H3027- Section on Critical Care Program: Day 2

Scientific Abstract Session

Topic: Critical Care

Sponsors: Section on Critical Care (SOCC)

Monday, October 24
8:00AM - 12:30PM
Moscone West, 2018

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This session will enable physicians, physician trainees, nurses, and other health care professionals to present original research in both oral/platform and poster presentation formats. Attendees will become conversant in new research in the field of pediatric critical care. Section abstract awards also will be presented.

8:00AM Oral Abstract Session I
9:30AM Poster Walk Rounds and Break
10:45AM Oral Abstract Session II
12:15PM Abstract Awards

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Oral (Podium)

Changing Ordering Practice for Inhaled Pulmonary Hypertension Treatment in the Icu

Monday, October 24
8:15AM - 8:30AM
Moscone West, 2018

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Intro: Inhaled nitric oxide is commonly utilized in pediatric hospitals for treatment of severe pulmonary hypertension in the ICU setting. Inhaled epoprostenol has been shown to be equally effective in reduction of pulmonary arterial pressures as inhaled nitric oxide and is significant less expensive. There is also data on potential deleterious side effects of long-term use of inhaled nitric oxide, including peroxynitrite and nitrogen dioxide formation. Barriers to utilizing inhaled epoprostenol include cultural norms and the lack of a refined delivery system.

Aim: To decrease inhaled nitric oxide use by 50% over a 15 month period for patients with pulmonary hypertension.

Methods: A PDSA cycle QI methodology was utilized. Team members included pediatric intensivist, respiratory therapy and pharmacist. Initial intervention included education of pediatric ICU providers in regards to clinical effectiveness of inhaled epoprostenol and cost differential. Subsequent interventions included creation of an order-set in the EMR, education of pediatric critical care nursing staff to new inhaled epoprostenol delivery system and rationale, improvements in the nebulizer system to avoid crystallization, improvement in pharmacy preparation to ensure appropriate concentrations of epoprostenol depending on dose, and education of neonatology providers to promote spread to the NICU. On going data collection included baseline nitric oxide and epoprostenol hours, monthly usage of nitric oxide and epoprostenol, cost data, and balancing metrics of adverse drug events with inhaled epoprostenol including adverse event reporting related to epoprostenol delivery and clinical effectiveness of either BNP and echocardiogram results obtained prior to and after delivery were utlized as part of the project. Patients were excluded from analysis if they expired within 6 hours of starting one of the two medications.

Results: At total of 29 number of patients received inhaled pulmonary artery vasodilatory therapy over the course of 15 months. There were 35 events when inhaled vasoactive agents were started. Two patients were excluded. 68.6% of patients were started on inhaled nitric oxide before transitioning to inhaled epoprostenol. Inhaled epoprostenol use increased dramatically in the PICU over the first six months (Figure 1) from 0-31% of total hours to 79% of total inhaled pulmonary vasodilators hours. Cost savings of epoprostenol was calculated to be approximately $78.67 per hour including materials costs for greater than $500,000 in savings over the 15 month time period. NICU inhaled epoprostenol use also increased in the later part of the initiative.

Conclusions: With a mixture of educational intervention along with improvement in systems and processes we were able to increase the use of inhaled epoprostenol and decrease inhaled nitric oxide to improve cost of care for our patients.

Percent of total time individual vasodilator medications were used over study period.
Epoprostenol use increased after the educational intervention while nitric oxide use proportional decreased.

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Oral (Podium)

Analysis of Education Surrounding Cost Effective Medicine on Bedside Rounds

Monday, October 24
8:30AM - 8:45AM
Moscone West, 2018

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Purpose:
The Affordable Care Act and recent focus on value (quality/cost) make it imperative that we identify educational and system-based methods to adequately train physicians. Recognition that the majority of physicians are unaware of the cost of healthcare and that our trainees often inappropriately order diagnostic tests resulted in the incorporation of cost-awareness as one of the Systems-Based Practice subcompetencies by the ACGME.

The need to demonstrate progression towards expert competency of developmental milestones has resulted in multiple attempts to incorporate educational interventions to increase cost awareness. However, none have resulted in measurably significant long term improvement. Thus, an understanding of current practices is required. The overall goal of this project is to evaluate current cost awareness teaching practices within the pediatric specialty and their impact on learning in order to develop effective education programs, creating sustainable changes in behavior.

Methods:
We designed a two pronged approach to better understand the current status of cost awareness education. Since bedside rounds are a preferred learning environment, we observed a convenience sample of rounds to determine the frequency of both explicit and implicit discussions related to cost effective medicine. This was followed by a survey to identify perceptions surrounding the current educational state of this subcompetency.

Results:
Observations occurred on 48 days over 7 months in a quaternary care pediatric intensive care unit. 24 critical care faculty members and 30 trainees were observed during 426 patient encounters.

5% (22/426) of patient encounters included explicit discussion of cost awareness. Notably, 36% of those discussions (8 of 22) were provided by 1 faculty. 9% (37/426) of patient encounters included discussion where the topic of cost awareness was implied. 86% (368/426) of patient encounters had no discussion of cost.

Surveyed perceptions were consistent with the infrequent observed occurrence. Additionally, 70% of faculty stated they cannot appropriately evaluate trainees’ understanding of cost effective medicine. Furthermore, the majority of faculty felt the current state of trainee education surrounding this topic is poor to non-existent. However, the overwhelming majority of faculty and trainees stated the definition of cost effective medicine is clear to them and more than half agreed they routinely practice cost effective medicine.

Conclusion:
The majority of patient encounters in this study do not address cost awareness education. Additionally, faculty do not feel they can appropriately evaluate their trainees’ ability to practice cost effective medicine. This raises concern for the accuracy of milestone assessment in areas such as systems based practice learning and improvement.

Given the majority of faculty identify comfort with the definition of cost effective medicine and routinely incorporate this into their practice, an opportunity exists to improve and develop effective and sustainable solutions surrounding both education and trainee formative assessment within this sub-competency.

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Oral (Podium)

The Association Between Mitochondrial f1f0-atp Synthase and the Organ Function in Children with Sepsis

Monday, October 24
8:45AM - 9:00AM
Moscone West, 2018

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Purpose To explore the difference of Mitochondrial F1F0-ATP synthase activity between children with sepsis and healthy children ,and to assess the relationship bettewen the activity of F1F0-ATP synthase and organ functions.
Method
1. 91 septic children treated in ICU of Children's Hospital Affiliated to the Capital Institute of Pediatrics and 90 healthy children were enrolled in the study from September 2013 to December 2015.
2. The activity of Mitochondrial F1F0-ATP synthase in peripheral blood leukocyte was measured when the diagnosis of sepsis was established and healthy children was on the day for health examination. The differences were assessed between the two groups.
3.The vital signs were monitored, the organ functions were evaluated, the outcomes were assessed for septic children in 28 days after the treatment.
4.The impacts of Mitochondrial F1F0-ATP synthase on the organ functions for septic children were assessed.
Results
1.There were 181 children enrolled in the study, 118 boys and 63 girls. The average age was 2.5 years,range from 0.1 to 14 years; There were no significant differences in mean age and gender between septic group and healthy group (P>0.05);
2.There were 18 patients dead within 28 days in hospital;
3.The median activity of Mitochondrial F1F0-ATP synthase in septic group was 382.7(25% (257.6),75%(577.8))nmol/min.mg, the healthy group were 754.8(25%(604.3),75%(903.6))nmol/min.mg. The level of the former was significantly lower than that of the latter (P < 0.05);
4.The sepsis group was divided into diffrent dysfunctions  groups and Non-dysfunctions  groups according to whether the patients had a kind of organ dysfunctions or not,including MOF 、 liver dysfunctions、gastrointestinal dysfunctions、Coagulation dysfunctions 、brain dysfunctions and metabolize dysfunctions ,The average activity of the dysfunctions  group was significantly lower than that of the Non-dysfunctions  group(P < 0.05);
Conclusion
The activity of Mitochondrial F1F0-ATP synthase in septic group was significantly lower than that of the control group. There is significant association between the Mitochondrial F1F0-ATP synthase activity and organ functions in septic children. Low level of mitochondrial F1F0-ATP synthase activity may be a predictor of organ dysfunction in sepsis.

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Oral (Podium)

Viral Respiratory Infections and Their Pediatric Intensive Care Unit Outcomes

Monday, October 24
9:00AM - 9:15AM
Moscone West, 2018

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Purpose:
Viral respiratory infections are important causes of morbidity and mortality in young children & frequently require pediatric intensive care unit (PICU) admission. Recently it has become possible to identify common viral infections with molecular assay panels. However the PICU outcomes related to single or multiple viral infections remains unknown. The objective of our study is to compare PICU outcomes between single and multiple viral respiratory infections in relatively healthy children < 5 years.
Methods:
A retrospective, single center, cohort study of children < 5 years of age admitted to PICU from January 2012 to March 2015 who had a positive respiratory molecular panel. Exclusion criteria were 1) Children with baseline requirement of tracheostomy or positive pressure ventilation 2) Known cardiac, neurological, muscular, metabolic, renal or genetic disorders 3) PICU stay with respiratory illness or with same pathogens in previous 4 weeks. After exclusions the children were divided into single or multiple viral groups based on results of molecular panel. Their demographics and PICU outcomes were compared and analyzed. Single viral group was further divided into respiratory syncytial viral (RSV) group and other single viral group for similar comparison.
Results:
After exclusions 593 relatively healthy children were identified, out of which 541 had a molecular panel. The panel was positive in 477 (88.1%) children with 432 positive for single pathogen (single virus group) and 45 positive for multiple pathogen (multi viruses group). Both the groups were statistically similar for age, sex and gestational age. Children with multiple viruses had a longer PICU stay (4.5 days) compared to single virus group (3 days) p < 0.002. In further multivariable analysis adjusted for age, sex, gestational age and history of asthma, multiple viruses infections resulted in higher risk of significant PICU stay (>3day) (OR- 2.2, 95%CI- 1.1 to 3.7, p=0.02) and central line requirement (OR- 2.4, 95%CI- 1.3 to 4.6, p 0.008), but not at higher risk of ventilation requirement or cardiovascular dysfunction. Further analysis amongst only ventilated patients showed multi virus infections resulted into higher risk of prolonged ventilation (>7 days) (OR – 3.4, 95%CI- 1.2 to 9.4, p=0.01) and bacterial pneumonia confirmed by quantitative broncheoalveolar lavage (OR – 2.1, 95%CI- 1.1 to 11.2, p=0.03). We also divided single viral infection (n=432) into respiratory syncytial virus (n=213, 49.3%) versus other single viruses (n=219) for analysis. The comparison between these two single viral groups did not show any increase risk of PICU outcome.
Conclusion:
In our study multiple viral infections resulted in longer PICU stay as well as higher risk of prolonged mechanical ventilation, bacterial pneumonia and central line requirement. Further prospective studies are needed to support the outcomes. Results may guide to triage children in PICU, emergency departments or inpatient units.

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Oral (Podium)

Association Between Insurance and Transfer of Non-injured Children from Emergency Departments

Monday, October 24
9:15AM - 9:30AM
Moscone West, 2018

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Importance: Pediatric patients receiving treatment in emergency departments (EDs) that require inpatient services can either be admitted locally or transferred to another hospital for admission. Previous research has demonstrated that non-medical factors, such as lack of insurance, are associated with increased odds of transfer to another hospital for admission among adult patients.

Objective: We sought to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital for admission among children requiring hospital admission.

Methods: This cross-sectional study used the Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample. Pediatric patients receiving care in EDs from 950 hospitals located in 30 states that were either admitted or transferred were included. Clinical Classification Software was used to categorize patients into thirteen non-injury diagnostic cohorts. Multivariable logistic regression models adjusting for confounders, including severity of illness and comorbidities, and incorporating nationally representative weights were used to determine the association between insurance and the odds of transfer relative to admission.

Results: 240,620 non-injury pediatric ED events met inclusion criteria. Patient and hospital characteristics, including older age and non-teaching hospitals, were associated with greater odds of transfer relative to admission. Patients that were uninsured had higher odds of transfer (Odds Ratio (OR): 3.84, 95% Confidence Interval (CI): 3.65, 4.03), as did patients with Medicaid (OR: 1.05, 95% CI: 1.03, 1.07) and other insurance types (OR: 1.14, 95% CI: 1.07, 1.21) compared to those with private insurance. Uninsured patients also had significantly higher odds of transfer, ranging from 2.96 to 12.00, across all thirteen diagnostic categories. Additionally, patients with Medicaid were significantly more likely to be transferred with mental illness (OR: 1.39, 95% CI: 1.10, 1.76) and circulatory system diseases (OR: 1.30, 95% CI: 1.01, 1.68).

Conclusion and Relevance: Children without insurance and those with Medicaid are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared to children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.

Table 1. Adjusted Odds of Transfer to Another Hospital
Table 2. Odds of Transfer by Diagnostic Categories relative to Other Diagnoses

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1- The Changes of Plasma Antibacterial Peptide ll-37 in the Bloodstream Infected Children

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Purpose To explore the changes of plasma LL-37 in the bloodstream infected children.
Methods 40 patients with bloodstream infection were included in case group,they visited the Capital Institute of Pediatrics Affiliated to Children's Hospital between May 30th and January 1st,2015.Double blood cultures from different parts were positive in these children. 40 normal children with matched age and gender were control groups.We determine plasma LL-37 content of two groups by enzyme-linked immunosorbent,and observed evolution and prognosis of the disease.
Results Case group can be divided into MODS group and N-MODS group according to whether the patients had multiple organ dysfunction. Critical group and non critical group were defined according to whether the severity score is above 90.The concentration of plasma LL-37 in patients with bloodstream infection was 35.37±18.23ng/ml, the concentration in control group was 23.20±9.25ng/ml, The concentration of plasma LL-37 in bloodstream infection group was significantly higher than that of control group (t=3.765, p < 0.001).we draw ROC curve using plasma LL-37 levels and whether the child had bloodstream infection (AUC=0.711,p=0.001), it prompts bloodstream infections when the concentration of plasma LL-37 is higher than 28.43 ng/ml.The concentration of plasma LL-37with bloodstream infections is related to the number of peripheral blood neutrophils (Pearson correlation coefficient r=0.426,p=0.006).In bloodstream infection group, the level of LL-37 was increased in 18 cases. The number of peripheral blood neutrophils in these patients was (12.92±9.05)x109/L. The level of LL-37 was not increased in other 22 cases. The number of peripheral blood neutrophils in these patients was (4.79±6.20) x 109/L.The numble of neutrophil in increased group was significantly higher than the other one (t=3.362,p=0.002).The bloodstream infection patinents were include 22 cases with MODS and 18 patients with N-MODS.The concentration of plasma LL-37in patients with MODS group is 28.35±15.45ng/ml,N-MODS group is 43.94±18.09ng/ml,the lever of plasma LL-37 in patients with MODS was significantly lower than N-MODS group(t=2.892,p=0.007). The bloodstream infection group were divided into critical group o(15 cases )and non critical group (25 cases),the concentration of plasma LL-37 in critical group was 27.25±17.09 ng/ml, non critical group was 40.23±17.45ng/ml,the level of plasma LL-37 in critical group was significantly lower than the non critical groups(t=2.306, p=0.028).
Conclusion The number of peripheral blood neutrophils and the level of plasma LL-37 were positive correlation, high concentrations of plasma LL-37 may be one of the risk factors of bloodstream infection.In bloodstream infectious children,the levels of plasma LL-37 in patients with MODS were lower than other patients with N-MODS,the critical group was lower than the non critical group, it is warning that body's defense function is impaired when patients with bloodstream infection had a low level of plasma LL-37.

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2- Use of Nitric Oxide in an Unapproved Clinical Setting: A Single Center Experience

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Purpose: The only FDA approved indication for inhaled nitric oxide (iNO) is the treatment of persistent pulmonary hypertension (PPHN) in the neonate to reduce the need for ECMO. However, numerous reports of usage including postoperative refractory pulmonary hypertension and hypoxemic respiratory failure have been reported with variable effect on mortality. These off-label uses have been associated with increased resource utilization without consistent evidence of benefit. The objective of this study is to describe uses of iNO in a pediatric intensive care unit (PICU) and evaluate outcomes.
Methods: Single center retrospective (Jun2009-Jul2014) analysis using the Virtual Pediatric Systems (VPS, LLC) clinical PICU database for case identification, patient demographics, and outcomes. Patient demographics include cardiac, trauma, and post-operative status. Demographic and severity of illness scores included Pediatric Risk of Mortality (PRISM-III), PEdiatric Logistic Organ Dysfunction (PELOD), Pediatric Index of Mortality (PIM-2) and disability assessment using admission POPC/PCPC score. Data are presented as descriptive statistics with parametric and non-parametric statistics used as appropriate.
Main Results: 129 patients received iNO during the 5 year study period, of whom 97 had cardiac disease. There was no difference in ICU length of stay, PRISM-III or PIM2 scores between cardiac and non-cardiac patients receiving iNO. There was no difference in mortality between cardiac and non-cardiac patients (0.14 vs 0.25, p = 0.12). Patients with cardiac disease had longer duration of iNO therapy [76.3h (42.3 to 152.9, n=97) vs 43.9h (18.7 – 92.3, n=32) p < 0.01]. In cardiac patients, starting iNO in the OR vs starting in the PICU did not change mortality (0.12 vs 0.14 p=0.8). Twenty-five patients received multiple runs of iNO, 23 of whom had cardiac disease and no mortality. Mortality was independently associated with PRISM3, greater than 1 iNO run, and presence of traumatic brain injury (p < 0.001).
Conclusion: Off label use if iNO is common in this PICU. Within this cohort, iNO was 3 times more likely to be used after cardiac surgery and was associated with a survival advantage. Further analysis is needed using multiple, larger data sets to further clarify the role of multiple runs, the predictive value of severity of illness scores, and the utility in specific patient populations.

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3- Critical Procedure Skill Maintenance Through Simulation Based Curriculum in Pediatric Intensive Care Unit and Pediatric Emergency Medicine

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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INTRODUCTION:
Critical procedural skill proficiency and maintenance present concerns for the quality of care in pediatric patient population. Previous studies have shown that simulation-based training improved physician performance and led to favorable patient outcomes. We evaluated the need for simulation-based curriculum specific to the cohort of pediatric critical care and emergency attending physicians.

METHODS:
Attending physicians from pediatric emergency medicine and intensive care unit rotated through simulation-based training for thoracotomy and cricothyrotomy. Prior to education, physicians performed each procedure on mannequins using standard kits. Performance was evaluated against procedure-specific checklists. Physician confidence was assessed via survey. Statistical analysis was performed using SPSS version 23.0 software (IBM, Armonk, NY).

RESULTS:
13 physicians participated in this study, 12 performed thoracotomy and 11 performed cricothyrotomy via simulation. 15.4% of the physicians felt completely confident in performing thoracotomy, and none of the physicians felt completely confident in cricothyrotomy. For thoracotomy, 8.3% of physicians completed all items on the checklist, and on average physicians had an 86.7% completion rate. For cricothyrotomy, no one completed all items on the checklist, and on average physicians had a 62.5% completion rate. The median times to perform thoracotomy and cricothyrotomy are 228 seconds (range=148-487s) and 84s (range=43-158s) respectively.

CONCLUSION:
Physicians in emergency medicine and critical care lack confidence and skills in performing critical procedures such as thoracotomy and cricothyrotomy due to deficiency of practice in the clinical setting. Simulation-based curriculum can effectively improve physician confidence level and maintain proficiency in such low-frequency high-risk procedures.

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4- In-situ Simulation in the Congenital Cardiac Intensive Care Unit (ccicu): A Quality Improvement Initiative

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Introduction/Background. With the now emerging adult congenital heart disease population, we have established a Congenital Cardiac ICU (CCICU) with majority pediatric and some adult congenital heart disease population in an urban tertiary care institution. With this mixed population, in-situ simulation provides a feasible platform for improvement in team dynamics. Based on crisis resource management and resilience engineering from the aviation industry we built this on the principle of arrest in CCICU patient being an irregular threat; one that could be anticipated and imagined but still rare. The response to this threat requires an improvisation of a routine response. Critical care teams perform many activities where effective communication is crucial for ensuring patient safety and reducing susceptibility to error. Interventions to improve communication in the intensive care unit have resulted in reduced reports of adverse events, and simulated emergency scenarios have shown effective communication to be correlated with improved technical performance. We also planned it to improve self-efficacy in all the team members: a challenging group built to satisfy needs for both pediatric and adult patients. Literature supports that efficacious individuals are able to handle diverse conditions and are prepared to meet new challenges whilst people with low self-efficacy beliefs will shy away from difficult situations, dwelling on personal deficiencies and perceiving challenges as threats. 
Methods: We designed a quality improvement CCICU in-situ simulation study using the PDSA model. Ten pediatric and adult scenarios were researcher designed with increasing complexity to address team performance. The multidisciplinary participants consist of nurses, doctors, respiratory therapists, and pharmacists from September 2014 to now with the assistance of the simulation center educator and simulation specialist. Analysis of the current state in team structure (human and system issues) and communication during emergencies was assessed. Fifteen in-situ simulation mock codes were conducted using the pediatric and adult high fidelity Gaumard mannequins. Surveys were filled out by all participants at the end of the last five simulations session of the fifteen. Structured debriefing with feedback from all participants in the simulation were reviewed. This study continues to address team dynamics, technology,patient and system factors using in-situ simulation to improve patient care.
Results: Human, equipment and system factors identified after the first ten simulations were summarized in “lessons learnt during mock code” document and distributed to the entire staff of the CCICU. The next phase included surveys filled out at the end of simulation. The team members perceived their educational experience in a positive manner with 96% perceiving the learning environment as safe and allowed learning to occur. 100% achieved their learning objectives and perceived as the scenario was appropriate for their learning. The mean overall satisfaction was 87%. This led to acquisition of skills/knowledge/attitudes in a learning environment. Our in-situ simulation demonstrated to be particularly effective in enhancing non-technical skills like communication: (82% thought we communicated effectively as a team), decision making and situation awareness (82% thought we adapted to changing situations and prioritized tasks). We need improvement in leadership and role assignment (36% did not think that the roles were clearly defined).
Conclusions: Simulation can help determine provider workload, refine team responsibilities and identify latent safety threats. The limitations of this study are that we don’t have any surveys in the first phase of the study. The future direction of this study is whether there is transfer of the learners behavioral changes to the clinical setting and whether this leads to improved patient outcomes.


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5- Parental Satisfaction in the Pediatric Intensive Care Unit (picu)

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Background: Parents have a central role in the care of their sick child in the PICU. Parental satisfaction with their child’s care is a critical part of quality assessment and outcome measure in healthcare.
Aim: To assess parental satisfaction of children admitted in the PICU by developing a PICU-specific parent satisfaction survey and comparing their responses in this survey with an existent hospital wide (Pres Ganey) survey.
Materials and methods: Study was undertaken at a 20 bed PICU of a university hospital over a 5-month period (October 2015-February 2016). A PICU-specific parent satisfaction survey was developed with input from all PICU personals and parents of previously admitted patients. Based on concern for poor communication, the PICU survey included 10 questions that focused on communication (5 questions), patient care (3 questions), and PICU environment (2 questions). The PICU survey was given to the parents by the bed-side nurse prior to their transfer to the floor and they were required to respond to each question on a 5-point Likert scale (1=worst and 5=best) followed by an open ended question. All parents also received a Pres Ganey survey by mail following their child’s discharge. Parents whose children died in the PICU or who were discharged directly from the PICU were excluded from the survey.
Results: 442 pediatric (0-18 years) patients were admitted to the PICU in the 5-month study period. 139 patients were discharged home directly from the PICU and 8 patients died in the PICU. Of the 295 patients transferred to the floor, 157 parents (53%) responded to the PICU-specific survey as compared to 11 parents (3.7%) responding to Pres Ganey survey (p < 0.0001). Analysis of the PICU-specific survey Likert scale responses revealed that the parents gave a mean score of 4.97±0.19 to communication; 4.94±0.27 to patient care; and 4.92±0.27 to environment. The lowest response score was for their child’s room being clean and comfortable (4.87±0.43) that correlated with maximal negative open ended suggestion (8 of 11 negative comments). In 92 of 157 (59%) surveys parents gave comments in open ended question. 76 (82%) comments appreciated their child’s care, 5 comments suggested PICU policy changes and 11 comments requested improvement (8 for PICU environment and 3 for communication). The PICU-specific survey responses revealed high internal consistency, inter-rater reliability, and content validity.
Discussion: PICU deserve individual surveys to assess parent satisfaction and interpretation of general hospital survey responses for PICU care should be undertaken cautiously. A high level of satisfaction was observed in communication that was the main concern in our PICU-specific survey. Further work is needed to identify the degree of significance of our PICU-specific survey responses.
Conclusion: Parent satisfaction with PICU care can be assessed by a well-designed PICU-specific survey.

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6- Experience of United States Pediatric Critical Care Medicine Fellows with Brain Death Examinations

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Purpose:
Brain death (BD) declaration is an infrequent occurrence in pediatric ICUs, occurring in less than 1% of admissions. Brain death is determined by a specialized examination including an apnea test. Pediatric BD guidelines written in 2011 suggest that the exam “should be performed by experienced clinicians who … have specific training in neurocritical care;” however, there were no recommendations as to the amount or type of training needed. Notably, there have not been any published studies evaluating current experience of pediatric critical care medicine (PCCM) fellows with BD determination; and there have been no formal guidelines developed regarding fellow education in this area.

This study sought to evaluate the current experience of PCCM fellows with brain death examinations. We hypothesized that fellows would report having performed relatively few BD exams and that fellows from programs with fewer trainees would have increased exposure.

Methods:
An internet-based survey was developed using SurveyMonkey™ and distributed to a convenience sample of fellows and recent graduates from U.S. PCCM fellowship programs. Survey questions focused on the number of brain death examinations that each respondent had actively participated in, as well as demographic questions about their training institution. Surveys were collected between November of 2015 and February of 2016. Data were analyzed using SPSS.

Results:
230 subjects were invited to participate; 31/65 US PCCM fellowship programs were represented. 91 responses were received (40% response rate). First year fellows reported performing a median of 0 brain death exams by that point in their training (IQR: 0-1 exams) while second year fellows reported a median of 3 exams (IQR: 1-5), third year fellows reported a median of 5 exams (IQR: 3-6) and recent graduates reported a median of 8 exams (IQR: 4 to >8). There was a tendency of fellows from smaller programs to report more experience with brain death exams than fellows from larger programs, but this did not reach statistical significance. There was not any difference based on number of PICU beds or presence of in-house attending physicians at night.

Conclusion:
PCCM fellows overall have limited experience with performing brain death examinations and there is wide variation in the experience among fellows. Exposure to brain death examination is less than many of the other technical skills acquired in PCCM fellowships (such as central line placement and chest tubes). While further study will be needed to determine the amount of training needed for acquisition of skills in this exam and the rate of skill deterioration over time, fellowship programs should consider new ways to give fellows additional exposure to this important process.

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7- Dysnatremia in the Pediatric Cardiac Critical Care Unit: incidence and Outcomes in Post-operative Congenital Heart Disease Patients

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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"Background"
Abnormalities of sodium balance (dysnatremia) are one of the most common electrolyte disorders in intensive care and have been associated with adverse outcomes in a number of adult populations. Few studies have examined the incidence and outcome of dysnatremia in pediatric patients following cardiac surgery. The objective of this study is to better understand the incidence of dysnatremia in pediatric patients following congenital heart surgery and its impact on outcome.

"Methods"
Retrospective chart review of children under 18 years old admitted to Texas Children’s Hospital Cardiovascular Intensive Care Unit following congenital heart surgery between January 1, 2012 and January 1, 2015. Infants operated at less than 37 completed weeks of gestation or over 18 years of age were excluded. Data collected included: age, gender, weight, Risk Adjusted Congenital Heart Surgery Score (RACHS-1) classification, cardiopulmonary bypass (CPB) and cross clamp (CC) times; serum sodium at 24, 48 and 72 hrs; Hospital length of stay (LOS), duration of mechanical ventilation (MV), and mortality. Dysnatremia has been defined as serum sodium level lower than 135mmol/L (hyponatremia) or higher than 145 mmol/L (hypernatremia). Comparisons between groups were performed using Mann-Whitney and logistic regression analysis.

"Results"
A total of 1345 encounters (55.7% males) were included in this review. The median (IQR) age was 10 (2.7-60) months, weight 8.1 (4.5-18) kg. 1163 (86.5%) patients were in RACHS-1 category 1-3, and 182 (13.5%) patients were in category 4-6. Hospital LOS was 8 (5-15) days; duration of MV 23.9 (7.1-59.3) hours; CPB time 138 (92-192) min and CC time 77 (38-121) min. Pre-operative dysnatremia, 138 (137-140) mmol/L, incidence was 10.2%; 8.7% had hyponatremia and 1.5% had hypernatremia. The overall incidence of post-operative dysnatremia was 46.5%; 19.1% had hyponatremia, 25.6% had hypernatremia, and 1.8% had both hyponatremia and hypernatremia in the first 72 hours after surgery.
The overall mortality was 1.8% and was associated with hypernatremia at 24 hrs after surgery (Odds Ratio (OR) 3.61 [1.6-8.11], p=0.0019); at 48 hrs (OR 6.04 [2.52-14.43], p=0.0001); at 72 hrs (OR 6.07 [2.32-15.83], p=0.0002). There was no association between hyponatremia and mortality. In a multivariable model adjusting for age, LOS,CPB and CC times, post-operative dysnatremia at 24 hours was associated with increased hospital LOS (OR1.01 [1.00-1.01], p=0.0013).

"Conclusions"
Perioperative dysnatremia was a common finding in pediatric cardiac surgical patients. Hypernatremia was more prevalent than hyponatremia, and was associated with poor early post-operative outcomes. Post-operative dysnatremia was associated with increased hospital length of stay and mortality.

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8- Design and Implementation of a Curriculum to Teach Communication Skills to Pediatric Critical Care Fellows

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Objective The aim of this project is to design and implement a curriculum to improve confidence and communication skills and among pediatric critical care fellows while improving family satisfaction regarding communication. Good communication is an essential skill for all physicians. Fellows in pediatric subspecialties are required by the ACGME Core Competencies and the Pediatric Milestones Project to demonstrate competency in communication skills. There is a growing body of literature that demonstrates curricula can improve communication skills based on trainee confidence and perception. The aim of this project is to design and implement a curriculum to improve confidence and communication skills and among pediatric critical care fellows while improving family satisfaction regarding communication.
Study Design This study examines the effect of a curricular intervention on observed, standardized communication skills among trainees. The prospective design targets current pediatric critical care medicine (intervention) and neonatal intensive care fellows (control) at MCJCHV. The intervention consists of longitudinal curriculum designed to teach communication skills in the care of critically ill pediatric patients. Using a difference-in-differences study design, all participants complete pre- and post-curriculum standardized assessment of communication skills. This assessment utilizes as standardized encounter with simulated patient families and scenario using a communication performance evaluation checklist. Additionally, pre- and post-curriculum surveys assessing participant confidence in communication skills are used for comparative analysis of subjective improvement. The final assessment of skill acquisition utilizes actual patient family evaluation of communication by the trainees utilizing a standardized communication tool pre and post intervention.
Results Data analysis thus far consisting of pre-curriculum surveys assessing trainee confidence in communication skills demonstrated a statistically significant weakness in the following areas (paired t-test, α ≤ .05): encouraging questions; answering them clearly (p = 0.001); using words patients and families can understand (p = 0.05); detecting verbal cues regarding understanding or emotional state (p = 0.001); responding empathetically to feelings (p = 0.01). Analysis of the control group confidence surveys found a statistically significant improvement (paired t-test, α ≤ .05) for only one skill without educational intervention - using words patients and families can understand (p = 0.02).
Conclusions Communication has been previously shown to be a teachable skill, however little data exists for pediatrics and much of this data has shown improvement only in learner confidence. Prior to implementation of a longitudinal communication curriculum, pediatric ICU fellows showed significant areas of low confidence. Without educational intervention, only one area of low confidence showed statistically significant improvement. Data regarding confidence survey for the experimental group, communication skill performance and family satisfaction will be forthcoming when the curriculum completes this June.

Pre-curriculum confidence data
Pre-curriculum surveys assessing trainee confidence in communication skills demonstrated a statistically significant weakness in the following areas (paired t-test, α ≤ .05): encouraging questions; answering them clearly (p = 0.001); using words patients and families can understand (p = 0.05); detecting verbal cues regarding understanding or emotional state (p = 0.001); responding empathetically to feelings (p = 0.01).
Control group confidence data
Analysis of the control group confidence surveys found a statistically significant improvement (paired t-test, α ≤ .05) for only one skill without educational intervention - using words patients and families can understand (p = 0.02).

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9- Application of Therapeutic Intervention Scoring System (tiss) to an Electronic Health Record: A Feasibilty Study

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Background: Nurse staffing represents a significant cost to hospitals. However, literature suggests a direct link between nurse/patient ratios and mortality. (Aiken, 1987) Thus hospitals need to balance an appropriate, cost efficient nursing staffing with patient care needs. The need for balance is aggravated by the lack of validated tools to determine nurse staffing on a daily basis.
The Therapeutic Intervention Scoring System (TISS-28) was developed to measure nurse workload and severity of illness in the context of an intensive care units (ICUs) (Moreno, 1997.) It has since been validated and used in a variety of contexts to analyze workflow based on specific patient populations (Dickie, 1998) (Graf, 2003), including pediatric critical care (TISS-C, Trope, 2015). Collection of TISS is labor intensive and thus precludes use in daily ICU operations. Further, TISS has not been integrated into electronic health record (EHR) systems. A successful integration of TISS into electronic medical records would give management teams the tools to accurately measure nurse workload based on patient need in real time. The first step in this process is the evaluation of TISS criteria in the context of a commercial EHR in order to test the feasibility of future integration.
Methods:
This prospective descriptive study used no human data or patient health information; therefor approval from the Institutional Review Board was not applicable. The setting was a freestanding children’s hospital. A commercial EHR (Epic Systems, Verona, WI) was reviewed for the presence or absence of the elements of the TISS-C. For each potential TISS-C element and, the EHR test system was reviewed for the presence of the element or its components. Elements were categorized into one of four categories: “In EHR,” “In EHR with modification,” “Components of Element in EHR partially missing,” and “Not in EHR.” Agreement by at least two of three investigators was required for classification. Consultation with internal EHR experts was obtained when it was unclear on the status of an element.

Results: Review of the TISS-C tool yielded 112 elements, which reflected the various components of elements. 45 elements existed in the EHR (40%) with another 40 elements (35%) existing but required additional modification in the form of calculations or combinations. 18 of the TISS elements (16%) required components that were not in the EHR. Finally, 9 elements (8%) were completing missing from the existing EHR record.
Conclusions: The majority of elements (75%) necessary to calculate TISS-C using an EHR were available with minimal changes. For the remaining elements, additional fields would be required in the EHR for use. This suggests that automating TISS-C is moderately feasible. Next steps include incorporation of missing elements into EHR documentation, and piloting use in daily care.

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10- The Cost of Being Poor: The Relationship Between Poverty and Hospital Outcomes in Children Critically Ill with Bronchiolitis

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Purpose: Based on 2014 US Census data, over 40% of children live in or near poverty. There are well established associations between adverse health outcomes and poverty in children. These include, but are not limited to, infant mortality, obesity, delayed language development, poor school achievement, asthma exacerbations, and mental health disorders. However, little is known regarding the effects of childhood poverty on outcomes in critically ill children. We hypothesized that poverty would be associated with unfavorable outcomes in children critically ill with bronchiolitis.
Methods: We identified children < 2 years old with a primary diagnosis of bronchiolitis admitted to our ICU from October 2013 through April 2014 using local Virtual PICU data. The electronic charts of these children were also queried. Collected data included demographics, length of stay, respiratory support utilized, comorbidities, and hospital charges. Median household income was estimated from patient zip codes and 2014 US Census Bureau data. The 2014 Federal Poverty Level (FPL) for a family of 4 was $24,008. For this study, patients were classified as living below the 150% FPL ( < 150FPL) or above the 150% FPL (>150FPL). Statistical methods included descriptive statistics, Wilcoxon rank-sum, and odds ratios. Data shown as n (%) or median (interquartile range).
Results: The median age of 145 subjects was 5 (2-11) months. Seventy-one (49%) children were African American and 61 (42%) were Caucasian. Forty-five (31%) children were born prematurely ( < 37 weeks gestation). Twenty-eight (19%) children required invasive mechanical ventilation (MV). Of those children who did not receive MV, 69 (47%) required high flow nasal cannula (HFNC). In this cohort, 22 children (15%) were living in poverty, 63 children (43%) were living below the 150% FPL, and 102 (70%) of children were classified as low income (< 200% FPL), or poorer. Living < 150FPL was associated with worse clinical outcomes. These include longer PICU length of stay (LOS) (3.2 days [1.8-7.8] vs 2.0 [1.1-4.5], p=0.008), longer hospital LOS (6 days [4-12] vs 4.5 [2.8-7.5], p=0.006), longer duration of supplemental oxygen (87 hours [50-178] vs. 55 [18-113], p=0.032), and higher hospital charges ($45,335 [28,367-122,867] vs [$28,878.5 [16,440-56,122.5], p=0.003). Furthermore, children living < 150FPL had higher odds of needing mechanical ventilation (OR 2.39 [95% CI 1.03-5.55], p=0.04) vs those living >150FPL. The same effect was not seen for HFNC utilization (OR 1.54 [95% CI 0.72-3.31], p=0.27).
Conclusion: In this cohort of predominantly low income, critically ill children with bronchiolitis, greater poverty was associated with more unfavorable clinical outcomes including longer hospital length of stay and higher hospital charges.

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11- Standardization of Post-operative Hand-off Practices in the Pediatric Icu: A Quality Improvement Project

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Abstract
Background: In 2006, the Joint Commission required all health care providers to “implement a standardized approach to patient hand-offs”.
Problem: At our institution, we identified gaps in post-surgical patient hand-offs which included incomplete transfer of information and inadequate communication between the medical and surgical teams. This resulted in a high level of anxiety, frequent paging and at times, delay in patient care.
Methods: We distributed a Satisfaction Survey to quantify this problem. Those surveyed included the physicians on both the surgical and medical teams as well as the nursing staff within the Pediatric ICU. We then implemented a comprehensive Post-operative Patient Hand-off Tool designed for use on surgical patients admitted to the PICU. After six months of use, we redistributed a post-intervention survey to measure a change.
Intervention: All stakeholders were introduced and oriented to the hand-off tool which was then piloted and revised during its use. Changes were made and a final tool was implemented. Users were continuously updated with the changes made throughout this time.
Results: Post intervention survey results showed an improvement in the quality of patient hand-offs in the following areas: completeness of information, clarity of surgical and medical plan, availability and courtesy of providers, as well as confidence in provider’s ability to care for the patient. The number of frequent pages and redundant questions also saw a reduction. Pre-intervention results revealed that stakeholders paged the sending team more than twice in a 24-hour period 37% of the time; post-intervention this decreased to 26.27%. However, we found that perception of efficiency declined. See attached table and figures for results.
Conclusions: Standardization in hand-off practices improves communication, confidence and ensures clarity of patient plan. Efficiency may initially be decreased when implementing new tools, however we believe that over time and with frequent use this may improve. We recommend that a follow up study be performed after an extended time of use.

Table 1
The above table represents our data pre and post-intervention.
Figure 1
The above figure is a graphical representation of our data.

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12- Familiarity with Diabetes as a Protective Factor for Severity of Condition at Type One Diabetes Diagnosis

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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The onset of type one diabetes produces symptoms that do not reflect the severity of the condition. As a result, the diagnosis is often initially missed by parents and health care providers alike, which delays treatment, increasing the risk of negative health effects for the child.

For this study, a snowball, social media request recruited the parents of children with type one diabetes. To meet inclusion criteria, the child with diabetes had to be under 18 years old and diagnosed within the last ten years. The parent completed a university-IRB approved online survey about the experience of diagnosis. Data was transferred into SPSS for analysis and although there were respondents from many countries, for the purpose of this presentation only those from the United States and Canada were used (n=1036).

The most common symptoms for the child reported at diagnosis were urination (90.2%), thirst (87.8%), weight loss (64.2%) and fatigue (60.9%). Just over half (53.4%) of the participants were diagnosed in a doctor’s office and 29.9% were diagnosed in an Emergency Room. The majority (86%) were admitted to a hospital at diagnosis and stayed for an average of 3.8 days.

Blood glucose level at diagnosis was associated with hospital admittance, diabetic ketoacidosis (DKA), and time spent in the Intensive Care Unit (ICU). As shown in Table 1, blood glucose level was significantly higher among those treated with more intensive critical care measures. Thus, diagnosing a child at a lower glucose level is critical to reducing the complications and severity of condition at diagnosis.

(Insert Table 1 here)

One protective factor that reduced the likelihood of severity at diagnosis was the familiarity that the parent had about type one diabetes prior to the child’s diagnosis. A higher familiarity score was found among those who specifically asked a health care provider to check their child for diabetes (t=8.2, p < 0.01). Of the parents in the total population, 38.8% (n=402) specifically asked a health care provider to test their child for diabetes. Among those who asked to be tested, the severity of the condition at diagnosis was better (t=-6.1, p < 0.01), blood sugar at diagnosis was lower (t=-4.3, p < 0.01), and incidence of ICU (chi-square=45.7, p < 0.01) and DKA (chi-squar28.6, p < 0.01) were lower.

The results of this research makes a case for more education about type one diabetes to parents. Information about type one should be added to the education given at well-child visits and may be distributed through fliers, posters, electronic media and/or handouts throughout medical offices. Increasing the familiarity of the parent with type one diabetes appears to decrease the severity of condition at onset.

Table 1
Blood sugar differences by severity markers

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13- Use of Ezpap Positive Airway Pressure System for Ventilator Weaning in Pediatric Respiratory Failure

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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Introduction: We are unaware of any prior published case reports describing the use of EzPAP positive airway pressure system to facilitate ventilator weaning in pediatric patients with refractory respiratory failure.

Case Report: A 7-year old female presented to the pediatric ICU due to 35% TBSA burns and severe inhalational injury suffered during a house fire. Within one week of injury, she developed severe acute respiratory distress syndrome (ARDS) requiring VV-ECMO. She was ultimately transitioned to a right CentriMag ventricular assist device (RVAD) with an oxygenator in line to both allow for recovery of right ventricle function as well as improve oxygenation and ventilation, while allowing for slow lung recovery. A tracheostomy was performed one week after RVAD placement due to ventilator dependence, which facilitated improved rehabilitation. Over the course of 18 months in the PICU, her RVAD was weaned and ultimately explanted. Her ventilator was also weaned as her lungs were recovering and she was able to rehabilitate weakened muscles. However, despite tolerance of ventilator weaning to low settings, she was unable to tolerate CPAP with pressure support trials through her ventilator due to complaints of ‘air hunger’, with resultant tachycardia and ultimately hypoxia. Attachment to her ventilator continuously also interfered with other daily activities aimed at increasing her mobility. We then trialed attachment of EzPAP to her tracheostomy with discontinuation of her ventilator, which she immediately tolerated.

Discussion: EzPAP is a small, portable device that is normally used as post-operative therapy to prevent or reverse atelectasis in adult patients unable to do incentive spirometry or other maneuvers to augment lung volumes. It has been shown in adults to decrease atelectasis and hypoxia as compared to other traditional pulmonary physiotherapy and is very well hemodynamically tolerated. EZPAP works by amplifying an input flow of either air or oxygen approximately four times using the coanda effect. Once the liter flow reaches 5 LPM, a positive air pressure of 4 to 5 cmH2O can be obtained. We placed this patient on EzPAP with 6 LPM, which provided a positive airway pressure of 5 to 6 cmH2O. She is now tolerating extended EzPAP trials off the ventilator for over 8 hours daily without any setbacks. Our plan for continued weaning will be to decrease the liter flow ultimately to 3 LPM on an Heat Moisture Exchanger (HME) attached to her tracheostomy, such that she will be off the ventilator during the entire day.

Conclusion: EzPAP is inexpensive and was well tolerated in this pediatric patient, facilitating weaning of ventilator support when other traditional weaning strategies had recurrently failed. Further evaluation of the use of this device in pediatric post-op patients or other patients with lung disease exacerbations will now be conducted.

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14- Risk Factors of Opioid/benzodiazepines-induced Withdrawal Syndrome in Critically Ill Hispanic Children

Monday, October 24
9:30AM - 10:45AM
Moscone West, 2018

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PURPOSE
Critically ill children may receive prolonged sedation and analgesia as pain management and to facilitate intensive care therapies. Those patients are at risk to develop iatrogenic withdrawal syndrome (IWS) when medications are stopped or weaned suddenly. In this study, we evaluated the incidence and risks factors of IWS in children admitted to the Pediatric Intensive Care Unit (PICU) exposed to opioids and benzodiazepines for 3 days or more.
METHODS
In this prospective observational study conducted at a tertiary academic hospital in Puerto Rico, we assessed IWS using the Withdrawal Assessment Tool Version 1 (WAT-1). All admitted children who received sedation and analgesia by continuous infusions or bolus for more than 3 days were included in the study. Patients with cerebral palsy, chronic use of opioids or benzodiazepines, oncology patients and status epilepticus were excluded. Once opioid/benzodiazepines weaning started, IWS was assessed twice a day for 72 hours. Data was expressed as percentiles or medians ± SD when appropriate. Mann-Whitney test were used for comparisons.
RESULTS
From 400 newly admissions to PICU, 25 patients met inclusion criteria. An incidence of 60% of opioid/benzodiazepines IWS was observed, with 50% of patients showing withdrawal signs within the first 14 days of admission. Younger patients (median: 24 months) and females (58%) were more prone to develop IWS. Our study revealed that CNS/Trauma (50%) and postsurgical patients (33%) had highest IWS incidence, followed by patients with respiratory problems (25%). 84% of patients were on mechanical ventilation support and 2.4% developed Ventilator Associated Pneumonia. Patients with IWS had prolonged mechanical ventilation support as compared to controls (p= 0.02). The cumulative dose and maximum peak dose of opioid/benzodiazepine drip were higher in patients with IWS.
CONCLUSIONS
Incidence of IWS in our population was higher than those reported in the literature. This may be explained by lack of a standardized opiod/benzodiazepines weaning protocol as well as a behavioral scale to measure level of sedation and analgesia to avoid over-sedation. In our PICU standard of care, we did not use the Pediatric Confusion Assessment Measure for Intensive Care Unit (pCAM-ICU) to measure delirium symptoms, those that can be confused with withdrawal signs. Postsurgical patients and CNS/Trauma patient have the highest IWS incidence due to prolonged therapy to provide adequate pain control and CNS protection. Patients on prolonged mechanical ventilation support required prolong opiod/benzodiazepines therapy increasing the risk to develop IWS. This study revealed the importance to have a standardized weaning protocol is needed to adequately prevent and lower the risk for IWS. Moreover, it is essential for physicians in the intensive care setting to have appropriate instruments to early detect IWS and/or delirium.

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Plasma f2-isoprostane Levels in Neonatal Extra Corporeal Membrane Oxygenation

Monday, October 24
10:45AM - 11:00AM
Moscone West, 2018

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Background:
Neonates are managed with extracorporeal membrane oxygenation (ECMO) for refractory hypoxemic respiratory failure. While on ECMO, the blended oxygen exposes the neonate to high oxygen concentrations. It is believed that neonates treated with ECMO are exposed to reactive oxygen species, typically free radicals that can induce oxidative injury. F2-isoprostane (F2-IsoP) is a prostaglandin-like molecule formed in vivo by free radical mediated oxidation of arachidonic acid. F2-IsoP is an ideal biomarker to assess in vivo oxidant stress.
Purpose:
The purpose of this study is to evaluate oxidative stress by measuring plasma F2-IsoP levels during ECMO treatment in neonates.
Methods:
In this prospective study, plasma F2-IsoP levels were measured in term neonates at three different time points: before ECMO support, 24 hours into veno-arterial ECMO, and 24 hours post ECMO. Plasma F2-IsoPs were analyzed by using gas chromatography and mass spectrometry.
Results:
Six neonates with mean gestational age 39.3 ± 2.2 weeks and mean birth weight of 3.6 ± 0.3 kg were studied at a mean age of 2.2 ± 1.7 days. The average duration of ECMO support was 223 ± 168 hours [94-555 hours]. F2-IsoP levels significantly increased during ECMO compared to levels obtained Pre-ECMO (0.085 ± 0.039 ng/mL) to during ECMO (0.095 ± 0.027 ng/mL; p=0.026). Post ECMO F2-IsoP levels decreased significantly compared to the levels during ECMO (0.047 ± 0.008 ng/mL; p=0.03).
Conclusion:
This is the first study to evaluate oxidative stress in neonates being treated with ECMO. These preliminary data suggest that the oxygen-enriched environment during ECMO produces oxidative stress in neonates as quantified by a significant rise in F2-IsoPs. Further studies are warranted to delineate the oxidative stress responses induced during ECMO therapy.

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The Fragility Index in Pediatric Critical Care Randomized Controlled Clinical Trials

Monday, October 24
11:00AM - 11:15AM
Moscone West, 2018

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Introduction:
Clinicians commonly rely on p-values to determine the strength of evidence presented in randomized controlled trials (RCT). Interventions supported by statistically significant p-values often guide clinical decision-making. However, a shift of only a few events in the experimental group could change hypothesis testing results from a significant P-value to one above the statistically significant threshold. The Fragility Index Statistic identifies the number of events required to change statistically significant results to non-significant and can be used to assess the robustness of clinically significant findings. The aim of this study was to investigate the stability of pediatric RCT results by calculating Fragility Indices.

Methods:
OVID Medline and PubMed searches were used to identify English-language RCTs performed between 2000 and 2015. Studies were included if they were pediatric RCTs with a dichotomous primary outcome between two randomized parallel groups. A convenience sample was obtained by limiting results to high-impact journals and critical care themes. Original results from each RCT were extracted and a two-by-two contingency table was created. Fragility Index was calculated, as described by Walsh et al, by adding an event to the intervention group while subtracting a non-event from the same group to keep the total number of patients constant. A two-sided Fisher’s exact test was used to derive new P-values. Events were iteratively changed until the P-value exceeded 0.05. The Fragility Index was the number of events to achieve the P-value change. Characteristics of RCTs were summarized using descriptive statistics. Correlations were assessed using Pearson correlation coefficient.

Results:
A total of 429 RCTs were screened for inclusion. The 17 eligible RCTs had a median sample size of 150 (range 41-3141) and a median of 53 events (range 16-290); 65% had P-values < 0.01. The median Fragility Index was 7 (range 0-24) with interquartile range of 2-12. When comparing RCT sample size and event frequency to Fragility Index, there were moderate positive correlations respectively (R =0.6321, p=0.006; R=0.5779, p=0.015). Eight studies reported Fragility Index equal to or less than the number of patients not analyzed after randomization.

Discussion:
This study of Fragility Index demonstrates that results from pediatric RCTs frequently hinge on 7 or fewer events. Additionally, the Fragility Index was 2 or less in 25% of pediatric RCTs sampled from high-impact medical journals. RCTs with fragile results were found across a wide range of sample sizes and number of events. In 47% of RCTs studied, more participants were excluded from analysis than would be required to make the result non-significant based on the Fragility Index.

Conclusions:
Pediatric critical care RCTs with significant findings are statistically fragile. Reporting the Fragility Index for significant results would better allow clinicians to make informed conclusions regarding treatment effects in pediatric RCTs.

Fragility Index compared to RCT total sample size (R =0.6321, p=0.006)
Fragility Index compared to total number of events (R=0.5779, p=0.015)

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Developmental Outcomes in Critically Ill Children: A Population Based Birth Cohort Report

Monday, October 24
11:15AM - 11:30AM
Moscone West, 2018

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Introduction
The burden of pediatric critical illness within a general community is not well understood. Study of the impact of critical care on patients and their community is essential for creating opportunities for early identification and intervention. Scoring systems for evaluating ICU admission and discharge morbidity exist, but have yet to be linked with longer term outcomes. As a result, the utility of these tools for predicting persistent disability to guide follow up remains unknown.

Purpose
The objective of this study was to evaluate the association between acute disability assessments performed at ICU admission and discharge with school age developmental outcomes at long term follow up for children who experienced early childhood critical illness.

Methods
This study focused on a population-based cohort served by one pediatric ICU. Among all children born in the county between 2003 and 2007, those with ICU admission between the age of five days and four years were studied via retrospective review. Direct birth to ICU admissions and admissions for the primary diagnosis of prematurity were excluded. Clinical charts provided information about intensive care hospitalization, from which Functional Status Score (FSS) and Pediatric Overall Performance Category (POCP) were calculated. School records were reviewed for documentation of developmental delay, speech or language impairment, ADHD, learning disability, and individualized education plan requirements.

Results
A total of 9,441 children were born in the studied county between January 1, 2003 and December 31, 2007. During 61,770 person-years of follow-up, a total of 175 children within this cohort met study inclusion criteria.
Of the children requiring ICU admission, 43 had impaired functional status at time of admission; 24 with FSS > 6, and 22 with POCP > 1. At the time of discharge, only 32 patients had an impaired functional status.
Within this ICU cohort, 32 (18%; 50% male; mean age at testing, 4.5 years; mean time from ICU discharge 3.4 years) children required formal developmental testing, 12 of whom had impaired functional status at hospital discharge. For speech and language assessment, 41 (23%; 56% male; mean age at testing, 3.1 years; mean time from ICU discharge 4.2 years) required evaluation, 14 of whom had impaired functional status at hospital discharge. ADHD diagnosis was made in18 (10%; 50% male) children and 17 (10%; 47% male) required individualized education plans and specialized accommodations in school for their developmental disability.

Conclusion
This is the first report of population-based school age developmental outcomes for children admitted to the ICU before 4 years of age. In-hospital assessment of developmental disability using FSS and POCP scores did not predict long term disability in ICU survivors. These discrepancies highlight the need for alternative short term measurements of disability to predict long term developmental morbidity after ICU admission.

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Pediatric Emergency and Critical Care in Low Middle Income Countries – an International Collaborative Approach to Capacity Building in Kenya

Monday, October 24
11:30AM - 11:45AM
Moscone West, 2018

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Background: 90% of global pediatric mortality and critical illness occurs in resource-poor settings, with a daily under-five mortality of 17,000. The majority of these deaths occurs in sub-Saharan Africa and is due to preventable and treatable illnesses. Since 87% of inpatient deaths occur within the first 24 hours of admission, advances in early recognition and effective management of critical illness are crucial. Currently, Kenya has two trained Pediatric intensivists serving a population of 17 million children. There are no Kenyan Pediatric Emergency Medicine sub-specialists in the country. The African continent has only two training centers in Pediatric Critical Care; none in Pediatric Emergency Medicine. Recognizing the urgent need for a Pediatric Emergency and Critical Care training program to serve the region, we built a global partnership to fill the educational gap.
Methods: Built on prior relationships, the University of Nairobi (UoN) and Gertrude’s Children’s Hospital (GCH) in Kenya approached the University of Washington/Seattle Children’s to develop a Kenyan fellowship training program in Pediatric Emergency and Critical Care. A core group of Kenya- and Seattle-based pediatric emergency and critical care specialists formed in 2012-13 and determined the Pediatric Emergency and Critical Care-Kenya (PECC-Kenya) partnership’s mission: To improve the management and outcomes of critically-ill children in sub-Saharan Africa through education, research, advocacy, service, and effective global partnerships. A detailed fellowship curriculum based on local needs and resources was developed with a larger group of experts during a 2-day workshop in Nairobi, with representatives from the Kenyan Paediatric Association and Ministry of Health solidifying fellowship content, structure and goals.
Results: The UoN, Kenyatta National Hospital, AIC Kijabe Hospital and GCH will offer a 2-year fellowship program in Pediatric Emergency and Critical Care commencing September 2017, providing a UoN certificate in PECC. Subspecialty education in public and private, urban and rural healthcare settings, provision of leadership, project management and implementation science training will help PECC-graduates transform their local healthcare systems for better outcomes in critical illness. Visiting specialists in the initial years of program operation will supplement and train local trainers, helping provide long-term program sustainability.
Discussion: The burden of critically-ill children in Low Middle Income Countries is disproportionately high. Challenges to addressing this problem include local staff retention to maintain unit standards, and obtaining sustainable funding for capacity building programs. Recruitment of visiting trainers and global collaborations remain part of the solution. Healthy partnerships, respect for local human resource and culture, and an in-depth understanding of resource-poor settings will help lead to success.
Conclusion: Sustainable capacity building in critical care and emergency medicine is a slow, time-consuming, resource-intensive process. To achieve beneficial results we need to combine local and external expertise, commitment, and support.

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Complications and Outcomes for Children Hospitalized with Typical Hemolytic Uremic Syndrome in the United States

Monday, October 24
11:45AM - 12:00PM
Moscone West, 2018

Take Evaluation

Purpose
Diarrhea-associated, or “typical” Hemolytic Uremic Syndrome (HUS) remains a significant source of morbidity and mortality in the pediatric population. Despite its prevalence, the clinical course and short-term complications of children hospitalized with HUS has not been described on a national level in the United States. Using a national database, we sought to describe the complication rates and burden of hospitalization with HUS to enable clinicians to define an expected clinical course and better understand the risks for clinical complications and poor outcomes.

Methods
We performed a retrospective population-based cohort study using the 2012 Kids’ Inpatient Database (KID) from the U.S. Healthcare Cost and Utilization Project (HCUP). We identified the diagnosis of HUS, acute complications of HUS, and procedures during hospitalization using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, and HCUP-provided Clinical Classification Codes (CCS). We identified patients ≤20 years with a diagnosis of HUS who lacked diagnoses associated with atypical HUS. Each discharge was weighted to allow generation of national estimates using HCUP algorithms. Complications were classified as renal or non-renal (including neurologic, cardiac, and gastrointestinal). We compared outcomes and resource utilization between patients with no complications, renal complications only, and other complications (with or without renal complications) using Fisher Exact (categorical variables) and t-tests (continuous variables).

Results
Weighted analysis identified 913 pediatric patients hospitalized with HUS in the United States in 2012, representing greater than 13,500 total hospital days. Among this patient population, the average length of stay was 15 days. Of these patients with HUS, 57% experienced at least one complication and 30% experienced a non-renal complication during their hospital course. Patients with only renal complications had similar outcomes to patients with no complications. Patients with any non-renal complications (with or without renal complications) had an 11-fold increase in mortality (p=0.002), almost two-fold longer length of stay (p < 0.001), and more than double the hospital charges (p < 0.001) compared to patients with only renal complications.

Conclusion
Hemolytic uremic syndrome is a significant cause of morbidity among American children. More than half of hospitalized patients experience a complication of HUS during their hospital stay, with nearly one third of cases experiencing non-renal complications that are associated with increased mortality and resource utilization.

Hospital outcomes for patients with no complications, renal complications, and other complications (with or without renal complications).
*comparing renal complications only to other complications.

Send Email for Complications and Outcomes for Children Hospitalized with Typical Hemolytic Uremic Syndrome in the United States

Attendees who have added this session to their plan

Hemant Agarwal, MBBS, FAAP

Medical Director, PICU, Department of Pediatrics
University of New Mexico
University of New Mexico
Albuquerque, NM

Presentation(s):

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Andrew Ausmus, MD

Pediatric Critical Care Fellow
Medical College of Wisconsin
Wauwatosa, WI

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Tammy Camelli, CPNP, AC-PC

Critical Care Nurse Practitioner
Akron Childrens Hospital
Akron, OH

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Jigar Chauhan, MD

Pediatric Critical Care Fellow
Nemours/A.I.Dupont hospital for children
Wilmington, DE

Presentation(s):

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Holly Gillis, MD

University of Minnesota Masonic Children's Hospital
Houston, TX

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Ruth Hickok, B.S.

Medical Student
Oregon Health & Science University
Oregon Health & Science University
Portland, OR

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Sue Jackson, PhD, MPH

Utah Valley University
Orem, UT

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Alex Katz, MedicalStudent

Medical College of Wisconsin
milwaukee, WI

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Rashmi Kumar, MMED.Paediatrics

M.B.B.S, MMed. Pediatric Intensivist, Sr Lecturer
University of Nairobi
Nairobi, Nairobi Area, Kenya

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Carlos López-Ortiz, B.S.

Medicine Student
UPR-School of Medicine
Toa Alta, Puerto Rico

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Shuang Li, B.S.

University of Central Florida College of Medicine
Orlando, FL

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Xiuxiu Lu, Postgraduate

the Capital Institute of Pediatrics Affiliated to Children's Hospital
Beijing, China

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Xiuxiu Lu, Postgraduate

the Capital Institute of Pediatrics Affiliated to Children's Hospital
Beijing, China

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Travis Matics, DO

Critical Care Fellow
University of Chicago Comer Children's Hospital
Chicago, IL

Presentation(s):

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Michael Mendez, B.S., RRT

Respiratory Therapist
Hershey Medical Center and Prompt Care
Hershey, PA

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Sinead Murphy, B.A.

Mayo Clinic Rochester
Mayo Clinic Rochester
Rochester, MN

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Pooja Nawathe, MD

Cedars Sinai Medical Center
Cedars Sinai Medical Center
90025, CA

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Andrea Ontaneda, MD, FAAP

Pediatric critical care fellow
Baylor College of Medicine/Texas Children’s Hospital, Department of Pediatrics, Houston, Texas; Section of Pediatric Critical Care Medicine
Baylor College of Medicine/ Texas Children's Hospital
Houston, TX

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Tara Petersen, MD

Assistant Professor of Pediatrics, Section of Pediatric Critical Care
Medical College of Wisconsin/Children's Hospital of Wisconsin
Milwaukee, WI

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Erin Powell, MD

Clinical Fellow
Monroe Carell Jr. Children's Hospital at Vanderbilt
Nashville, TN

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Aaron Reitman, D.O.

NEONATOLOGY FELLOW
LAC/USC MEDICAL CENTER AND CHILDREN'S HOSPITAL LOS ANGELES
Beverly Hills, CA

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Ilyssa Scheinbach, DO

Pediatric Hospitalist
Maimonides Infants and Children's Hospital of Brooklyn
Maimonides Infants and Children's Hospital of Brooklyn
Brooklyn, NY

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Katherine Slain, D.O.

University Hospitals Rainbow Babies and Children's Hospital
Bentleyville, OH

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Jennifer Andres, RN, BSN

Children's Hospital of Wiscsonsin
milwaukee, WI

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Meredith Broberg, M.D.

University Hospitals Rainbow Babies and Children's Hospital
Cleveland, OH

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Rachel Chapman, M.D.

Associate Professor of Pediatrics
Center for Fetal and Neonatal Medicine, USC Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine of USC
Los Angeles, California

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Carl Eriksson, MD, MPH

Oregon Health & Science University
Portland, OR

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Maria Escobar, MD

Pediatric Resident
Maimonides Infants and Children's Hospital of Brooklyn
New York, NY

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Matthew Flint, PhD, MS

Associate Professor
Utah Valley University
Orem, UT

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Sameer Gupta, MD

Inpatient Medical Director
University of Minnesota Masonic Children's Hospital
Minneapolis, Minnesota

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Tessie Hernandez, RN

Cedars Sinai Medical Center
Los Angeles, CA

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Nadia Khan, MD

Assistant Professor of Pediatrics
University of Chicago Comer Children's Hospital
Chicago, IL

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Javier Lasa

Assistant Professor
Baylor College of Medicine/Texas Children’s Hospital, Department of Pediatrics, Houston, Texas; Section of Pediatric Critical Care Medicine; Section of Pediatric Cardiology
Houston, TX

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Karen Marcdante, MD

Professor of Pediatrics, Section of Pediatric Critical Care. Interim Section Chief for Pediatric Critical Care
The Medical College of Wisconsin/Children's Hospital of Wisconsin
Milwaukee, WI

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Kristen Nelson McMillan, MD

Director, Pediatric cardiac critical care
Johns Hopkins University School of Medicine
Glen Rock, PA

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Christopher Page-Goertz, MD

Pediatric Intensivist
Akron Childrens Hospital
Akron, OH

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Tara Petersen, MD

Assistant Professor of Pediatrics, Section of Pediatric Critical Care
Medical College of Wisconsin/Children's Hospital of Wisconsin
Milwaukee, WI

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Kristie Rordriguez-Otero, MD

Pediatric Critical Care Fellow
UPR-School of Medicine
Trujillo Alto, Puerto Rico

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Jennifer Setlik, MD

Nemours Children's Hospital Orlando Florida
Orlando, Florida

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Nicholas Slamon, MD

Program director, Pediatric Critical Care Fellowship
Nemours/A.I.Dupont Hospital for Children
Wilmington, DE

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Jessica Turnbull, MD, MA

Faculty, Pediatric Critical Care Medicine and Center for Biomedical Ethics and Society
Monroe Carell Jr. Children's Hospital at Vanderbilt
Nashville, TN

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Chaitanya Undavalli, M.B.B.S

Mayo Clinic Rochester
Rochester, MN

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Amelie von Saint Andre-von Arnim, MD

Assistant Professor, Department of Pediatrics, Division of Pediatric Critical Care
University of Washington, Seattle Children's
Seattle, WA

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Qi Zhang, Professor

the Capital Institute of Pediatrics Affiliated to Children's Hospital
beijing, AL, China

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Qi Zhang, Professor

the Capital Institute of Pediatrics Affiliated to Children's Hospital
beijing, AL, China

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Ayse Akcan-Arikan

Assistant Professor
Baylor College of Medicine/Texas Children’s Hospital, Department of Pediatrics, Houston, Texas; Section of Pediatric Critical Care Medicine; Section of Pediatric Nephrology
Houston, TX

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James Bills, EdD, MS

Education Manager, Center for Experiential Learning and Assessment
Vanderbilt University Medical Center
Nashville, TN

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Mary Brown, PhD, MS

Associate Professor
Utah Valley University
Orem, UT

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Heda Dapul, MD

Pediatric Intensive Care Physician
Maimonides Infants and Children's Hospital of Brooklyn
Brooklyn, NY

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Priti Jani, MD, MPH

Assistant Professor of Pediatrics
University of Chicago Comer Children's Hospital
Chicago, IL

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AiJin Lee, RN

Cedars Sinai Medical Center
Los Angeles, CA

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Danielle Markus, B.A.

Research Assistant
University of Southern California
Los Angeles, CA

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Anabel Puig-Ramos, Ph.D, FCCP

Assistant Professor, Director Pediatric Critical Care Research Program
UPR-School of Medicine
Carolina, Puerto Rico

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Matthew Scanlon, MD, CPPS

Medical College of Wisconsin
Milwaukee, WI

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Angie Skoglund, Pharmacist

Pharmacy Supervisor
University of Minnesota
Minneapolis, MN

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Guowei Song, Doctor

Capital Institute of Pediatrics
Beijing, AL, China

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Guowei Song, Doctor

Capital Institute of Pediatrics
Beijing, AL, China

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Mardi Steere, MD

Medical Director
AIC Kijabe Hospital Kenya; University of Florida U.S.A.
Kijabe, Kenya

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Anne Stormorken, M.D.

University Hospitals Rainbow Babies and Children's Hospital
Cleveland, OH

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Kathleen Taylor, RN, BSN

Site Coordinator, Virtual Pediatric Systems, LLC
Akron Childrens Hospital
Akron, OH

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Amy Weaver, M.S.

Mayo Clinic Rochester
Rochester, Minnesota

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Cydni Williams, MD, MPH

Oregon Health & Science University
Portland, OR

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David Bliss, M.D.

Associate Professor of Surgery
Division of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, USC, Los Angeles
Los Angeles, CA

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Miraides Brown, MS, GStat

Biostatistician
The Rebecca D Considine Research Institute
Akron, OH

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Jorge Coss-Bu

Director of Research, Section of Critical Care Medicine
Baylor College of Medicine/Texas Children’s Hospital, Department of Pediatrics, Houston, Texas; Section of Pediatric Critical Care Medicine
Houston, TX

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Sheri Crow, M.D.

Mayo Clinic Rochester
Rochester, MN

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Jason Kane, MD, MS, FAAP

Associate Professor of Pediatrics
University of Chicago Comer Children's Hospital
Chicago, IL

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Jenny Kingsley, MD

Resident Physician
Monroe Carell Jr. Children's Hospital at Vanderbilt
Nashville, TN

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Russell Metcalfe Smith, Simulation specialist

Cedars Sinai Medical Center
Los Angeles, CA

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Samuel Pabon-Rivera, BS

Medicine Student
Ponce Health Sciences University
Trujillo Alto, Puerto Rico

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Sharon Ritter, Respiratory Therapist

Manager, Cardiopulmonary and ECMO Services
University of Minnesota Masonic Children's Hospital
Minneapolis, MN

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Steven Shein, M.D.

University Hospitals Rainbow Babies and Children's Hospital
Cleveland, Ohio

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Michael Forbes, MDFAAPFCCM

Northeast Ohio Medical University
Akron, Ohio

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Maria Gomez

Undergraduate Student
UPR-Bayamon Campus
Aguas Buenas, Puerto Rico

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Ginger Milne, Ph.D

Research Associate Professor of Medicine and Pharmacology
University of Vanderbilt School of Medicine
Nashville, TN

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Alistair Phillips, MD

Cedars Sinai Medical Center
Los Angeles, CA

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Jack Price

Associate Professor
Baylor College of Medicine/Texas Children’s Hospital, Department of Pediatrics, Houston, Texas; Section of Pediatric Cardiology
Houston, TX

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Jennifer Rosenthal, MD

Assistant Professor, Department of Pediatrics
UC Davis Children's Hospital
Sacramento, California

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Alexandre Rotta, MD

Rainbow Babies & Children's Hospital
Cleveland, OH

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Jian Yang, no

Capital Institute of Pediatrics
Beijing, China, Peoples Rep

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Jian Yang, no

Capital Institute of Pediatrics
Beijing, China, Peoples Rep

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Thomas Coates, M.D.

Professor of Pediatrics
Children’s Center for Cancer and Blood Diseases, Children's Hospital Los Angeles
Los Angeles, CA

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Kevin Rodriguez

Undergraduate Student
UPR-Rio Piedras Campus
Aguas Buenas, Puerto Rico

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Lara Shekerdemian, MD, MHA

Professor of Pediatrics, Chief of Pediatric Critical Care Medicine
Texas Children's Hospital/Baylor College of Medicine
Houston, TX

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Philippe Friedlich, MD, MS Epi, MBA

Neonatologist
Center for Fetal and Neonatal Medicine, Division of Neonatal Medicine, Children's Hospital Los Angeles and LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
Los Angeles, California

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Ricardo Nieves

Undergraduate Student
UPR-Rio Piedras Campus
Guaynabo, Puerto Rico

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Lianet Mamposo, MD

Pediatrician
San Juan City Hospital
Miami, FL

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John Wood, M.D., Ph.D

Associate Professor of Pediatrics
Division of Cardiology Children's Hospital Los Angeles, Keck School of Medicine, USC
Los Angeles, CA

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Maria Villar-Prados, MD, FAAP

Pediatric Intensivist
UPR-School of Medicine
San Juan, Puerto Rico

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Jessica Wisnowski, PhD.

Center for Fetal and Neonatal Medicine, USC Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine of USC
Los Angeles, CA

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Ricardo Garcia, MD, FAAP, FCCP, FCCM

Program Director Pediatric Critical Care Fellowship Program
UPR-School of Medicine
Caguas, Puerto Rico

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