Traumatic brain injury (TBI) is a leading cause of critical illness and mortality in children. Transfusion of blood products, a common intervention in the management of pediatric TBI, has important implications for related principles, including trauma-induced coagulopathy, cerebral perfusion, and cerebral oxygen delivery. Knowledge gaps persist due to the limited availability of pediatric-specific data regarding blood product transfusion in TBI. In particular, there is a lack of prospective studies defining appropriate specific laboratory thresholds and transfusion targets, as well as insufficient evidence to guide the weighing of potential benefits against transfusion-related risks in this population. Although blood product transfusion in pediatric TBI has been associated with worse clinical outcomes, the underlying mechanisms and contributing factors remain poorly understood. In this review, we aimed to describe the pediatric literature on component and whole blood product transfusion in children with TBI and the pathophysiological mechanisms underlying the development of coagulopathy in this population. In addition, we incorporated available pediatric guidelines and recommendations specific to the setting of acute brain injury.

OBJECTIVE:To develop consensus statements that clinicians can apply to standardize and optimize endotracheal aspirate culture (EAC) practices in hospitalized children with artificial airways who are being evaluated for a bacterial lower respiratory tract infection (LRTI).DESIGN:A modified Delphi consensus process with expert panelists. Panelists conducted a "pre-survey" to itemize respiratory signs of bacterial LRTI. Round 1 included a literature summary and electronic survey of 50 potential statements sent to all panelists. We surveyed panelist opinions using a 5-point Likert scale. We grouped the responses "agree" and "strongly agree" as agreement. Consensus was defined as statements reaching greater than 75% agreement. Round 2 was moderated by an independent expert in consensus methodology. Panelists convened in person in November 2023, discussed any statements not reaching consensus or statements with disagreement, were resurveyed, and finalized statements in real time.SETTING:Electronic surveys and in-person meetings in Baltimore, MD.SUBJECTS:The BrighT STAR (Testing STewardship for Antibiotic Reduction) collaborative along with U.S.-based pediatric experts in critical care, cardiac critical care, infectious diseases, hospital medicine, otolaryngology, pulmonology, and clinical microbiology.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Thirty-eight of 40 invited panelists completed round 1. Of 50 initial statements, 28 reached greater than 90% agreement, 16 had 75-89% agreement, and 6 had less than 75% agreement. Twenty-eight statements were finalized. Round 2 involved 37 panelists: 23 statements were discussed, of which 17 reached an agreement and 6 did not reach consensus. We concluded with 30 statements and 15 sub-statements, 37 of which had greater than 90% agreement. Final statements informed a clinical decision support algorithm.CONCLUSIONS:The BrighT STAR collaborative group achieved consensus for 45 clinical practice statements that can standardize EAC practices, including indications to consider for testing, reasons to defer, optimal specimen collection, and result interpretation. These statements offer a starting point for clinical decision support tools and diagnostic stewardship programs for EAC practices in patients with artificial airways.

OBJECTIVES:To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs.DESIGN:Cross-sectional survey conducted May 2021-January 2022.SETTING:Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative.SUBJECTS:Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%).CONCLUSIONS:Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.

OBJECTIVE:To design and evaluate a clinical decision support (CDS) module to improve guideline concordant venous thromboembolism (VTE) pharmacoprophylaxis prescribing for pediatric inpatients with COVID-19.MATERIALS AND METHODS:The proportion of patients who met our institutional clinical practice guideline's (CPG) criteria for VTE prophylaxis was compared to those who triggered a CDS alert, indicating the patient needed VTE prophylaxis, and to those who were prescribed prophylaxis pre and post the launch of a new VTE CDS module to support VTE pharmacoprophylaxis prescribing. The sensitivity, specificity, positive predictive value (PPV), negative predictive value, F1-score and accuracy of the tool were calculated for the pre- and post-intervention periods using the CPG recommendation as the gold standard. Accuracy was defined as the sum of the true positives and true negatives over the sum of the true positives, false positives, true negatives, and false negatives. Logistic regression was used to identify variables associated with correct thromboprophylaxis prescribing.RESULTS:A significant increase in the proportion of patients triggering a CDS alert occurred in the post-intervention period (44.3% vs. 6.9%, p < .001); however, no reciprocal increase in VTE prophylaxis prescribing was achieved (36.6% vs. 40.9%, p = .53). The updated CDS module had an improved sensitivity (55.0% vs. 13.3%), NPV (44.9% vs. 36.3%), F1-score (66.7% vs. 23.5%), and accuracy (62.5% vs. 42.0%), but an inferior specificity (78.6% vs. 100%) and PPV (84.6% vs. 100%).DISCUSSION:The updated CDS model had an improved accuracy and overall performance in correctly identifying patients requiring VTE prophylaxis. Despite an increase in correct patient identification by the CDS module, the proportion of patients receiving appropriate pharmacologic prophylaxis did not change.CONCLUSION:CDS tools to support correct VTE prophylaxis prescribing need ongoing refinement and validation to maximize clinical utility.

The incidence of venous thrombo‐embolism (VTE) in hospitalized children has increased by 130%–200% over the last two decades. Given this increase, many centers utilize electronic clinical decision support (CDS) to prognosticate VTE risk and recommend prophylaxis. SARS‐CoV‐2 infection (COVID‐19) is a risk factor for VTE; however, CDS developed before the COVID‐19 pandemic may not accurately prognosticate VTE risk in children with COVID‐19. This study's objective was to identify areas to improve thromboprophylaxis recommendations for children with COVID‐19.

BACKGROUND:The optimal monitoring strategy for anticoagulation management in extracorporeal membrane oxygenation (ECMO) remains a clinical controversy. The Extracorporeal Life Support Organization Anticoagulation Guidelines suggest that multiple anticoagulation assays may be needed but do not specify a preferred management strategy.STUDY QUESTION:In adult ECMO patients, which anticoagulation assays demonstrate the highest correlation with unfractionated heparin (UFH) dose requirements?STUDY DESIGN:We performed a retrospective chart review of adult patients cannulated to ECMO between February 2013 and July 2015.MEASURES AND OUTCOMES:The primary outcome was the correlation between activated clotting time (ACT), activated partial thromboplastin time (aPTT), and anti-Xa and UFH dose. Secondary outcomes included correlations between anticoagulation assays. Correlations were calculated for the entire cohort, with subgroup analysis of venoarterial and venovenous ECMO patients.RESULTS:Forty-eight patients were included in the analysis, 26 initially cannulated to venoarterial ECMO and 22 to veno-venous ECMO. The median duration of ECMO therapy was 7 days. Mean UFH requirements were 1149 units/h or 15.3 units/kg/h. Total UFH dose was most correlated with anti-Xa levels (r = 0.467), whereas weight-based heparin dose was most correlated with aPTT (0.405). For correlations between anticoagulation assays, anti-Xa and aPTT were more highly correlated with each other (r = 0.633) compared with ACT.CONCLUSIONS:In adult patients requiring ECMO, anti-Xa and aPTT monitoring were correlated more closely with UFH dosing than ACT.

Use of extracorporeal membrane oxygenation (ECMO) is increasing among critically ill adults with cardiac and/or respiratory failure. Use of ECMO is associated with hemostatic alterations requiring use of anticoagulation and blood product support. There are limited guidelines to direct transfusion management in the adult patient supported with ECMO. The objective of this article is to describe (1) the role of the transfusion service in providing transfusion support and current understanding of transfusion thresholds, (2) the complexities of monitoring anticoagulation, and (3) the consideration regarding additional factor concentrates and antifibrinolytics within the context of ECMO support. The information provided should assist ECMO care teams in informing transfusion and anticoagulation practice while highlighting key areas for future research and collaboration.

More than 5 million patients are admitted to US intensive care units (ICUs) each year. Many of these patients have risk factors for dysphagia. Dysphagia must be promptly addressed and appropriately treated to avoid the deleterious impacts of aspiration and malnutrition. Therefore, clinicians must be aware of ways to identify and treat dysphagia. This review will highlight the risk factors, mechanisms, and impact of dysphagia in the ICU as well as provide screening, diagnostic, and management options.

OBJECTIVES Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mortality. DESIGN Retrospective cohort study. Demographics, hemoptysis location, and management were collected. Pediatric Logistic Organ Dysfunction-2 score within 24 hours of hemoptysis described illness severity. Primary outcome was inhospital mortality. SETTING Quaternary pediatric referral center between July 1, 2010, and June 30, 2017. PATIENTS Medical/surgical (PICU), cardiac ICU, and term neonatal ICU admissions with hemoptysis during or within 24 hours of ICU admission. INTERVENTIONS No intervention. MEASUREMENTS AND MAIN RESULTS There were 326 hemoptysis-associated ICU admissions in 300 patients. Most common diagnoses were cardiac (46%), infection (15%), bronchiectasis (10%), and neoplasm (7%). Demographics, interventions, and outcomes differed by diagnostic category. Overall, 79 patients (26%) died inhospital and 109 (36%) had died during follow-up (survivor mean 2.8 ± 1.9 yr). Neoplasm, bronchiectasis, renal dysfunction, inhospital hemoptysis onset, and higher Pediatric Logistic Organ Dysfunction-2 score were independent risk factors for inhospital mortality (p < 0.02). Pharmacotherapy (32%), blood products (29%), computerized tomography angiography (26%), bronchoscopy (44%), and cardiac catheterization (36%) were common. Targeted surgical interventions were rare. Of survivors, 15% were discharged with new respiratory support. Of the deaths, 93 (85%) occurred within 12 months of admission. For patients surviving 12 months, 5-year survival was 87% (95% CI, 78-92) and mortality risk remained only for those with neoplasm (log-rank p = 0.001). CONCLUSIONS We observed high inhospital mortality from hemoptysis-associated ICU admissions. Mortality was independently associated with hemoptysis onset location, underlying diagnosis, and severity of critical illness at event. Additional mortality was observed in the 12-month posthospital discharge. Future directions include further characterization of this vulnerable population and management recommendations for life-threatening pediatric hemoptysis incorporating underlying disease pathophysiology.

OBJECTIVES:Medication reconciliation errors on hospital admission can lead to significant patient harm. A pediatric intermediate care unit initiated a quality improvement project and aimed to reduce errors in admission medication reconciliation by 50% in 12 months.METHODS:From August 2017 to December 2018, a multidisciplinary team conducted a quality improvement project with plan-do-study-act methodology. Continuous data collection was achieved by reviewing medications with home caregivers within 18 hours of admission to identify errors. Cycle 1 consisted of nursing training in accurate and thorough medication history documentation. Cycle 2 was aimed at improving data collection. Cycle 3 was aimed at improving pediatric housestaff processes for medication reconciliation. In cycle 4 intervention, the reconciliation process was redesigned to incorporate the bedside nurse reviewing final medication orders with the patient's home caregivers once the medication reconciliation process was complete. Intermittent maintenance data collection continued for 12 months thereafter.RESULTS:Cycle 1 and 2 interventions resulted in improvement in the medication reconciliation error rate from 9.8% to 4.7%. In cycle 2, the data collection rate improved from 61% to 80% of admissions sustained. Cycle 3 resulted in a further reduction in the medication error rate to 2.9%, which was sustained in cycle 4 and over the 12-month maintenance period. A patient's number of home medications did not correlate with the error rate.CONCLUSIONS:Reductions in admission medication reconciliation errors can be achieved with staff education on medication history and process for medication reconciliation and with process redesign that incorporates active medication order review as a closed-loop communication with home caregivers.

Introduction: There is no consensus definition for ventilator-associated tracheitis and limited evidence to guide diagnosis and treatment. To improve acute tracheitis evaluation and management, this quality improvement project aimed to (1) improve the appropriateness of tracheal aspirate cultures while decreasing the number of unnecessary cultures by 20% and (2) decrease antibiotic use for acute tracheitis not consistent with local guidelines by 20% over 12 months among pediatric patients requiring mechanical ventilation. Methods: All patients admitted to the Medical Intensive Care Unit requiring mechanical ventilation via an artificial airway were included. Tracheal aspirate sampling criteria, technique, and minimum intervals were standardized. Primary outcome measures were the number of tracheal aspirate cultures obtained per 100 ETT/tracheostomy days and ventilator-associated antibiotic days per 100 ETT/tracheostomy days. Improvement cycles included: Implementation of tracheal aspirate sampling criteria, sampling technique standardization, limiting repeat cultures to >72-hour intervals, and standardizing empiric antibiotic therapy. Results: Tracheal aspirate culture rate decreased from 10.70 to 7.10 cultures per 100 ETT/tracheostomy days (P < 0.001). Cultures meeting sampling criteria increased from 28% to 80%. Ventilator-associated antibiotic use decreased from 24.88 to 7.30 ventilator-associated antibiotic days per 100 ETT/tracheostomy days. There were no associated increases in ventilator-associated events or days of mechanical ventilation. Conclusions: Implementation of standardized criteria for tracheal aspirate sampling, improved tracheal aspirate sampling technique, limiting repeat tracheal aspirate cultures, and utilizing standardized antibiotic treatment guidelines safely decreased resource utilization and antibiotic use among critically ill children requiring mechanical ventilation.

BACKGROUND Noninvasive ventilation (NIV) is increasingly used to manage acute respiratory failure in children, decreasing the need for mechanical ventilation. Safely managing these patients outside of the ICU improves ICU resource use. We measured the impact of a guideline permitting initiation of NIV in an intermediate care unit (IMCU) on ICU bed use. METHODS A guideline for an NIV trial for acute respiratory failure was implemented in a 10-bed IMCU. The guideline stipulated criteria for initiation and maintenance of NIV. There were 4.5 years of intervention data collected. Baseline data were gathered for patients with acute respiratory failure who were transferred from the IMCU to the ICU for NIV initiation in the 3.25 years before guideline implementation. RESULTS Three hundred eight patients were included: 101 in the baseline group and 207 in the intervention group. In the intervention group, 143 patients (69%) remained in the IMCU after NIV initiation, and 64 (31%) transferred to the ICU. A total of 656.4 ICU bed-days were saved in the intervention period (3.3 days per patient initiated on NIV in the IMCU). There was a significant decrease in the rate of intubation in the IMCU for patients awaiting ICU transfer (3 patients in the baseline group versus 0 patients in the intervention group; P = .035). CONCLUSIONS The initiation of NIV in the IMCU for pediatric patients with acute respiratory failure saved ICU bed-days without increasing intubation in the IMCU for patients awaiting transfer. Close monitoring of these critically ill patients is a key component of their safe care.

Background Hospital-acquired infections contribute to morbidity and mortality while increasing healthcare resource utilization. While certain ventilator-associated infections are well defined, there is no consensus definition for ventilator-associated tracheitis and limited evidence to guide tracheal aspirate sampling and antibiotic treatment. Local Problem Evaluation of Boston Children’s Hospital Medicine Intensive Care Unit (BCH MICU) practice identified tracheal aspirate culture sampling occurred more frequently than recommended and antibiotic treatment exceeded suggested duration. This practice increases antibiotic exposure with associated risks of bacterial resistance, side effects, and increased costs. The project objective was to improve and standardize acute tracheitis evaluation and management with the intent to accomplish the …

Objectives: To determine if transfusing ABO compatible platelets has a greater effect on incremental change in platelet count as compared to ABO incompatible platelets in critically ill children. Design: Secondary analysis of a prospective, observational study. Transfusions were classified as either ABO compatible, major incompatibility, or minor incompatibility. The primary outcome was the incremental change in platelet count. Transfusion reactions were analyzed as a secondary outcome. Setting: Eighty-two PICUs in 16 countries. Patients: Children (3 d to 16 yr old) were enrolled if they received a platelet transfusion during one of the predefined screening weeks. Interventions: None. Measurements and Main Results: Five-hundred three children were enrolled and had complete ABO information for both donor and recipient, as well as laboratory data. Three-hundred forty-two (68%) received ABO-identical platelets, 133 (26%) received platelets with major incompatibility, and 28 (6%) received platelets with minor incompatibility. Age, weight, proportion with mechanical ventilation or underlying oncologic diagnosis did not differ between the groups. After adjustment for transfusion dose, there was no difference in the incremental change in platelet count between the groups; the median (interquartile range) change for ABO-identical transfusions was 28 × 109 cells/L (8–68 × 109 cells/L), for transfusions with major incompatibility 26 × 109 cells/L (7–74 × 109 cells/L), and for transfusions with minor incompatibility 54 × 109 cells/L (14–81 × 109 cells/L) (p = 0.37). No differences in count increment between the groups were noted for bleeding (p = 0.92) and nonbleeding patients (p = 0.29). There were also no differences observed between the groups for any transfusion reaction (p = 0.07). Conclusions: No differences were seen in the incremental change in platelet count nor in transfusion reactions when comparing major ABO incompatible platelet transfusions with ABO compatible transfusions in a large study of critically ill children. Studies in larger, prospectively enrolled cohorts should be performed to validate whether ABO matching for platelet transfusions in critically ill children is necessary.

Objectives: To describe the epidemiology of platelet transfusions in critically ill children with an underlying oncologic diagnosis and to examine effects of prophylactic versus therapeutic transfusions. Design: Subgroup analysis of a prospective, observational study. Setting: Eighty-two PICUs in 16 countries. Patients: All children (3 d to 16 yr old) who received a platelet transfusion during one of the six predefined screening weeks and had received chemotherapy in the previous 6 months or had undergone hematopoietic stem cell transplantation in the last year. Interventions: None. Measurements and Main Results: Of the 548 patients enrolled in the parent study, 237 (43%) had an underlying oncologic diagnosis. In this population, 71% (168/237) of transfusions were given prophylactically, and 59% (139/237) of transfusions were given at a total platelet count greater than 20 × 109/L, higher than the current recommendations. Those with an underlying oncologic diagnosis were significantly older, and received less support including less mechanical ventilation, fewer medications that affect platelet function, and less use of extracorporeal life support than those without an underlying oncologic diagnosis. In this subpopulation, there were no statistically significant differences in median (interquartile range) platelet transfusion thresholds when comparing bleeding or nonbleeding patients (50 × 109/L [10–50 × 109/L] and 30 × 109/L [10–50 × 109/L], respectively [p = 0.166]). The median (interquartile range) interval transfusion increment in children with an underlying oncologic diagnosis was 17 × 109/L (6–52 × 109/L). The presence of an underlying oncologic diagnosis was associated with a poor platelet increment response to platelet transfusion in this cohort (adjusted odds ratio, 0.46; 95% CI, 0.22–0.95; p = 0.035). Conclusions: Children with an underlying oncologic diagnosis receive nearly half of platelet transfusions prescribed by pediatric intensivists. Over half of these transfusions are prescribed at total platelet count greater than current recommendations. Studies must be done to clarify appropriate indications for platelet transfusions in this vulnerable population.

Altered response to the intestinal microbiota strongly associates with inflammatory bowel disease (IBD); however, how commensal microbial cues are integrated by the host during the pathogenesis of IBD is not understood. Epigenetics represents a potential mechanism that could enable intestinal microbes to modulate transcriptional output during the development of IBD. Here, we reveal a histone methylation signature of intestinal epithelial cells isolated from the terminal ilea of newly diagnosed pediatric IBD patients. Genes characterized by significant alterations in histone H3-lysine 4 trimethylation (H3K4me3) showed differential enrichment in pathways involving immunoregulation, cell survival and signaling, and metabolism. Interestingly, a large subset of these genes was epigenetically regulated by microbiota in mice and several microbiota-sensitive epigenetic targets demonstrated altered expression in IBD patients. Remarkably though, a substantial proportion of these genes exhibited H3K4me3 levels that correlated with the severity of intestinal inflammation in IBD, despite lacking significant differential expression. Collectively, these data uncover a previously unrecognized epigenetic profile of IBD that can be primed by commensal microbes and indicate sensitive targets in the epithelium that may underlie how microbiota predispose to subsequent intestinal inflammation and disease.