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Introduction: In mechanically ventilated adults, thickening fraction of diaphragm (dTF) measured by ultrasound is used to predict extubation success. Whether dTF can also predict extubation success in children is unclear. Aim: To investigate the association between dTF and extubation success in children. Second, to assess diaphragm thickness during ventilation and the correlation between dTF, diaphragm thickness (Tdi), age and body surface. Method: Prospective observational cohort study in children aged 0–18 years old with expected invasive ventilation for >48 h. Ultrasound was performed on day 1 after intubation (baseline), day 4, day 7, day 10, at pre-extubation, and within 24 h after extubation. Primary outcome was the association between dTF pre-extubation and extubation success. Secondary outcome measures were Tdi end-inspiratory and Tdi end-expiratory and atrophy defined as <10% decrease of Tdi end-expiratory versus baseline at pre-extubation. Correlations were calculated with Spearman correlation coefficients. Inter-rater reliability was calculated with intraclass correlation (ICC). Results: Fifty-three patients, with median age 3.0 months (IQR 0.1–66.0) and median duration of invasive ventilation of 114.0 h (IQR 55.5–193.5), were enrolled. Median dTF before extubation with Pressure Support 10 above 5 cmH2O was 15.2% (IQR 9.7–19.3). Extubation failure occurred in six children, three of whom were re-intubated and three then received non-invasive ventilation. There was no significant association between dTF and extubation success; OR 0.33 (95% CI; 0.06–1.86). Diaphragmatic atrophy was observed in 17/53 cases, in three of extubation failure occurred. Children in the extubation failure group were younger: 2.0 months (IQR 0.81–183.0) vs. 3.0 months (IQR 0.10–48.0); p = 0.045. At baseline, pre-extubation and post-extubation there was no significant correlation between age and BSA on the one hand and dTF, Tdi- insp and Tdi-exp on the other hand.

BACKGROUND: Sparse data are available on prehospital care by Helicopter Emergency Medical Service (HEMS) for pediatric patients with traumatic brain injury (TBI). This study focusses on prehospital interventions, neurosurgical interventions and mortality in this group. METHODS: We performed a retrospective analysis of pediatric (0-18 years of age) patients with TBI treated by Rotterdam HEMS. RESULTS: From January 2012 to December 2017 415 pediatric (<18 years of age) patients with TBI were included. Intubation was required in in 92 of 111 patients with GCS ≤ 8, 92 (82.9%), compared to 12 of 77 (15.6%) with GCS 9-12, and 7 of 199 (3.5%) with GCS 13-15. Hyperosmolar therapy (HSS) was started in 73 patients, 10 with a GCS ≤8. Decompressive surgery was required in 16 (5.8%), nine patients (56.3%) of these received HSS from HEMS. Follow-up data was available in 277 patients. A total of 107 (38.6%) patients were admitted to a (P)ICU. Overall mortality rate was 6.3%(n = 25) all with GCS ≤8, 15 (60.0%) died within 24 hours and 24 (96.0%) within a week. Patients with neurosurgical interventions (N = 16) showed a higher mortality rate (18.0%). CONCLUSIONS: The Dutch HEMS provides essential emergency care for pediatric TBI patients, by performing medical procedures outside of regular EMS protocol. Mortality was highest in patients with severe TBI (n = 111) (GCS≤8) and in those who required neurosurgical interventions. Despite a relatively good initial GCS (>8) score, there were patients who required prehospital intubation and HSS. This group will require further investigation to optimize care in the future.

Purpose: The first-pass success rate for endotracheal intubation (ETI) depends on provider experience and exposure. We hypothesize that video laryngoscopy (VL) improves first-pass and overall ETI success rates in low and intermediate experienced airway providers and prevents from unrecognized oesophageal intubations in prehospital settings. Methods: In this study 3632 patients were included. In all cases, an ambulance nurse, HEMS nurse, or HEMS physician performed prehospital ETI using direct Laryngoscopy (DL) or VL. Results: First-pass ETI success rates for ambulance nurses with DL were 45.5% (391/859) and with VL 64.8% (125/193). For HEMS nurses first-pass success rates were 57.6% (34/59) and 77.2% (125/162) respectively. For HEMS physicians these successes were 85.9% (790/920) and 86.9% (1251/1439). The overall success rate for ambulance nurses with DL was 58.4% (502/859) and 77.2% (149/193) with VL. HEMS nurses successes were 72.9% (43/59) and 87.0% (141/162), respectively. HEMS physician successes were 98.7% (908/920) and 99.0% (1425/1439), respectively. The incidence of unrecognized intubations in the oesophagus before HEMS arrival in traumatic circulatory arrest (TCA) was 30.6% with DL and 37.5% with VL. In medical cardiac arrest cases the incidence was 20% with DL and 0% with VL. Conclusion: First-pass and overall ETI success rates for ambulance and HEMS nurses are better with VL. The used device does not affect success rates of HEMS physicians. VL resulted in less unrecognized oesophageal intubations in medical cardiac arrests. In TCA cases VL resulted in more oesophageal intubations when performed by ambulance nurses before HEMS arrival.

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Purpose: The quality of resuscitation and effective leadership are decisive for the outcome of a resuscitation. Nurses are usually the first responders upon cardiac arrest. Therefore, we started the “proficiency check” project, which aims to improve nurses' resuscitation and teamwork skills. This article describes the effectiveness of the proficiency check and nurses' experiences with it. Design and methods: This study was done among intensive care nurses working on a pediatric ICU (PICU) in the Netherlands. It was designed as a mixed-methods study combining a quantitative and a qualitative approach. Quantitative data were obtained through a pre-posttest comparison of nurses' resuscitation and teamwork skills, in a simulation setting. Qualitative data on nurses' experiences were collected through semi-structured individual interviews. Results: Both resuscitation and teamwork skills improved significantly. In 39 nurses (32%), the improvement of both resuscitation and teamwork skills after the intervention was large (effect size >0.8). The experiences of nurses regarding the proficiency check were diverse: on the positive side, increased knowledge and confidence were reported, whereas negative experiences related, among other things, to stress and anxiety. Conclusions: Resuscitation and teamwork skills of PICU nurses can be enhanced by the ‘proficiency check’ studied here. This simulation-based training can be further improved by incorporating the nurses' experiences. Practice implications: A simulation-based assessment for resuscitation may play an important role in a PICU, and possibly for other skills and in other settings as well. Particular attention should be paid to the stress that many nurses experience due to skills assessment.

Background: The incidence of hemostatic complications in pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) is high. The optimal anticoagulation strategy in children undergoing ECMO is unknown. Objectives: To study the association between hemostatic complications, coagulation tests, and clinical parameters in pediatric patients undergoing ECMO and their effect on survival. Methods: We performed a retrospective cohort study of pediatric patients undergoing centrifugal pump ECMO. Collected data included patient characteristics, risk factors, and coagulation test results. Statistical analysis was done using logistic regression analysis for repeated measurements. Dependent variables were thrombosis and bleeding, independent variables were rotational thromboelastometry (ROTEM), activated partial thromboplastin time (aPTT) and antifactor-Xa assay (aXa) results, ECMO duration, age <29 days, sepsis and surgery. Results: Seventy-three patients with 623 ECMO days were included. Cumulative incidences of thrombosis and bleeding were 43.5% (95% confidence interval [CI], 26.0%-59.8%) and 25.4% (95% CI, 13.4%-39.3%), respectively. A lower maximum clot firmness of intrinsic ROTEM (INTEM; odds ratio [OR], 0.946; 95% CI, 0.920-0.969), extrinsic ROTEM (OR, 0.945; 95% CI, 0.912-0.973), and INTEM with heparinase (OR, 0.936; 95% CI, 0.896-0.968); higher activated partial thromboplastin time aPTT; OR, 1.020; 95% CI, 1.006-1.024) and age <29 days (OR, 2.900; 95% CI, 1.282-6.694); surgery (OR, 4.426; 95% CI, 1.543-12.694); and longer ECMO duration (OR, 1.149; 95% CI, 1.022-1.292) significantly increased thrombotic risk. Surgery (OR, 2.698; 95% CI, 1.543-12.694) and age <29 days (OR 2.242, 95% CI 1.282–6.694) were significantly associated with major bleeding. Patients with hemostatic complications had significantly decreased survival to hospital discharge (P =.009). Conclusion: The results of this study help elucidate the role of ROTEM, aPTT, anti–factor Xa

Background: Congenital diaphragmatic hernia (CDH) can be repaired on or off extracorporeal membrane oxygenation (ECMO). In many centers, operating off ECMO is advocated to prevent bleeding complications. We aimed to compare surgery-related bleeding complications between repair on or off ECMO. Methods: All patients with CDH repair and ECMO treatment between January 1, 1995, and May 31, 2008, were retrospectively reviewed. Tranexamic acid was routinely given to all patients repaired on ECMO for 24 hours perioperatively after 2003. Extra-fluid expansion, transfusion, or relaparotomy caused by postoperative bleeding were scored as surgery-related bleeding complications and were related to the Extracorporeal Life Support Organization (ELSO) registry. We used chi(2) test and t test for sta Results: Demographic data and surgery-related bleeding complications in the on-ECMO group were not significantly different compared with the off-ECMO group (P = .331) in our institute. In contrast, more surgery-related bleeding complications were reported by ELSO in their on-ECMO group (P < .0001). Conclusion: In contrast to the data from the ELSO registry, we did not observe significantly more surgery-related bleeding complications after CDH repair on ECMO. Using a specific perioperative hemostatic treatment enabled us to perform CDH repair on ECMO with a low frequency of bleeding complications, thereby taking advantage of having the physiologic benefits of ECMO available perioperatively. (C) 2012 Elsevier Inc. All rights reserved.

Introduction: The purpose of the present study was to critically review the existing body of evidence on ventilation modes for infants and children up to the age of 18 years. Methods: The PubMed and EMBASE databases were searched using the search terms 'artificial respiration', 'instrumentation', 'device', 'devices', 'mode', and 'modes'. The review included only studies comparing two ventilation modes in a randomized controlled study and reporting one of the following outcome measures: length of ventilation (LOV), oxygenation, mortality, chronic lung disease and weaning. We quantitatively pooled the results of trials where suitable. Results: Five trials met the inclusion criteria. They addressed six different ventilation modes in 421 children: high-frequency oscillation (HFO), pressure control (PC), pressure support (PS), volume support (VS), volume diffusive respirator (VDR) and biphasic positive airway pressure. Overall there were no significant differences in LOV and mortality or survival rate associated with the different ventilation modes. Two trials compared HFO versus conventional ventilation. In the pooled analysis, the mortality rate did not differ between these modes (odds ratio = 0.83, 95% confidence interval = 0.30 to 1.91). High-frequency ventilation (HFO and VDR) was associated with a better oxygenation after 72 hours than was conventional ventilation. One study found a significantly higher PaO(2)/FiO(2) ratio with the use of VDR versus PC ventilation in children with burns. Weaning was studied in 182 children assigned to either a PS protocol, a VS protocol or no protocol. Most children could be weaned within 2 days and the weaning time did not significantly differ between the groups. Conclusions: The literature provides scarce data for the best ventilation mode in critically ill children beyond the newborn period. There is no evidence, however, that high-frequency ventilation reduced mortality and LOV. Longer-term outcome measures such as pulmonary fu

Introduction Extracorporeal membrane oxygenation is a supportive cardiopulmonary bypass technique for patients with acute reversible cardiovascular or respiratory failure. Favourable effects of haemofiltration during cardiopulmonary bypass instigated the use of this technique in infants on extracorporeal membrane oxygenation. The current study aimed at comparing clinical outcomes of newborns on extracorporeal membrane oxygenation with and without continuous haemofiltration. Methods Demographic data of newborns treated with haemofiltration during extracorporeal membrane oxygenation were compared with those of patients treated without haemofiltration in a retrospective 1: 3 case-comparison study. Primary outcome parameters were time on extracorporeal membrane oxygenation, time until extubation after decannulation, mortality and potential cost reduction. Secondary outcome parameters were total and mean fluid balance, urine output in mL/kg/day, dose of vasopressors, blood products and fluid bolus infusions, serum creatinin, urea and albumin levels. Results Fifteen patients with haemofiltration (HF group) were compared with 46 patients without haemofiltration (control group). Time on extracorporeal membrane oxygenation was significantly shorter in the HF group: 98 hours (interquartile range (IQR) = 48 to 187 hours) versus 126 hours (IQR = 24 to 403 hours) in the control group (P = 0.02). Time from decannulation until extubation was shorter as well: 2.5 days (IQR = 0 to 6.4 days) versus 4.8 days (IQR = 0 to 121.5 days; P = 0.04). The calculated cost reduction was (sic)5000 per extracorporeal membrane oxygenation run. There were no significant differences in mortality. Patients in the HF group needed fewer blood transfusions: 0.9 mL/kg/day (IQR = 0.2 to 2.7 mL/kg/day) versus 1.8 mL/kg/day (IQR = 0.8 to 2.9 mL/kg/ day) in the control group (P<0.001). Consequently the number of blood units used was significantly lower in the HF group (P<0.001). There was no significant