Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Robert P. Naftel
- Department of Neurosurgery, Vanderbilt University Medical Center; and Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Eric M. Jackson
- Department of Neurosurgery, The Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland
| | | | - Jonathan A. Pindrik
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - David D. Limbrick
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Patrick J. McDonald
- Division of Neurosurgery, British Columbia Children’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Madeep S. Tamber
- Division of Neurosurgery, British Columbia Children’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Brent R. O’Neill
- Department of Neurosurgery, Children’s Hospital Colorado, Colorado Springs, Colorado
| | - Jason S. Hauptman
- Department of Neurosurgery, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Mark D. Krieger
- Department of Neurosurgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Jason Chu
- Department of Neurosurgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Tamara D. Simon
- Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Jay Riva-Cambrin
- Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, Canada
| | - John R. W. Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon G. Rocque
- Department of Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | |
Collapse
|
45
|
Yates AR, Berger JT, Reeder RW, Banks R, Mourani PM, Berg RA, Carcillo JA, Carpenter T, Hall MW, Meert KL, McQuillen PS, Pollack MM, Sapru A, Notterman DA, Holubkov R, Dean JM, Wessel DL. Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients. Pediatr Crit Care Med 2022; 23:245-254. [PMID: 35200229 PMCID: PMC9058189 DOI: 10.1097/pcc.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery. DESIGN Observational cohort study. SETTING PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals. PATIENTS Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days. CONCLUSIONS Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.
Collapse
Affiliation(s)
- Andrew R. Yates
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | | | | | | | - Peter M. Mourani
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Robert A. Berg
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Todd Carpenter
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark W. Hall
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Kathleen L. Meert
- Children’s Hospital of Michigan, Detroit, Michigan; Central Michigan University, Mt. Pleasant, MI
| | | | | | - Anil Sapru
- Mattel Children’s Hospital, Los Angeles, CA
| | | | | | | | | |
Collapse
|
46
|
Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, Burns C, Diddle JW, Federman M, Fernandez R, Franzon D, Frazier AH, Friess SH, Graham K, Hehir D, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, Morgan RW, Nadkarni VM, Naim MY, Palmer CA, Schneiter C, Sharron MP, Siems A, Srivastava N, Tabbutt S, Tilford B, Viteri S, Berg RA, Bell MJ, Carcillo JA, Carpenter TC, Dean JM, Fink EL, Hall M, McQuillen PS, Meert KL, Mourani PM, Notterman D, Pollack MM, Sapru A, Wessel D, Yates AR, Zuppa AF. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. JAMA 2022; 327:934-945. [PMID: 35258533 PMCID: PMC8905390 DOI: 10.1001/jama.2022.1738] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes. OBJECTIVE To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings. DESIGN, SETTING, AND PARTICIPANTS A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021). INTERVENTION During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge. RESULTS Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47). CONCLUSIONS AND RELEVANCE In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02837497.
Collapse
Affiliation(s)
| | | | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Aisha H Frazier
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - David Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Ashley Siems
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Michael J Bell
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| |
Collapse
|
47
|
Tsitsiklis A, Osborne CM, Kamm J, Williamson K, Kalantar K, Dudas G, Caldera S, Lyden A, Tan M, Neff N, Soesanto V, Harris JK, Ambroggio L, Maddux AB, Carpenter TC, Reeder RW, Locandro C, Simões EAF, Leroue MK, Hall MW, Zuppa AF, Carcillo J, Meert KL, Sapru A, Pollack MM, McQuillen PS, Notterman DA, Dean JM, Zinter MS, Wagner BD, DeRisi JL, Mourani PM, Langelier CR. Lower respiratory tract infections in children requiring mechanical ventilation: a multicentre prospective surveillance study incorporating airway metagenomics. The Lancet Microbe 2022; 3:e284-e293. [PMID: 35544065 PMCID: PMC9446282 DOI: 10.1016/s2666-5247(21)00304-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alexandra Tsitsiklis
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Christina M Osborne
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | | | - Gytis Dudas
- Gothenburg Global Biodiversity Centre, Gothenburg, Sweden
| | - Saharai Caldera
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | | | - Norma Neff
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Todd C Carpenter
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chris Locandro
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric A F Simões
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew K Leroue
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Mark W Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Anil Sapru
- Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital and George Washington School of Medicine and Health Services, Washington, DC, USA
| | - Patrick S McQuillen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Matt S Zinter
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Charles R Langelier
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA.
| |
Collapse
|
48
|
Traube C, Tucci M, Nellis ME, Avery KL, McQuillen PS, Fitzgerald JC, Muszynski JA, Cholette JM, Schwarz AJ, Stalets EL, Quaid MA, Hanson SJ, Lacroix J, Reeder RW, Spinella PC. Transfusion-Associated Delirium in Children: No Difference Between Short Storage Versus Standard Issue RBCs. Crit Care Med 2022; 50:173-182. [PMID: 35100190 PMCID: PMC8820396 DOI: 10.1097/ccm.0000000000005393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Primary objective is to determine if transfusion of short storage RBCs compared with standard issue RBCs reduced risk of delirium/coma in critically ill children. Secondary objective is to assess if RBC transfusion was independently associated with delirium/coma. DESIGN This study was performed in two stages. First, we compared patients receiving either short storage or standard RBCs in a multi-institutional prospective randomized controlled trial. Then, we compared all transfused patients in the randomized controlled trial with a single-center cohort of nontransfused patients matched for confounders of delirium/coma. SETTING Twenty academic PICUs who participated in the Age of Transfused Blood in Critically Ill Children trial. PATIENTS Children 3 days to 16 years old who were transfused RBCs within the first 7 days of admission. INTERVENTIONS Subjects were randomized to either short storage RBC study arm (defined as RBCs stored for up to seven days) or standard issue RBC study arm. In addition, subjects were screened for delirium prior to transfusion and every 12 hours after transfusion for up to 3 days. MEASUREMENTS AND MAIN RESULTS Primary outcome measure was development of delirium/coma within 3 days of initial transfusion. Additional outcome measures were dose-response relationship between volume of RBCs transfused and delirium/coma, and comparison of delirium/coma rates between transfused patients and individually matched nontransfused patients. We included 146 subjects in the stage I analysis; 69 were randomized to short storage RBCs and 77 to standard issue. There was no significant difference in delirium/coma development between study arms (79.5% vs 70.1%; p = 0.184). In the stage II analysis, adjusted odds for delirium in the transfused cohort was more than eight-fold higher than in the nontransfused matched cohort, even after controlling for hemoglobin (adjusted odds ratio, 8.9; CI, 2.8-28.4; p < 0.001). CONCLUSIONS RBC transfusions (and not anemia) are independently associated with increased odds of subsequent delirium/coma. However, storage age of RBCs does not affect delirium risk.
Collapse
Affiliation(s)
- Chani Traube
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Marisa Tucci
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Marianne E Nellis
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - K Leslie Avery
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL
| | - Patrick S McQuillen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester, Golisano Children's Hospital, Rochester, NY
| | | | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maureen A Quaid
- Department of Pediatrics, Advocate Children's Hospital, Park Ridge, IL
| | - Sheila J Hanson
- Department of Pediatrics and Children's Wisconsin, Critical Care Section, Medical College of Wisconsin, Milwaukee, WI
| | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
49
|
Prout A, Banks RK, Reeder RW, Zimmerman JJ, Meert KL. Trajectory and Risk Factors of Persistent Decline in Health-Related Quality of Life after Septic Shock in Children with Preexisting Neurologic Disability. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0041-1741402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractPreexisting neurologic disability is common among children with septic shock. Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter cohort study that evaluated health-related quality of life (HRQL) in children with community-acquired septic shock. In this secondary analysis of LAPSE, we described the burden, trajectory, and risk factors for reduced HRQL in children with preexisting neurologic disability. Children (1 month–18 years) with community-acquired septic shock were evaluated for HRQL at baseline (reflecting pre-hospitalization status), day 7 and 28, and month 3, 6, and 12 following admission using the Pediatric Quality of Life Inventory or the Stein–Jessop Functional Status Scale. HRQL was expressed as a percentage of baseline scores. Of 365 evaluable children, 133 (36%) had preexisting neurologic disability. Neurologically disabled children had less decline in HRQL at day 7 (median −15% [interquartile range IQR −38, 8] vs. −22% [−51, −3], p = 0.005) and day 28 (4% [−16, 22] vs. −11% [−37, 7], p < 0.001) than those without neurologic disability, and there was no difference in the extent of decline at month 3 (p = 0.241). Using multivariable modeling, higher baseline HRQL (odds ratio [OR] 1.04 [95% confidence interval [CI] 1.00, 1.08], p = 0.027) and acute renal dysfunction (OR 1.08 [1.02, 1.16], p = 0.007) were associated with HRQL less than 90% of baseline at month 3 in neurologically disabled children who survived. Children with preexisting neurologic disability recover to baseline HRQL after septic shock sooner than those without neurologic disability. Higher baseline HRQL and acute renal dysfunction are risk factors for reduced HRQL in neurologically disabled children who survive sepsis.
Collapse
Affiliation(s)
- Andrew Prout
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Detroit, Michigan, and Central Michigan University College of Medicine, Mt. Pleasant, Michigan, United States
| | - Russell K. Banks
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children's Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA, United States
| | - Kathleen L. Meert
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Detroit, Michigan, and Central Michigan University College of Medicine, Mt. Pleasant, Michigan, United States
| |
Collapse
|
50
|
Ankola AA, Bailly DK, Reeder RW, Cashen K, Dalton HJ, Dolgner SJ, Federman M, Ghassemzadeh R, Himebauch AS, Kamerkar A, Koch J, Kohne J, Lewen M, Srivastava N, Willett R, Alexander PMA. Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis. Front Cardiovasc Med 2022; 8:812881. [PMID: 35097029 PMCID: PMC8792849 DOI: 10.3389/fcvm.2021.812881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac patients. We aimed to identify anticoagulation practices, cardiac diagnoses, and surgical variables associated with bleeding during pediatric cardiac ECMO by combining two established databases, the Collaborative Pediatric Critical Care Research Network (CPCCRN) Bleeding and Thrombosis in ECMO (BATE) and the Extracorporeal Life Support Organization (ELSO) Registry. Methods: All children (<19 years) with a primary cardiac diagnosis managed on ECMO included in BATE from six centers were analyzed. ELSO Registry criteria for bleeding events included pulmonary or intracranial bleeding, or red blood cell transfusion >80 ml/kg on any ECMO day. Bleeding odds were assessed on ECMO Day 1 and from ECMO Day 2 onwards with multivariable logistic regression. Results: There were 187 children with 114 (61%) bleeding events in the study cohort. Biventricular congenital heart disease (94/187, 50%) and cardiac medical diagnoses (75/187, 40%) were most common, and 48 (26%) patients were cannulated directly from cardiopulmonary bypass (CPB). Bleeding events were not associated with achieving pre-specified therapeutic ranges of activated clotting time (ACT) or platelet levels. In multivariable analysis, elevated INR and fibrinogen were associated with bleeding events (OR 1.1, CI 1.0–1.3, p = 0.02; OR 0.77, CI 0.6–0.9, p = 0.004). Bleeding events were also associated with clinical site (OR 4.8, CI 2.0–11.1, p < 0.001) and central cannulation (OR 1.75, CI 1.0–3.1, p = 0.05) but not with cardiac diagnosis, surgical complexity, or cannulation from CPB. Bleeding odds on ECMO day 1 were increased in patients with central cannulation (OR 2.82, 95% CI 1.15–7.08, p = 0.023) and those cannulated directly from CPB (OR 3.32, 95% CI 1.02–11.61, p = 0.047). Conclusions: Bleeding events in children with cardiac diagnoses supported on ECMO were associated with central cannulation strategy and coagulopathy, but were not modulated by achieving pre-specified therapeutic ranges of monitoring assays.
Collapse
Affiliation(s)
- Ashish A. Ankola
- Department of Pediatrics, Divisions of Critical Care and Cardiology, Baylor College of Medicine, Houston, TX, United States
- *Correspondence: Ashish A. Ankola
| | - David K. Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, United States
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Katherine Cashen
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States
| | - Heidi J. Dalton
- Department of Pediatrics and Heart and Vascular Institute, Inova Fairfax Hospital, Fall Church, VA, United States
| | - Stephen J. Dolgner
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, United States
| | - Rod Ghassemzadeh
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Adam S. Himebauch
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Asavari Kamerkar
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Josh Koch
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Joseph Kohne
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
| | - Margaret Lewen
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, United States
| | - Renee Willett
- Department of Pediatrics, Children's National Hospital, Washington, DC, United States
| | - Peta M. A. Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics and Harvard Medical School, Boston, MA, United States
| |
Collapse
|