RECENT NATIONAL STUDY indicated that illicit drug use is 16.2% among pregnant teens and 7.4% among pregnant women aged 18 to 25 years. 1 Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome in newborns following birth. The syndrome most commonly occurs in the context of antepartum opiate use, although other drugs have also been implicated. [2][3][4][5] In addition to NAS, illicit drug use (specifically opioid dependence) during pregnancy is associated with a significantly increased risk of adverse neonatal outcomes such as low birthweight (Ͻ2500 g) and mortality. [6][7][8][9] Neonatal abstinence syndrome is characterized by a wide array of signs and symptoms including increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures, and respiratory distress. 10 Symptoms of withdrawal associated with NAS have been described in 60% to 80% of newborns exposed to heroin or methadone in utero. 11 Recently, analyses from Australia 12 and the Florida Medicaid program (D. Aronberg, JD, written communication, November 30, 2011) found that the incidence of NAS has been increasing. To date, there are no national es-Author Affiliations are listed at the end of this article.

Innovation: Establish formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decreases length of stay for patients with lifethreatening illnesses.Evaluation: Pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls.Setting: Pediatric Intensive Care Unit in a quaternary care Children's Hospital. Participants: Physicians and nurses on staff in the unit.Patients: There were 60 patients in the interventional and 66 patients in the historical control group.Intervention: Over a year, weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU. Results:Moral distress scores measured intermittently with the MDT fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall MDS-R scores were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p=0.015), a statistically significant increase in both code status changes DNR (11% control, 28% PEACE, p=0.013), and in-hospital death (9% control, 25% PEACE, p=0.015), with no change in patient 30 or 365 day mortality. Conclusion:The addition of a clinical ethicist and senior intensivist to weekly interprofessional team meetings facilitates difficult conversations regarding realistic goals of care. The PEACE

Discharges for children associated with LTMV require substantively greater inpatient resource use than other children with CCCs. As the number of discharges and associated aggregate charges increase over time, additional research must examine patterns of care for specific clinical subgroups of LTMV, especially children aged 4 years and younger.

Background: Information concerning tracheostomy after surgery for congenital heart

Objectives: To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease. Study Design:We conducted a prospective observational study of neonates ≤ 30 days of age who underwent cardiac surgery at seven centers within the United States in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified using multivariable logistic regression analysis and reported as odds ratios (OR) with 95% confidence intervals (CI). Multivariable logistic regression analysis was also conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length-of-stay in the upper 25% or operative mortality.

Objective In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. Methods We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within-center correlation. Results The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18%had major extracardiac anomalies, and 74%underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95%confidence interval, 1.4–6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in-hospital mortality (8% vs 2%, P = .002). Conclusions This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4-fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes.

There is little overlap in diagnosis of various ventilator-associated infection. However, the risk factors and outcomes associated with individual criteria are similar, indicating that they may have validity in identifying true pathology. Ventilator-associated infection in general is likely a larger problem than indicated by low hospital-reported rates of ventilator-associated pneumonia. There is clinical confusion due to the presence of several diagnostic criteria for ventilator-associated infection. Developing a more inclusive and clinically relevant criterion for diagnosing ventilator-associated infection is warranted to accurately assess their impact and improve guidance for clinicians in evaluating and treating ventilator-associated infection.

Our objectives were to review and categorize the existing data sources that are important to pediatric critical care medicine (PCCM) investigators and the types of questions that have been or could be studied with each data source. We conducted a narrative review of the medical literature, categorized the data sources available to PCCM investigators, and created an online data source registry. We found that many data sources are available for research in PCCM. To date, PCCM investigators have most often relied on pediatric critical care registries and treatment- or disease-specific registries. The available data sources vary widely in the level of clinical detail and the types of questions they can reliably answer. Linkage of data sources can expand the types of questions that a data source can be used to study. Careful matching of the scientific question to the best available data source or linked data sources is necessary. In addition, rigorous application of the best available analysis techniques and reporting consistent with observational research standards will maximize the quality of research using existing data in PCCM.