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Background: The SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) coronavirus has emerged as a highly contagious respiratory pathogen causing severe acute lung injury. Extracorporeal membrane oxygenation is a standard tool for the management of life-threatening acute respiratory distress syndrome, but the use of this resource-intensive therapy has come into question due to strained medical systems and limited proven treatments for COVID-19. Case summary: A 16-year-old female with obesity presented with fever, myalgias, cough, and tachypnea and was diagnosed with COVID-19. She progressed to severe pediatric acute respiratory distress syndrome requiring intubation on hospital day 4 and cannulation to veno-venous extracorporeal membrane oxygenation on hospital day 6. The patient received remdesivir, steroids, and anakinra. The patient was successfully decannulated on hospital day 12 and was discharged home on hospital day 21. Conclusion: We report the use of veno-venous extracorporeal membrane oxygenation as a bridge to lung recovery in a pediatric patient with severe pediatric acute respiratory distress syndrome due to COVID-19.

Objectives Patients with obstructive airway disease have varying degrees of pulsus paradoxus that correlate with illness severity. Pulsus paradoxus can be measured using plethysmography. We investigated whether plethysmograph (pleth) variability on admission to the pediatric emergency department (ED) could predict patient disposition. We hypothesized that patients with a larger pleth variability would have a higher likelihood of being admitted to a general pediatrics unit or the intensive care unit (ICU). Methods We conducted a prospective single-center study of children aged 1 to 18 years who presented to a pediatric ED with a diagnosis of asthma or reactive airway disease. The pleth variability index (PVI) was calculated from their initial plethysmography tracing. Disposition from the ED was recorded as discharge, admission to the floor, or admission to the ICU. Results A total of 117 patients were included in our study. Forty-eight patients were discharged home, 61 were admitted to the floor, and 8 were admitted to the ICU. The median PVI for each of these groups was 0.27 (interquartile range [IQR], 0.19–0.39) for discharges, 0.29 (IQR, 0.20–0.44) for patients admitted to the floor, and 0.56 (IQR, 0.35–0.70) for patients admitted to the ICU. A Kruskal-Wallis test demonstrated a significant difference in the PVI between each of the groups (P = 0.0087). Conclusions Our results suggest that PVI may be a useful tool in the triage of children who present to the ED with obstructive airway disease. Further studies should aim to assess the validity of PVI in predicting the response to bronchodilator therapy during the course of a patient's hospitalization.

Purpose: Physical restraints are utilized in the critically ill to reduce interference with life-saving therapies. Last year, restraint usage in our pediatric intensive care unit (PICU) increased by 13%. In an effort to assure adherence to our existing restraints policy, we conducted a quality improvement project to (1) evaluate providers’ attitudes toward restraint usage; (2) develop a reliable process to achieve a minimum of 90% compliance with a newly developed restraint bundle by July 31st, 2016, and (3) assess whether implementation of this restraint bundle …

Schneider, James; Bakar, Adnan; Meyer, David; Parnell, Vincent; Silver, Peter; Sethna, Christine Author Information

PURPOSE:To determine if implementing a protocol maintaining an air leak when using cuffed endotracheal tubes (ETT) throughout the course of mechanical ventilation (MV) in children would decrease the rate of postextubation stridor (PES).METHODS:All children requiring MV through a cuffed ETT were included, except those with (1) upper airway anomaly, (2) died while on MV, (3) received tracheostomy before extubation, and (4) transferred before extubation. We implemented a protocol limiting the volume of air instilled into the cuff, allowing an air leak by 25 cm H2O pressure or by peak inspiratory pressure, whichever was higher. Monitoring occurred every 6 hours, adjusting cuff volumes if necessary. Patients receiving nebulized racemic epinephrine within 24 hours of extubation for upper airway obstruction were defined as having PES.RESULTS:At baseline, 110 patients received cuffed ETTs. The proportion of patients who had an air leak at the time of extubation was 47.3%, and that who developed PES was 21.8%. During the intervention, 101 patients received cuffed ETTs. Most (72.3%) had an air leak at the time of extubation (P< .01), and 9.9% developed PES, a 54.6% relative decrease (relative risk, 0.45; 95% confidence interval, 0.22-0.90; P= .018).CONCLUSIONS:Maintaining an appropriate air leak throughout the course of MV using cuffed ETT decreases the rate of PES in children.

Objective: To complete an objective analysis of the activities that occur during the course of daily rounds in a high acuity academic tertiary care pediatric intensive care unit (PICU). Design: Prospective observational work sampling design. Setting: Tertiary care academic Children's Hospital Pediatric Intensive Care Unit. Subjects: Multidisciplinary PICU teams. Interventions: None. Methods: Intensive care unit rounds were observed as part of an initiative to improve efficiency over a 2-month period. The number of observations required was determined by Neibel's work sampling method. Rounds were broken into various constituent events and then later classified as “value-added/essential,” “value-added/nonessential,” and “nonessential” based on whether the observed event was essential to the core mission of PICU rounds. Results: The mean time spent per patient for all observed teams was 17.9 min (SD 1.3 min). Teams spent 64% of their time doing value-added/essential tasks (11.2 min, SD 2.2 min) and 13% of their time doing value-added/nonessential tasks (2.4 min, SD 0.9 min). Teams spent 23% of their time on non–value-added activities (4.1 min, SD 2.3 min). The top three non–value-added activities conducted during rounds were travel, waiting, and interruptions regarding care of other patients. Given the consistency of time spent on value-added activities among attendings, these non–value-added activities might explain the significant variability observed among attendings in total time spent rounding. Conclusions: This was an observational study to characterize the activities that occur during the course of a routine PICU work rounds. Although there was significant consistency in the time spent per patient in value-added activities, there was significant disparity in time spent on nonessential activities, such as travel and waiting. A dedicated attempt to reduce time spent on nonessential activities can substantially reduce rounding times and improve the efficiency and value of rounds.

880 www.pccmjournal.org November 2015 • Volume 16 • Number 9 healthy young adult kidneys because they have a longer predicted graft survival than smaller pediatric kidneys, and they preferentially receive kidneys donated by DNDD because they have a longer predicted graft survival than DCDD kidneys (13). Bennett et al (1) provide important evidence that parents do not consent for DCDD as often as they consent for DNDD. As PICU providers, we can hypothesize about the reasons families decline DCDD even though they support organ donation, but we do not know which of these factors weigh most heavily in their decision. Further study and a deeper understanding are required to help us ensure that eligible families who would benefit from donating their child’s organs are given the maximal opportunity to do so.

Background: We sought to determine whether the introduction of a new anticoagulation protocol improved the frequency with which target anticoagulation parameters were met in children supported with extracorporeal membrane oxygenation (ECMO). Additionally, we sought to correlate the results of various tests of anticoagulation with the heparin infusion dose (HID) for patients on ECMO and to evaluate the utility of these anticoagulation monitoring tests for the titration of the HID.Methods: A retrospective chart review of 18 patients who received ECMO at an academic tertiary care children's hospital. Nine patients who were managed using a new anticoagulation protocol were matched by age and diagnosis with 9 patients managed with the old protocol. We collected data relating to patient demographics, type of extracorporeal support, disease process, and incidence of bleeding or thrombosis. Anticoagulation parameters collected include the activated clotting time (ACT), activated partial thromboplastin time (aPTT), prothrombin time/international normalized ratio, anti-factor Xa level, and antithrombin 3 level along with the HID at each time point. Patient groups were compared using a Generalized Linear Mixed Model, a mixed model analysis of variance, and correlational studies.Main Results: The percentage of in-range ACT values was not different between the 2 protocols, whereas the percentage of in-range aPTT values was higher in the new anticoagulation protocol (ACT: 37.7% vs 39.5%; aPTT: 25.1% vs 39.8%). After accounting for repeated and variable measures within patients, the probability of obtaining an in-range ACT and aPTT did not differ significantly between the 2 protocols (ACT: P = .3488; aPTT: P = .16). The mean HID did not differ between the 2 groups (35.0 unit/kg/h vs 37.6 unit/kg/h, P = .56). Correlation coefficients demonstrated a significant inverse correlation between the ACT and the HID in both the groups (old: r = -.22, P < .0001; new: r = -.26, P < .0001). We observed a significant positive correlation between the aPTT and the HID in the historical group (r = .25, P < .0001), but no correlation between the aPTT and the HID in the current group (r = -.02, P = .71). The anti-factor Xa level showed a significantly positive correlation with the HID in the current group (r = .62, P < .0001).Conclusions: A multipronged monitoring regimen slightly increased the amount of time that anticoagulation parameters were within range. Correlations between the HID and the aPTT differed based on anticoagulation protocol, with a positive correlation in the older protocol and no correlation in the new protocol. This may highlight a problem in study design and analysis that requires further examination. Further trials are needed to assess the most useful markers with which anticoagulation protocols for ECMO can be created, adjusted, and evaluated.

Extracorporeal membrane oxygenation (ECMO) is used for severe neonatal and pediatric respiratory failure that fails to respond to maximal therapy, including but not limited to high frequency oscillatory ventilation (HFOV), surfactant replacement, inhaled nitric oxide (NO) and prone positioning of the patient. This report reviews our decade of experience with ECMO and describes various factors that affect the outcome of neonatal and pediatric ECMO for respiratory failure (RF). General clinical and technical concepts regarding ECMO use are also reviewed. We retrospectively evaluated 84 patients, 70 neonatal and 14 pediatric, who were treated with ECMO in our Children's Hospital and showed that the outcome of these patients depends on their underlying pulmonary pathology and the degree of its clinical reversibility. We divided our neonatal and pediatric RF patients into 3 groups: patients with high disease reversibility (Group N1 for neonates and group P1 for pediatric patients), low disease reversibility (groups N2 and P2) and no predicted disease reversibility (groups N3 and P3). The characteristics of the patients and their outcome in these 3 categories are described. Overall, our neonatal ECMO had a better outcome than pediatric ECMO with survival to discharge rates of 76% and 29%, respectively. Patients with neonatal RF without surgically treatable problems in their lungs or ribcages (group N1) had a 92% survival to discharge rate, while neonates with congenital diaphragmatic hernia (group N2) have a survival rate of only 53%. Achieving sustained negative fluid balance during neonatal ECMO of patients in group N1 is an excellent predictor of ECMO success. In pediatric RF the noninfectious etiology for ARDS had a better prognosis (75%) than infectious etiology had (10%). We support the concept that patients who have received more than 7 days of mechanical ventilation for acute respiratory distress syndrome (ARDS) should not be considered for ECMO as their predicted outcome is extremely grave.

Objective: We evaluated whether or not changes in bispectral index (BIS) are associated with concomitant changes in autonomic variables that are in agreement with the different level of sedation that the changes in BIS indicate.Design: A retrospective chart review.Setting: A pediatric ICU of a children's hospital.Methods and main results: Charts of patients who were receiving mechanical ventilation and IV sedation, neuromuscular blockade, and continuous BIS monitoring were enrolled in the study. Changes in BIS values >= 30% from previous readings were evaluated to determine whether or not concomitant changes of >= 10% in autonomic variables, in the same direction, coexisted. Forty-seven patients (35 male and 12 female) were enrolled in our study; ages ranged from 10 days to IS years (mean, 4.2 +/- 6.2 years [+/- SD]). Twenty-five patients were < I year of age (53%). All patients were sedated and pharmacologically paralyzed. Overall, 387 BIS readings (15%) showed a >= 30% change from the previously documented BIS number. These BIS changes were in agreement with heart rate (HR) changes, mean arterial pressure (MAP) changes, and both HR and MAP changes in 10.6%, 23.8%, and 5.7% of the time, respectively. The same analysis of agreement was done for patients <= I year old, and results were no different from those of older patients. Among 21 patients who were not receiving any vasoactive drugs (alpha- and/or beta-adrenergic agonists) during the study period, 157 BIS recordings (15%) showed a : 30% change from the previously documented BIS number. The percents of agreement with HR, MA-P, and HR and MAP for these patients were 14.6%, 17.2%, and 7.6%, respectively. In 26 patients who were receiving vasoactive medications during the study, 230 BIS recordings (15%) showed a >= 30% change from the previously documented BIS number. For these patients, the percentages of agreement were 7.8%, 28.3%, and 4.3%, respectively. Agreement with MAP was significantly better than with HR for this group of patients (p < 0.05; Fisher Exact Test).Summary: While significant changes in BIS are thought to reflect significant changes in depth of sedation, they have a very low rate of agreement with changes in vital signs. In the absence of BIS, the level of sedation of chemically paralyzed pediatric patients can be better guided by changes in MAP than in HR, particularly in patients receiving vasoactive drug treatment.