Characterization of the bias between oxygen saturation measured by pulse oximetry and calculated by an arterial blood gas analyzer in critically ill neonates

Continuous monitoring of oxygenation with pulse oximetry is the standard of care for critically ill neonates. A better understanding of its measurement bias compared to arterial oxygen saturation could be helpful both for the clinician and researcher. Towards that end, we examined the electronic database from a large neonatal ICU. From a 24-month period we identified 23,032 paired SpO2-SaO2 measurements from 1,007 infants who were receiving supplemental oxygen during mechanical ventilation. We found that SpO2 was consistently higher than SaO2. The size of the bias was fairly constant when SpO2 was between 75-93%, above which it dropped steadily. The median size of this bias was 1% SpO2 during hyperoxemia (SpO2 97-100%) with a median variation of 1.3% above and below. During periods of hypoxemia (SpO2 75-85%) and normoxemia (SpO2 89-93%) the bias was approximately 5% SpO2, with a median variation of 5% above and below

Predicting Body Height in a Pediatric Intensive Care Unit Using Ulnar Length

Objective: To determine if ulnar length obtained by the bedside nurse can be used to estimate patient length. To compare our findings to previous predictive equations of height and ulnar length. To evaluate the performance of predictive equations for height and ulnar length on patients with syndromes that affect height.Design: Retrospective observational study of prospectively collected data.Settings: Multidisciplinary Pediatric Intensive Care Unit in a university teaching hospital.Patients: 1,177 patients, ages 1 month to 23 years. Mean age was 79.7 months (1,3 IQR 19.5, 164.5 months) and 55.4% male.Measurements: Ulnar length was obtained using digital calipers by bedside nurses in PICU as well as height and weight. The electronic health care record was used to extract patient information.Main Results: The predictive equation for height for the entire group is: height (cm) = 0.59*ulnar length (mm) + 13.1 (r2 = 0.93). Bland Altman analysis of the derivation formula applied to the testing group did not show any systematic bias.Conclusions: Our study shows that ulnar length measurements can be used to predict height with a simple linear formula in a PICU setting. Not having specific individuals or specific training for ulnar measurement did not seem to alter the accuracy (r2 = 0.93). The robust nature of the measurement and ease of use may make this an unconventional but reasonable alternative to obtaining height when that cannot be measured directly

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees

Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions.Objective: Our hypothesis was that over the past decade the rate of procedures performed by Pediatric Critical Care Medicine Fellowship trainees decreased.Methods: Retrospective review at a single institution, tertiary, academic, children's hospital of patients admitted from July 1, 2007–June 30, 2017 to the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit. A Poisson regression model with a scale adjustment for over-dispersion estimated by the square root of Pearson's Chi-Square/DOF was applied.Results: There has been a statistically significant decrease in the average rate of central venous lines (p = 0.004; −5.72; 95% CI: −9.45, −1.82) and arterial lines (p = 0.02; −7.8; 95% CI: −13.90, −1.25) per Fellow per years in Fellowship over the last 10 years. There was no difference in the rate of intubations per Fellow per years in Fellowship (p = 0.27; 1.86; 95% CI:−1.38, 5.24).Conclusions: There has been a statistically significant decrease in the rate of central venous lines and arterial lines performed by Pediatric Critical Care Medicine Fellowship trainees per number of years in Fellowship over the last 10 years. Educators need to be constantly reassessing the clinical landscape in an effort to make sure that trainees are receiving adequate educational experiences as this has the potential for an impact on the education of trainees and the safety of the patients that they care for

Potential Hazard to Human Health from Exposure to Fragments of Lead Bullets and Shot in the Tissues of Game Animals

Peer reviewedPublisher PD

Minimal Change in Cardiac Index With Increasing PEEP in Pediatric Acute Respiratory Distress Syndrome

Objective: To determine if increasing positive end expiratory pressure (PEEP) leads to a change in cardiac index in children with Pediatric Acute Respiratory Distress Syndrome ranging from mild to severe.Design: Prospective interventional study.Setting: Multidisciplinary Pediatric Intensive Care Unit in a University teaching hospital.Patients: Fifteen intubated children (5 females, 10 males) with a median age of 72 months (IQR 11, 132) and a median weight of 19.3 kg (IQR 7.5, 53.6) with a severity of Pediatric Acute Respiratory Distress Syndrome that ranged from mild to severe with a median lung injury score of 2.3 (IQR 2.0, 2.7).Measurements: Cardiac index (CI) and stroke volume (SV) were measured on baseline ventilator settings and subsequently with a PEEP 4 cmH2O higher than baseline. Change in CI and SV from baseline values was evaluated using Wilcoxon signed rank test.Results: A total of 19 paired measurements obtained. The median baseline PEEP was 8 cmH2O (IQR 8, 10) Range 6–14 cmH2O. There was no significant change in cardiac index or stroke volume with change in PEEP. Baseline median CI 4.4 L/min/m2 (IQR 3.4, 4.8) and PEEP 4 higher median CI of 4.3 L/min/m2 (IQR 3.6, 4.8), p = 0.65. Baseline median SV 26 ml (IQR 13, 44) and at PEEP 4 higher median SV 34 ml (IQR 12, 44) p = 0.63.Conclusion: There is no significant change in cardiac index or stroke volume with increasing PEEP by 4 cmH2O in a population of children with mild to severe PARDS.Clinical Trial Registration: The study is registered on Clinical trails.gov under the Identifier: NCT02354365

A guided tour of asynchronous cellular automata

Research on asynchronous cellular automata has received a great amount of attention these last years and has turned to a thriving field. We survey the recent research that has been carried out on this topic and present a wide state of the art where computing and modelling issues are both represented.Comment: To appear in the Journal of Cellular Automat

Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome:A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study

OBJECTIVES: To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome. DESIGN: A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher FIO2 grid recommendations. SETTING: Seventy-one international PICUs. PATIENTS: Children with pediatric acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/FIO2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/FIO2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome. CONCLUSIONS: Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children

BACKGROUND: Targeted temperature management is recommended for comatose adults and children after out-of-hospital cardiac arrest; however, data on temperature management after in-hospital cardiac arrest are limited. METHODS: In a trial conducted at 37 children’s hospitals, we compared two temperature interventions in children who had had in-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose children older than 48 hours and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a score of 70 or higher on the Vineland Adaptive Behavior Scales, second edition (VABS-II, on which scores range from 20 to 160, with higher scores indicating better function), was evaluated among patients who had had a VABS-II score of at least 70 before the cardiac arrest. RESULTS: The trial was terminated because of futility after 329 patients had undergone randomization. Among the 257 patients who had a VABS-II score of at least 70 before cardiac arrest and who could be evaluated, the rate of the primary efficacy outcome did not differ significantly between the hypothermia group and the normothermia group (36% [48 of 133 patients] and 39% [48 of 124 patients], respectively; relative risk, 0.92; 95% confidence interval [CI], 0.67 to 1.27; P = 0.63). Among 317 patients who could be evaluated for change in neurobehavioral function, the change in VABS-II score from baseline to 12 months did not differ significantly between the groups (P = 0.70). Among 327 patients who could be evaluated for 1-year survival, the rate of 1-year survival did not differ significantly between the hypothermia group and the normothermia group (49% [81 of 166 patients] and 46% [74 of 161 patients], respectively; relative risk, 1.07; 95% CI, 0.85 to 1.34; P = 0.56). The incidences of blood-product use, infection, and serious adverse events, as well as 28-day mortality, did not differ significantly between groups. CONCLUSIONS: Among comatose children who survived in-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a favorable functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute; THAPCA-IH ClinicalTrials.gov number, NCT00880087.

Child mental health differences amongst ethnic groups in Britain: a systematic review

BACKGROUND: Inter-ethnic differences have been reported for many mental health outcomes in the UK, but no systematic review on child mental health has been published. The aim of this review is to compare the population-based prevalence of child mental disorders between ethnic groups in Britain, and relate these findings to ethnic differences in mental health service use. METHODS: A systematic search of bibliographic databases for population-based and clinic-based studies of children aged 0-19, including all ethnic groups and the main child mental disorders. We synthesised findings by comparing each minority group to the White British study sample. RESULTS: 31 population-based and 18 clinic-based studies met the inclusion criteria. Children in the main minority groups have similar or better mental health than White British children for common disorders, but may have higher rates for some less common conditions. The causes of these differences are unclear. There may be unmet need for services among Pakistani and Bangladeshi children. CONCLUSION: Inter-ethnic differences exist but are largely unexplained. Future studies should address the challenges of cross-cultural psychiatry and investigate reasons for inter-ethnic differences