A variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.

WHAT'S KNOWN ON THIS SUBJECT:CA-BSIs are a significant source of morbidity, mortality, and added medical costs to hospitalized adult and pediatric patients. Despite these data, strategies for reducing health care complications such as pediatric CA-BSIs have received relatively little attention. WHAT THIS STUDY ADDS:In contrast with adult ICU care, maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. Instead, the main drivers for additional reductions in pediatric CA-BSI rates seem to be issues surrounding daily maintenance care for central lines.abstract OBJECTIVE: Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective cathetercare practices to reduce pediatric CA-BSIs. STUDY DESIGN AND METHODS:Our study was a multi-institutional, interrupted time-series design with historical control data and was conducted in 29 PICUs across the United States. Two central venous catheter-care practice bundles comprised our intervention: the insertion bundle of pediatric-tailored care elements derived from adult efforts and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations and expert pediatric clinician consensus. The bundles were deployed with quality-improvement teaching and methods to support their adoption by teams at the participating PICUs. The main outcome measures were the rate of CA-BSIs from January 2004 to September 2007 and compliance with each element of the insertion and maintenance bundles from October 2006 to September 2007. RESULTS:Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs 3.1 CA-BSIs per 1000 central-line-days; P Ͻ .0001). By September 2007, insertion-bundle compliance was 84% and maintenance-bundle compliance was 82%. Hierarchical regression modeling showed that the only significant predictor of an observed decrease in infection rates was the collective use of the insertion and maintenance bundles, as demonstrated by the relative rate (RR) and confidence intervals (CIs) (RR: 0.57 [95% CI: 0.45-0.74]; P Ͻ .0001). We used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the results showed that the only significant predictor of an infection-rate decrease was maintenancebundle compliance (RR: 0.41 [95% CI: 0.20 -0.85]; P ϭ .017). CONCLUSIONS:In contrast with adult ICU care, maximizing insertionbundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in our maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children. Catheter-associated bloodstream infections (CA-BSIs) are a significant cause of morbidity, morta...

Objective To empirically derive the optimal measure of pharmacologic cardiovascular support in infants undergoing cardiac surgery with bypass, and to assess the association between this score and clinical outcomes in a multi-institutional cohort. Design Prospective, multi-institutional cohort study. Setting Cardiac intensive care units (CICU) at 4 academic children’s hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC4) during the study period. Patients Children <1 year of age at the time of surgery treated post-operatively in the CICU. Interventions None Measurements and Main Results Three hundred ninety-one infants undergoing surgery with bypass were enrolled consecutively from 11/2011–4/2012. Hourly doses of all vasoactive agents were recorded for the first 48 hours after CICU admission. Multiple derivations of an inotropic score were tested, and maximum vasoactive-inotropic score (VIS) in the first 24 hours was further analyzed for association with clinical outcomes. The primary composite “poor outcome” variable included at least one of mortality, mechanical circulatory support, cardiac arrest, renal replacement therapy, or neurologic injury. High VIS was empirically defined as ≥20. Multivariable logistic regression was performed controlling for center and patient characteristics. Patients with high VIS had significantly greater odds of a poor outcome [OR 6.5, 95% confidence interval (CI) 2.9–14.6], mortality (OR 13.2, 95% CI 3.7–47.6), time to first extubation, and CICU length of stay compared to patients with low VIS. Stratified analyses by age (neonate vs. infant) and surgical complexity (low vs. high) showed similar associations with increased morbidity and mortality for patients with high VIS. Conclusions Maximum VIS calculated in the first 24 hours after CICU admission was strongly and significantly associated with morbidity and mortality in this multi-institutional cohort of infants undergoing cardiac surgery. Maximum VIS≥20 predicts an increased likelihood of a poor composite clinical outcome. The findings were consistent in stratified analyses by age and surgical complexity.

Focused attention on consistent adherence to the use of pediatrics-specific central line insertion and maintenance bundles produced sustained, continually decreasing PICU CLA-BSI rates. Additional use of either chlorhexidine for central line entry scrub or chlorhexidine-impregnated sponges did not produce any statistically significant additional reduction in PICU CLA-BSI rates.

Application of HFOV and early HFOV compared with CMV in children with acute respiratory failure is associated with worse outcomes. The results of our study are similar to recently published studies in adults comparing these 2 modalities of ventilation for acute respiratory distress syndrome.

This multicenter study suggests that proportion of patients extubated in the OR after heart operation is low. These data further suggest that extubation in the OR can be done successfully with a low complication rate.

The 2008 CLA-BSI definition change decreased the measured incidence. The daily CLA-BSI risk was very low in patients during the first 7 days of catheterization but doubled thereafter. The risk of CLA-BSI was lower in patients with lines inserted in the jugular vein and higher in patients with gastrointestinal and oncologic diagnoses. These patients are target populations for additional study and intervention.

Objectives: There are limited reports of the impact of the coronavirus disease 2019 pandemic focused on U.S. and Canadian PICUs. This hypothesis-generating report aims to identify the United States and Canadian trends of coronavirus disease 2019 in PICUs. Design and Setting: To better understand how the coronavirus disease 2019 pandemic was affecting U.S. and Canadian PICUs, an open voluntary daily data collection process of Canadian and U.S. PICUs was initiated by Virtual Pediatric Systems, LLC (Los Angeles, CA; http://www.myvps.org) in mid-March 2020. Information was made available online to all PICUs wishing to participate. A secondary data collection was performed to follow-up on patients discharged from those PICUs reporting coronavirus disease 2019 positive patients. Measurements and Main Results: To date, over 180 PICUs have responded detailing 530 PICU admissions requiring over 3,467 days of PICU care with 30 deaths. The preponderance of cases was in the eastern regions. Twenty-four percent of the patients admitted to the PICUs were over 18 years old. Fourteen percent of admissions were under 2 years old. Nearly 60% of children had comorbidities at admission with the average length of stay increasing by age and by severity of comorbidity. Advanced respiratory support was necessary during 67% of the current days of care, with 69% being conventional mechanical ventilation. Conclusions: PICUs have been significantly impacted by the pandemic. They have provided care not only for children but also adults. Patients with coronavirus disease 2019 have a high frequency of comorbidities, require longer stays, more ventilatory support than usual PICU admissions. These data suggest several avenues for further exploration.