Gordon Krahn | University of British Columbia (original) (raw)

Papers by Gordon Krahn

Research paper thumbnail of Pediatric Delirium Educational Tool Development: A Focus Group Study with Intensive Care Unit Clinicians and Caregivers in Canada (Preprint)

JMIR pediatrics and parenting, Dec 10, 2023

Research paper thumbnail of Improved patient safety with a simplified operating room to pediatric intensive care unit handover tool (PATHQS)

Frontiers in pediatrics, Jan 24, 2024

Research paper thumbnail of Reducing Catheter-Associated Blood Stream Infections in a Pediatric Intensive Care Unit

Journal of Patient Safety, Dec 1, 2008

ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-assoc... more ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-associated blood stream infection (CA-BSI) pre- and postintroduction of our CA-BSI bundle. Design: Retrospective chart review for 2004 and prospective descriptive study for 2005. Setting: A tertiary referral, university affiliated, medical-surgical pediatric intensive care unit with 22 beds and approximately 1100 admissions per year. Patients: All patients who were admitted to our unit who had any documented CA-BSI according to the Centre for Disease Control criteria between January 2004 and December 2005. Interventions: Education and institution of a bundle for decreasing CA-BSI. The CA-BSI bundle was adapted for pediatrics and included components for catheter insertion and ongoing catheter maintenance. Measurements and Main Results: Cases of CA-BSI were collected and rates per 1000 line days and per 1000 admissions were calculated pre institution of bundle (January to September 2004), during institution (October 2004 to May 2005) and postinstitution (June 2005 to December 2005). Infection rates per 1000 line days decreased from pre 8.8 (17/1934; 95% confidence interval [CI], 5.2-14) to during 1.8 (3/1665; 95% CI, 0.4-5.3) and post 2.2 (3/1367; 55% CI, 0.4-6.4). Decreases per 1000 admissions were also seen: pre 18.3 (17/928; 95% CI, 10.7-29), during 4.3 (3/691; 95% CI, 0.9-12.3) and post 5.1 (3/583; 95% CI, 1-15). Conclusion: Strategies aimed at reducing CA-BSI appear to be effective.

Research paper thumbnail of Continuous Central Venous Oxygen Saturation Monitoring under Varying Physiological Conditions in an Animal Model

Anaesthesia and Intensive Care, Sep 1, 2010

Venous saturation as an early indicator of cardiac output and hence tissue perfusion is feasible ... more Venous saturation as an early indicator of cardiac output and hence tissue perfusion is feasible in adults with true mixed venous measurements obtained via pulmonary artery catheterisation 6-10. Pulmonary catheter placement in children is difficult and risky because of their small size and the often complex cardiac anatomy of children with congenital heart disease 11,12. In adults, central venous oxygen saturations (ScvO 2) have been used as a surrogate for mixed venous saturations 6,9,12-14. Although there is debate as to the correlation of ScvO 2 to mixed venous saturations 15-17 , some have suggested that central venous oxygen saturation can be used as a surrogate for mixed venous oxygen saturations in children 18,19. A novel device, the PediaSat ® Oximetry Catheter recently developed by Edwards Life Sciences LLC (Mississauga, ON, Canada) provides continuous monitoring of ScvO 2 values. The catheter functions as a conventional central venous catheter allowing measurement of pressure, delivery of fluids and drugs and blood sampling. While showing promise as a useful clinical tool, this device has not been tested under the wider clinical ranges of hypotension, hypoxaemia and during drug

Research paper thumbnail of The Association of Nutrition Status Expressed as Body Mass Index z Score With Outcomes in Children With Severe Sepsis: A Secondary Analysis From the Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study

Critical care medicine, Jan 7, 2018

The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the ... more The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the association of nutrition status (expressed as body mass index z score) with outcomes in pediatric severe sepsis. Secondary analysis of the Sepsis Prevalence, Outcomes, and Therapies study. Patient characteristics, ICU interventions, and outcomes were compared across nutrition status categories (expressed as age- and sex-adjusted body mass index z scores using World Health Organization standards). Multivariable regression models were developed to determine adjusted differences in all-cause ICU mortality and ICU length of stay by nutrition status. One-hundred twenty-eight PICUs across 26 countries. Children less than 18 years with severe sepsis enrolled in the Sepsis Prevalence, Outcomes, and Therapies study (n = 567). None. Nutrition status data were available for 417 patients. Severe undernutrition was seen in Europe (25%), Asia (20%), South Africa (17%), and South America (10%), with se...

Research paper thumbnail of Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated events in critically ill children

Critical Care

Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic pha... more Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO was as follows: 5 L/min for infants (< 1 year), 10 L/min for young children (1–7 years), and 15 L/min for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Results Of 6549 TIs during the study period, 2554 (39.0%) occurred during the pre-implementation phase and 3995 (61.0%) during post-implementation phase. AO utilization increased from 23 to 68%, p < 0.001. AO was utilized less often when intubating infant...

Research paper thumbnail of Utility of Apneic Oxygenation with Intubation to Reduce Severe Desaturation and Adverse Tracheal Intubation Associated Events in Critically Ill Children

Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic pha... more Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units (ICUs) as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO were as follows: 5 liters/minute for infants (< 1 year), 10 liters/minute for young children (1–7 years), and 15 liters/minute for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Results Of 6,549 TIs during the study period, 2,554 (39.0%) occurred during the pre-implementation phase and 3,995 (61.0%) during post-implementation phase. AO utilization increased from 23–68%, p < 0.001. AO was utilized l...

Research paper thumbnail of Prevent Ventilator Associated Pneumonia: Getting Started Kit

Research paper thumbnail of Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions

Annals of Intensive Care, 2016

Background: Organ dysfunction scores, based on physiological parameters, have been created to des... more Background: Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions. Methods: This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer-Lemeshow test). Results: Four hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71-0.81) and the Hosmer-Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1. Conclusions: In a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.

Research paper thumbnail of Does troponin-I measurement predict low cardiac output syndrome following cardiac surgery in children?

OBJECTIVE To determine whether serum troponin I (TnI), measured 4 hours after surgery for congeni... more OBJECTIVE To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart disease, is a predictor of myocardial dysfunction and low cardiac output syndrome (LCOS). DESIGN Prospective, observational study. SETTING Paediatric intensive care unit in a tertiary care academic children's hospital, 1 June 2003 to 12 May 2004. PATIENTS 99 consecutive eligible children who underwent a variety of surgical procedures for congenital heart disease, using cardiopulmonary bypass. All patients were cared for by a consistent perioperative care team. INTERVENTIONS Measurement of TnI preoperatively, and at 0, 4, 8, 12, 24 and 36 hours after ICU admission. RESULTS Patient demographics and outcome (as median and 25th-75th percentile) were as follows: age, 23.9 (4.6- 65.9) months; cardiopulmonary bypass time, 135 (98-178) minutes; aortic cross-clamp time, 65 (28-85) minutes; preoperative TnI level, 0.02 (0.01-0.03) ng/mL; 4h TnI, 10.6 (3.0-23.4) ng/mL; highest 24 h Tn...

Research paper thumbnail of Validation of finger blood pressure monitoring in children

Blood Pressure Monitoring

Research paper thumbnail of Citrate anticoagulation in pediatric continuous venovenous hemofiltration

Pediatric nephrology (Berlin, Germany), 2004

Regional citrate anticoagulation has become a common alternative to systemic heparinization in ad... more Regional citrate anticoagulation has become a common alternative to systemic heparinization in adult continuous venovenous hemofiltration (CVVH) practice. We report our experience with the technique in critically ill children. We carried out a retrospective chart review of a 22-bed pediatric intensive care unit. CVVH with pre-filter citrate and systemic calcium replacement infusions was performed according to a strict protocol in nine consecutive critically ill children. All charts were reviewed for patient characteristics and CVVH circuit parameters, including filter survival. All complications were noted. Nurse specialists were interviewed about the practical management of citrate anticoagulation. All patient measurements of blood urea nitrogen, creatinine, sodium, ionized calcium (iCa), potassium, and bicarbonate were collected over the CVVH period. In seven patients, 12 simultaneous citrate measurements were taken from patient blood, pre-filter blood, and hemofiltrate fluid. Nin...

Research paper thumbnail of Continuous central venous oxygen saturation monitoring under varying physiological conditions in an animal model

Anaesthesia and intensive care, 2010

We compared saturations from a paediatric central venous oximetry catheter with co-oximetry value... more We compared saturations from a paediatric central venous oximetry catheter with co-oximetry values with changes in drug infusions, intravascular blood volume and hypoxia in an animal model. Piglets (large white) were anaesthetised, intubated and mechanically ventilated. PediaSat oximetry catheters were placed in the superior vena cava via jugular vein cut-down and in the inferior vena cava percutaneously via the femoral vein. A carotid arterial catheter was placed via cut-down for blood sampling and pressure monitoring. Anaesthesia was maintained with continuous thiopentone and supplemental morphine. Haemodynamics (heart rate, mean arterial blood, central venous pressure), fibreoptic ScvO2 (ScvO2-inferior) from inferior vena cava, fibreoptic ScvO2 (ScvO2-superior) from superior vena cava and blood gas oximetry (ScvO2-co-ox) were measured simultaneously at predetermined intervals during increasing adrenaline and sodium nitroprusside infusions and during increasing hypoxia and hypovol...

Research paper thumbnail of Does troponin-I measurement predict low cardiac output syndrome following cardiac surgery in children?

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2009

To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart ... more To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart disease, is a predictor of myocardial dysfunction and low cardiac output syndrome (LCOS). Prospective, observational study. Paediatric intensive care unit in a tertiary care academic children's hospital, 1 June 2003 to 12 May 2004. 99 consecutive eligible children who underwent a variety of surgical procedures for congenital heart disease, using cardiopulmonary bypass. All patients were cared for by a consistent perioperative care team. Measurement of TnI preoperatively, and at 0, 4, 8, 12, 24 and 36 hours after ICU admission. Patient demographics and outcome (as median and 25th-75th percentile) were as follows: age, 23.9 (4.6- 65.9) months; cardiopulmonary bypass time, 135 (98-178) minutes; aortic cross-clamp time, 65 (28-85) minutes; preoperative TnI level, 0.02 (0.01-0.03) ng/mL; 4h TnI, 10.6 (3.0-23.4) ng/mL; highest 24 h TnI, 11.7 (3.9-29.5) ng/mL; time to discontinuation of ino...

Research paper thumbnail of Acute renal failure in children undergoing cardiopulmonary bypass

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2005

To investigate the incidence, implicating factors and outcome of acute renal failure after cardio... more To investigate the incidence, implicating factors and outcome of acute renal failure after cardiopulmonary bypass in patients admitted to a paediatric intensive care unit. Prospective observational pilot study. A 14 bed paediatric intensive care unit in a university affiliated, tertiary care referral children's hospital. One hundred and one children (less than sixteen years of age) admitted to the Pediatric Intensive Care Unit following cardiopulmonary bypass between June 2003 and May 2004. None. PRISM-III score was calculated on admission. Baseline admission urea (mmol/L) and creatinine (micromol/L) serum levels and highest urea and creatinine levels were measured. Urine output (mL/kg/hour) and frusemide dose (mg/kg/day) were also noted. A baseline inotrope score was calculated on admission and the highest inotrope score was noted based on maximum infused doses of inotrope in the first 36 hours. The surgical procedure was used to determine a Jenkins score. Eleven (11%) children...

Research paper thumbnail of Surgical Suite to Pediatric Intensive Care Unit Handover Protocol

Journal of Nursing Care Quality, 2014

The article reports the long-term sustainability of a standardized transfer protocol from cardiac... more The article reports the long-term sustainability of a standardized transfer protocol from cardiac surgical suite to the pediatric intensive care unit. Using rapid process improvement technique, the original mean defect rate per handover decreased from 13.2 to 0 and 0.3, 12, and 24 months postimplementation, respectively. This study stresses the importance of long-term assessment to control for possible observation biases; it also illustrates a successful implementation strategy that used video recording to engage staff in identifying solutions to the observed defects.

Research paper thumbnail of Reducing Catheter-Associated Blood Stream Infections in a Pediatric Intensive Care Unit

Journal of Patient Safety, 2008

ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-assoc... more ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-associated blood stream infection (CA-BSI) pre- and postintroduction of our CA-BSI bundle. Design: Retrospective chart review for 2004 and prospective descriptive study for 2005. Setting: A tertiary referral, university affiliated, medical-surgical pediatric intensive care unit with 22 beds and approximately 1100 admissions per year. Patients: All patients who were admitted to our unit who had any documented CA-BSI according to the Centre for Disease Control criteria between January 2004 and December 2005. Interventions: Education and institution of a bundle for decreasing CA-BSI. The CA-BSI bundle was adapted for pediatrics and included components for catheter insertion and ongoing catheter maintenance. Measurements and Main Results: Cases of CA-BSI were collected and rates per 1000 line days and per 1000 admissions were calculated pre institution of bundle (January to September 2004), during institution (October 2004 to May 2005) and postinstitution (June 2005 to December 2005). Infection rates per 1000 line days decreased from pre 8.8 (17/1934; 95% confidence interval [CI], 5.2-14) to during 1.8 (3/1665; 95% CI, 0.4-5.3) and post 2.2 (3/1367; 55% CI, 0.4-6.4). Decreases per 1000 admissions were also seen: pre 18.3 (17/928; 95% CI, 10.7-29), during 4.3 (3/691; 95% CI, 0.9-12.3) and post 5.1 (3/583; 95% CI, 1-15). Conclusion: Strategies aimed at reducing CA-BSI appear to be effective.

Research paper thumbnail of Sepsis and septic shock: Progress and future considerations

The Indian Journal of Pediatrics, 2008

Objective. To define sepsis and septic shock in children, to outline an approach to treatment in ... more Objective. To define sepsis and septic shock in children, to outline an approach to treatment in the emergency, critical care units and to outline a global sepsis initiative.

Research paper thumbnail of Evaluation of a pediatric central venous oximetry catheter in critically ill children

Pediatric Critical Care Medicine, 2010

To compare the readings from a modified pediatric central venous oximetry (Scvo2) catheter with c... more To compare the readings from a modified pediatric central venous oximetry (Scvo2) catheter with co-oximetry saturations of blood samples from critically ill children. Prospective descriptive study. None. A pediatric intensive care unit at a tertiary care children&amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital. Nineteen children, predominantly postcardiac by-pass surgery, were enrolled (mean age, 24.5 mos [range 1 day to 14.3 yrs], mean weight, 9.7 kg [range, 3.2-45 kg]). Measured oxygen saturations were obtained from venous blood samples drawn from the distal port of the catheter and compared with simultaneous values displayed by the oximetry monitor. Sampling was performed every 6 hrs, with the distal port infusions either on, or off, or as clinically indicated. A total of 104 paired samples were obtained. Two subjects were excluded due to the catheter being removed, before the study commenced, to facilitate initiation of extracorporeal support. Regression analysis of the mean oximetry catheter and co-oximetry values showed a correlation of 0.81. The difference between the mean values of both methods was evenly distributed (Bland-Altman analysis) and resulted in a mean percentage difference (oximetry catheter vs. co-oximetry) of 1.09 and a sd of 8.48. There were no device malfunctions or complications. Pediatric central venous oximetry catheters provide accurate trending of continuous Scvo2 within the physiologic range studied.

Research paper thumbnail of Continuous central venous saturation monitoring in pediatrics: A case report

Pediatric Critical Care Medicine, 2008

To report the use of a new pediatric central venous catheter that offers continuous central venou... more To report the use of a new pediatric central venous catheter that offers continuous central venous saturation (ScVO2) monitoring in the critically ill child. Case report. Pediatric intensive care unit in a tertiary care children&amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital. A 3-month-old child, following cardiac surgery, with an isolated decrease in central venous saturations. Diagnosis of pericardial effusion by echocardiography followed by surgical drainage. ScVO2 readings quickly returned to normal, and the remaining patient course was uneventful. We report the first case of a newly modified central venous catheter (PediaSat Oximetry Catheter, Edwards Lifesciences LLC, Irvine, CA) for children and demonstrate its utility in a patient with impaired oxygen delivery when traditional markers remain stable. This catheter enabled the rapid diagnosis of cardiac compromise due to pericardial effusion, leading to early treatment. Traditional central catheter functions and insertion technique are maintained, making the catheter potentially useful in any critically ill child.

Research paper thumbnail of Pediatric Delirium Educational Tool Development: A Focus Group Study with Intensive Care Unit Clinicians and Caregivers in Canada (Preprint)

JMIR pediatrics and parenting, Dec 10, 2023

Research paper thumbnail of Improved patient safety with a simplified operating room to pediatric intensive care unit handover tool (PATHQS)

Frontiers in pediatrics, Jan 24, 2024

Research paper thumbnail of Reducing Catheter-Associated Blood Stream Infections in a Pediatric Intensive Care Unit

Journal of Patient Safety, Dec 1, 2008

ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-assoc... more ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-associated blood stream infection (CA-BSI) pre- and postintroduction of our CA-BSI bundle. Design: Retrospective chart review for 2004 and prospective descriptive study for 2005. Setting: A tertiary referral, university affiliated, medical-surgical pediatric intensive care unit with 22 beds and approximately 1100 admissions per year. Patients: All patients who were admitted to our unit who had any documented CA-BSI according to the Centre for Disease Control criteria between January 2004 and December 2005. Interventions: Education and institution of a bundle for decreasing CA-BSI. The CA-BSI bundle was adapted for pediatrics and included components for catheter insertion and ongoing catheter maintenance. Measurements and Main Results: Cases of CA-BSI were collected and rates per 1000 line days and per 1000 admissions were calculated pre institution of bundle (January to September 2004), during institution (October 2004 to May 2005) and postinstitution (June 2005 to December 2005). Infection rates per 1000 line days decreased from pre 8.8 (17/1934; 95% confidence interval [CI], 5.2-14) to during 1.8 (3/1665; 95% CI, 0.4-5.3) and post 2.2 (3/1367; 55% CI, 0.4-6.4). Decreases per 1000 admissions were also seen: pre 18.3 (17/928; 95% CI, 10.7-29), during 4.3 (3/691; 95% CI, 0.9-12.3) and post 5.1 (3/583; 95% CI, 1-15). Conclusion: Strategies aimed at reducing CA-BSI appear to be effective.

Research paper thumbnail of Continuous Central Venous Oxygen Saturation Monitoring under Varying Physiological Conditions in an Animal Model

Anaesthesia and Intensive Care, Sep 1, 2010

Venous saturation as an early indicator of cardiac output and hence tissue perfusion is feasible ... more Venous saturation as an early indicator of cardiac output and hence tissue perfusion is feasible in adults with true mixed venous measurements obtained via pulmonary artery catheterisation 6-10. Pulmonary catheter placement in children is difficult and risky because of their small size and the often complex cardiac anatomy of children with congenital heart disease 11,12. In adults, central venous oxygen saturations (ScvO 2) have been used as a surrogate for mixed venous saturations 6,9,12-14. Although there is debate as to the correlation of ScvO 2 to mixed venous saturations 15-17 , some have suggested that central venous oxygen saturation can be used as a surrogate for mixed venous oxygen saturations in children 18,19. A novel device, the PediaSat ® Oximetry Catheter recently developed by Edwards Life Sciences LLC (Mississauga, ON, Canada) provides continuous monitoring of ScvO 2 values. The catheter functions as a conventional central venous catheter allowing measurement of pressure, delivery of fluids and drugs and blood sampling. While showing promise as a useful clinical tool, this device has not been tested under the wider clinical ranges of hypotension, hypoxaemia and during drug

Research paper thumbnail of The Association of Nutrition Status Expressed as Body Mass Index z Score With Outcomes in Children With Severe Sepsis: A Secondary Analysis From the Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study

Critical care medicine, Jan 7, 2018

The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the ... more The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the association of nutrition status (expressed as body mass index z score) with outcomes in pediatric severe sepsis. Secondary analysis of the Sepsis Prevalence, Outcomes, and Therapies study. Patient characteristics, ICU interventions, and outcomes were compared across nutrition status categories (expressed as age- and sex-adjusted body mass index z scores using World Health Organization standards). Multivariable regression models were developed to determine adjusted differences in all-cause ICU mortality and ICU length of stay by nutrition status. One-hundred twenty-eight PICUs across 26 countries. Children less than 18 years with severe sepsis enrolled in the Sepsis Prevalence, Outcomes, and Therapies study (n = 567). None. Nutrition status data were available for 417 patients. Severe undernutrition was seen in Europe (25%), Asia (20%), South Africa (17%), and South America (10%), with se...

Research paper thumbnail of Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated events in critically ill children

Critical Care

Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic pha... more Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO was as follows: 5 L/min for infants (< 1 year), 10 L/min for young children (1–7 years), and 15 L/min for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Results Of 6549 TIs during the study period, 2554 (39.0%) occurred during the pre-implementation phase and 3995 (61.0%) during post-implementation phase. AO utilization increased from 23 to 68%, p < 0.001. AO was utilized less often when intubating infant...

Research paper thumbnail of Utility of Apneic Oxygenation with Intubation to Reduce Severe Desaturation and Adverse Tracheal Intubation Associated Events in Critically Ill Children

Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic pha... more Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units (ICUs) as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO were as follows: 5 liters/minute for infants (< 1 year), 10 liters/minute for young children (1–7 years), and 15 liters/minute for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Results Of 6,549 TIs during the study period, 2,554 (39.0%) occurred during the pre-implementation phase and 3,995 (61.0%) during post-implementation phase. AO utilization increased from 23–68%, p < 0.001. AO was utilized l...

Research paper thumbnail of Prevent Ventilator Associated Pneumonia: Getting Started Kit

Research paper thumbnail of Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions

Annals of Intensive Care, 2016

Background: Organ dysfunction scores, based on physiological parameters, have been created to des... more Background: Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions. Methods: This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer-Lemeshow test). Results: Four hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71-0.81) and the Hosmer-Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1. Conclusions: In a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.

Research paper thumbnail of Does troponin-I measurement predict low cardiac output syndrome following cardiac surgery in children?

OBJECTIVE To determine whether serum troponin I (TnI), measured 4 hours after surgery for congeni... more OBJECTIVE To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart disease, is a predictor of myocardial dysfunction and low cardiac output syndrome (LCOS). DESIGN Prospective, observational study. SETTING Paediatric intensive care unit in a tertiary care academic children's hospital, 1 June 2003 to 12 May 2004. PATIENTS 99 consecutive eligible children who underwent a variety of surgical procedures for congenital heart disease, using cardiopulmonary bypass. All patients were cared for by a consistent perioperative care team. INTERVENTIONS Measurement of TnI preoperatively, and at 0, 4, 8, 12, 24 and 36 hours after ICU admission. RESULTS Patient demographics and outcome (as median and 25th-75th percentile) were as follows: age, 23.9 (4.6- 65.9) months; cardiopulmonary bypass time, 135 (98-178) minutes; aortic cross-clamp time, 65 (28-85) minutes; preoperative TnI level, 0.02 (0.01-0.03) ng/mL; 4h TnI, 10.6 (3.0-23.4) ng/mL; highest 24 h Tn...

Research paper thumbnail of Validation of finger blood pressure monitoring in children

Blood Pressure Monitoring

Research paper thumbnail of Citrate anticoagulation in pediatric continuous venovenous hemofiltration

Pediatric nephrology (Berlin, Germany), 2004

Regional citrate anticoagulation has become a common alternative to systemic heparinization in ad... more Regional citrate anticoagulation has become a common alternative to systemic heparinization in adult continuous venovenous hemofiltration (CVVH) practice. We report our experience with the technique in critically ill children. We carried out a retrospective chart review of a 22-bed pediatric intensive care unit. CVVH with pre-filter citrate and systemic calcium replacement infusions was performed according to a strict protocol in nine consecutive critically ill children. All charts were reviewed for patient characteristics and CVVH circuit parameters, including filter survival. All complications were noted. Nurse specialists were interviewed about the practical management of citrate anticoagulation. All patient measurements of blood urea nitrogen, creatinine, sodium, ionized calcium (iCa), potassium, and bicarbonate were collected over the CVVH period. In seven patients, 12 simultaneous citrate measurements were taken from patient blood, pre-filter blood, and hemofiltrate fluid. Nin...

Research paper thumbnail of Continuous central venous oxygen saturation monitoring under varying physiological conditions in an animal model

Anaesthesia and intensive care, 2010

We compared saturations from a paediatric central venous oximetry catheter with co-oximetry value... more We compared saturations from a paediatric central venous oximetry catheter with co-oximetry values with changes in drug infusions, intravascular blood volume and hypoxia in an animal model. Piglets (large white) were anaesthetised, intubated and mechanically ventilated. PediaSat oximetry catheters were placed in the superior vena cava via jugular vein cut-down and in the inferior vena cava percutaneously via the femoral vein. A carotid arterial catheter was placed via cut-down for blood sampling and pressure monitoring. Anaesthesia was maintained with continuous thiopentone and supplemental morphine. Haemodynamics (heart rate, mean arterial blood, central venous pressure), fibreoptic ScvO2 (ScvO2-inferior) from inferior vena cava, fibreoptic ScvO2 (ScvO2-superior) from superior vena cava and blood gas oximetry (ScvO2-co-ox) were measured simultaneously at predetermined intervals during increasing adrenaline and sodium nitroprusside infusions and during increasing hypoxia and hypovol...

Research paper thumbnail of Does troponin-I measurement predict low cardiac output syndrome following cardiac surgery in children?

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2009

To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart ... more To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart disease, is a predictor of myocardial dysfunction and low cardiac output syndrome (LCOS). Prospective, observational study. Paediatric intensive care unit in a tertiary care academic children's hospital, 1 June 2003 to 12 May 2004. 99 consecutive eligible children who underwent a variety of surgical procedures for congenital heart disease, using cardiopulmonary bypass. All patients were cared for by a consistent perioperative care team. Measurement of TnI preoperatively, and at 0, 4, 8, 12, 24 and 36 hours after ICU admission. Patient demographics and outcome (as median and 25th-75th percentile) were as follows: age, 23.9 (4.6- 65.9) months; cardiopulmonary bypass time, 135 (98-178) minutes; aortic cross-clamp time, 65 (28-85) minutes; preoperative TnI level, 0.02 (0.01-0.03) ng/mL; 4h TnI, 10.6 (3.0-23.4) ng/mL; highest 24 h TnI, 11.7 (3.9-29.5) ng/mL; time to discontinuation of ino...

Research paper thumbnail of Acute renal failure in children undergoing cardiopulmonary bypass

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2005

To investigate the incidence, implicating factors and outcome of acute renal failure after cardio... more To investigate the incidence, implicating factors and outcome of acute renal failure after cardiopulmonary bypass in patients admitted to a paediatric intensive care unit. Prospective observational pilot study. A 14 bed paediatric intensive care unit in a university affiliated, tertiary care referral children's hospital. One hundred and one children (less than sixteen years of age) admitted to the Pediatric Intensive Care Unit following cardiopulmonary bypass between June 2003 and May 2004. None. PRISM-III score was calculated on admission. Baseline admission urea (mmol/L) and creatinine (micromol/L) serum levels and highest urea and creatinine levels were measured. Urine output (mL/kg/hour) and frusemide dose (mg/kg/day) were also noted. A baseline inotrope score was calculated on admission and the highest inotrope score was noted based on maximum infused doses of inotrope in the first 36 hours. The surgical procedure was used to determine a Jenkins score. Eleven (11%) children...

Research paper thumbnail of Surgical Suite to Pediatric Intensive Care Unit Handover Protocol

Journal of Nursing Care Quality, 2014

The article reports the long-term sustainability of a standardized transfer protocol from cardiac... more The article reports the long-term sustainability of a standardized transfer protocol from cardiac surgical suite to the pediatric intensive care unit. Using rapid process improvement technique, the original mean defect rate per handover decreased from 13.2 to 0 and 0.3, 12, and 24 months postimplementation, respectively. This study stresses the importance of long-term assessment to control for possible observation biases; it also illustrates a successful implementation strategy that used video recording to engage staff in identifying solutions to the observed defects.

Research paper thumbnail of Reducing Catheter-Associated Blood Stream Infections in a Pediatric Intensive Care Unit

Journal of Patient Safety, 2008

ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-assoc... more ABSTRACT Objective: The objectives of our study were to determine the incidence of catheter-associated blood stream infection (CA-BSI) pre- and postintroduction of our CA-BSI bundle. Design: Retrospective chart review for 2004 and prospective descriptive study for 2005. Setting: A tertiary referral, university affiliated, medical-surgical pediatric intensive care unit with 22 beds and approximately 1100 admissions per year. Patients: All patients who were admitted to our unit who had any documented CA-BSI according to the Centre for Disease Control criteria between January 2004 and December 2005. Interventions: Education and institution of a bundle for decreasing CA-BSI. The CA-BSI bundle was adapted for pediatrics and included components for catheter insertion and ongoing catheter maintenance. Measurements and Main Results: Cases of CA-BSI were collected and rates per 1000 line days and per 1000 admissions were calculated pre institution of bundle (January to September 2004), during institution (October 2004 to May 2005) and postinstitution (June 2005 to December 2005). Infection rates per 1000 line days decreased from pre 8.8 (17/1934; 95% confidence interval [CI], 5.2-14) to during 1.8 (3/1665; 95% CI, 0.4-5.3) and post 2.2 (3/1367; 55% CI, 0.4-6.4). Decreases per 1000 admissions were also seen: pre 18.3 (17/928; 95% CI, 10.7-29), during 4.3 (3/691; 95% CI, 0.9-12.3) and post 5.1 (3/583; 95% CI, 1-15). Conclusion: Strategies aimed at reducing CA-BSI appear to be effective.

Research paper thumbnail of Sepsis and septic shock: Progress and future considerations

The Indian Journal of Pediatrics, 2008

Objective. To define sepsis and septic shock in children, to outline an approach to treatment in ... more Objective. To define sepsis and septic shock in children, to outline an approach to treatment in the emergency, critical care units and to outline a global sepsis initiative.

Research paper thumbnail of Evaluation of a pediatric central venous oximetry catheter in critically ill children

Pediatric Critical Care Medicine, 2010

To compare the readings from a modified pediatric central venous oximetry (Scvo2) catheter with c... more To compare the readings from a modified pediatric central venous oximetry (Scvo2) catheter with co-oximetry saturations of blood samples from critically ill children. Prospective descriptive study. None. A pediatric intensive care unit at a tertiary care children&amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital. Nineteen children, predominantly postcardiac by-pass surgery, were enrolled (mean age, 24.5 mos [range 1 day to 14.3 yrs], mean weight, 9.7 kg [range, 3.2-45 kg]). Measured oxygen saturations were obtained from venous blood samples drawn from the distal port of the catheter and compared with simultaneous values displayed by the oximetry monitor. Sampling was performed every 6 hrs, with the distal port infusions either on, or off, or as clinically indicated. A total of 104 paired samples were obtained. Two subjects were excluded due to the catheter being removed, before the study commenced, to facilitate initiation of extracorporeal support. Regression analysis of the mean oximetry catheter and co-oximetry values showed a correlation of 0.81. The difference between the mean values of both methods was evenly distributed (Bland-Altman analysis) and resulted in a mean percentage difference (oximetry catheter vs. co-oximetry) of 1.09 and a sd of 8.48. There were no device malfunctions or complications. Pediatric central venous oximetry catheters provide accurate trending of continuous Scvo2 within the physiologic range studied.

Research paper thumbnail of Continuous central venous saturation monitoring in pediatrics: A case report

Pediatric Critical Care Medicine, 2008

To report the use of a new pediatric central venous catheter that offers continuous central venou... more To report the use of a new pediatric central venous catheter that offers continuous central venous saturation (ScVO2) monitoring in the critically ill child. Case report. Pediatric intensive care unit in a tertiary care children&amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital. A 3-month-old child, following cardiac surgery, with an isolated decrease in central venous saturations. Diagnosis of pericardial effusion by echocardiography followed by surgical drainage. ScVO2 readings quickly returned to normal, and the remaining patient course was uneventful. We report the first case of a newly modified central venous catheter (PediaSat Oximetry Catheter, Edwards Lifesciences LLC, Irvine, CA) for children and demonstrate its utility in a patient with impaired oxygen delivery when traditional markers remain stable. This catheter enabled the rapid diagnosis of cardiac compromise due to pericardial effusion, leading to early treatment. Traditional central catheter functions and insertion technique are maintained, making the catheter potentially useful in any critically ill child.