Intermittent Bolus versus Continuous Infusion of Propofol for Deep Sedation during ABR/Nuclear Medicine Studies

Objective  A comparison of intermittent bolus (IB) versus continuous infusion of propofol for deep sedation. Material and Methods  A retrospective review of patients sedated for Auditory Brainstem Response (ABR)/nuclear medicine studies between September 2008 and February 2015. A ketamine bolus (0.5 mg/kg 20 kg) followed by propofol bolus of 1 mg/kg over 2 minutes. In the IB group, maintenance of deep sedation was with incremental bolus of 10 to 20 mg of propofol. In continuous infusion group (CG), maintenance was with a continuous infusion of 83 mcg/kg/min of propofol. Results  Of the 326 cases completed, 181 were in CG group and 145 were in IB group. There were no statistical differences in patient's age, weight, and American Society of Anesthesiologist (ASA) classification. The cardiovascular and respiratory parameters in the two groups were not different statistically. Mean total propofol dose was higher in CG group versus IB group (CG 7.6 mg ± 3.6 mg, IB 6.5 mg ± 3.6 mg; p  = 0.008). Procedure time in CG group was longer by 8 minutes compared with IB group (CG 49.8 min ± 25.4 min versus 42.3 min ± 19.2 min; p  = .003). CG group has both shorter recovery time (CG 8.1 min ± 4.7 min versus IB 10.0 min ± 8.5 min; p  = 0.01) and discharge time. Conclusion  Satisfactory sedation and completion of the procedure was accomplished with both sedation protocols

Propofol-Based Procedural Sedation with or without Low-Dose Ketamine in Children

Objective Examine comparative dosing, efficacy, and safety of propofol alone or with an initial, subdissociative dose of ketamine approach for deep sedation. Background Propofol is a sedative-hypnotic agent used increasingly in children for deep sedation. As a nonanalgesic agent, use in procedures (e.g., bone marrow biopsies/aspirations, renal biopsies) is debated. Our intensivist procedural sedation team sedates using one of two protocols: propofol-only (P-O) approach or age-adjusted dose of 0.25 or 0.5 mg/kg intravenous ketamine (K + P) prior to propofol. With either approach, an initial induction dose of 1 mg/kg propofol is recommended and then intermittent dosing throughout the procedure to achieve adequate sedation to safely and effectively perform the procedure. Approach: Retrospective evaluation of 754 patients receiving either the P-O or K + P approach to sedation. Results A total of 372 P-O group patients and 382 K + P group. Mean age (7.3 ± 5.5 years for P-O; 7.3 ± 5.4 years for K + P) and weight (30.09 ± 23.18 kg for P-O; 30.14 ± 24.45 kg for K + P) were similar in both groups (p = NS). All patients successfully completed procedures with a 16% combined incidence of hypoxia (SPO2 < 90%). Procedure time was 3 minutes longer for K + P group than P-O group (18.68 ± 15.13 minutes for K + P; 15.11 ± 12.77 minutes for P-O; p < 0.01), yet recovery times were 5 minutes shorter (17.04 ± 9.36 minutes for K + P; 22.17 ± 12.84 minutes for P-O; p < 0.01). Mean total dose of propofol was significantly greater in P-O than in K + P group (0.28 ± 0.20 mg/kg/min for K + P; 0.40 ± 0.26 mg/kg/min for P-O; p < 0.0001), and might explain the shorter recovery time. Conclusion Both sedation approaches proved to be well tolerated and equally effective. Addition of ketamine was associated with reduction in the recovery time, probably explained by the statistically significant decrease in the propofol dose

Nurse practitioner coverage is associated with a decrease in length of stay in a pediatric chronic ventilator dependent unit

AIM: To hypothesize a dedicated critical care nurse practitioner (NP) is associated with a decreased length of stay (LOS) from a pediatric chronic ventilator dependent unit (PCVDU). METHODS: We retrospectively reviewed patients requiring care in the PCVDU from May 2001 through May 2011 comparing the 5 years prior to the 5 years post implementation of the critical care NP in 2005. LOS and room charges were obtained. RESULTS: The average LOS decreased from a median of 55 d [interquartile range (IQR): 9.8-108.3] to a median of 12 (IQR: 4.0-41.0) with the implementation of a dedicated critical care NP (P < 1.0001). Post implementation of a dedicated NP, a savings of 25738049 in room charges was noted over 5 years. CONCLUSION: Our data demonstrates a critical care NP coverage model in a PCVDU is associated with a significantly reduced LOS demonstrating that the NP is an efficient and likely cost-effective addition to a medically comprehensive service

Practice Variation in the Immediate Postoperative Care of Pediatric Kidney Transplantation: A National Survey

Introduction Advances in organ allocation, surgical technique, immunosuppression, and long-term follow-up have led to a significant improvement in kidney transplant outcomes. Although there are clear recommendations for several aspects of kidney transplant management, there are no pediatric-specific guidelines for immediate postoperative care. The aim of this survey is to examine practice variations in the immediate postoperative care of pediatric kidney transplant patients. Methods We surveyed medical directors of Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)-affiliated pediatric intensive care units regarding center-specific immediate postoperative management of pediatric kidney transplantation. Results The majority of PALISI centers admit patients to the pediatric intensive care unit postoperatively, and 97% of the centers involve a pediatric nephrologist in immediate postoperative care. Most patients undergo invasive hemodynamic monitoring; 97% of centers monitor invasive arterial blood pressure and 88% monitor central venous pressure. Most centers monitor serum electrolytes every 4 to 6 hours. Wide variation exists regarding blood pressure goal, fluid replacement type, frequency of obtaining kidney ultrasound, and use of prophylactic anticoagulation. Conclusion There is consistent practice across PALISI centers in regards to many aspects of immediate postoperative management of pediatric kidney transplantation. However, variation still exists in some management aspects that warrant further discussions to reach a national consensus

Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes

Background: Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. Objective: We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). Design: A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. Results: A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. Conclusions: The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patient's experience, reduce redundant services, and expedite care

Testing and development of transfer functions for weighing precipitation gauges in WMO-SPICE

Weighing precipitation gauges are used widely for the measurement of all forms of precipitation, and are typically more accurate than tipping-bucket precipitation gauges. This is especially true for the measurement of solid precipitation; however, weighing precipitation gauge measurements must still be adjusted for undercatch in snowy, windy conditions. In WMO-SPICE (World Meteorological Organization Solid Precipitation InterComparison Experiment), different types of weighing precipitation gauges and shields were compared, and adjustments were determined for the undercatch of solid precipitation caused by wind. For the various combinations of gauges and shields, adjustments using both new and previously existing transfer functions were evaluated. For most of the gauge and shield combinations, previously derived transfer functions were found to perform as well as those more recently derived. This indicates that wind shield type (or lack thereof) is more important in determining the magnitude of wind-induced undercatch than the type of weighing precipitation gauge. It also demonstrates the potential for widespread use of the previously developed transfer functions. Another overarching result was that, in general, the more effective shields, which were associated with smaller unadjusted errors, also produced more accurate measurements after adjustment. This indicates that although transfer functions can effectively reduce measurement biases, effective wind shielding is still required for the most accurate measurement of solid precipitation

Measuring solid precipitation using heated tipping bucket gauges: an overview of performance and recommendations from WMO‐SPICE

Comunicación presentada en: TECO-2016 (Technical Conference on Meteorological and Environmental Instruments and Methods of Observation) celebrada en Madrid, del 27 al 30 de septiembre de 2016

Errors and adjustments for WMO-SPICE tipping-bucket precipitation gauges

Presentación realizada en: 19th Symposium on Meteorological Observation and Instrumentation celebrado del 7 al 11 de enero de 2018 en Austin, Texas

Analysis of single-Alter-shielded and unshielded measurements of mixed and solid precipitation from WMO-SPICE

Precipitation measurements were combined from eight separate precipitation testbeds to create multi-site transfer functions for the correction of unshielded and single-Alter-shielded precipitation gauge measurements. Site-specific errors and more universally applicable corrections were created from these WMO-SPICE measurements. The importance and magnitude of such wind speed corrections were demonstrated.This research was funded by the Korean Ministry of Land, Infrastructure and Transport through a grant (16AWMP-B079625-03) from the Water Management Research Program