ABSTRACT Background: Central venous catheters (CVCs) are used in pediatric patients to deliver IV fluids, blood products, medications, and nutrients. Potential complications include central line infection, which carries a high risk of morbidity and mortality in this population. Pediatric critical care nurses play a crucial role in helping to reduce the risk of infection. Purpose: The aim of this study was to develop, implement, and evaluate the effectiveness of a serious, simulated, gaming-based intervention to improve the skills and knowledge of RNs in the early stages of their career regarding central line insertion, care, and infection prevention. Methods: A single-arm, pre- and postinterventional pilot study was conducted at the Riley Hospital for Children at Indiana University Health, from July 2021 to July 2022. The study participants were bedside pediatric critical care nurses who were provided with education and skills training regarding CVC placement and maintenance through a so-called serious game—essentially, a video game with a purpose. A simulation session and multiple-choice knowledge test were used to assess skills and knowledge retention both before and after the intervention. Results: A total of 32 pediatric critical care nurses participated in the study; however, 1 nurse did not complete the follow-up assessment. The study revealed a statistically significant increase in the overall mean (SD) global performance score from 4.06 (2.11) before the intervention to 5.97 (1.80) afterward. Specific areas of performance also showed significant improvement: handwashing prior to the procedure (P = 0.04), covering the procedure site (P = 0.01), cleaning the site properly (P < 0.01), and ensuring central line placement before use (P < 0.01). However, there was no statistically significant difference in the nurses' performance on the multiple-choice knowledge test before and after the intervention. Conclusion: This study suggests that serious games have the potential to improve nursing education, particularly in complex procedures like central line insertion and maintenance. Our findings indicate that serious gaming is effective in engaging learners and enhancing their skills. More research is needed to evaluate the long-term impact of serious games on learning outcomes and patient care.

Introduction: Costs for bronchiolitis have risen over the years. Previous studies have shown that respiratory therapist (RT) driven high flow nasal cannula (HFNC) management protocols can decrease length of HFNC as well as pediatric intensive care unit (PICU) and hospital length of stay (LOS). The aim of this study was to determine if modifications to an existing RT-driven HFNC management protocol could further safely decrease length of HFNC and PICU and hospital LOS. Methods: This is a quality improvement project performed at a quaternary academic PICU. This study included patients less than 24 months of age admitted to the PICU with an admission diagnosis of bronchiolitis requiring HFNC. After initial implementation of a (RT)-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. Duration of HFNC was used as the primary outcome measure and PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use and 7-day PICU and hospital readmission rates were used as balancing measures. Results: A total of 1,310 patients were included. Patients in PDSA 2, PDSA 3&4 groups were older compared to pre-intervention and PDSA 1 (median of 9 and 10 months compared to 8 months, p=0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2 and 1.5 days after PDSA 3&4. Hospital LOS decreased from 5.7 days to 4.5 days after PDSA 1, 3.1 days after PDSA 2 and 2.7 days after PDSA 3&4. The use of non-invasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at end of the project. The 7-day PICU and hospital readmission rates did not increase. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. Conclusions: Modifications to an existing RT-driven HFNC protocol and standardized discharge criteria led to an improvement in bronchiolitis patients’ outcomes without an increase in adverse events.

OBJECTIVES: To decrease length of high-flow nasal cannula (HFNC), PICU, and hospital length of stay (LOS). DESIGN: Quality improvement project. SETTING: A quaternary academic PICU. PATIENTS: Patients with bronchiolitis less than 24 months old. INTERVENTIONS: After initial implementation of a respiratory therapist (RT)-driven HFNC protocol (Plan-Do-Study-Act [PDSA] 1) in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. MEASUREMENTS AND MAIN RESULTS: Duration of HFNC was used as the primary outcome measure. PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use, and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 1,310 patients were included in this study. Patients in PDSA 2, PDSA 3 and 4 groups were older compared with pre-intervention and PDSA 1 (median of 9 and 10 mo compared with 8 mo; p = 0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2, and 1.5 days after PDSA 3 and 4. Hospital LOS decreased from 5.7 to 4.5 days after PDSA 1, 3.1 days after PDSA 2, and 2.7 days after PDSA 3 and 4. The use of noninvasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at the end of the project. The 7-day PICU and hospital readmission rates did not increase after implementation. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. CONCLUSIONS: Modifications to an existing RT-driven HFNC protocol and standardization of discharge criteria led to an improvement in outcomes for patients admitted to the PICU with bronchiolitis without an increase in adverse events.

Objectives: The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children. Design: The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3). Setting: A 12-bed academic pediatric cardiac ICU. Patients: Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day. Interventions: Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25–0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old. Measurements and Main Results: We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23–47%), 42% (IQR, 30–51%), and 38% (IQR, 35–52%) in periods 1–3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17–210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3–4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0–9.3), 3.8 (IQR, 0–12), and 0 (IQR, 0–5.3) in periods 1–3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12–87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2–18%) between periods 1 and 3. Conclusions: The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.

OBJECTIVES: With decreasing PICU mortality, survivor morbidity has increased. This study aims to evaluate feasibility of virtual PICU-led follow-up of patients at risk for pediatric postintensive care syndrome. DESIGN: Prospective cohort study. SETTING: Single-center, quaternary children's hospital. PATIENTS: Children less than or equal to 4 years without known preexisting neurodevelopmental deficits requiring greater than or equal to 12 hours mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age-appropriate Ages and Stages Questionnaires, Third Edition (ASQ-3) were administered via a web-based system at 3, 6, and 12 months following PICU discharge. Primary-care physicians were notified of results; at-risk patients were referred to early developmental intervention. Forty-eight patients enrolled with median age 11.5 months (interquartile range [IQR], 2-19.5 mo) and median mechanical ventilation duration 92.5 hours (IQR, 40.5-147 hr). Fifty-eight percent completed greater than or equal to 1 ASQ-3. Lower caregiver educational achievement, lower income, and single-caregiver status were associated with lower ASQ-3 completion rates. Of those completing any ASQ-3, 50% flagged as at-risk for developmental delay and referred to early developmental intervention. There was no association between patient characteristics and abnormal ASQ-3. CONCLUSIONS: Virtual caregiver-completed surveillance is a promising method to screen children for neurodevelopmental abnormalities following PICU hospitalization and facilitate early referral for developmental intervention, but special attention must be dedicated to families with limited resources for follow-up.

Initiatives aimed at optimizing value and decreasing waste are traditionally carried out at a system level. Consequently, physician involvement may not be a key driver of the process, which can affect project outcomes and sustainability. To improve physician alignment with systemwide goals and create a culture of accountability, leaders at Riley Hospital for Children at Indiana University Health engaged medical directors by requiring them to carry out at least one clinical effectiveness project a year and present at one of the monthly meetings. The new position of medical director of clinical effectiveness helps oversee this. Within the first year, 26 new clinical effectiveness projects were started, and 75% of medical directors identified a project. This led to an estimated savings or revenue generation of more than $3 million. Another 25 projects were started during the second year, with an additional estimated savings or revenue generation of more than $13 million.

Advancements in critical care management have led to improvement in pediatric LT outcomes. However, there are no specific guidelines for many aspects of immediate post-LT care. This survey examines practice variations in the immediate postoperative care of pediatric LT patients at a large number of active US centers. This study is a cross-sectional survey of medical directors at PALISI-affiliated PICU in the United States. Centers performing pediatric LT were analyzed. Study measures included PICU practices regarding staffing, composition of the multidisciplinary team, early post-LT graft and patient monitoring, and anticoagulation. Of the thirty-five responding centers, twenty-five had a LT program which accounted for one-half of all US pediatric LTs. For analysis, centers were categorized by volume: high (7), medium (11), and low (7). The majority of PICU teams included an intensivist (80%) and hepatologist (84%). High-volume centers were less likely to have 24-hour in-house attending coverage (29%, compared to 64% (medium) and 100% (low)). High-volume centers were most likely to have pre-printed orders, but least likely to have written PICU management protocols. Most centers utilize routine daily liver ultrasound. Routine prophylactic anticoagulation, and the agent of choice, was variable. There is marked inconsistency in post-LT practice across PALISI centers in regards to team composition and immediate post-LT management. A national US consensus for post-LT PICU practices would facilitate outcomes research and would establish a platform for multicenter studies.

Objective To evaluate the impact of a collaborative initiative between general emergency departments (EDs) and the pediatric academic medical center on the process of clinical care in a group of general EDs. Study design This retrospective cohort study assessed the process of clinical care delivered to critically ill children presenting to 3 general EDs. Our previous multifaceted intervention included the following components: post-simulation debriefing, designation of a pediatric champion, customized performance reports, pediatric resources toolkit, and ongoing interactions. Five pediatric emergency care physicians conducted chart reviews and scored encounters using the Pediatric Emergency Care Research Network's Quality of Care Implicit Review Instrument, which assigns scores between 5 and 35 across 5 domains. In addition, safety metrics were collected for medication, imaging, and laboratory orders. Results A total of 179 ED encounters were reviewed, including 103 preintervention and 76 postintervention encounters, with an improvement in mean total quality score from 23.30 (SD 5.1) to 24.80 (4.0). In the domain of physician initial treatment plan and initial orders, scores increased from a mean of 4.18 (0.13) to 4.61 (0.15). In the category of safety, administration of wrong medications decreased from 28.2% to 11.8% after the intervention. Conclusion A multifaceted collaborative initiative involving simulation and enhanced pediatric readiness was associated with improvement in the processes of care in general EDs. This work provides evidence that innovative collaborations between academic medical centers and general EDs may serve as an effective strategy to improve pediatric care.

BACKGROUND: In general emergency departments, advanced airway management of pediatric patients who are critically ill has been associated with increased adverse events given the varying exposure to pediatric patients and limited resources. Previous studies have shown significant improvement of simulated pediatric airway management in general emergency departments. The aim of this retrospective study was to determine the effect of an in situ simulation-based collaborative intervention program on the actual care of pediatric airway management in general emergency departments. METHODS: This was a retrospective study of pediatric subjects who were critically ill and required intubation at a diverse set of general emergency departments before referral to the academic medical center. The primary outcome was the quality of clinical care measured by adherence to best practices via a critical action checklist. Secondary outcomes included tracheal intubation associated adverse events and clinical outcomes. RESULTS: A total of 135 pediatric subjects (48 pre- and 87 post-intervention) who were transferred to the academic medical center from 9 general emergency departments between May 2014 and August 2019 were included in the analysis. The use of a cuffed endotracheal tube improved, from 44% to 72% (P = .001) , whereas there was no significant change in the appropriate endotracheal tube size. Overall, severe tracheal intubation associated adverse events decreased, from 18.8% to 9.2% (P = .03), and post-intubation cardiac arrest events decreased, from 6.3% to 0% (P = .02). CONCLUSIONS: A simulation-based collaborative intervention program led to improvement in pediatric airway management and subject outcomes in general emergency departments. This model demonstrated the transfer of improvement from a simulated setting to a clinical setting and may be targeted in other clinical settings.

BACKGROUND: More children are discharged from ICUs on prolonged mechanical ventilation (PMV) via tracheostomy than ever before. These patients have long hospitalizations with high resource expenditure. Our objective was to describe the characteristics of these resource-intensive patients and to evaluate their costs of care. We hypothesized that subjects requiring PMV for neurologic diagnoses would have higher costs, longer hospital length of stay (LOS), and worse outcomes than those with primarily respiratory diagnoses. METHODS: We identified 50 pediatric subjects between January 2015 and December 2017 at our institution who had a new tracheostomy placement and were enrolled in a home mechanical ventilation program. Collected data included demographics, indication for tracheostomy, LOS, hospital costs, readmissions, and outcomes. We also compared subjects who required PMV for respiratory diagnoses versus neurologic diagnoses. RESULTS: Of 50 subjects, 41 were < 12 months old at the time of tracheostomy. Thirty-four subjects had a respiratory diagnosis requiring PMV, 14 had a neurologic diagnosis, and 2 had a cardiac diagnosis. The total initial hospitalization cost was $31,133,582, which averages to $622,671 per subject. The average initial hospitalization LOS was 155 d. Respiratory subjects had longer LOS and higher average costs than neurologic subjects. The average readmission rate was 2.16 per subject in the first year after discharge, and the average readmission cost per subject was $73,144. Eight subjects died in the first year after discharge, and 4 suffered a serious morbidity. CONCLUSIONS: This descriptive study evaluated the social and medical characteristics of subjects being discharged from the pediatric ICU with PMV via tracheostomy, as well as quantified the financial impact of their care. Those requiring PMV for neurologic diagnoses had shorter hospital LOS and lower hospital costs than those with respiratory diagnoses. No definitive differences in outcomes were found.

BACKGROUND:We describe organisms found in the respiratory tracts of a multicenter cohort of pediatric hematopoietic cell transplant (HCT) recipients with respiratory failure.METHODS:Twelve centers contributed up to 25 pediatric allogeneic HCT recipients requiring mechanical ventilation for respiratory failure to a retrospective database. Positive respiratory pathogens and method of obtaining sample were recorded. Outcomes were assessed using Mann-Whitney U test or chi-squared analysis.RESULTS:Of the 222 patients in the database, ages 1 month through 21 years, 34.6% had a positive respiratory culture. 105 pathogens were identified in 77 patients; of those, 48.6% were viral, 34.3% bacterial, 16.2% fungal, and 1% parasitic. PICU mortality with a respiratory pathogen was 68.8% compared to 54.9% for those without a respiratory pathogen (P = .045). Those with a positive respiratory pathogen had longer PICU length of stay, 20 days (IQR 14.0, 36.8) vs 15 (IQR 6.5, 32.0), P = .002, and a longer course of mechanical ventilation, 17 days (IQR 10, 29.5) vs 8 (3, 17), P < .0001. Method of pathogen identification, type of pathogen, and the presence of multiple pathogens were not associated with changes in PICU outcomes.CONCLUSIONS:In this multicenter retrospective cohort of intubated pediatric post-HCT patients, there was high variability in the respiratory pathogens identified. Type of pathogen and method of detection did not affect PICU mortality. The presence of any organism leads to increased PICU mortality, longer PICU stay, and increased duration of mechanical ventilation suggesting that early detection and treatment of pathogens may be beneficial in this population.

Objectives The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. Methods This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. Results A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. Conclusions This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Objectives: Acute respiratory failure is common in pediatric hematopoietic cell transplant recipients and has a high mortality. However, respiratory prognostic markers have not been adequately evaluated for this population. Our objectives are to assess respiratory support strategies and indices of oxygenation and ventilation in pediatric allogeneic hematopoietic cell transplant patients receiving invasive mechanical ventilation and investigate how these strategies are associated with mortality. Design: Retrospective, multicenter investigation. Setting: Twelve U.S. pediatric centers. Patients: Pediatric allogeneic hematopoietic cell transplant recipients with respiratory failure. Interventions: None. Measurements and Main Results: Two-hundred twenty-two subjects were identified. PICU mortality was 60.4%. Nonsurvivors had higher peak oxygenation index (38.3 [21.3–57.6] vs 15.0 [7.0–30.7]; p < 0.0001) and oxygen saturation index (24.7 [13.8–38.7] vs 10.3 [4.6–21.6]; p < 0.0001), greater days with Fio 2 greater than or equal to 0.6 (2.4 [1.0–8.5] vs 0.8 [0.3–1.6]; p < 0.0001), and more days with oxygenation index greater than 18 (1.4 [0–6.0] vs 0 [0–0.3]; p < 0.0001) and oxygen saturation index greater than 11 (2.0 [0.5–8.8] vs 0 [0–1.0]; p < 0.0001). Nonsurvivors had higher maximum peak inspiratory pressures (36.0 cm H2O [32.0–41.0 cm H2O] vs 30.0 cm H2O [27.0–35.0 cm H2O]; p < 0.0001) and more days with peak inspiratory pressure greater than 31 cm H2O (1.0 d [0–4.0 d] vs 0 d [0–1.0 d]; p < 0.0001). Tidal volume per kilogram was not different between survivors and nonsurvivors. Conclusions: In this cohort of pediatric hematopoietic cell transplant recipients with respiratory failure in the PICU, impaired oxygenation and use of elevated ventilator pressures were common and associated with increased mortality.

INTRODUCTION: The effectiveness of high-frequency oscillatory ventilation (HFOV) in the pediatric hematopoietic cell transplant patient has not been established. We sought to identify current practice patterns of HFOV, investigate parameters during HFOV and their association with mortality, and compare the use of HFOV to conventional mechanical ventilation in severe pediatric ARDS. METHODS: This is a retrospective analysis of a multi-center database of pediatric and young adult allogeneic hematopoietic cell transplant subjects requiring invasive mechanical ventilation for critical illness from 2009 through 2014. Twelve United States pediatric centers contributed data. Continuous variables were compared using a Wilcoxon rank-sum test or a Kruskal-Wallis analysis. For categorical variables, univariate analysis with logistic regression was performed. RESULTS: The database contains 222 patients, of which 85 subjects were managed with HFOV. Of this HFOV cohort, the overall pediatric ICU survival was 23.5% (n = 20). HFOV survivors were transitioned to HFOV at a lower oxygenation index than nonsurvivors (25.6, interquartile range 21.1-36.8, vs 37.2, interquartile range 26.5-52.2, P = .046). Survivors were transitioned to HFOV earlier in the course of mechanical ventilation, (day 0 vs day 2, P = .002). No subject survived who was transitioned to HFOV after 1 week of invasive mechanical ventilation. We compared subjects with severe pediatric ARDS treated only with conventional mechanical ventilation versus early HFOV (within 2 d of invasive mechanical ventilation) versus late HFOV. There was a trend toward difference in survival (conventional mechanical ventilation 24%, early HFOV 30%, and late HFOV 9%, P = .08). CONCLUSIONS: In this large database of pediatric allogeneic hematopoietic cell transplant subjects who had acute respiratory failure requiring invasive mechanical ventilation for critical illness with severe pediatric ARDS, early use of HFOV was associated with improved survival compared to late implementation of HFOV, and the subjects had outcomes similar to those treated only with conventional mechanical ventilation. (c) 2018 Daedalus Enterprises

This article reviews the definition, pathophysiology, etiology, assessment, and management of acute respiratory failure in children. Acute respiratory failure is the inability of the respiratory system to maintain oxygenation or eliminate carbon dioxide. Acute respiratory failure is a common cause for admission to a pediatric intensive care unit. Most causes of acute respiratory failure can be grouped into one of three categories: lung parenchymal disease, airway obstruction, or neuromuscular dysfunction. Many patients with acute respiratory failure are managed successfully with noninvasive respiratory support; however, in severe cases, patients may require intubation and mechanical ventilation. [Pediatr Ann. 2018;47(7):e268-e273.].

Objective: Immunodeficiency is both a preexisting condition and a risk factor for mortality in pediatric acute respiratory distress syndrome. We describe a series of pediatric allogeneic hematopoietic stem cell transplant patients with pediatric acute respiratory distress syndrome based on the recent Pediatric Acute Lung Injury Consensus Conference guidelines with the objective to better define survival of this population. Design: Secondary analysis of a retrospective database. Setting: Twelve U.S. pediatric centers. Patients: Pediatric allogeneic hematopoietic stem cell transplant recipients requiring mechanical ventilation. Interventions: None. Measurements and Main Results: During the first week of mechanical ventilation, patients were categorized as: no pediatric acute respiratory distress syndrome or mild, moderate, or severe pediatric acute respiratory distress syndrome based on oxygenation index or oxygen saturation index. Univariable logistic regression evaluated the association between pediatric acute respiratory distress syndrome and PICU mortality. A total of 91.5% of the 211 patients met criteria for pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition: 61.1% were severe, 27.5% moderate, and 11.4% mild. Overall survival was 39.3%. Survival decreased with worsening pediatric acute respiratory distress syndrome: no pediatric acute respiratory distress syndrome 66.7%, mild 63.6%, odds ratio = 1.1 (95% CI, 0.3–4.2; p = 0.84), moderate 52.8%, odds ratio = 1.8 (95% CI, 0.6–5.5; p = 0.31), and severe 24.6%, odds ratio = 6.1 (95% CI, 2.1–17.8; p < 0.001). Nonsurvivors were more likely to have multiple consecutive days at moderate and severe pediatric acute respiratory distress syndrome (p < 0.001). Moderate and severe patients had longer PICU length of stay (p = 0.01) and longer mechanical ventilation course (p = 0.02) when compared with those with mild or no pediatric acute respiratory distress syndrome. Nonsurvivors had a higher median maximum oxygenation index than survivors at 28.6 (interquartile range, 15.5–49.9) versus 15.0 (interquartile range, 8.4–29.6) (p < 0.0001). Conclusion: In this multicenter cohort, the majority of pediatric allogeneic hematopoietic stem cell transplant patients with respiratory failure met oxygenation criteria for pediatric acute respiratory distress syndrome based on the Pediatric Acute Lung Injury Consensus Conference definition within the first week of invasive mechanical ventilation. Length of invasive mechanical ventilation, length of PICU stay, and mortality increased as the severity of pediatric acute respiratory distress syndrome worsened.

BACKGROUND:Respiratory failure in the pediatric hematopoietic cell transplant (HCT) recipient is the leading cause for admission to the intensive care unit and carries a high mortality rate. The objective of this study is to investigate the association of clinical risk factors with the development of respiratory failure in the pediatric allogeneic HCT recipient.PROCEDURES:This is a single-center, retrospective review of allogeneic pediatric HCT from 2008 to 2014. Multiple variables were examined. The primary outcome was respiratory failure. Percent weight gain was investigated at multiple time points. Bivariate and multivariate regression was used.RESULTS:Of the 87 allogeneic HCT recipients, 22 (25%) developed respiratory failure. Mortality for entire cohort was 13.8%. All who died were intubated prior to death. The group with respiratory failure had significantly higher percent weight gain increase at multiple time points: peak weight prior to discharge or intubation (P = 0.008), weight at discharge or intubation (P = .001), and weight at day 43 (median day for intubation) (P = 0.02). Odds ratio (OR) for respiratory failure increased with increasing percentage peak weight gain: 10% increase (3.1 [1.1, 9.0]), 15% increase (4.1 [1.5, 11.2]), and 20% (8.3 [2.4. 28.9]). Fifty percent of all patients required supplemental O2 . OR for respiratory failure in patients requiring more than 1 l supplemental O2 is 25.3 (6.5, 98.7).CONCLUSION:Percent weight gain and need for supplemental oxygen is highly associated with the development of respiratory failure in pediatric HCT recipients, representing predictors of acute respiratory failure in pediatric HCT. These data could be incorporated into an algorithm that should be developed, implemented, and validated in a prospective, multicenter fashion.

Objectives To evaluate whether a pediatric intensive care unit initiative promoting physical contact between caregiver and patient improves caregiver spiritual wellbeing. The secondary objectives were to evaluate caregiver perceptions of care before and after the initiative and to follow unplanned extubation rate as a marker of safety of the initiative. We hypothesized that caregiver spiritual wellbeing and caregiver perceptions of care would improve with implementation of our physical contact initiative known as Project ROSE (Reach Out, Soothe, and Embrace). Study design Project ROSE was a practice change initiative promoting physical contact between caregiver and hospitalized child in an academic quaternary care pediatric intensive care unit. Caregivers' spiritual wellbeing and perceptions of care were surveyed at days 1 and 4, then compared pre- and postimplementation of the unit-wide initiative. Wilcoxon rank sum tests compared groups (pre- and post-Project ROSE). A total of 331 caregivers returned surveys. Results We analyzed 331 surveys (pre, n = 174/post, n = 157). Caregiver spiritual wellbeing at enrollment (day 1) was no different between groups (P = .47). Caregiver spiritual wellbeing on day 4 was greater in the postintervention group (pre 40.0 [32.0, 44.0] vs post 42.0 [37.5, 45.0] P = .03). Caregiver perceptions of care improved postintervention. There was no change in the unplanned extubation rate between groups. Conclusion Project ROSE improved caregiver spiritual wellbeing and perceptions of care, was implemented safely, addresses a need in family-centered care of critically ill pediatric patients, and merits consideration for integration into practice.

Pediatric acute liver failure is rare but life-threatening illness that occurs in children without preexisting liver disease. The rarity of the disease, along with its severity and heterogeneity, presents unique clinical challenges to the physicians providing care for pediatric patients with acute liver failure. In this review, practical clinical approaches to the care of critically ill children with acute liver failure are discussed with an organ system-specific approach. The underlying pathophysiological processes, major areas of uncertainty, and approaches to the critical care management of pediatric acute liver failure are also reviewed.

This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer (MDT) scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised (MDS-R), were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p = 0.015), a statistically significant increase in both code status changes DNR (11 % control, 28 % PEACE, p = 0.013), and in-hospital death (9 % control, 25 % PEACE, p = 0.015), with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients.