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Objectives: Sleep promotion bundles being tested in PICUs use elements adapted from adult bundles. As children may react differently than adults in ICU environments, this study investigated what parents report disrupted the sleep of their child in a PICU., Design: Secondary analysis of a multicenter validation study of the Survey of Sleep quality in the PICU., Setting: Four Northeastern U.S. PICUs, one hospital-based pediatric sleep laboratory., Patients: Parents sleeping at the bedside of a child in the PICU or hospital-based sleep laboratory., Interventions: Anonymous one-time survey eliciting parts of hospital or ICU environments that have been described as disruptive to sleep in validated adult ICU and pediatric inpatient questionnaires., Measurements and Main Results: Level of sleep disruption was scored by Likert scale, with higher scores indicating more disruption. Age, demographics, baseline sleep, and PICU exposures were used to describe causes of sleep disruption in a PICU. Of 152 PICU parents, 71% of their children's sleep was disrupted significantly by at least one aspect of being in the PICU. The most prevalent were "being in pain or uncomfortable because they are sick" (38%), "not sleeping at home" (30%), "alarms on machines" (28%), and "not sleeping on their home schedule" (26%). Only 5% were disrupted by excessive nocturnal light exposure. Overall sleep disruption was not different across four PICUs or in those receiving sedation. The validation study control group, healthy children undergoing polysomnography, had less sleep disruption than those in a PICU despite sleeping in a hospital-based sleep laboratory., Conclusions: There are multiple aspects of critical care environments that affect the sleep of children, which are different from that of adults, such as disruption to home schedules. Future interventional sleep promotion bundles should include sedated children and could be applicable in multicenter settings., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objectives: Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children., Design/setting: Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020., Patients: Critically ill children, 0 to 17 years old, undergoing TI in PICUs., Interventions: None., Measurements and Main Results: Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002)., Conclusions: In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events., Competing Interests: Ms. Napolitano’s, Dr. Shults’s, Dr. Nadkarni’s, and Dr. Nishisaki’s institution received funding from the Agency for Healthcare Research and Quality (R18HS024511). Ms. Napolitano’s institution received funding from Dräger, Actuated Medical, and Philips Respironics; they received support for article research from Timpel and VERO-Biotech. Dr. Krawiec received funding from New England Journal of Medicine Healer Cases and Carle Illinois School of Medicine Admissions Committee. Dr. Polikoff received funding from Novavax. Dr. Lee’s institution received funding from National Research Medical Council, Singapore. Dr. Shenoi is an elected member of the Society of Critical Care Medicine (SCCM) Council of the SCCM. Dr. Peihl disclosed that he is founder and Chief Medical Officer of 410 Medical; his institution received funding the Department of Defense (grants: USSOCOM W81XWH-22-C-0002, USAF SBIR AF212-CSO1 Phase II, F2-15653 USAF, SBIR AF211-CSO1 Phase II, F2-15254). Dr. Hasegawa disclosed work for hire. Dr. Nishisaki’s institution received funding from Chiesi USA, AHRA, and the National Institute of Child Health and Human Development. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019., Design/setting: Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia., Subjects: Critically ill children requiring TI in a PICU or pediatric cardiac ICU., Interventions: None., Measurements and Main Results: Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021)., Conclusions: TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs., Competing Interests: Dr. Polikoff received funding from Novavax. Drs. Napolitano’s and Shults’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ) (R18HS024511). Dr. Napolitano’s institution received funding from Drager, Timpel, Respironics, Actuated Medical, and Vero-Biotech. Dr. Shults received support for article research from the AHRQ (R18HS024511). Dr. Berkenbosch received funding from Pfizer. Dr. Nishisaki’s institution received funding from the AHRQ, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Chiesi USA; she received support for article research from the AHRQ. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted., Methods: We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO 2  > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI., Results: A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p  < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p  = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p  = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p  = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p  = 0.759)., Conclusion: In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2024.)

The pediatric intensive care unit (PICU) is bright, loud, and disruptive to children. Strategies to improve the sleep of adults in the ICU have improved delirium and mortality rates. Children need more sleep than adults for active growth, healing, and development when well; this is likely true when they are critically ill. This review was performed to describe what we know in this area to date with the intent to identify future directions for research in this field. Since the 1990s, 16 articles on 14 observational trials have been published investigating the sleep on a total of 312 critically ill children and the melatonin levels of an additional 144. Sleep measurements occurred in 9 studies through bedside observation (n = 2), actigraphy (n = 2), electroencephalogram (n = 1) and polysomnography (n = 4), of which polysomnography is the most reliable. Children in the PICU sleep more during the day, have fragmented sleep and disturbed sleep architecture. Melatonin levels may be elevated and peak later in critically ill children. Early data suggest there are at-risk subgroups for sleep and circadian disruption in the PICU including those with sepsis, burns, traumatic brain injury and after cardiothoracic surgery. The available literature describing the sleep of critically ill children is limited to small single-center observational studies with varying measurements of sleep and inconsistent findings. Future studies should use validated measurements and standardized definitions to begin to harmonize this area of medicine to build toward pragmatic interventional trials that may shift the paradigm of care in the pediatric intensive care unit., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Extracorporeal membrane oxygenation (ECMO) and/or inhaled anesthetics (IAs) are considered in the management of asthma when refractory to conventional therapy. We aimed to compare the outcomes of these two modalities in asthma PICU care and determine associated survival to hospital discharge among patients in a United States database., Design: Retrospective analysis using the Virtual Pediatric Systems (VPS, LLC) database., Setting: PICUs participating in the VPS database., Patients: Patients less than 18 years old with diagnosis of asthma treated with IA and/or ECMO from January 2010 to December 2020., Interventions: None., Measurements and Main Results: A total of 221 patients were included; 149 (67%) received ECMO, 62 (28%) received IA, and 10 (5%) received both interventions. We failed to identify any difference between the ECMO and IA groups in demographics, Pediatric Index of Mortality 2 percentage, Pediatric Risk of Mortality 3 score, Pediatric Logistic Organ Dysfunction score, or pre-intervention pH and Pa co2 levels. Use of ECMO versus IA was associated with lower pre-intervention Pa o2 (60 torr [7.99 kPa] vs 78 torr [10.39 kPa]; p < 0.001) and higher utilization of high-frequency oscillatory ventilation. We failed to identify an association between type of intervention (IA vs ECMO) and greater odds of survival (57/62 [92%] vs 128/149 [86%]; odds ratio [OR], 1.87; 95% CI, 0.67-5.21; p = 0.23). However, these data do not exclude the possibility that IA use is associated with more than five-fold greater odds of survival. ECMO use was associated with longer duration of intervention (5 vs 1.3 d; p < 0.001) and PICU length of stay (LOS) (13 vs 7 d; p < 0.001). As expected, ECMO versus IA was also associated with greater odds of undergoing bronchoscopy (34% vs 11%; OR, 3.7; 95% CI, 1.5-9.4; p = 0.004)., Conclusions: In the VPS database of asthma management cases, we failed to identify an association between ECMO versus IA use and survival to hospital discharge. However, ECMO was associated with longer duration of intervention and PICU LOS., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees., Methods: This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods., Results: There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods., Conclusions: The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes., Competing Interests: All authors report no conflicts of interest., (© 2022 Society for Academic Emergency Medicine.)

Purpose: During the first few months of the COVID-19 outbreak, healthcare workers (HCW) faced levels of personal risk, emotional distress, and professional strain not seen in their lifetimes. This study described how these stressors influenced various aspects of their sleep patterns., Methods: From May 19 to June 20, 2020, an electronic, cross-sectional survey was administered to a convenience sample of in- and outpatient HCW in a large, nonprofit healthcare system. Respondents described the pandemic's initial impact on personal and professional life and various sleep dimensions: regularity, efficiency, duration, timing, quality, and daytime sleepiness., Results: Two hundred seven providers responded, representing 17 different healthcare roles. Most (82%) were women with a median age of 39 years (IQR1-3, 31-53). A majority of respondents (81%) worked in an inpatient setting, with half (46%) primarily on the "frontline." Approximately one-third of respondents (37%) were physicians and one-quarter (28%) were nurses. Overall, 68% of HCW reported at least one aspect of sleep worsened during the beginning of the pandemic; the most impacted were daytime sleepiness (increased in 43%) and sleep efficiency (worse in 37%). After adjusting for COVID exposure and burnout, frontline providers had twofold higher odds of poor pandemic sleep, aOR 2.53, 95%CI 1.07-5.99. Among frontline providers, physicians were fivefold more likely to develop poor pandemic sleep compared to nurses (OR 5.73, 95%CI 1.15-28.57)., Conclusions: During the initial wave of COVID-19, a majority of HCW reported a decline in sleep with an increase in daytime sleepiness and insomnia. Frontline workers, specifically physicians, were at higher risk., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship., Design: Retrospective cohort study., Setting: Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children., Patients: All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017., Interventions: None., Measurements and Main Results: The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14)., Conclusions: The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.

Objective: Our institution performed an educational initiative targeting previously identified barriers to pediatric sepsis recognition and treatment. We hypothesized that provider knowledge, attitude, and behavior would be improved 1 year after implementation., Methods: This was a prospective, observational study of a multi-faceted quality initiative introduced to providers in the Emergency Department, inpatient wards, and Pediatric Intensive Care Unit of a tertiary care children's hospital. Educational platforms consisted of quarterly electronic sepsis "newsletters," brightly colored posters highlighting protocol and screening strategies displayed throughout the hospital, and low-fidelity simulation sessions (drills) led by trained staff and incorporated into daily workflows. The content was driven by feedback from a baseline needs assessment of sepsis education. One year after implementation, the needs assessment was repeated., Results: Over 3 months, facilitators conducted 197 drills and captured a majority of nurses (89%), pediatrics residents (96%), and respiratory therapists (62%). By 6 months, 241 sessions had been completed. Approximately 55.4% of the 442 eligible staff participated in our post-intervention survey. Overall, knowledge of diagnostic criteria for pediatric sepsis and septic shock increased from pre-intervention levels ( P = 0.015). Among post-implementation respondents, drill participants outperformed their colleagues ( P = 0.001). A greater percentage of post-intervention respondents indicated comfort with sepsis recognition ( P < 0.001), and fewer reported hesitating to bring sepsis concerns to their care team ( P < 0.01)., Conclusions: Our findings suggest that a multidisciplinary curriculum balancing active education-through brief, targeted simulation-and general awareness-through electronic resources and a poster campaign-can improve sepsis-related knowledge, attitude, and behavior among pediatric practitioners., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Pediatric antibiotic prescriptions originate from an increasingly broad range of ambulatory settings. In this retrospective study, pharyngitis, otitis media, sinusitis, pneumonia, and upper respiratory infection cases, at 11 primary care offices, 2 independent urgent care centers (UCCs), and a pediatric emergency department in Western New York, were analyzed relative to medical society practice guidelines and antibiotic utilization. Of 2358 eligible visits across all sites, 25% were for study diagnoses, with 38% at UCC ( P < .01). Across all sites, 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection. At primary care offices and UCCs, guideline recommended first-line agents for pharyngitis and otitis media were used in only 58% and 63% of treated cases, respectively. Overall, an estimated 9855 to 12 045 avoidable antibiotic and 8030 non-guideline antibiotic courses annually are represented by the 14 sites studied. These and other study findings highlight numerous opportunities for outpatient pediatric antibiotic stewardship.

Objective: Pediatric sepsis remains a significant cause of morbidity and mortality despite the development of strategies proven to improve diagnosis and treatment. Specifically, early recognition and urgent therapy initiation are consistently associated with improved outcomes. However, providers bring these principles inconsistently to the bedside. The objective of this study was to describe practitioner knowledge of, and attitudes toward, sepsis as a means of identifying potentially modifiable factors delaying life-saving treatment. We hypothesized there would be difficulties with sepsis recognition and self-reported discomfort with making the diagnosis among all provider groups in a pediatric tertiary care center., Methods: Emergency department and inpatient pediatric physicians, nurses, and respiratory therapists in a single, freestanding children's hospital received an electronic survey. Likert scales permitted anonymous self-reporting of comfort and diagnostic delays. Seven clinical vignettes assessed diagnostic knowledge. Independent sample t tests and Chi-square compared responses., Results: Three hundred two staff participated (73% response rate), 41% of whom had at least 10 years of clinical experience. One in 5 was uncomfortable alerting coworkers to a patient with suspected sepsis or septic shock, and almost half were uncomfortable doing so in cases of compensated shock. Every role self-reported diagnostic delays, including faculty physicians. On average, physicians answered a greater percentage of vignette questions correctly (66%), compared with nurses (58%; P = 0.013) and respiratory therapists (52%; P = 0.005)., Conclusions: Sepsis knowledge deficits, provider discomfort, and diagnostic delays are prevalent within a tertiary care children's hospital. Their presence and scale suggest areas for future research and targeted intervention.

IntroductionChildren with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.Materials and methodsWe sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation., Results: A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease., Conclusions: The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.

Objectives: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU., Design: A retrospective cohort study of a multicenter pediatric airway quality improvement registry., Settings: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand)., Patients: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015., Interventions: None., Measurements and Main Results: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036)., Conclusions: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

Objectives: As of July 2013, pediatric resident trainee guidelines in the United States no longer require proficiency in nonneonatal tracheal intubation. We hypothesized that laryngoscopy by pediatric residents has decreased over time, with a more pronounced decrease after this guideline change., Design: Prospective cohort study., Setting: Twenty-five PICUs at various children's hospitals across the United States., Patients: Tracheal intubations performed in PICUs from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children)., Intervention: None., Measurements and Main Results: Prospective cohort study in which all primary tracheal intubations occurring in the United States from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children) were analyzed. Participating PICU leaders were also asked to describe their local airway management training for residents. Resident participation trends over time, stratified by presence of a Pediatric Critical Care Medicine fellowship and airway training curriculum for residents, were described. A total of 9,203 tracheal intubations from 25 PICUs were reported. Pediatric residents participated in 16% of tracheal intubations as first laryngoscopists: 14% in PICUs with a Pediatric Critical Care Medicine fellowship and 34% in PICUs without one (p < 0.001). Resident participation decreased significantly over time (3.4% per year; p < 0.001). The decrease was significant in ICUs with a Pediatric Critical Care Medicine fellowship (p < 0.001) but not in ICUs without one (p = 0.73). After adjusting for site-level clustering, patient characteristics, and Pediatric Critical Care Medicine fellowship presence, the Accreditation Council for Graduate Medical Education guideline change was not associated with lower participation by residents (odds ratio, 0.86; 95% CI, 0.59-1.24; p = 0.43). The downward trend of resident participation was similar regardless of the presence of an airway curriculum for residents., Conclusion: Laryngoscopy by pediatric residents has substantially decreased over time. This downward trend was not associated with the 2013 Accreditation Council for Graduate Medical Education change in residency requirements.

Objectives: Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease., Design: Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children)., Setting: Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016., Patients: Children with medical or surgical cardiac disease who underwent intubation in an ICU., Interventions: None., Measurements and Main Results: Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002)., Conclusions: In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

Objectives: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs., Design: A retrospective observational study using a multicenter emergency airway quality improvement registry., Setting: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand)., Patients: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015., Measurements and Main Results: Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001)., Conclusions: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Background: The objective of this work was to describe the use of negative-pressure ventilation (NPV) in a heterogeneous critically ill, pediatric population., Methods: A retrospective chart review was conducted of all patients admitted to a pediatric ICU with acute respiratory failure supported with NPV from January 1, 2012 to May 15, 2015., Results: Two hundred thirty-three subjects at a median age of 15.5 months were supported with NPV for various etiologies, most commonly bronchiolitis (70%). Median (interquartile range) duration of support was 18.7 (8.7-34.3) h. The majority were NPV responders (70%), defined as not needing escalation to any form of positive-pressure ventilation. In non-responders, escalation occurred at a median (interquartile range) of 6.9 (3.3-16.6) h. More NPV non-responders had upper-airway obstruction ( P = .02), and fewer had bronchiolitis ( P = .008) compared with responders. A bedside scoring system developed on these data was 98% specific in predicting NPV failure by 4 h after NPV start (area under the curve 0.759, 95% CI 0.675-0.843, P < .001). Complications from NPV were rare (3%); however, delayed enteral nutrition (33%) and continuous intravenous sedation use (51%) in children while receiving NPV were more frequent. The annual percentage of pediatric ICU admissions requiring intubation declined by 28% in the 3 y after NPV introduction, compared with the 3 y prior., Conclusions: NPV is a noninvasive respiratory support for pediatric acute respiratory failure from all causes with few complications and a 70% response rate. Children receiving NPV often required intravenous sedation for comfort, and one third received delayed enteral nutrition. Those who required escalation from NPV worsened within 6 h; this may be predictable with a bedside scoring system., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2017 by Daedalus Enterprises.)

Objectives: To improve handover communication and patient outcomes for postoperative admissions to a multidisciplinary PICU., Design: Prospective cohort study., Setting: Multidisciplinary PICU in a university hospital., Subjects: The multidisciplinary team responsible for postoperative PICU admissions and patient care, including attending, fellow, house staff physicians, and nurses from pediatric critical care medicine, surgery, and anesthesia., Interventions: An online survey distributed to PICU, surgery, and anesthesia providers identified existing barriers and challenges to effective postoperative PICU handovers and guided the formation of a standard protocol. Handovers for postoperative PICU admissions were then directly observed for 3 months pre- and postimplementation of the protocol, with data collected on communication, metrics, and patient outcomes. Observations and data collection, as well as the online provider survey, were repeated approximately 1 year after handover protocol implementation., Measurements and Main Results: Survey data demonstrated increases in provider ratings of handover attendance, communication, and quality after implementation of the handover protocol (p < 0.001). Surgical report errors were eliminated (p = 0.03), and the prevalence of provider attendance for the handover duration increased from 39.3% to 68.2% (p = 0.01). Following protocol implementation, fewer patients experienced antibiotic delays (34.5% to 13.9%; p = 0.03) or required hemodynamic or respiratory interventions within the first 6 hours of PICU admission (24.6% to 9.1%; p = 0.04). Patients received their first dose of analgesia (62.3 to 17.4 min; p = 0.01) and had their admission laboratory studies sent (42.3 to 32.9 min; p = 0.04) more quickly. Data collected at 12 months postimplementation demonstrated sustained reductions in analgesia timing, antibiotic delays, and handover barriers., Conclusions: Postoperative communication and patient outcomes can be improved and sustained over time with implementation of a standardized handover protocol.

Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the effectiveness of a structured postoperative handover protocol for postoperative transfer to the SICU. This study was a randomized controlled trial conducted in a comprehensive teaching hospital in China. Patients who were transferred to the SICU after surgery were randomly divided into two groups. The intervention group underwent postoperative structured handover protocol, and the control group still applied conventional oral handover. A total of 101 postoperative patients and 50 clinicians were enrolled. Although the intervention group did not shorten the handover duration (6.18 ± 1.66 vs 5.94 ± 1.91; P = 0.505), the handover integrity was significantly improved, mainly reflected in fewer information omissions (1.44 ± 0.97 vs 0.67 ± 0.62; P < 0.001), fewer additional questions raised by ICU physicians (1.06 ± 1.04 vs 0.24 ± 0.43; P < 0.001) and fewer additional handovers via phone call (16% vs 3.9%; P = 0.042). The total score of satisfaction of the intervention group was significantly higher than that of the control group (76.44 ± 7.32 vs 81.24 ± 6.95; P = 0.001). With respect to critical care, the incidence of stage I pressure sore within 24 h was lower in the intervention group than in the control group (20% vs 3.9%, P = 0.029). Structured postoperative handover protocol improves the efficiency and quality of interdisciplinary communication and clinical care in SICU. Trial registration This study was registered in China on January 8th, 2022 at Chinese Clinical Trial Registry (ChiCTR2200055400). [ABSTRACT FROM AUTHOR]

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population. [ABSTRACT FROM AUTHOR]

Providing the right respiratory support is an essential skill, vital for anyone treating sick children. Recent advances in respiratory support include developments in both non-invasive and invasive ventilatory strategies. In non-invasive ventilation, newer modalities are being developed, in an attempt to decrease the need for invasive ventilation. This include newer techniques like Heated humidified high-flow nasal cannula (HHHFNC) and improvements in existing modes. The success of Continuous positive airway pressure (CPAP) and other non-invasive modes depend to a large extent on choosing and maintaining a suitable interface. When it comes to invasive ventilation, recent advances are focussing on increasing automation, improving patient comfort and minimising lung injury. Concepts like mechanical power are attempts at understanding the mechanisms of unintended injuries resulting from respiratory support and newer monitoring methods like transpulmonary pressure, thoracic impedance tomography are attempts at measuring potential markers of lung injury. Using the vast arrays of available ventilatory options judiciously, considering their advantages and drawbacks in every individual case will be the prime responsibility of clinicians in the future. Simultaneously, efforts have been made to identify potential drugs that can favourably modify the pathophysiology of acute respiratory distress syndrome (ARDS). Unfortunately, though eagerly awaited, most pharmaceutical agents tried in pediatric ARDS have not shown definite benefit. Pulmonary local drug and gene therapy using liquid ventilation strategies may revolutionize our future understanding and management of lung diseases. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was first identified in December 2019 and emerged into an ongoing global pandemic. Both the pandemic itself and the associated public restrictive measures of social mobility established with different intensity over different periods in various countries have significantly affected the everyday activities and lifestyles of people all over the world. The impact of lockdown and quarantine measures on hypertension incidence and blood pressure (BP) control is an important topic that requires further investigation. The aim of this review is: a) to present the current evidence regarding the actual effects of public restrictive measures on BP levels and control, originating primarily from studies investigating the impact of public restrictive measures on BP control with the use of various BP phenotypes; b) to summarize the possible pandemic-related effects of factors known to affect BP levels, including both traditional (e.g. dietary habits including alcohol and sodium intake, body weight, smoking and physical activity) and non-traditional (e.g. sleep patterns, air pollution, environmental noise, delayed diagnosis and medication adherence) ones. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial prescription rates tend to be high in outpatient settings and Primary Emergency Medical Centers (PECs) in Japan encounter difficulties in implementing antimicrobial stewardship programs (ASPs). While a nudge‐based ASP publishing monthly newsletters reduces inappropriate prescription of oral third‐generation cephalosporins (3GCs), which requires considerable effort. Therefore, developing more preferable ASP models in PECs is essential. Methods: We conducted a three‐center, retrospective observational study. Himeji City Emergency Medical Center (Site A) introduced a facility‐specific guideline for antimicrobial stewardship with reference to national guidelines. The Kobe Children's Primary Emergency Medical Center (Site B) provided the results of monitoring antibiotics prescription in a monthly newsletter. The Hanshin‐Kita Children's First‐Aid Center (Site C) did not perform a specific ASP. Prescription rates for 3GCs were categorized into pre‐ and post‐intervention and compared using Poisson regression analysis. The difference‐in‐difference method was used to assess the effect of these interventions. Results: The numbers of patients pre‐ and post‐ intervention were 177,126 and 91,251, respectively. The 3GCs prescription rate at Site A, Site B, and Site C decreased from 6.7%, 4.2%, and 6.1% in 2016 to 2.3%, 1.0%, and 2.0% in 2019, respectively. Site B had a greater reduction than Site A and Site C (relative risk [RR] 0.71 [95% confidence interval (CI): 0.62–0.82]; p < 0.001, RR 0.71, [95% CI: 0.62–0.81]; p < 0.001). There was no significant difference between Site A and Site C (RR 1.00 [95% CI 0.88–1.13]; p = 0.963). Conclusion: A facility‐specific guideline was less effective than a nudge‐based ASP for decreasing oral 3GC prescriptions in PECs. [ABSTRACT FROM AUTHOR]

Introduction: There is limited knowledge on pediatric chest radiograph (pCXR) interpretation skill among practicing physicians. We systematically determined baseline interpretation skill, the number of pCXR cases physicians required complete to achieve a performance benchmark, and which diagnoses posed the greatest diagnostic challenge., Methods: Physicians interpreted 434 pCXR cases via a web-based platform until they achieved a performance benchmark of 85% accuracy, sensitivity, and specificity. Interpretation difficulty scores for each case were derived by applying one-parameter item response theory to participant data. We compared interpretation difficulty scores across diagnostic categories and described the diagnoses of the 30% most difficult-to-interpret cases., Results: 240 physicians who practice in one of three geographic areas interpreted cases, yielding 56,833 pCXR case interpretations. The initial diagnostic performance (first 50 cases) of our participants demonstrated an accuracy of 68.9%, sensitivity of 69.4%, and a specificity of 68.4%. The median number of cases completed to achieve the performance benchmark was 102 (interquartile range 69, 176; min, max, 54, 431). Among the 30% most difficult-to-interpret cases, 39.2% were normal pCXR and 32.3% were cases of lobar pneumonia. Cases with a single trauma-related imaging finding, cardiac, hilar, and diaphragmatic pathologies were also among the most challenging., Discussion: At baseline, practicing physicians misdiagnosed about one-third of pCXR and there was up to an eight-fold difference between participants in number of cases completed to achieve the standardized performance benchmark. We also identified the diagnoses with the greatest potential for educational intervention., (Copyright © 2024 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

Background: Preadmission discussions in the study institution's pediatric intensive care unit are not standardized and admission plans were thought to be disjointed, leading to a perceived lack of organization and preparation for the arrival of a critically ill child. Objective: To evaluate the impact of a new, formalized preadmission pediatric intensive care unit interdisciplinary huddle on clinician perceptions of interprofessional communication. The hypothesis was that preadmission huddles would improve unit clinicians' perceptions of interprofessional communication. Methods: Interprofessional pediatric intensive care unit clinicians (physicians, advanced practice providers, nurses, and respiratory therapists) completed surveys before and 7 months after preadmission interdisciplinary huddle implementation. Huddle compliance and perceptions of interprofessional communication in the unit were evaluated. Results: Of 265 eligible pediatric intensive care unit admissions, 69 huddles (26.0%) occurred. The postintervention survey revealed increased odds (odds ratio [95% CI]) of responding "strongly agree" or "agree" to questions about the opportunity to "communicate effectively with health care team members" (2.42 [1.10-5.34]), "respond to feedback from health care team members" (2.54 [1.23-5.24]), and "convey knowledge to other health care team members" (2.71 [1.31-5.61]) before an admission. Discussion: This study introduced a formalized huddle that improved pediatric intensive care unit clinicians' perceived communication with other health care team members in the preadmission period. Conclusions: Future studies are needed to determine if this perceived improvement in communication significantly affects health care outcomes of critically ill children or if these results are generalizable to other pediatric intensive care unit settings. [ABSTRACT FROM AUTHOR]

Background: Few studies have looked at health system factors associated with laboratory test use. Objective: To determine the association between health system factors and routine laboratory test use in medical inpatients. Design: We conducted a retrospective cohort study on adult patients admitted to clinical teaching units over a 3-year period (January 2015 to December 2017) at three tertiary care hospitals in Calgary, Alberta. Participants: Patients were assigned to a Case Mix Group+ (CMG+) category based on their clinical characteristics, and patients in the top 10 CMG+ groups were included in the cohort. Exposures: The examined health system factors were (1) number of primary attending physicians seen by a patient, (2) number of attending medical teams seen by a patient, (3) structure of the medical team, and (4) day of the week. Main Measures: The primary outcome was the total number of routine laboratory tests ordered on a patient during their admission. Statistical models were adjusted for age, sex, length of stay, Charlson comorbidity index, and CMG+ group. Results: The final cohort consisting of 36,667 patient-days in hospital (mean (SD) age 62.5 (18.4) years) represented 5071 unique hospitalizations and 4324 unique patients. Routine laboratory test use was increased when patients saw multiple attending physicians; with an adjusted incidence rate ratio (IRR) of 1.46 (95% CI, 1.37–1.55) for two attending physicians, and 2.50 (95% CI, 2.23-2.79) for three or more attending physicians compared to a single attending physician. The number of routine laboratory tests was slightly lower on weekends (IRR 0.98, 95% CI, 0.96–0.99) and on teams without a senior resident as part of their team structure (IRR 0.89, 95% CI 0.830.96). Conclusions: The associations observed in this study suggest that breaks in continuity of care, including increased frequency in patient transfer of care, may impact the utilization of routine laboratory tests. [ABSTRACT FROM AUTHOR]

Extraordinary progress has been made during the past few decades in the development of anesthesia machines and ventilation techniques. With unprecedented precision and performance, modern machines for pediatric anesthesia can deliver appropriate mechanical ventilation for children and infants of all sizes and with ongoing respiratory diseases, ensuring very small volume delivery and compensating for circuit compliance. Along with highly accurate monitoring of the delivered ventilation, modern ventilators for pediatric anesthesia also have a broad choice of ventilation modalities, including synchronized and assisted ventilation modes, which were initially conceived for ventilation weaning in the intensive care setting. Despite these technical advances, there is still room for improvement in pediatric mechanical ventilation. There is a growing effort to minimize the harm of intraoperative mechanical ventilation of children by adopting the protective ventilation strategies that were previously employed only for prolonged mechanical ventilation. More than ever, the pediatric anesthesiologist should now recognize that positive‐pressure ventilation is potentially a harmful procedure, even in healthy children, as it can contribute to both ventilator‐induced lung injury and ventilator‐induced diaphragmatic dysfunction. Therefore, careful choice of the ventilation modality and its parameters is of paramount importance to optimize gas exchange and to protect the lungs from injury during general anesthesia. The present report reviews the novel ventilation techniques used for children, discussing the advantages and pitfalls of the ventilation modalities available in modern anesthesia machines, as well as innovative ventilation modes currently under development or research. Several innovative strategies and devices are discussed. These novel modalities are likely to become part of the armamentarium of the pediatric anesthesiologist in the near future and are particularly relevant for challenging ventilation scenarios. [ABSTRACT FROM AUTHOR]

Background: Acute otitis media (AOM) is a common cause for antibiotic prescription. Most guidelines endorse abstaining from immediate antibiotic treatment ('watchful waiting', WW) in mild-moderate episodes. We studied adherence rates to the latest AOM guidelines (2013), in terms of antibiotic type and prescription options.Methods: In this population-based study, AOM episodes were identified in Clalit Health Services-insured children aged 0-10 years between 2011 and 2018, using a data-sharing platform. After identifying the index, prescription and issuing dates for antibiotics for each AOM episode, treatment was categorized as immediate (≤2 days after diagnosis) or WW (antibiotic not prescribed/issued; prescribed ≤2 days after diagnosis but issued on Days 2-7; or prescribed/issued on Days 2-7). Guideline adherence was measured according to age.Results: Of the 491 106 episodes, 361 518 (73.6%) were treated with antibiotics. Following the 2013 guidelines, the ratio of episodes in children aged ≤6 months that were adherent (immediate treatment) was higher (OR = 1.22; 95% CI 1.15-1.29; P < 0.001), whereas the adherent episode ratio for children aged 6-24 months and 2-10 years (WW) was lower (OR = 0.87; 95% CI 0.85-0.88 and OR = 0.94; 95% CI 0.92-0.96, respectively; P < 0.001). Antibiotic prescription rates after 2013 for children aged ≤6 months were not different (OR = 1.03; 95% CI 0.96-1.1; P = 0.4), but were higher in children aged 6-24 months and 2-10 years (OR = 1.07; 95% CI 1.05-1.09; P < 0.001 and OR = 1.02; 95% CI 1.01-1.04; P = 0.015, respectively). Amoxicillin was the most common antibiotic, administered in 75.6% of episodes. Azithromycin was most commonly associated with treatment failure (6.6%).Conclusions: Improved adherence to the 2013 guidelines was observed only in children aged ≤6 months and over-treatment with antibiotics was still high. [ABSTRACT FROM AUTHOR]

This document is a reply to a letter regarding the control of SARS-CoV-2 infection and burnout prevention among healthcare workers. The author agrees with the importance of maintaining good sleep quality to prevent burnout and cites a study showing a correlation between burnout and insomnia among COVID-19 healthcare workers. The author emphasizes the increased workload, stress, and patient acuity experienced by healthcare workers during the pandemic, leading to burnout and sleep disturbances. They suggest addressing sleep hygiene and promoting mindfulness-based practices as interventions to mitigate burnout. The author also discusses the challenges of staffing during the pandemic and clarifies that they did not advocate for mandatory vaccination of healthcare workers, but rather recommended strongly encouraging vaccination through transparent disclosure of information. [Extracted from the article]

Background: The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings.Methods: The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU).Discussion: The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings.Trial Registration: ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020. [ABSTRACT FROM AUTHOR]

An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM. [ABSTRACT FROM AUTHOR]

Postsurgical handover of paediatric patients from operating rooms to intensive care units is a critical moment. This process is susceptible to errors and inefficiencies particularly if poor teamwork in this multidisciplinary and ad hoc collaboration occurs. Through combining provider- and observer-rated team performance, we aimed to determine agreement levels on team performance and associations with mental demands, disruptions, and stress. An observational and multisource study of provider and concomitant expert-observer ratings was established. In an Academic Paediatric Hospital, we conducted standardized observations of postsurgical handovers to PICU. We applied established observational and self-reported teamwork tools. Nested fixed and mixed models were established to estimate agreement within teams, between providers' and observer's ratings, as well as for estimations between team performance and mental demands, disruptions, and stress outcomes. Thirty-one postsurgical patient handovers were included with overall 109 ratings of involved providers. Provider-perceived team performance was rated high. Within the receiving sub-team, situation awareness was perceived lower compared to the handoff sub-team [F(df = 1) = 4.41, p = .04]. Inter-provider agreement on handover team performance was low for the overall team yet higher within handover sub-teams. We observed that high level of distractions during the handover was associated with inferior team performance rated by observers (B = - 0.72, 95% CI = - 1.44, - 0.01).Conclusion: We observed substantial disagreements on how involved professionals as well as observers rated teamwork during patient transfers. Investigations into paediatric teamwork and particular team-based handovers should carefully consider if concurrent provider and observer assessments are a valid and reliable way to evaluate teamwork in paediatric care. Common handover language should be established and mandatory before jointly evaluating this process. Our findings advocate also that handovers should be performed under low levels of distractions.What is Known:• Efficient teamwork during transfers of critically ill children is fundamental to quality and safety of handover practice.• Postoperative handovers are often performed by ad hoc teams of caregivers with multiple backgrounds and are prone to suboptimal team performance, communication, and information transfer.What is New:• Our provider and expert evaluations of team performance during OR-PICU handovers showed poor agreement for team performance. Our findings challenge previous results drawing upon single source assessments and inform future studies to carefully consider what approach of team performance assessments is required.• We further demonstrate that high levels of disruptions are associated with poor team performance during patient handovers and that efforts to ensure undisrupted handover practices in clinical care are necessary. [ABSTRACT FROM AUTHOR]

Background/objective: Literature shows a positive association between antibiotics and obesity in childhood, but fails to account for confounding by indication. We evaluate the direct effect of infection on obesity and the indirect effect mediated by antibiotics by performing a mediation analysis of the infection-obesity association., Methods: A Medicaid cohort of children age 2-14 years old between 2015-2019 (n = 61,330) is used to perform mediation analysis of infections and antibiotic use in the first year of life, and obesity in childhood in Missouri, U.S.A., Results: An additional infection increases the risk of obesity in childhood (aIRR = 1.050, p < 0.001); however, mediation by antibiotic use is clinically and statistically insignificant. If the number of infections is not considered in the analysis, then antibiotic use as a risk factor for obesity is overstated (aIRR = 1.037 vs. 1.013 p < 0.001)., Conclusions: The number of infections exhibits a significant relationship with obesity and is a stronger risk factor for obesity than antibiotic use. In particular, a greater number of bronchitis, otitis media, and upper respiratory infections in the first year of life are associated with a significant increased risk of obesity in childhood. We find only weak evidence that an additional antibiotics claim increases the risk of obesity in childhood and this risk may not be clinically meaningful. Further research is needed to explore the association between early childhood infections, especially in the first 6 months of life, and obesity including the biological mechanism and environmental factor of early life infections associated with obesity., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Pediatric emergency telemedicine consultations have been shown to provide support to community emergency departments treating critically ill pediatric patients. However, despite the recognized value of telemedicine, adoption has been slow. To determine why clinicians frequently do not use telemedicine when it is available for pediatric patients, as well as to learn how to improve telemedicine programs, we conducted a qualitative study using stakeholder interviews. Methods: We conducted a qualitative study using grounded theory methodology, with in‐depth interviews of referring and accepting physicians and referring, transport, and transfer center nurses. We analyzed data iteratively and adapted the interview guide based on early interviews. We solicited feedback from the participants on the conceptual model. Results: Sixteen interviews were conducted; all respondents had been involved in a telemedicine consultation at least five times, with some having used telemedicine more than 30 times. Analysis resulted in three themes: 1) recognizing and addressing telemedicine biases are central to gaining buy‐in; 2) as technology advances, telemedicine processes need to adapt accordingly; and 3) telemedicine increases collaboration among health care providers and patients/families in the patient care process. Conclusions: To improve patient care through increased use of telemedicine for pediatric emergency consultations, processes need to be modified to address provider biases and end‐user concerns. Processes should be adapted to allow users to utilize a variety of technologies (including smartphones) and to enable more users, such as nurses, to participate. Finally, telemedicine can be used to improve the patient and family experience by including them in consultations. [ABSTRACT FROM AUTHOR]