Seizures are reported to occur more frequently among children with diagnoses of autism and pervasive developmental disorder (PDD), and some reports indicate a frequency as high as 30%. Sedation is often necessary to perform diagnostic electroencephalograms (EEGs) in these children, who are known to be difficult to sedate with current available pediatric sedating agents, including chloral hydrate. We used clonidine as a sedative agent in children with autism and PDD, and our findings are presented. In a prospective study, 27 children with autism and PDD diagnoses underwent conscious sedation for EEG recording. Informed consents were obtained, and clonidine was administered orally as a sedating agent in a dose ranging from 0.05 mg to 0.2 mg. Subjects were monitored for pulse rate, respiration rate, blood pressure, and oxygen saturation on a continuous basis by a registered nurse. Study parameters included time to induction, time to recovery, changes in vital signs, and technical quality of EEGs. Sedation was achieved in 23 of 27 patients (85%) per our sedation criteria, and this included five patients who had previously failed to be sedated with chloral hydrate. Two patients did not satisfy the sedation criteria but cooperated enough to allow acceptable EEG tracings, increasing the success rate to 93% (25/27). The mean time to achieve sedation was 58 minutes, and the mean time to recovery was 105 minutes. Two patients (0.07%) experienced an asymptomatic heart rate reduction up to 40%, which was not sustained and recovered promptly without any intervention. Two patients (0.07%) experienced systolic blood pressure reductions of 30% and 40%. They remained asymptomatic, had no changes in other cardiorespiratory parameters, and required no intervention. All EEGs were of good technical quality without any "drug effect." Clonidine is a viable alternative for sedation in children with autism and PDD. It is well tolerated without any significant side effects and is efficacious in children with autism and PDD. The advantages of clonidine include ease of administration, shorter duration of total sedation, lack of EEG drug effect, and high overall success rate.
PRISM readily stratifies pediatric trauma patients for resource utilization. PRISM appears to underestimate mortality in pediatric trauma as compared with ISS using TRISS methodology.
OBJECTIVE:To report our quality improvement efforts to reduce total parenteral nutrition (TPN)-associated bloodstream infections, and the results of those efforts, during the period including the first quarter of 2004 through the third quarter of 2010.
METHODS:A variant on failure modes and effect analysis and existing guidelines were used to develop and modify interventions. Effectiveness of the interventions was assessed by using a graphical depiction of interrupted time-series data on TPN-associated infections per 1000 TPN-days, aggregated across quarters within intervention periods.
RESULTS:Although initial interventions yielded limited reductions in infection rates, it was not until the implementation of a multifaceted "maintenance intervention bundle" that rates strongly responded. After this key intervention revision, the TPN-associated infection rate decreased between implementation in the first quarter of 2008 from 26.1 to 4.8 per 1000 TPN-days during the 8 quarters aggregated comprising the first quarter of 2008 through the fourth quarter of 2009. The final addition of an alcohol-swab cap resulted in a reduction of rates to 0 for the first three-quarters of 2010.
CONCLUSIONS:Our evidence suggests that iterative design/redesign of interventions using failure modes and effect analysis has directly reduced TPN-associated bloodstream infections. KEY WORDS central line-associated bloodstream infection, total parenteral nutrition, failure modes and effect analysis, maintenance intervention bundle ABBREVIATIONS CLABSI-central line-associated bloodstream infection TPN-total parenteral nutrition NACHRI-National Association of Children's Hospitals and Related Institutions CSH-Children's Specialized Hospital FMEA-failure modes and effect analysis MIB-maintenance intervention bundleDr Castello and Ms Maher made substantial contributions to conception and design, drafting and revising the article, and acquiring the data and were part of the team involved in final approval of the manuscript; Dr Cable made substantial contributions to the design, analysis and interpretation of the data, and drafting and revising the article; and Dr Cable was part of the team involved in final approval of the manuscript.www.pediatrics.org/cgi/doi/10.1542/peds.
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