Pediatrics Commons^™

Implementation Of The Comprehensive Unit-Based Safety Program To Improve Infection Prevention And Control Practices In Four Neonatal Intensive Care Units In Pune, India, Julia Johnson, Asad Latif, Bharat Randive, Abhay Kadam, Uday Rajput, Aarti Kinikar, Nandini Malshe, Sanjay Lalwani, Tushar B. Parikh, Umesh Vaidya

Department of Anaesthesia

Objective: To implement the Comprehensive Unit-based Safety Program (CUSP) in four neonatal intensive care units (NICUs) in Pune, India, to improve infection prevention and control (IPC) practices.
Design: In this quasi-experimental study, we implemented CUSP in four NICUs in Pune, India, to improve IPC practices in three focus areas: hand hygiene, aseptic technique for invasive procedures, and medication and intravenous fluid preparation and administration. Sites received training in CUSP methodology, formed multidisciplinary teams, and selected interventions for each focus area. Process measures included fidelity to CUSP, hand hygiene compliance, and central line insertion checklist completion. Outcome measures included the rate …

Still Birth Classification: Application Of Relevant Condition At Death (Recode) Classification System In A Tertiary Care Hospital Of Pakistan, Urooj Kashif, Shelina Bhamani, Asma Patel, Zaheena Shamsul Islam

Department of Obstetrics & Gynaecology

Objectives: To determine the cause of stillbirth after application of relevant condition at death (ReCoDe) classification system.
Methods: This was a retrospective cross sectional study of 207 women diagnosed with stillbirth after 24 completed weeks of pregnancy at the Aga Khan University Hospital (AKUH), Karachi between 1st January 2015 and 31st December 2019. The primary objective was to find the cause of stillbirth according to the new classification of relevant condition at death (ReCoDe).
Results: There were a total of 32413 live births and 207 stillbirths during the study period thus stillbirth rate of 6 per 1000 live births. In …

Incidence, Etiology, Sociodemographic And Clinical Characterization Of Acute Respiratory Failure In Pediatric Patients At A High-Altitude City: A Multicenter Cohort Study, Sarha M Vargas Muñoz, Sara De Vivero Haddad, Aldo M Beltran, Carolina Bonilla Gonzalez, Melisa Naranjo Vanegas, Sergio Moreno-Lopez, Paola Rueda-Guevara, Pedro Barrera, Juan Gabriel Piñeros, Luz Marina Mejía, María Lucia Mesa, Sonia Restrepo-Gualteros, Olga Lucía Baquero Castañeda, Andrea Ramírez Varela

Faculty, Staff and Student Publications

BACKGROUND: Acute respiratory failure is a life-threatening medical condition, associated with a variety of conditions and risk factors, including acute respiratory diseases which are a frequent cause of pediatric morbidity and mortality worldwide. In Colombia, the literature related to ARF is scarce.

OBJECTIVE: To determine the incidence, causes, and sociodemographic and clinical characteristics of ARF in three hospitals in Bogota, a high-altitude city located in Colombia, during the COVID-19 pandemic.

METHODS: A multicenter prospective cohort study called the FARA cohort was developed between April 2020 - December 2021. Patients older than one month and younger than 18 years with respiratory …

An Exploratory Assessment Of The Management Of Pediatric Traumatic Brain Injury In Three Centers In Africa, Madiha Raees, Shubhada Hooli, Amélie O Von Saint André-Von Arnim, Tsegazeab Laeke, Easmon Otupiri, Anthony Fabio, Kristina E Rudd, Rashmi Kumar, Patrick T Wilson, Abenezer Tirsit Aklilu, Lisine Tuyisenge, Chunyan Wang, Robert C Tasker, Derek C Angus, Patrick M Kochanek, Ericka L Fink, Tigist Bacha

Faculty, Staff and Students Publications

PURPOSE: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs.

METHODS: We completed a secondary analysis of a prospective observational study in children (<18 >years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and …

The Burden Of Critical Illness In Hospitalized Children In Low- And Middle-Income Countries: Protocol For A Systematic Review And Meta-Analysis, Teresa B Kortz, Katie R Nielsen, Rishi P Mediratta, Hailey Reeves, Nicole F O'Brien, Jan Hau Lee, Jonah E Attebery, Emaan G Bhutta, Carter Biewen, Alvaro Coronado Munoz, Mary L Dealmeida, Yudy Fonseca, Shubhada Hooli, Hunter Johnson, Niranjan Kissoon, Mara L Leimanis-Laurens, Amanda M Mccarthy, Carol Pineda, Kenneth E Remy, Sara C Sanders, Yemisi Takwoingi, Matthew O Wiens, Adnan T Bhutta

Faculty, Staff and Students Publications

BACKGROUND: The majority of childhood deaths occur in low- and middle-income countries (LMICs). Many of these deaths are avoidable with basic critical care interventions. Quantifying the burden of pediatric critical illness in LMICs is essential for targeting interventions to reduce childhood mortality.

OBJECTIVE: To determine the burden of hospitalization and mortality associated with acute pediatric critical illness in LMICs through a systematic review and meta-analysis of the literature.

DATA SOURCES AND SEARCH STRATEGY: We will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, and LILACS using MeSH terms and keywords. Results will be limited to infants or children (ages >28 …

A Novel Code Team Leader Card To Improve Leader Identification, Palak Shah, Vinod Havalad

Journal of Patient-Centered Research and Reviews

Prompt and clear code team leader identification is vital in effective cardiopulmonary resuscitation (CPR), and pediatric trainees often have limited experience in these scenarios. This project sought to develop a tangible object that provided clear leader identification and assisted in code team management and simulated team training. A Code Team Leader Card (CTLC) was designed to provide clear leader identification while simultaneously providing a cognitive aid via integration of pediatric advanced life support (PALS) algorithms. Additionally, CTLC served to occupy the leader’s hands to limit their ability to intervene on procedural tasks. The CTLC was incorporated into pediatric resident simulation …

Conference Proceedings: Select Abstracts Presented At 2021 Advocate Aurora Health Scientific Day

Journal of Patient-Centered Research and Reviews

Abstracts published within this supplement were presented at the 47th annual Advocate Aurora Health Scientific Day, held virtually on May 26, 2021. This research symposium provides a forum for disseminating results from studies conducted by faculty, fellows, residents, and other allied health professionals associated with Midwest-based health system Advocate Aurora Health, which publishes the Journal of Patient-Centered Research and Reviews.

Severe Diastolic Dysfunction Following Prolonged Extracorporeal Membrane Oxygenation In A Pediatric Burn Patient., Cara Holton, Johanna I. Orrick, Igor Areinamo, Jenna Miller

Posters

A previously healthy 3-year-old female was admitted following a 22% TBSA scald burn. She was initially hemodynamically stable on room air. However, one week into hospitalization she developed ARDS with catecholamine-refractory shock requiring VA-ECMO. She was enterovirus positive, grew MRSA in respiratory cultures and was treated with prolonged antibiotics. The patient spent 26 days on VA-ECMO followed by 61 days on VV- ECMO after failing decannulation due to refractory hypoxia. She developed anuric renal failure requiring CRRT during her second ECMO course. Following VV-ECMO decannulation, she required mechanical ventilation with high settings and had severe recurrent pulmonary hemorrhage requiring FFP, …

Syndrome Of Inappropriate Antidiuretic Hormone Secretion And Lead Toxicity In A Child With Sickle Cell Disease And Pica., Akshay Gupta Do, Alexandra Amaducci Do, Andrew L. Koons, John D. Lindmark, Gillian A. Beauchamp Md

Department of Emergency Medicine

We describe the presentation and management of a three-year-old child with a history of pica, vitamin D deficiency, and sickle cell disease, who was admitted for pyelonephritis, and found to have elevated blood lead level (BLL) of 103.7 µg/dL, and who subsequently developed altered mental status and syndrome of inappropriate antidiuretic hormone secretion (SIADH). In consultation with Medical Toxicology, the patient was chelated with calcium disodium edetate (EDTA) and British Anti Lewisite (BAL). The patient's hyponatremia was managed with hypertonic saline infusion. The patient's encephalopathy improved throughout her hospital course, and she was discharged on hospital day 8. Following five …

Association Of New And/Or Progressive Multiple Organ Dysfunction Syndrome With Mortality And New Morbidity Among Children Encountering Septic Shock, Rachel L. Waworuntu

Capstone Experience: Master of Public Health

Despite reductions in sepsis mortality, there remains a substantial morbidity burden among children who survive sepsis. Furthermore, the majority develop multiple organ ‘group has historically been analyzed as a single cohort. Using the Life After Pediatric Sepsis Evaluation (LAPSE) investigation database, we studied the association of new and progressive multiple organ dysfunction syndrome (NPMODS) with morbidity and mortality among children with septic shock. We hypothesized that NPMODS represents a distinct phenotype based on evolving organ dysfunction. There was evidence of an association but it did not reach the 0.05 level of significance. We also hypothesized and confirmed that children with …

A Rare Presentation Of Bilateral Bochdaleck Congenital Diaphragmatic Hernia, A Case Study, Manuel Britto, Sean Michael, Sofia I. Cartaya, Bernard Alfredo Cartaya

HCA Healthcare Journal of Medicine

Introduction

Congential diaphragmatic hernias (CDH) are a rare process that have a prevalence of 1–4 cases per 10,000 live births, and of these, bilateral Bochdalek congenital diaphragmatic hernias are even rarer entities that occur in about 1% of cases. This finding is rarely documented in literature. This paper offers a detailed methodical timeline documentation of the events that occurred after delivery and includes how to approach the diagnosis and management of such a rare and volatile condition.

Presentation

The neonate was born at 35 weeks and 6 days gestation. Unfortunately, despite intensive cardiopulmonary resuscitation efforts, the neonate expired within less …

A New Paradigm: Ecmo Therapy In Pediatric Hematology/Oncology Patients, Igor Areinamo

Research Days

Background: The use of extracorporeal membrane oxygenation (ECMO) for support of pediatric patients has significantly increased in the past years. Patients with known oncologic diseases, immunodeficiencies, or bone marrow transplants (BMT) have traditionally not been considered candidates for Extracorporeal membrane oxygenation (ECMO) due to perceived high risk for mortality. Ongoing advances have continued to push the boundaries of ECMO use and we report our recent experience with this patient population

Objectives/Goal: To evaluate survival to discharge of pediatric patients who require ECMO support and who also have an underlying hematologic or oncologic disease process. To determine specific patient characteristics that …

Multimodal Pain Control In Common Neonatal Surgeries: Post-Operative Pain Protocol Reduces Opiate Exposure And Side Effects, Jamesia Donato

Research Days

Background: Opioids are the primary post-operative (post-op) analgesic in neonates. Side effects include hypotension, apnea and ileus. Previous studies show IV acetaminophen decreases opiate need in specific populations including cleft palate repair, cardiac surgery. The effect of IV acetaminophen as part of a post-op pain algorithm is not known in common neonatal surgical procedures.

Objectives/Goal: To determine if (a) a post-op pain algorithm including IV acetaminophen and (b) IV acetaminophen exposure reduces cumulative opioid requirements in neonates undergoing common surgeries in the NICU.

Methods/Design: This is a retrospective cohort study comparing cumulative post-operative opiate exposure between infants with common surgeries …

Pediatric Pulmonary Artery Aneurysms Causing Pulmonary Hemorrhage: A Case Of Transcatheter Intervention While On Va Ecmo Support, Igor Areinamo

Research Days

Background: The incidence of pulmonary artery aneurysm (PAA) in children remains unknown. There are few reports of a transcutaneous interventional approach to address this type of pathology. Management of PAAs while on VA ECMO has not been described in pediatrics.

Objectives/Goal:

Methods/Design:

Case: 9-year-old previously healthy male presented with MRSA associated ARDS and sepsis requiring urgent VA ECMO cannulation. Chest CT done on ECMO day 22 showed development of right sided PAAs. Patient had an episode of significant pulmonary hemorrhage. Angiogram demonstrated two fusiform right PAAs, one of which had ruptured and was bleeding into the lung parenchyma. Patient had …

Local Implementation And Standardization Of The Pediatric Severe Traumatic Brain Injury Guidelines, Michelle Brown

Research Days

Problem Statement/Question: Severe pediatric Traumatic Brain Injury (TBI) remains a significant cause of morbidity and mortality. Evidence-based guidelines leave gaps in how to best implement and deliver standardized care on the local hospital level.

Background/Project Intent (Aim Statement): We aim to improve clinical outcomes for severe TBI patients (Glasgow Coma Scale ≤8) with standardization of care according to updated evidence-based guidelines. We will target early guideline adherence (initial 72 hours of PICU admission) with a focus on 1) targeted temperature management (TTM40mmHg).

Methods (include PDSA cycles): The Children’s Mercy Hospital Pediatric ICU Severe TBI Guidelines were updated after the 3rd …

C-Reactive Protein Values To Predict Sepsis-Induced Inflammatory Response In Premature Infants, Megan H. Tucker

Research Days

Background: C-reactive protein (CRP) is an inflammatory marker that has been recognized as a biomarker of the systemic inflammatory response in preterm neonates. We hypothesized that initial and peak CRP values would correlate with the degree of sepsis-induced acute lung injury (ALI) as measured by the pulmonary severity score (PSS).

Objectives/Goal: 1) Determine if confirmed (CF) sepsis events are associated with higher initial and peak CRP values than rule out (RO) sepsis events. 2) Investigate if initial and/or peak CRP correlates with severity of sepsis-induced ALI as measured by the PSS.

Methods/Design: In this retrospective case control study, we included …

Educating Providers: Timely Post-Operative Pain Management In A Level Iv Neonatal Intensive Care Unit (Nicu), Jamesia Donato, Jamesia Donato

Research Days

Background/Project Intent (Aim Statement): NICU patients often encounter painful procedures and can have significant short and long-term consequences from inadequately treated pain. Ensuring adequate pharmacological and nonpharmacological pain management while minimizing associated risks is paramount. Our NICU is part of the Children’s Hospitals Neonatal Consortium “Erase Pain” collaborative to improve management of postop pain in neonates. SMART Aim: Increase the percentage of patients receiving acetaminophen within one hour after surgery to greater than 70% by July 2020.

Methods (include PDSA cycles): A multidisciplinary team developed pain treatment algorithms and postop order plans to standardize the approach to postop pain management. …

Pulmonary Severity Score As A Measure Of Sepsis-Induced Acute Lung Injury In Preterm Infants, Megan H. Tucker

Research Days

Background: Sepsis is the most common indirect cause of acute lung injury (ALI) in adult and pediatric patients, yet no studies have described this phenomenon in preterm infants. We hypothesize that sepsis-induced ALI occurs in neonates and increases the risk of bronchopulmonary dysplasia (BPD) in preterm infants.

Objectives/Goal: 1) To investigate whether late onset sepsis (LOS) and other systemic inflammatory diseases are temporally correlated with ALI as quantified by pulmonary severity score (PSS) trajectory. 2) To determine the sepsis subtypes associated with the greatest severity of ALI.

Methods/Design: We included infants < 31 weeks gestational age and < 1500 grams with LOS in this retrospective case control study. The PSS was calculated at 72, 48, and 24 hours (hr) prior to, at the time of, and 24, 48, 72, and 168hr after sepsis diagnosis. We further defined rule out (RO) sepsis (blood culture negative; antibiotics continued only 48-72hr), blood culture positive (Cx+) sepsis, necrotizing enterocolitis (NEC), urinary tract infection (UTI), and culture negative (Cx-) clinical sepsis (blood culture negative; antibiotics continued > 6 days; specific lab criteria met). PSS trajectories for …

Utilization Of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage In Pediatric Patients On Ecmo, Gina Patel, Jenna Miller, Thomas M. Attard, Asdis Finnsdottir Wagner

Presentations

Background:

Incidence and management of Gastrointestinal (GI) bleeding on ECMO isn’t well reported Patients on ECMO require systemic anticoagulation making GI bleeding difficult to manage We describe the use of enteral tranexamic acid (TXA) in two pediatric patients with GI hemorrhage on ECMO

Utilization Of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage In Pediatric Patients On Ecmo, Gina Patel, Jenna Miller, Thomas M. Attard, Asdis Finnsdottir Wagner

Posters

Hemorrhagic and thrombotic complications on Extracorporeal Membrane Oxygenation (ECMO) support are associated with significant morbidity and mortality. There is a paucity of literature describing the incidence and management of Gastrointestinal (GI) bleeding on ECMO. We describe the use of enteral tranexamic acid (TXA) as an alternative strategy in two pediatric patients with GI hemorrhage on ECMO. Case 1 A 5-year-old with Wilms Tumor required Veno-Venous ECMO due to respiratory failure associated with pulmonary hemorrhage and air-leak syndrome. Her course was complicated by severe GI hemorrhage refractory to IV proton pump inhibitor (PPI), IV TXA and octreotide infusions. Concomitant IV TXA …

Recalibration Of The Renal Angina Index For Pediatric Septic Shock., Natalja L. Stanski, Hector R. Wong, Rajit K. Basu, Natalie Z. Cvijanovich, Julie C. Fitzgerald, Scott L. Weiss, Michael T. Bigham, Parag N. Jain, Adam Schwarz, Riad Lutfi, Jeffrey Nowak, Geoffrey L. Allen, Neal J. Thomas, Jocelyn R. Grunwell, Michael Quasney, Bereketeab Haileselassie, Lakhmir S. Chawla, Stuart L. Goldstein

Manuscripts, Articles, Book Chapters and Other Papers

Introduction: Sepsis-associated acute kidney injury (AKI) is a common diagnosis in children that is associated with poor outcomes. The lack of therapeutic options once present makes early identification of at-risk patients essential. The renal angina index (RAI) has been previously validated to predict severe AKI in heterogeneous populations of critically ill children. The performance of this score specifically in children with septic shock is unknown.

Methods: A secondary analysis of a multicenter, prospective, observational study of 379 children with septic shock to determine the ability of the RAI to predict severe AKI at day 3, and to assess for the …

“Ecmo In A Bag”: Successful Adaptation And Implementation Of A Novel Conference Idea, Johanna I. Orrick, Debra E. Newton, Kari L. Davidson, Jenna Miller, Alyssa Stoner

Posters

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) is an ever-evolving technical landscape that requires an advanced level of education. At our institution, a 367-bed pediatric teaching and research facility, learners include registered nurses, registered respiratory therapists, advanced practice registered nurses, resident physicians, pediatric and neonatal intensive care physicians. A certification class followed by an advanced course covers ECMO diagnoses, complications, equipment, and management prior to providing care for ECMO patients in our institution. Educational strategies include high and low fidelity simulations, didactic learning, and clinical hours at the bedside. A desire to increase the experiential learning opportunities was identified as an ECMO …

Optimizing A Pediatric Dka Protocol In A Tertiary Care Hospital System In Northern West Virginia, Jennifer L. Burky

Graduate Theses, Dissertations, and Problem Reports (ETD)

Background: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body compensates for insufficient insulin, producing dangerously high levels of ketones. Without proper treatment, DKA can be fatal. For that reason, staff in the pediatric intensive care unit (PICU) at a tertiary care hospital in northern West Virginia expressed concerns about the complexity of and lack of adherence to a poorly referenced and dated DKA treatment protocol.

Objective: The purpose of this project was to assess the feasibility and sustainability of optimizing the DKA protocol in the PICU. The primary objective was to implement an updated, …

Neurally Adjusted Ventilatory Assist: Summation Of The Safety Proofs And Benefits, Landry Carneal

Williams Honors College, Honors Research Projects

Neurally Adjusted Ventilatory Assist (NAVA) is a mode of ventilation that is triggered by neither flow nor pressure but by the electrical activity of the diaphragm (Stein & Firestone, 2018, p. 227). NAVA puts ventilatory control into the hands of the patient and is often used in neonates who are more challenging to ventilate. Medical practitioners, however, are skeptical to put this mode of ventilation into practice with fear that neonates are neither strong enough nor capable to manage their own respiratory efforts without hypoventilation or damage to the lungs (Lubarsky et al., 2020, p. 3). Research shows that despite …

Performance Of Lung Ultrasound In The Diagnosis Of Pediatric Pneumonia In Mozambique And Pakistan, Amy Sarah Ginsburg, Jennifer L. Lenahan, Fyezah Jehan, Rubao Bila, Alessandro Lamorte, Jun Hwang, Lola Madrid, Muhammad Imran Nisar, Benazir Baloch, Naila Nadeem

Department of Paediatrics and Child Health

Introduction: Improved pneumonia diagnostics are needed in low-resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia. The objective was to compare LUS versus chest radiograph (CXR), and among LUS interpreters, to compare expert versus limited training with respect to interrater reliability.
Methods: We conducted a prospective, observational study among children with World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) chest-indrawing pneumonia at two district hospitals in Mozambique and Pakistan, and assessed LUS and CXR examinations. The primary endpoint was interrater reliability between LUS and CXR interpreters for pneumonia diagnosis among children with WHO IMCI …

Accuracy Of Rn Visual Quantification Of Emesis Volumes In The Neonatal Intensive Care Unit, Stephen Stoever

Seton Hall University DNP Final Projects

An important component of nursing assessment of feeding tolerance in the neonatal intensive care unit (NICU) for both low-risk and high-risk babies, is the quantification of emesis volumes. While some nurses attempt to weigh the items saturated in emesis in order to quantify volume loss (QEV), there is no or limited consistency in this practice across nurses in this unit. Rather, volumes are “best-guessed” or estimated (EEV) and reported to the practitioner for decision-making. Often feed advances are paused or limited due to perceived feeding intolerance connected to emesis events in neonates.

For this project, 158 NICU nurses at a …

Moral Distress To Moral Courage, A Pathway To Success For Resident Nurses, Melinda Furrer

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No abstract provided.

Not All Free Air In The Nicu Is Necrotizing Enterocolitis., Paul Holtrop, Paras Khandar, Nathan Novotny

Articles

When a tiny preterm baby in our neonatal intensive care unit (NICU) has an intestinal perforation, it is always necrotizing enterocolitis (NEC), right? Not so fast, my friend. Many of these preterm infants who perforate have free air from spontaneous intestinal perforation (SIP) and not NEC. As it turns out, not all free air in the NICU is NEC. How can you tell the difference and does it matter?

It can be challenging to tell the difference, but SIP tends to occur earlier in life, often within the first week, whereas NEC usually occurs slightly later. One analysis of a …

Idiopathic Pulmonary Hemosiderosis - A Rare Cause Of Chronic Anemia, Ayesha Butt, Rashida Ahmed, Muhammad Dawood Amir Sheikh, Omar Khan, Nousheen Iqbal, Arshalooz Rahman, Javaid Khan

Medical College Documents

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease marked by alveolar bleeding and accumulation of hemosiderin in the lungs. Here we present three cases of IPH. The first case is of a 26-year-old male with anemia, hemoptysis and dyspnea. Bronchoscopy confirmed diffuse alveolar hemorrhage (DAH). A diagnosis of IPH was made after ruling out other causes of DAH and observing good response to steroids. The patient's condition improved with prednisolone and azathioprine. The second case is of 26-year-old female with severe anemia. Imaging suggested IPH and lung biopsy confirmed it. She died shortly afterwards. The third case is of a …

Isolated Polymorphic Ventricular Tachycardia: An Unusual Presentation Of Acute Myocarditis, Natalie S. Shwaish

Research Days

No abstract provided.