SOCC NCE FullProgram

AMERICAN ACADEMY OF PEDIATRICS
SECTION ON CRITICAL CARE
SCIENTIFIC ABSTRACT & EDUCATIONAL

PROGRAM
SUNDAY, NOVEMBER 4, 2018
section on CRITICAL CARE program
day 1 | 8AM - 3PM | Hyatt Regency orlando
plaza international ballroom f
JOINT SESSION 1 – SECTION ON CRITICAL CARE & SECTION ON

ANESTHESIOLOGY & PAIN MEDICINE
Anesthesia and the ICU, its more than passing gas

Problem: There are a number of areas of overlap between the practices of anesthesia and critical
care. Providers need to maintain competency and remain up to date in these areas.
Objectives:
1) Improved understanding of issues related to difficult airway management in the Intensive Care
Unit (ICU) setting from the anesthesiologist’s perspective.
2) Overview of acute and chronic pain management in the ICU setting.
3) Update on the neurodevelopmental implications of anesthesia in the OR and ICU setting.
4) Special considerations of the palliative care patient from the anesthesiologist’s perspective.
8:00- 8:15AM INTRODUCTIONS

LAURA IBSEN, MD, FAAP & COURTNEY HARDY, MD, FAAP
8:15- 9:00AM DIFFICULT AIRWAY MANAGEMENT IN THE

PEDIATRIC ICU SETTING
JOE TOBIAS, MD, FAAP
9:00- 9:45AM ACUTE AND CHRONIC PAIN MANAGEMENT IN

THE ICU SETTING
TARUN BHALLA, MD, MBA, FAAP
9:45- 10:00AM BREAK
10:00-10:45AM NEURODEVELOPMENTAL IMPLICATIONS IN

PEDIATRIC ANESTHESIOLOGY AND
INTENSIVE CARE PRACTICE
LISA WISE-FABEROWSKI, MD, FAAP
10:45-11:30AM SPECIAL CONSIDERATIONS OF THE

PALLIATIVE CARE PEDIATRIC PATIENT AND
THE IMPLICATIONS OF DNR STATUS IN THE
PERIOPERATIVE ENVIRONMENT
NANCY GLASS, MD, MBA, FAAP
11:30- 12:00PM PANEL QUESTION AND ANSWER

SUNDAY, NOVEMBER 4, 2018
JOINT SESSION 2 – SECTION ON CRITICAL CARE & SECTION ON NEPHROLOGY
Title: The Kidney in Critical Care – The Canary in the Coal Mine
Problem: Pediatric intensive care frequently requires care of patients with acute or pre-existing
kidney injury. Advances in both fields require ongoing education.
Topic and Procedure:

The methods to diagnose acute kidney injury have been revolutionized by the development of
more accurate biomarkers. At the same time, consensus definitions of acute kidney injury have
been developed by international groups, allowing for comparison of trials that have similar criteria.
Simultaneously, the technologies for continuous dialysis are now much more advanced. Kidney
transplant peri-operative and longer-term management have also changed, especially with the
advent of paired exchanges across distant centers and newer medications. Critical care
practitioners need to be familiar with these developments.
Objectives:
1) Understand the indications for and application of continuous renal replacement therapy.
2) Be aware of recent advances in the understanding and treatment of acute kidney injury.
3) Be aware of updates in kidney transplant, including donor management, donation after cardiac
death, post-transplant management, and outcomes.
1:00- 1:10PM INTRODUCTIONS

LAURA IBSEN, MD, FAAP
1:10- 1:40PM CONTINUOUS RENAL REPLACEMENT

THERAPY: INDICATIONS, MODALITIES,
PEARLS AND PITFALLS
TARA NEUMAYR, MD
1:40- 2:10PM ACUTE KIDNEY INJURY, UPDATE

SARAH SWARTZ, MD, FAAP
2:10- 2:40PM KIDNEY INJURY UPDATE: DONOR

MANAGEMENT, DONATION AFTER CARDIAC
DEATH, POST-TRANSPLANT
KENNETH ANDREONI, MD
2:40- 3:00PM PANEL OF SPEAKERS

MONDAY, NOVEMBER 5, 2018
SOCC SCIENTIFIC ABSTRACT PROGRAM
Objectives:
This session will enable physicians, trainees, nurses, and other healthcare professionals to present
original research in oral/platform and poster presentation formats. Attendees will become
conversant in new research in the field. Section abstract awards will be presented, as well as the
SOCC Distinguished Career Award.
8:00- 8:15AM INTRODUCTIONS

LAURA IBSEN, MD, FAAP
8:15- 9:30AM ORAL ABSTRACT SESSION I
8:15AM SAMUEL KASE

A CROSS-SECTIONAL ANALYSIS OF
COMPASSION FATIGUE, BURNOUT, AND
COMPASSION SATISFACTION IN PEDIATRIC
CRITICAL CARE PROVIDERS IN THE U.S.
8:30AM SARAH HILTON, MD, MSHS

CERIUM OXIDE NANOPARTICLE CONJUGATED
WITH MICRORNA-146A DECREASES LUNG
INFLAMMATION AND FIBROSIS IN BLEOMYCIN
MURINE MODEL
8:45AM AMBRISH PATEL, MD, FAAP

COMPARISON OF BLOOD PRESSURE
MEASUREMENTS IN UPPER AND LOWER
EXTREMITIES IN CHILDREN LESS THAN 1 YEAR
OF AGE UNDER GENERAL ANESTHESIA
9:00AM ALLISON WHALEN, MD, FAAP

2017 SOCC SMALL PROJECT AWARD
DEFINING COMPETENCY IN NEONATAL AND
PEDIATRIC BAG MASK VENTILATION
9:15AM PETA ALEXANDER, MBBS

EPIDEMIOLOGY AND OUTCOMES OF PATIENTS
WITH HEMOPTYSIS IN A PEDIATRIC REFERRAL
CENTER
9:30- 10:30AM POSTER WALK ROUNDS
1.) SNEHA KOLLI, MD, FAAP

A CASE OF PEDIATRIC THROMBOTIC
MICROANGIOPATHY IN A JEHOVAH’S
WITNESS
2.) MOISÉS GARCÍA-ROSA, MD, FAAP, FCCM

A RARE GENETIC CAUSE OF HYPERGLYCEMIA
IN AN INFANT
3.) ERICK JARAN LEON, MD, MBA

A RETROSPECTIVE ANALYSIS OF
HOSPITALIZATION TIME IN INFANTS WITH
RESPIRATORY DISTRESS SYNDROME
4.) AMINA JAJI, MD, FAAP

A RETROSPECTIVE STUDY EXAMINING THE
INFLUENCE OF PRE-ILLNESS DIET ON THE
CLINICAL COURSE OF VIRAL RESPIRATORY
ILLNESS IN CRITICALLY ILL INFANTS, 0-5
MONTHS OF AGE
5.) LARA OLIVER, MD, FAAP

ACUTE ASTHMA EXACERBATION AND
MANAGEMENT OF HISPANIC PATIENTS
ADMITTED TO HOSPITAL
6.) JENNIFER SETLIK, MD, FAAP

ADJUSTABLE SEPSIS SCORING IN THE
PEDIATRIC CRITICAL CARE SETTING
7.) ASHLESHA KAUSHIK, MD, FAAP

AN 11 YEAR OLD WITH SICKLE CELL DISEASE,
SOMNOLENCE AND HIGH FEVER- AND IT'S
NOT SICKLE CELL CRISIS
8.) ERNESTO MEIJA, MD
AN UNUSUAL CASE OF SEVERE
HYPOKALEMIA: THYROTOXIC PERIODIC
PARALYSIS IN A 16- YEAR-OLD HISPANIC MALE
9.) HANNAH LIVELY, MD, FAAP

ANURIC RENAL FAILURE WITH SIGNIFICANT
UREMIA IN AN INFANT FOUND TO HAVE
INFERIOR VENA CAVA, BILATERAL RENAL
VEIN, AND BILATERAL RENAL ARTERY
THROMBOSES
10.) DUSTIN HIPP, MD, FAAP

ASSESSMENT OF PHYSICIAN & NURSING
ATTITUDES & BARRIERS TO IMPLEMENTATION
PRIOR TO UNIVERSAL PICU DELIRIUM
SCREENING
11.) GRAHAM CHAMBERLAIN, BSC, MSC, MD

BEFORE THE CODE TURNS BLUE: AN
ANALYSIS OF CRITICAL ACTIONS PERFORMED
BY HEALTH CARE PROVIDERS PRIOR TO CODE
TEAM ARRIVAL
12.) JUAN BARRON, MD, MPH, FAAP

CODES, LOSS, & BURNOUT: HOW DO THEY
IMPACT US AND OUR PATIENTS?
13.) TAHIRA SARWAR
CONGENITAL DIAPHRAGMATIC HERNIA
PATIENTS WITH HYPOXIC ISCHEMIC
ENCEPHALOPATHY NEEDING
EXTRACORPOREAL MEMBRANE
OXYGENATION HAVE A POOR OUTCOME
14.) JORDAN MERZ, MD, FAAP

DO CORTISOL LEVELS PREDICT THE OUTCOME
OF PEDIATRIC ONCOLOGY PATIENTS
ADMITTED TO THE PICU FOR CONCERNS OF
SEPSIS?
15.) RAWAN MUSAITIF, MD
EFFECT OF POTASSIUM INFUSION ON SERUM
LEVELS IN CHILDREN DURING TREATMENT OF
DIABETIC KETOACIDOSIS
16.) ASHLESHA KAUSHIK, MD, FAAP

ENCEPHALITIS & POLIOMYELITIS IN A
VACCINATED 12 YEAR OLD
17.) JENNIFER BARTLETT, CPNP

ENTERAL NUTRITION DURING NON-INVASIVE
VENTILATION FOR CHILDREN WITH ACUTE
BRONCHIOLITIS ADMITTED TO THE PICU IS
WELL TOLERATED AND ASSOCIATED WITH
REDUCED RESPIRATORY RATE
18.) MUHAMMED ELHADI, MD, FAAP

EVALUATION OF THE OUTCOME OF PATIENTS
ADMITTED TO THE PICU IN TRIPOLI USING THE
PEDIATRIC RISK OF MORTALITY SCORE
19.) FERNANDO PENA-CRUZ, MD, FAAP

FULMINANT HEPATIC FAILURE DUE TO
NEONATAL HERPES SIMPLEX VIRUS TYPE 1:
UNUSUAL PRESENTATION OF NEWBORN
SEPSIS
20.) COURTNEY BRANTLEY, MD, FAAP

IMPROPER CAR SEAT USE LEADING TO SPINAL
CORD INJURY, NEUROGENIC SHOCK, & DEATH
21.) CASEY MEHRHOFF, DO, MS

IVIG-INDUCED COOMBS-POSITIVE HEMOLYTIC
ANEMIA IN A CRITICALLY ILL ADOLESCENT
MALE
22.) THAO NGUYEN, DO
LISTERIA MENINGITIS IN A PATIENT WITH
ENCEPHALOPATHY
23.) LEAH ABECASSIS, MSN, RN, CCRN

MAKING THE BEST OF A BAD SITUATION:
CLINICIAN’S PERSPECTIVES ON ETHICS
ROUNDS
24.) TAHIRA SARWAR
OUTCOMES OF HYPOXIC ISCHEMIC
ENCEPHALOPATHY PATIENTS NEEDING
EXTRACORPOREAL MEMBRANE
OXYGENATION – EXTRA CORPOREAL LIFE
SUPPORT ORGANIZATION DATABASE
ANALYSIS
25.) DANIELLE GREEN, MD, FAAP

PALLIATIVE CARE UTILIZATION IN CHILDREN
WITH HEART DISEASE
26.) ERIN BURNS, MD, FAAP

QUALITY IMPROVEMENT INITIATIVE TO
REDUCE EXCESS USE OF HEATED HUMIDIFIED
HIGH-FLOW NASAL CANNULA IN INFANTS
WITH BRONCHIOLITIS
27.) YAHAIRA PIZARRO, MD, FAAP

RECURRENT TRANSVERSE COLON VOLVULUS
IN ADOLESCENT WITH MARFAN SYNDROME: A
CASE REPORT
28.) LISA BELTER, MPH

RESULTS FROM THE CURE SMA NEWLY
DIAGNOSED SURVEY
29.) JESSICA LEE, MD, MHS

SEVERE HYPERTRIGLYCERIDEMIA: A RARE &
HARMFUL COMPLICATION IN DIABETIC
KETOACIDOSIS, TREATED SUCCESSFULLY
WITH PLASMAPHERESIS
30.) APRIL EDWELL, MD, FAAP

SHOCK FROM KAWASAKI DISEASE LEADING
TO PROFOUND CORONARY ANEURYSMS
31.) KEWAN HAMID, MD
SONOGRAPHIC INFERIOR VENA CAVA
ASSESSMENT TO PREDICT FLUID
RESPONSIVENESS IN PATIENTS WITH SEPSIS
32.) IVANNA MAXSON, MD, FAAP

THE HEART’S HALO: CARING FOR PEDIATRIC
PNEUMOPERICARDIUM
33.) AIRELLA BARHEN, MD, FAAP

THE ROLE OF VIDEO DEBRIEFING AS A
METHOD OF FEEDBACK FOLLOWING
SIMULATED PEDIATRIC RESUSCITATION
34.) ZASHA VAZQUEZ-COLON, MD, FAAP

THROMBOEMBOLIC EVENTS IN CHILDREN
AFTER INVASIVE PROCEDURES IN A
PEDIATRIC CARDIAC INTENSIVE CARE UNIT
35.) THAIS SALIM, MSC

TRACHEOSTOMY IN THE PICU: WHEN, WHY &
OUTCOMES
36.) ALLISON BLATZ, MD
TRENDS IN NEUROPHARMACOLOGIC
MEDICATIONS OVER TIME IN MECHANICALLY
VENTILATED CHILDREN
37.) BRITTANY DIFABIO, MD, FAAP

USE OF THE CORNELL ASSESSMENT OF
PEDIATRIC DELIRIUM FOR IDENTIFYING
DELIRIUM & ASSOCIATED RISK FACTORS IN
THE PICU
10:30-10:45AM SOCC UPDATES

MICHAEL S.D. AGUS, MD, FAAP, SOCC CHAIR
10:30-10:45AM DISTINGUISHED CAREER AWARD

JAMES FORTENBERRY, MD, FAAP
11:00- 12:15PM ORAL ABSTRACT SESSION II
11:00AM MATTHEW ZACKOFF, MD, FAAP

2017 SOCC SMALL PROJECT AWARD
IMPACT OF AN IMMERSIVE VIRTUAL REALITY

CURRICULUM ON MEDICAL STUDENT CLINICAL
ASSESSMENT OF INFANTS WITH
RESPIRATORY DISTRESS
11:15AM CONOR O’HALLORAN, MD

MORTALITY AND FACTORS ASSOCIATED WITH
HEMORRHAGE DURING PEDIATRIC
EXTRACORPOREAL LIFE SUPPORT
11:30AM JONATHAN FELDMAN, MD, FAAP

SAFETY & EFFICACY OF HIGH FLOW NASAL
CANNULA USE ON PEDIATRIC WARDS
11:45AM PRIYANKA PATEL, MBBS

SAFETY AND EFFICACY OF NON-INVASIVE
INHALED NITRIC OXIDE IN PEDIATRIC
CARDIAC INTENSIVE CARE UNIT
12:00PM ANIREDDY REDDY, MD

SOCIOECONOMIC DISPARITIES ASSOCIATED
WITH SEPSIS MORTALITY
12:15- 12:30PM ABSTRACT AWARDS

TBD
12:30- 1:30PM LUNCH

SOCC PROGRAM FOR TRAINEES & EARLY CAREER PHYSICIANS
Making a Brighter Future: Pediatric Critical Care Fellows Moving Forward
1:30- 1:55PM NAVIGATING THE JOB SEARCH & PREPARING

FOR THE INTERVIEW
Michael S.D. Agus, MD, FAAP
1:55- 2:20PM CONTRACT NEGOTIATION IN PEDIATRIC

CRITICAL CARE
W. Bradley Poss, MD, MMM, FAAP
2:20- 2:45PM BREAK
2:45- 3:10PM WHAT I WISH I’D KNOWN

Edward Conway Jr, MD, MS, FAAP
3:10- 3:35PM USING YOUR ADVOCACY VOICE

Elizabeth Mack, MD, MS, FAAP
3:35- 3:50PM BREAK
3:50- 4:00PM MOCK INTERVIEW ORIENTATION

Elizabeth Mack, MD, MS, FAAP & Erika Bernardo, MD,
FAAP
4:00- 4:15PM ROOM CHANGE

Florida Ballroom C
4:15- 5:30PM MOCK INTERVIEWS

Interviewers: Drs Michael Agus, Edward Conway, Laura
Ibsen, Elizabeth Mack, Brad Poss
5:30- 8:00PM JOB FAIR / NETWORKING RECEPTION

For additional details on the AAP National Conference &
Exhibition, including registration, please visit:
www.aapexperience.org
ABSTRACT & POSTER SESSIONS | 8:15AM – 12:30PM
ABSTRACT SESSION I | 8:15 AM – 9:30 AM

Presentation Time: Monday, November 5, 2018 at 8:15 AM – 8:30 AM
A Cross-Sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric

Critical Care Providers in the U.S.
Samuel M. Kase1; Andrea Weintraub2; Jeanie Gribben1; Elisha D. Waldman3, (1) Icahn School of Medicine at
Mount Sinai, New York, NY, (2) Division of Newborn Medicine, Department of Pediatrics, Mount Sinai Medical
Center and Icahn School of Medicine at Mount Sinai, New York, NY, (3) Ann & Robert H. Lurie Children's Hospital
of Chicago, Chicago, IL
Purpose: Compassion fatigue (CF) is emotional distress experienced by providers witnessing their patients'
suffering. Burnout (BO) is distress due to uncontrollable workplace factors that manifest in career and personal
dissatisfaction. CF and BO can independently lead to emotional exhaustion, depression, and depersonalization, all
of which can directly impact patient care. Compassion satisfaction (CS) is emotional fulfillment derived from
providing care to others. While BO in healthcare providers has been studied extensively, less is known about CF
and CS. Due to chronic exposure to distress in patients and families, pediatric critical care (PCC) providers may be
at particular risk for CF. Therefore, we determined the prevalence of CF, BO, and CS and identified potential
predictors of these phenomena in PCC providers.
Methods: A modified Compassion Fatigue and Satisfaction Self-Test for Helpers (CFST) and a questionnaire of
personal and professional characteristics were distributed electronically to a self-generated national list of providers
(Table 1). Prevalences of these phenomena were calculated. Hierarchical linear regression models for CF, BO, and
CS as a function of potential risk factors were constructed.
Results: The survey response rate was 35.7%. The prevalence of CF, BO, and CS was 25.7%, 23.2%, 16.8%,
respectively. BO score, emotional depletion, and distress about a patient and/or the physical work environment
were each significant determinants of higher CF scores. Preparing for didactics, CF score, distress about
administrative issues and/or coworkers, and 'self-care is not a priority' were each significant determinants of higher
BO scores. Female sex, CS score, and distress about the physical work environment were each significant
determinants of lower BO scores. Prayer/meditation, talking with colleagues, senior faculty level, and student and/or
chaplain involvement when delivering bad news were each significant predictors of higher CS scores. Female sex,
BO score, emotional depletion, and distress about coworkers were each significant predictors of lower CS scores
(Table 2). Conclusion: Lack of awareness of CF and BO can have profound implications for PCC provider well-
being and occupational performance. Unexpressed grief and the inability to reconcile distressing experiences may
be integral to the development of CF in PCC providers. This may be compounded by high levels of emotional
depletion and lack of formal training in constructive coping mechanisms reported by PCC providers. Protecting
against CF and BO while augmenting CS improves both the quality of patient care delivered as well as a provider's
enduring satisfaction with his or her career. Self-care practices, both at the individual and/or institutional level, may
enhance CS and offset CF and BO. Education about these phenomena and the importance of self-care and
reflection may be essential to promote healthy coping mechanisms and foster resilience.
Table 1. Modified Compassion Fatigue and Satisfaction Self-Care Test for Helpers
Table 2. Hierarchical multiple regression of predictors of CF, BO, and CS score in PCC providers.
Presentation Time: Monday, November 5, 2018: 8:30 AM – 8:45 AM
Cerium Oxide Nanoparticle Conjugated with MicroRNA-146a Decreases Lung Inflammation and Fibrosis in
Bleomycin Murine Model
Sarah Hilton, MD, MSHS1; Kenneth Liechty, MD2; Carlos Zgheib, PhD1; Lindel C. Dewberry, MD3; Maggie Hodges,
MD, MPH1; Junyi Hu, MD1; Junwang Xu, PhD1; Sudipta Seal, Phd4; Eva Nozik-Grayck, MD2, (1) University of
Colorado, Aurora, CO, (2) University of Colorado, Children's Hospital Colorado, Aurora, CO, (3) University of
Colorado, Denver, CO, (4) University of Central Florida, Orlando, FL
Purpose: Bronchopulmonary dysplasia and chronic lung disease due to prematurity are significant sources of
morbidity and mortality in former pre-term infants. Central to the pathogenesis of bronchopulmonary dysplasia is the
presence of chronic inflammation and increased oxidative stress which lead to pulmonary fibrosis. We hypothesized
that a novel therapeutic directed at reducing inflammation and oxidative stress may also reduce fibrosis and the
long-term sequela these infants face. MicroRNAs are short, non-coding RNAs that post-transcriptionally regulate
gene activity. MicroRNA-146a is a key regulatory molecule in the NFkB mediated inflammatory response, with
downstream effects on pro-inflammatory cytokines including IL-6. MicroRNA-146a was conjugated to cerium oxide
nanoparticles (CNP146a), which are scavengers of reactive oxygen species and rapidly taken up by epithelial cells.
The aim of this project was to evaluate intratracheal delivery of CNP146a at the time of bleomycin injury and
examine its effects on decreasing pulmonary inflammation and subsequent fibrosis.
Methods: Using an established murine model, 29 juvenile (10 week) male and female C57BL/6 mice, underwent
intratracheal instillation of bleomycin (3units/kg), PBS (as a control), or bleomycin and a single dose of CNP146a
(10uM). Animals were euthanized either 7 days post-injury for bronchial alveolar lavage and tissue harvest or 14
days post-injury for lung inflation and tissue harvest. Results Histologic analysis 14 days post-injury (Figure 1)
shows significant lung injury with bleomycin, including the presence of alveolar hemorrhage, increased collagen
deposition, and an abundance of CD45+ cells when compared to PBS treated controls. The study group treated
with CNP146a at the time of bleomycin injury showed less mucosal sloughing/hemorrhage, decreased
CD45+inflammatory cells, and markedly decreased lung fibrosis. Bronchial alveolar lavage (BAL) specimens were
processed for cell viability. There were no viable cells observed in the BAL obtained from the bleomycin treated
group at 7 days (0.0% cell viability compared to 32.04% cell viability in the PBS controls). The CNP146a treated
group had improved cell viability, equivalent to the control animals (35.92% cell viability).
Results: CNP-146a is a new therapeutic that may possess applications for the prevention and treatment of chronic
pulmonary disease in former pre-term infants at risk of developing bronchopulmonary dysplasia or chronic lung
disease. Histology 14 days post-injury demonstrates decreased inflammation, hemorrhage, and fibrosis the
CNP146a treated group. Further, the BAL samples show improved cell viability in the CNP-146a treated group.
These results indicate that CNP146a decreases the inflammation and fibrosis associated with the bleomycin
induced model of pulmonary fibrosis and may be an effective therapy in the mitigation of chronic pulmonary
disease.
Figure 1
Histology at 14 days. Images A, C, F represent trichrome stain with collagen stained light blue. Images B, D, F
show CD45 staining in brown. CD45 stains pro-inflammatory cells.
Comparison of Blood Pressure Measurements in Upper and Lower Extremities in Children Less than 1 year
of Age Under General Anesthesia
Ambrish B. Patel, MD, FAAP1; Joseph D. Tobias, MD1; Seth Hayes, MD1; Tariq Wani, MD1; Samar E. Adam, MD2;
Rebecca Miller, BS1; Dmitry Tumin, PhD1; Khalid Kadah, MD3; Hina Walia, MBBS1; Mohammed Hakim, MBBS1;
Faizaan Syed, MBBS1, (1) Nationwide Children's Hospital, Columbus, OH, (2) King Fahd Medical Center, Riyah, Ar
Riyad, Saudi Arabia, (3) King Fahd Medical Center, Riyadh, Ar Riyad, Saudi Arabia
Purpose: Blood pressure (BP) monitoring can be obtained non-invasively (NIBP) by oscillometry or invasively (IBP)
by an arterial cannula. Limited data exists comparing NIBP to IBP and NBIP taken in the upper versus lower
extremities in pediatric patients. With BP guiding major therapeutic decisions in pediatric intensive care units,
inaccuracies may complicate the timely diagnosis and treatment of hypotension. We aim to evaluate clinically
significant errors in NIBP relative to IBP measurements, while secondarily investigating the consistency of upper
versus lower extremity NIBP.
Methods: Using anesthetized patients as a surrogate for mechanically ventilated patients in the PICU, patients
under 1 year of age were enrolled if placement of an arterial cannula was planned. NIBPs were measured with two
separate but similar oscillometers with appropriately sized BP cuffs. Mean arterial pressures (MAP) from 3 sites
(radial artery, arm, and leg) were recorded at 5-minute intervals for 10 readings per patient. The primary outcome
was deviation of MAP >5 mmHg between IBP and at least one NIBP at any point during the study. This prospective
observational study included 8 patients, 4 boys and 4 girls. Across all data points, MAP was 57 ± 12 mmHg at the
arm, 56 ± 11 mmHg at the leg, and 59 ± 13 mmHg via the arterial cannula. On a Bland-Altman plot (Figure) the bias
and precision of BP measured at the arm, relative to IBP, was -1 and 7 mmHg, respectively (95% Iimits of
agreement: -15, +13 mmHg). The bias and precision of BP measured at the leg, relative to IBP, was -2 and 9
mmHg, respectively (95% limits of agreement: -19, +15 mmHg). When comparing IBP to NIBP at the arm, the
absolute deviation was 6 ± 4 mmHg (range: 0, 17 mmHg; 35/80 observations deviated by >5 mmHg, and 11/80
observations deviated by >10 mmHg). When comparing IBP to NIBP at the leg, the average absolute deviation was
7 ± 6 mmHg (range: 0, 26 mmHg; 44/78 observations deviate by >5 mmHg and 18/78 observations deviated by >10
mmHg).
Results: Our preliminary results suggest NIBP and IBP generally correlate well, but clinically significant
discrepancies using NIBP occurred one or more times during the study period in all patients. Although there was no
consistent trend in over or under measuring MAP by NIBP, our findings suggest caution is necessary when using
NIBP monitoring in patients in whom close hemodynamic monitoring is vital.
Conclusion: There were no clinically significant differences in the upper versus lower extremity NIBP
measurements, making either site viable options for hemodynamic monitoring in young pediatrics patients. The
frequency of clinically significant NIBP deviation supports the importance of invasive BP monitoring when
hemodynamic fluctuations would be particularly detrimental.
Figure
Bland-Altman plot of agreement between invasive mean arterial pressure (MAP) measurement and non-invasive
MAP measurement.
Defining Competency in Neonatal and Pediatric Bag Mask Ventilation
Allison M. Whalen, MD, FAAP; Donald Boyer, MD, MSEd, FAAP; Akira Nishisaki, MD, MSCE, Children's Hospital
of Philadelphia, Philadelphia, PA
2017 SOCC Small Project Award
Purpose: Bag-mask ventilation (BMV) is a lifesaving skill required of neonatal and pediatric practitioners, including
all those who hold NRP and PALS certification. As neonatal and pediatric practice evolves and further specializes,
trainee exposure and opportunity to perform BMV has changed. There exists no standardized definition or
measurement of competency in this procedure.
Methods: Currently, performance in BMV is most often described by global assessment by an expert provider from
which competency to perform BMV is inferred. As assessment in medical education shifts towards competency-
based performance and milestones, further definition of procedural competencies is warranted. We plan to develop
a tool to define competency in BMV in both the neonatal and pediatric patients. We utilized the INSPIRE network
checklist for neonatal BMV with Cronbach's alpha of 0.868 and developed an adapted pediatric BMV checklist. A
series of experimental plans are in place to generate validity evidence using both checklist and global assessment
with entrustable professional activity (EPA). Standardized simulation scenarios requiring BMV in a neonatal and
pediatric patient have been developed through iterative pilot-simulation and revisions. Specific cues with a set
timing are embedded in the scenario to ensure consistency and elicit each step of BMV. A standardized script for
confederate participants has been developed with standard language and delivery of the simulation. "Raters," non-
expert individuals trained in use of the checklist through standardized videos and "experts," neonatologists,
anesthesiologists, and pediatric critical care medicine, have been identified. BMV performance of the participants:
medical students, pediatric residents, neonatology and pediatric critical care fellows, and neonatology and pediatric
critical care (PCCM) attending physicians will be video recorded. Raters, blinded to participant identity and level of
training, will complete a checklist evaluation of the video of participant performance. Experts, blinded to participant
identity and level of training, will provide global assessment and entrustable professional activity (EPA) assessment
of the video of participant performance as the gold standard comparison.
Results: Inter-rater reliability and internal consistency of the checklist items will be established. Checklist scores by
raters will be compared to expert global assessment to provide evidence of checklist validity. The checklist scores
will be compared among the provider training level to produce criterion validity evidence. Finally, the comparison of
checklist scores and EPA assessment by expert will provide initial data for the checklist use for EPA assessment in
this procedural skill.
Epidemiology and Outcomes of Patients with Hemoptysis in a Pediatric Referral Center
Peta MA Alexander, MBBS1; Diego Porras, MD, MPH2; Katie Moynihan, MBBS2; Kris Andren, BS2; Jessica
Mecklosky, BS2; Lynn Sleeper, ScD3; Reza Rehbar, MD2; Ahmet Uluer, DO2; John Arnold, MD2; Ravi Thiagarajan,
MD, MPH2, (1) Boston Children's Hospital and Harvard Medical School, Boston, MA, (2) Boston Children's Hospital,
Boston, MA, (3) Boston Children's Heart Center, Boston, MA
Purpose: Hemoptysis is an uncommon pediatric symptom often associated with underlying medical conditions.
There is limited contemporary literature, but significant morbidity and mortality have been reported. We aimed to
describe the epidemiology of patients with hemoptysis in a quaternary pediatric center, and identify factors
associated with mortality. METHODS. We performed a retrospective, single center study of patients with
hemoptysis at presentation or during admission from 1 January 2008 to 30 June 2017. Demographics, hemoptysis
etiology, severity and onset were collated. Severe hemoptysis was defined as Intensive Care Unit admission,
hematocrit fall >10% or blood transfusion within 24 hours of hemoptysis. Logistic regression was used to examine
the primary outcome was 30-day mortality from hemoptysis onset. Survival to latest follow-up (survivor median 2.7,
interquartile range 1.0, 4.9 years) is also reported.
Results: There were 1087 hemoptysis admissions in 667 patients. Hemoptysis was the presenting complaint in 715
admissions (65.8%) and 364 patients (54.6%). Only 129 patients (19.3%) had multiple admissions (range 2-13
admissions). Median age at initial hemoptysis was 13.4 (interquartile range 3.1,18.6) years including 16.2% infants,
14.1% young children (1-<5 years), 16.6% children (5-<12 years), 25.8% adolescents and 27.1% patients >18
years. Diagnostic categories of those with hemoptysis were congenital heart disease (CHD) in 31.5% patients
(24.1% admissions); bronchiectasis 20.8% patients (42.1% admissions); respiratory tract infections in 17.8%
patients (12.3% admissions); and malignancy in 7.5% patients (5.2% admissions). In the study period 192 patients
died (28.7%). Based on first admission, 82 (12.3%) patients died within 30-days, 41 (6.1%) died >30 days after
hemoptysis in hospital and 68 (10.2%) died after hospital discharge. Multivariable analysis of all admissions
identified independent risk factors for 30-day mortality as severe hemoptysis (odds ratio [OR] 2.7, 95% Confidence
Interval [95%CI] 1.4-5.2, p=0.002), prior anticoagulation (OR 3.4, 95%CI 1.8-6.3, p<0.001), thrombocytopenia (OR
2.5, 95%CI 1.2-5.5, p=0.02), renal dysfunction (OR 3.7, 2.1-6.5, p<0.001), neurological impairment (OR 2.9, 95%CI
1.6-5.1, p=0.001), and diagnostic category (p=0.005). Relative to patients with bronchiectasis, higher 30-day
mortality was seen in malignancy (adjusted OR 8.9, 95% CI 2.9-27.4), with a trend in CHD (adjusted OR 2.3,
95%CI 0.9-5.5). The figure demonstrates Kaplan-Meier survival curves from initial hemoptysis differed by etiology
(A. Log-rank p=0.027), severity of hemoptysis (B. Log-rank p<0.001) and timing of hemoptysis onset (C. Log-rank
p<0.001).
Conclusions: Hemoptysis presentations are associated with significant mortality (12% at 30 days) in our center.
Severity and timing of hemoptysis presentation, coagulopathy, end organ dysfunction and underlying diagnosis of
malignancy or CHD were independently associated with mortality. Further investigation of this vulnerable population
is required to identify preventative measures and therapeutic strategies to manage the underlying pathophysiology.
ABSTRACT SESSION I | 11:00 AM – 12:15 PM
Impact of an Immersive Virtual Reality Curriculum on Medical Student Clinical Assessment of Infants with
Respiratory Distress
Matthew W. Zackoff, MD1, FAAP; Melissa Klein, MD2; Francis Real, MD, MEd2; Amy B. Guiot, MD, MEd1; Corinne
Lehmann, MD, MEd1; Ken Tegtmeyer, MD1, (1) Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (2)
CCHMC, Cincinnati, OH
2017 SOCC Small Project Award
Purpose: Respiratory distress is the most common cause of hospital admission during the 1st year of life.
Identification of respiratory distress is critical for escalation of care, relying upon exam skills which are often under-
developed in medical students. Our objective was to develop and assess the impact of an immersive virtual reality
(VR) curriculum on medical student competence in assessment of respiratory distress. Methods A randomized,
controlled study was initiated at a large, academic children’s hospital in July 2017. All 3rd year medical students on
the pediatric rotation were eligible. All medical students received standard training on respiratory distress through
didactics, mannequin simulation, and inpatient instruction. The intervention group also underwent an independent
30-minute VR curriculum with three simulations: 1) infant in no distress, 2) respiratory distress, and 3) impending
respiratory failure. The VR environment, experienced through an Oculus Rift headset, was created to replicate an
inpatient room. A facilitator-controlled VR preceptor guided the medical student through the simulation. The VR
patient portrayed exam findings (i.e. retractions, breath sounds, and mental status) with corresponding vital signs
on the VR monitor. A post-session survey included an anchored response, retrospective pre-post self-assessment
of competence and Likert scale questions regarding attitudes towards the VR environment and VR education.
Results were analyzed with binomial testing. At the end of each rotation, all students completed a free response
clinical assessment requiring evaluation of videos of 3 patients (included patient findings, vital sign data, and audio
of breath sounds). Assessments were coded utilizing rubrics developed by 6 clinical experts (Emergency Medicine
and Critical Care faculty), with consensus findings generated via a modified Delphi approach. Findings were
analyzed with Fisher’s exact test.
Results: Forty-two intervention and 46 control students participated between July 2017 and December 2017.
Ninety-four percent of intervention students demonstrated improvement in self-assessed competence (95% CI
[80.8-99.3], p<0.0001). A statistical majority of students rated the VR training as highly effective and immersive
(p<0.0001), as well as rated VR as equally or more effective than other key teaching modalities such as high-fidelity
mannequins (p=0.005) and standardized patients (p<0.001) (Table 1). The video-based assessment demonstrated
a significant difference between intervention and control students’ ability to consider, recognize, and interpret key
components of the pediatric respiratory assessment (Table 2).
Conclusion: We successfully implemented an immersive VR-based simulation curriculum targeting medical

student clinical assessment skills. This well received modality represents a unique approach to clinical training and
was successful in leading to improved self-assessed competence as well as an objective difference in competence
at the assessment of respiratory distress.
Table 1. Binomial testing demonstrates that a statistical majority of students agree or strongly agree with the
simulation’s clinical accuracy, ability to reinforce key assessment components, and likely impact on future
assessment of patients with respiratory distress or impending respiratory failure. A statistical majority of students
additionally found VR training equally or more effective than didactic teaching, online learning, low fidelity
mannequins, high fidelity mannequins, and standardized patients.
Thirty-five intervention medical students’ data analyzed; *denotes statistical significance; **only includes students
who have experienced the modality to allow comparison (otherwise selected N/A); N - number of students; CI -
confidence interval.
Table 2. Fisher’s exact testing demonstrates a statistical difference in the number of intervention students, as
compared to control, who considered mental status, commented on awake/alert status and commented on
movement/activity status for the respiratory failure and respiratory distress cases. A statistical difference was noted
for commenting on the presence or absence of a prolonged expiratory phase for all three cases and for
interpretation of respiratory rate in the no distress case. Lastly, a statistical difference was demonstrated for the
correct recognition of respiratory distress.
46 control and 42 intervention students’ data analyzed; *denotes statistical significance; C- Control Group; I -
Intervention Group; N - number of students
Mortality and Factors Associated with Hemorrhage during Pediatric Extracorporeal Life Support
Conor O'Halloran, MD1; Peta MA Alexander, MBBS2; Kris Andren, BS3; Jessica Mecklosky, BS3; Stephanie
Larsen, RRT3; Sally Vitali, MD4; Jill Zalieckas, MD, MPH3; Ravi Thiagarajan, MD, MPH3, (1) Boston Children's
Hospital, Brookline, MA, (2) Boston Children's Hospital and Harvard Medical School, Boston, MA, (3) Boston
Children's Hospital, Boston, MA, (4) Boston Children's Hospital, Boston, MA
Purpose: Pediatric Extracorporeal Membrane Oxygenation (ECMO) is associated with a high risk of hemorrhage.
We aimed to describe survival and factors associated with clinically significant bleeding during pediatric ECMO.
Methods: This retrospective cohort study included all patients supported by ECMO for > 12 hours from January 1st,
2015 through December 31st, 2016 at a single tertiary pediatric hospital. A 'Bleeding day' was defined if mediastinal
or cannula site exploration, Factor VIIa administration, gastrointestinal, pulmonary, or intracranial hemorrhages
occurred. Logistic regression was used to assess factors associated with bleeding days.
Results: 122 patients with median age of 0.3 (Interquartile range [IQR]: 0, 3) years were analyzed. Congenital
heart disease (CHD; n=56, 46%) was the most common diagnosis. Bleeding days comprised 179 (19%) of the 1121
observed ECMO days. By 4 days of ECMO, 50% of ECMO users have experienced a bleeding day (figure 1).
Compared to non-bleeding days, bleeding days more frequently occured in older patients (10 vs 2 months,
p<0.001), patients with cardiac diagnosis (51 vs 37%, p<0.001), and venoarterial ECMO (87 vs 76%, p<0.001). In
logistic regression central cannulation (OR 1.12, p<0.001), older age (OR 1.01, P<0.001), higher lactate (OR 1.01,
p=0.005), lower platelets (0.99, p=0.01), and higher prothrombin time (OR 1.01, p=0.03) were associated with
bleeding days. Patients who experienced more frequent bleeding (>75 percentile) had fewer ventilator-free and
hospital-free days in the 2 months after cannulation (12 vs 26, p = 0.003 & 3 vs 12, p=0.009) and higher in hospital
mortality (68 vs 34%, p=0.002).
Conclusion: Central cannulation, older age, low platelets, high lactate, and high prothrombin time are associated
with bleeding days during pediatric ECMO. Patients who bleed more frequently during ECMO have higher in
hospital mortality.
Figure 1
Cumulative Event-Free Survival from Bleeding Events

Safety and Efficacy of High Flow Nasal Cannula Use on Pediatric Wards
Jonathan D. Feldman, MD1,FAAP; Alexander s. Zusman, MD2; Tariq E. Chaudry, MD3; Liisa l. Lyon4; Debbie a.
Postlethwaite, RNP, MPH5, (1) Kaiser Santa Clara Medical Center, Santa Clara, CA, (2) The Permanente Medical
Group, Walnut Creek, IL, (3) The Permanente Medical Group, Santa Clara, CA, (4) Kaiser Permanente, Oakland,
CA, (5) Kaiser Pernamanente, Oakland, CA
Purpose: High flow nasal cannula (HFNC) is increasingly used to provide non-invasive respiratory support to
children with bronchiolitis and other causes of respiratory distress. Many institutions require that all children treated
with HFNC be admitted to the Pediatric Intensive Care Unit (PICU), while others allow HFNC use on pediatric
wards. There are little data on outcomes or complication rates for children treated with HFNC on pediatric wards.
Our main study objectives were to evaluate the efficacy and safety of HFNC use on pediatric wards.
Results: A retrospective cohort study was conducted of all (N= 309) children < 2 years of age treated with HFNC
on pediatric wards for bronchiolitis and other respiratory distress causes between 11/1/2010 and 4/30/2015 at 9
hospitals within a large integrated health care system. Three of these hospitals had both a pediatric ward and an
onsite PICU, 6 had no PICU. Descriptive statistics (frequencies, means, medians and proportions) and chi-square
tests were used to describe and compare demographic (age, race, gender) and clinical characteristics (weight,
onsite PICU status, history of prematurity, cardiac or chronic lung disease, respiratory syncytial virus, baseline heart
and respiratory rates) of subjects with successful HFNC use on the ward versus failure, defined as transfer to a
PICU. We used multivariable logistic regression models to assess factors associated with HFNC success on the
ward, controlling for other demographic and clinical factors. After meeting inclusions and exclusions, there were 208
patients in the final analytic cohort. In the overall cohort, 68% (N=141) and 78% (N=110) of those admitted to
hospitals with no onsite PICU succeeded with HFNC on the ward regardless of other demographic or clinical
characteristics (Appendix A). Controlling for all other factors, the logistic regression model demonstrated that
children admitted to hospitals without onsite PICU were 4 times more likely to succeed on the ward, compared to
those admitted to hospitals with an onsite PICU (aOR: 4.0 (CI: 2.1-7.9, p<0.01) (Appendix B). Patients weighing >
5kg were 2.6 times more likely to succeed on the ward compared with those weighing < 5kg (aOR: 2.6 (CI 1.3-5.2,
p<0.01). However, patients with higher than normal respiratory rates were less likely to succeed on the ward (aOR:
0.4, (CI 0.2-1.0, p=0.05). The rate of intubation following a trial of HFNC on the wards was 3.8%, with only 1 patient
requiring intubation prior to PICU transfer. There were no reports of pneumothorax.
Conclusion: These data suggest HFNC may successfully and safely be used on pediatric wards for many young
patients with respiratory distress. Further research might focus on development and validation of models with
characteristics predicting success or failure of HFNC on the ward, aiding earlier recognition of those likely to
succeed or require transfer to a PICU.
All p values calculated using Chi-Square tests unless otherwise noted *Fishers Exact Test † Normal versus high
heart and respiratory rates based on Pediatric Advanced Life Support (PALS) guidelines
†Normal versus high heart and respiratory rates based on Pediatric Advanced Life Support (PALS) guidelines
Presentation Time: Monday, November 5, 2018: 11:45 AM – 12:00 PM
Safety and Efficacy of Non-Invasive Inhaled Nitric Oxide in Pediatric Cardiac Intensive Care Unit
Priyanka Patel, MBBS1; Shriprasad Deshpande, MD2; Leslie Smitley, RN BSN3; Kevin Maher, MD4, (1) Emory
University, Atlant, GA, (2) Emory University, CHOA, Atlanta, GA, (3) Children's Healthcare of Atlanta, Atlanta, GA,
(4) Emory University / Children's Healthcare of Atlanta, Atlanta, GA
Purpose: The efficacy of inhaled nitric oxide (iNO) for treatment of postoperative hypoxemia and increased
pulmonary vascular resistance has been documented in a limited capacity in small randomized control studies.
There is no data regarding the use of iNO with non-invasive ventilation. We review our center experience with use
of iNO non-invasively in pediatric patients in our cardiac ICU and assess the safety and utility of no-invasive
delivery of iNO. Method: Retrospective study of patients treated with iNO in the cardiac ICU between 2010-2016.
Detailed data was collected prior to iNO, at the initiation of iNO, as well as at 1 hour, 12 hours and 24 hours after
starting iNO. Statistical analysis was performed with appropriate tests including repeated measures ANOVA.
Results: A total of 8 /178 patients (4.5%) were treated with non-invasive iNO during the study period. Patients with
diagnosis of primary PHN were excluded. Mean age at the initiation of iNO was 137.87 days (3-279 days). Male to
female ratio was 5:3. Mean weight at iNO was 5.03 kg. Primary diagnoses included Transposition of great vessels
(2), Ebstein’s anomaly (2), Tricuspid atresia (1), Congenital atresia of pulmonary valve (1), Chronic lung disease
(1), and Unbalanced common AV canal (1). 6 patients were administered iNO post-operatively, 1 pre-operatively,
and 1 without surgery. The most common indication for initiation of iNO was desaturations on high ventilator
support, high oxygen support (7 out of 8 patients), followed by elevated pulmonary vascular resistance (2 out of 8
patients). Non-invasive iNO was delivered using nasal cannula in 6 patients and NPPV in 2 patients. iNO dose was
initiated between 20-40 ppm. For 6 out of 8 patients, iNO was initiated post extubation. Changes in the vital signs,
blood gas, lactate, oxygen saturations by pulse oximetry, central venous pressure (CVP) and NIRS were reviewed
at various time points (table 1). Statistically significant changes were seen in saturations, CVP, pa02 and pCO2
post iNO initiation. There was a trend towards improvement for NIRS, from 40.33 at onset to 44.0 at 1 hour-post
iNO therapy (p-value=0.053). There were no significant changes in the hemodynamic parameters, including systolic
and diastolic blood pressures and heart rate. No adverse effects were noted. 7 of 8 (87.5%) patients successfully
weaned off iNO without the need for further ventilation.
Conclusion: This is the first study to assess and demonstrate a significant and positive impact of initiation of iNO
on patient hemodynamics, oxygenation, ventilation as well as measures of cardiac output such as NIRS with no
discernible side effects. Therefore, non-invasive delivery of iNO in certain clinical indications may be appropriate
and effective and warrants larger scale study.
Presentation Time: Monday, November 5, 2018: 12:00 PM – 12:15 PM
Socioeconomic Disparities Associated with Sepsis Mortality
Anireddy R. Reddy, MD; Monika Goyal, MD, MSCE; James Chamberlain, MD; Gia Badolato, MPH, Children's
National Medical Center, Washington, DC
Purpose: Disparities in healthcare related to socioeconomic differences have been well documented in adult
medicine but are less characterized in the pediatric population. Each year, more than 75,000 children are treated for
sepsis in the United States, with up to 20% resulting in death. We performed this study to test the hypothesis that
socioeconomic status is associated with the risk of mortality among children treated for sepsis in pediatric intensive
care units (PICU).
Methods: This was a retrospective cross-sectional study of 48 children’s hospitals from 2010 through 2016 using
the Pediatric Health Information System database. We included all visits by children ≤ 21 years old with APR-DRG
diagnosis codes of septicemia and disseminated infections that resulted in PICU admission. We measured the
bivariable association of sociodemographic factors (insurance status and median household income for the
patient’s zip code) with mortality. We performed multivariable logistic regression to measure the effect of
socioeconomic status on mortality after adjustment for age, gender, race/ethnicity, illness severity, and presence of
complex chronic condition with generalized estimating equations to account for clustering by hospital.
Results: During the study period, there were 14,276 PICU patients with sepsis. The median (IQR) age was 7.8
(1.5-14.8) years. Half (49.6%) identified as white, non-Hispanic. The majority (58.4%) were publicly insured and
1.5% were uninsured. Among the entire population, mortality rate from sepsis was 6.8 per 100 children.
Race/ethnicity was not associated with mortality risk. After adjusting for age, race/ethnicity, household income,
presence of a complex condition, and severity of illness, non-privately insured children had increased odds of
mortality when compared to privately insured children (public: aOR 1.3; 95% CI 1.1, 1.5; uninsured: aOR 2.3; 95%
CI 1.3, 4.1). Similarly, children who lived in zip codes with the lowest quartile of annual household income had
higher mortality rates than children living in zip codes with the highest quartile of annual household income (aOR
1.2 95% CI 1.0, 1.5).
Conclusions: These data suggest potential disparities in sepsis mortality in children based on socioeconomic
differences and insurance status. Further research is warranted to understand why such disparities exist.
Sociodemographic Factors Associated with Sepsis-related Mortality

POSTER SESSION | MONDAY, NOVEMBER 5, 2018 | 9:30 AM – 10:30 AM

(1) A Case of Pediatric Thrombotic Microangiopathy in a Jehovah’s Witness
Sneha Kolli, MD, FAAP; Nicole Christin, MD; Ryan Halickman, MD; Priyanka Seshadri, MD, Nicklaus Children's
Hospital, Miami, FL
Purpose: Thrombotic microangiopathy (TMA) is a disease affecting vessel walls leading to aggregation of platelets
and wall thickening. Laboratory findings include hemolytic anemia, thrombocytopenia, and elevated LDH. TMA is a
rare finding in the pediatric population. The main causes are thrombotic thrombocytopenic purpura (TTP), toxin-
mediated hemolytic uremic syndrome (D+ HUS), and atypical HUS. Less commonly TMA can occur as result of
malignant hypertension (MHTN), lupus/antiphospholipid syndrome, or medications.
Methods: We present a 15-year-old previously healthy Jehovah’s witness on no medications who presented in
hypertensive emergency, found to have azotemia (BUN 130 mg/dL, creatinine 25 mg/dL), anemia (Hgb 6 mg/dL),
thrombocytopenia (platelets 82 10K/uL), elevated LDH (1,283 IU/L), decreased haptoglobin (<20 mg/dL), and anion
gap metabolic acidosis (pH 7.29). Chest xray showed cardiomegaly and pulmonary edema. Troponin, CKMB, and
BNP were elevated, but MI was excluded. Urinalysis was notable for hematuria and proteinuria and there were
echogenic small kidneys on renal ultrasound. Patient admitted to the pediatric intensive care unit for further
management. Blood pressures and chemistries improved after hemodialysis, aggressive fluid removal, and
antihypertensive medications. TMA workup was extensive and currently ongoing. Shiga toxin mediated HUS was
excluded based on stool studies. ADAMTS13 did not meet criteria for TTP. Paroxysmal nocturnal hemoglobinuria
testing was negative. Lupus excluded as ANA and dsDNA antibodies were negative. Genetic testing for alternative
complement pathway suggesting atypical HUS is pending. Our case is uncommon and presents many challenges.
As our patient is a Jehovah’s witness, we were unable to perform genetic testing, kidney biopsy, or placement of a
more permanent dialysis catheter. In addition, at presentation the underlying etiology of his TMA was unclear but
throughout his admission we have narrowed down the possible cause. There was evidence suggesting chronic
kidney disease as his primary diagnosis causing MHTN including small echogenic kidneys on ultrasound, elevated
PTH levels, and asymptomatic anemia as patient was without tachycardia with a Hgb of 6 mg/dL. With aggressive
blood pressure control there has been a decrease in serum LDH and CBC has remained stable. He did not receive
plasmapheresis, plasma infusion, or C5 blocking monoclonal antibody. MHTN is characterized by severe
hypertension and end-organ damage. The pathology of organ damage is typically from endothelial cell injury
causing activation of proinflammatory cytokines and clotting factors.
Conclusion: This results in thrombi formation in arteriolar lumens and resultant narrowing of blood vessels and
destruction of RBCs and platelets. The patient is clinically improving, although kidney function is not and remains on
dialysis. The kidney biopsy cannot be safely performed at this time due to blood product refusal and we hope to do
so in the future once his hematologic parameters improve.
(2) A Rare Genetic Cause of Hyperglycemia in an Infant
Moisés García-Rosa, MD1, FAAP; Ana García-Puebla, MD1; Carlos Ocasio, MD1; Carolina Currais, MD2, (1)
University Pediatric Hospital, University of Puerto Rico, Medical Sciences Campus, San Juan, N/A, Puerto Rico, (2)
University Pediatric Hospital, University of Puerto Rico, Medical Sciences Campus, Guaynabo, N/A, Puerto Rico
Purpose: Diabetes diagnosed in the first 6 months of life is termed Neonatal Diabetes Mellitus. Neonatal Diabetes
Mellitus is extremely rare, affecting approximately 1 in 100,000 live births. A genetic diagnosis is possible in 80% of
patients and mutations in 22 different genes have been reported. Depending on the mutation, disease may be
transient or permanent. Early genetic diagnosis is essential since some forms involve the ATP-sensitive potassium
(KATP) channel within the pancreatic beta cell and respond to treatment with Sulfonylurea. Case Presentation A 2-
month-old baby girl born term adequate for gestational age without complications, to a 29-year-old deaf-mute
mother, and with history of failed audiology screening at Nursery, was transferred to University Pediatrics Hospital
due to hyperglycemia (>500 mg/dL). Upon further history, patient had previously developed tachypnea, irritability
and vomits; one week prior to presentation, she also had increased number of wet diaper changes. No other
associated symptoms were reported. Upon physical examination, patient was hypoactive, in moderate respiratory
distress and with dry mucosas.
Results: Laboratories were remarkable for hyperglycemia, high anion gap metabolic acidosis (see Table 1 and
Table 2), ketones in urine and elevated Glycosylated hemoglobin at 8.9%. Patient was immediately given IV
hydration and started in an Insulin drip following Hospital’s Diabetic Ketoacidosis (DKA) protocol. When DKA
resolved, patient was started in Glargine and Lispro. Patient remained in the Pediatric Intensive Care Unit where
she continued with uncontrolled glucose levels. Samples for gene testing were taken in both patient and patient’s
mother who was diagnosed with Diabetes Mellitus type II at 19 years of age. Sequence analysis of patient’s ABCC8
gene identified a homozygous missense variant p. (Arg1380His). This variant is predicted to be pathogenic
confirms a genetic diagnosis of recessively inherited neonatal diabetes due to a homozygous variant in the SUR1
subunit of the pancreatic KATP channel. Patient’s mother was heterozygous for the ABCC8 p. (Arg1380His)
variant. When heterozygous, this variant has been previously reported to cause transient neonatal and/or later
onset diabetes. Both mutations involved the KATP channel, which responds to high dose Sulfonylurea. Patient
achieved adequate glycemic control after Lispro and Glargine were discontinued, and Sulfonylurea was started.
Follow up Glycosylated Hemoglobin 2.5 months after presentation decreased to 6.9%.
Conclusion: Neonatal Diabetes Mellitus is very rare and should be highly suspected in children (<6months) of
Diabetic mothers who present with polyuria and hyperglycemia. Early intervention when in DKA prevents cerebral
edema as the most fatal complication; high index of suspicion and prompt diagnosis of genetic mutations are
clinically essential as treatment with Sulfonylurea is highly effective.
(3) A Retrospective Analysis of Hospitalization Time in Infants with Respiratory Distress Syndrome
Erick Alexander Jara Leon, MD1; Diego Antonio. Vasquez Cedeño1; Lizandro Leandro. Loor Salvatierra1; Maria
Daniela. Rendon Salazar2; Jose Andres. Dueñas Cisneros2, (1) Universidad Catolica de Santiago de Guayaquil,
Guayaquil, Guayas, Ecuador, (2) Universidad Catolica de Santiago de Guayaquil, Chicago, IL
Purpose: To describe the hospitalization time of infants with Respiratory Distress Syndrome that are admitted to
the Neonatal Intensive Care Unit. Methods: A non-experimental, descriptive, retrospective study was conducted.
The population sample consisted in 134 newborns diagnosed with Respiratory Distress Syndrome that were
admitted to the Neonatal Intensive Care Unit at a hospital in Guayaquil, Ecuador during the years 2015 and 2016.
The variables: sex, gestational age, weight, type of ventilation, hospitalization time and patient`s status at discharge
were analyzed by reviewing patients records on the system. All patients that were transferred to other units, or had
incomplete clinical records were excluded of the study. The data was then recollected on Microsoft Excel 2016 and
analyzed using Kruskal-Wallis test and Spearman correlation. The significant level was set at p=0.05.
Results: 134 newborns were included. 80 (60%) boys and 54 (40%) girls. The mortality rate was 16%. It was
evidenced that a bigger proportion of cases with RDS (46%) developed in infants at term. A significant relationship
between the gestational age and the hospitalization time was stablished (p=0.014). Infants at term tend to stay less
time hospitalized with an average between 4 to 7 days. The type of ventilation most frequently used was the
cephalic mask (54.47%) but it was determined that the type of ventilation and hospitalization time also presented a
significant relationship. The use of OXIHOOD was directly related with less days of hospitalization with an average
between 1 and 7 days (p=0.02). The average hospitalization time in newborns with RDS was stablished between 4
and 7 days (36,57%) with a chance of extending between 8 to 14 days in some cases (27,61%). In the minority of
cases (10,44%) the infants were discharged in less than 3 days.
Conclusion: It is stablished that the hospitalization time is influenced by the gestational age of the infant and the
type of ventilation used. Key words: Respiratory Distress Syndrome, Respiratory Insufficiency, Intensive Care,
Pulmonary Ventilation
Relationship between the type of ventilation used as treatment and hospitalization time
Relationship between gestational age and hospitalization time
(4) A Retrospective Study Examining the Influence of Pre-illness Diet on the Clinical Course of Viral
Respiratory Illness in Critically Ill Infants, 0-5 Months of Age
Amina Jaji, MD1,FAAP; Mara L. Leimanis, PhD2; Jessica Montgomery, BSc, MD(2020)3; Jennifer Jess, BSc,
MD(2021)3; Alan Davis, PhD4; Dominic Sanfilippo, MD2; Surender Rajasekaran, MD, MPH2, (1) Spectrum Health,
Helen DeVos Children’s Hospital, Grand Rapids, MI, (2) Pediatric Intensive Care Unit, Helen DeVos Children’s
Hospital; Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, (3)
Michigan State University, Grand Rapids, MI, (4) Spectrum Health, Grand Rapids, MI
Purpose: Studies have shown that breastfeeding offers several health benefits such as optimal weight gain and
lower rates of infectious diseases. The macro and micronutrient content of breast milk has been studied for
decades but only recently are we beginning to understand its impact on the developing immune system. In spite of
attempts to mimic the metabolic content of breast milk, immune proteins are harder to mimic as they are more labile
and less likely to survive storage. It is accepted that breast milk provides some resistance to viral illness, but little is
understood whether it modifies the clinical course of established illness. We examined if an aggressive immune
response that would be expected from breast milk would shorten the course or be a disadvantage by increasing
inflammation and prolonging critical illness. Objective: Our central hypothesis is that infant’s nutrition is an integral
factor in the recovery from severe respiratory illness. Primary endpoint: PICU days of hospitalization.
Results: After IRB approval, clinical data was extracted from 204 patients admitted to the PICU from January 2011
to May 2017 at a tertiary care facility. Inclusion criteria: infants (0-5mths), fed enterally, patients of the PICU,
admitted with a respiratory diagnosis grouped into, formula, breast fed or mixed; exclusion criteria: prematurity <32
weeks gestation, respiratory or immune comorbidities, G-tube fed infants, patients with pre-existing gut motility
disorders. Data expressed as median [interquartile range], qualitative data expressed as frequency (percent),
differences between groups was assessed using a Mann-Whitney U test. Results: Dietary admission profiles
included: breast fed (n=65; 32%), formula fed (n=97; 48%), and mixed diet (n=42; 21%). Initial univariate analysis
revealed statistical differences between the three groups, and were separated for subsequent analysis, however
admission PELOD scores were similar amongst groups. Breast fed infants had older gestational ages (P<0.001),
higher median household income (P<0.01), Caucasian (P<0.05), and younger age (median 1.3 mth; P<0.001), as
compared to the formula fed group. Although not statistically significant, breast and mixed fed infants spent one day
less in the PICU compared to formula fed infants (4.6, 4.3 vs. 5.5). While within normal reference ranges breast fed
infants had higher eosinophil counts, hematocrit, hemoglobin (all P<0.05), creatinine (P<0.01), bilirubin (P<0.001)
levels as compared to formula fed infants. Formula fed infants had higher immature WBC’s, albumin (P<0.05),
tCO2 (P=0.08).
Conclusion: Breast fed patients had the advantage in spite of being of younger age when they required a PICU
admission with a shorter PICU LOS. Key hematological and biochemical indicators may imply that there are
significant differences in the way that the three groups respond to critical respiratory illness. Further analysis is
necessary to explore sub-groupings with specific microbiological diagnosis of infection, to reveal differences (viral
vs. bacterial vs. co-infections).
(5) Acute Asthma Exacerbation and Management of Hispanic Patients Admitted to Hospital
Lara S. Oliver1, MD, FAAP; Lymarie Rosado-Barreras2; Bryan López-Ortiz3; Gabriela Gorbea-Fuxench3; Jesus
Merced-Román3; Gabriela Mendez-González3; Anabel Puig, Ph.D, FCCP4, (1) San Jorge Children's Hospital, San
Juan, N/A, Puerto Rico, (2) UPR- Medical Sciences Campus, San Juan, N/A, Puerto Rico, (3) UPR- Rio Piedras
Campus, San Juan, N/A, Puerto Rico, (4) University of Puerto Rico Medical Sciences Campus Department of
Pediatrics Critical Care Medicine Section, San Juan, N/A, Puerto Rico
Purpose: Asthma is the third most common cause for hospitalization among the pediatric population under 15
years old. Studies report a higher prevalence of asthmatic children and hospital admissions due to asthma attacks
among Puerto Rican children living in the island, than those living in the United States. This study assessed the
profile of patients admitted to PICU and Ward due to asthma exacerbations. Methods This retrospective case-
control study evaluated all admissions to a pediatric children’s hospital in the San Juan metropolitan area of Puerto
Rico from July 2016 to July 2017 due to asthma. Patients between the ages of 4 and 21 years old admitted with an
official diagnosis of asthma were evaluated. Patients under mechanical ventilation at home, history of any
neuromuscular disorder, history of cystic fibrosis, history of bronchopulmonary dysplasia, history of NICU
admission, history of immunosuppression, and history of less than 48 hours with symptoms were excluded. The
following data was collected: demographic, origin (PICU or Ward), clinical, previous hospital admissions, and
relevant past medical history and management. Severity of asthma was assigned using the Asthma Clinical
Respiratory Score (CRS) on admission. Data was expressed as means, medians ± SD, frequencies and
percentages as appropriate. An un-paired Mann-Whitney test was used to compare continuous variables from
patients from PICU vs Ward. A Fisher’s Exact Test was used for proportions and categorical data.
Results: A total of 254 admissions were evaluated, of which 34% were from PICU. PICU admissions were 51%
female with an average age of 8.9 years. Ward had 52% males with a mean age of 9 years. Hospital LOS of
admissions to PICU were longer than admissions to Ward (9.2 vs 5.4 days). Average PICU LOS was 4.8 ± 2.4 days
and average Ward LOS was 5.4 ± 3.3 days. PICU patients had 65% moderate and 35% mild asthma. Ward
patients had 48% moderate and 52% mild asthma. A 95% of patients received IV steroids in the first 24 hours,
whereas only 28% used Ipatropium for asthma management.
Conclusion: Patients with asthma are at risk for life-threatening exacerbations requiring PICU admissions,
especially those not receiving or adherent to long-term control medication. Physicians and parents should be aware
of risk factors, and efforts should be made to counteract them. It is possible to use findings from this study to define
guidelines for admission of asthmatic patients to Ward or PICU and their clinical management needed.
(6) Adjustable Sepsis Scoring in the Pediatric Critical Care Setting
Jennifer Setlik, MD1, FAAP; Meg Frizzola, DO2; Erica Stevens, BSN, RN, CCRN3; Hannah Stinson, MD4; Shirley
Viteri, MD4; Mashael Alqahtani, MD1, (1) Nemours Childrens Hospital, Orlando, FL, (2) Nemours AI duPont Hopsital
for Children, Wilmington, DE, (3) Nemours Foundation, Wilmington, DE, (4) AI DuPont Hospital for Children,
Wilmington, DE
Purpose: Sepsis is an all too common event, responsible for 75,000 hospitalizations and 7,000 deaths in the
United States annually. Timely recognition of clinical change or deterioration in a critically ill patient is essential for
the reduction of morbidity and mortality.
Results: Creation and utilization of a shock score across a pediatric healthcare enterprise. The shock tool was
utilized in the pediatric intensive care unit in both the teaching and community clinical settings. The tool
incorporates vital signs and nursing assessments. Through continuous improvement methodology this tool was also
utilized in the inpatient and emergency departments. A shock huddle initiated upon scoring threshold, at huddle
critical care team able to adjust shock score based on the patient’s chronic condition. Shock huddles occurring up
to twice a day. Results: Shock score with similar sensitivity and specificity within the critical care and non-critical
care setting. High negative predictive value (figure 1). Overall length of stay and decrease of stay by 3 days (figure
2). 20-25% of the tool alerts within the hospital occurred within the critical care setting.
Conclusion: An adjustable shock tool can provide a reasonable alert to clinical changes in the critically ill patient.
The bundled alerts increase use of standardized order sets and timely interventions. The scoring and alerts lead to
a decreased hospital length of stay.
Figure 1: Predictive Value of Speis Score
Figure 2: Hospital and ICU length of stay

(7) An 11 Year Old with Sickle Cell Disease, Somnolence and High Fever- And it's Not Sickle Cell Crisis
Ashlesha Kaushik, MD, FAAP; UnityPoint Health and Siouxland Medical Education Foundation, Sioux City, IA
Purpose: 11 y/o African- American male with sickle-cell disease with 3 days of fever. H/o travel to Nigeria X2
weeks; returned 10 days ago. At admission, the patient was febrile at 39°C with icterus+. Hemoglobin was 6.2 g/dL
with a baseline of 8 g/dL. Peripheral blood smear for malarial parasites was negative. Within 2 hours of admission,
the patient became hypoxic, somnolent and hypotensive. Repeat laboratory work-up showed a hemoglobin of 4.5
g/dL, platelet count of 44 X109/L, total and direct bilirubin of 36.5/ 29 mg/L. Differential Diagnoses were fever in a
returned traveler (Typhoid, Malaria, Dengue) and Noninfectious (Sickle-cell crisis). The second peripheral smear for
malarial parasites was positive and revealed ring forms with parasite index 2.2%. Quinidine and doxycycline were
initiated for severe malaria. By day-6, parasite load was zero and the patient did well.
Results: WHO estimates about 3.3 billion people at risk for malaria. Malaria is the 5th leading infectious disease
that causes deaths. Plasmodium falciparum causes severe malaria and cerebral malaria, and peripheral smear
shows characteristic multiple ring forms. Per CDC, diagnostic criteria for severe malaria are positive smear/history
of recent exposure with >1 of the following: coma/severe anemia/renal failure/pulmonary edema/ARDS/shock/DIC/
acidosis/ hemoglobinuria/ jaundice/ seizures, and/or parasitemia > 5%. Treatment: Quinidine or artesunate
+doxycycline / clindamycin. Exchange transfusion if parasite density >10%. Malaria, sickle-cell-trait and sickle-cell-
disease: Usually low parasite loads seen in sickle cell anaemia.
Conclusion: It is unclear why sickle-cell trait has protective effect while sickle-cell-disease predisposes to severe
malaria. According to one theory [3] homozygous and heterozygous patients for the HbS allele have higher level of
free heme in blood. Heterozygotes (sickle-trait) show resistance to severe malaria and have survival benefit
because Heme-oxygenase and carbon-monoxide are upregulated in sickle-cell trait due to their anti-oxidant effects.
Whereas modest increases in free heme is protective, higher concentrations of free heme scavenges nitric-oxide
and low levels of nitric-oxide have been linked to endothelial dysfunction in human and mouse severe malaria and
could explain severe disease in sickle-cell-disease. References: 1. World Health Organization: Malaria diagnosis
and treatment. Available at: WHO/malaria 2. Centers for Disease control and prevention: Malaria. Available at:
http://www.cdc.gov/malaria 3. Haque A, Engwerda CR. An antioxidant link between sickle cell disease and severe
malaria. Cell. 2011 Apr 29;145(3):335-6. PMID: 21529707
(8) An Unusual Case of Severe Hypokalemia: Thyrotoxic Periodic Paralysis in a 16-Year-Old Hispanic Male
Ernesto Meija, MD1; Vikas Shah, MD2; Peter Pastolero, MD1; Anmol Goyal, MBBS1; Dimpy Mody, MD1, (1) SUNY
Downstate, Brooklyn, NY, (2) Kings County Hospital, Brooklyn, NY
Purpose: Thyrotoxic periodic paralysis (TPP) is a rare and serious complication of hyperthyroidism associated with
Graves' disease which typically presents as an acute paralysis in the second decade of life and rarely in the
pediatric population. Case Report: A 16-year-old Hispanic male with no prior medical or family history of paralysis
presented to the emergency department with acute onset generalized muscle weakness upon awakening. Despite
being unable to ambulate that day, there was no acute distress or facial asymmetry. Physical exam revealed poor
strength in bilateral hip flexors (⅖) and shoulders (⅗) but normal strength in all other muscle groups. The remaining
neurological examination was unremarkable. Respiratory and cardiac exam were unremarkable. Initial
investigations (see table 1) were significant for hypokalemia and an abnormal thyroid function test (TFT). EKG
findings reflected hypokalemia (see figure 1a). The patient was admitted to the PICU for management of severe
hypokalemia and observed for cardiac and respiratory compromise. PICU management included infusion of
crystalloid with 40 mEq/L of potassium chloride and initiation of methimazole (10 mg daily) and propranolol (20 mg
daily) for Graves' disease confirmed with a RAIU scan (see figure 1b). Serum level of potassium increased to 3
mEq/L after 8 hours, with complete resolution of weakness and a normalized EKG. After resolution of symptoms,
the patient was discharged with anti-thyroid medication and an endocrinology follow-up. One month following
discharge, his TFT normalized and no additional paralytic episodes were reported.
Results: TPP is an uncommon consequence of hypokalemia in the presence of hyperthyroidism. Although most
commonly occurring in the second decade of life and in Asian males, there are increasing cohort of patients with
TPP which include younger patients and other ethnicities. TPP presents as periodic episodes of acute weakness
affecting the lower extremities and proximal muscle groups. The sparing of ocular, bulbar, and respiratory muscles,
consciousness, sensation, and bowel/bladder function help distinguish it from other acute myopathies. The
distinguishing feature of TPP is that the paralysis occurs only in a hyperthyroid state. This is a result of an
intracellular shift of potassium via the stimulating effect of thyroid hormone on the Na+/K+ ATPase in those
genetically predisposed with mutations in the Kir 2.6 gene. Potassium repletion remains the mainstay treatment of
acute attacks to improve symptoms and avoid cardiac complications but ultimately correcting the underlying thyroid
disease is necessary to prevent future episodes.
Conclusion: TPP should be considered as a differential diagnosis for acute paralysis in adolescent males who
present with weakness. A thorough history and physical exam may aid in the diagnosis, but laboratory studies are
needed to conclusively link the paralysis to a hypokalemic and hyperthyroid state. Education of the disorder among
pediatricians allows early recognition and timely intervention.
(9) Anuric Renal Failure with Significant Uremia in an Infant Found to Have Inferior Vena Cava, Bilateral
Renal Vein, and Bilateral Renal Artery Thromboses
Hannah R. Lively-Endicott1, MD, FAAP; Joyce Varghese, D.O.2; Angelina M. Dixon, MD3, (1) University of
Queensland, Ochsner Clinical School, New Orleans, LA, (2) Ochsner Hospital for Children, New Orleans, LA, (3)
Tulane University School of Medicine, New Orleans, LA
Purpose: We present the case of a 5-month-old, ex-24-week female transferred to our pediatric intensive care unit
(PICU) from an outside hospital neonatal intensive care unit (NICU) with anuric renal failure and significant uremia
(BUN>200) secondary to inferior vena cava (IVC), bilateral renal vein (RV), and bilateral renal artery (RA)
thromboses associated with a right broviac line. Introduction Preterm infants are at increased risk for acute kidney
injury (AKI); however, developing a BUN greater than 200 is still uncommon. Common neonatal etiologies of uremia
include IVC and RV thrombosis (1), maternal use of non-steroidal anti-inflammatory drugs (NSAIDs) (2, 3), and
congenital renal disease (4). However, past the neonatal period, intrinsic renal disease is the leading cause of
acute kidney injury in pediatric patients (5, 6). Renal vein thrombosis (RVT) is predominantly a neonatal disease (7-
9), and RVT in patients beyond the neonatal period is more often associated with nephrotic syndrome and renal
transplantation (8, 10).
Results: Our patient’s creatinine quadrupled ten days prior to transfer and in the following days she became anuric.
Upon arrival, she was placed on SLED/SCUF. Ultrasound studies demonstrated complete obliteration of renal
venous flow, increased echogenicity of the IVC, and increased resistance in renal arterial flow, so our patient was
immediately started on a heparin drip. Subsequent catheterization confirmed bilateral renal vein, renal artery and
IVC thromboses, and the patient underwent mechanical thrombectomy of her IVC and right renal vein, in addition to
site-directed TPA to her renal veins, renal arteries, and IVC. Ultimately, anticoagulation to further resolve these
thromboses was not sustainable due to development of severe coagulopathy, and the decision to withdraw support
was made. The patient passed away comfortably, surrounded by family.
Conclusion: data on abdominal venous thromboembolism in pediatric patients is limited, and current diagnosis and
management principles rely heavily on extrapolation from adult studies (8, 9, 11). The three “cardinal features” often
seen in patients with RVT are hematuria (macroscopic or microscopic), a palpable abdominal or flank mass, and
thrombocytopenia, though this “classic” presentation is rare, and a patient with any one of these three signs plus
risk factors should be evaluated further (1, 7, 10, 12-14). Renal insufficiency is often seen at presentation, but the
degree of renal dysfunction varies (1, 7, 8, 14). Conclusion Early diagnosis of RVT is important to prevent
perpetuation of the thromboembolism. Since the presentation of RVT can non-specific, diagnosis of RVT requires
maintaining a high index of suspicion when risk factors and any of the cardinal features are present (8, 10).
(10) Assessment of Physician & Nursing Attitudes & Barriers to Implementation Prior to Universal Pediatric
ICU Delirium Screening
Dustin M. Hipp, MD, MBA1, FAAP; Nicholas A. Ettinger, MD, PhD1; Erika Bernardo, MD1; Noelle Gorgis, MD1;
Sridevi Ellickal, MD1; Nathan A. Serazin, MD1; Kyle A. Brown, MD1; Saleh Bhar, MD1; Karla M. Abela, MSN, RN,
CCRN-K, CPN2; Matthew A. Musick, MD1, (1) Baylor College of Medicine/Texas Children's Hospital, Houston, TX,
(2) Texas Children's Hospital, Houston, TX
Purpose: Delirium is defined as an acute, global brain dysfunction that is common, yet underappreciated in
critically-ill pediatric patients. Delirious patients have longer hospital stays, increased risk of mortality, and higher
rates of post-traumatic stress syndrome. To address this problem, several screening tools have been developed to
facilitate diagnosis of pediatric ICU delirium. Implementation of delirium screening has been associated with
decreased prevalence and improved outcomes. In the initial phase of a broader QI project, we conducted a pre-
intervention survey of clinicians and nurses to identify barriers to successful implementation of a delirium screening
tool.
Results: To characterize pre-intervention comfort levels of nurses and clinicians with delirium and to identify
specific barriers to universal screening Methods: A 9-question pre-intervention survey was developed to assess
comfort with the diagnosis, treatment, and management of delirious patients according to a Likert scale. In addition,
one free response question was included to allow respondents to identify perceived barriers. This survey was
administered to nurses and clinicians (fellows, advanced practice providers, attendings) via an online survey
(REDCap). Responses were analyzed according to frequency and compared between groups. For scaled
responses, this was described as percentage of responses as being extremely comfortable, slightly comfortable,
neutral, slightly comfortable or extremely comfortable. Common free-response themes were identified and
subsequently reported as percentage of all responses. Results: A total of 221 surveys were completed. 68% of
respondents (n=151) were nurses, and 32% (n=70) were clinicians. In both groups, the majority reported being
slightly or extremely comfortable with identifying risk factors for delirium (75% of clinicians vs. 64.2% of nurses).
Similarly, the majority in both groups reported comfort with delirium diagnosis (61.1% of clinicians vs. 61.4% of
nurses). With respect to reported barriers, the common themes identified included environmental concerns within a
busy PICU, lack of general education, need for sedation to keep patients safe, need for cultural change prioritize
delirium, lack of experience, and lack of a standardized protocol. In the clinician group, the top response was a
need for education (44% of responses) followed by a need for cultural change (21%). Among nurses, environmental
concerns were most commonly reported (25%) followed by need for education (24%).
Conclusion: Our survey demonstrates there are multiple barriers to successful implementation of delirium
screening in the PICU. First, while both nurses and clinicians self-report being comfortable with delirium in the
PICU, both also report that general lack of education is a major barrier to improving management. Furthermore,
while the common barriers identified are similar, the relative frequency varies between the 2 groups, suggesting that
interventions should be tailored to each group to facilitate mutual understanding. Understanding this baseline
information will be an essential component to implementation of screening tools within our PICUs.
(11) Before the Code Turns Blue: An Analysis of Critical Actions Performed by Health Care Providers Prior
to Code Team Arrival
Graham Chamberlain, BSc, MSc, MD1, FAAP; Anna-Theresa Lobos, MD, FRCP1; Ronish Gupta, MD, FRCPC2,
(1) Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, (2) McMaster Children's Hospital, Hamilton,
Ontario, Canada; School of Education, Johns Hopkins University, Baltimore, Maryland, USA, Hamilton, ON,
Canada
Purpose: Although uncommon, the critical deterioration of a pediatric inpatient requiring a code blue activation is
associated with significant morbidity and mortality. Early recognition and immediate management of the
deteriorating patient by ward health care providers is crucial to improving outcomes prior to the arrival of critical
care support. Simulation studies suggest that ward providers (nurses and physicians) do not adhere to standard life
support algorithms. It is unclear whether this reflects real life or is a function of the simulation environment.
Confidently identifying the specific skill needs of multi-professional ward providers in real-world code blues is
necessary to develop appropriately targeted education programs to improve provider performance. We aimed to
review code blue activations and create a profile of critical action performance by non-acute care ward providers.
Results: Setting: We retrospectively reviewed all code blue activations at an academic tertiary care pediatric
hospital between 2008-2017. The hospital has over 6000 admissions annually with 170 inpatient beds. Code blue
events are considered a medical emergency where critical-care staff and equipment are required immediately,
although the patient need not necessarily be in cardiopulmonary arrest. The hospital also has a Medical Emergency
Team (MET) available 24/7. Data Collection and Analysis: Demographics, activation characteristics, provider
response, performance of critical actions, and event outcome was extracted from individual medical charts. The
data was combined and summarized descriptively. The project was exempt from review by the local ethics
committee. Results: A total of 60 code blues were reviewed, of which 21 (36%) involved cardiopulmonary arrest.
The most common reason for arrest was respiratory (15/21, 71%). Prior to code blue personnel arrival, ward
providers did not consistently perform critical actions (Figure 1). Pulses were not assessed in 27 (45%) patients.
Airway suctioning was not performed in 30 (50%) patients. Appropriate airway positioning was not performed in 21
(36%) patients. Thirteen (22%) patients required intubation by critical care personnel on the ward. No patient
required cardioversion or defibrillation. Preliminary data demonstrates that most code blues (39, 68%) were
activated for patient instability rather than true cardiopulmonary arrest. Ward nurses were present before 52 (86%)
activations and called the code blue team most of the time 35 (35/60, 58%). The MET was called before 21 (38%)
of the code blue activations.
Conclusion: Consistent with simulation research, our data shows that critical resuscitation actions are performed
inconsistently by ward providers. In addition, our study demonstrates the essential role that nurses play in the initial
recognition and resuscitation of deteriorating children. This highlights the need for a multi-professional educational
initiative focused on the essential basic resuscitation skills for non-acute care ward providers. Our findings suggest
that maintenance of advanced cardiopulmonary skills may not be required for general ward providers.
Proportion of Critical Actions Performed by Ward Providers
Figure 1. Significant variability exists in performance of critical actions by ward providers with no critical action being
performed consistently.
(12) Codes, Loss, and Burnout: How Do They Impact Us and Our Patients?
Juan R. Barron, MD, MPH1, FAAP; K. Sarah Hoehn, MD, MBe2; Stephanie Raghubeer, MD2, (1) University of
Chicago Comer Children's Hospital, Trujillo Alto, N/A, Puerto Rico, (2) University of Chicago Comer Children's
Hospital, Chicago, IL
Purpose: Pediatricians are often exposed to emotionally difficult situations like patient deaths and codes; these
may lead to significant grief and burnout. This may impair the ability of physicians to care for patients in a
competent and compassionate manner (emotional exhaustion). These traumatic events may increase burnout
rates, which has been reported to start in training.
Objectives: The purpose of this research is to evaluate the degree to which pediatricians are immediately affected
by patient deaths and codes, and the prevalence rates of burnout among attending physicians and trainees.
Methods: We conducted a web-based survey for attending physicians, residents, and fellows currently working at a
children’s hospital. The survey evaluated exposures to patient deaths and codes, coping strategies, and patient
care. The Masloch Burnout Inventory was embedded in the survey and utilized as a tool to assess for risk of
burnout in participants.
Results: A total of 286 responses were recorded and analyzed, from which we had 66 training physicians (TP) and
41 attending physicians (AP). Our response rate was 48% and 41% respectively for both groups. AP reported more
deaths experiences and code participation compared to TP. The groups had similar reactions to events with
acceptance and grieving. Their coping strategies were also similar; most commonly reported were talking with
someone, spending time with family, and exercise. When asked if these events impacted their care of other
patients, more than half reported yes (56% for TP and 59% for AP). TP reported they have felt the need for
professional psychiatric help (33%) compared to AP (17%). Sixty percent of TP felt the need to take time off after
these experiences and 10% have actually taken it. Similarly, the AP reported 69% needed to take time off and 30%
have taken it. Eighty eight percent of TP reported feeling burned out, which correlated with 90% of them at
moderate to severe risk of burnout. Similarly, AP had 77% reporting feels of burn out with 80% having moderate to
severe risks.
Conclusion: Our respondents report significant rates of burnout, and a third of trainees may benefit from
psychiatric help. In addition, more than half reported that their stress after an event impacted their care of other
patients. Having significant burnout rates in both TP and AP could impact patient care and safety. More work needs
to be done to change the culture of healthcare to address ways for those who are struggling with difficult events to
get the help they need in the moment. In addition, more professional support may need to be available for
physicians. The future of health care may depend on our ability to provide the right support at the right time for
providers in need.
(13) Congenital Diaphragmatic Hernia Patients with Hypoxic Ischemic Encephalopathy Needing
Extracorporeal Membrane Oxygenation Have a Poor Outcome
Tahira Sarwar; Hitesh S. Sandhu; Mark F. Weems; Kirtikumar Upadhyay, Le Bonheur Children's Hospital,
Memphis, Tennessee, Memphis, TN
Purpose: Congenital diaphragmatic hernia (CDH), in its severe form has poor outcome due to associated
pulmonary hypertension. ECMO is used for respiratory failure associated with CDH with survival between 55-80%.
The presence of hypoxic ischemic encephalopathy (HIE) in CDH patients can lead to worse outcomes due to the
complications associated with HIE and its treatments. Therapeutic Hypothermia (TH) is widely used for the
treatment of HIE from 2009 onwards due to improvement in the mortality and long-term outcomes in clinical trials.
We hypothesized that CDH patients with HIE have worse short-term outcomes compared to CDH patients.
Methods: The ELSO database was queried for patients with diagnosis of CDH and HIE needing ECMO for
respiratory failure from 2000 to 2016. Results: There were 158 patients with diagnosis of CDH and HIE needed
ECMO for respiratory support in the ELSO database. There were 118 with left-sided (39% survival) lesions and 37
with right-sided lesions (42% survival). Of these patients, 107(68%) were repaired and 62(39%) survived to
discharge. VA ECMO was the preferred mode of support for this patient subgroup; used in 75% of patients. The
median ECMO run was 240 hours. There were 32 patients with 5-minute APGAR of 0-3 with a 32 % survival, 71
with APGAR5 of 4-6 with 37% survival and 43 with APGAR5 of 7-10 with 48% survival (Table 1). There were 74
patients in the preTH group (2000-2008) and 84 in the post TH group (2009-2016). Deaths during the post ECMO
period were the single largest cause of death in this patient subgroup (Figure 1).
Results: Our study showed that patients with CDH who also suffered from HIE had a survival of 39%, which is less
than the CDH ELSO registry survival rate of 51%. The additional complications associated with HIE may worsen
the chances of survival of this patient subgroup. There was no statistical difference in survival between the three
ECMO support modes. Similarly, the three Apgar groups had similar survival. The non-survivors were on ECMO for
a longer duration, however not statistically different. Left sided CDH lesions were more common than right sides
lesions with similar survival rates. Half of the CDH repaired survived to discharge home
Conclusion: ECMO is being used to treat respiratory failure in patients with CDH and HIE. This subgroup has a
worse survival to discharge compared to CDH patients without HIE. Caution should be used in the use of ECMO in
CDH patients with HIE.
Figure 1. Table 1:
Effects of different variables on survival with the use of ECMO
(14) Do Cortisol Levels Predict the Outcome of Pediatric Oncology Patients Admitted to the PICU for
Concerns of Sepsis?
Jordan Merz, MD, FAAP; Holly Miller, D.O.; Apurvi Patel, M.D.; Teresa Blaskovich, M.D., Phoenix Children's
Hospital, Phoenix, AZ
Introduction: Sepsis is the leading cause of death in children worldwide and the diagnosis and treatment of sepsis
in pediatric patients are often guided by studies of adult patients. Sepsis is a leading cause of morbidity and
mortality in febrile pediatric oncology patients, with shock demonstrating even poorer outcomes. Steroid
supplementation with hydrocortisone is recommended in patients with septic shock not responsive to fluid and
vasopressors, despite the unknown underlying pathophysiological mechanism for this treatment. This
recommendation is based on the results of a systematic review that demonstrated reduced mortality when low dose
steroids were administered to severely ill adult patients. Steroids are heavily utilized in several pediatric oncologic
treatment protocols putting patients at increased risk for adrenal insufficiency. Therefore, they may benefit from
hydrocortisone early on in their clinical course when admitted for concern of sepsis.
Purpose: To identify whether or not hydrocortisone supplementation in pediatric oncology patients with low cortisol
levels and concern for septic shock results in improved clinical outcomes.
Methods: We performed a retrospective EMR review of all oncology patients admitted to the pediatric ICU for fever
from 2010-2015. Basic demographics, vital signs on admission to the PICU, laboratory data (presenting CBC,
cortisol level and absolute neutrophil count), use of pressers, and interventions in the emergency room prior to
transfer to the PICU were recorded.
Results: Each patient who presented with an oncologic diagnosis, fever, and hypotension received at least three
20ml/kg boluses of normal saline in the emergency room. All patients who did not clinically respond to aggressive
fluid resuscitation were admitted to the PICU for further management. Not all patients received pressers in the
PICU, and the subsequent management varied. Most patients did not receive a cortisol level. In patients with
cortisol levels, those with low levels were all given stress dose hydrocortisone at 2mg/kg. Those with high cortisol
levels did not receive stress dose steroids. Length of stay in the PICU did not vary between patients who received
steroids and those who did not.
Conclusion: Further prospective studies will need to be performed to assess the utility of steroid use in febrile
septic patients. This may also lead to the ability to coordinate care and management of adrenal insufficiency.
(15) Effect of Potassium Infusion on Serum Levels in Children During Treatment of Diabetic Ketoacidosis
Rawan Musaitif, MD1; Sangita Basnet, MD2, (1) Southern Illinois University School of Medicine, Springfield, IL, (2)
Southern Illinois University, Springfield, IL
Purpose: Profound total body potassium deficits occur in children admitted with diabetic ketoacidosis (DKA).
However, amount required to maintain normal serum concentration during treatment of DKA is largely unknown. At
our institution 40 mEq/L and 60 mEq/L is administered during treatment of DKA, based on initial serum potassium.
We aimed to determine the effect of these infusions on potassium levels in children during treatment of DKA.
Methods: A retrospective chart review was conducted, after IRB approval, in children admitted to the pediatric ICU
from December 2010 to December 2013 with diagnosis of DKA. Duration of insulin infusion was considered as
treatment period. Clinical characteristics and laboratory data were analyzed. Statistical analysis was done using
means, standard deviations, t-test, and Chi-square.
Results: Out of 124 eligible patients, complete data was available (and analyzed) in 94 (67% female). Average age
was 12±4 years, mean weight 47±22 kg. Lab values at admission included mean serum bicarbonate 8.3±3.5
mEq/L, potassium 4.6±1 mEq/L, pH 7.13±12, glucose 352±172 mg/dL, anion gap 22±6. Average insulin infusion
duration (treatment period) was 14.3±11.4 hours. Lab values at the end of this period included serum bicarbonate
17±3.4 mEq/L, potassium 3.8±0.6 mEq/L, pH 7.3±0.06, glucose 205±93 mg/dL, chloride 111±6.4 mEq/L, anion gap
11±3. Total fluid administered minus initial bolus was mean 2.8±2.3 L/kg, total initial bolus mean 23±13 ml/kg. Total
potassium administered until resolution of DKA was mean 2.3±1.6 mEq/kg. Thirteen patients required additional
potassium supplementation of mean 0.8±0.5 mEq/kg. Eighty-two percent of patients received fluids with 40mEq/L
of potassium and 18% received 60 mEq/L. There were 35 low potassium values (<3.5 mEq/L) and 9 high values
(>5.5 mEq/L). Patients that received 60 mEq/L potassium infusion had significantly higher number of low serum
values (82.4%) at any given time point during the treatment period than those receiving 40 mEq/L (22.7%)
(p=0.0001). Initial mean potassium values in children receiving 60 mEq/L were significantly lower 3.7±0.6 mEq/L as
compared to 4.8±0.9 in 40 mEq/L group, (p<0.0001). However, total potassium received, treatment period, and
additional potassium supplementation were all similar between the 2 groups.
Conclusions: This study suggests high potassium infusions are needed when treating DKA. Close monitoring of
serum potassium is needed even when administering fluids containing 40 mEq/L and 60 mEq/L potassium.
(16) Encephalitis and Poliomyelitis in a Vaccinated 12 Year Old
Ashlesha Kaushik, MD, FAAP; UnityPoint Health and Siouxland Medical Education Foundation, Sioux City, IA
Purpose: 12 y/o healthy male with altered mental status. H/o 2 days of vomiting, slurred speech, headache,
progressing to altered sensorium. No seizures/rash. H/o camping in East Texas 1-week ago; playing with dogs at
home. No diving in lakes/tick bites/cats/farm-animals. Patient had received all age appropriate vaccines. O/E,
comatose, febrile at 39.5C. Pupils minimally reactive, gag reflex absent, hypotonic with diminished DTRs.
Meningeal signs absent. MRI brain:left thalamus edema (Figure1). Differential Diagnosis: Viral Encephalitis: HSV,
Enteroviruses, Arboviruses, Influenza Rickettsial neuroinvasive disease Amoebic Encephalitis Mycoplasma
encephalitis NMDA receptor antibody encephalitis
Results: CSF and serum testing negative except serum for West Nile virus IgM+. Repeat testing after a week:
serum West Nile virus IgM and serum West Nile virus IgG+ Course: Patient received IVIG after second serology.
Sensorium improved however, progressed to flaccid quadriplegia with MRI consistent with poliomyelitis, which
gradually improved. (Figure 2).
Conclusion: WNV is ssRNA flavivirus, isolated in 1937 in West-Nile district Uganda, transmitted through Culex
mosquito bites with birds as reservoirs (300 species). About 1/3 of all cases reported from Texas in recent years.
80% asymptomatic, 20% develop West Nile fever. West Nile Neuroinvasive disease (WNND) in < 1%: meningitis in
25-35%, encephalitis in 60-75%, poliomyelitis in 5-10%. WNV encephalitis is rare in children. WN poliomyelitis
affects all ages unlike encephalitis (affects elderly) and occurs in isolation or with meningoencephalitis.
Pathogenesis related to pure motor deficit due to involvement of anterior horn cells. Per CDC, WNV IgM antibody in
serum within 8-14 days or CSF within 8 days of onset is diagnostic. CSF PCR lacks sensitivity. MRI usually normal,
however, abnormalities in thalamus, basal-ganglia, spinal-cord can be seen. Case-fatality rate for WNND in children
is <1%; in adults over 10%. WNV Poliomyelitis has the worst prognosis, with strength recovery usually occurring
within first 6-8 months followed by subsequent plateau. Management is supportive with unproven role of interferon,
anti-WNVIG, IVIG. No vaccine is available and primary prevention is mosquito control.
(17) Enteral Nutrition during Non-Invasive Ventilation for Children with Acute Bronchiolitis Admitted to the
Pediatric Intensive Care Unit Is Well Tolerated and Associated with Reduced Respiratory Rate
Jennifer L. Bartlett, CPNP1; Anthony A. Sochet, MD, MS2; Michelle Smith, MD3; Eddie K. Barrie, BS3; Thomas
Nakagawa, MD1, (1) Johns Hopkins University, Johns Hopkins All Children's Hospital, St. Petersburg, FL, (2) Johns
Hopkins All Children's Hospital, Tierra Verde, FL, (3) Johns Hopkins All Children's Hospital, St. Petersburg, FL
Purpose: Recently published data from our group suggest nutrition during non-invasive ventilation (NIV) is well
tolerated without incidence of aspiration-related respiratory failure. Yet, potential therapeutic benefits of enteral
nutrition during NIV have not been determined. We sought to assess for differences in respiratory rate and clinical
outcomes in children receiving enteral nutrition during NIV.
Methods: We performed a prospective, observational cohort study in children 1 month - 2 years of age admitted to
the pediatric intensive care unit (PICU) for acute bronchiolitis in a free-standing, tertiary pediatric referral center
from 11/01/2017 - 03/01/2018. We defined NIV as high flow nasal cannula (HFNC), nasal continuous positive
airway pressure (nCPAP), Ramanathan cannula (RAM), and bilevel positive airway pressure (BiPAP). We excluded
children with unrepaired congenital heart disease, existing tracheostomy, and those on NIV only post-extubation.
Demographics, anthropometrics, diagnoses, NIV data, Pediatric Index of Mortality 3 Risk of Mortality (PIM-3 ROM),
Pediatric Logistic Organ Dysfunction-2 Predicted Death Rate (PELOD-2 PDR), nutrition data, lengths of stay,
modality failure, and mortality were recorded for cohort analyses. The primary outcome was mean respiratory rate
two hours before and after initiation of bolus or continuous nutrition during NIV. Paired comparative and descriptive
statistics were completed in Stata v15.1.
Results: Forty-two children met study criteria of which 29 (69%) were permitted enteral nutrition. Nutrition route
was delivered orally in 76% or via nasoenteric tube in 24%. Nutrition was started at a median of 11.7 hours post
NIV initiation. Non-invasive modality during concurrent nutrition were HFNC in 83% and RAM in 17%. None were
fed on nCPAP or BiPAP. Paired respiratory rates before and after nutrition reduced by a median of 14% from 47 ±
12 to 39 ± 11 breaths per min (p<0.01). Children provided enteral nutrition were younger (8.2 ± 5.3 vs 13.4 ± 5.3
months of age) and weighed less (7.5 ± 2.3 vs 9.5 ± 2.3 kilograms) than those not permitted nutrition (both p<0.05).
Both groups had similar median PIM-3 ROM (1% vs. 1%, p=0.46), median PELOD-2 PDR (3% vs 3%, p=0.11),
mean peak-HFNC flow rates (1.2 ± 0.4 vs 1.3 ± 0.4, p=0.46), and rate of NIV modality failure (17% vs 23%,
p=0.68). No interruptions of nutrition, aspiration-related respiratory failure, or mortality were noted. There were no
differences in hospital (3.8 [IQR:2.6-6.9] vs 3.8 [IQR:2.7-5.8] days, p=0.64) or PICU (1.8 [IQR:1.2-2.6] vs 2.7
[IQR:1.8-3.8] days, p=0.2) lengths of stay.
Conclusions: Oral and nasoenteric tube nutrition during NIV for children with acute bronchiolitis was well tolerated
without interruptions, aspiration-related respiratory failure, or altered lengths of stay. A post-prandial reduction in
respiratory rate of 14% was observed. These data suggest enteral nutrition may be of therapeutic value and may
allow faster weaning from respiratory support.
(18) Evaluation of the Outcome of Patients Admitted to the Pediatric Intensive Care Unit in Tripoli Using the
Pediatric Risk of Mortality (PRISM) Score
Muhammed Elhadi1, MD, FAAP; Hamida Esahli, MD1; Hazem Ahmed1; Samira Ittire, MD2; Khairia Dougman, MD2;
Mounir Khalil, MBBCh1; Aliya Miftah Ali1; Ala Khaled1; Enas Ahmed Sadouh1; Mohamed Abugrin1; Ahmed Elhadi1,
(1) Tripoli University, Tripoli, Tripoli, Libya, (2) Pediatric intensive care unit, Elkhadra Hospital, Tripoli, Libya, Tripoli,
Tripoli, Libya
Purpose: The PRISM score (Pediatric Risk of Mortality Score) is an objective measurement of 17 physiological
variables with a range of 26 which reflect the severity the illness. This study aims to define the significant factors
associated with the outcome prediction, to test the reliability of the PRISM score as a predictive factor for the
outcome in terms of survival and, to define the mortality rate for every PRISM score value in Elkhadra Hospital,
Tripoli.
Methods: In this prospective study, a sample of 150 patients was randomly selected from all the 313 patients
admitted during the period from May 2006 to May 2007. For each patient, age, sex, diagnosis, PRISM score,
ventilator status and survival status on discharge were recorded. The diagnosis variable was categorized into
groups; respiratory, nervous, gastrointestinal, urinary, metabolic, sepsis and others. Patients with a score of zero
(n=6) and congenital malformations as a cause of admission (n=3) were excluded. Two postoperative patients were
also excluded, leaving a total of 139 patients for the study. The statistics tested the association between each
variable (age, PRISM score, sex, and diagnosis) and the patient's survival status on discharge (the outcome).
Statistical analysis involved trend chi-square and logistic regression for testing the association and Receiver
Operating Characteristics (ROC) curve analysis for assessing the appropriateness of the model.
Results: Out of the 139 patients, 122 patients survived while 17 patients died (Mortality rate 12.2%, overall
mortality was 11.8%). Of the 139 patients, 95 were males (68.3%) while 44 were females (31.7%). 28 patients were
put on a ventilator during their hospitalization period, out of them 9 died. The mean age was 10 months ranging
from 1 day (newborn) to 14 years. The mean PRISM score was 7.15, ranging from 1 to 26, with a predominance of
patients with low scores; 52.5% of patients had PRISM scores below 6, 62% had scores below 11 and only 7% had
scores above 15. Age, sex, and diagnosis showed no significant association with the outcome. Also, the expected
versus observed mortality rates (using the PRISM score only) showed no difference throughout the different
variable. The mortality rate showed a constant increase in the PRISM score, starting from only 4.8% for patients
with a score of 1 and reaching 57 in patients with a score of 25. The ROC curve plotted showed good results with
an area of 71% under the curve. A value which is consistent compared to other countries using the PRISM score.
(Figure 3)
Conclusion: The study concluded that the PRISM score is a suitable scoring system for the prediction of the
mortality and survival rates in EL-KHADRA PICU provided the current circumstances, services, and experience.
Figure 1
Table 1
(19) Fulminant Hepatic Failure Due to Neonatal Herpes Simplex Virus Type 1: Unusual Presentation of
Newborn Sepsis
Fernando L. Pena-Cruz, M.D 1, FAAP; Gilberto Puig, M.D, F.A.A.P2; Anabel Puig, Ph.D, FCCP3, (1) San Juan City
Municipal Hospital, Ponce, Puerto Rico, (2) Department of Pediatrics, San Jorge Children’s Hospital; University of
Puerto Rico Medical Sciences Campus Department of Pediatrics Critical Care Medicine Section, San Juan, N/A,
Puerto Rico, (3) University of Puerto Rico Medical Sciences Campus Department of Pediatrics Critical Care
Medicine Section, San Juan, N/A, Puerto Rico
Purpose: Neonatal Herpes infection is divided into three categories: SEM, CNS disease and Disseminated
Disease. Infection is usually through intrapartum transmission and carries a high mortality and morbidity rate. We
report the case of a 12-day-old female patient born at 39 WGA via SVD with no complications. Patient was
discharged from nursery ward after 48 hours of observation. Maternal prenatal laboratories reported as negative,
including GBS. Father does mention history of “cold sores”. Mother denies any previous history of genital herpetic
lesions, but states having a painful rash at genital area at 2nd to 3rd trimester. Bacterial Vaginosis was diagnosed
and treated at 35 WGA.
Results: Patient was taken to Emergency Department at tenth day of life with chief complaint of fever (39C
rectally). Upon evaluation, patient was found acutely ill and febrile. Sepsis evaluation was done, including LP for
CSF analysis. At ER, patient received ampicillin and gentamycin. CSF analysis showed pleocytosis. No organisms
reported on gram stain. Small vesicles were noted on left side of scalp for which infectious disease specialist
advised on acyclovir therapy and HSV PCR (Blood and CSF). Liver enzymes were found elevated, suggestive for
hepatic failure. On day of life 12, patient presented with hypothermia and active bleeding from venipuncture sites.
At PICU, patient intubated after presenting with worsening agonic breathing. An O negative unit as emergency base
started. Active bleeding noted at endotraqueal tube suggestive of pulmonary hemorrhage. Cardiologist performed
bedside ECHO showing; a PFO, empty RV, severe dyskinesia of the apex, akinetic LVPW and paradoxical septal
movement of the interventricular septum most likely due to blood loss. Patient died despite CPR cardiac massage
and inotropic support (i.e., dopamine and epinephrine drip). CSF PCR analysis was reported positive for HSV type I
infection. High clinical suspicion is necessary to avoid lethal and fatal complication of this preventable and treatable
condition.
Conclusion: Pregnant women with active genital lesions should undergo serologic and/or virological testing for
HSV infection. The vulnerable patient (i.e., maternal or neonatal identification of virus, skin lesion) should be started
on IV acyclovir to avoid disseminating disease. It is important to consider and rule out HSV infection in a neonatal
septic patient with increasing liver enzymes and cutaneous findings, since early administration of antiviral therapy
can be life-saving.
(20) Improper Car Seat Use Leading to Spinal Cord Injury, Neurogenic Shock, and Death
Courtney W. Brantley, MD, FAAP; Lauren Piper, MD, Carolinas Medical Center- Levine Children's Hospital,
Charlotte, NC
Purpose: Pediatric spinal cord injuries cause significant morbidity and mortality. They are often caused by MVCs
and are preventable with proper car seat use. This is a case of an improperly restrained child presenting with spinal
cord injury and refractory neurogenic shock after MVC. Case Report: A 14-month-old previously healthy female
presented after being the improperly restrained backseat passenger in an MVC. First-responders found the patient
pulseless in her forward-facing car seat. ROSC was obtained after 1 minute of CPR. The patient had a GCS of 3
with dilated and non-reactive pupils bilaterally, hypothermia, and hypotension upon arrival to the ED. She was
noted to have total body flaccidity with absent rectal tone. She required ongoing fluid and vasoactive resuscitation
and empiric stress dose hydrocortisone was given for refractory shock. CT head and neck were significant for C1-
C2 and C6-C7 distraction injury and acute intraventricular hemorrhage (Figure 1). Despite ongoing resuscitation,
she continued to have refractory neurogenic shock. It was agreed among providers that her injuries, given C1-C2
and C6-C7 distraction, were incompatible with life and that further resuscitation would be futile. No further
vasoactive therapies were administered, and the patient died peacefully in her mother’s arms.
Results: Over 100,000 children are injured and more than 700 children die each year in MVCs. While spinal cord
injuries are rare in the pediatric population, the majority are caused by MVCs. The cervical spine is particularly
susceptible to injury and accounts for 60-80% of all spinal cord injuries in children. This is due to the relative large
size of a child’s head in comparison to their body, creating a higher center of gravity and more prominent neck
motions. The chances of injury are further increased by the laxity of the ligamentous structures of the spine in
children. Pediatric cervical spine injuries have a 16-35% mortality rate and even higher morbidity. Studies have
shown that children are more likely to sustain cervical spine injuries during a MVC if they are forward-facing. The
AAP currently recommends children remain rear-facing until age 2, or until they reach maximum height and weight
for their rear-facing seat. The risk of death in an MVC has been shown to be reduced by 75% in children under 2 if
they were rear-facing. Despite the AAP’s recommendations, studies show that approximately 30% of parents were
unaware of these recommendations and approximately 50% of children in car seats were improperly restrained,
placing them at risk for spinal cord injury.
Conclusion: Pediatric spinal cord injuries cause significant morbidity and mortality and are preventable with proper
car seat use. Pediatric providers must give appropriate anticipatory guidance regarding proper car seat use to
prevent long term disability and death related to cervical spine injuries.
(21) IVIG-Induced Coombs-Positive Hemolytic Anemia in a Critically Ill Adolescent Male
Casey Mehrhoff, DO, MS1; Astha Sharma, MD2; Clare Zimmerman, MD2; Phillip DeChristopher, MD, PhD2, (1)
Loyola University Medical Center, Chicago, IL, (2) Loyola University Medical Center, Maywood, IL
Purpose: A well-described but not universally appreciated side effect of IVIG administration is clinically apparent,
sometimes severe hemolysis. We describe a severe case of Coombs-positive hemolytic anemia secondary to IVIG.
IVIG is a blood derivative manufactured from pools of 5,000 to 10,000 individual plasma donations. IVIG is not
ABO-type restricted, so anti-A, anti-B and anti-A-B isoagglutinins are measureable in IVIG. A number of other RBC
alloantibodies to minor blood group antigens have also been detected.
Results: A 16-year-old male with PMH of OSA and obesity was admitted for adenoviral pneumonia leading to
respiratory failure requiring mechanical ventilation. A complicated PICU course included severe ARDS, septic-
shock, AKI and Coombs-positive hemolytic anemia. The patient was treated with IVIG, 400 mg/Kg daily for five
days, after which severe hemolysis occurred, associated with elevated LDH and total bilirubin. The hemolytic
process dropped the hemoglobin from 13.8 g/dL to a nadir of 6.6 g/dL, requiring transfusion of four units of Red
Blood Cells. The pre-transfusion peripheral blood smear showed spherocytosis with rouleaux formation and large
clumped rbc aggregates. The patient’s blood type was Blood Group A-negative and all transfusions were type
specific. The Coombs test was positive with polyspecific and anti-IgG typing antisera, and acid eluate prepared
from the Coombs-positive rbc's revealed anti-A. The patient’s antibody screen (against Group O reagent cells) was
negative ruling out both allo- and autoantibodies. However, Anti-A was also detected in his plasma. The patient’s
hemolysis was associated with the anti-A passively transmitted from the IVIG. RBC transfusion support was
changed to use of Group O-negative RBCs and the hemolytic process resolved. The patient later died due to
complications of ARDS.
Discussion: Before this severe hemolytic event, the patient was already in multi-system organ failure due to
adenoviral pneumonia (severe ARDS, leading to pulmonary hypertension and pulmonary hemorrhage, septic
shock, AKI, adrenal insufficiency). He was not eligible for ECMO due to his progressive pulmonary hemorrhage,
was ultimately made DNR, and died due to progressive hypoxia despite maximal ventilator support. In this critically-
ill patient given IVIG in an attempt to treat a viral infection associated ARDS, an unexpected and harmful
comorbidity developed. The empirical use of IVIG in this setting is not yet an evidence-based indication for its use.
Conclusion: Although immune hemolysis is a recognized adverse effect of IVIG, it is seldom considered when
deciding to administer IVIG and has rarely been described in the pediatric population. IVIG is used to treat a
growing number of medical conditions. In the setting of managing critically-ill patients, unexpected iatrogenic
hemolysis adds unnecessary co-morbidity. Such events also require supplemental blood transfusions, the risks of
which are better avoided. Severe immune hemolytic events such as this require transfusion support with compatible
RBCs.
(22) Listeria Meningitis in a Patient with Encephalopathy
Thao L. Nguyen, D.O.1; Bibek Bista, M.D., M.P.H.1; Shivani Tripathi, M.D.1; Paul H. Dahm, M.D. 2, (1) University of
Texas Health Science Center at Houston, Houston, TX, (2) University of Texas Health Science Center at Houston,
Houton, TX
Purpose: Listeria monocytogenes is a gram-positive intracellular bacterium that causes uncommon but serious
infections. Its incidence in developed countries is about six per one million people with the common presentations
being neurolisteriosis, bacteremia, and maternal-neonatal infection. A surveillance study by the Center for Disease
Control and Food Net shows the incidence of Listeriosis is about 0.25-0.32 per 100,000 patients in the United
States. There were 24 Listeria outbreaks during 1998-2008, of which food vehicle was associated in 20 outbreaks,
and serotype 4b being most common. We present the case of a 7-year-old Hispanic female without significant past
medical history presenting to an outside emergency room (ER) with frontal headaches, emesis, subjective fever,
and chills. She deteriorated, was non-responsive to fluid bolus, and transferred to another ER. The lumbar puncture
(LP) was unsuccessful. She was empirically treated with broad spectrum antibiotics including vancomycin,
ceftriaxone, and acyclovir. Her antibiotics were only initiated after 24 hours of onset of symptoms. She was
transferred to another hospital, where LP findings were consistent with meningitis. Magnetic resonance imaging on
day 3 of illness revealed scattered perfusion abnormality. On day 5, the patient had acute deterioration, with
encephalopathy, requiring emergent intubation and mechanical ventilation. Computerized Tomography (CT) head
revealed hydrocephalus of the lateral and third ventricles. Subsequent CT head next day revealed worsening
ventriculomegaly requiring transfer to our hospital for neurosurgical evaluation. An external ventricular drain (EVD)
was placed emergently at bedside by the neurosurgical team. Post-antibiotic treated CSF from the outside hospital
grew gram positive rods. High dose ampicillin was added in suspicion of Listeria monocytogenes. MRI brain and
spine on day 8 of illness revealed cerebellar tonsillar herniation, severe cervicomedullary compression, ischemia of
cerebellum, cerebellar tonsils, and C1 spinal cord. Emergent posterior fossa decompression, C1-laminectomy, and
duraplasty was performed. Blood and CSF from outside hospital grew L. monocytogenes, sensitive to both
ampicillin and vancomycin. Gentamicin 7.5 mg/kg/d was added to ampicillin 400 mg/kg/d for synergistic effects. She
required a ventriculo-peritoneal shunt for progressive hydrocephalus. Her clinical course improved slowly. She was
extubated on day 11 of illness, aggressive rehabilitative measures initiated, and transferred to inpatient
rehabilitation facility on day 32 of illness.
Discussion: Our patient presents with Listeria meningitis, hydrocephalus requiring emergent EVD placement,
subsequent decompressive craniotomy, and persistent neurological deficit requiring transfer to an inpatient
rehabilitation facility. Her known predisposing factor was exposure to cheese, and contributory factor was initial
delay in initiation of antibiotics by about 24 hours. This case report provides us with a clinical opportunity to have
high suspicion of Listeria infection among patients presenting with signs of meningitis and neurological deficit, early
initiation of therapy, involvement of multidisciplinary team, and appropriate handover during transfer and transition
process.
(23) Making the Best of a Bad Situation: Clinician’s Perspectives on Ethics Rounds
Leah Abecassis, MSN, RN, CCRN1; Danielle DeCourcey, MD, MPH2; Teresa Richards, BSN, RN, CCRN3;
Jennifer Steadman, BSN, RN, CCRN1; Judi Friedson, MS, RN1, (1) Boston Childrens Hospital, Boston, MA, (2)
Boston Childrens Hospital, boston, MA, (3) Boston Children's Hospital, boston, MA
Purpose: Working in a Pediatric Medicine Intensive Care Unit (MICU) brings together two ethically fraught
populations: the critically ill and the chronically ill. As a result, moral distress, along with ethical concerns, is
prevalent amongst the health care professionals.
Results: In an effort to address moral distress, we have trialed numerous methods aimed at improving
understanding of ethical principles. Ethics Rounds are one way to support healthcare personnel in handling
ethically difficult situations. Ethics Rounds are held on our unit monthly and are led by a nurse ethicist, an ICU
attending, and unit-based Nurse Practice Specialist. While moral distress around the case is discussed, the primary
focus of the rounds has been joint formulation of the ethical question/s (“If __ is true, then is ___ ethical?”) and a
group effort to resolve the relevant issues that emerge. Rounds are attended by nurses, physicians, nurse
practitioners, social workers, and specialists involved in the case. This allows for a well-rounded multidisciplinary
discussion where each discipline can bring their concerns and viewpoints.
Conclusion: The aim of this project was to evaluate how Ethics Rounds were experienced by the multidisciplinary
staff and to identify ways to improve the ethical climate for the staff. A four question survey was emailed to the
multidisciplinary MICU team to determine how helpful Ethics Rounds have been in the past year and in what ways
they can be modified to meet the needs of the participants. The survey was sent to 147 MICU team members and
42 participants responded. Respondents included nurses (60% of total responses), physicians (30%), social work,
chaplaincy, and child life specialists (total of 10% combined). From the respondents, 62% had participated in an
Ethics Rounds in the past year, 69% or staff felt that rounds helped them understand their patients better, and 76%
felt that rounds improved the care of their patient. Suggestions to improve Ethics Rounds included informing the
night shift of what occurs in Ethics Rounds during the day through a summary if possible. Additional suggestions
involved improving the nurses voice in the rounds and improving attendance overall. Next steps include
implementation of these suggestions with further evaluation of the efficacy of our interventions.
(24) Outcomes of Hypoxic Ischemic Encephalopathy Patients Needing Extracorporeal Membrane

Oxygenation - Extra Corporeal Life Support Organization (ELSO) Database Analysis
Tahira Sarwar; Hitesh S. Sandhu; Mark F. Weems; Kirtikumar Upadhyay, Le Bonheur Children's Hospital,
Memphis, Tennessee, Memphis, TN
Purpose: Hypoxic ischemic encephalopathy (HIE) in its moderate to severe form is treated with therapeutic
hypothermia (TH) with trials showing significant improvement in the mortality and neuro-outcomes. Pulmonary
hypertension complicates the clinical course of up to10-25% of these patients with HIE. Extracorporeal membrane
oxygenation (ECMO) improves survival in pulmonary hypertension but its use is controversial in HIE as “irreversible
brain damage” is a contraindication per Extra corporeal life support organization (ELSO) guidelines. The inability to
predict neuro-outcomes in HIE patients has led to variable ECMO practice. There is an unproven concern that HIE
patients may have increased risk of intracranial bleeding, ischemia, stroke or coagulopathy during ECMO. Methods:
The ELSO database was queried for patients with diagnosis of HIE and respiratory failure needing ECMO from
2000 to 2016.
Results: 605 patients with diagnosis of HIE needed ECMO for respiratory support. Of these patients, 509(84%)
survived to discharge, with multi-organ failure being the most common cause of death (36%). The median ECMO
run was 137 hours, with VA ECMO utilized 53% of the time. There was a statistically significant increase in the
number of HIE patients going on ECMO from the pre-TH era (2000-2008) from 172 to 433 in the post TH era (2009-
2016). (Figure 1) Comparison of survivor and non-survivor groups showed that conversion of VV to VA ECMO,
APGAR 5 score of 7-10 and use of ECMO for cardiac support showed a statistically significant difference in
survival. (Table 1)
Discussion: Our study shows a significant increase in the number of HIE patients going on ECMO in the post TH
era without a change in the mortality rate. Patients with meconium aspiration syndrome (MAS) with HIE had a
survival of 90% compared to 95% for patients with MAS alone. Primary pulmonary hypertension (PPHN) with HIE
had a similar survival of 81% compared to 82% for PPHN alone. This suggests that the mortality of HIE patients
depends on the primary diagnosis of the patient. The database showed that HIE needing cardiac support instead of
respiratory support had a significant difference in mortality, as did patients needing conversion from VV to VA
ECMO compared to VV ECMO.
Conclusion: HIE patients with respiratory failure are increasingly being supported with ECMO after the introduction
of TH. The primary indication for ECMO dictates the outcomes of HIE patients needing ECMO. The use of ECMO in
patients with HIE should there be considered whenever clinically indicated.
Figure 1.
Table 1: Effects of different variables on survival with the use of ECMO
(25) Palliative Care Utilization in Children with Heart Disease
Danielle Green, MD1, FAAP; Claudia Delgado-Corcoran, MD, MPH2; Erin Bennett, MD2; Stephanie Bodily, NP2;
Dominic Moore, MD3; Victoria Wilkins, MD, MPH3; Leonora Olson, PhD4; Randall Smout, MS5; Kelly Mansfield,
RN2; Sarah Wawrzynski, RN2, (1) Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt
Lake City, UT, (2) Division of Pediatric Critical Care Medicine, Department of Pediatrics, Primary Children's
Hospital, University of Utah, Salt Lake City, UT, (3) Division of Pediatric Inpatient Medicine, Department of
Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT, (4) Division of Pediatric Critical Care
Medicine, Department of Family & Preventative Medicine, Primary Children's Hospital, University of Utah, Salt Lake
City, UT, (5) Information Technology Department, Primary Children’s Hospital, Intermountain Healthcare, Salt Lake
City, UT
Purpose: Pediatric palliative care (PPC) teams can manage distressing symptoms, enable informed decision-
making, coordinate multidisciplinary care, and if applicable, provide end-of-life and bereavement support. Access to
pediatric palliative care has increased in the last decade; however, information regarding access for children with
heart disease remains limited. Objective. Describe demographic and clinical characteristics of patients, admitted to
a tertiary children hospital, with congenital or acquired heart disease who received PPC consultation.
Methods: We conducted a retrospective chart review for all patients with congenital or acquired heart disease and
a PPC consultation from January 2014 to June 2017 at a single tertiary pediatric hospital. Patients were excluded
from the analysis if they did not have congenital or acquired heart disease or if they had an initial palliative care
consult outside of the study window. Descriptive statistics and non-parametric tests were used to describe
demographics and clinical characteristics.
Results: Of 116 patients, 15% (n=18) had acquired heart disease and 85% (n=98) had congenital heart disease
with 52% (n=51) having a prenatal diagnosis (Table 1). The median age at PPC consultation was 77 days
(Interquartile Range (IQR) 16-84). The median number of hospitalizations during the study period was 3 (IQR 1-5)
and median number of cumulative hospital days was 65 (IQR 28-122). Patients had a median of 4 complex chronic
conditions (CCC) (IQR 2-5) at the time of first hospitalization and also at the time of palliative care referral. Over
half of patients (54%, n=62) had an underlying genetic syndrome and 72% (n=84) had a lifetime intervention or
complication. Neonatologists were the most likely subspecialty to make a PPC referral 37% (n=43), followed by
pediatric or cardiac intensivists 30% (n=34), and hospitalists 18% (n=21, Image 1). Cardiologists were the least
likely subspecialty to make a referral 12% (n=14). Among the 56 patients who died, 66% (n=37) died in the ICU and
60% (n=33) had withdrawal of life-sustaining therapies. The median time between PPC consultation and death was
47 days (IQR 6-135).
Conclusion: Pediatric palliative care utilization occurred more often in children with congenital heart disease who
had a high lifelong disease burden with an underlying genetic syndrome and/or lifetime intervention or complication.
Despite a high percentage of prenatal diagnoses, most PPC referrals do not occur until early in infancy. Complex
chronic conditions were similar during the first hospitalization and at the time of palliative care referral. Pediatric
palliative care consultation should be considered earlier in children with heart disease.
(26) Quality Improvement Initiative to Reduce Excess use of Heated Humidified High-Flow Nasal Cannula in
Infants with Bronchiolitis
Erin C. Burns, MD1, FAAP; Laura M. Ibsen, MD2; Michelle B. Noelck, MD2; Mackenzie Treible, BS3; Serena Kelly,
CPNP-AC2; Bradley Meyers, RRT, BHA2; Mina Tahai, MD2; Pearl Payton, HOD Analyst4; Andrea Smith, RN2; Carly
Byrne, RN2; Ashley Arehart, RN2; Karen Alles, RN5; Keri Vorres, HOD Analyst4, (1) Oregon Health & Science
University, Portland, OR, (2) Oregon Health & Science University / Doernbecher Children's Hospital, Portland, OR,
(3) Oregon Health & Science University / School of Medicine, Portland, OR, (4) Oregon Health & Science University
/ Information Technology, Portland, OR, (5) Oregon Health and Science University / Doernbecher Children's
Hospital, Portland, OR
Purpose: Use of heated humidified high flow nasal cannula (HHFNC) is common and increasing among pediatric
bronchiolitis patients despite a lack of standardization or known efficacy. In our center, it is associated with longer
hospitalization and capacity strain when used in excess at lower flows. We aim to acculturate accelerated HHFNC
weaning practice across multiple hospital units via a novel protocol. Initial assessment: Key stakeholders reviewed
practices during the previous season (Sept 1 2016 - Apr 30 2017), noting large variation in respiratory support at
time of transfer from PICU to pediatric ward. We hypothesized that we could a) successfully implement the protocol,
b) reduce HHFNC use at transfer, and c) reduce hospital LOS. Choice of solution: Our group developed a novel
Simple Cannula / Room Air Trial for Children (SCRATCH) to rapidly trial qualifying patients on 2LPM simple
cannula or room air for 60 minutes at 0400 daily. A daily management system monitored adherence and patient
safety as we piloted this protocol in our PICU.
Results: A review of 2 months' (Jan 15 - Mar 15, 2018) post-implementation data revealed 46 subjects meeting
criteria for primary diagnosis. Six patients were excluded for young age (<1 mo) or chronic cardiopulmonary
disease. Of the remaining 40 patients, we observed 53 patient-days where patients on HHFNC were eligible for a
trial. Of these opportunities, 24 trials were done on 22 patients (45% compliance.) SCRATCHed patients were
significantly less likely to leave PICU on HHFNC compared to non-SCRATCHed patients in either season. Two
patients who passed a trial were left on HHFNC per clinician judgement. One patient who left PICU on room air was
later restarted on HHFNC. No patients were intubated or re-admitted to PICU following a trial. Hospital and PICU
LOS were not significantly different between groups.
Conclusion: In the setting of lower compliance during this pilot, we safely reduced incidence of HHFNC use at time
of ward transfer for SCRATCHed patients compared to both contemporary and historical controls. This did not
translate into shorter LOS for SCRATCHed patients, likely reflecting our small single-unit sample and non-
randomized implementation. Less-ill patients may have been weaned and discharged from PICU or transferred
prior to a SCRATCH opportunity, thus skewing LOS findings in favor of non-SCRATCH patients. Barriers to
SCRATCH compliance included lapses in ordering, transfer of patients prior to trial times, and subjective clinical
concerns by staff regarding safety of rapid weaning (a primary target of this initiative.) Next steps include further
staff education, finalization of an order set and flowsheet to streamline ordering and documentation, and
implementation of the trial on the pediatric ward. Goals for next season include hospital-wide implementation with
>90% compliance and ongoing reduction in HHFNC usage.
(27) Recurrent Transverse Colon Volvulus in Adolescent with Marfan Syndrome: A Case Report
Yahaira Pizarro, MD1, FAAP; Gilberto Puig, MD, FAAP2; Carlos Sánchez, MD3; Anabel Puig, Ph.D, FCCP4, (1)
San Juan City Hospital, Santa Isabel, Puerto Rico, (2) Department of Pediatrics, San Jorge Children’s Hospital;
University of Puerto Rico Medical Sciences Campus Department of Pediatrics Critical Care Medicine Section, San
Juan, N/A, Puerto Rico, (3) Surgery Department Auxilio Mutuo Hospital; Pediatric Surgery Department San Jorge's
Children Hospital, San Juan, N/A, Puerto Rico, (4) University of Puerto Rico Medical Sciences Campus Department
of Pediatrics Critical Care Medicine Section, San Juan, N/A, Puerto Rico
Purpose: Marfan syndrome is a connective tissue disorder that more commonly involves the skeletal,
cardiovascular and ocular system, however gastrointestinal complications as volvulus are rare. Volvulus refer when
a part of the intestine twists on its mesentery resulting in bowel obstruction and ischemia. The most common site of
large bowel volvulus is the sigmoid colon (80%), followed by the cecum (15%) and less common in the transverse
colon (3%). Transverse colon volvulus (TCV) is the rarest type but is the one with the highest morbidity and
mortality.
Results: We report a case of a 16 years old patient that started with lower acute abdominal pain associated with
emesis of gastric content, hypoactive bowel sounds, generalized abdominal tenderness and abdominal distention.
Abdominal CT scan was done showing grossly distention of small bowel. An emergency laparotomy was performed
for suspected large bowel obstruction. Intra operative findings were TCV with ischemia and distention of ascending
colon. Transverse colon resection with colostomy was performed. Patient was doing well until eight-day post-
surgery that presented with abdominal distention, stoma edema and no output per stoma. Abdominal X-ray was
done showing markedly dilated bowel loop, for which was taken for second time to OR. On OR the laparotomy
incision was re-open with finding of twisting of mesentery of ascending colon. Stoma was removed, and colo-
colonic anastomosis was done. Patient was doing well, until five days post op, of the second surgery, that
presented three episodes of bilious vomit with an abdominal CT scan showing a transition point of the duodenum
with a distended stomach. A third surgery was performed with findings of adhesions as the cause of obstruction.
Thirteen days post op he was discharge to home with follow up with surgery, genetics and cardiology. Though
extremely rare, transverse colonic volvulus is an uncommon cause for large bowel obstruction, but worthy of early
recognition due high mortality and morbidity. Is extremely rare to find TCV as part of the gastrointestinal
manifestations of Marfan Syndrome.
Conclusion: In literature, there are no reported cases of TCV in a pediatric patient with MFS. Patients with MFS
are known to have redundant bowel and mesenteries with possible structural intestinal defects that predispose
them to developing a volvulus, but such cases are extremely rare.
(28) Results from the Cure SMA Newly Diagnosed Survey
Lisa Belter, MPH1; Kenneth Hobby, MBA1; Rosangel Cruz, MA1; Jill Jarecki, PhD1; Cynthia C. Jones, PhD2;
Sandra Reyna-Merida, MD2, (1) Cure SMA, Elk Grove Village, IL, (2) Biogen, Cambridge, MA
Purpose: Since 1996, Cure SMA, an organization providing information to individuals diagnosed with spinal
muscular atrophy (SMA) and their families has maintained a database of individuals with SMA. To date there are
6,990 affected individuals in this database, with the majority having type I SMA (46.9%), followed by type II (28.6%)
and type III (13.5%). In March 2016, Cure SMA launched a survey targeting newly diagnosed individuals and their
caregivers. This survey consists of questions on diagnosis, healthcare experiences, maximum motor function
achieved, breathing assistance, nourishment and previous knowledge of SMA-related studies.
Results: Between March 1st, 2016 and October 1st, 2017, 73 surveys have been received. Among the affected
individuals, 45.2% had type I, 31.5% had type II, 15.1% had type III, and 8.2% had an unknown or other type of
SMA. 19.2% of the surveys completed were for a child that has now passed away. Survey respondents were asked
to indicate when they first noticed symptoms and when they received an SMA diagnosis. On average, the delay
between onset and diagnosis was 2.3 months for type I, 7.1 months for type II, and 26.0 months for type III. The
most common initial diagnoses were low muscle tone or hypotonia for type I (12.1%) and type II (17.4%) and
muscular dystrophy for type III (18.2%). The average age at diagnosis was 4.6 months for type I, 15.0 months for
type II, and 100.2 months for type III. A pediatric neurologist made 63.0% of the SMA diagnoses.
Conclusion: The delay among patients with later onset of SMA was longer than those with early onset. The initial
diagnosis varied by type of SMA and pediatric neurologists provided the SMA diagnosis in the majority of cases. As
more treatments become available it will be important to evaluate the changes in diagnostic delay.
(29) Severe Hypertriglyceridemia: A Rare and Harmful Complication in Diabetic Ketoacidosis, Treated
Successfully with Plasmapheresis
Jessica M. Lee, MD MHS1; Asma Razavi, MD1; Anh Vu Le, MD1; Robin Williams, MD2, (1) Loma Linda University
Children's Hospital, Loma linda, CA, (2) Loma Linda University Children's Hospital, Loma Linda, CA
Purpose: Diabetic ketoacidosis (DKA) is highly prevalent in pediatric patients with both newly diagnosed and
established diabetes. Hypertriglyceridemia is a rare, adverse complication.
Results: A previously healthy 14-year-old female presented to the emergency room with 3 days of headaches. Her
initial vitals: blood pressure 130/94, heart rate 124 bpm, respiratory rate 23 breaths per minute, body mass index
21.3, and glascow coma scale (GCS) of 15. She was diagnosed with DKA with a blood glucose level of 539 mg/dL,
bicarbonate level of 6 mMol/L, ketonuria and venous pH of 6.95. She received fluid resuscitation, insulin drip
initiation, and was transferred to a tertiary level pediatric intensive care unit (PICU). During transport, she became
somnolent, with no improvement in mental status despite hyperosmolar therapy. Head computed tomography was
normal, but her encephalopathy persisted. Routine DKA labs had difficulty resulting due to the blood’s “lipemic”
nature. (Fig. 1) Upon evaluation she was found to have a total cholesterol of 1,004 mg/dL and profoundly elevated
triglyceride level of 14,820 mg/dL. Despite receiving DKA treatment for 36 hours, the patient remained
encephalopathic and triglyceride levels remained elevated at 8,070 mg/dL. Lipase levels were monitored closely
and rose to 208 U/dL. To prevent development of acute pancreatitis, nephrology was consulted to evaluate the
utility of plasmapharesis in hypertriglyceridemia. Despite a paucity of literature on therapy of acute
hypertriglyceridemia, the American Society of Apheresis’ 2016 guidelines recommend Grade 2C for use of
plasmapharesis in hypertriglyceridemic pancreatitis. Thus, only one cycle of albumin bound plasmapharesis therapy
was administered on hospital day 2 with immediate reduction of the triglyceride level to 941 mg/dL and resolution of
her encephalopathy. She was transitioned to subcutaneous insulin on hospital day 4, and discharged home on
hospital day 8. At a 3 week follow up visit, her triglyceride level was 79 mg/dL, and total cholesterol 82 mg/dL.
Discussion: In DKA, insulin deficiency results in lipolysis causing free fatty acid (FFA) release. Hepatic uptake of
FFAs leads to increased production of very low-density lipoproteins and subsequent hypertriglyceridemia. Patients
with severe hypertriglyceridemia, (> 1000 mg/dl) are at high risk for acute pancreatitis. Rapidly lowering serum
triglyceride levels in severe hypertriglyceridemia is paramount to prevent development of acute pancreatitis and its
complications (i.e., septic shock and multi organ failure). Conventional treatment of hypertriglyceridemia with dietary
restrictions and lipid lowering drugs is not effective in the acute setting. During the filtration of the separated plasma
in plasmapharesis, the passage of high molecular weight molecules (ie triglycerides) is prevented, alleviating
hypertriglyceridemia.
Conclusion: Plasmapharesis is a safe, effective therapy for severe hypertriglyceridemia. Although invasive and
expensive, it rapidly lowers dangerously high triglyceride levels leading to prevention of untoward complications
such as pancreatitis.
(30) Shock from Kawasaki Disease Leading to Profound Coronary Aneurysms
April Edwell, MD, FAAP; University of California at San Francisco, San Francisco, CA
Purpose: Historically, Kawasaki Disease is a process that general pediatricians are trained to recognize and that
can generally be managed on the floor. Diagnosis requires fever for 5 days and 4/5 of: conjunctival injection, oral
mucous membrane changes, peripheral extremity changes, rash, and cervical lymphadenopathy. However, an
estimated 5% or greater of these patients can present in florid shock, necessitating critical care.
Discussion: An 8-year-old female presented with 6 days of fever and rash and was found to be in shock with
systolics in the 60s. Her exam was notable for cool extremities, scattered red macules on her legs and torso,
conjunctival injection, and left cervical adenopathy. Labs demonstrated elevated inflammatory markers,
leukocytosis, pyuria, and anemia. She was started on inotropes, and had an Echo done at bedside that showed
diminished left ventricular function and ectasia of both right and left coronary arteries, concerning for Kawasaki
shock. Over her course she was given high dose aspirin, IVIGx2, infliximab, and pulse dose steroids. Her left
ventricular function returned to baseline, however, she developed long segment fusiform coronary aneurysms. She
received Cytoxan and Abciximab in an attempt to target coronary remodeling and was started on dual maintenance
aspirin and warfarin therapy. Three weeks later her coronary dilation seemed to plateau, leaving her left anterior
descending coronary at 9.8mm and her right coronary artery at 5.5mm, both still extremely enlarged.
Results: The underlying pathophysiology of Kawasaki disease is still incompletely understood but is felt to be a
combination of vasculitis with capillary leak and increased cytokine release. There is a subset of Kawasaki patients
who present in florid shock felt to be due to that same underlying inflammatory process. Shock associated with
Kawasaki disease can be multifactorial, with both distributive and cardiogenic components. This patient represents
a particularly severe case of Kawasaki shock because she presented with significant myocardial dysfunction and
despite recommended optimal therapy, went on to develop profoundly dilated coronaries. The American Heart
Association divides Kawasaki associated coronary aneurysms into 4 categories using Z scores that adjust for
absolute size and body surface area. Most affected patients have coronary dilation only, with a Z score of <2.5.
Their most severe category (giant aneurysms) is defined as a Z score of >10. This patient's Z score for her left
anterior descending was 24.7.
Conclusion: For the intensivist, it is important to recognize that in patients in shock who also meet the criteria for
Kawasaki, there may be early cardiac involvement necessitating afterload reduction in addition to inotropy. While
there are still refractory cases, the literature suggests that the earlier IVIG is initiated, the lower the risk of severe
coronary aneurysms, and thus should be given as soon as hemodynamic stability allows.
(31) Sonographic Inferior Vena Cava Assessment to Predict Fluid Responsiveness in Patients with Sepsis
Kewan A. Hamid, MD1; Rashed Hasan, MD2; Mohamed Mohamed, BA, MD Candidate3; Laura Caravallah,, MD4;
Arul Chandran, MD2; Dunya Mohammad, MD2, (1) Hurley Medical Center, flint, MI, (2) hurley Medical Center, flint,
MI, (3) Michigan State University, grand rapids, MI, (4) Michigan State University, flint, MI
Purpose: Sonographic assessment of Inferior Vena Cava diameter has been shown to have a role in predicting
fluid responsiveness in critically-ill patients. This diagnostic accuracy of this method, however, has yet been
assessed among septic patients.
Objective: A systematic review and meta-analysis of observational studies to assess the diagnostic accuracy of
this method in predicting fluid responsiveness among septic patients. Methods: Electronic searches were
conducted using appropriate terms. Inclusion criteria were: (1) observational full text studies of any age (2)
recognized reference standard for fluid responsiveness (3) stratified patients into fluid responders and non-
responders (4) provided adequate individual patient data and used summary statistics to describe results. Age
group, definition and criteria of fluid responsiveness, use of mechanical ventilation, summary statistics and study
design, size, and setting were abstracted. Measurements: Summary statistics were pooled and measured for
diagnostic accuracy.
Results: Ten (n = 10) studies involving 446 patients with 244 fluid responders were included. The pooled sensitivity
and specificity (95% confidence interval) for a positive measurement of fluid responsiveness was 0.75 (0.55-0.88)
and 0.86 (0.75-0.93), respectively. Summary receiver operating characteristic curve was 0.89 (0.86-0.91).
Subgroup analysis revealed that this method may be more specific in ventilated patients.
Conclusion: Sonographic assessment of Inferior Vena Cava diameter is of clinical value in predicting fluid
responsiveness in patients with sepsis. A positive test may be of great value in guiding management decisions
particularly in ventilated patients.
(32) The Heart’s Halo: Caring for Pediatric Pneumopericardium
Ivanna N. Maxson, MD1, FAAP; Richard P. Lion, DO, MPH2; Harsha Chandnani, MD3, (1) Loma Linda University
Children's Hospital, Redlands, CA, (2) Loma Linda University Children's Hospital, Loma Linda, CA, (3) Loma Linda
Univeristy Children's Hospital, Loma Linda, CA
Purpose: Pediatric pneumomediastinum (PM) and pneumopericardium (PPC) are rare complications which can
arise from various etiologies. We report a case of pediatric PPC secondary to an asthma exacerbation and discuss
relevant diagnostic and management principles.
Conclusion: Physicians must be aware of PPC and its implications due to the high mortality rate. PPC patients
require close observation with continuous cardiorespiratory and telemetry monitoring, and providers experienced in
the management of cardiac tamponade at a center capable of providing cardiothoracic surgical intervention. Time to
resolution is multifactorial, but can be achieved promptly with supportive care and treatment of underlying condition.
(33) The Role of Video Debriefing as a Method of Feedback Following Simulated Pediatric Resuscitation
Ariella Barhen, MD1, FAAP; Horton Lee, MD2; Jose Quitain, III, MD2; Tania Lopez, MD2; Suzanne Bentley, MD2,
(1) Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, Brooklyn, NY, (2) Icahn School of Medicine
at Mount Sinai, Elmhurst Hospital Center, Elmhurst, NY
Purpose: An integral part of Pediatric residency training is learning how to resuscitate and stabilize critically ill
children. Opportunities to encounter these situations in order to achieve a level of competence are often limited in
residency. Simulation-based education (SBE) is an effective tool used by medical professionals to practice
techniques and assess performance in a structured, patient-safe setting. While debriefing is an essential
component of effective simulation exercises, the best model of debriefing remains under debate. The purpose of
this study is to evaluate whether the use of video debriefing after simulated pediatric resuscitation improves
residents’ performance, confidence, and self-perceived competence in managing pediatric resuscitation.
Methods: Residents were given a pre-assessment questionnaire evaluating their prior experience with pediatric
arrests and critical care cases, perceptions of previous team functioning during resuscitations, as well as their level
of confidence and self-perceived competence in performing pediatric resuscitation and caring for critically ill
children. Questionnaire data will be used to inform Phase 2 of this study to encompass participation of learners in a
simulated case including 3 critical care management sub-sections. Residents will be randomized to either video
debriefing group (intervention group) or traditional debriefing group (control) following case completion.
Questionnaires will be completed both 24 hours and 6 months post-simulation to assess retention of content and
level of confidence.
Results: The pre-assessment questionnaire showed a 54% response rate to date and reveals that residents felt
most uncomfortable managing pediatric cardiac arrest (71% vs 6% “very comfortable”), followed by 65% for sepsis,
64% for difficult airway, and 58% for an overdose patient. Conversely, majority reported feeling “comfortable” or
“very comfortable” managing allergic reaction, status asthmaticus, and trauma. These results will tailor the Phase 2
interventional step of this study (likely simulation case of sepsis requiring vasopressors, seizure with difficult airway,
and pediatric cardiac arrest), which will be utilized to compare the 2 types of debriefing in regard to change in
confidence and self-perceived competence.
Conclusion: Pediatric residents are expected to complete residency confident and competent in managing critically
ill children. Our pre-assessment survey reveals the types of cases that residents are most uncomfortable managing,
which will inform the Phase 2 educational intervention. We hope to determine if the use of video debriefing as a
method of direct feedback results in improved provider performance, confidence, and self-perceived competence
during pediatric resuscitation when compared to standard oral debriefing alone. This will aid in optimizing residents’
training and education, as well as establishing whether video debriefing is a more effective method of direct
feedback during Phase 2 of this study.
(34) Thromboembolic Events in Children after Invasive Procedures in a Pediatric Cardiac Intensive Care
Unit
Zasha F. Vazquez-Colon, MD1, FAAP; Ricardo Garcia, MD, FAAP, FCCM 2; William Miranda - Lopez, MD 3;
Franchesca Garcia, M.D.4, (1) San Juan City Hospital, Bayamon, Puerto Rico, (2) Department of
Pediatrics/University of Puerto Rico Medical Sciences Campus/ University Pediatric Hospital, San Juan, N/A,
Puerto Rico, (3) Department of Pediatrics/ University of Puerto Rico, Medical Sciences Campus/ University
Pediatric Hospital, San Juan, N/A, Puerto Rico, (4) San Juan Municipal Hospital, Pediatrics Department, San Juan,
N/A, Puerto Rico
Purpose: Thromboembolic events are known complications associated to central venous catheters and arterial
catheterization. The exact mechanism of thrombus formation not completely understood, but it has been suggested
that intimal flaps and dissection can occur after direct vessel puncture, which can lead to occlusion of the true
lumen and predispose patient to thrombosis and limb ischemia. Thromboembolic complications are particularly
important in the pediatric population because it can be associated with other morbidities. Prior studies have
identified risk factors associated with thromboembolic events in pediatric population, but there is limited information
about the incidence of thromboembolic events in children with congenital heart disease. Our aim is to identify cases
of thromboembolic events, risk factors, management and outcomes in pediatric patients who were admitted to the
Cardiac Intensive Care Unit as part of a quality improvement initiative to decrease intensive unit complications.
Methods: A cross - sectional, descriptive database review was performed on patients admitted to the cardiac
intensive care unit at the Centro Cardiovascular de Puerto Rico y del Caribe that developed thromboembolic
complications and had positive Doppler/duplex ultrasound for thrombus formation. Study period from January 2016
- March 2018. Data included patient demographics, weight, diagnosis, procedure performed, type and location of
thrombus, management, and other complications.
Results: A total of 30 patients were identified with a thromboembolic event in the study period. They were most
common of arterial origin (89.7%). Cases were most frequently in male patients, a mean age of 1.7 ± 4.8 months
and with mean weight of 8.3 ± 12 kg. The events occurred more frequently after congenital heart disease surgery
and associated with femoral artery placement (60%). Management included heparin infusion (37%) and there were
no major sequelae or complication related to thrombotic event nor therapy. But we found that no standardized
protocol was used.
Conclusion: In review of the findings we conclude that thromboembolic events were mostly seen in patients of low
weight and were most likely of arterial origin. These data is important to improve and establish management and
prevention protocols to decrease likelihood of these events in the pediatric population and risk of major
complications.
(35) Tracheostomy in Pediatric Intensive Care Unit (PICU): When, Why and Outcomes
Thais Rocha. Salim, MSc1; Tatiana Vasconcelos. Santos, MSC2, (1) Universidade Federal Rio de Janeiro
(UFRJ)/Universidade Severino Sombra (USS), Vassouras, Rio de Janeiro, Brazil, (2) Universidade Federal do Rio
de Janeiro (UFRJ), Rio de Janeiro, Rio de Janeiro, Brazil
Purpose: There is no certain time for tracheostomy for children after prolonged ventilation. The objectives were
identified when and why tracheostomy was indicated, its complications and outcomes. Methods:It was retrospective
study with all patients that had a tracheostomy indication in the period from January 2015 to May 2017 in a PICU.
Demographic and clinical characteristics, functional status through the Pediatric Overall and Cerebral Performance
Categories, tracheostomy indications and complications, the median duration of mechanical ventilation (MV) before
indication and procedure, and ventilator weaning after surgery were analyzed.
Results: Seventeen patients were analyzed, 10 (59%) male, at a median age of 21 months (IQR 8,5 - 43,5). The
median Pediatric Index of Mortality 2 at admission was 5,13 (IQR 3,34-23,91). Ninety four percent had chronic
health conditions, including 88% with severe disability at admission.The main tracheostomy indication was
prolonged mechanical ventilation (47%). The median of MV before tracheostomy indication was of 18 days (IQR
11-30) and 25 days (IQR 19-38) until the insertion of a tracheostomy tube. Twenty nine percent had complications
after the procedure, the most frequent was pneumothorax (60%). Eighty percent happened in the immediate pos-
op. After tracheostomy, 70% were successfully weaned from MV and were discharged from PICU and 18% died
during PICU stay because of ventilation problems. The median timing for weaning was of 1 day (IQR 0-1).
Conclusion: Tracheostomy was indicated to patients with chronic conditions and severe disability requiring
prolonged mechanical ventilation. The procedure facilitated the PICU discharge and ventilator weaning
(36) Trends in Neuropharmacologic Medications Over Time in Mechanically Ventilated Children
Allison M. Blatz, MD; Steven L. Shein, MD; Alexandre Rotta, MD, FCCM, FAAP; Deanne Wilson-Costello, MD,
Rainbow Babies & Children's Hospital, Cleveland, OH
Purpose: Pediatric Intensive Care Unit (PICU) patients who require mechanical ventilation (MV) frequently receive
neuropharmacologic agents like benzodiazepines, opioids, neuromuscular antagonists, and dexmedetomidine. The
United States Food and Drug Administration recently warned against the use of some neuropharmacologic agents
in young children due to risk of neurotoxicity. Our group recently reported increasing prescription of many
neuropharmacologic agents in patients mechanically ventilated for bronchiolitis, and a concurrent increase in use of
rehabilitative services. The aim of this study is to determine if similar trends exist in a more heterogeneous cohort of
young children undergoing MV in a large, multicenter database.
Methods: With approval from the IRB, the Pediatric Health Information Systems (PHIS) database was queried for
young children (<36mo) with receipt of MV and ICU admission (excluding neonatal ICUs). Children with a pre-
existing tracheostomy were excluded and only the first admission for each subject during the study period (2006-
2016) was analyzed. Data extracted included demographics, neuropharmacologic medications prescribed for ≥2
days, receipt of services that evaluate/treat neurologic morbidity (e.g. occupational therapy, neurology
consultation), duration of MV, hospital length of stay, and in-hospital mortality. For each subject, the total number of
days that each neuropharmacologicc medication was prescribed were summed together and divided by the number
of days of MV. Data were analyzed using simple linear regression and Kruskal-Wallis ANOVA with Dunn’s test;
alpha was set at 0.05.
Results: Among 111,064 subjects, median age was 103 days (IQR: 13-138 days), 43% were male, 65% underwent
surgery and the most common primary diagnoses were respiratory and cardiovascular disorders. Drugs/drug
classes prescribed per subject, drug days per MV day, and the number of children who received ≥5 drugs/drug
classes all increased significantly over the study period (Table 1). Drugs/drug classes with significantly increased
prescription over the study period included antipsychotics (1% [in 2006] to 3% [in 2016]), clonidine (2% to 14%),
dexmedetomidine (4% to 43%), diazepam (5% to 6%), hydromorphone (1% to 8%), ketamine (9% to 15%),
lorazepam (38% to 41%), methadone (17% to 21%) and propofol (9% to 15%). Mortality and use of parenteral
vasoactive medications (69% to 67%, p =0.316) did not increase during the study period. Use of neurorehabilitative
services also significantly increased (Figure 1).
Conclusion: Among young children receiving MV in the PHIS database, there have been concurrent increases in
prescription of several neuropharmacologic drugs and use of neurorehabilitative services, though indices of illness
severity (mortality and vasoactive medication prescription) did not increase. The fraction of subjects exposed to ≥5
drugs/drug classes increased by 36% while median drug exposure only increased modestly. Further work aimed at
identifying factors associated with increased drug exposure and determining if exposure affects clinical outcomes is
needed.
Table 1. Data trends by year
* p < 0.05 by simple linear regression; ** p<0.05 vs 2006 by Dunn's test

Figure 1. Use of rehabilitative services over time
* p < 0.05 for all trends

(37) Use of the Cornell Assessment of Pediatric Delirium (CAPD) for Identifying Delirium and Associated
Risk Factors in the Pediatric Intensive Care Unit
Brittany Difabio, MD1, FAAP; Molly McGetrick, MD1; Christopher Campbell, PharmD 2; Brian Kelly, PharmD3;
Jennifer Munoz-Pareja, MD 1, (1) University of Florida Department of Pediatrics, Gainesville, FL, (2) University of
Florida College of Pharmacy, Gainesville, FL, (3) Shand’s Children’s Hospital, Gainesville, FL
Purpose: Delirium in the pediatric intensive care unit (PICU) is a common, yet under recognized problem. In the
literature, incidence is estimated to be around 20-30% with much higher rates in certain sub-populations. Screening
for delirium in the pediatric population can often be challenging, though screening tools have been developed and
validated for use in children in all age groups. The Cornell Assessment of Pediatric Delirium (CAPD) is a tool that
has high inter-rater reliability and is easily applied in this population. Methods: In our study, 72 pediatric patients
aged 0-18 years between June 2017 and July 2018 were screened with the CAPD twice daily for a maximum of 7
days. Demographic factors, respiratory support data, medications and illness severity were collected for each
patient.
Results: Of the patients completing the study, the incidence of delirium was 72.8% (51/70). The average length of
stay at the time of enrollment was 5 days with a median of 17 days. There were no statistically significant
differences in the incidence of delirium when looking at demographic factors including sex, age and race. Longer
lengths of stay, history of surgery during admission, and location in the cardiac intensive care unit vs. pediatric
intensive care unit did not relate to higher rates of delirium. There was a statistically significant association between
delirium and use of sedation medications (OR=13.6; 95%CI 3.89- 47.71), antibiotics (OR=4.5; 95%CI 1.48-13.84),
steroids (OR=4.4; 95%CI 1.13-16.91), and fentanyl (OR=11.6; 95%CI 1.43- 93.95). Additionally, there was a
positive correlation with the number of sedation medications used and development of delirium.
Conclusion: Delirium in our pediatric intensive care unit and pediatric cardiac intensive care unit was much higher
that originally postulated. Risk factors we identified include the use of sedation medications, antibiotics, steroids
and fentanyl for pain control. This pilot study opens the door for further investigations into risk factors for delirium in
our institution.

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AMERICAN ACADEMY OF PEDIATRICS

SECTION ON CRITICAL CARE

SCIENTIFIC ABSTRACT & EDUCATIONAL

JOINT SESSION 1 – SECTION ON CRITICAL CARE & SECTION ON

Anesthesia and the ICU, its more than passing gas

8:00- 8:15AM INTRODUCTIONS

8:15- 9:00AM DIFFICULT AIRWAY MANAGEMENT IN THE

9:00- 9:45AM ACUTE AND CHRONIC PAIN MANAGEMENT IN

10:00-10:45AM NEURODEVELOPMENTAL IMPLICATIONS IN

10:45-11:30AM SPECIAL CONSIDERATIONS OF THE

11:30- 12:00PM PANEL QUESTION AND ANSWER

JOINT SESSION 2 – SECTION ON CRITICAL CARE & SECTION ON NEPHROLOGY

Topic and Procedure:

1:00- 1:10PM INTRODUCTIONS

1:10- 1:40PM CONTINUOUS RENAL REPLACEMENT

1:40- 2:10PM ACUTE KIDNEY INJURY, UPDATE

2:10- 2:40PM KIDNEY INJURY UPDATE: DONOR

2:40- 3:00PM PANEL OF SPEAKERS

SOCC SCIENTIFIC ABSTRACT PROGRAM

8:00- 8:15AM INTRODUCTIONS

8:15- 9:30AM ORAL ABSTRACT SESSION I

8:15AM SAMUEL KASE

8:30AM SARAH HILTON, MD, MSHS

8:45AM AMBRISH PATEL, MD, FAAP

9:00AM ALLISON WHALEN, MD, FAAP

9:15AM PETA ALEXANDER, MBBS

9:30- 10:30AM POSTER WALK ROUNDS

1.) SNEHA KOLLI, MD, FAAP

2.) MOISÉS GARCÍA-ROSA, MD, FAAP, FCCM

3.) ERICK JARAN LEON, MD, MBA

4.) AMINA JAJI, MD, FAAP

5.) LARA OLIVER, MD, FAAP

6.) JENNIFER SETLIK, MD, FAAP

7.) ASHLESHA KAUSHIK, MD, FAAP

9.) HANNAH LIVELY, MD, FAAP

10.) DUSTIN HIPP, MD, FAAP

11.) GRAHAM CHAMBERLAIN, BSC, MSC, MD

12.) JUAN BARRON, MD, MPH, FAAP

14.) JORDAN MERZ, MD, FAAP

16.) ASHLESHA KAUSHIK, MD, FAAP

17.) JENNIFER BARTLETT, CPNP

18.) MUHAMMED ELHADI, MD, FAAP

19.) FERNANDO PENA-CRUZ, MD, FAAP

20.) COURTNEY BRANTLEY, MD, FAAP

21.) CASEY MEHRHOFF, DO, MS

23.) LEAH ABECASSIS, MSN, RN, CCRN

25.) DANIELLE GREEN, MD, FAAP

26.) ERIN BURNS, MD, FAAP

27.) YAHAIRA PIZARRO, MD, FAAP

28.) LISA BELTER, MPH

29.) JESSICA LEE, MD, MHS

30.) APRIL EDWELL, MD, FAAP

32.) IVANNA MAXSON, MD, FAAP

33.) AIRELLA BARHEN, MD, FAAP

34.) ZASHA VAZQUEZ-COLON, MD, FAAP

35.) THAIS SALIM, MSC

37.) BRITTANY DIFABIO, MD, FAAP

10:30-10:45AM SOCC UPDATES

10:30-10:45AM DISTINGUISHED CAREER AWARD

11:00- 12:15PM ORAL ABSTRACT SESSION II

11:00AM MATTHEW ZACKOFF, MD, FAAP

IMPACT OF AN IMMERSIVE VIRTUAL REALITY

11:15AM CONOR O’HALLORAN, MD