Publications by authors named "Elise W van der Jagt"

17 Publications

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The American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock: Executive Summary.

Pediatr Crit Care Med 2017 09;18(9):884-890

1No institution affiliation. 2Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA. 3Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA. 4Department of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Bloomington, IN. 5Department of Pediatrics, Washington University School of Medicine, St. Louis, MO. 6Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. 7Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. 8Pediatric Critical Care Medicine, Covenant Women and Children's Hospital, Texas Tech University, Lubbock, TX. 9Department of Pediatrics, Division of Pediatric Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. 10Division of Pediatric Critical Care, University of British Columbia, Vancouver, BC, Canada. 11Department of Pediatrics, Division of Pediatric Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI. 12Department of Pediatrics, Baylor College of Medicine, Houston, TX. 13Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ. 14Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 15Intensive Care & Bioethics, Great Ormond St Hospital for Sick Children, London, United Kingdom. 16Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital/University of Alberta, Edmonton, AB, Canada. 17Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Children's, Durham, NC. 18Departments of Pediatrics and Critical Care, Clinical Epidemiology and Biostatistics, McMaster University, Pediatric Intensive Care Unit, McMaster Children's Hospital, Hamilton, ON, Canada. 19Beth Israel Medical Center, Hartsdale, NY. 20Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI. 21Departments of Pediatrics and Biochemistry, Washington University in Saint Louis School of Medicine, St. Louis, MO. 22Department of Pediatrics, Centre mère-enfant Soleil du CHU de Québec-Université Laval, Québec City, QC, Canada. 23Department of Inpatient Pediatrics, Kaiser Santa Clara Medical Center, Santa Clara, CA. 24Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and The Children's Hospital of Philadelphia, Philadelphia, PA. 25Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Mott C.S. Children's Hospital, Ann Arbor, MI. 26Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA. 27Department of Pediatrics-Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD. 28Division of Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, NY. 29Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH. 30Department of Critical Care Medicine, Children's Mercy Hospital, Kansas City, MO. 31Department of Pediatrics, Texas Tech University Health Sciences Center, El Paso, TX. 32Division of Pediatric Critical Care, University of Florida, Jacksonville, FL 33Bon Secours St. Mary's Hospital, Glen Allen, VA. 34Department of Pediatrics/Division of Pediatric Critical Care, University of Rochester School of Medicine and Dentistry, Rochester, NY. 35Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. 36Department of Pediatrics, Division of Critical Care, Stanford University School of Medicine, Palo Alto, CA. 37Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of Medicine, Bronx, NY. 38Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada. 39Department of Pediatrics, Naval Medical Center San Diego and University of California San Diego School of Medicine, San Diego, CA. 40Department of Pediatrics and Pediatric Critical Care Medicine, The Valley Hospital, Ridgewood, NJ. 41Cardiothoracic ICU, National University Hospital, Singapore. 42Paediatric ICU, The Royal Children's Hospital, Parkville, VIC, Australia. 43Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia. 44Children's Hospital of Pittsburgh, Pittsburgh, PA. 45Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA. 46Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI. 47Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA. 48Division of Emergency Medicine, Ann and Robert Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, IL. 49UCL Great Ormond Street Institute of Child Health and Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, NHS Trust, London, United Kingdom. 50Pediatric Intensive Care and Emergency Services, Apollo Children's Hospital, Chennai, India. 51Department of Pediatrics, Division of Pediatric Critical Care, Duke University School of Nursing and School of Medicine, Durham, NC. 52Pediatrics School of Medicine, Austral University, Pcia de Buenos Aires, Argentina. 53Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. 54Critical Care and Transport, Nemours Children's Hospital, Orlando, FL. 55Department of Pediatrics, Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY. 56Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 57Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle, WA. 58Departments of Pediatrics & Anesthesiology, Sinai Hospital/NAPA, Baltimore, MD. 59Department of Pediatrics, University of Maryland Medical School, Baltimore, MD.

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http://dx.doi.org/10.1097/PCC.0000000000001259DOI Listing
September 2017

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock.

Crit Care Med 2017 06;45(6):1061-1093

1No institution affiliation. 2Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA. 3Department of Pediatric Critical Care, Riley Hospital for Children, Indiana University, IN. 4Department of Pediatrics, Washington University School of Medicine, St. Louis, MO. 5Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. 6Pediatric Critical Care Medicine, Covenant Women and Children's Hospital, Texas Tech University, Lubbock, TX. 7Division of Pediatric Critical Care Medicine, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL. 8Division of Pediatric Critical Care, University of British Columbia, Vancouver, BC, Canada. 9Division of Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI. 10Department of Pediatrics, Baylor College of Medicine, Houston, TX. 11Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ. 12Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. 13Intensive Care & Bioethics, Great Ormond St Hospital for Sick Children, London, United Kingdom. 14Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital/University of Alberta, Edmonton, AB, Canada. 15Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's, Durham, NC. 16Departments of Pediatrics and Critical Care, Clinical Epidemiology and Biostatistics, McMaster University, Pediatric Intensive Care Unit, McMaster Children's Hospital, Hamilton, ON, Canada. 17Beth Israel Medical Center, Hartsdale, NY. 18Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI. 19Departments of Pediatrics and Biochemistry, Washington University in Saint Louis School of Medicine, Saint Louis, MO. 20Department of Pediatrics, Centre mère-enfant Soleil du CHU de Québec-Université Laval, Québec City, QC, Canada. 21Department of Inpatient Pediatrics, Kaiser Santa Clara Medical Center, Santa Clara, CA. 22Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. 23Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Mott C.S. Children's Hospital, Ann Arbor, MI. 24Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA. 25Department of Pediatrics-Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD. 26Division of Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, NY. 27Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH. 28Department of Critical Care Medicine, Children's Mercy Hospital, Kansas City, MO. 29Department of Pediatrics, Texas Tech University Health Sciences Center, El Paso, TX. 30Division of Pediatric Critical Care, University of Florida, Jacksonville, FL. 31Bon Secours St. Mary's Hospital, Glen Allen, VA. 32Division of Pediatric Critical Care, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY. 33Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. 34Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA. 35Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of Medicine, Bronx, NY. 36Department of Pediatrics, University of British Columbia, UBC & BC Children's Hospital Professor in Critical Care-Global Child Health, Vancouver, BC, Canada. 37Department of Pediatrics, Naval Medical Center San Diego and University of California San Diego School of Medicine, San Diego, CA. 38Department of Pediatrics and Pediatric Critical Care Medicine, The Valley Hospital, Ridgewood, NJ. 39Cardiothoracic ICU, National University Hospital, Singapore. 40Paediatric ICU, The Royal Children's Hospital, Melbourne, Australia. 41Department of Paediatrics, University of Melbourne, Melbourne, Australia. 42Children's Hospital of Pittsburgh, Pittsburgh, PA. 43Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA. 44Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI. 45Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA. 46Division of Emergency Medicine, Ann and Robert Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, IL. 47UCL Great Ormond Street Institute of Child Health and Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, NHS Trust, London, United Kingdom. 48Pediatric Intensive Care and Emergency Services, Apollo Children's Hospital, Chennai, India. 49Division of Pediatric Critical Care, Department of Pediatrics, Duke University School of Nursing and School of Medicine, Durham, NC. 50Pediatrics School of Medicine, Austral University, Pcia de Buenos Aires, Argentina. 51Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. 52Critical Care and Transport, Nemours Children's Hospital, Orlando, FL. 53Department of Pediatrics, Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY. 54Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. 55Departments of Pediatrics & Anesthesiology, Sinai Hospital/NAPA, Baltimore, MD. 56Department of Pediatrics, University of Maryland Medical School, Baltimore, MD.

Objectives: The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock."

Design: Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups.

Measurements And Main Results: The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations.

Conclusions: The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.
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http://dx.doi.org/10.1097/CCM.0000000000002425DOI Listing
June 2017

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children.

N Engl J Med 2017 01 24;376(4):318-329. Epub 2017 Jan 24.

From the University of Michigan, Ann Arbor (F.W.M., F.S.S.), and Wayne State University, Detroit (K.L.M., S. Shankaran) - both in Michigan; University of Utah, Salt Lake City (R. Holubkov, B.B., K.P., M.R.G., K.S.B., A.E.C., J.M.D.); Kennedy Krieger Institute and Johns Hopkins University (B.S.S., J.R.C.) and Johns Hopkins Children's Center (U.S.B.), Baltimore, and the National Heart, Lung, and Blood Institute, Bethesda (V.L.P.) - both in Maryland; Children's Hospital of Philadelphia, Philadelphia (V.M.N., A.T.), University of Pittsburgh Medical Center, Pittsburgh (E.L.F.), and Penn State Children's Hospital, Hershey (N.J.T.) - all in Pennsylvania; Birmingham Children's Hospital, Birmingham (B.R.S.), Great Ormond Street Hospital, London (S. Skellett), Alder Hey Children's Hospital, Liverpool (P.B.B.), and University Hospital Southampton, Southampton (J.P.) - all in the United Kingdom; Hospital for Sick Children, Toronto (J.S.H.); Children's National Medical Center, Washington, DC (J.T.B.); Duke Children's Hospital, Durham, NC (G.O.-A.); Children's Hospital Los Angeles (C.J.L.N.) and Mattel Children's Hospital UCLA (R. Harrison), Los Angeles, Children's Hospital of Orange County, Orange (A.J.S.), University of California, San Francisco Benioff Children's Hospital, San Francisco (P.M.), and Loma Linda University Children's Hospital, Loma Linda (M.M.) - all in California; Children's Medical Center Dallas, University of Texas Southwestern Medical School, Dallas (J.D.K.); University of Texas Health Sciences Center at San Antonio, San Antonio (T.W.); Children's Healthcare of Atlanta, Atlanta (N.P., N.K.C.); Washington University, St. Louis (J.A.P.); Phoenix Children's Hospital, Phoenix, AZ (H.J.D.); the Children's Hospital of Alabama, Birmingham (J.A.); Children's Hospital of New York, Columbia University Medical Center, New York (C.L.S.), and Golisano Children's Hospital, University of Rochester Medical Center, Rochester (E.W.J.) - both in New York; Ann and Robert Lurie Children's Hospital of Chicago, Chicago (D.M.G.); Seattle Children's Hospital, Seattle (J.J.Z.); Kosair Children's Hospital, University of Louisville, Louisville, KY (M.B.P.); University of Tennessee Health Science Center, Memphis (S. Shah); Children's Hospital and Clinics of Minnesota, Minneapolis (J.E.N.); Nationwide Children's Hospital, Columbus, OH (E.L.); Children's Hospital Colorado, Aurora (E.L.D.); Medical College of Wisconsin, Milwaukee (M.T.M.); and Arkansas Children's Hospital, Little Rock (R.C.S.).

Background: Targeted temperature management is recommended for comatose adults and children after out-of-hospital cardiac arrest; however, data on temperature management after in-hospital cardiac arrest are limited.

Methods: In a trial conducted at 37 children's hospitals, we compared two temperature interventions in children who had had in-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose children older than 48 hours and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a score of 70 or higher on the Vineland Adaptive Behavior Scales, second edition (VABS-II, on which scores range from 20 to 160, with higher scores indicating better function), was evaluated among patients who had had a VABS-II score of at least 70 before the cardiac arrest.

Results: The trial was terminated because of futility after 329 patients had undergone randomization. Among the 257 patients who had a VABS-II score of at least 70 before cardiac arrest and who could be evaluated, the rate of the primary efficacy outcome did not differ significantly between the hypothermia group and the normothermia group (36% [48 of 133 patients] and 39% [48 of 124 patients], respectively; relative risk, 0.92; 95% confidence interval [CI], 0.67 to 1.27; P=0.63). Among 317 patients who could be evaluated for change in neurobehavioral function, the change in VABS-II score from baseline to 12 months did not differ significantly between the groups (P=0.70). Among 327 patients who could be evaluated for 1-year survival, the rate of 1-year survival did not differ significantly between the hypothermia group and the normothermia group (49% [81 of 166 patients] and 46% [74 of 161 patients], respectively; relative risk, 1.07; 95% CI, 0.85 to 1.34; P=0.56). The incidences of blood-product use, infection, and serious adverse events, as well as 28-day mortality, did not differ significantly between groups.

Conclusions: Among comatose children who survived in-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a favorable functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute; THAPCA-IH ClinicalTrials.gov number, NCT00880087 .).
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http://dx.doi.org/10.1056/NEJMoa1610493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310766PMC
January 2017

Therapeutic hypothermia after out-of-hospital cardiac arrest in children.

N Engl J Med 2015 May 25;372(20):1898-908. Epub 2015 Apr 25.

The authors' affiliations are listed in the Appendix.

Background: Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.

Methods: We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.

Results: A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.

Conclusions: In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).
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http://dx.doi.org/10.1056/NEJMoa1411480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4470472PMC
May 2015

Multicenter cohort study of out-of-hospital pediatric cardiac arrest.

Crit Care Med 2011 Jan;39(1):141-9

Pediatric Emergency Care Applied Research Network, Salt Lake City, UT, USA.

Objectives: To describe a large cohort of children with out-of-hospital cardiac arrest with return of circulation and to identify factors in the early postarrest period associated with survival. These objectives were for planning an interventional trial of therapeutic hypothermia after pediatric cardiac arrest.

Methods: A retrospective cohort study was conducted at 15 Pediatric Emergency Care Applied Research Network clinical sites over an 18-month study period. All children from 1 day (24 hrs) to 18 yrs of age with out-of-hospital cardiac arrest and a history of at least 1 min of chest compressions with return of circulation for at least 20 mins were eligible.

Measurements And Main Results: One hundred thirty-eight cases met study entry criteria; the overall mortality was 62% (85 of 138 cases). The event characteristics associated with increased survival were as follows: weekend arrests, cardiopulmonary resuscitation not ongoing at hospital arrival, arrest rhythm not asystole, no atropine or NaHCO3, fewer epinephrine doses, shorter duration of cardiopulmonary resuscitation, and drowning or asphyxial arrest event. For the 0- to 12-hr postarrest return-of-circulation period, absence of any vasopressor or inotropic agent (dopamine, epinephrine) use, higher lowest temperature recorded, greater lowest pH, lower lactate, lower maximum glucose, and normal pupillary responses were all associated with survival. A multivariate logistic model of variables available at the time of arrest, which controlled for gender, age, race, and asystole or ventricular fibrillation/ventricular tachycardia anytime during the arrest, found the administration of atropine and epinephrine to be associated with mortality. A second model using additional information available up to 12 hrs after return of circulation found 1) preexisting lung or airway disease; 2) an etiology of arrest drowning or asphyxia; 3) higher pH, and 4) bilateral reactive pupils to be associated with lower mortality. Receiving more than three doses of epinephrine was associated with poor outcome in 96% (44 of 46) of cases.

Conclusions: Multiple factors were identified as associated with survival after out-of-hospital pediatric cardiac arrest with the return of circulation. Additional information available within a few hours after the return of circulation may diminish outcome associations of factors available at earlier times in regression models. These factors should be considered in the design of future interventional trials aimed to improve outcome after pediatric cardiac arrest.
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http://dx.doi.org/10.1097/CCM.0b013e3181fa3c17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3297020PMC
January 2011

In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study.

Crit Care Med 2009 Jul;37(7):2259-67

Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA.

Objectives: : To describe a large multicenter cohort of pediatric cardiac arrest (CA) with return of circulation (ROC) from either the in-hospital (IH) or the out-of-hospital (OH) setting and to determine whether significant differences related to pre-event, arrest event, early postarrest event characteristics, and outcomes exist that would be critical in planning a clinical trial of therapeutic hypothermia (TH).

Design: : Retrospective cohort study.

Setting: : Fifteen Pediatric Emergency Care Applied Research Network sites.

Patients: : Patients aged 24 hours to 18 years with either IH or OH CA who had a history of at least 1 minute of chest compressions and ROC for at least 20 minutes were eligible.

Interventions: : None.

Measurements And Main Results: : A total of 491 patients met study entry criteria with 353 IH cases and 138 OH cases. Major differences between the IH and OH cohorts were observed for patient prearrest characteristics, arrest event initial rhythm described, and arrest medication use. Several postarrest interventions were used differently, however, the use of TH was similar (<5%) in both cohorts. During the 0-12-hour interval following ROC, OH cases had lower minimum temperature and pH, and higher maximum serum glucose recorded. Mortality was greater in the OH cohort (62% vs. 51%, p = 0.04) with the cause attributed to a neurologic indication much more frequent in the OH than in the IH cohort (69% vs. 20%; p < 0.01).

Conclusions: : For pediatric CA with ROC, several major differences exist between IH and OH cohorts. The finding that the etiology of death was attributed to neurologic indications much more frequently in OH arrests has important implications for future research. Investigators planning to evaluate the efficacy of new interventions, such as TH, should be aware that the IH and OH populations differ greatly and require independent clinical trials.
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http://dx.doi.org/10.1097/CCM.0b013e3181a00a6aDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711020PMC
July 2009

Multicenter cohort study of in-hospital pediatric cardiac arrest.

Pediatr Crit Care Med 2009 Sep;10(5):544-53

Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA.

Objectives: 1) To describe clinical characteristics, hospital courses, and outcomes of a cohort of children cared for within the Pediatric Emergency Care Applied Research Network who experienced in-hospital cardiac arrest with sustained return of circulation between July 1, 2003 and December 31, 2004, and 2) to identify factors associated with hospital mortality in this population. These data are required to prepare a randomized trial of therapeutic hypothermia on neurobehavioral outcomes in children after in-hospital cardiac arrest.

Design: Retrospective cohort study.

Setting: Fifteen children's hospitals associated with Pediatric Emergency Care Applied Research Network.

Patients: Patients between 1 day and 18 years of age who had cardiopulmonary resuscitation and received chest compressions for >1 min, and had a return of circulation for >20 mins.

Interventions: None.

Measurements And Main Results: A total of 353 patients met entry criteria; 172 (48.7%) survived to hospital discharge. Among survivors, 132 (76.7%) had good neurologic outcome documented by Pediatric Cerebral Performance Category scores. After adjustment for age, gender, and first documented cardiac arrest rhythm, variables available before and during the arrest that were independently associated with increased mortality included pre-existing hematologic, oncologic, or immunologic disorders, genetic or metabolic disorders, presence of an endotracheal tube before the arrest, and use of sodium bicarbonate during the arrest. Variables associated with decreased mortality included postoperative cardiopulmonary resuscitation. Extending the time frame to include variables available before, during, and within 12 hours following arrest, variables independently associated with increased mortality included the use of calcium during the arrest. Variables associated with decreased mortality included higher minimum blood pH and pupillary responsiveness.

Conclusions: Many factors are associated with hospital mortality among children after in-hospital cardiac arrest and return of circulation. Such factors must be considered when designing a trial of therapeutic hypothermia after cardiac arrest in pediatric patients.
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http://dx.doi.org/10.1097/PCC.0b013e3181a7045cDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741542PMC
September 2009

Medical emergency and rapid response teams.

Pediatr Clin North Am 2008 Aug;55(4):989-1010, xi

Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, Melbourne, Australia 3052.

Hospitals that care for children are establishing medical emergency or rapid response teams as system solutions for preventing unexpected but foreseeable respiratory and cardiac arrest on inpatient units. Typically, an experienced team of doctors and nurses responds quickly to a direct request by any level of staff or even a parent for assistance with a child whose physiologic parameters meet predetermined criteria or whose condition causes concern to them. Several pediatric studies comparing outcomes before and after introduction of these rapid response systems reported reductions in rates of respiratory or cardiac arrest and death but no prospective study has compared pediatric hospitals that have implemented rapid response teams to hospitals that have not.
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http://dx.doi.org/10.1016/j.pcl.2008.04.006DOI Listing
August 2008

Bispectral index as a guide for titration of propofol during procedural sedation among children.

Pediatrics 2005 Jun;115(6):1666-74

Division of Pediatric Critical Care, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.

Objective: To determine whether the bispectral index (BIS) monitor could be used to guide physicians in titrating propofol to an effective safe level of deep sedation for children undergoing painful medical procedures.

Design: Multiphase clinical trial.

Setting: Outpatient treatment center of a university children's hospital.

Patients: Pediatric outpatients undergoing painful medical procedures.

Interventions: Patients were sedated with propofol for the procedures. Patients were monitored with a BIS monitor, and the BIS score was correlated with the patient's clinical level of sedation. The BIS score was then used as a guide to titrate propofol in the last phase of the study.

Measurements And Main Results: The study consisted of 3 phases. In a chart review of data for 154 children who underwent 212 procedures, propofol was found to be safe and effective, with consistent dosing among the intensivists administering the medication. The children received a mean bolus dose of propofol of 1.56 mg/kg, with a mean total dose of propofol of 0.33 mg/kg per minute for the duration of the procedure. In the second phase, 21 patients ranging in age from 27 weeks to 18 years, with normal neurologic function, were sedated with propofol. An observer who was blinded to the BIS scores recorded clinical levels of sedation and reactivity (with a modified Ramsay scale and reactivity score) every 1 to 3 minutes. Another observer recorded the BIS scores at the same times. A total of 275 data points were collected and evaluated. All data points from the times at which patients were considered to be sedated adequately were used to construct a normal distribution of BIS scores. The mean BIS score was 62. This distribution was used to predict that a maximal BIS score of 47 was needed to ensure adequate sedation for 90% of the population. In the third phase of the study, an algorithm was devised to determine the target BIS score necessary for adequate sedation of 95% of the patients. We chose an initial BIS score of 50 (at which 85% of the patients in phase 2 were sedated) because of the possibility of data from phase 2 being skewed toward oversedation. Propofol was administered by an intensivist in an attempt to maintain the target BIS score. A blinded observer noted the patient's clinical level of sedation. In this group, there were 2 failures, ie, patients were clinically uncomfortable despite a BIS score of < or =50, representing only 90% success. Therefore, with the algorithm, propofol was titrated to sedate the next patients to a BIS score of 45. These patients required a mean bolus dose of 1.47 mg/kg and a mean total dose of 0.51 mg/kg per minute to maintain a BIS score of 45. They awakened in 12.75 minutes. All patients were sedated adequately, all procedures were successful, and no patients experienced complications from the sedation. To eliminate variability in the way propofol was dosed, the next 10 patients were given propofol according to a standardized protocol. These 10 children received an initial bolus of 1 mg/kg, with incremental bolus doses of 0.5 mg/kg per dose (maximum: 20 mg) to achieve and to maintain a BIS score of 45. With this protocol, all patients were sedated adequately and none experienced complications from the sedation. The patients required a mean bolus dose of 2.23 mg/kg and a mean dose of 0.52 mg/kg per minute to maintain a BIS score of 45. The mean time until awakening was 14.9 minutes. Regarding the total dose over time and the time until awakening, there was no statistical significance between this group and the group sedated to a BIS score of 45 without the dosing protocol.

Conclusion: The BIS monitor can be a useful monitoring guide for the titration of propofol by physicians who are competent in airway and hemodynamic management, to achieve deep sedation for children undergoing painful procedures.
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http://dx.doi.org/10.1542/peds.2004-1979DOI Listing
June 2005

Duration of mechanical ventilation in life-threatening pediatric asthma: description of an acute asphyxial subgroup.

Pediatrics 2004 Sep;114(3):762-7

Division of Pediatric Critical Care, Strong Children's Research Center of the University of Rochester, Rochester, New York, USA.

Objective: Acute asphyxial asthma (AAA) is well described in adult patients and is characterized by a sudden onset that may rapidly progress to a near-arrest state. Despite the initial severity of AAA, mechanical ventilation often restores gas exchange promptly, resulting in shorter durations of ventilation. We believe that AAA can occur in children and can lead to respiratory failure that requires mechanical ventilation. Furthermore, children with rapid-onset respiratory failure that requires intubation in the emergency department (ED) are more likely to have AAA and a shorter duration of mechanical ventilation than those intubated in the pediatric intensive care unit (PICU).

Methods: An 11-year retrospective chart review (1991-2002) was conducted of all children who were aged 2 through 18 years and had the primary diagnosis of status asthmaticus and required mechanical ventilation.

Results: During the study period, 33 (11.4%) of 290 PICU admissions for status asthmaticus required mechanical ventilation. Thirteen children presented with rapid respiratory failure en route, on arrival, or within 30 minutes of arrival to the ED versus 20 children who progressed to respiratory failure later in their ED course or in the PICU. Mean duration of mechanical ventilation was significantly shorter in the children who presented with rapid respiratory failure versus those with progressive respiratory failure (29 +/- 43 hours vs 88 +/- 72 hours). Children with rapid respiratory failure had greater improvements in ventilation and oxygenation than those with progressive respiratory failure as measured by pre- and postintubation changes in arterial carbon dioxide pressure, arterial oxygen pressure/fraction of inspired oxygen ratio, and alveolar-arterial gradient. According to site of intubation, 23 children required intubation in the ED, whereas 10 were intubated later in the PICU. Mean duration of mechanical ventilation was significantly shorter in the ED group versus the PICU group (42 +/- 63 hours vs 118 +/- 46 hours). There were significantly greater improvements in ventilation and oxygenation in the ED group versus the PICU group as measured by pre- and postintubation changes in arterial carbon dioxide pressure and arterial oxygen pressure/fraction of inspired oxygen ratio.

Conclusions: AAA occurs in children and shares characteristics seen in adult counterparts. Need for early intubation is a marker for AAA and may not represent a failure to maximize preintubation therapies. AAA represents a distinct form of life-threatening asthma and requires additional study in children.
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http://dx.doi.org/10.1542/peds.2004-0294DOI Listing
September 2004

Apparent life-threatening events as an indicator of occult abuse.

Arch Pediatr Adolesc Med 2004 Apr;158(4):402; author reply 402-3

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http://dx.doi.org/10.1001/archpedi.158.4.402-aDOI Listing
April 2004