AAP Section on Critical Care Scientific & Educational ... · Adjusting for severity of illness with...

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Note: Meeting rooms are subject to change. Double-check onsite.

AAP Section on Critical Care Program Schedule

SUNDAY, OCTOBER 3, 2010

8:00 AM – 6:00 PM (H2016)

SAN FRANCISCO MARRIOTT MARQUIS – ROOM GOLDEN GATE B-C

Section on Critical Care Scientific Abstract, Educational Program & Reception The morning session will include presentation of scientific research abstracts, posters, professor walk rounds, and audience

discussion of important topics in pediatric critical care. The afternoon session will examine the changes affecting the

education of residents and fellows such as impact of duty hours in the PICU and use of simulation, as well as teach non-

clinical skills for improving the educational process, and will include a panel discussion. The program will conclude with

presentation of the SOCC Distinguished Career Award and a reception for Section members to include a business meeting,

presentation of abstract awards – physician, nursing, and in-training – as well as plenty of time to meet faculty and network

with colleagues.

SECTION ON CRITICAL CARE SCIENTIFIC ABSTRACT PRESENTATION SESSION

8:00 – 8:15 am Introduction: John Straumanis, MD, FAAP

8:15 – 9:30 am Abstract Session I Moderators: John Straumanis, MD, FAAP & Mary Lieh-Lai, MD, FAAP

1. 8:15 am #11772 Kristina Deeter, MD, FAAP

How a Little Sedation Protocol Can Have a Big Impact On a Pediatric Intensive Care

Unit

2. 8:30 am #11489 H. J. Ladd, MD

Neutrophil Aldose Reductase Expression in Pediatric Acute Lung Injury and Acute

Respiratory Distress Syndrome

3. 8:45 am #10923 Richard B. Mink, MD, FAAP

Reliability and Validity of Measurement Instruments to Assess Pediatric Resident

Airway Skills

4. 9:00 am #10393 M. Hossein Tcharmtchi, MD, FAAP

Impact of Duty Hour Limits On Attending Physicians; Effects of Accreditation Council

for Graduate Medical Education Duty Hour Limits On Intensive Care Unit Attending

Physician Fatigue, Work Hours, Self-Reported Errors, and Patient Safety

5. 9:15 am #10656 Treva C. Ingram, MD

Position 16 Polymorphisms in the ADRB2 Gene in Hospitalized Pediatric Patients

9:30 – 10:30 am Poster Walk Rounds & Coffee Break Moderators: Alice Ackerman, MD, MBA, FAAP & Richard Salerno, MD, MS, FAAP

1. #9900 William van Beever, DO

Palliative Balloon Dilatation of Cor Triatriatum in An Adolescent Athlete

2. #9419 Sonal R. Chandratre, MD

Variations in Management of Diabetic Ketoacidosis Amongst Pediatricians and Sub-Specialists in United

States



3. #9750 Chur Chin

Gold Nanoparticle-Choline Complexes Can Block Nicotinic Acetylcholine Receptors

4. #9866 Ulka Kothari, MBBS

Hypertonic Saline for Cerebral Edema in Diabetic Ketoacidosis

5. #10878 J. Caplow

Non-Invasive Assessment of Changes in Cardiac Output in Ambulatory Infants Hospitalized with

Bronchiolitis

6. #10927 Adalberto Torres Jr, MD, MS, FAAP

Prolonged Administration of Dexmedetomidine in Infants After Cardiac Surgery

7. #10123 K. Sarah Hoehn, MD, FAAP

Despite Less Trust and More Mistrust, African American Parents in the PICU Report No Differences in

Satisfaction with Communication

8. #11503 Ruifang Xu, MD

Highly Successful Bedside Transpyloric Feeding Tube Placement by Nursing Staff in the Pediatric

Intensive Care Patients

9. #11559 Jonathan Byrnes, MD, FAAP

Hemolysis Is Increased In Cardiac Extracorporeal Life Support With Roller-Head Pumps As Compared to

Centrifugal Pumps

Note: Posters should be set up between 7-8am on Sunday, October 3 and removed by

6pm the same day. Any poster materials left in the room at the conclusion of the

SOCC program on Sunday will be discarded.

10:30 – 12:00 pm Abstract Session II Moderators: Donald Vernon, MD, FAAP & Edward Conway Jr., MD, MS, FAAP

6. 10:30 am #9175 Sheila J. Hanson, MD, MS, FAAP

Incidence and Risk Factors for Venous Thromboembolism in Critically Ill Children with

Cardiac Disease

7. 10:45 am #11718 Barry Markovitz, MD, MPH, FAAP

Severity-Adjusted Mortality and PICU Volume: Role of Reason for Admission

8. 11:00 am #11650 Mayer Sagy, MD, FCCM, FCCP, FAAP

Utilizing a Pediatric Disaster Coalition to Develop Guidelines for Increasing the Overall

Pediatric Critical Care Surge Capacity of a Large City

9. 11:15 am #11062 Marilyn M. Kioko, MD

Using High-Fidelity Simulation to Assess the Efficacy of the Broselow-Luten Software

in the Resuscitation of Critically-Ill Pediatric Patients

10. 11:30 am #9109 Maria Marchenko, MD, FAAP

The Effect of Sevoflurane Exposure On RSV Infection in Mice




SUNDAY, OCTOBER 3, 2010

1:00 PM – 6:00 PM (H2016)

SAN FRANCISCO MARRIOTT MARQUIS, ROOM GOLDEN GATE B-C

SECTION ON CRITICAL CARE EDUCATIONAL SESSION

Education in the PICU: Teaching the Next Generation

1:00 – 1:10 pm Introduction

John Straumanis, MD, FAAP

1:10 – 2:00 pm Duty Hours: Do we have time to teach?

Mary Lieh-Lai, MD, FAAP

2:00 – 2:50 pm Simulation: Is it the answer?

Louis P. Halamek, MD, FAAP

2:50 – 3:10 pm Coffee Break

3:10 – 4:00 pm Professionalism: How do we teach it?

Richard Mink, MD, FAAP

4:00 – 4:30 pm Panel Discussion

4:30 – 5:00 pm Presentation of Distinguished Career Award 2010

Recipient: M. Michele Moss, MD, FAAP

5:00 – 6:00 pm SOCC RECEPTION

(Room Yerba Buena Salon 14)

Business Meeting, Awards Ceremony

Best Abstract, Best Nursing Abstract, In-Training Abstract




MONDAY, OCTOBER 4, 2010

8:30 AM – 12:00 AM (H3024)

SAN FRANCISCO MARRIOTT MARQUIS – ROOM GOLDEN GATE A-B

Joint Section on Critical Care, Cardiology and Cardiovascular Surgery, Emergency Medicine,

and Hospital Medicine Program: Resuscitation Controversies 2010 This is a multi-section joint program designed to update cardiologists, intensivists, hospitalists, pediatricians, and

emergency medicine physicians on important new clinical recommendations from the American Heart Association (AHA)

on cardiopulmonary resuscitation (CPR). Topics to be included are the physiology of CPR, use of hypothermia,

controversies of vasopressin versus epinephrine, goal directed therapy in shock, and CPR in children with congenital heart

disease. The rationale of changes in the AHA Pediatric Advance Life Support to these topics will be discussed including the

evidence based grading used to evaluate the literature.

JOINT SECTION ON CRITICAL CARE, CARDIOLOGY, EMERGENCY & HOSPITAL MEDICINE

EDUCATIONAL SESSION

Resuscitation Controversies 2010: American Heart Association Guideline Revisions

8:30 – 8:35 am Introduction

John Straumanis, MD, FAAP

8:35 – 9:05 am The Physiology of CPR: How does it work?

Marc D. Berg, MD, FAAP

9:05 – 9:40 am Hypothermia: To chill out or not?

Ericka Fink, MD, FAAP

9:40 – 10:15 am Ventilation and CPR: Do we go straight to “C”?

Marc D. Berg, MD, FAAP

10:15 – 10:30 am Coffee Break

10:30 – 11:05 am Goal Directed Therapy for Resuscitation: Where's the end zone?

Todd Kilbaugh, MD, FAAP

11:05 – 11:40 am Resuscitation in Congenital Heart Disease: Is it different if they are supposed to be

blue? Brad Marino, MD, FAAP

11:40 – 12:00 pm Panel Discussion

All speakers



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________________________________________________________________

1. (11772) How a Little Sedation Protocol Can Have a Big Impact On A Pediatric Intensive Care

Unit

Kristina Deeter, MD, FAAP,1 Mary A. King, MD, MPH,

2 Jerry J. Zimmerman, MD, PhD, FCCM.

2 1Pediatric Critical Care

of South Florida, Joe DiMaggio Children's Hospital, Hollywood, FL; 2Pediatric Critical Care Medicine, Seattle Children's

Hospital, Seattle, WA 98015

Purpose: To compare a nursing-driven comfort protocol with traditional practice for mechanically ventilated pediatric

patients. Our hypothesis was that a sedation protocol would minimize the morbidities associated with PICU admission by

decreasing length of stay, days of mechanical ventilation, and exposure to potentially harmful analgesics and sedatives.

Methods: Study was conducted in a university-affiliated, 31-bed, tertiary care medical-surgical PICU in a metropolitan

children's hospital. Pediatric patients aged 0 to 21 years requiring mechanical ventilation for longer than 48 hours were

screened for exclusion criteria (severe neurologic injury or seizure disorder, transfer from another institution on sedatives,

paralytic infusion, tracheostomy placement, ECLS, or death during admission). Traditional group included patients

admitted during the 12-month period prior to protocol implementation (n=153). Protocol group included patients admitted

during the 12 months following protocol implementation (n=166). Data was gathered retrospectively for both the traditional

cohort and protocol cohort.

Results: The median duration of total sedation days (intravenous + enteral) was 5 days for the protocol group and 7 days for

the traditional group (p=0.026). Specifically, the median duration of morphine infusion was 5 days for the protocol group

and 6 days for the traditional group (p=0.015) whereas the median duration of lorazepam infusion was zero days for the

protocol group and 2 days for the traditional group. We were unable to detect a significant difference between patient age,

gender, percentage surgical or PRISM score between groups. Adjusting for severity of illness with PRISM score, simple

linear regression analysis demonstrated that being on protocol was significantly associated with on average 4.1 fewer total

sedation days (95% CI: -7.7 to -0.5, p=0.026), 1.7 fewer days of mechanical ventilation (95% CI: -3.3 to -0.1, p=0.037), and

a 2.5 day shorter PICU length of stay (95% CI: -4.9 to -0.2, p=0.036).

Conclusion: A pediatric sedation protocol can significantly decrease days of both intravenous and enteral benzodiazepine

and opiate administration, duration of mechanical ventilation and length of stay in the pediatric intensive care unit.



2. (11489) Neutrophil Aldose Reductase Expression in Pediatric Acute Lung Injury and Acute

Respiratory Distress Syndrome

H. J. Ladd, MD,1 T. M. Ravindranath,

1 Q. Wang,

2 R. Ananthakrishnan,

3 P. Mong,

2 R. Ramasamy,

3 J. S. Baird,

1 1Department

of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY; 2Mount Sinai School of Medicine;

3Department of Surgery, Columbia University College of Physicians & Surgeons.

Purpose: Aldose reductase (AR) catalyzes the first and rate-limiting step of the polyol pathway. Increased AR expression is

associated with chronic inflammation, especially in the presence of chronic hyperglycemia. A recent animal study suggests

that AR may also be involved early in acute lung injury (ALI). We hypothesized that AR expression in peripheral blood

neutrophils is increased early after the onset of respiratory failure in children with ALI or acute respiratory distress

syndrome (ARDS) compared to children without lung injury.

Methods: Pediatric patients with acute respiratory failure (<24 hours of mechanical ventilation) were enrolled in a minimal

risk, IRB-approved study from 10/2008 to 3/2010. ALI and ARDS were defined using the criteria from the American-

European Consensus Conference on ARDS (AJRCCM 1994). AR expression in peripheral blood neutrophils was measured

by Western blot and correlated with markers for severity of ALI and ARDS (i.e.: peak PaO2/FiO2, peak oxygenation index

[OI], length of mechanical ventilation, and survival).

Results: 15 patients (age: 8 mo to 18 yrs; mean: 7 ± 6 yrs) were enrolled; 2 had ALI (both subsequently developed ARDS),

and 2 had ARDS, while 7 patients had sepsis (including 1 with ALI and both patients with ARDS). Four patients had

measurable AR expression, 2 of whom had very high levels compared to all other patients: all 4 had sepsis, and 1 also had

ARDS (Table 1). There was no correlation between neutrophil AR expression and peak PaO2/FiO2 (p=0.5), peak OI

(p=0.39), or length of mechanical ventilation (p=0.93). Thirteen patients survived, including all those with ALI, ARDS, and

sepsis.

Conclusion: AR expression in neutrophils was not increased early in most children with ALI or ARDS in this small series,

and did not correlate with the severity of lung injury. AR expression was increased in most children with sepsis. The role of

AR expression in pediatric sepsis deserves further investigation.

Age Gender Clinical Diagnosis* AR expression

5 years male sepsis +++

22 months male sepsis, ARDS +++

8 years male sepsis +

15 years female septic shock +

Table 1. Characteristics of the 4 patients with elevated aldose reductase expression.

*Sepsis and septic shock defined using criteria from International Sepsis Definitions Conference (CCM 2003)

________________________________________________________________

3. (10923) Reliability and Validity of Measurement Instruments To Assess Pediatric Resident

Airway Skills

Richard B. Mink, MD, FAAP,1 Nicole Baier, MD,

1 Chris Babbit, MD,

2 Esther An, MD,

3 Khanh-Van Le-Bucklin, MD,

4 Tom

Kallay, MD.1 1Pediatric Critical Care, Harbor-UCLA Medical Center, Torrance, CA;

2Pediatric Critical Care, Miller

Children's Hospital, Long Beach, CA; 3Pediatrics, Harbor-UCLA Medical Center, Torrance, CA;

4Pediatrics, University of

California, Irvine, Orange, CA.

Purpose: Residency programs are required to teach Pediatric Residents airway skills, including the ability to intubate.

However, there is concern that this requirement is not being met due to reduced opportunities for intubation by residents

resulting from changes in medical practice and reduced work hours. Some institutions are now using other means to teach

airway skills such as simulation and airway courses. However, the efficacy of these methods cannot be reliably determined



without validated methods of assessment. We developed measurement instruments to appraise the knowledge, skills and

attitude of pediatric resident airway skills. The purpose of this study was to evaluate the internal reliability and construct

validity of these instruments.

Methods: The assessments included two tests of airway knowledge (15 multiple choice questions and 2 case scenarios),

checklists to assess bag-mask ventilation (7 items) and intubation (11 items), and a confidence questionnaire (5 questions).

Internal reliability and construct validity were determined by administering the instruments to 3rd

year medical students,

pediatric residents and pediatric critical care medicine attendings. Reliability was assessed by using Cronbach's alpha and

validity by a stepwise comparison of group scores using the Kruskal-Wallis test and Mann-Whitney U. Data are median

(25th -75th percentile).

Results: Internal reliability was excellent ranging from 0.68 to 0.99 (table). For knowledge (figure) and confidence, there

was a significant difference (p<0.05) between the scores of medical students and residents. For skills, 3rd

year residents

performed better (p<0.05) compared with those in their 1st year.

Conclusion: These measurement instruments showed excellent reliability and validity. They will be useful in assessing

resident airway skills and in the determining the efficacy of new programs devised to teach these skills.

RELIABILITY

Measurement Cronbach's α

Knowledge: Multiple Choice Questions 0.88

Knowledge: Case-Based Questions 0.68

Confidence: Questionnaire 0.99

Skill: Bag-Mask Ventilation 0.73

Skill: Intubation 0.74



4. (10393) Impact of Duty Hour Limits On Attending Physicians; Effects of Accreditation

Council for Graduate Medical Education Duty Hour Limits On Intensive Care Unit

Attending Physician Fatigue, Work Hours, Self-Reported Errors, and Patient Safety

M. Hossein Tcharmtchi, MD, FAAP,1 Katri V. Typpo, MD, MPH,

2 Eric J. Thomas, MD, MPH,

3 Leticia Castillo, MD,

4 P.

Adam Kelly, PhD, MBA,5 Hardeep Singh, MD.

5 1Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine,

Texas Children's Hospital, Houston, TX; 2Pediatrics, Section of Critical Care Medicine, University of Arizona, Tucson, AZ;

3Memorial Hermann Center for Healthcare Quality and Safety, The University of Texas, Houston, TX;

4Pediatrics, Division

of Critical Care Medicine, UT Southwestern, Dallas, TX; 5Medicine-Health Services Research, Baylor College of Medicine,

Houston, TX.

Purpose: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour limits

commonly referred to as the “80/30 rules,” for resident-physicians in an effort to reduce the risks of fatigue-related and

preventable medical errors. Our study seeks to determine if there are unanticipated adverse consequences such as increased

rates of attending physician fatigue and errors as a result of current or further reductions in resident physician duty hours

which might negatively impact patient safety.

Methods: We administered an anonymous 26 item web-based survey nationally to all attending physicians who provide

coverage in the PICU, NICU, and CVICU in fellowship programs to determine attitudes and perceptions regarding the

impact of residency work hour rules on attending physician fatigue, error rates, and overall patient safety. We pilot tested the

survey to evaluate question performance amongst the 17 Pediatric Critical Care physicians at Texas Children's Hospital in

the Department of Pediatrics, Section of Critical Care Medicine. Physicians who were familiar with the survey/study or part

of the investigative team were excluded from the distribution list. The providers received an email message to complete an

anonymous web-based survey as well as a reminder email 2 weeks after the initial email.

Results: The survey was distributed nationally to 687 ICU attending physicians. The response rate to initial survey and

subsequent reminder was 32.1 and 45.6 % respectively. Of respondents, 59.3% worked in NICU, 37.4% in PICU and 13.6%

in CVICU. Most have seen either no improvement or some worsening in patient safety (84%) and resident error rates (94%)

with current work hour rules; however, approximately 2/3 perceived that residents are less fatigued. In contrast, 56.7% of

respondents felt to be more fatigued with current regulations, 42.9% perceived no change. In regards to further reduction in

duty hours; the respondents do worry that their own hours and fatigue will increase 74.5% and 78.8% respectively. In

addition, 42.8% of respondents felt that error rates will increase with further reduction in duty hours while 54% thought that

it will worsen patient safety culture in ICU.

Conclusion: Attending physicians in the NICU, PICU, and CVICU perceive that resident physician duty hour limits have

not improved patient safety and error rates in the ICU setting although resident physicians seem less fatigued. In addition,

attending physicians perceive that duty hour restrictions may have worsened attending physician fatigue. Many of the

attending physicians think that error rates will increase with further duty hour restrictions negatively impacting patient

safety.

________________________________________________________________

5. (10656) Position 16 Polymorphisms in the ADRB2 Gene in Hospitalized Pediatric Patients

Treva C. Ingram, MD,1 Toni M. Petrillo, MD, FAAP,

1 Deidre Crocker, MD,

2 Mark R. Rigby, MD, PhD.

1 1Pediatric Critical

Care, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA; 2Pediatrics, Medical

College of Georgia, Augusta, GA.

Purpose: Asthma is a leading cause of chronic illness, hospital admission and preventable death in children. It strikes all

races, yet African-Americans have significantly higher emergency room visits, hospitalizations and asthma related deaths

than other racial groups. The contribution of genetics vs. socio-economic factors for this disparity is unclear. The beta-2

adrenergic (ADRB2) receptor is found on a variety of cell types in the lung, including smooth muscle and endothelial cells.

The identification of structural differences of this receptor supports the concept that molecular polymorphisms may

influence disease severity and/or responsiveness to therapy. For example, there is currently conflicting data on whether an

amino acid substitution of the Arg (R)→ Gly (G) at position 16 is associated increased severity. There is also speculation

that this increase severity is associated with poor response to albuterol. We sought to investigate if patients with an R at



position 16 (as a homo- or hetero-zygote) were associated with increased illness severity during acute asthma flair as

assessed by initial hospital placement in the ICU vs. general ward or hospital length of stay (LOS).

Method: Cheek swabs were collected on patients 3–21 years with a previous history of physician-diagnosed asthma

admitted to a children’s hospital. DNA was isolated from the swab and subjected to PCR to identify position 16 amino acid

and recoded as Arg homozygous (R/R), heterozygous (R/G) or Gly homozygous (G/G). Data on level of care (i.e. ICU vs

ward admission), therapy used, history and demographics were collected.

Results: Definitive genetic analysis was obtained from 26 patients, 18 admitted to the ICU and 8 to the ward. The genotype

of patients is summarized below.

Amino acids position 16 of ADRB2 ICU (n=18) Ward (n=8)

R/R 5 (28%) 2 (25%)

R/G 9 (50%) 3 (38%)

G/G 4 (22%) 3 (38%)

Of patients who were originally admitted to the ICU 14 of 18 (78%) had at least one R containing allele; whereas 5 of 8

(62.5%) of patients with at least one R were admitted originally to a hospital ward (p = 0.6 via Fishers Exact Test). Median

LOS was 3 days for those patients with at least one R containing allele and 2 days for homozygous (G/G) which was found

not to be statistically significant.

Conclusion: This small cohort of patients suggests that R at position 16 in the ADRB2 receptor dose not predict initial

asthma flair acuity as assessed by admission placement or LOS. Continuation of this study will investigate the influence of

these polymorphisms on ER admission, hospital admission and acute care outcome of children of different races with

asthma exacerbations. This study will assist in determining how genetic factors may affect asthma severity and therapeutic

responsiveness in pediatric asthma.

________________________________________________________________

6. (9175) Incidence and Risk Factors for Venous Thromboembolism in Critically Ill Children

with Cardiac Disease

Sheila J. Hanson, MD, MS, FAAP,1 Rowena C. Punzalan, MD,

2 Nancy S. Ghanayem, MD,

1 Melissa Christensen, BS,

1

Evelyn M. Kuhn, PhD,3 Peter L. Havens, MD, MS.

4 1Pediatrics, Critical Care Section, Medical College of Wisconsin and

Children's Hospital and Health System, Milwaukee, WI; 2Pediatrics, Hematolgy Section, Medical College of Wisconsin,

Children's Hospital and Health System, and Blood Center of Wisconsin, Milwaukee, WI; 3Outcomes Department, Children's

Hospital and Health System, Milwaukee, WI; 4Pediatrics, Infectious Disease Section, Medical College of Wisconsin and

Children's Hospital and Health System, Milwaukee, WI.

Purpose: To determine the incidence and risk factors for developing venous thromboembolism (VTE) in critically ill

children with cardiac disease.

Methods: Children with cardiac disease admitted to a tertiary care pediatric ICU (PICU) from April 2006 to June 2008,

were followed prospectively for clinically recognized VTE. Potential risk factors were compared for the cases developing

VTE to the next 3 sequentially admitted cardiac patients admitted to the PICU (1:3 case to control).

Results: Forty-one cases of VTE were identified from 1070 admissions; an incidence of 3.8%. Dichotomous variables

associated with unadjusted risk for VTE include inotrope use (p=.08, OR 2.1), arterial –somatic oxygen saturation gradient >

30 (p<.0001, OR 5.4), fluid bolus > 20cc/kg (p=.005, OR 4.1), cyanosis (p=.009, OR 2.6), presence of Blalock-Taussig

shunt (p=.009, OR 3.4), single ventricle physiology (p<.0001, OR 7.5), cardiac catheterization during hospitalization

(p=0.034, OR 2.3), bacteremia (p=.002, OR 7.2), physician diagnosed sepsis (p=.039, OR 2.4), chylous effusion (p<.001),

recombinant Factor 7a administration (p=.001, OR 6.3), parenteral nutrition (p<.0001, OR 10.8), deep sedation (p<.0001,

OR 4.0), and neuromuscular blockade (p<.0001, OR 11.7). Other variables associated with unadjusted risk for VTE include:

age < 30 days (41.5% cases vs. 12.2% for controls, p < 0.001), central venous line (CVL) number (median 3 cases vs. 1 for

controls, p<.0001), CVL days (median of 46 for cases vs. 2 for controls, p<.0001), and later initiation of enteral nutrition

(median 9 days for cases vs. 2 for controls, p<.001), History of previous clot or stroke was not a significant risk factor.

Patients who developed VTE were more likely to receive therapeutic anticoagulation during the PICU admission both prior

to VTE diagnosis (31.7% vs. 8.9% for controls, p=.0004), and concurrent with VTE diagnosis (17% vs. 2% for controls,

p=.0007). There was no difference in prophylactic anticoagulation use. After logistic regression, single ventricle physiology

(OR 11.2, 95% CI 2.98-41.89), and CVL days (OR 1.081, 95% CI 1.039-1.125) remained significant.



Conclusions: Critically ill children with cardiac disease are at increased risk for VTE. Risk factors identified are younger

age, cyanotic and single ventricle cardiac lesions, increased illness severity and complicated hospital course. Current

anticoagulation prophylaxis is not effective in preventing VTE in this population.

________________________________________________________________

7. (11718) Severity-Adjusted Mortality and PICU Volume: Role of Reason for Admission

Barry Markovitz, MD, MPH, FAAP, Robinder Khemani, MD, MsCI. Anesthesia Critical Care Medicine, Children's Hospital

Los Angeles, Los Angeles, CA.

Many areas of healthcare have a positive relationship between institutional volume and outcomes. Tilford (1) and Marcin (2)

have previously demonstrated modest relationships between PICU patient volume and severity-adjusted mortality rates. We

previously were unable to demonstrate a clear relationship between overall PICU volume and severity-adjusted mortality

(3).

Purpose: We hypothesized that there is an inverse relationship between PICU patient volume and severity-adjusted

mortality that relates to reason for admission to the PICU.

Methods: The VPS database (VPS, LLC) was queried for all patients discharged in 2005-2006. Anonymized data received

included PICU ID, reason for admission, ICU mortality, pediatric index of mortality 2 (PIM2) score. Average PICU

volume/quarter (VOL) was calculated as total discharges divided by the number of valid quarters (VPS sites submit data

quarterly) per PICU. VOL was then recoded as VOL-100 to measure the impact per 100 discharges per quarter. Several

multiple logistic regression models were performed to assess the impact of VOL-100 on severity-adjusted mortality filtering

for reason for admission. This study received a waiver as non-human research from the IRB at CHLA.

Results: From 32 PICU's, 64,188 patients were studied, with an overall ICU mortality rate of 3.1% and a mean PIM2 risk of

mortality of 3.1%. VOL ranged from 62 to 595. The three most prevalent reasons for admission were cardiovascular/shock

(17.4% of patients), respiratory distress/failure (31%) and neurologic compromise (21.6%). The table reports the odds ratios

(OR) with 95% confidence intervals (CI) for VOL-100 for all patients and by reason for admission; each represents

individual models of VOL-100 and PIM2 score. The PIM2 OR was 2.60 (95% CI 2.53, 2.68) for the all patients model and

varied little amongst the other analyses.

Conclusion: This preliminary analysis suggests that severity-adjusted PICU mortality relates to PICU volume only in

patients admitted with cardiovascular compromise or shock.

PIM2-adjusted risk of mortality per 100 discharges/quarter by reason for admission.

Category OR of mortality 95% CI

All patients 0.97 0.93, 1.01

Cardiovascular/shock 0.90 0.83, 0.97

Respiratory distress/failure 1.03 0.95, 1.11

Neurologic Compromise 0.98 0.87, 1.09

1. Tilford et al. Pediatrics 2000; 106:289-294. 2. Marcin et al. Pediatr Crit Care Med 2005; 6:136-141. 3. Markovitz et al.

Crit Care Med 2009; 37(12):A356

________________________________________________________________

8. (11650) Utilizing a Pediatric Disaster Coalition to Develop Guidelines for Increasing the

Overall Pediatric Critical Care Surge Capacity of a Large City

Mayer Sagy, MD, FCCM, FCCP, FAAP,1 Avram Flamm, B.EMS, EMT-P,

1 George Foltin, MD, FAAP, FACEP,

2 Bruce M.

Greenwald, MD, FCCM, FAAP,3 Edward E. Conway, MD, MS,

4 Michael Ushay, MD, Ph.D,

5 Vikas Shah, MD,

6 Katherine

Biagas, MD,7 Katherine Uraneck, MD,

8 Michael Frogel, MD, FAAP.

9 1Pediatric Critical Care Medicine, Steven and

Alexander Cohen Children's Medical Center, North Shore – Long Island Jewish Health System, New Hyde Park, NY; 2Center for Pediatric Emergency Medicine, NYU School of Medicine, Bellevue Hospital;

3Weill Cornell Medical College;

4Beth Israel Medical Center;

5Children's Hospital at Montefiore;

6Kings County Hospital Center;

7Columbia University,



College of Physicians and Surgeons; 8New York City Department of Health and Mental Hygiene;

9Pediatrics, Steven and

Alexander Cohen Children's Medical Center North Shore – Long Island Jewish Health System, New Hyde Park, NY.

Purpose: The Department of Health (DOH) has supported an initiative to create a Pediatric Disaster Coalition (PDC)

comprised of pediatric critical care and emergency preparedness consultants from major city hospitals and health agencies.

One of the PDC's goals was to develop and recommend guidelines for hospital-based pediatric critical care surge plans and

once fully implemented will increase the overall city's pediatric critical care bed capacity by at least 50%.

Methods: Members of the PDC convened bi-monthly over the course of 2008-2009. After reviewing relevant literature and

existing surge plans an outline of an evolving disaster scenario was developed and general guidelines for handling surge

issues generated (See table). Guidelines were combined with a scalable activation of communication protocols and response

strategies. Recommendations were presented at a DOH sponsored conference and revised using received feedback.

Results: Recommended guidelines for making additional Pediatric Critical Care (PCC) beds available included: 1. rapidly

transferring patients and/or discharging them; 2. preparing hospitals' floors to receive patients sicker than usual practice; 3.

increasing the number of beds per room or per floor space which may be accomplished by replacing existing beds with

smaller beds or stretchers with pre-organized equipment; and 4. converting hospitals' clinical and non-clinical spaces into

PICU environments. Two categories of communication protocols, for limited and extensive events, were developed. The

limited communication protocol involved activation of existing hospital's staff at the time of a disaster, whereas the

extensive communication protocol called for enlisting hospital's leadership and additional staff from home. Many of the city

hospitals' PCC programs are currently utilizing these guidelines to develop and implement their specific plans.

Conclusion: Utilization of a PDC was a successful model for development and implementation of citywide PCC surge

capacity planning. Once city hospitals complete their plans, the PDC will assist them in evaluating their plans by drills and

exercises, and will have effectively increased PCC surge capacity by at least 50%.

Evolving Scenario Guidelines

1. ED receives critically ill patients

Ø ED is overwhelmed

Ø Hospital has no beds

Ø Critically ill patients are constantly arriving.

1. ED receives help through

Ø Activating communication protocols

Ø Allocating additional ED space

Ø Transferring critical care staff to help in ED

2. The ED needs to rapidly manage and admit many

critically ill patients

2. More resources are made available to ED

Ø More critical care staff is enlisted

Ø More equipment and supplies are delivered

3. Despite ‘no bed situation' within the hospital,

patients must be admitted.

3. Specific recommendations:

Ø PICU: more patients per given spaces; consider

stretcher packets

Ø The floors: prepared to receive and manage sicker

patients

Ø Non-clinical areas: prepared to serve as PICU;

consider stretcher packets

________________________________________________________________

9. (11062) Using High-Fidelity Simulation to Assess the Efficact of the Broselow-Luten Software

in the Resuscitation of Critically-Ill Pediatric Patients

Marilyn M. Kioko, MD, Ashish O. Gupta, MD, Nagraj Kasi, MD, Sajad Khazal, MD, Rohit Pinto, MD, Adebayo Adeyinka,

MD, Louisdon Pierre, MD. Pediatrics, The Brooklyn Hospital Center, Brooklyn, NY.

Introduction: The utility of a crisis resource management (CRM) tool to quickly determine weight-based drug dosages in

the management of life-threatening pediatric emergencies is imperative. In a controlled setting, a computerized calculator

proves more accurate and efficient than conventional methods in calculating resuscitation requirements.

Purpose: The Broselow-Luten Pediatric System™ software (eBroselow™) is introduced as a replacement for our current

Microsoft Excel generated crisis management (code)sheet for enhanced efficiency during resuscitation efforts.



Methods: 2 crisis management teams consisting of 3 senior pediatric residents and 1 pediatric intensive care Unit

(PICU) nurse participated in clinical scenarios of common pediatric emergencies, directed by a pediatric intensivist trained

to use a high fidelity simulator (Simbaby™). The setting is a simulation lab within our institution that closely replicates the

PICU patient care area. A crisis management tool was randomly assigned to each scenario and all participants except the

team leader were blinded to the tool being used. Team performance was scored using The Ottawa Crisis Resource

Management Global Rating Scale1. Video recorded simulated scenarios were used for data collection and analysis. Scenarios

in which the team performed proficiently were included to determine the efficiency of the CRM tool used. A post-

participation survey was administered to participants to assess the usability of eBroselow as a CRM tool.

Results: Statistical analysis of 38 interventions from 5 scenarios showed average time to drug delivery was 30.2 s with

eBroselow compared to 31s when using the code sheet. Incidence in dose discrepancy were also similar (Code sheet: 2/16,

Broselow: 1/14). Interpretation of the usability survey suggests that although users reported eBroselow’s event-specific

classification of drugs useful, efficiency (e.g. wait time between screens) and memorability (i.e. user relies on recall rather

than recognition) were reduced. The product design had varied learnability with some users reporting difficulty in using the

software on the first encounter and limited proficiency on subsequent scenarios.

Conclusion: Preliminary results suggest that eBroselow when used by pediatric practitioners with proficiency in

resuscitation may not provide additional benefit over the current crisis resource management tool used in our pediatric

intensive care unit, however a larger data set would be required to validate these findings conclusively.

Reference: 1. The University of Ottawa Critical Care Medicine, High Fidelity Simulation, and Crisis Resource management

I Study. Crit Care Med 2006 Vol.34, No. 8

________________________________________________________________

10. (9109) The Effect of Sevoflurane Exposure on RSV Infection in Mice

Maria Marchenko, MD, FAAP,1 Robert C. Welliver, MD,

2 Mark S. Dowhy,

1 Paul E. Frisicaro,

1 Rita M. Ryan,

MD,3 Bradley P. Fuhrman, MD, FCCM.

1 1Department of Pediatric Critical Care, Women and Children's

Hospital of Buffalo, Buffalo, NY; 2Division of Infectious Diseases, Women and Children's Hospital of Buffalo,

Buffalo, NY; 3Division of Neonatology, Women and Children's Hospital of Buffalo, Buffalo, NY.

Purpose: Inhaled halogenated anesthetics have been used for general anesthesia for decades and for sedation in the pediatric

intensive care unit (PICU) sporadically. They also have anti-inflammatory effects in ischemia-reperfusion injury. We wished

to determine if the halogenated anesthetic, Sevoflurane, reduced inflammation in respiratory syncytial virus (RSV) infection,

a common viral infection requiring PICU admission.

Methods: We studied Sevoflurane in a mouse model of severe RSV infection using 4-week old New Zealand White mice.

Mice were randomized into 5 groups (Pretreatment, Postexposure treatment, RSV controls, Sevoflurane Controls and Sham

Controls). Animals assigned to treatment and Sevoflurane control groups were exposed to Sevoflurane at 1% for 1h either

before inoculation with RSV on day 0 (Pretreatment) or daily after inoculation (days 1-5 – Postexposure) with anesthetic

concentration monitored during exposure. Mice were weighed daily and observed for general appearance, behavior, and

mortality. Plethysmography was performed to determine respiratory rate and enhanced pause, or Penh. On day 3 or day 5

mice had tracheal cannulation under intraperitoneal anesthesia followed by sacrifice in CO2 chamber. Lung mechanics were

studied using FlexiVent, and lungs were processed for histology scoring. Samples were scored on a scale from 0 to 4 based

on the amount of infiltrates in lung tissue.

Results: In contrast to healthy-looking and active mice in the Sham and Sevoflurane Control groups, mice in the RSV-

infected groups had progressively decreased activity, labored breathing and wasting noticeable from day 3 (Table).

Mortality

abWeight change, %

from Day 0

Day 3 / Day 5

abPenh,

Day 0 /

Day 3 / Day 5

abCdyn, ml/cmH2O

Day 3 / Day 5

aMedian Histology

Score,

Day 3 / Day 5

Sevoflurane

Pretreatment 2 / 15 -12% / -23%

0.62 /

3.45 / 4.83 0.022 / 0.0094 3 / 3

Sevoflurane

Postexposure 2 / 20 -12% / -26%

0.58 /

3.41 / 5.44 0.020 / 0.011 3 / 4



RSV controls 1 / 25 -13% / -23% 0.71 /

3.62 / 4.91 0.018 / 0.011 3 / 4

Sevoflurane Controls 0 / 10 0% / 4% 0.58 /

0.49 / 0.48 0.033 0

Sham Controls 0 / 10 2% / 9% 0.60 /

0.85 / 0.59 0.031 0

ap<0.05 for RSV vs. non-RSV infected mice and

bfor day 3 vs. day 5

RSV-infected mice in all groups, including Sevoflurane treatment groups, demonstrated significantly greater weight loss,

increased Penh, decreased dynamic compliance (Cdyn) and higher histology score than controls.

Conclusion:The NZW mouse is an excellent model for severe RSV disease. Sevoflurane exposure at 1% for 1h did not

produce clinical benefit in our model. Longer exposure time or a different halogenated anesthetic may be more effective in

decreasing inflammation in RSV infection.



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NNaattiioonnaall CCoonnffeerreennccee && EExxhhiibbiittiioonn PPoosstteerr WWaallkk RRoouunnddss OOccttoobbeerr 33--44,, 22001100 SSaann FFrraanncciissccoo,, CCAA ___________________________________________________________________________________________

1. (9900) Palliative Balloon Dilatation of Cor Triatriatum in an Adolescent Athlete

William van Beever, DO,1 Carl Owada, MD,

2 Paul Francis, MD,

2 Narakesari Heragu, MD,

2 Edwin Petrossian, MD,

3 Kelly

Thorson, RDCS,4 Ana Lia Graciano, MD, FAAP.

5 1Pediatrics, UCSF-Fresno, Fresno, CA;

2Cardiology, Childrens Hospital

Central California, Madera, CA; 3Cardiothoracic Surgery, Childrens Hospital Central California, Madera, CA;

4Cardiology, Echocardiography, Childrens Hospital Central California, Madera, CA;

5Pediatrics Critical Care Medicine,

Childrens Hospital Central California, Fresno, CA.

Introduction: Cor triatriatum is a rare congenital heart disease (0.1-0.4% of all congenital cardiac anomalies). It is

characterized by a fibromuscular septum dividing the atrium into two chambers, an upper chamber that receives the

pulmonary veins and a lower chamber that is related to the left atrial appendage and the mitral valve orifice. Clinical

manifestations vary based on age of presentation and fenestration size. Treatment is surgical excision; however, palliative

balloon dilatation of the atrial membrane can play a roll in the management of this rare condition.

Case Report: A fifteen-year-old athletic male, with a history of "exercised induced asthma" presented to an outside

emergency room in respiratory failure and shock. The patient had a four-day history of cough, sore throat and low-grade

fever. Initial vital signs showed: temperature 38.5° C, heart rate140 bpm (sinus rhythm), blood pressure 80/40 mmHg and

oxygen saturations of 80% in room air. Chest radiograph showed bilateral pulmonary infiltrates. The patient received

intravenous fluid resuscitation, oxygen via a facemask and broad-spectrum antibiotics for suspected pneumonia and sepsis.

He was subsequently transferred to our center for further management. Upon arrival to the PICU the patient had markedly

increased work of breathing and hypotension. He also had an episode of hemoptysis. Fluid resuscitation was continued and

inotropic support was initiated. BiPAP was instituted with improvement in his work of breathing and oxygenation.

Echocardiogram was performed to assess cardiac function. Images revealed cor triatriatum sinister with significant

pulmonary venous inflow obstruction (figure 1). Pulmonary hypertension was noted with estimated right ventricular

pressures at 90% of the systemic pressure. Given the presumed respiratory tract infection and shock, surgery was deferred.

Under transesophageal echocardiogram guidance radiofrequency catheter perforation and balloon dilatation were

performed. This created a new opening in the membrane and relieved the severe left atrial hypertension (figure 2). Balloon

dilatation of the cor triatriatum was successful in relieving the mean proximal to distal LA diastolic gradient from 24mmHg

to 4mmHg. The patient was discharged from the PICU within 3 days and was discharged home 7 days after admission.

Discussion: Cor triatriatum sinister is a rare congenital heart disease with excellent outcomes when diagnosed and corrected

early. Management to date has been surgical excision. There are two published case reports of cor triatriatum treated with

balloon dilation. We believe balloon dilatation should be considered as a palliative option when total surgical repair is

contraindicated due to confounding factors such as sepsis and shock. We would propose that balloon dilatation may be an

adequate long-term alternative to surgical repair when done by an interventional cardiologist with expertise in the transeptal

technique.



Figure 1.

Figure 2

________________________________________________________________



2. (9419) Variations in Management of Diabetic Ketoacidosis Amongst Pediatricians and Sub-

Specialists in United States

Sonal R. Chandratre, MD,1 Aamod C. Soman, MD,

2 Fernanda Kupferman, MD,

1 Susana Rapaport, MD,

1 Lily Q. Lew, MD.

1

1Pediatrics, Flushing Hospital Medical Center, Flushing, NY;

2Medicine, Private Practice, Flushing, NY.

Background: Despite consensus statements by the European Society of Pediatric Endocrinology / Lawson Wilkins Pediatric

Endocrine Society ( 2004 ) and the International Society for Pediatric and Adolescent Diabetes (2009) recommending

guidelines for management of diabetic ketoacidosis (DKA), there is no standardized protocol for DKA management in

United States.

Purpose: To study the variations in management of DKA amongst subspecialists, general pediatricians and trainees, and

their opinion of a need for written guidelines.

Methods: We conducted a descriptive study by sending an online survey to specialists(SP) general pediatricians (GP),

pediatric residents and fellows (PL). The specialists included intensivists (PICU), endocrinologists (Endo), hospitalists

(Hosp) and emergency room attendings (ER). Our questionnaire involved knowledge and management based questions

related to fluid, insulin, dextrose, bicarbonate, potassium and monitoring. Responses were categorized into SP, GP, PL and

subgroups of SP. Data were statistically analyzed using frequencies and Pearson chi square test.

Results: Out of 1918 electronic invites, 694 participated. We included 577 (83%) pediatricians in our analysis, of whom

44% were SP (20% PICU, 29% Endo, 21% Hosp, 30% ER), 31% GP and 25% PL. Bicarbonate treatment was considered by

50% SP (62% Endo), 60% GP, 58% PL ( p<0.001). Initial fluid bolus of 10 ml/kg vs 20 ml/kg over 1 hour was considered

by only 31% SP (53% Endo), 24% GP, 16% PL (p=0.003). There were 50% pediatricians who chose 5% dextrose (D) and

28% chose two bag titrating technique ( 5% D and 10% D each ) vs other D concentrations (p<0.001). Amongst SP, 47%

PICU preferred using the two bag technique. Potassium as combination of potassium chloride (KCl) and potassium

phosphate vs other forms of potassium salts was used by 48% pediatricians. KCl alone was used by 18% pediatricians

(p<0.001).Significant variation was noted in other aspects of management of fluid, insulin, dextrose and monitoring (p

≤0.05). A need for written guidelines was perceived by 62% SP ( 75% ER ), 73% GP and 81% PL.

Conclusions: There were significant variations in DKA management amongst pediatricians and subspecialists, especially

for larger fluid bolus and bicarbonate usage. The majority of subspecialists, general pediatricians and trainees still perceived

a need for guidelines.

________________________________________________________________

3. (9750) Gold Nanoparticle-Choline Complexes Can Block Nicotinic Acetylcholine Receptors

Chur Chin. Pediatrics, Fatima Hospital, Daegu, South Korea.

Purpose: Previously we identified that negatively charged nanoparticles can block the ion pores of ligand gated ion

channels when they are introduced into the pores via choline (International Journal of Nanomedicine 2010:5:315-321). We

are trying to identify the therapeutic window using patch clamp technique.

Method: The 1.4-nm negatively charged gold nanoparticles were purchased from Nanoprobes, Inc (New York, NY, USA).

The ionic bond was induced by vortexing positively charged choline and negatively charged gold nanoparticles for about

15 min followed by mixing with a pipette for 15 min. The negatively charged CoO− particles coated on the thin film of

nanoparticles bound to the N+ group of the choline molecule. Choline hydroxide solution was obtained from Sigma-Aldrich

(St. Louis, MO, USA). The PC 12 cell line was obtained from the American Type Culture Collection (CRL-1721; Manassas,

VA, USA). We plated the PC 12 cells on collagen and poly-l-lysine-coated coverslips. The cells were cultured on these

coverslips for 2–4 days before use. Membrane currents were recorded by using the whole cell voltage clamp method. The

cells on coverslips were placed in a recording bath with an approximate volume of 1.5 mL and continuously perfused at the

rate of 1–2 mL / min with a standard external solution containing 140-mM NaCl, 5.4-mM KCl, 1.8-mM CaCl2, 1.0-mM

MgCl2, 10-mM HEPES, and 11.1-mM glucose (titrated to pH 7.4 with NaOH). The heat-polished patch pipettes had a tip

resistance of 3–7 M when filled with an intracellular solution containing 150-mM CsCl, 10-mM HEPES, 5-mM ethylene

glycol tetraacetic acid (EGTA), and 2-mM adenosine triphosphate (ATP)-Mg (titrated to pH 7.3 with CsOH). The cells were

voltage-clamped at −60 mV with a patch clamp amplifier (Flyscreen 8500 Patch Clamp Robot; Irvine, USA). Whole cell



currents were filtered at 0.2 kHz with a Bessel filter and digitized at 1 kHz. Data were stored and analyzed on a

microcomputer by using pCLAMP software. All experiments were performed at room temperature (22–25°C).

Result: The PC 12 cloned cell line was derived from a CA-secreting tumor of rat adrenal medulla, which has sympathetic

neurons. When the cells were voltage-clamped at −60 mV, bath application of 30-µM ACh produced an inward current.

Next, when treated with the 0.2, 0.4, 0.8-mM choline and 15, 30-nM nanoparticle complex each, the peak amplitude was

inhibited. This inhibition was reversible and was easily eliminated by a 40-min washout. A solution of 0.8-mM choline and

30-nM nanoparticles inhibited the peak amplitude completely, probably because of complete occlusion of the ion pores: this

effect was not eliminated by washout.

Conclusion: We identified a therapeutic window of the direct ion-channel blockers.

________________________________________________________________

4. (9866) Hypertonic Saline for Cerebral Edema in Diabetic Ketoacidosis

Ulka Kothari, MBBS, ML Quintos-Alagheband, MD, Pediatric Critical Care Unit, Winthrop University Hospital, Mineola,

NY.

Introduction: Cerebral Edema complicating Diabetic Ketoacidosis (CEDKA) occurs in 1% of all children presenting with

Diabetic Ketoacidosis (DKA). Although rare, CEDKA is associated with a high mortality rate (40-90%) and accounts for

50-60% of diabetes-related deaths in children. We report 2 cases of CEDKA that responded to Hypertonic Saline (HS) with

good outcomes.

Case Reports

Case 1: An 11 y/o male with type 1 diabetes mellitus, presented to the emergency room in DKA (blood glucose: 509 mg/dL,

pH: 7.11, bicarbonate: <10 mEq/L). He received 20 cc/kg of normal saline and an insulin bolus of 0.1 units/kg . He arrived

to the PICU with decerebrate posturing, GCS of 4, fixed and dilated left pupil. He was intubated and received 10 cc/kg of

HS. Anisocoria resolved immediately. CT brain showed paucity of sulci at vertex and small lateral ventricles. His mental

status improved and he had no neurologic deficits at discharge.

Case 2: An 18 y/o male, with type 1 diabetes mellitus, presented to the emergency room in DKA (blood glucose: 795

mg/dL, pH: 6.87, bicarbonate: <10 mEq/L). He received 10 cc/kg of normal saline and an insulin drip was started at 0.6

units/kg/hr. During treatment he became aggressive and combative. CT brain was negative. He became somnolent and GCS

decreased to 13. Fundoscopy showed absent venous pulsation. He received 10 cc/kg of HS with gradual return of GCS to 15.

He was discharged with no neurologic sequelae.

Discussion: The exact pathogenesis of CEDKA remains elusive and is most likely multi-factorial. Proposed mechanisms

include osmotic disequilibrium, over-hydration, hyponatremia and altered cerebral blood flow. Recent evidence suggests

presence of Na+/H+ anti-port and Na+-K+-Cl- channels on rat brain cells, which are directly influenced by insulin and

promote Na+ influx and cerebral swelling. The administration of exogenous insulin appears to potentiate the cascade

towards the development of CEDKA in these animal models. Current management centers on judicious fluid management,

correction of metabolic abnormalities and aggressive treatment of Intracranial Pressure (ICP). Literature reports a beneficial

role for mannitol, however very few case reports on the use of HS in CEDKA have been published. Use of HS restores

sodium imbalance, improves cerebral blood flow and may reverse cerebral edema. HS has been studied extensively as an

alternative hyper-osmolar agent in other subsets of critically-ill patients with raised ICP including patients with traumatic

brain injury, subarachnoid hemorrhage etc. HS compared to mannitol has more sustained effects, equal efficacy and better

hemodynamic profile. It avoids the side effects of mannitol such as brisk diuresis, intravascular dehydration and rapid drop

in blood pressure. Both of our patients responded to HS infusion promptly without clinical sequelae suggesting that HS may

be used as a safer alternative to mannitol in CEDKA.

________________________________________________________________



5. (10878) Non-Invasive Assessment of Changes in Cardiac Output in Ambulatory Infants

Hospitalized with Bronchiolitis

J. Caplow, K. Dorney, M. Hannon, G.M. Steil, J. Wong. Children's Hospital Boston, Boston, MA.

Introduction: Electrical Velocimetry (EV) is an emerging non-invasive method to assess cardiac output (CO) and stroke

volume (SV). The method has been validated in sedated infants with congenital heart disease (1), but research is limited

regarding its application in ambulatory children. We present the first prospective observational study of non-invasive EV

monitoring in ambulatory infants who are hospitalized with bronchiolitis.

Purpose: To assess whether EV can detect changes in CO and SV in ambulatory infants with bronchiolitis from hospital

admission to recovery.

Methods: We enrolled 16 otherwise healthy infants (mean age 4.44±4.72 months; mean weight 6.45±2.15 kg) with a

primary diagnosis of bronchiolitis. Patients were recruited from the Medical Intensive Care Unit (N= 5), Intermediate Care

Program (N= 6), and Medical Inpatient Units (N=5). Average length of stay for the subjects was 3.86±1.89 days. CO, SV

and heart rate (HR) were assessed over a 5+ minute period with an AESCULON EV monitor (Cardiotronic La Jolla, CA)

within 24 hours of admission and again within 24 hours of discharge.

Table 1. Changes in heart rate, cardiac output and stroke volume during recovery from bronchiolitis

.

.

Results: HR did not change between the initial and final time points (Table 1). CO decreased significantly with the change

largely attributed to a decrease in SV, albeit this latter measure did not reach statistical significance.

Conclusion: Our results suggest that non-invasive EV monitors are sufficiently sensitive to detect even small hemodynamic

changes in ambulatory unsedated infants during recovery from acute illness. Pending further clinical validation, non-

invasive CO monitors may provide a practical alternative to invasive cardiac catheters for hemodynamic monitoring in

pediatric patients including infants.

________________________________________________________________

6. (10927) Prolonged Administration of Dexmedetomidine In Infants After Cardiac Surgery

Adalberto Torres Jr., MD, MS, FAAP,1 Kris Schultz,

2 PNP, Tara Osman, PNP,

2 Carolyn Henricks, RN,

2 Randall Fortuna,

MD,3 Hannah Wang, PhD.

1 1Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, IL;

2Pediatrics,

Children's Hospital of Illinois at OSF Saint Francis Medical Center, Peoria, IL; 3 Surgery, University of Illinois College of

Medicine at Peoria, Peoria, IL.

Purpose: Short-term administration of dexmedetomidine (DEX) has been demonstrated to be well tolerated in infants (< 1

year old) after cardiac surgery (1). Prolonged DEX administration (≥ 7 days) in this same population has not been studied.

We hypothesized that infants who received DEX ≥ 7 days after cardiac surgery received as much or more other sedatives

and analgesics than infants who did not.

Methods: This retrospective chart review of infants who underwent cardiac surgery and were hospitalized for ≥ 14 days in

the PICU post-operatively was approved by local IRB. Patient characteristics (age, weight, type of surgery, Aristotle

Comprehensive Complexity score, ICU LOS, days ventilated) and total opioids and benzodiazepenes received were entered

into a Microsoft Excel spreadsheet. Amount of methadone and lorazepam received were converted to equipotent doses of

fentanyl and midazolam, respectively, for analysis. Eligible infants were divided into 2 groups, those who received DEX ≥ 7

days and those who didn't. The results are reported as median (range). Fisher's test and Wilcoxon-Mann-Whitney test were

used to detect for significant differences in bivariate and continuous variables, respectively, between the two groups. A p

value < 0.05 was considered significant.

Initial Mean ± SE Final Mean ± SE Mean %Change P-value

HR (bpm) 145.0 ± 4.2 144.6 ± 2.6 -0.8% 0.925

CO (L/min) 1.3 ± 0.1 1.1 ± 0.1 -10.1% 0.034

SV (cc/beat) 9.3 ± 1.0 8.0 ± 0.8 -7.6% 0.065



Results: 25 infants were analyzed. 6 infants, all greater than 28 days old, received DEX for ≥ 7 days. Infants who received

DEX ≥ 7 days received significantly more opioids and benzodiazepenes than those infants who did not (table).

Prolonged DEX Little or no DEX p value

n (%) 6 (24%) 19 (76%) na

Age (in days @ time of surgery) 212 (65, 254) 7 (5, 77) < 0.001

Weight (kg) 5.5 (3, 7.1) 3.1 (1.9, 3.7) 0.003

Aristotle Comprehensive Score 11 (6,13) 14 (8, 20) 0.14

PICU days 46 (25, 74) 35 (16, 149) 0.55

Days ventilated post-op 21 (4, 61) 13 (7, 95) 0.88

Opioid received (mcg/kg/h) 3.2 (2.4, 5.9) 1.0 (0.3, 3.1) 0.001

Sedative received (mg/kg/h) 0.26 (0.18, 0.51) 0.06 (0.03, 0.37) 0.002

DEX received (mcg/kg/h) 0.78 (0.4, 0.89) 0 (0, 0.86) < 0.001

Clonidine received (mcg/kg/d) 7.8 (0, 18.2) 0 (0, 11.7) 0.006

Conclusion: Certain infants received large doses of sedatives and analgesics despite receiving DEX. Alternative

sedative/analgesic agents should be considered in these difficult-to-sedate infants.

________________________________________________________________

7. (10123) Despite Less Trust and More Mistrust, African American Parents in the PICU Report

No Differences in Satisfaction with Communication

Courtney C. Hilts, Amanda M. Satyran, Destinee T. DeLemos, K. Sarah Hoehn, MD, MBe, FAAP. Critical Care, St.

Christopher's Hospital for Children, Philadelphia, PA.

Purpose: The goal of this study is to better understand the factors that impact parents' trust, communication, and decision-

making in the pediatric intensive care unit (PICU) in order to reduce racial disparities and improve children's health

outcomes.

Methods: Oral interviews were administered to English-speaking parents in the pediatric intensive care unit (PICU) at

tertiary care inner city hospital. Eligible parents had a child in the PICU for a minimum of forty-eight hours. Four

quantitative questionnaires were used- a demographic questionnaire, a self-constructed questionnaire focusing on

communication between parents and physicians (HICCC), Pediatric Trust in Physician Scale (Pedi-TIPS), and the Group

Based Medical Mistrust Scale (GBMMS). The Pedi TIPS and GBMMS are well validated scales with good internal

reliability. The HICCC questionnaire was developed from previous qualitative research that found that parents wanted

communication to be Honest, Inclusive, Clear and Comprehensive, Coordinated, and Compassionate.

Results: Eighty three percent of the participants were female and 55% of the children hospitalized were male. Seven percent

of the sample population was uninsured, 23% were single, and 90% had at least a high school degree. At the time of the

preliminary analysis, there were100 participants who identified as Caucasian (51%) or African American (49%). Based on a

p-value of 0.05 using simple t-tests, none of the chosen variables from the HICCC questionnaire were associated with race.

Race had a significant association with the Pedi-TIPS total score (p=0.001) with mean of 45.7 (Caucasians) and 41.6

(African Americans). A similar association was found between race and GBMMS total score (p=0.005) with mean of 21.3

(Caucasians) and 24.5 (African Americans). Trust was also associated with identifying with Christianity as a religion

(p=0.04). In further analysis, being Caucasian and identifying with Christianity is associated with feeling like a partner with

the physician (p=0.02).

Conclusion: In this analysis, Caucasian parents had a higher trust level in physicians and and less medical mistrust, when

compared to African Americans. However, based on the HICCC questionnaire, there were no significant differences on

aspects of trust and communication in regards to race. Additionally, this was the pilot for the HICCC questionnaire and more

research may be needed to improve its internal reliability. Physicians should strive to make all parents feel like partners in

their child's care. Further research is needed to delineate ways physicians can improve trust and communication with all

parents, but especially those who are non Caucasian.

________________________________________________________________



8. (11503) Highly Successful Bedside Transpyloric Feeding Tube Placement by Nursing Staff in

the Pediatric Intensive Care Patients

Ruifang Xu, MD, Garrett Kitt, Robert J Dimand. Pediatrics, UCSF Fresno, Children's Hospital Central California, Madera,

CA.

Purpose: The aim of this study was to demonstrate the efficacy of placing transpyloric feeding tubes at the bedside without

using any guidance devices by nursing staff in the pediatric intensive care unit.

Methods: A prospective study was designed to collect data from patients admitted to a 34-bed pediatric intensive care unit

from September 2009 to April 2010. The patients eligible for enteral nutrition were enrolled consecutively. Transpyloric

feeding tubes were inserted using insufflation air technique by the bedside nurse following a hospital standard procedure

protocol. Each placement was confirmed by abdominal x-ray. If the first placement failed, a second attempt was usually

performed within 20 minutes.

Results: A total of 46 transpyloric placements on 42 patients were recorded in this study. Patients were aged 37.2 ± 65.2

months, weighed 12.8 ± 14.3 kg, all of the patients were endotracheally intubated and on mechanical ventilation under

sedation. Our pediatric intensive unit nursing staff followed the standard hospital protocol in 85% placement; 15%

placements were using the same protocol with modifications based on individual experiences. Our nurses achieved 100%

successful rate on 46 placements. No physician involvement, no fluorescent or endoscopic guidance required in these

procedures. 70% (32/46) insertions succeeded in the first attempt and a second attempt brought up successful rate to 89%

(41/46). The number of attempts to place transpyloric feeding tube on each patient ranged 1-5 (mean 1.5 ± 0.9, median

1.0). The exposures of abdominal X-ray on each patient to confirm the tube position was 1 to 4 (mean 1.4 ± 0.7, median

1.0). The length of transpyloric feeding tube usage on each patient was 1-45 days (mean 11.9 ± 10.2, median 8.5). No

complications registered on any patients.

Conclusion: The bedside transpyloric feeding tube placement protocol in this study is simple, safe, well tolerated and highly

successful. It can be performed routinely by bedside nursing staff in the pediatric intensive care unit.

________________________________________________________________

9. (11559) Hemolysis Is Increased in Cardiac Extracorporeal Life Support with Roller-Head

Pumps as Compared to Centrifugal Pumps

Jonathan W. Byrnes, MD FAAP1, Wesley A. McKamie, CCP

2, Christopher Swearingen, PhD

2, Adnan Bhutta

3, Parthak

Prodhan4, Michiaki Imamura, MD, PhD

2, Robert D. B. Jaquiss, MD

1, Richard Fiser, MD

1; 1University of Arkansas for

Medical Sciences; 2Arkansas Children's Hospital;

3Arkansas Children's Hospital, University of Arkansas for Medical

Sciences; 4Arkansas Children's Hospital, COM- University of Arkansas for Medical Sciences

Purpose: Extracorporeal life support (ECLS) is a life saving therapy which has been utilized for the support of children with

a broad range of diseases. Two pumps of differing mechanisms have been used to generate the extracorporeal flow: roller-

head pumps (RHP) and centrifugal pumps (CP). We hypothesize that hemolysis as measured by plasma free hemoglobin

(PFH) is elevated in patients supported with RHP versus CP during cardiac ECLS.

Methods: Seven patients supported by ECLS on CP (Centrimag, Levitronix) were matched to fourteen patients supported

on RHP ( Stockert-Shiley) for age, weight, ECMO duration in hours, and exposure to cardiopulmonary bypass in the

previous 72 hours at a single institution from July 2007 to July 2009. Propensity scores were used to complete a 2:1 match

between patients receiving CP and those receiving RHP Categorical data were analyzed using Fisher's Exact test. PFH

differences between groups were analyzed using both Wilcoxon Rank Sum and Beta Regression.

Results: PFH measurements were significantly lower in patients supported with CP vs RHP( Table 1). Overall, RHP

patients had 2 times the odds of having a higher PFH than CP patients adjusting for repeated measures (OR=1.96, 95%CI:

(1.15, 3.34, p < 0.014). A trend towards more early circuit failures was observed with RHP (1/7 CP versus 7/14 RHP;

p=0.174).



Conclusion: Contrary to past reports, this series demonstrates that plasma free hemoglobin is elevated in patients supported

by RHP as compared to CP. In addition, a trend towards less frequent circuit changes occurred in the centrifugal group.

Table 1: Daily PFH in Centrifugal versus Roller-head Pumps

PFH Roller-head Centrifugal WRS Beta Regression

Day N Mean (SD) N Mean (SD) p-value OR (95% CI) p-value

1 13 44.6 (29.9) 6 30.9 (19.8) 0.430 1.67 (0.64, 4.38) 0.296

2 13 38.4 (30.3) 7 11.7 (4.8) 0.019 4.82 (2.52, 9.21) <0.001

3 12 30.8 (29.9) 4 12.4 (5.7) 0.146 3.55 (1.72, 7.30) 0.001

4 10 32.4 (26.0) 4 16.9 (4.2) 0.090 2.86 (1.42, 5.77) 0.003

5 9 48.9 (30.9) 4 37.3 (42.2) 0.215 1.37 (0.35, 5.34) 0.654

6 7 42.2 (26.9) 4 35.9 (42.7) 0.155 1.14 (0.28, 4.54) 0.855

7 5 43.4 (35.0) 2 10.6 (0.0) -

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