Extracorporeal Membrane Oxygenation Use in Asphyxiated Newborns Treated with Hypothermia: Review of the Current Evidence

Asphyxiated newborns may be hemodynamically unstable during their first days of life. They often present with severe persistent pulmonary hypertension and/or cardiac dysfunction, which may require aggressive supportive management to maintain homeostasis and prevent further brain injury. In the most severe cases, extracorporeal membrane oxygenation (ECMO) may be required to ensure adequate oxygenation, ventilation and cardiac output. However, due to the risk of irreversible brain injury, clinicians often are concerned about offering ECMO to these newborns. Therapeutic hypothermia during the first days of life has become the standard of care for these newborns to improve their prognosis; however, this treatment in itself has been associated with increased hemodynamic instability and coagulopathy. An additional concern with using ECMO in these newborns is the potential increased bleeding risk when continuing the hypothermia treatment during the ECMO course. This chapter reviews the reported feasibility of performing hypothermia during ECMO. We also review the reported outcomes of asphyxiated newborns treated with hypothermia and ECMO and highlight their potential survival without neurodevelopmental impairments. Thus, ECMO should be considered as a therapeutic option for asphyxiated newborns treated with hypothermia

Effect of a pediatric early warning system on all-cause mortality in Hospitalized pediatric patients: The epoch randomized clinical trial

IMPORTANCE: There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. OBJECTIVE: To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. DESIGN, SETTING, AND PARTICIPANTS: A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. INTERVENTIONS: The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. RESULTS: Among 144539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P =.96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P =.03). CONCLUSIONS AND RELEVANCE: Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report

OBJECTIVES: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation

Who’s in drag? : strong critical thinking about prejudice, normalcy, gender and sexuality

This project undertakes a conceptual exploration of prejudice formation, maintenance, and reduction within the context of Educational Studies. It investigates some common sources of prejudice and offers an ethically defensible, realistic resource for teaching aimed at diminishing gender and sexual prejudice. In doing so, this project aims to make three important contributions to social justice research and practice. First, it brings together insights from the feminist, post-structuralist work of the identity theorist Judith Butler and from the philosopher of education Richard Paul. I argue that, taken together, their independent work on performativity, undisciplined thinking, and egocentrism offers a more complete picture of the dynamics that support and undermine social practice and belief than either can provide alone. Second, this project draws on the literature of strong critical thinking to argue that self-knowledge plays a vital but thorny role in reducing personal prejudice. To this end, it explores four interconnected aspects of self about which people may lack a deep understanding: (1) their modes of thinking, i.e., the manner in which they form their beliefs; (2) their background logics, i.e., the content and relationships of their beliefs about themselves and the world; (3) their dispositions, i.e., their habitual cognitive, affective, and behavioural inclinations; and (4) their identities, i.e., people’s own experience of who they are, what they value, and how they relate to the world. I argue that the knowledges, competencies, and dispositions essential to strong critical thinking can reduce prejudices rooted in performativity, undisciplined thinking, and egocentrism, as it helps to develop self-knowledge, improve purposeful thinking, and modify character traits. Third, this project provides educators addressing heterosexism and homophobia a conceptual tool--The Continuum of (Subversive) Drag Performance--designed to encourage strong critical thinking about gender and sexuality. The six ranges of the continuum facilitate the analysis of pervasive conceptions of gender and sexual normalcy and the wide-spread patterns of performance in which they are based. They also support educators in creating communities of inquiry that are relatively flexible, unconstrained by common conceptions of normalcy, humour-filled, and ripe with opportunities for the constructive practice of critical thinking.Education, Faculty ofEducational Studies (EDST), Department ofGraduat

Presence of a Physician Safety Champion Is Associated with a Reduction in Urinary Catheter Utilization in the Pediatric Intensive Care Unit.

BACKGROUND:Safety champions are effective in a variety of safety initiatives; however, there are no reports of their role in hospital-acquired infections prevention. OBJECTIVE:We aimed to describe the association of the presence of a physician safety champion with our urinary catheter device utilization ratios (DUR) in the Pediatric Intensive Care Unit (PICU). METHODS:Our PICU has incidence rates of catheter-associated urinary tract infections (CAUTI) and urinary catheter DUR above the 90th percentile. Using a quasi-experimental design, we compared our DUR when the PICU team was exposed and unexposed (champion's maternity leaves) to a physician safety champion. Hospital acquired infection (HAI) surveillance of all PICU admissions between April 1st 2009 and June 29th 2013 was done prospectively. To ensure stable acuity of the patient population over time, we used the central venous catheter (CVC) DUR as a control. RESULTS:The urinary catheter DUR was 0.44 (95% confidence interval [CI] 0.42-0.45) during the unexposed period versus 0.39 (95%CI 0.38-0.40) during the exposed period, for an absolute difference of 0.05 (95%CI 0.03-0.06; p<0.0001). The overall CVC DUR increased from 0.57 (95%CI 0.55-0.58) during the unexposed period to 0.63 (95%CI 0.61-0.64) during the exposed period, an absolute increase of 0.06 (95%CI 0.04-0.08; p<0.0001). Comparing the exposed and unexposed periods, adjusting for time trend, we observed a 17% decrease in the urinary catheter DUR when the safety champion was present (odds ratio [OR] 0.83; 95%CI 0.77-0.90). The rate of catheter-associated urinary tract infections did not change. CONCLUSIONS:The presence of a unit-based safety champion can have a positive impact on urinary catheter DUR in a PICU

Gender and Authorship in Pediatric Critical Care Randomized Control Trials

Item does not contain fulltextOBJECTIVES: To examine the gender distribution of authorship of pediatric critical care randomized control trials. DATA SOURCES: The 415 randomized control trials in pediatric critical care published before 2019. STUDY SELECTION: We included all randomized control trials enrolling children in a PICU. We used PICUtrials.net, which uses comprehensive search strategies of multiple databases, to identify published randomized control trials. DATA EXTRACTION: We manually extracted the name and profession of each listed author from each publication and classified each author as male or female based on their name. RESULTS: We included 2,146 authors and were able to classify 1,888 (88%) as men or women. Overall, 38% of authors were women, this varied with the authorship position: 37% of first, 38% of middle, and 25% of last authors were women (p &lt; 0.001). The three most common professions were physician (63%), nonclinician (11%), and nurse (6%)-of which 30%, 45%, and 97%, respectively, were women. The percentage of female authorship overall has increased from 28% in 1985-1989 to 39% in 2015-2018 (p for trend = 0.004). There were no significant differences in the characteristics of randomized control trials published with a female first or last author versus those with both male first and last authors with respect to the median number of children randomized (60 vs. 50; p = 0.41), multicentred trials (17% vs. 24%; p = 0.12), trials at low risk of bias (50% vs. 66%; p = 0.26), reporting any funding (55% vs. 51%; p = 0.66), or median number of citations per year (1.5 vs. 2.4; p = 0.09). CONCLUSIONS: Although increasing over time, the percentage of researchers publishing pediatric critical care randomized control trials who are women still lags behind the percentage clinicians who are women. Trials that female researchers publish are similar in characteristics and impact as male researchers. Further work should identify barriers to gender diversity and potential solutions in pediatric critical care research