Gregory Hansen

The COronaVirus Disease 2019 (COVID-19) pandemic disproportionately overwhelmed adult critical care resources. It also led to a reduction of pediatric inte

Background: There is a lack of evidence related to weaning noninvasive ventilation in bronchiolitis. The purpose of this study was to identify variables related to NIV weaning readiness and approach in bronchiolitis. Methods: A retrospective cohort study of 74 children less than two years of age with bronchiolitis, requiring NIV and admitted to a pediatric intensive care unit (PICU) from 2022 to 2023. Demographic variables, clinical metrics, NIV mode, and weaning metrics were collected. Results: Mean total duration of NIV therapy was 40 h with weans lasting 13 h. Duration for children on CPAP alone was shorter (26 h) than for children on combination of BiPAP and CPAP (45 h, 95% CI 4.258 to 33.742, p = 0.0123). Wean times were also shorter for children on CPAP alone (mean 5 h) than children on BiPAP and CPAP (mean 16 h) (95% CI 1.899 to 20.101, p = 0.0185). Patients were more likely to have a “complex wean,” defined as escalation and de‐escalation between multiple settings, with BiPAP (44.6%) than with CPAP (18.8%). RR at first wean was a significant predictor of NIV weaning duration ( p = 0.007). Conclusion: There is a need for NIV weaning guidelines. RR may be an important predictor of NIV weaning readiness and approach. A “complex wean” may be a potential outcome variable for weaning NIV in children with bronchiolitis. This study may be used to inform future research and guidelines for weaning NIV in children with bronchiolitis.

Background: Severe bronchiolitis within seasonal outbreaks is increasing. This places significant strain on pediatric intensive care unit (PICU) resources and capacity. Non-invasive ventilation (NIV) and high flow nasal cannula (HFNC) have reduced rates of intubation and conventional mechanical ventilation (CMV) but risk factors and mitigation strategies continue to be elucidated. The primary objective of this study was to identify bronchiolitis intubation risk factors within a provincial protocol for HFNC. Secondarily intubation rates before and after implementation of the protocol were evaluated. Methods: A retrospective chart review was conducted on all Results: One hundred and eighty-two patients met criteria, and 19 (10.4%) required intubation. Risk factors for intubation were multiple viruses (P=0.02), secondary bacterial infection (Pvs. 4.16 days; Pvs. 19 of 182; P=0.04) decrease in intubation rates following provincial HFNC protocol initiation. Conclusions: A protocol driven provincial HFNC algorithm for early respiratory support may promote decreased intubation rates in severe bronchiolitis. Within the same structure risk factors such as multiple viruses, concomitant infections and elevated CRP may serve as early warning for bronchiolitis patients at higher risk for intubation.

Background: Pediatric intensive care units (PICUs) may not have timely access to therapeutic plasma exchange (TPE) for critically ill patients. The purpose of this study was to evaluate the common indications for TPE in a smaller tertiary PICU-developed TPE program and to evaluate the associated predictors of mortality. We hypothesized that a PICU-developed TPE program could provide timely access for a wide breadth of pathologies and can be delivered safely. Subjects and Methods: This was a retrospective case-comparison within-cohort study in a PICU from Canada. Data from pediatric patients between October 2015 and January 2022 was examined. The study included all patients < 18 years admitted to the PICU and requiring TPE. Multiorgan dysfunction syndrome (MODS) was defined to agree with the International Pediatric Sepsis Consensus Conference. Proportions, medians, and interquartile ranges (IQR) were calculated where appropriate. Results: Twenty-five patients with a median age of 14 years underwent 118 acute TPE runs. The most common diagnosis (24%) was MODS. The median time from PICU admission to initiation of TPE was 38 h (IQR: 5–113.5) hours. The median PICU length of stay was 10 (IQR: 5.5–26) days. Twenty percent (n = 5) of patients who received TPE acutely in the PICU required chronic TPE. There were no adverse events. Conclusions: TPE may be delivered quickly and safely from a small PICU for many indications, with MODS being the most common.

BACKGROUND Remote presence robotic technologies (RPRT) in medicine have been primarily utilized as a virtual clinical interface for geographically isolated or resource limited communities. However, its potential as an educational conduit is slowly beginning to be realized. OBJECTIVE To study the acceptability and perspectives of RPRT in acute pediatric simulation education. METHODS Pediatric residents and health care providers participated in a qualitative mixed methods sequential study including post simulation surveys and semi-structured interviews. RESULTS Main themes from surveys and interviews included the improved communication and objective assessment that occurred with RPRT guided simulation, as well as improved feedback for the multi-disciplinary team. The major drawback of RPRT were technological difficulties in establishing RPRT connection during debrief. Feedback provided from this study has led to regular integration of RPRT into the multi-disciplinary simulation program and improved connectivity on our teaching unit. CONCLUSIONS Simulation using RPRT may improve communication between the multi-disciplinary team and pediatric intensivists. It may also be considered for pediatric post-graduate medicine education. CLINICALTRIAL N/A

Article: Noninvasive versus conventional mechanical ventilation in bronchiolitis - Minerva Pediatrics 2023 April;75(2):305-7 - Minerva Medica - Journals

Background: The COVID-19 pandemic overwhelmed Canadian hospitals with adult admissions. A large number of adult patients required critical care therapies, placing significant strain on hospital resources. In order to decompress adult intensive care units, pediatric intensive care units (PICUs) introduced adapted models of traditional care to lessen these burdens. Objective: We aimed to evaluate how PICUs across Canada adapted care for the high volumes of critically ill adults. Methods: A survey containing 40 questions was sent to the medical directors of 14 Canadian PICUs where English was the primary clinical language. The survey was designed to gain perspective on the various adaptations that PICUs instituted during the COVID-19 pandemic. Results: Of the 13 PICUs that returned survey responses (response rate: 13/14, 93%), 10 (77%) participated in at least one adaptation to support the influx of admitted adults with COVID-19. The key challenges included disorganization, loss of autonomy, and compromised patient care. The significant advantages of these adaptations included a sense of learning and comradery. Conclusions: Our study highlighted an unpreparedness in critical care surge capacity. During the COVID-19 pandemic, adaptations rapidly emerged in Canada that involved PICUs with adult care. In the future, preplanned adaptations for optimizing robust critical care services should be developed based on what has been learned from the COVID-19 pandemic.

BACKGROUND The COVID-19 pandemic overwhelmed Canadian hospitals with adult admissions. A large number of adult patients required critical care therapies, placing significant strain on hospital resources. In order to decompress adult intensive care units, pediatric intensive care units (PICUs) introduced adapted models of traditional care to lessen these burdens. OBJECTIVE We aimed to evaluate how PICUs across Canada adapted care for the high volumes of critically ill adults. METHODS A survey containing 40 questions was sent to the medical directors of 14 Canadian PICUs where English was the primary clinical language. The survey was designed to gain perspective on the various adaptations that PICUs instituted during the COVID-19 pandemic. RESULTS Of the 13 PICUs that returned survey responses (response rate: 13/14, 93%), 10 (77%) participated in at least one adaptation to support the influx of admitted adults with COVID-19. The key challenges included disorganization, loss of autonomy, and compromised patient care. The significant advantages of these adaptations included a sense of learning and comradery. CONCLUSIONS Our study highlighted an unpreparedness in critical care surge capacity. During the COVID-19 pandemic, adaptations rapidly emerged in Canada that involved PICUs with adult care. In the future, preplanned adaptations for optimizing robust critical care services should be developed based on what has been learned from the COVID-19 pandemic.

In response to the burden of coronavirus disease 2019 (COVID-19) and overwhelmed intensive care unit (ICU) resources, some pediatric intensive care units (PICUs) have had to adapt. The purpose of this study was to assess the criticality, scope of diagnosis, and outcomes of an adult cohort admitted to a Canadian PICU. A retrospective chart review was completed on all patients between 17 and 50 years of age admitted to the PICU between June 2020 and December 2021. Admission data included body mass index (BMI), admission sequential organ failure assessment score (SOFA), COVID-19 status, diagnosis, and comorbidities. The duration of ventilatory support, PICU and hospital admission, and mortality and discharge disposition were assessed. Discrete variables were reported as percentages and continuous data as means with standard deviations or medians with interquartile range. Sixty-five adult patients were admitted to the PICU for a total of 437 days, with a mean SOFA score of 6.6 and the overall mortality rate of 4.6%. Six patients were diagnosed with COVID-19 pneumonia, were admitted with a mean SOFA score of 11.8 and a BMI of 38.3 kg/m², and all were discharged to the ward. During the COVID-19 pandemic, pediatric intensivists in a Canadian PICU managed adult patients up to 50 years of age with high criticality and broad-ranging diagnoses with a low mortality rate. PICUs may be a safe critical care decompression option for adult ICUs during future endemics or pandemics. Received: 06 January 2022 Accepted: 06 March 2022 Article published online: 20 June 2022 © 2022. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Objective: Severity of illness scoring during pediatric critical care transport may provide objective data to determine illness trajectory and disposition and contribute to quality assurance data for pediatric transport programs. The objective of this study was to ascertain the breadth of severity of illness scoring tool application among North American pediatric critical care transport teams. Methods: A cross-sectional quantitative survey using REDCap was distributed to 137 North American pediatric transport programs. Baseline team characteristics were established along with questions related to severity of illness tool application. Descriptive statistics were used for analysis. Results: There were 55 responses (40%), and of those, 13 (24%) use a severity of illness scoring tool within their practice. A variety of tools were used including: Transport Risk Index of Physiologic Stability, Children's Hospital Medical Center Cincinnati, Canadian Triage and Acuity Score, Transport Risk Assessment in Pediatrics, Pediatric Early Warning Scores, Levels of Acuity, Transport Pediatric Early Warning Scores, and an unspecified tool. The timing of scoring, team personnel who applied the score, and the frequency of analysis varied between transport programs. Conclusions: Severity of illness scoring is not consistently performed by pediatric interfacility transport programs in North America. Among the programs that use a scoring tool, there is variability in its application. There is no universally accepted or performed severity of illness scoring tool for pediatric interfacility transport. Future research to validate and standardize a pediatric transport severity of illness scoring tool for North America is necessary.