Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility

OBJECTIVES: Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN: Cross-sectional. SETTING: A tertiary pediatric center and its satellite facility. PATIENTS: Patients admitted to the satellite facility. INTERVENTIONS: Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS: We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS: Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS: Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities

Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges

Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24-59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI's impact on long-term health in malaria-endemic areas are urgently needed

Quality of Resuscitative Care Provided to an Infant with Abusive Head Trauma in Community Emergency Departments: An In Situ, Prospective Simulation-Based Study

Objectives Abusive head trauma (AHT) is a very common and serious form of physical abuse, and a major cause of mortality and morbidity for young children. Early Recognition and supportive care of children with AHT is a common challenge in community emergency department (CEDs). We hypothesized that standardized, in situ simulation can be used to measure and compare the quality of resuscitative measures provided to children with AHT in a diverse set of CEDs. Methods This prospective, simulation-based study measured teams' performance across CEDs. The primary outcome was overall adherence to AHT using a 15-item performance assessment checklist based on the number of tasks performed correctly on the checklist. Results Fifty-three multiprofessional teams from 18 CEDs participated in the study. Of 270 participants, 20.7% were physicians, 65.2% registered nurses, and 14.1% were other providers. Out of all tasks, assessment of airway/breathing was the most successfully conducted task by 53/53 teams (100%). Although 43/53 teams (81%) verbalized the suspicion for AHT, only 21 (39.6%) of 53 teams used hyperosmolar agent, 4 (7.5%) of 53 teams applied cervical spine collar stabilization, and 6 (11.3%) of 53 teams raised the head of the bed. No significant difference in adherence to the checklist was found in the CEDs with an inpatient pediatric service or these with designated adult trauma centers compared with CEDs without. Community emergency departments closer to the main academic center outperformed CEDs these that are further away. Conclusions This study used in situ simulation to describe quality of resuscitative care provided to an infant presenting with AHT across a diverse set of CEDs, revealing variability in the initial recognition and stabilizing efforts and provided and targets for improvement. Future interventions focusing on reducing these gaps could improve the performance of CED providers and lead to improved patient outcomes

Prevention of Withdrawal in Pediatric Patients Receiving Long-term Dexmedetomidine Infusions

Objective: Determine if the addition of clonidine was associated with a decreased incidence of dexmedetomidine withdrawal in patients who received prolonged dexmedetomidine infusions. Methods: This was a retrospective observational cohort study conducted at a single-center PICU in an academic children's hospital. Children 1 month to 18 years of age who received dexmedetomidine infusion for 5 days or longer were included in the study. Results: Fifty patients met the inclusion criteria with 15 patients who received clonidine and 35 who received a dexmedetomidine wean alone. Withdrawal criteria included blood pressure changes, heart rate changes, and documented agitation. Overall, there was no difference in change in blood pressure or documented agitation between groups. Patients who did not receive clonidine had a greater number of heart rate readings above normal for age following discontinuation of the infusion, yet this was not statistically significant. Potentially more importantly, the addition of clonidine did not impact the duration of dexmedetomidine wean or the PICU length of stay after dexmedetomidine discontinuation. Conclusions: The addition of clonidine while weaning a long-term dexmedetomidine infusion did not lead to lower blood pressures or agitation, but did lead to decreased percentage of heart rates above the age-appropriate range. The clinical significance of this is unknown, and further investigation is warranted. The addition of clonidine did not decrease time to weaning off dexmedetomidine or shorten PICU length of stay

Diabetic Ketoacidosis With Refractory Hypokalemia Leading to Cardiac Arrest

Diabetic ketoacidosis (DKA) is known to cause total body potassium depletion, but during initial presentation, very few patients are hypokalemic, and even fewer patients experience clinical effects. As the correction of acidosis and insulin drive potassium intracellularly, measured serum potassium levels decrease and require repletion. This phenomenon is well described, and severe hypokalemia necessitates delaying insulin therapy. Less well described is the kaliuretic nature of treatments of cerebral edema. We present a case of an adolescent male with new-onset type 2 diabetes who presented in DKA with signs of cerebral edema, hyperosmolarity, and hypokalemia. As insulin and cerebral edema therapy were initiated, his hypokalemia worsened despite significant IV repletion, eventually leading to ventricular tachycardia and cardiac arrest. Over the following 36 hours, the patient received >590 milliequivalents (mEq) of potassium. He was discharged home 12 days after admission without sequelae of his cardiac arrest

Additional file 1: of Interleukin-27: a novel biomarker in predicting bacterial infection among the critically ill

Test characteristics for predicting bacterial blood culture-positive bacterial infection. Test characteristics, including sensitivity, specificity, and positive and negative predictive values of the subset of patients defined as infection through the presence of positive bacterial blood cultures. (DOCX 12 kb

Interleukin-27 as a candidate diagnostic biomarker for bacterial infection in immunocompromised pediatric patients.

BACKGROUND:Immunocompromised pediatric patients constitute a growing population that is particularly vulnerable to bacterial infection, necessitating prompt recognition and treatment. This study assessed the utility of interleukin-27 (IL-27) and procalcitonin (PCT) as biomarkers of bacterial infection among immunocompromised pediatric subjects. METHODS:This is a single-center prospective cohort study conducted from July 2016 through September 2017, drawing subjects from the inpatient units at Cincinnati Children's Hospital Medical Center (CCHMC), a large, tertiary care children's hospital. Patients were included if they fit the definition of immunocompromised and were under clinical suspicion for infection, defined by the acquisition of a blood culture at any point during the admission. The primary analysis assessed the accuracy of IL-27 to diagnose bacterial infection in immunocompromised pediatric patients, using PCT as a comparator. RESULTS:293 patients were recruited, representing 400 episodes of suspected bacterial infection. The median age was 7.8 years (IQR 3.1-13.8 years). Fifty-three percent (n = 213) of the population had a primary oncologic diagnosis, 24% (n = 95) had received a bone marrow transplant, and 21% (n = 85) had received a solid organ transplant. The overall infection rate was 37%, with 70% of those patients having some form of culture positivity. Twenty-eight-day mortality was 5%, 60-day mortality was 9%, with 87% of patients surviving to hospital discharge. The AUC's of the ROC curve to diagnose bacterial infection were 0.62 (0.5-0.68) for IL-27 and 0.65 (0.6-0.73) for PCT. Using the previously determined cutoff of 5.0 ng/mL, the specificity of IL-27 to diagnose bacterial infection reached 94%, with a negative predictive value of 64%. CONCLUSIONS:Despite prior work demonstrating IL-27 and PCT as possible biomarkers of bacterial infection in immunocompromised pediatric patients, we were unable to validate these findings. This illustrates the challenges associated with developing reliable biomarkers of bacterial infection in this vulnerable population

Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges

Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24-59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI's impact on long-term health in malaria-endemic areas are urgently needed

Genetic Diversity of Paired Middle-Ear and Pharyngeal Nontypeable Haemophilus influenzae Isolates from Children with Acute Otitis Media▿

Pulsed-field gel electrophoresis was used to determine genetic diversities of multiple nontypeable Haemophilus influenzae isolates from throat and ear specimens of eight children with otitis media. From five children, all ear and throat isolates were identical. The bacterial populations in these specimens showed less diversity than populations in throat isolates of healthy children

Acute kidney injury interacts with coma, acidosis, and impaired perfusion to significantly increase risk of death in children with severe malaria

Background: (AKI) is a common complication of severe malaria, but the interactions between AKI and other complications on the risk of mortality in severe malaria are not well characterized. Methods: Between 2014 and 2017, 600 children aged 6–48 months to 4 years hospitalized with severe malaria were enrolled in a prospective clinical cohort study evaluating clinical predictors of mortality in children with severe malaria. Results:The mean age of children in this cohort was 2.1 years (standard deviation, 0.9 years) and 338 children (56.3%) were male. Mortality was 7.3%, and 52.3% of deaths occurred within 12 hours of admission. Coma, acidosis, impaired perfusion, AKI, elevated blood urea nitrogen (BUN), and hyperkalemia were associated with increased mortality (all P \u3c .001). AKI interacted with each risk factor to increase mortality (P \u3c .001 for interaction). Children with clinical indications for dialysis (14.4% of all children) had an increased risk of death compared with those with no indications for dialysis (odds ratio, 6.56; 95% confidence interval, 3.41-12.59). Conclusions: AKI interacts with coma, acidosis, or impaired perfusion to significantly increase the risk of death in severe malaria. Among children with AKI, those who have hyperkalemia or elevated BUN have a higher risk of death. A better understanding of the causes of these complications of severe malaria, and development and implementation of measures to prevent and treat them, such as dialysis, are needed to reduce mortality in severe malaria