Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.

Objectives: To explore changes to expected, age-related transcranial Doppler ultrasound variables during pediatric extracorporeal membrane oxygenation. Design: Prospective, observational, multicenter study. Setting: Tertiary care PICUs. Patients: Children 1 day to 18 years old requiring veno arterial extracorporeal membrane oxygenation. Methods: Participants underwent daily transcranial Doppler ultrasound measurement of bilateral middle cerebral artery flow velocities. Acute neurologic injury was diagnosed if seizures, cerebral hemorrhage, or diffuse cerebral ischemia was detected. Measurements and Main Results: Fifty-two children were enrolled and analyzed. In the 44 children without acute neurologic injury, there was a significant reduction in systolic flow velocity and mean flow velocity compared with predicted values over time (F [8, 434] = 60.44; p ≤ 0.0001, and F [8, 434] = 17.61; p ≤ 0.0001). Middle cerebral artery systolic flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1–5, and mean flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1–3. In the six infants less than 90 days old suffering diffuse cerebral ischemia, middle cerebral artery systolic flow velocity, mean flow velocity, and diastolic flow velocity from extracorporeal membrane oxygenation days 1–9 were not significantly different when compared with children of similar age in the cohort that did not suffer acute neurologic injury (systolic flow velocity F [8, 52] = 0.6659; p = 0.07 and diastolic flow velocity F [8, 52] = 1.4; p = 0.21 and mean flow velocity F [8, 52] = 1.93; p = 0.07). Pulsatility index was higher in these infants over time than children of similar age in the cohort on extracorporeal membrane oxygenation that did not suffer acute neurologic injury (F [8, 52] = 3.1; p = 0.006). No patient in the study experienced cerebral hemorrhage. Conclusions: Flow velocities in the middle cerebral arteries of children requiring extracorporeal membrane oxygenation are significantly lower than published normative values for critically ill, mechanically ventilated, sedated children. Significant differences in measured systolic flow velocity, diastolic flow velocity, and mean flow velocity were not identified in children suffering ischemic injury compared with those who did not. However, increased pulsatility index may be a marker for ischemic injury in young infants on extracorporeal membrane oxygenation.

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OBJECTIVES: Survivors of the PICU face long-term morbidities across health domains. In this study, we detail active PICU follow-up programs (PFUPs) and identify perceptions and barriers about development and maintenance of PFUPs. METHODS: A web link to an adaptive survey was distributed through organizational listservs. Descriptive statistics characterized the sample and details of existing PFUPs. Likert responses regarding benefits and barriers were summarized. RESULTS: One hundred eleven respondents represented 60 institutions located in the United States (n = 55), Canada (n = 3), Australia (n = 1), and the United Kingdom (n = 1). Details for 17 active programs were provided. Five programs included broad PICU populations, while the majority were neurocritical care (53%) focused. Despite strong agreement on the need to assess and treat morbidity across multiple health domains, 29% were physician only programs, and considerable variation existed in services provided by programs across settings. More than 80% of all respondents agreed PFUPs provide direct benefits and are essential to advancing knowledge on long-term PICU outcomes. Respondents identified “lack of support” as the most important barrier, particularly funding for providers and staff, and lack of clinical space, though successful programs overcome this challenge using a variety of funding resources. CONCLUSIONS: Few systematic multidisciplinary PFUPs exist despite strong agreement about importance of this care and direct benefit to patients and families. We recommend stakeholders use our description of successful programs as a framework to develop multidisciplinary models to elevate continuity across inpatient and outpatient settings, improve patient care, and foster collaboration to advance knowledge.

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OBJECTIVESevere traumatic brain injury remains a leading cause of morbidity and mortality in the pediatric population. Providers focus on reducing secondary brain injury by avoiding hypoxemia, avoiding hypotension, providing normoventilation, treating intracranial hypertension, and reducing cerebral metabolic demand. Hyperthermia is frequently present in patients with severe traumatic brain injury, contributes to cerebral metabolic demand, and is associated with prolonged hospital admission as well as impaired neurological outcome. The objective of this quality improvement initiative was to reduce the duration of hyperthermia for pediatric patients with severe traumatic brain injury during the initial 72 hours of admission to the pediatric intensive care unit.METHODSA retrospective chart review was performed to evaluate the incidence and duration of hyperthermia within a preintervention cohort. The retrospective phase was followed by three 6-month intervention periods (intervention Phase 1, the maintenance phase, and intervention Phase 2). Intervention Phase 1 entailed placement of a cooling blanket on the bed prior to patient arrival and turning it on once the patient’s temperature rose above normothermia. The maintenance phase focused on sustaining the results of Phase 1. Intervention Phase 2 focused on total prevention of hyperthermia by initiating cooling blanket use immediately upon patient arrival to the intensive care unit.RESULTSThe median hyperthermia duration in the preintervention cohort (n = 47) was 135 minutes. This was reduced in the Phase 1 cohort (n = 9) to 45 minutes, increased in the maintenance phase cohort (n = 6) to 88.5 minutes, and decreased again in the Phase 2 cohort (n = 9) to a median value of 0 minutes. Eight percent of patients in the intervention cohorts required additional sedation to tolerate the cooling blanket. Eight percent of patients in the intervention cohorts became briefly hypothermic while on the cooling blanket. No patient required neuromuscular blockade to tolerate the cooling blanket, experienced an arrhythmia, had new coagulopathy, or developed a pressure ulcer.CONCLUSIONSThe placement of a cooling blanket on the bed prior to patient arrival and actively targeting normothermia successfully reduced the incidence and duration of hyperthermia with minimal adverse events.

This study examined the role of personality factors in differences between three methods of assessing blood pressure (clinic, self, ambulatory) in 45 patients with mild hypertension. The data were obtained after the patients were withdrawn from antihypertensive medications and had achieved stable clinic diastolic blood pressure levels of 95 to 110 mm Hg, averaged over three visits in 2 to 4 weeks. Significant differences were obtained in systolic blood pressure (SBP) and diastolic blood pressure (DBP) as a function of method of assessment. These differences in both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were associated with individual differences in the total score and several subscales of the Buss-Durkee Hostility Inventory (Assault, Resentment, Guilt), but not in anxiety, depression, or other characteristics. High hostile subjects had consistently high blood pressure values in both clinic, self, and ambulatory recordings. Low hostile subjects were significantly lower in self-recorded blood pressure readings taken at home and in ambulatory recordings, compared with clinic values. Implications of these findings for "white coat hypertension" are discussed.

Introduction Chest compression (CC) quality directly impacts cardiac arrest outcomes. Provider body type can influence the quality of cardiopulmonary resuscitation (CPR); however, the magnitude of this impact while using visual feedback is not well described. The aim of the study was to determine the association between provider anthropometric variables on fatigue and CC adherence to 2015 American Heart Association CPR while receiving visual feedback. Methods This was a planned secondary analysis of healthcare professionals from multiple hospitals performing continuous CC for 2 minutes on an adult CPR mannequin with dynamic visual feedback. Main outcome measures include compression data (depth, rate, and lean) evaluated in 30-second epochs to explore performance fatigue. Multivariable models examined the relationship of provider anthropometrics to CC quality. Binomial mixed effects models were used to characterize fatigue by examining performance for 4 epochs. Results Three hundred seventy-seven 2-minute CC episodes were analyzed. Extreme (low and high) BMI and weight are associated with poorer CC. Larger size (height, weight, and BMI) is associated with better depth but worse lean compliance. Performance fatigued for all providers for 2 minutes, but shorter, lighter weight, female participants had the greatest decline. On multivariable analysis, rate compliance did not deteriorate regardless of provider anthropometrics. Conclusions Anthropometrics impact provider CC quality. Despite visual feedback, variable effects are seen on compression depth, rate, recoil, and fatigue depending on the provider sex, weight, and BMI. The 2-minute interval for changing chest compressors should be reconsidered based on individual provider characteristics and risk of fatigue's impact on high-quality CPR.