Plasma cell free DNA (cfDNA) Test for Diagnosis of Infectious Diseases in Children: A Tertiary Care Children\u27s Hospital Experience

Introduction: Plasma cell free DNA (cfDNA) test (Karius Test®, KT) has emerged as an attractive diagnostic modality allowing noninvasive broad-range pathogen detection, and fast diagnosis. There are however few studies examining the impact of the KT in the diagnosis and management of infections in children. Our study aimed at evaluating the clinical impact of plasma cfDNA test since it was used at our institution. Methods: Our retrospective study included children between 0 to 21 years of age who were admitted to Driscoll Children’s Hospital, Corpus Christi, Texas between January 2019 and January 2022. Demographic and clinical course data were collected. KT and conventional tests (CT) results were analyzed to determine their agreement and clinical relevance of organisms. Clinical impact in diagnosis was assessed separately according to revised objective grading criteria. Results: Among 182 patients identified, the median (SD) age was 9 (6.1) years, with 99 (54.4%) males and 150 (82.4%) Hispanic, 53 (29.1%) patients are immunocompromised, the median (SD) hospital length of stay was 17.2 (37.7) days. Among 186 Karius Test® ordered (Table 1), 97 (52.2%) tests were sent from general wards. 102 (54.8%) were positive for one or more organisms. Median (range) turn-around time for KT 2.8 (1.7-11.6) days. 59 (31.7%) KT results had positive clinical impact in diagnosis (Table 2 and 3), higher positive impact were found in the diagnosis of pneumonia (44.4%), bacteremia (42.9%), and musculoskeletal infection (41.2%). KT was the only diagnostic modality that provided the diagnosis in 41 (22%) cases (Table 3), including Streptococcus pneumoniae, Pneumocystis jirovecii, Rickettsia typhi, and Bartonella henselae. Among 41 cases, KT had shorter turnaround time than conventional tests in 31 (75.6%) cases. Conclusions: In this retrospective cohort, we show that the plasma cell free DNA (cfDNA) test (Karius Test®) provided the only method of etiological diagnosis in 41 children. It was particularly useful in the diagnosis of pneumonia, musculoskeletal infection, bacteremia, Pneumocystis jirovecii and murine typhus with a relatively short turnaround time

Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study

Introduction Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members. Methods This is a prospective observational study analyzing data obtained between July 2018–December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies. Results Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of \u3e3 were reported by 100% of participants in all domains (p \u3c .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills. Conclusion This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter

Cardiac Tamponade: Innovative Sternotomy Simulation Model for Training Pediatric Cardiac Intensive Care Team

Introduction: Cardiac tamponade occurring after cardiac surgery is rare but life threatening and requires simultaneous resuscitation and emergent sternotomy by the intensive care team. A simulated scenario using innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the face validity of this innovative mannequin, the confidence level and crisis resource management skills of the team during sternotomy to manage postoperative cardiac tamponade. Methods: The simulation case scenario was developed using innovative sternotomy mannequin for children’s hospital cardiac intensive care unit (CICU) teams. The case involved a 3-year old male, intubated, mechanically ventilated after surgical repair of CHD, progressing to cardiac arrest due to cardiac tamponade. We conducted a structured, video debriefing following each scenario. We conducted a formative learner assessment before and after each scenario and analyzed the data using student t-test. Results: Of the 72 CICU providers, a statistically significant proportion of providers (p \u3c 0.0001) showed improved confidence in assessing and managing cardiac arrest occurring following postoperative cardiac tamponade. All the providers scored ≥ 3 for impact of the scenario on practice, teamwork, communication, assessment skills, improvement in CPR and opening the chest and their confidence in attending similar clinical situation in future. Most (96–100%) scored ≥ 3 for perception on realism of mannequin, the scenario, re-opening the sternotomy and level of stress. Conclusions: Innovative adaptation of a high-fidelity mannequin for cardiac tamponade simulation can achieve a realistic and reproducible training model with a positive impact on multi-disciplinary team training

Pediatric Critical Care Medicine Training in India: Past, Present, and Future

Pediatric critical care services in India have grown with leaps and bounds. There has been a growing need of physicians specially trained in pediatric critical care medicine (PCCM) in India. Physicians returning to India after their formal training in PCCM abroad have partly supported this growing need. Development of formal PCCM training programs in India has been a huge step toward supporting the growing clinical needs. This article focuses on advances in pediatric critical care training in India and its future directions

Hands-On Defibrillation Skills of Pediatric Acute Care Providers During a Simulated Ventricular Fibrillation Cardiac Arrest Scenario

Introduction: Timely defibrillation in ventricular fibrillation cardiac arrest (VFCA) is associated with good outcome. While defibrillation skills of pediatric providers have been reported to be poor, the factors related to poor hands-on defibrillation skills of pediatric providers are largely unknown. The aim of our study was to evaluate delay in individual steps of the defibrillation and human and non-human factors associated with poor hands-on defibrillation skills among pediatric acute care providers during a simulated VFCA scenario.Methods: We conducted a prospective observational study of video evaluation of hands-on defibrillation skills of pediatric providers in a simulated VFCA in our children's hospital. Each provider was asked to use pads followed by paddles to provide 2 J/kg shock to an infant mannequin in VFCA. The hands-on skills were evaluated for struggle with any step of defibrillation, defined a priori as >10 s delay with particular step. The data was analyzed using chi-square test with significant p-value < 0.05.Results: A total of 68 acute care providers were evaluated. Median time to first shock was 97 s (IQR: 60–122.5 s) and did not correlate with provider factors, except previous experience with the defibrillator used in study. The number of providers who struggled (>10 s delay) with each of connecting the pads/paddles to the device, using pads/paddles on the mannequin and using buttons on the machine was 34 (50%), 26 (38%), and 31 (46%), respectively.Conclusions: The defibrillation skills of providers in a tertiary care children's hospital are poor. Both human and machine-related factors are associated with delay in defibrillation. Prior use of the study defibrillator is associated with a significantly shorter time-to-first shock as compared to prior use of any other defibrillator or no prior use of any defibrillator

Advances in Pediatric Critical Care Research in India

Over last 2 decades, there has been a significant progress made in the field of pediatric critical care in India. There has been complementary and parallel growth in the pediatric critical care services in India and the number of pediatric critical care providers who are either formally trained in India or who have returned to India after their formal training abroad. The pediatric critical care community in India has recognized obvious differences in profiles of critical illnesses and patients between Indian subcontinent and the West. Therefore there is a growing interest in generating scientific evidence through local research which would be applicable to critically ill children in Indian subcontinent. This article focuses on advances in pediatric critical care research in India and its future directions

Poor Compliance with Sepsis Guidelines in a Tertiary Care Children’s Hospital Emergency Room

ObjectivesThis study aimed to assess factors related to adherence to the Pediatric Advanced Life Support guidelines for severe sepsis and septic shock in an emergency room (ER) of a tertiary care children’s hospital.MethodsThis was a retrospective, observational study of children (0–18 years old) in The Children’s Hospital of San Antonio ER over 1 year with the International Consensus Definition Codes, version-9 (ICD-9) diagnostic codes for “severe sepsis” and “shocks.” Patients in the adherent group were those who met all three elements of adherence: (1) rapid vascular access with at most one IV attempt before seeking alternate access (unless already in place), (2) fluids administered within 15 min from sepsis recognition, and (3) antibiotic administration started within 1 h of sepsis recognition. Comparisons between groups with and without sepsis guideline adherence were performed using Student’s t-test (the measurements expressed as median values). The proportions were compared using chi-square test. p-Value ≤0.05 was considered significant.ResultsA total of 43 patients who visited the ER from July 2014 to July 2015 had clinically proven severe sepsis or SS ICD-9 codes. The median age was 5 years. The median triage time, times from triage to vascular access, fluid administration and antibiotic administration were 26, 48.5, 76, and 135 min, respectively. Adherence to vascular access, fluid, and antibiotic administration guidelines was 21, 26, and 34%, respectively. Appropriate fluid bolus (20 ml/kg over 15–20 min) was only seen in 6% of patients in the non-adherent group versus 38% in the adherent group (p = 0.01). All of the patients in the non-adherent group used an infusion pump for fluid resuscitation. Hypotension and ≥3 organ dysfunction were more commonly observed in patients in adherent group as compared to patients in non-adherent group (38 vs. 14% p = 0.24; 63 vs. 23% p = 0.03).ConclusionOverall adherence to sepsis guidelines was low. The factors associated with non-adherence to sepsis guidelines were >1 attempt at vascular access, delay in antibiotic ordering, fluid administration using infusion pump, absence of hypotension, and absence of three or more organs in dysfunction at ER presentation

Heart Rate Variability (HRV) Loss and other EKG Changes prior to a Cardiopulmonary Event in Children admitted to the ICU at a Tertiary Care Children’s Hospital

Introduction: HRV and EKG changes prior to cardiopulmonary events (CPEs) occurring in children in intensive care unit (ICU) settings is not well documented. We assess if substantial losses of HRV and/or other EKG changes, if any, may be detectable prior to a CPE occurring in children admitted to the ICU. Methods: A prospective observational cohort study was conducted in the ICU from January to February of 2023 at Driscoll Children’s Hospital. A “CPE” was defined as a change in the clinical status of a child warranting a cardiopulmonary intervention. Demographic and clinical data from each patient was collected, along with EKG central monitor tracings prior to a CPE occurring. To assess HRV, R-R intervals will be manually measured, and HRV-specific metrics will be calculated using LabChart Pro software. To asses other EKG parameter changes, other EKG intervals and positions will be recorded. We will compare our obtained data with standard reference HRV and EKG parameter values for age and sex. Results: 34 children admitted to the pediatric and cardiac ICUs in Driscoll Children’s Hospital during January and February of 2023 were studied, with a total of 128 CPEs. Study population was 17 females (50%) and 17 males (50%). Median (IQR) age was 7.36 (0.86-75.55) months. 27 (79.41%) patients were White/Hispanic. Primary pathologies were mainly cardiac or respiratory in origin (18 (52.94%) cardiac, 9 (26.47%) respiratory). 15 (11.72%) CPEs were primarily cardiac, 113 (88.28%) CPEs were primarily respiratory. Discussion: EKG tracing measurements remaining ongoing. Results regarding HRV metrics and other EKG parameter analyses are pending

Neuroinflammation and Neuroimmune Dysregulation After Acute Hypoxic-Ischemic Injury of Developing Brain

Hypoxic-ischemic injury to developing brain results from birth asphyxia in neonates and from cardiac arrest in infants and children. It is associated with varying degrees of neurologic sequelae, depending upon the severity and length of hypoxia-ischemia. Global hypoxia-ischemia triggers a series of cellular and biochemical pathways that lead to neuronal injury. One of the key cellular pathways of neuronal injury is inflammation. The inflammatory cascade comprises activation and migration of microglia—the so-called brain macrophages, infiltration of peripheral macrophages into the brain, and release of cytotoxic, proinflammatory cytokines. In this article, we review the inflammatory and immune mechanisms of secondary neuronal injury after global hypoxic-ischemic injury to developing brain. Specifically, we highlight the current literature on microglial activation in relation to neuronal injury, proinflammatory and anti-inflammatory/restorative pathways, the role of peripheral immune cells, and the potential use of immunomodulators as neuroprotective compounds