Phoebe Yager - Academia.edu (original) (raw)
Papers by Phoebe Yager
Health security, Feb 1, 2022
Treatment of multisystem inflammatory syndrome in children (MIS-C) can require significant critic... more Treatment of multisystem inflammatory syndrome in children (MIS-C) can require significant critical care resources. Our aim is to alert mixed pediatric and adult hospitals worldwide of the possibility that pediatric and adult patients may simultaneously require cannulation to extracorporeal membrane oxygenation (ECMO) for MIS-C and severe COVID-19. We conducted a retrospective review of operations required to treat cardiogenic shock in 3 pediatric patients with a diagnosis of MIS-C admitted to a single medium-sized pediatric referral center located within a large academic medical center over a 14-day period. At this time, a large number of adult patients required ECMO for severe COVID-19 at our institution. Of the 11 pediatric patients who presented with MIS-C during the first surge of 2020, 2 patients required cannulation to venoarterial extracorporeal membrane oxygenation (VA-ECMO), and a third patient developed a lifethreatening arrhythmia requiring transfer to a neighboring institution for consideration of VA-ECMO when our institution's ECMO capacity had briefly been reached. Pediatric referral centers located within institutions providing ECMO to adult patients with severe COVID-19 may benefit from frequent and direct communication with their adult and regional colleagues to devise a collaborative plan for safe and timely provision of ECMO to patients with MIS-C as the ongoing pandemic continues to consume this limited, lifesaving resource.
Pediatrics in Review, Aug 1, 2010
Annals of Pharmacotherapy, Feb 18, 2020
Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but th... more Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but the concentration, dosing and administration of HTS in pediatrics is variable. With emerging pediatric experience of 23.4% HTS, a standard volume dose approach may be helpful. Objective: To describe initial experience with a standardized 23.4% HTS weightbased volume dosing protocol of 10, 20, or 30 mL in the pediatric intensive care unit. Methods: Standard volume doses of 23.4% HTS were developed from weight dosing equivalents of 3% HTS. Pre and post sodium and intracranial pressure (ICP) measurements were compared with paired t-test or Wilcoxon rank-sum test. The site of administration and complications were noted. Results: A total of 16 pediatric patients received 37 doses of 23.4% HTS, with the smallest patient weighing 11 kg. For protocol compliance, 17 doses (46%) followed recommended dosing, 19 were less volume than recommended (51%), and 1 dose (3%) was more than recommended. Mean increase in sodium was 3.5 mEq/L (95% CI = 2-5 mEq/L); P < 0.0001. The median decrease in ICP was 10.5 mm Hg (interquartile range [IQR] 8.3-19.5) for a 37% (IQR 25%-64%) reduction. Most doses were administered through central venous access, although peripheral intravenous administrations occurred in 4 patients without complication. Conclusion and Relevance: Three standard-volume dose options of 23.4% HTS based on weight increases sodium and reduces ICP in pediatric patients. Standard-volume doses may simplify weight-based dosing, storage and administration for pediatric emergencies, although the optimum dose, and safety of 23.4% HTS in children remains unknown.
Pediatric Clinics of North America, Aug 1, 2020
Parents whose children are admitted to a pediatric intensive care unit (PICU) suffer significant ... more Parents whose children are admitted to a pediatric intensive care unit (PICU) suffer significant life disruption and anxiety. The incidence of parental post-traumatic stress disorder has been reported to be 21%. 1,2 Obtaining honest, open, timely, and understandable information from providers is important to parents, with more than 90% of parents in one study identifying communication with clinicians as an important coping strategy. 3 As pediatricians have championed the concept of family-centered care, the literature linking family participation on daily PICU rounds with improved parent satisfaction and decreased parent stress is growing. 4-6 The 2017 Society of Critical Care Medicine guidelines for family-centered care in the neonatal intensive care unit (NICU), PICU, and adult intensive care unit (ICU) recommend "family members of critically ill patients be offered the option of participating
Health security, Aug 1, 2021
The objective of this study was to describe the clinical characteristics and outcomes of adult co... more The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH 2 O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible.
The New England Journal of Medicine, Jun 16, 2021
The authors' full names, academic degrees, and affiliations are listed in the Appendix. Address r... more The authors' full names, academic degrees, and affiliations are listed in the Appendix. Address reprint requests to Dr. Randolph, Boston Children's Hospital, 300 Longwood Ave., Bader 634, Boston, MA 02115, or at adrienne. randolph@ childrens. harvard. edu.
American Journal of Emergency Medicine, Nov 1, 2021
The New England Journal of Medicine, Oct 11, 2012
Dr. Patricia L. Musolino (Neurology): An 18-year-old man was transferred to this hospital because... more Dr. Patricia L. Musolino (Neurology): An 18-year-old man was transferred to this hospital because of blurred vision, dysarthria, and ataxia, which had reportedly progressed to coma. The patient had been well until 6 p.m. the evening before admission, when he had an abrupt onset of weakness, shaking and buckling of his legs, and clumsiness of his right hand. Approximately 20 minutes later, his speech became slurred; his parents transported him to the emergency department at another hospital. While in transit, the dysarthria worsened and the patient reported blurred vision. On arrival at the hospital 1 hour after the onset of symptoms, he required assistance getting into a wheelchair. He reported being off-balance and light-headed, with blurred vision and pain at the base of the right side of the skull. On examination, he was alert and oriented but slow to respond, and he intermittently laughed inappropriately. The vital signs were normal, and the oxygen saturation was 100% while he was breathing ambient air. On neurologic examination, the pupils and extraocular movements were reportedly normal, without nystagmus. The speech was slurred. The first cranial nerve was not tested; results of testing of the other cranial nerves were normal. The deep-tendon reflexes were 1+ and symmetric. Alternating movements of the hands were slow, with some lack of coordination; his performance on finger-to-nose testing was accurate. The white-cell count was 8600 per cubic millimeter, with 80% granulocytes, 14% lymphocytes, and 6% monocytes. The remainder of the complete blood count and the results of renaland liver-function tests were normal, as were the levels of electrolytes and glucose, measurements of arterial blood gases performed while the patient was breathing ambient air, and other test results. Screening of the blood for alcohol and the urine for toxins and drugs was negative. Computed tomography (CT) of the head was reportedly normal. The patient was admitted to the other hospital. A lumbar puncture was performed; tube 1 of the cerebrospinal fluid (CSF) appeared bloody, with gradual clearing. Reportedly, the white-cell count was 9 per cubic millimeter in tube 1 and 1 per cubic millimeter in tube 4, and the red-cell count was 10,000 per cubic millimeter in tube 1 and 54 per cubic millimeter in tube 4. The protein level was 58 mg per deciliter, and the glucose level 62 mg per deciliter (3.4 mmol per liter). No organisms were seen on Gram’s staining.
Pediatric Critical Care Medicine
Clinical Infectious Diseases
Background Clinical differences between critical illness from influenza infection vs coronavirus ... more Background Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. Methods We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. Results Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechani...
International Journal of Pediatric Otorhinolaryngology, 2021
JAMA Neurology, 2021
IMPORTANCE Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The ... more IMPORTANCE Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The spectrum of neurologic involvement in children and adolescents is unclear. OBJECTIVE To understand the range and severity of neurologic involvement among children and adolescents associated with COVID-19. SETTING, DESIGN, AND PARTICIPANTS Case series of patients (age <21 years) hospitalized between March 15, 2020, and December 15, 2020, with positive severe acute respiratory syndrome coronavirus 2 test result (reverse transcriptase-polymerase chain reaction and/or antibody) at 61 US hospitals in the Overcoming COVID-19 public health registry, including 616 (36%) meeting criteria for multisystem inflammatory syndrome in children. Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening involvement was adjudicated by experts based on clinical and/or neuroradiologic features. EXPOSURES Severe acute respiratory syndrome coronavirus 2. MAIN OUTCOMES AND MEASURES Type and severity of neurologic involvement, laboratory and imaging data, and outcomes (death or survival with new neurologic deficits) at hospital discharge. RESULTS Of 1695 patients (909 [54%] male; median [interquartile range] age, 9.1 [2.4-15.3] years), 365 (22%) from 52 sites had documented neurologic involvement. Patients with neurologic involvement were more likely to have underlying neurologic disorders (81 of 365 [22%]) compared with those without (113 of 1330 [8%]), but a similar number were previously healthy (195 [53%] vs 723 [54%]) and met criteria for multisystem inflammatory syndrome in children (126 [35%] vs 490 [37%]). Among those with neurologic involvement, 322 (88%) had transient symptoms and survived, and 43 (12%) developed life-threatening conditions clinically adjudicated to be associated with COVID-19, including severe encephalopathy (n = 15; 5 with splenial lesions), stroke (n = 12), central nervous system infection/demyelination (n = 8), Guillain-Barré syndrome/variants (n = 4), and acute fulminant cerebral edema (n = 4). Compared with those without life-threatening conditions (n = 322), those with life-threatening neurologic conditions had higher neutrophil-tolymphocyte ratios (median, 12.2 vs 4.4) and higher reported frequency of D-dimer greater than 3 μg/mL fibrinogen equivalent units (21 [49%] vs 72 [22%]). Of 43 patients who developed COVID-19-related life-threatening neurologic involvement, 17 survivors (40%) had new neurologic deficits at hospital discharge, and 11 patients (26%) died. CONCLUSIONS AND RELEVANCE In this study, many children and adolescents hospitalized for COVID-19 or multisystem inflammatory syndrome in children had neurologic involvement, mostly transient symptoms. A range of life-threatening and fatal neurologic conditions associated with COVID-19 infrequently occurred. Effects on long-term neurodevelopmental outcomes are unknown.
Pediatric Critical Care Medicine, 2019
here may not be appropriate, limiting the generalizability of these findings beyond this specific... more here may not be appropriate, limiting the generalizability of these findings beyond this specific population. Finally, and most importantly, the current study by Namachivayam et al (9) does not address any comparison between those infants who never received PD and those in the "early" and "late" cohorts. Thus, it remains unclear how those groups may have differed from each other, complicating efforts to apply these findings broadly at the bedside. Once the decision to use PD after CPB has been made by the clinician and CICU team, it appears to be beneficial to expedite the PD initiation as much as possible. The basic question of which infants may derive the most benefit from early initiation of PD versus continuing nondialytic fluid management, however, remains unanswered. As we move forward, protocolized prospective studies with tangible clinical outcomes that can help to guide clinical decision-making remain badly needed.
Health Security, 2019
During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small hand... more During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small handful of expatriate patients were evacuated to specialized high-level containment care units, or biocontainment units, in the United States and Western Europe. Given the lower mortality rate (18% versus 40% for those treated in Africa) among these patients, it is likely that high-level containment care will be used in the future with increasing frequency. It is also likely that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients. We report here the results of those discussions.
International Journal of Pediatric Otorhinolaryngology
INTRODUCTION Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Inten... more INTRODUCTION Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU. METHODS This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was 1.32perchild.PICUmortalitywasevaluatedasanexploratoryoutcome.RESULTSNine−hundredandfifty−seven(859pre−interventionand98post−intervention)patientsmetinclusioncriteria.PatientswithoneormoreUEsdecreasedsignificantlyfrom29.41.32 per child. PICU mortality was evaluated as an exploratory outcome. RESULTS Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28-0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17-0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24-0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is 1.32perchild.PICUmortalitywasevaluatedasanexploratoryoutcome.RESULTSNine−hundredandfifty−seven(859pre−interventionand98post−intervention)patientsmetinclusioncriteria.PatientswithoneormoreUEsdecreasedsignificantlyfrom29.430.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44. CONCLUSION This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.
JAMA Network Open, 2021
IMPORTANCE Multisystem inflammatory syndrome in children (MIS-C) is associated with recent or cur... more IMPORTANCE Multisystem inflammatory syndrome in children (MIS-C) is associated with recent or current SARS-CoV-2 infection. Information on MIS-C incidence is limited. OBJECTIVE To estimate population-based MIS-C incidence per 1 000 000 person-months and to estimate MIS-C incidence per 1 000 000 SARS-CoV-2 infections in persons younger than 21 years. DESIGN, SETTING, AND PARTICIPANTS This cohort study used enhanced surveillance data to identify persons with MIS-C during April to June 2020, in 7 jurisdictions reporting to both the Centers for Disease Control and Prevention national surveillance and to Overcoming COVID-19, a multicenter MIS-C study. Denominators for population-based estimates were derived from census estimates; denominators for incidence per 1 000 000 SARS-CoV-2 infections were estimated by applying published age-and month-specific multipliers accounting for underdetection of reported COVID-19 case counts.
Critical Care Clinics
Pediatric providers were called on to care for patients outside their typical scope of practice d... more Pediatric providers were called on to care for patients outside their typical scope of practice during the first surge of the SARS-CoV-2 pandemic. Providers were forced to think creatively while working within established hospital systems and to use resources collaboratively across units and teams. Already published in the literature are examples of collaboration between pediatric and adult critical care groups, None of the authors have commercial or financial conflicts of interest to disclose.
Applied Clinical Informatics, 2021
Objective Based on feedback from nurses regarding the challenges of code documentation following ... more Objective Based on feedback from nurses regarding the challenges of code documentation following the implementation of a new electronic health record (EHR), we sought to better understand inpatient nurse attitudes and practices in code documentation and to identify opportunities for improvement. Methods An anonymous electronic survey was distributed to all inpatient nurses working at a single, 999-bed, university-based, and quaternary care hospital. Participation in the study was voluntary and consent was implied by survey completion. Results Overall, 432 (14%) of 3,121 inpatient nurses completed the survey. While nearly 80% of respondents indicated feeling very comfortable using computers for personal use, only 5% felt very comfortable navigating the EHR to document codes in real time. While 53% had documented codes in the new EHR, most admitted to documenting on paper with retroactive entry into the EHR. About 25% reported having participated in a code that was not accurately docu...
The Journal of Pediatrics, 2021
Pseudohyperkalemia and pseudohyponatremia are phenomena in which hematologic disorders with high ... more Pseudohyperkalemia and pseudohyponatremia are phenomena in which hematologic disorders with high cell counts result in factitious electrolyte measurements which can result in inappropriate treatment. We describe two children with leukemia presenting with both disturbances to highlight the importance of correlating electrolyte results from plasma with those from whole blood before intervening.
Health security, Feb 1, 2022
Treatment of multisystem inflammatory syndrome in children (MIS-C) can require significant critic... more Treatment of multisystem inflammatory syndrome in children (MIS-C) can require significant critical care resources. Our aim is to alert mixed pediatric and adult hospitals worldwide of the possibility that pediatric and adult patients may simultaneously require cannulation to extracorporeal membrane oxygenation (ECMO) for MIS-C and severe COVID-19. We conducted a retrospective review of operations required to treat cardiogenic shock in 3 pediatric patients with a diagnosis of MIS-C admitted to a single medium-sized pediatric referral center located within a large academic medical center over a 14-day period. At this time, a large number of adult patients required ECMO for severe COVID-19 at our institution. Of the 11 pediatric patients who presented with MIS-C during the first surge of 2020, 2 patients required cannulation to venoarterial extracorporeal membrane oxygenation (VA-ECMO), and a third patient developed a lifethreatening arrhythmia requiring transfer to a neighboring institution for consideration of VA-ECMO when our institution's ECMO capacity had briefly been reached. Pediatric referral centers located within institutions providing ECMO to adult patients with severe COVID-19 may benefit from frequent and direct communication with their adult and regional colleagues to devise a collaborative plan for safe and timely provision of ECMO to patients with MIS-C as the ongoing pandemic continues to consume this limited, lifesaving resource.
Pediatrics in Review, Aug 1, 2010
Annals of Pharmacotherapy, Feb 18, 2020
Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but th... more Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but the concentration, dosing and administration of HTS in pediatrics is variable. With emerging pediatric experience of 23.4% HTS, a standard volume dose approach may be helpful. Objective: To describe initial experience with a standardized 23.4% HTS weightbased volume dosing protocol of 10, 20, or 30 mL in the pediatric intensive care unit. Methods: Standard volume doses of 23.4% HTS were developed from weight dosing equivalents of 3% HTS. Pre and post sodium and intracranial pressure (ICP) measurements were compared with paired t-test or Wilcoxon rank-sum test. The site of administration and complications were noted. Results: A total of 16 pediatric patients received 37 doses of 23.4% HTS, with the smallest patient weighing 11 kg. For protocol compliance, 17 doses (46%) followed recommended dosing, 19 were less volume than recommended (51%), and 1 dose (3%) was more than recommended. Mean increase in sodium was 3.5 mEq/L (95% CI = 2-5 mEq/L); P < 0.0001. The median decrease in ICP was 10.5 mm Hg (interquartile range [IQR] 8.3-19.5) for a 37% (IQR 25%-64%) reduction. Most doses were administered through central venous access, although peripheral intravenous administrations occurred in 4 patients without complication. Conclusion and Relevance: Three standard-volume dose options of 23.4% HTS based on weight increases sodium and reduces ICP in pediatric patients. Standard-volume doses may simplify weight-based dosing, storage and administration for pediatric emergencies, although the optimum dose, and safety of 23.4% HTS in children remains unknown.
Pediatric Clinics of North America, Aug 1, 2020
Parents whose children are admitted to a pediatric intensive care unit (PICU) suffer significant ... more Parents whose children are admitted to a pediatric intensive care unit (PICU) suffer significant life disruption and anxiety. The incidence of parental post-traumatic stress disorder has been reported to be 21%. 1,2 Obtaining honest, open, timely, and understandable information from providers is important to parents, with more than 90% of parents in one study identifying communication with clinicians as an important coping strategy. 3 As pediatricians have championed the concept of family-centered care, the literature linking family participation on daily PICU rounds with improved parent satisfaction and decreased parent stress is growing. 4-6 The 2017 Society of Critical Care Medicine guidelines for family-centered care in the neonatal intensive care unit (NICU), PICU, and adult intensive care unit (ICU) recommend "family members of critically ill patients be offered the option of participating
Health security, Aug 1, 2021
The objective of this study was to describe the clinical characteristics and outcomes of adult co... more The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH 2 O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible.
The New England Journal of Medicine, Jun 16, 2021
The authors' full names, academic degrees, and affiliations are listed in the Appendix. Address r... more The authors' full names, academic degrees, and affiliations are listed in the Appendix. Address reprint requests to Dr. Randolph, Boston Children's Hospital, 300 Longwood Ave., Bader 634, Boston, MA 02115, or at adrienne. randolph@ childrens. harvard. edu.
American Journal of Emergency Medicine, Nov 1, 2021
The New England Journal of Medicine, Oct 11, 2012
Dr. Patricia L. Musolino (Neurology): An 18-year-old man was transferred to this hospital because... more Dr. Patricia L. Musolino (Neurology): An 18-year-old man was transferred to this hospital because of blurred vision, dysarthria, and ataxia, which had reportedly progressed to coma. The patient had been well until 6 p.m. the evening before admission, when he had an abrupt onset of weakness, shaking and buckling of his legs, and clumsiness of his right hand. Approximately 20 minutes later, his speech became slurred; his parents transported him to the emergency department at another hospital. While in transit, the dysarthria worsened and the patient reported blurred vision. On arrival at the hospital 1 hour after the onset of symptoms, he required assistance getting into a wheelchair. He reported being off-balance and light-headed, with blurred vision and pain at the base of the right side of the skull. On examination, he was alert and oriented but slow to respond, and he intermittently laughed inappropriately. The vital signs were normal, and the oxygen saturation was 100% while he was breathing ambient air. On neurologic examination, the pupils and extraocular movements were reportedly normal, without nystagmus. The speech was slurred. The first cranial nerve was not tested; results of testing of the other cranial nerves were normal. The deep-tendon reflexes were 1+ and symmetric. Alternating movements of the hands were slow, with some lack of coordination; his performance on finger-to-nose testing was accurate. The white-cell count was 8600 per cubic millimeter, with 80% granulocytes, 14% lymphocytes, and 6% monocytes. The remainder of the complete blood count and the results of renaland liver-function tests were normal, as were the levels of electrolytes and glucose, measurements of arterial blood gases performed while the patient was breathing ambient air, and other test results. Screening of the blood for alcohol and the urine for toxins and drugs was negative. Computed tomography (CT) of the head was reportedly normal. The patient was admitted to the other hospital. A lumbar puncture was performed; tube 1 of the cerebrospinal fluid (CSF) appeared bloody, with gradual clearing. Reportedly, the white-cell count was 9 per cubic millimeter in tube 1 and 1 per cubic millimeter in tube 4, and the red-cell count was 10,000 per cubic millimeter in tube 1 and 54 per cubic millimeter in tube 4. The protein level was 58 mg per deciliter, and the glucose level 62 mg per deciliter (3.4 mmol per liter). No organisms were seen on Gram’s staining.
Pediatric Critical Care Medicine
Clinical Infectious Diseases
Background Clinical differences between critical illness from influenza infection vs coronavirus ... more Background Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. Methods We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. Results Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechani...
International Journal of Pediatric Otorhinolaryngology, 2021
JAMA Neurology, 2021
IMPORTANCE Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The ... more IMPORTANCE Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The spectrum of neurologic involvement in children and adolescents is unclear. OBJECTIVE To understand the range and severity of neurologic involvement among children and adolescents associated with COVID-19. SETTING, DESIGN, AND PARTICIPANTS Case series of patients (age <21 years) hospitalized between March 15, 2020, and December 15, 2020, with positive severe acute respiratory syndrome coronavirus 2 test result (reverse transcriptase-polymerase chain reaction and/or antibody) at 61 US hospitals in the Overcoming COVID-19 public health registry, including 616 (36%) meeting criteria for multisystem inflammatory syndrome in children. Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening involvement was adjudicated by experts based on clinical and/or neuroradiologic features. EXPOSURES Severe acute respiratory syndrome coronavirus 2. MAIN OUTCOMES AND MEASURES Type and severity of neurologic involvement, laboratory and imaging data, and outcomes (death or survival with new neurologic deficits) at hospital discharge. RESULTS Of 1695 patients (909 [54%] male; median [interquartile range] age, 9.1 [2.4-15.3] years), 365 (22%) from 52 sites had documented neurologic involvement. Patients with neurologic involvement were more likely to have underlying neurologic disorders (81 of 365 [22%]) compared with those without (113 of 1330 [8%]), but a similar number were previously healthy (195 [53%] vs 723 [54%]) and met criteria for multisystem inflammatory syndrome in children (126 [35%] vs 490 [37%]). Among those with neurologic involvement, 322 (88%) had transient symptoms and survived, and 43 (12%) developed life-threatening conditions clinically adjudicated to be associated with COVID-19, including severe encephalopathy (n = 15; 5 with splenial lesions), stroke (n = 12), central nervous system infection/demyelination (n = 8), Guillain-Barré syndrome/variants (n = 4), and acute fulminant cerebral edema (n = 4). Compared with those without life-threatening conditions (n = 322), those with life-threatening neurologic conditions had higher neutrophil-tolymphocyte ratios (median, 12.2 vs 4.4) and higher reported frequency of D-dimer greater than 3 μg/mL fibrinogen equivalent units (21 [49%] vs 72 [22%]). Of 43 patients who developed COVID-19-related life-threatening neurologic involvement, 17 survivors (40%) had new neurologic deficits at hospital discharge, and 11 patients (26%) died. CONCLUSIONS AND RELEVANCE In this study, many children and adolescents hospitalized for COVID-19 or multisystem inflammatory syndrome in children had neurologic involvement, mostly transient symptoms. A range of life-threatening and fatal neurologic conditions associated with COVID-19 infrequently occurred. Effects on long-term neurodevelopmental outcomes are unknown.
Pediatric Critical Care Medicine, 2019
here may not be appropriate, limiting the generalizability of these findings beyond this specific... more here may not be appropriate, limiting the generalizability of these findings beyond this specific population. Finally, and most importantly, the current study by Namachivayam et al (9) does not address any comparison between those infants who never received PD and those in the "early" and "late" cohorts. Thus, it remains unclear how those groups may have differed from each other, complicating efforts to apply these findings broadly at the bedside. Once the decision to use PD after CPB has been made by the clinician and CICU team, it appears to be beneficial to expedite the PD initiation as much as possible. The basic question of which infants may derive the most benefit from early initiation of PD versus continuing nondialytic fluid management, however, remains unanswered. As we move forward, protocolized prospective studies with tangible clinical outcomes that can help to guide clinical decision-making remain badly needed.
Health Security, 2019
During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small hand... more During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small handful of expatriate patients were evacuated to specialized high-level containment care units, or biocontainment units, in the United States and Western Europe. Given the lower mortality rate (18% versus 40% for those treated in Africa) among these patients, it is likely that high-level containment care will be used in the future with increasing frequency. It is also likely that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients. We report here the results of those discussions.
International Journal of Pediatric Otorhinolaryngology
INTRODUCTION Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Inten... more INTRODUCTION Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU. METHODS This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was 1.32perchild.PICUmortalitywasevaluatedasanexploratoryoutcome.RESULTSNine−hundredandfifty−seven(859pre−interventionand98post−intervention)patientsmetinclusioncriteria.PatientswithoneormoreUEsdecreasedsignificantlyfrom29.41.32 per child. PICU mortality was evaluated as an exploratory outcome. RESULTS Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28-0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17-0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24-0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is 1.32perchild.PICUmortalitywasevaluatedasanexploratoryoutcome.RESULTSNine−hundredandfifty−seven(859pre−interventionand98post−intervention)patientsmetinclusioncriteria.PatientswithoneormoreUEsdecreasedsignificantlyfrom29.430.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44. CONCLUSION This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.
JAMA Network Open, 2021
IMPORTANCE Multisystem inflammatory syndrome in children (MIS-C) is associated with recent or cur... more IMPORTANCE Multisystem inflammatory syndrome in children (MIS-C) is associated with recent or current SARS-CoV-2 infection. Information on MIS-C incidence is limited. OBJECTIVE To estimate population-based MIS-C incidence per 1 000 000 person-months and to estimate MIS-C incidence per 1 000 000 SARS-CoV-2 infections in persons younger than 21 years. DESIGN, SETTING, AND PARTICIPANTS This cohort study used enhanced surveillance data to identify persons with MIS-C during April to June 2020, in 7 jurisdictions reporting to both the Centers for Disease Control and Prevention national surveillance and to Overcoming COVID-19, a multicenter MIS-C study. Denominators for population-based estimates were derived from census estimates; denominators for incidence per 1 000 000 SARS-CoV-2 infections were estimated by applying published age-and month-specific multipliers accounting for underdetection of reported COVID-19 case counts.
Critical Care Clinics
Pediatric providers were called on to care for patients outside their typical scope of practice d... more Pediatric providers were called on to care for patients outside their typical scope of practice during the first surge of the SARS-CoV-2 pandemic. Providers were forced to think creatively while working within established hospital systems and to use resources collaboratively across units and teams. Already published in the literature are examples of collaboration between pediatric and adult critical care groups, None of the authors have commercial or financial conflicts of interest to disclose.
Applied Clinical Informatics, 2021
Objective Based on feedback from nurses regarding the challenges of code documentation following ... more Objective Based on feedback from nurses regarding the challenges of code documentation following the implementation of a new electronic health record (EHR), we sought to better understand inpatient nurse attitudes and practices in code documentation and to identify opportunities for improvement. Methods An anonymous electronic survey was distributed to all inpatient nurses working at a single, 999-bed, university-based, and quaternary care hospital. Participation in the study was voluntary and consent was implied by survey completion. Results Overall, 432 (14%) of 3,121 inpatient nurses completed the survey. While nearly 80% of respondents indicated feeling very comfortable using computers for personal use, only 5% felt very comfortable navigating the EHR to document codes in real time. While 53% had documented codes in the new EHR, most admitted to documenting on paper with retroactive entry into the EHR. About 25% reported having participated in a code that was not accurately docu...
The Journal of Pediatrics, 2021
Pseudohyperkalemia and pseudohyponatremia are phenomena in which hematologic disorders with high ... more Pseudohyperkalemia and pseudohyponatremia are phenomena in which hematologic disorders with high cell counts result in factitious electrolyte measurements which can result in inappropriate treatment. We describe two children with leukemia presenting with both disturbances to highlight the importance of correlating electrolyte results from plasma with those from whole blood before intervening.