Search

OBJECTIVES To describe the patient characteristics, clinical management, and infectious etiology in critically ill children with bronchiolitis. The secondary objective was to determine the association between antibiotic use and hospital length of stay among patients without concomitant bacterial infections. METHODS Retrospective cohort study including patients ≤2 years old with bronchiolitis admitted to 3 Canadian pediatric intensive care units between 2016 and 2018. RESULTS We included 372 patients with a median age of 2.1 months (interquartile range 1.2–6.6) and Pediatric Risk of Mortality III score 3.0 (interquartile range 0–3.0). Initial ventilatory management included high flow nasal cannula (28.2%) and noninvasive positive pressure ventilation (53.7%), of which 41.9% and 87.5%, respectively, did not require escalation of ventilatory support. Chest radiographs (81.7%) and respiratory virus testing (95.4%) were performed in most patients; 14.0% received systemic steroids. Respiratory syncytial virus was detected in 61.3% patients, and 7.5% had a culture-positive concomitant bacterial infection. Of 258 (69.4%) patients with a viral infection, only 45.3% received antibiotics. In this group, antibiotic use beyond 72 hours was not associated with hospital length of stay (ratio 1.14, 95% confidence interval 0.97–1.34). CONCLUSIONS High flow nasal canulae and noninvasive ventilation are commonly used in severe bronchiolitis. Despite contrary evidence, steroids and antibiotics were also frequently used. Evidence-based guidelines specific to children with severe bronchiolitis are needed to improve the care delivered to this patient population.

Adequate dosing of antimicrobials is critical to properly treat infections and limit development of resistance and adverse effects. Limited guidance exists for antimicrobial dosing adjustments in patients requiring extracorporporeal membrane oxygenation (ECMO) therapy. A systematic review was conducted to delineate the pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in critically ill adult patients requiring ECMO. Medline, EMBASE, Global Health, and All EBM Reviews databases were searched. Grey literature was examined. All studies reporting PK/PD parameters of antimicrobials in critically ill adults treated with ECMO were included, except for case reports and congress abstracts. Ex vivo studies were included. Two independent reviewers applied the inclusion and exclusion criteria. Reviewers were then paired to independently abstract data and evaluate methodological quality of studies using the ROBINS-I tool and the compliance with ClinPK guidelines. Patients’ and studies’ characteristics, key PK/PD findings, details of ECMO circuits and co-treatments were summarized qualitatively. Dosing recommendations were formulated based on data from controlled studies. Thirty-two clinical studies were included; most were observational and uncontrolled. Fourteen ex vivo studies were analysed. Information on patient characteristics and co-treatments was often missing. The effect of ECMO on PK/PD parameters of antimicrobials varied depending on the studied drugs. Few dosing recommendations could be formulated given the lack of good quality data. Limited data exist on the PK/PD of antimicrobials during ECMO therapy. Rigorously designed and well powered populational PK studies are required to establish empiric dosing guidelines for antimicrobials in patients requiring ECMO support. CRD42018099992 (Registered: July 24th 2018).

A 16-year-old female presents to a community emergency room following a suicide attempt by hanging. Prehospital, on arrival of paramedics, the patient was in a pulseless electrical activity rhythm. Paramedics provided advanced cardiac life support for 20 minutes before they obtained return of spontaneous circulation. In the emergency department, she had another 25-minute cardiac arrest with ultimate return of spontaneous circulation. She is now hemodynamically stable on Levophed 0.2 µg/kg/min. Her neurological exam shows pupils to be 3 mm and fixed bilaterally, absent cough and gag, and no response to central or peripheral pain. She occasionally triggers 2–3 spontaneous breaths per minute above the set rate on the ventilator. Her CT head scan shows severe anoxic changes and cerebral edema.

Item does not contain fulltext OBJECTIVES: 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 < 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.

ObjectiveTo determine the value and perspectives of intensive care unit (ICU) healthcare professionals (HCPs) and families about the Glass Door (GD) decal team communication tool.DesignQuality improvement methodology was used to design, test and implement the GD. Uptake was measured through audit. Impact was assessed through mixed methodology (survey of ICU HCPs (n=96) and semi-structured interviews of HCPs (n=10) and families (n=7)).SettingEighteen bed, closed, mixed medical–surgical–cardiac ICU in a tertiary care, university-affiliated, paediatric hospital.PopulationInterdisciplinary ICU HCPs and families of children admitted to the ICU.InterventionA transparent template (the GD) applied to the outside of ICU patients’ doors with sections for HCPs names, physiological goals and planned tests and treatments for the day. Medical staff completed the GD in rounds (AM and PM) and any HCP caring for the patient updated it throughout the day.Measurements and main resultsAfter 3 months, 96% of 613 doors were employed of which 99% respected confidentiality. ICU HCPs reported improved understanding of the patient’s plan (84% today vs 59% pre-GD, pConclusionsThe GD decal communication tool, visible on the patient’s door, improved ICU HCPs’ perceived knowledge of their patient’s plan. The GD improved the shared mental model, facilitated teaching and information transfer and fostered family engagement. Challenges included knowing the rules for use and consistent application. Concerns initially raised by HCPs about confidentiality were denied by families.

Background This study aims to assess the impact of a quality improvement initiative to increase assessments of pain, agitation, and iatrogenic withdrawal syndrome, on the use of sedative and analgesic medication in a pediatric intensive care unit. Methods This is a retrospective pre and post, observational, quality improvement study conducted in an 18-bed medical-surgical-cardiac, tertiary intensive care unit. We included patients consecutively admitted from October 1 to March 31 (pre-period 2015-2016, post-period 2016-2017) who were mechanically ventilated beyond 48 hours. A multidisciplinary team, including a family advisor, implemented the following interventions using rapid "Plan-Do-Study-Act cycles:" (a) standardized pain and sedation assessments, (b) standardized sedation goal setting, and (c) non-pharmacological strategies to manage pain and agitation. We did not implement any specific sedation protocol. We used audit and feedback to reinforce change. Results The post-intervention phase started once sedation scores were documented q12h for >60% of patients. The groups (n = 45 per group) were similar regarding demographics, severity of illness, and mechanical ventilation duration, but different in length of intensive care stay. The cumulative dose of midazolam equivalent was significantly lower in the post-intervention period (3.71 vs 2.65 mg/kg/mechanical ventilation day, P = 0.009, 95% CI: -1.12 (-1.89, -0.31)). Morphine equivalent usage went from 3.51 to 2.57 mg/kg/mechanical ventilation day (P = 0.066, 95% CI: -0.67 [-1.44, 0.05]). There were no significant pre-post-differences in the use of other sedative agents, rates of iatrogenic withdrawal syndrome or severe pain, nor medication cost. Conclusion Implementation of a multifaceted QI project was successful at increasing standardized assessments of pain and agitation, and was associated with a significant reduction in midazolam use. We also observed a decrease in morphine use without increasing rates of severe pain. Incidence of iatrogenic withdrawal syndrome and cost were unchanged.

Deceased donation rates in Canada remain below the predicted potential and lag behind leading countries. Missing a potential donor leads to preventable death and disability of transplant candidates and increased healthcare costs. Stakeholders were invited to a national consensus conference on improving deceased organ donor identification and referral (IDR 2) donor IDR 3) enhancing accountability: gaps and solutions; and 4) enhancing accountability: quality/safety organizations. Thirty-seven consensus statements were generated. At the healthcare professional (HCP) level, key statements include: 1) donation be consistently addressed as part of end-of-life care but only after a decision to withdraw life-sustaining treatment; 2) HCP know how and when to identify and refer potential donors; and 3) transplant candidates be informed of local allocation guidelines and performance. At the healthcare system level, key statements include: 1) national adoption of clinical criteria to trigger IDR 2) dedicated resources to match donation activities, including transfer of a potential donor; 3) performance measurement through death audits; 4) reporting and investigation of missed donation opportunities (MDO); 5) recognition of top performers; and 6) missed donor ID&R be considered a preventable and critical safety incident. Our consensus statements establish HCP and healthcare system responsibilities regarding potential organ donor ID&R and include the tracking, reviewing and elimination of MDO through system-wide death audits. Once implemented, these consensus statements will help honour patients’ wishes to donate, improve service to potential transplant recipients, and support HCPs in fulfilling their ethical and legal responsibilitites. Next steps include implementation, assessment of their impact on donation rates, and investigation of new evidence-based targets for system improvement.

Prolonged use of indwelling catheters is associated with hospital-acquired urinary tract infections (UTIs). Literature is scarce about the factors influencing urinary catheter removal and maintenance in children. This study aims to describe the determinants of urinary catheter removal in pediatric intensive care unit (PICU) patients.Cross-sectional survey of 171 physicians and nurses working at 2 tertiary PICUs in Montreal, Canada. We used focus groups and literature review to design the survey questions and 3 clinical scenarios. We analyzed our results using descriptive statistics and multivariate multinomial regression.There were 131 (77%) participants who answered the survey. Factors prompting urinary catheter removal (P .01) included recent extubation, superficial sedation level, fever, and history of previous UTI. Presence of shock (P .01) and fluid overload (P .05) were associated with maintenance of catheters. Physicians were more likely to remove urinary catheters than nurses in all scenarios.We identified a consistent set of variables that drive the removal of indwelling catheters in PICUs. Studies are needed to determine whether incorporating these determinants into infection control interventions will reduce urinary catheter use and catheter-associated UTIs in critically ill children.

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.

Innovation in patient engagement and empowerment has been identified as a priority area in the Canadian healthcare system. This article describes the development and implementation of the We Should Talk campaign at an academic pediatric hospital. Through the use of a guiding theoretical framework and a multidisciplinary project team, a multimedia campaign was designed to inspire staff, patients and families to effectively communicate to improve patient safety. The We Should Talk campaign provides a case study for how an organization can foster frontline improvement through the engagement of patient, families, and healthcare providers.

Deceased donation rates in Canada remain below the predicted potential and lag behind leading countries. Missing a potential donor leads to preventable death and disability of transplant candidates and increased healthcare costs.Stakeholders were invited to a national consensus conference on improving deceased organ donor identification and referral (IDR) and healthcare system accountability. In advance, participants received evidence-based, background documents addressing death audits, clinical triggers, required referral legislation, ethics, clinical pathways, and donation standards. At the conference, expert presentations and summaries of background information prepared by the Steering Committee informed group discussions of the preset questions. The conference's themes were: 1) expectations of potential donors, recipients and their families; 2) donor IDR: clinical and legal perspectives; 3) enhancing accountability: gaps and solutions; and 4) enhancing accountability: quality/safety organizations.Thirty-seven consensus statements were generated. At the healthcare professional (HCP) level, key statements include: 1) donation be consistently addressed as part of end-of-life care but only after a decision to withdraw life-sustaining treatment; 2) HCP know how and when to identify and refer potential donors; and 3) transplant candidates be informed of local allocation guidelines and performance. At the healthcare system level, key statements include: 1) national adoption of clinical criteria to trigger IDR; 2) dedicated resources to match donation activities, including transfer of a potential donor; 3) performance measurement through death audits; 4) reporting and investigation of missed donation opportunities (MDO); 5) recognition of top performers; and 6) missed donor IDR be considered a preventable and critical safety incident.Our consensus statements establish HCP and healthcare system responsibilities regarding potential organ donor IDR and include the tracking, reviewing and elimination of MDO through system-wide death audits. Once implemented, these consensus statements will help honour patients' wishes to donate, improve service to potential transplant recipients, and support HCPs in fulfilling their ethical and legal responsibilitites. Next steps include implementation, assessment of their impact on donation rates, and investigation of new evidence-based targets for system improvement.RéSUMé: OBJECTIF: Au Canada, les dons des personnes décédées restent inférieurs aux possibilités prédites et loin derrière les pays les plus performants. Le manque de donneurs potentiels aboutit à des décès évitables, à l’invalidité des candidats à la transplantation et à des coûts de soins de santé plus élevés. MéTHODES: Les principaux acteurs ont été invités à une conférence de consensus nationale sur l’amélioration de l’identification et de l’orientation des donneurs d’organes décédés (IDR —Identification and referral) et sur la responsabilité du système de santé. Les participants ont reçu à l’avance des documents basés sur des données probantes qui abordaient l’audit des décès, les facteurs cliniques identifiants, la législation requise pour l’orientation, l’éthique, les cheminements cliniques et les normes de dons. Au cours de la conférence, les présentations d’experts et des résumés de l’information de fond préparés par le Comité de pilotage ont alimenté les discussions de groupe sur les questions préparées. Les thèmes de la conférence étaient les suivants : 1) attentes des donneurs potentiels, des receveurs et de leurs familles; 2) identification et orientation des donneurs : points de vue cliniques et légaux; 3) amélioration de la responsabilité : lacunes et solutions; et 4) amélioration de la responsabilité : organisations de la qualité/sécurité. RéSULTATS: Trente-sept énoncés de consensus ont été générés. Au niveau des professionnels de santé, les principaux énoncés sont les suivants : 1) que le don soit constamment abordé dans le cadre des soins de fin de vie, mais seulement après avoir pris la décision d’arrêter les traitements de maintien de vie; 2) les professionnels de santé ont le savoir-faire pour identifier et orienter les donneurs potentiels; et 3) les candidats à la transplantation doivent être informés des lignes directrices locales sur les attributions et sa performance. Au niveau du système de soins de santé, les principaux énoncés sont les suivants : 1) l’adoption au niveau national de critères cliniques déclenchant l’identification et l’orientation des donneurs; 2) des ressources dédiées aux activités d’appariement des dons, y compris au transfert des donneurs potentiels; 3) des mesures de performance par des audits des décès; 4) la déclaration et des investigations sur les opportunités de dons manqués; 5) la reconnaissance des plus performants; et 6) l’identification et l’orientation manquées de donneurs doivent être considérées comme un incident évitable et critique. CONCLUSION: Nos énoncés de consensus établissent les responsabilités des professionnels de santé et du système de soins pour ce qui concerne l’identification et l’orientation des donneurs potentiels d’organes; ils incluent le suivi, l’analyse et l’élimination des dons manqués via une vérification des causes de décès dans tout le système. Une fois mis en œuvre, ces énoncés de consensus contribueront à honorer les souhaits des patients en matière de dons, améliorer les services apportés aux receveurs potentiels de greffes et soutenir les professionnels de santé dans l’accomplissement de leurs obligations éthiques et légales. Les étapes suivantes incluront la mise en œuvre, l’évaluation de leur impact sur les taux de dons et la recherche de nouvelles cibles basées sur des données probantes pour améliorer le système.

Background Tube thoracostomies in children are required for multiple indications and can be associated with significant discomfort. In 2010, a multidisciplinary team at our institution developed a protocol to replace stiff chest tubes with 8.5-French soft pleural catheters in children requiring pleural drainage. Methods Before initiating the protocol, an audit sheet was developed to prospectively capture data regarding insertion, removal, complications, and success. After 8 months of new protocol utilization, these data were reviewed, along with a retrospective review of the patients' charts. Results Twenty-three patients had 33 pleural catheters inserted over an 8-month period. Mean age was 6.7 years (1 day to 17 years). Indications for insertion were pneumothorax (24%), simple effusion (24%), chylothorax (27%), parapneumonic effusion/empyema (21%), and malignant effusion (3%). Complications included premature dislodgment (33%), blockage (15%), pneumothorax (3%), and bleeding (3%). Mean duration of pleural drainage was 7.27 days (0 to 37 days). Pleural drainage was successful in 91% of patients. Conclusion Soft pleural catheters are an acceptable alternative to traditional stiff chest tubes in the pediatric population. Premature dislodgment was the most common problem. Prospective audits are extremely valuable in assessing new procedural protocols and practice changes.

OBJECTIVE: To achieve national consensus on standards of training, quality assurance and maintenance of competence for critical care ultrasound for intensivists and critical care trainees in Canada using recently published international training statements.DATA SOURCES: Existing internationally endorsed guidelines and expert opinion.DATA SYNTHESIS: In November 2013, a day-long consensus meeting was held with 15 Canadian experts in critical care ultrasound in which essential topics relevant to training ultrasound were discussed.CONCLUSIONS: Consensus was achieved to direct training curriculum, oversight, quality assurance and maintenance of competence for critical care ultrasound. In providing the first national guideline of its kind, these Canadian recommendations may also serve as a model of critical care ultrasound dissemination for other countries.

The Institute of Medicine’s landmark report To Err Is Human revealed that tens of thousands of patient safety errors occur in hospitals across the United States every year.1 Canadian studies in both adult and pediatric hospitals corroborated these findings, revealing that 1 in 13 patients are victims of medical errors.2 To reduce these errors, it is important to have a culture where adverse events can be openly discussed and learned from in the hopes of preventing recurrences.3,4 In the pediatric setting, an open culture is one where everyone involved in the care of children, including the children themselves and their families, can speak up and be heard. The Montreal Children’s Hospital is an academic pediatric hospital that provides medical and surgical care to children 0 to 18 years of age. Results from patient and staff satisfaction surveys and from first-hand experience of front-line staff indicated that the safety culture could be improved at the hospital. Therefore, 3 physicians founded an interest group called “Champions for Patient Safety” to facilitate discussions and learning opportunities pertaining to patient safety, and broad participation is encouraged … Address correspondence to Nadine Korah, MDCM, MSc, FRCPC, The Montreal Children’s Hospital, 1001 Decarie Blvd. Montreal, QC, Canada H4A 3J1. E-mail: nadine.korah{at}mcgill.ca