Blog Archive

Αλέξανδρος Γ. Σφακιανάκης

Friday, December 18, 2020

Family Medicine and Primary Care

Post-COVID healthcare reform in India: What to expect?
Soham D Bhaduri

Journal of Family Medicine and Primary Care 2020 9(11):5427-5431

COVID-19 has exposed the fault lines of India's public health system. The pandemic can be a useful window of opportunity to undertake public healthcare reforms that are long due. Such reforms are, however, constrained by the path-dependent characteristics of private healthcare in India. Measures taken to expand healthcare during the pandemic appear unlikely to sow the seeds of successful path transformation, and may rather reinforce the private sector dominated trajectory. Policymakers must introduce a bold set of pro-public healthcare reforms during the pandemic, which can then be incrementally built upon through securing legitimacy and support.


Why COVID-19 pandemic builds a convincing case for investing in 'Young Physician Leaders (YPL)'
Paramdeep Singh

Journal of Family Medicine and Primary Care 2020 9(11):5432-5434

There are pressing issues that are plaguing healthcare systems across the world (especially in the lower-middle-income countries), which comprise low-quality care, affordability, accessibility, poor infrastructure, violence against healthcare personnel, deficiency of physicians and healthcare staff. COVID-19 has put an immense physical and mental strain on the young physicians who are at the forefront in fighting this pandemic. This has lead to an increase in incidences of burnout among young doctors, which adversely impacts the quality of healthcare, patient well-being and satisfaction. The present-day medical training typically creates solo medical experts; but, modern-day management of patients and organisations require team-work and leadership. To profoundly alter the way the young physicians work and for creating physician leaders for the future, leadership training ought to commence during the medical school.


A low-cost solution for converting existing stethoscope into tele-stethoscope in resource-constrained setting for COVID-19 pandemic
Sumit Kalra, Preeti Mutreja, Amit Goyal, Abhinav Dixit

Journal of Family Medicine and Primary Care 2020 9(11):5435-5436

In the present scenario of COVID-19, there has been a sudden surge in demand for tele- consultancy. Such measures require resources to support the system. Replacement of conventional equipment used in a clinic with digital equipment is not feasible due to their cost and scalability issues. The authors developed a simple low-cost (almost zero cost) method to convert a conventional stethoscope into a tele-stethoscope. Such a simple modification can be useful in periphery wherein doctors are still not available and the growing number of patients would require a diagnosis of the chest conditions.


COVID-19: Lab medicine expect due respect
Amrita Ghosh

Journal of Family Medicine and Primary Care 2020 9(11):5437-5438



Preparing for a COVID-19 pandemic: Redefining roles of multidisciplinary team in a large tertiary hospital in Rajasthan
Abhay Elhence, Binit Sureka, Mahendra Kumar Garg, Pankaj Bhardwaj, Tanuj Kanchan, Arvind Sinha, Pradeep Kumar Bhatia, Vijaya Lakshmi Nag, Nikhil Kothari, Naveen Dutt, Suryanarayanan Bhaskar, Vibhor Tak, NR Bishnoi, Sanjeev Misra

Journal of Family Medicine and Primary Care 2020 9(11):5439-5444

Through this manuscript, we would like to share our experience with building a COVID hospital, allocating duties, planning and managing supplies during COVID-19 pandemic. This manuscript is prepared by the Doctors of various specialties with vast experience involved in actual planning of the infrastructure and resources. This comprehensive manuscript will help teams to prepare and train, stockpile necessary equipment and prepare their staff to deal with current crisis if there is a surge in infected cases.


COVID-19 reinfection: Linked possibilities and future outlook
Ekta Krishna, Vineet Kumar Pathak, Reshma Prasad, Hannah Jose, M Mohan Kumar

Journal of Family Medicine and Primary Care 2020 9(11):5445-5449

SARS-CoV-2 is the third major coronavirus epidemic to affect humans. There had been multiple instances of patients turning positive after recovering from SARS-2-CoV infection. Though many different theories emerge, false positive RT-PCR is logically the foremost cause and there is a general consensus that during quarantine re-infection from outside seems unlikely when strictly adhered to. As many new strains emerge worldwide during the course of on-going pandemic, the chances of re-infection cannot be ignored as it may contribute to false negative RT-PCR test results. SARS-2-CoV though a novel virus, is phylogenetically similar to SARS-like CoV with around 79% similarity. Studies on immunological response to these infections suggest that antibodies formed after infection confers immunity only for a short period of time before it starts to wane. Also studies on SARS-CoV-2 suggest that antibody formation and longevity of immunity in an individual is dependent on the strain of coronavirus, its severity and age of the person infected. All these considerations demand reviewing the treatment duration, discharge criteria, appropriate use of imaging techniques and importance of risk communication and health education to those recovered.


Fixed-dose combination in management of type 2 diabetes mellitus: Expert opinion from an international panel
Sanjay Kalra, AK Das, G Priya, S Ghosh, RN Mehrotra, S Das, P Shah, S Bajaj, V Deshmukh, D Sanyal, S Chandrasekaran, D Khandelwal, A Joshi, T Nair, F Eliana, H Permana, MD Fariduddin, PK Shrestha, D Shrestha, S Kahandawa, M Sumanathilaka, A Shaheed, AA Rahim, A Orabi, A Al-ani, W Hussein, D Kumar, K Shaikh

Journal of Family Medicine and Primary Care 2020 9(11):5450-5457

Type 2 diabetes mellitus (T2DM) is a progressive disease with multifactorial etiology. The first-line therapy includes monotherapy (with metformin), which often fails to provide effective glycemic control, necessitating the addition of add-on therapy. In this regard, multiple single-dose agents formulated as a single-dose form called fixed-dose combinations (FDCs) have been evaluated for their safety, efficacy, and tolerability. The primary objective of this review is to develop practice-based expert group opinion on the current status and the causes of concern regarding the irrational use of FDCs, in Indian settings. After due discussions, the expert group analyzed the results from several clinical evidence in which various fixed combinations were used in T2DM management. The panel opined that FDCs (double or triple) improve patient adherence, reduce cost, and provide effective glycemic control and, thereby, play an important role in the management of T2DM. The expert group strongly recommended that the irrational metformin FDC's, banned by Indian government, should be stopped and could be achieved through active participation from the government, regulatory bodies, and health ministry, and through continuous education of primary care physicians and pharmacists. In T2DM management, FDCs play a crucial role in achieving glycemic targets effectively. However, understanding the difference between rational and irrational FDC combinations is necessary from the safety, efficacy, and tolerability perspective. In this regard, primary care physicians will have to use a multistep approach so that they can take informed decisions.


Mapping of Health Technology Assessment (HTA) teaching and training initiatives: Landscape for evidence-based policy decisions in India
Rinshu Dwivedi, Ramesh Athe, Sanghamitra Pati, Krushna C Sahoo, Debdutta Bhattacharya

Journal of Family Medicine and Primary Care 2020 9(11):5458-5467

Demographic transitions accompanied with epidemiological shifts are affecting many countries around the globe. These apprehensions have raised the concern for constructing and sustaining healthcare systems especially among resource-constrained low- and middle-income-countries (LMICs) such as India. Introducing Health-Technology-Assessment (HTA) in the educational initiatives could support planners and policy-makers in formulating evidence-based-decision-making along with tackling inequalities/inefficiencies and promoting cost-effectiveness in resource allocation. A mapping exercise has been undertaken for examining the feasibility and implementation of HTA curriculum in the existing courses in India. To gain best possible insight on HTA curriculum, a situational analysis was conducted using systematic search strategy through search engines such as Google, Google Scholar, ProQuest and PubMed. Currently, seventy-one institutes in India are offering one or more courses through regular mode at undergraduate/postgraduate/diploma-certificate/doctorate-level pertaining to Medical-technology (MT), Biostatistics (BS), and Health-economics (HE). MT was offered in 37 institutes (52.12%), followed by BS in 23 (32.39%), and HE in nine (12.67%). Only two institutes (2.81%) are offering certificate-courses on HTA, mainly confined in virtual modules. This review reveals noticeable gaps in the existing curriculum in India and necessitates a novel academic initiative by introducing HTA in a full-fledged manner. Reforms in the research and educational initiatives need to be brought for promoting awareness regarding HTA. The application of domain needs to be widened from the field of health-policy formulators to research and teaching. This should be further strengthened with the strong academic collaborations to generate replicable findings, address challenges, and offer solutions for existing threats to HTA.


Managing pregnancy in COVID-19 pandemic: A review article
Vinita Singh, Pragati Trigunait, Sagarika Majumdar, Rajeshwari Ganeshan, Rajshree Sahu

Journal of Family Medicine and Primary Care 2020 9(11):5468-5473

The outbreak Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a highly contagious and lethal beta coronavirus SARS-CoV-2, which has spread fast to encroach the entire globe and hence declare pandemic. Pregnancy alters body physiology and immune systems, can have worse effects of some respiratory infections and due to limited research and published data we still are in dilemma of appropriate management guidelines This article covers the updated guidelines for infection prevention and control (IPC), screening, sampling, antenatal visit schedules, risk scoring, triaging, supportive care, delivery, postpartum care and care of the newborn. This article aims to provide up-to-date information as per recent guidelines of various association which would serve as guidance in managing pregnant women and newborn with suspected or confirmed COVID-19. All the published papers till date, NCPRE, WHO Interim guidelines, RCOG, FOGS GCPRI, Medical Council of India, ICMR, MOFHW, CDC, ACOG guidelines are referred to compile this article to reach to a conclusion of evidence based management of pregnant ladies during COVID-19 pandemic. This article covers the not only infection prevention and control (IPC) guidelines, but also screening and sampling guidelines, antenatal visit schedules, risk scoring, triaging but also in-patient supportive care, delivery, postpartum care and care of the newborn. Data are very limited and hence very difficult to accurately define clinical management strategies and needs to be constantly updated.


Novel coronavirus (COVID-19) and its potential G.I. manifestation: A review
Amar Deep, Kamlendra Verma, Suchit Swaroop, Ajay Kumar, Sumit Rungta

Journal of Family Medicine and Primary Care 2020 9(11):5474-5479

The outbreak of the new coronavirus in Wuhan, Chinese Hubei City (COV-2) was also known as COVID-19 and has spread to more than 213 countries, zones or territories worldwide, and is an emergency of international public health with no antiviral drugs or vaccines; and, also, the presencouragement of the disease has become a global public health emergency. This novel coronavirus is now the seventh member of the coronaviridae family, known for infecting humans and showing evidence of causing gastric symptoms, and has the potential to be transmitted through the fecal-oral route according to a new report published online by physicians at Shanghai Jiao Tong University (Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro. 2020.02.054). Here we identify the efforts to compile and disseminate the COVID-19 epidemiological information on Its potential G.I. Demonstration of news media and social networks, and few newspapers recently published. Physicians should know, how GI manifestation discussed in different publications to suspect CORONA virus infection in that patients who does not have any upper and lower respiratory tract symptom and intervein to discuss the disease severity and duration. It will increase the threshold of suspicion of physician toward Covid-19 disease.



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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Orthopaedic Trauma

Acknowledgment
No abstract available

In Memoriam: David Gershuni, MD (1938 - 2020)
imageNo abstract available

Distal Femur Replacement Versus Surgical Fixation for the Treatment of Geriatric Distal Femur Fractures: A Systematic Review
imageObjectives: The management of geriatric distal femur fractures is controversial, and both primary distal femur replacement (DFR) and surgical fixation (SF) are viable treatment options. The purpose of this study was to compare patient outcomes after these treatment strategies. Data Sources: PubMed, Embase, and Cochrane databases were searched for English language articles up to April 24, 2020, identifying 2129 papers. Study Selection: Studies evaluating complications in elderly patients treated for distal femur fractures with either immediate DFR or SF were included. Studies with mean patient age <55 years, nontraumatic indications for DFR, or SF with nonlocking plates were excluded. Data Extraction: Two studies provided Level II or III evidence, whereas the remaining 28 studies provided Level IV evidence. Studies were formally evaluated for methodological quality using established criteria. Treatment failure between groups was compared using an incidence rate ratio. Data Synthesis: Treatment failure was defined for both SF and arthroplasty as complications requiring a major reoperation for reasons such as mechanical failure, nonunion, deep infection, aseptic loosening, or extensor mechanism disruption. There were no significant differences in complication rates or knee range of motion between SF and DFR. Conclusions: SF and DFR for the treatment of geriatric distal femur fractures demonstrate similar overall complication rates. Given the available evidence, no strong conclusions on the comparative effectiveness between the 2 treatments can be definitively made. More rigorous prospective research comparing SF vs. DFR to treat acute geriatric distal femur fractures is warranted. Level of Evidence: Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.

Surgical and Nonoperative Management of Olecranon Fractures in the Elderly: A Systematic Review and Meta-Analysis
imageObjectives: The aim of this comparative effectiveness study was to perform a meta-analysis of adverse events and outcomes in closed geriatric olecranon fractures, without elbow instability, after treatment with surgical or nonoperative management. Data Sources: PubMed, Web of Science, and Embase databases. Study Selection: Articles were included if they contained clinical data evaluating outcomes in patients ≥65 years of age with closed olecranon fractures, without elbow instability, treated surgically, or with nonoperative management. Data Extraction: Data regarding patient age, olecranon fracture type, fracture union, adverse events, reoperation, elbow range of motion, and surgeon and patient reported outcome measures were recorded according to intervention. The interventions included for analysis were tension band wire fixation, plate fixation, or nonoperative management. Data Synthesis: Separate random effects meta-analyses were conducted for each outcome according to intervention. Prevalence and 95% confidence intervals were calculated for dichotomous variables, whereas weighted means and confidence intervals were calculated for continuous variables. Conclusions: Comparable outcomes were achieved with surgical or nonoperative management of olecranon fractures in geriatric patients. Surgical intervention carried a high risk of reoperation regardless of whether plate or tension band wire fixation was used. Functional nonunion can be anticipated if nonoperative treatment is elected in low-demand elderly patients. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Topical Vancomycin Powder Decreases the Proportion of Staphylococcus aureus Found in Culture of Surgical Site Infections in Operatively Treated Fractures
imageObjectives: To determine whether patients with operatively treated fractures and surgical site infection after use of topical vancomycin powder have a lower proportion of Staphylococcus aureus infections than patients who did not receive topical vancomycin powder. Design: Retrospective cohort study. Setting: Level I trauma center. Patients: Treatment group: 10 of 133 patients (145 fractures) with surgical site infections who received intrawound vancomycin powder at the time of wound closure for fracture fixation. Control group: 175 patients who sustained deep surgical site infections during the same period but did not receive vancomycin powder. Intervention: Vancomycin powder or no vancomycin powder. Main Outcome Measurement: Proportion of patients' cultures positive for S. aureus. Results: The proportion of cultures positive for S. aureus was significantly lower in patients with surgical site infection who received vancomycin powder than in those who did not receive vancomycin powder (10% [1 of 10 patients in the treatment group] vs. 50% [87 of 175 patients in the control group]; P = 0.02). A trend was observed for a lower proportion of methicillin-resistant S. aureus (0% vs. 23%; P = 0.12). Conclusions: Vancomycin powder might alter the bacteriology of surgical site infections and decrease the proportion in culture of the most common organism typically present after fracture surgery infection. These findings suggest that the application of vancomycin powder might change the bacteriology of surgical site infections when they occur, regardless of the effect on overall infection rates. Although our bacteriology results are clinically and statistically significant, these findings must be confirmed in larger randomized controlled trials. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection
imageObjectives: To determine if the use of intrawound vancomycin powder reduces surgical-site infection after open reduction and internal fixation of bicondylar tibial plateau, tibial pilon, and calcaneus fractures. Design: Retrospective analysis. Setting: Level I trauma center. Patients: All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, of which 35 received topical vancomycin powder. A previously published prospectively collected cohort of 235 similar high-risk fractures treated at our center from 2007 through 2010 served as a second comparison group. Intervention: Topical vancomycin powder at wound closure. Main Outcome Measurements: Deep surgical-site infection. Analyses used both univariate comparison of all patients and 1:2 matching analysis using both nearest neighbor and propensity-based matching. Results: Compared with a control group of fractures treated during the same time period without vancomycin powder, the infection rate with vancomycin powder was significantly lower [0% (0/35) vs. 10.6% (58/548), P = 0.04]. Compared with our previously published historical infection rate of 13% for these injuries, vancomycin powder was also associated with significantly decreased deep surgical-site infection (0% vs. 13%, P = 0.02). These results agreed with the matched analyses, which also showed lower infection in the vancomycin powder group (0% vs. 11%–16%, P ≤ 0.05). Conclusions: Vancomycin powder may play a role in lowering surgical-site infection rates after fracture fixation. A larger randomized controlled trial is needed to validate our findings. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Systemic Absorption and Nephrotoxicity Associated With Topical Vancomycin Powder for Fracture Surgery
imageObjectives: To determine whether using topical vancomycin powder in fracture surgery may result in low levels of vancomycin in the serum and not result in nephrotoxicity. Design: Prospective observational at a single site as a substudy of the VANCO trial. Setting: Single, large urban level I trauma center. Patients/Participants: Fifty-eight patients with tibial plateau and pilon fractures randomized to the treatment arm at the principal investigator's site. Intervention: Topical vancomycin powder (1000 mg) applied directly in the wound over all metal implants at the time of wound closure. Main Outcome Measurements: Serum vancomycin levels at 1 hour and 6–8 hours after surgery. Secondary outcomes included serum creatinine before surgery, a day after surgery, and at 2 weeks postoperatively and complete blood count at 2 weeks postoperatively. Results: Except in 2 patients who also received intravenous vancomycin, none of the study patients had detectable (>5 µg/mL) serum vancomycin levels at 1 hour and 6–8 hours after surgery. One patient with a history of elevation of serum creatinine had a minor increase of serum creatinine but had undetectable vancomycin levels. None of the other patients had a clinically significant increase in creatinine levels. Conclusions: Despite its relatively widespread usage, little data exist regarding the systemic levels and nephrotoxicity associated with the topical use of vancomycin powder in orthopaedic fracture surgery. These prospective data indicate that there seems to be little clinical concern regarding toxicity associated with systemic absorption of vancomycin powder in this specific clinical application. Level of Evidence: Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.

Intraoperative Tobramycin Powder Prevents Enterobacter cloacae Surgical Site Infections in a Rabbit Model of Internal Fixation
imageObjectives: To evaluate the efficacy of intraoperative tobramycin powder in preventing surgical site infection (SSI) and implant colonization with Enterobacter cloacae in a rabbit fixation model. Gram-negative rods, particularly Enterobacter species, comprise an increasing percentage of SSI at our institution. Methods: Eighteen New Zealand White rabbits underwent surgical fixation of the left tibia with implantation of a plate and screws. The surgical site and implant were inoculated with 1 × 107 CFUs E. cloacae. The selected E. cloacae isolate was resistant to tobramycin and capable of forming biofilms. Nine rabbits received 125 mg tobramycin powder directly into the surgical site, overlying the implant. The control group was untreated. Fourteen days postinfection, the tibiae and implants were explanted. Radiographs were taken with and without the implants in place. One tibia from each group was examined after hematoxylin and eosin staining. The remaining tibiae and implants were morselized or sonicated, respectively, and plated on agar to determine infection burden. Data were analyzed with Fisher exact tests and Mann–Whitney U tests. Results: No bone infection or implant colonization occurred in the tobramycin-treated group. In the control group, 7 of 8 rabbits developed bone infections (P = 0.001), and 4 of 8 implants were colonized (P = 0.07). No gross disruption of the normal bone architecture was observed in either group. Conclusions: Intraoperative tobramycin powder applied at the time of contamination prevented bone infection with E. cloacae in this rabbit fixation model. The results are encouraging because the E. cloacae isolate was tobramycin-resistant, demonstrating the utility of intraoperative powdered antibiotics.

Comparison Between the Direct Anterior and Posterior Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture
imageObjectives: To compare 90-day and 1-year outcomes, including mortality, of femoral neck fracture patients undergoing total hip arthroplasty (THA) by direct anterior approach (DAA) versus posterior approach (PA). Design: Retrospective cohort. Setting: Level I Trauma Center. Patients: One hundred forty-three consecutive intracapsular femoral neck fractures treated with THA from 2010 to 2018. The minimum follow-up was 12 months, and the average follow-up was 14.6 months (12–72 months). Main Outcome Measures: Postoperative outcomes, including discharge ambulation, dislocation, periprosthetic joint infection, revision THA, and mortality at 90 days and 1 year after THA. Results: Of the 143 THA included, 44 (30.7%) were performed by DAA while 99 (69.3%) were performed by PA. In-hospital outcomes were similar between the cohorts. Compared with DAA patients, PA patients were more likely to ambulate without assistance preinjury (88.9% vs. 72.7%, P = 0.025) and be nonambulatory at the time of discharge (27.3% vs. 11.4%, P = 0.049). There were no significant differences in 90-day and 1-year postoperative outcomes between the DAA and PA groups, including dislocation, periprosthetic joint infection, periprosthetic fracture, mechanical complications, and revision surgery. Although there was no difference in mortality rate at 90 days, at 1-year follow-up the mortality rate was lower in the DAA group (0% vs. 11.1%, P = 0.018). Conclusions: Performing THA by DAA provides similar benefits in regards to medical and surgical outcomes compared with the PA for displaced femoral neck fracture. However, the DAA may lead to decreased 1-year mortality rates, possibly, because of improved early ambulation capacity that is an important predictor of long-term mortality. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is Immediate Weight-Bearing Safe After Single Implant Fixation of Elderly Distal Femur Fractures?
imageObjectives: To compare early complications in elderly patients with extra-articular distal femur fractures (DFFs) allowed to weight-bear as tolerated (WBAT) immediately versus patients prescribed initial touchdown weight-bearing (TDWB). Design: Retrospective cohort study. Setting: Level 1 academic trauma center. Patients: One hundred thirty-five patients 60 years or older who underwent surgical fixation of an extra-articular DFF, including the OTA/AO fracture classification of 33-A1-3, and periprosthetic fractures with a stable knee prosthesis (Lewis and Rorabeck type I or II) with at least 6 months follow-up. Intervention: Immediate WBAT or TDWB after surgical fixation of an extra-articular DFF with either an intramedullary nail or locked plate. Main Outcome Measurements: The primary outcome was a major adverse event within the first 6 months, defined as (1) early fixation failure or change in alignment leading to reoperation, (2) nonunion, or (3) deep infection. Secondary outcomes included postoperative inpatient length of stay, discharge disposition (secondary facility vs. home), malunion, mortality, and patient-reported outcomes. Results: The rate of early adverse events requiring reoperation was similar between the WBAT group (6, 10.7%) and the TDWB group (15, 19.0%; P = 0.23). There was no difference between groups with respect to length of stay, discharge disposition, malunion, and patient-reported outcomes. Conclusions: This study supports allowing carefully selected elderly patients, based on surgeon preference, to immediately weight-bear after operative fixation of an extra-articular DFF regardless of implant choice. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Telephone consultation 11855 int 1193,

Anesthesia & Analgesia

Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients
imageBACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24–31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.

Efficiency Metrics at an Academic Freestanding Ambulatory Surgery Center: Analysis of the Impact on Scheduled End-Times
imageBACKGROUND: Understanding the impact of key metrics on operating room (OR) efficiency is important to optimize utilization and reduce costs, particularly in freestanding ambulatory surgery centers. The aim of this study was to assess the association between commonly used efficiency metrics and scheduled end-time accuracy. METHODS: Data from patients who underwent surgery from May 2018 to June 2019 at an academic freestanding ambulatory surgery center was extracted from the medical record. Unique operating room days (ORDs) were analyzed to determine (1) duration of first case delays, (2) turnover times (TOT), and (3) scheduled case duration accuracies. Spearman's correlation coefficients and mixed-effects multivariable linear regression were used to assess the association of each metric with scheduled end-time accuracy. RESULTS: There were 1378 cases performed over 300 unique ORDs. There were 86 (28.7%) ORDs with a first case delay, mean (standard deviation [SD]) 11.2 minutes (15.1 minutes), range of 2–101 minutes; the overall mean (SD) TOT was 28.1 minutes (19.9 minutes), range of 6–83 minutes; there were 640 (46.4%) TOT >20 minutes; the overall mean (SD) case duration accuracy was −6.6 minutes (30.3 minutes), range of −114 to 176; and there were 389 (28.2%) case duration accuracies ≥30 minutes. The mean (SD) scheduled end-time accuracy was 6.9 minutes (68.3 minutes), range of −173 to 229 minutes; 48 (15.9%) ORDs ended ≥1 hour before scheduled end-time and 56 (18.6%) ORDs ended ≥1 hour after scheduled end-time. The total case duration accuracy was strongly correlated with the scheduled end-time accuracy (r = 0.87, 95% confidence interval [CI], 0.84-0.89, P < .0001), while the total first case delay minutes (r = 0.12, 95% CI, 0.01-0.21, P = .04) and total turnover time (r = −0.16, 95% CI, 0.21-0.05, P = .005) were less relevant. Case duration accuracy had the highest association with the dependent variable (0.95 minutes changed in the difference between actual and schedule end time per minute increase in case duration accuracy, 95% CI, 0.90-0.99, P < .0001), compared to turnover time (estimate = 0.87, 95% CI, 0.75-0.99, P < .0001) and first case delay time (estimate = 0.83, 95% CI, 0.56-1.11, P < .0001). CONCLUSIONS: Standard efficiency metrics are similarly associated with scheduled end-time accuracy, and addressing problems in each is requisite to having an efficient ambulatory surgery center. Pursuing methods to narrow the gap between scheduled and actual case duration may result in a more productive enterprise.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures
imageBACKGROUND: Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration. METHODS: We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients. RESULTS: A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1–3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3–3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes. CONCLUSIONS: Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

Intermittent Hypoxia and Effects on Early Learning/Memory: Exploring the Hippocampal Cellular Effects of Pediatric Obstructive Sleep Apnea
imageThis review provides an update on the neurocognitive phenotype of pediatric obstructive sleep apnea (OSA). Pediatric OSA is associated with neurocognitive deficits involving memory, learning, and executive functioning. Adenotonsillectomy (AT) is presently accepted as the first-line surgical treatment for pediatric OSA, but the executive function deficits do not resolve postsurgery, and the timeline for recovery remains unknown. This finding suggests that pediatric OSA potentially causes irreversible damage to multiple areas of the brain. The focus of this review is the hippocampus, 1 of the 2 major sites of postnatal neurogenesis, where new neurons are formed and integrated into existing circuitry and the mammalian center of learning/memory functions. Here, we review the clinical phenotype of pediatric OSA, and then discuss existing studies of OSA on different cell types in the hippocampus during critical periods of development. This will set the stage for future study using preclinical models to understand the pathogenesis of persistent neurocognitive dysfunction in pediatric OSA.

Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery
imageBACKGROUND: Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts. METHODS: The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure. RESULTS: The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients. CONCLUSIONS: Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure's validity.

Do Elderly Patients With Diastolic Dysfunction Require Higher Doses of Norepinephrine During General Anesthesia for Noncardiac Surgeries? A Prospective Observational Study
imageBACKGROUND: Diastolic dysfunction is a risk factor for postoperative major cardiovascular events. During anesthesia, patients with diastolic dysfunction might experience impaired hemodynamic function and worsening of diastolic function, which in turn, might be associated with a higher incidence of postoperative complications. We aimed to investigate whether patients with diastolic dysfunction require higher doses of norepinephrine during general anesthesia. Furthermore, we aimed to examine the association between the grade of diastolic dysfunction and the E/e' ratio during anesthesia. A high E/e' ratio corresponds to elevated filling pressures and is an important measure of impaired diastolic function. METHODS: We conducted a prospective observational cohort study at a German university hospital from February 2017 to September 2018. Patients aged ≥60 years and undergoing general anesthesia (ie, propofol and sevoflurane) for elective noncardiac surgery were enrolled. Exclusion: mitral valve disease, atrial fibrillation, and implanted mechanical device. The primary outcome parameter was the administered dose of norepinephrine within 30 minutes after anesthesia induction (μg·kg−1 30 min−1). The secondary outcome parameter was the change of Doppler echocardiographic E/e' from ECHO1 (baseline) to ECHO2 (anesthesia). Linear models and linear mixed models were used for statistical evaluation. RESULTS: A total of 247 patients were enrolled, and 200 patients (75 female) were included in the final analysis. Diastolic dysfunction at baseline was not associated with a higher dose of norepinephrine during anesthesia (P = .6953). The grade of diastolic dysfunction at baseline was associated with a decrease of the E/e' ratio during anesthesia (P < .001). CONCLUSIONS: We did not find evidence for an association between diastolic dysfunction and impaired hemodynamic function, as expressed by high vasopressor support during anesthesia. Additionally, our findings suggest that diastolic function, as expressed by the E/e' ratio, does not worsen during anesthesia.

Fiber-Needle Swept-Source Optical Coherence Tomography for the Real-Time Visualization of the Transversus Abdominis Plane Block Procedure in a Swine Model
imageBACKGROUND: Fascia blocks (eg, the transversus abdominis plane [TAP] block) target the intermuscular fascia layers. Ultrasound techniques have allowed peripheral blocks to be performed with accuracy and safety, however, with limitations. Optical coherence tomography (OCT) is based on low-coherence interferometry. In this study, we examined the ability of OCT to identify the TAP. METHODS: A swept-source OCT probe was placed in a 17-gauge needle to obtain imaging. The needle was inserted within 2 different angle ranges (0°–30° and 30°–60°) on a slice of pork belly to assess imaging characteristics. A series of real-time OCT imaging of the muscle, fascia, and interfascial space was obtained. The tissue location of the needle tip was identified using near-infrared (NIR) imaging. In vivo OCT imaging was further done on 3 female 6-month-old native Chinese Landrance Duroc pigs. Real-time images of tissue layers were obtained with needle insertion. Ultrasound imaging of the OCT needle probe was also performed at the same time for needle trajectory guidance. After imaging, the OCT probe was removed, and 5 mL of normal saline was injected via the needle to confirm correct fascia plane identification. RESULTS: In and ex vivo studies showed clear visual distinction of muscle, fascia, and interfascial layer with OCT, with limitations. Independent validation of OCT criteria for the muscle/fascia differentiation by 20 OCT readers for the in vivo data demonstrated the sensitivity = 0.91, specificity = 0.90, and accuracy = 0.89. Although the angle of needle entry affected the depth of OCT penetration in the muscle, the attenuation coefficient values of the fascia and muscle tissue were statistically different (P < .001) and with high area under the receiver operating characteristics (ROC) curve (AUC) (AUC = 0.93 in 0°–30° and AUC = 1 in 30°–60°) for fascia identification. CONCLUSIONS: This study introduced a novel needle imaging probe method to identify the transversus abdominis fascia plane in real-time. Quantitative calculation of the attenuation coefficients can further aid objective identification by providing direct confirmation of the tip position, increasing the first-pass success rate, and decreasing the need for needle repositioning. Combining OCT and ultrasound may improve the accuracy of anesthetics placement.

Incidence, Mortality, and Characteristics of 18 Pediatric Perioperative Cardiac Arrests: An Observational Trial From 22,650 Pediatric Anesthesias in a German Tertiary Care Hospital
imageBACKGROUND: Recently, a very low incidence of 3 per 10,000 and a mortality of 30% were reported for pediatric perioperative cardiac arrest (POCA). However, high-risk patients, namely children already anesthetized on the intensive care unit (ICU), were excluded. This study investigates the incidence and mortality of POCA in children in whom anesthesia was induced in the ICU or in the operating room using real-world data. In addition, different classifications of POCA were compared with respect to outcome relevance. METHODS: This is a retrospective observational study conducted at a German level 1 perinatal center and tertiary care hospital between 2008 and 2018. Children ≤15 years who underwent an anesthetic procedure and suffered from POCA (defined as any condition requiring chest compressions and/or defibrillation) from the beginning of care provided by an anesthesiologist to 60 minutes after anesthesia or sedation were included. Primary end points were incidence and mortality of POCA in children with anesthesia induced in the ICU versus in the operating room. Secondary end points included incidences and outcomes with respect to the pathophysiological cause (respiratory versus circulatory associated). RESULTS: There were 18 POCA during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality in circulatory-induced POCA (n = 8; 44%) was 100%, in respiratory-induced POCA (n = 9; 50%) 0% (P < .001). CONCLUSIONS: Children with anesthesia induction in the ICU represent a high-risk population for POCA and POCA-associated mortality. POCA classification should be based on the individual cause (respiratory versus circulatory) rather than on the perioperative phase or the responsible specialty.

A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort Study
imageBACKGROUND: Frailty—a multidimensional syndrome related to age- and disease-related deficits—is a key risk factor for older surgical patients. However, it is unknown which frailty instrument most accurately predicts postoperative outcomes. Our objectives were to quantify the probability of association and relative predictive performance of 2 frailty instruments (ie, the risk analysis index-administrative [RAI-A] and 5-item modified frailty index [mFI-5]) with postoperative outcomes in National Surgical Quality Improvement Program (NSQIP) data. METHODS: Retrospective cohort study using Bayesian analysis of NSQIP hospitals. Adults having inpatient small or large bowel surgery 2010–2015 (derivation cohort) or intermediate to high risk mixed noncardiac surgery in 2016 (validation cohort) had preoperative frailty assigned using 2 unique approaches (RAI-A and mFI-5). Probabilities of association were calculated based on posterior distributions and relative predictive performance using posterior predictive distributions and Bayes factors for 30-day mortality (primary outcome) and serious complications (secondary outcome). RESULTS: Of 50,630 participants, 7630 (14.0%) died and 19,545 (38.6%) had a serious complication. Without adjustment, the RAI-A and mFI-5 had >99% probability being associated with mortality with a ≥2.0 odds ratio (ie, large effect size). After adjustment for NSQIP risk calculator variables, only the RAI-A had ≥95% probability of a nonzero association with mortality. Similar results arose when predicting postoperative complications. The RAI-A provided better predictive accuracy for mortality than the mFI-5 (minimum Bayes factor 3.25 × 1014), and only the RAI-A improved predictive accuracy beyond that of the NSQIP risk calculator (minimum Bayes factor = 4.27 × 1013). Results were consistent in leave-one-out cross-validation. CONCLUSIONS: Translation of frailty-related findings from research and quality improvement studies to clinical care and surgical planning will be aided by a consistent approach to measuring frailty with a multidimensional instrument like RAI-A, which appears to be superior to the mFI-5 when predicting outcomes for inpatient noncardiac surgery.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala
imageBACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.


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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
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Pediatric Critical Care Medicine

Organ Donation Authorization After Brain Death Among Patients Admitted to PICUs in the United States, 2009–2018
Objectives: To identify trends in and factors associated with pediatric organ donation authorization after brain death. Design: Retrospective cohort study of data from Virtual Pediatric Systems, LLC (Los Angeles, CA). Setting: Data from 123 PICUs reporting to Virtual Pediatric Systems from 2009 to 2018. Patients: Patients less than 19 years old eligible for organ donation after brain death. Measurements and Main Results: Of 2,777 eligible patients, 1,935 (70%) were authorized for organ donation; the authorization rate remained unchanged over time (ptrend = 0.22). In a multivariable logistic regression model, hospitalizations lasting greater than 7 days had lower odds of authorization (adjusted odds ratio, 0.5; p < 0.001 vs ≤ 1 d) and White patients had higher odds than other race/ethnicity groups. Authorization was higher for trauma-related encounters (adjusted odds ratio, 1.5; p < 0.001) and when donation was discussed with an organ procurement organization coordinator (adjusted odds ratio, 1.7; p < 0.001). Of 123 hospitals, 35 (28%) met or exceeded a 75% organ donation authorization target threshold; these hospitals more often had an organ procurement organization coordinator discussing organ donation (85% vs 72% of encounters; p < 0.001), but no difference was observed by PICU bed size. Conclusions: Organ donation authorization after brain death among PICU patients was associated with length of stay, race/ethnicity, and trauma-related encounter, and authorization rates were higher when an organ procurement organization coordinator was involved in the donation discussion. This study identified factors that could inform initiatives to improve the authorization process and increase pediatric organ donation rates. No endorsement or editorial restriction of the interpretation of these data or opinions of the authors has been implied or stated. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Virtual Pediatric Systems (VPS) data were provided by VPS, LLC (Los Angeles, CA). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: alicen.spaulding@childrensmn.org ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Avoidable Serum Potassium Testing in the Cardiac ICU: Development and Testing of a Machine-Learning Model
Objectives: To create a machine-learning model identifying potentially avoidable blood draws for serum potassium among pediatric patients following cardiac surgery. Design: Retrospective cohort study. Setting: Tertiary-care center. Patients: All patients admitted to the cardiac ICU at Boston Children's Hospital between January 2010 and December 2018 with a length of stay greater than or equal to 4 days and greater than or equal to two recorded serum potassium measurements. Interventions: None. Measurements and Main Results: We collected variables related to potassium homeostasis, including serum chemistry, hourly potassium intake, diuretics, and urine output. Using established machine-learning techniques, including random forest classifiers, and hyperparameter tuning, we created models predicting whether a patient's potassium would be normal or abnormal based on the most recent potassium level, medications administered, urine output, and markers of renal function. We developed multiple models based on different age-categories and temporal proximity of the most recent potassium measurement. We assessed the predictive performance of the models using an independent test set. Of the 7,269 admissions (6,196 patients) included, serum potassium was measured on average of 1 (interquartile range, 0–1) time per day. Approximately 96% of patients received at least one dose of IV diuretic and 83% received a form of potassium supplementation. Our models predicted a normal potassium value with a median positive predictive value of 0.900. A median percentage of 2.1% measurements (mean 2.5%; interquartile range, 1.3–3.7%) was incorrectly predicted as normal when they were abnormal. A median percentage of 0.0% (interquartile range, 0.0–0.4%) critically low or high measurements was incorrectly predicted as normal. A median of 27.2% (interquartile range, 7.8–32.4%) of samples was correctly predicted to be normal and could have been potentially avoided. Conclusions: Machine-learning methods can be used to predict avoidable blood tests accurately for serum potassium in critically ill pediatric patients. A median of 27.2% of samples could have been saved, with decreased costs and risk of infection or anemia. Mr. Patel, Dr. Sperotto, and Mr. Molina contributed equally. Drs. Santillana and Kheir jointly supervised this research. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by the Gerber Foundation and, in part, by the Joyful Heart Fund. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: msantill@fas.harvard.edu; john.kheir@childrens.harvard.edu ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!
Objectives: To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU. Design: A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts. Setting: Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD. Subjects: Interprofessional PICU staff. Interventions: None. Measurements and Main Results: Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement. Conclusions: Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Mr. Patel was funded by the Johns Hopkins University Provost's Undergraduate Research Award. Dr. Kudchadkar was supported by the Johns Hopkins Clinical and Translational Science Awards Award Number 5KL2RR025006 from the National Center for Advancing Translational Sciences of the National Institutes of Health and the Johns Hopkins Bloomberg School of Public Health Sommer Scholars Program. Dr. Eakin's institution received funding from the National Heart Lung and Blood Institute (NHLBI). Dr. Balas's institution received funding from NHLBI 1 R01 HL146781-01, American Association of Critical Care Nurses Research Grant, and she received funding from the Society of Critical Care Medicine and H3C. Dr. Needham's institution received funding from Baxter Pharma and Reck Medical Devices, and he received funding from Haisco USA. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: sapna@jhmi.edu ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Respiratory Variation in Aortic Blood Flow Velocity in Hemodynamically Unstable, Ventilated Neonates: A Pilot Study of Fluid Responsiveness
Objectives: To assess whether respiratory variation in aortic blood flow peak velocity can predict preload responsiveness in mechanically ventilated and hemodynamically unstable neonates. Design: Prospective observational diagnostic accuracy study. Setting: Third-level neonatal ICU. Patients: Hemodynamically unstable neonates under mechanical ventilation. Interventions: Fluid challenge with 10 mL/kg of normal saline over 20 minutes. Measurements and Main Results: Respiratory variation in aortic blood flow peak velocity and superior vena cava flow were measured at baseline (T0), immediately upon completion of the fluid infusion (T1), and at 1 hour after fluid administration (T2). Our main outcome was preload responsiveness which was defined as an increase in superior vena cava flow of at least 10% from T0 to T1. Forty-six infants with a median (interquartile range) gestational age of 30.5 weeks (28–36 wk) were included. Twenty-nine infants (63%) were fluid responders, and 17 (37%) were nonresponders Fluid responders had a higher baseline (T0) respiratory variation in aortic blood flow peak velocity than nonresponders (9% [8.2–10.8] vs 5.5% [3.7–6.6]; p < 0.001). Baseline respiratory variation in aortic blood flow peak velocity was correlated with the increase in superior vena cava flow from T0 to T1 (rho = 0.841; p < 0.001). The area under the receiver operating characteristic curve of respiratory variation in aortic blood flow peak velocity to predict preload responsiveness was 0.912 (95% CI, 0.82–1). A respiratory variation in aortic blood flow peak velocity cut-off point of 7.8% provided a 90% sensitivity (95% CI, 71–97), 88% specificity (95% CI, 62–98), 7.6 positive likelihood ratio (95% CI, 2–28), and 0.11 negative likelihood ratio (95% CI, 0.03–0.34) to predict preload responsiveness. Conclusions: Respiratory variation in aortic blood flow velocity may be useful to predict the immediate response to a fluid challenge in hemodynamically unstable neonates under mechanical ventilation. If our results are confirmed, this measurement could be used to guide safe and individualized fluid resuscitation in critically ill neonates. Dr. Oulego-Erroz, guarantor, takes full responsibility of the content of the article, including data and analysis, and he conceived and designed the study, analyzed data, and drafted the article. Dr. Terroba-Seara acquired and analyzed data and critically reviewed the article. Dr. Alonso-Quintela conceived the study, acquired data, and critically reviewed the article. Dr. Rodríguez-Núñez conceived and designed the study and critically reviewed the article. All authors gave their approval for the final version of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Ignacio Oulego-Erroz, Complejo Asistencial Universitario de León, Altos de Nava s/n 24002, León, Spain. E-mail: ignacio.oulego@gmail.com. ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study
Objectives: The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants. Design: Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry. Setting: Four Pediatric Heart Network Collaborative Learning Study active-site hospitals. Patients: Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity). Interventions: None. Measurements and Main Results: Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras. Conclusions: We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices. Supported, in part, by funding from the National Heart, Lung, and Blood Institute, NIH5U10HL109781 and K08HL116639 (principal investigator Gailes). The Pediatric Cardiac Critical Care Consortium Data Coordinating Center receives funding from the University of Michigan Congenital Heart Center, CHAMPS for Mott, and the Michigan Institute for Clinical & Health Research (National Institutes of Health/National Center for Advancing Translational Sciences UL1TR002240), all University of Michigan, Ann Arbor, MI. Dr. Witte's institution received funding from the Pediatric Heart Network/National Heart, Lung, and Blood Institute. Drs. Witte, Mahle, Pasquali, and Gaies received support for article research from the National Institutes of Health (NIH). Dr. Pasquali's institution received funding from the NIH. Dr. Zhang disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: madolin.witte@hsc.utah.edu ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Brain Death Evaluation in Children With Suspected or Confirmed Coronavirus Disease 2019
Objectives: To discuss the challenges of conducting a death by neurologic criteria or brain death evaluation in the coronavirus disease 2019 era and provide guidance to mitigate viral transmission risk and maintain patient safety during testing. Design: Not applicable. Setting: Not applicable. Patients: Children with suspected or confirmed coronavirus disease 2019 who suffer catastrophic brain injury due to one of numerous neurologic complications or from an unrelated process and require evaluation for death by neurologic criteria. Interventions: Not applicable. Measurements and Main Results: There is a risk to healthcare providers from aerosol generation during the neurologic examination and apnea test for determination of death by neurologic criteria. In this technical note, we provide guidance to mitigate transmission risk and maintain patient safety during each step of the death by neurologic criteria evaluation. Clinicians should put on appropriate personal protective equipment before performing the death by neurologic criteria evaluation. Risk of aerosol generation and viral transmission during the apnea test can be mitigated by using continuous positive airway pressure delivered via the ventilator as a means of apneic oxygenation. Physicians should assess the risk of transporting coronavirus disease 2019 patients to the nuclear medicine suite to perform a radionucleotide cerebral blood flow study, as disconnections to and from the ventilator for transport and inadvertent ventilator disconnections during transport can increase transmission risk. Conclusions: When conducting the neurologic examination and apnea test required for death by neurologic criteria determination in patients with suspected or confirmed coronavirus disease 2019, appropriate modifications are needed to mitigate the risk of viral transmission and ensure patient safety. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: kirschenm@chop.edu ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Echocardiographic Parameters and Mortality in Pediatric Sepsis: A Systematic Review and Meta-Analysis
Objective: We conducted a systematic review and meta-analysis to investigate the prognostic value of echocardiographic parameters in pediatric septic patients. Data Sources: MEDLINE, PubMed, and EMBASE (last update April 5, 2020). Study Selection: Observational studies of pediatric sepsis providing echocardiographic parameters in relation to mortality. Data Extraction: Echocardiography data were categorized as those describing left ventricular systolic or diastolic function, right ventricular function, and strain echocardiography parameters. Data from neonates and children were considered separately. Analysis is reported as standardized mean difference and 95% CI. Data Synthesis: We included data from 14 articles (n = 5 neonates, n = 9 children). The fractional shortening was the most commonly reported variable (11 studies, n = 555 patients) and we did not identify an association with mortality (standardized mean difference 0.22, 95% CI [–0.02 to 0.47]; p = 0.07, I2 = 28%). In addition, we did not find any association with mortality also for left ventricular ejection fraction (nine studies, n = 417; standardized mean difference 0.06, 95% CI [–0.27 to 0.40]; p = 0.72, I2 = 51%), peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave (four studies, n = 178; standardized mean difference –0.01, 95% CI [–0.34 to 0.33]; p = 0.97, I2 = 0%), and myocardial performance index (five studies, n = 219; standardized mean difference –0.51, 95% CI [–1.10 to 0.08]; p = 0.09, I2 = 63%). However, in regard to left ventricular diastolic function, there was an association with mortality for higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging ratio (four studies, n = 189, standardized mean difference –0.45, 95% CI [–0.80 to –0.10]; p = 0.01, I2 = 0%) or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging wave (three studies, n = 159; standardized mean difference 0.49, 95% CI [0.13–0.85]; p = 0.008, I2 = 0%). We did not find any association with mortality for early wave of transmitral flow/late (atrial) wave of trans-mitral flow ratio (six studies, n = 273; standardized mean difference 0.28, 95% CI [–0.42 to 0.99]; p = 0.43, I2 = 81%) and peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave measured at the tricuspid annulus (three studies, n = 148; standardized mean difference –0.18, 95% CI [–0.53 to 0.17]; p = 0.32, I2 = 0%). Only a few studies were conducted with strain echocardiography. Conclusions: This meta-analysis of echocardiography parameters in pediatric sepsis failed to find any association between the measures of left ventricular systolic or right ventricular function and mortality. However, mortality was associated with higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging, indicating possible importance of left ventricular diastolic dysfunction. These are preliminary findings because of high clinical heterogeneity in the studies to date. Drs. La Rosa and Grasso contributed equally. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: filipposanfi@yahoo.it ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Intracranial and Cerebral Perfusion Pressure Thresholds Associated With Inhospital Mortality Across Pediatric Neurocritical Care
Objectives: Targets for treatment of raised intracranial pressure or decreased cerebral perfusion pressure in pediatric neurocritical care are not well defined. Current pediatric guidelines, based on traumatic brain injury, suggest an intracranial pressure target of less than 20 mm Hg and cerebral perfusion pressure minimum of 40–50 mm Hg, with possible age dependence of cerebral perfusion pressure . We sought to define intracranial pressure and cerebral perfusion pressure thresholds associated with inhospital mortality across a large single-center pediatric neurocritical care cohort. Design: Retrospective chart review. Setting: PICU, single quaternary-care center. Patients: Individuals receiving intracranial pressure monitoring from January 2012 to December 2016. Interventions: None. Measurements and Main Results: Intracranial pressure and cerebral perfusion pressure measurements from 262 neurocritical care patients (87 traumatic brain injury and 175 nontraumatic brain injury; 63% male; 8.3 ± 5.8 yr; mortality 11.1%). Mean intracranial pressure and cerebral perfusion pressure had area under the receiver operating characteristic curves of 0.75 and 0.64, respectively, for association of inhospital mortality. Cerebral perfusion pressure cut points increased with age (< 2 yr = 47, 2 to < 8 yr = 58 mm Hg, ≥ 8 yr = 73 mm Hg). In the traumatic brain injury subset, mean intracranial pressure and cerebral perfusion pressure had area under the receiver operating characteristic curves of 0.70 and 0.78, respectively, for association of inhospital mortality. Traumatic brain injury cerebral perfusion pressure cut points increased with age (< 2 yr = 45, 2 to < 8 yr = 57, ≥ 8 yr = 68 mm Hg). Mean intracranial pressure greater than 15 mm Hg, male sex, and traumatic brain injury status were independently associated with inhospital mortality (odds ratio, 14.23 [5.55–36.46], 2.77 [1.04–7.39], and 2.57 [1.03–6.38], respectively; all p < 0.05). Mean cerebral perfusion pressure less than 67 mm Hg and traumatic brain injury status were independently associated with inhospital mortality (odds ratio, 5.16 [2.05–12.98] and 3.71 [1.55–8.91], respectively; both p < 0.01). In the nontraumatic brain injury subset, mean intracranial pressure had an area under the receiver operating characteristic curve 0.77 with an intracranial pressure cut point of 15 mm Hg, whereas mean cerebral perfusion pressure was not predictive of inhospital mortality. Conclusions: We identified mean intracranial pressure thresholds, utilizing receiver operating characteristic and regression analyses, associated with inhospital mortality that is below current guidelines-based treatment targets in both traumatic brain injury and nontraumatic brain injury patients, and age-dependent cerebral perfusion pressure thresholds associated with inhospital mortality that were above current guidelines-based targets in traumatic brain injury patients. Further study is warranted to identify data-driven intracranial pressure and cerebral perfusion pressure targets in children undergoing intracranial pressure monitoring, whether for traumatic brain injury or other indications. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by K23 NS104133 (to Dr. Au), 1K23 HD099331-01A1 (to Dr. Horvat), T32 HD040686 (to Dr. Rakkar), R21 NS115174 (to Dr. Clark), The Children's Trust Fund (to Drs. Horvat and Simon), and the UPMC Children's Hospital of Pittsburgh Scientific Program. Drs. Clark and Au are funded by the National Institute of Neurological Disorders and Stroke. Drs. Horvat and Rakkar are funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The work was performed at the UPMC Children's Hospital of Pittsburgh. For information regarding this article, E-mail: auak@upmc.edu ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Influence of Cardiopulmonary Resuscitation Coaching on Interruptions in Chest Compressions During Simulated Pediatric Cardiac Arrest
Objectives: To determine the impact of a cardiopulmonary resuscitation coach on the frequency and duration of pauses during simulated pediatric cardiac arrest. Design: This is a secondary analysis of video data collected from a prospective multicenter trial. Forty simulated pediatric cardiac arrest scenarios (20 noncoach and 20 coach teams), each lasting 18 minutes in duration, were reviewed by three clinical experts to document events surrounding each pause in chest compressions. Setting: Four pediatric academic medical centers from Canada and the United States. Subjects: Two-hundred healthcare providers in five-member interprofessional resuscitation teams that included either a cardiopulmonary resuscitation coach or a noncoach clinical provider. Interventions: Teams were randomized to include either a trained cardiopulmonary resuscitation coach or an additional noncoach clinical provider. Measurements and Main Results: The frequency, duration, and associated factors with each interruption in chest compressions were recorded and compared between the groups with and without a cardiopulmonary resuscitation coach, using t tests, Wilcoxon rank-sum tests, or chi-squared tests, depending on the distribution and types of outcome variables. Mixed-effect linear models were used to explore the effect of cardiopulmonary resuscitation coaching on pause durations, accounting for multiple measures of pause duration within teams. A total of 655 pauses were identified (noncoach n = 304 and coach n = 351). Cardiopulmonary resuscitation-coached teams had decreased total mean pause duration (98.6 vs 120.85 s, p = 0.04), decreased intubation pause duration (median 4.0 vs 15.5 s, p = 0.002), and similar mean frequency of pauses (17.6 vs 15.2, p = 0.33) when compared with noncoach teams. Teams with cardiopulmonary resuscitation coaches are more likely to verbalize the need for pause (86.5% vs 73.7%, p < 0.001) and coordinate change of the compressors, rhythm check, and pulse check (31.7% vs 23.2%, p = 0.05). Teams with cardiopulmonary resuscitation coach have a shorter pause duration than non-coach teams, adjusting for number and types of tasks performed during the pause. Conclusions: When compared with teams without a cardiopulmonary resuscitation coach, the inclusion of a trained cardiopulmonary resuscitation coach leads to improved verbalization before pauses, decreased pause duration, shorter pauses during intubation, and better coordination of key tasks during chest compression pauses. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http:journals.lww.com/pccmjournal). Drs. Kessler and Cheng conceptualized and designed the study. Dr. Kessler, Dr. Grabinski, Dr. Shepard, Ms. Jones, and Dr. Cheng designed the data collection instruments. Dr. Grabinski, Dr. Shepard, and Ms. Jones reviewed videos and coordinated data collection. Drs. Kessler and Lin contributed to the statistical analysis and the interpretation of data. Dr. Kessler takes overall responsibility for the article. All authors contributed to the drafting and meaningful review of the article and approved the final article as submitted. Ms. Nye, Ms. Gaither, Dr. Hunt, Ms. Davidson, and Ms. Chatfield (International Network for Simulation-based Pediatric Innovation, Research, and Education Cardiopulmonary Resuscitation Group byline authors) contributed to the conceptualization and design of the study, coordinated and supervised data collection at one site, and approved the final article as submitted. Findings from this study were presented in poster format at the International Pediatric Simulation Society annual meeting in Toronto on May 20, 2019. Dr. Cheng reports that the parent study for this project was funded through a research grant from the Heart and Stroke Foundation of Alberta, Alberta Health Services, and the University of Calgary. He also reports additional research infrastructure support provided by the Alberta Children's Research Institute, the Alberta Children's Hospital Foundation, and the Department of Pediatrics, Cumming School of Medicine, University of Calgary, to support investigator initiated research conducted in concert with the Kid Simulation Research Program, Alberta Children's Hospital. Dr. Hunt was responsible for the initial description of the cardiopulmonary resuscitation (CPR) coach. She reports funding from International Network for Simulation-Based Innovation, Research, & Education to investigate further the impact of the CPR Coach on compliance with CPR guidelines. She also reports that unrelated to this study she and her research partners do have nonexclusive agreement with Zoll Medical Corporation licensing educational technology on which they hold patents with the potential for revenue. She has also received reimbursement for travel expenses and honoraria for speaking about the CPR Coach role she created. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: dk2592@cumc.columbia.edu ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Use of Honey Versus Standard Care for Hospital-Acquired Pressure Injury in Critically Ill Children: A Multicenter Randomized Controlled Trial
Objectives: To examine if the use of honey (medicated) for dressing is superior to standard care in terms of time to complete wound healing in stages 1–3 of pressure injuries in children admitted to the PICU. Design: Multicenter, open-label, parallel-group, randomized trial. Setting: Tertiary-care PICU from August 2017 to January 2019. Patients: Critically ill children, 2 months to 17 years old, who developed pressure injury (stages 1–3) were included; those on more than two inotropes or with signs of acute wound infection or wounds with greater than 5 cm diameter or known allergy to honey were excluded. Interventions: Children were randomized to receive either medicated honey dressing or standard (routine) wound care for the management of their pressure injury. Measurements and Main Results: The primary outcome was the time to complete wound healing. Manuka or active Leptospermum honey dressing/gel was used in the intervention group. Enrolled children were followed up until death or discharge from the hospital. A total of 99 children were enrolled: 51 in the intervention group and 48 in the standard care group. Baseline characteristics, including the nutritional status, were comparable between the groups. The most common sites of injury were bony prominences at face mask contact points. The median time to complete healing was 7 days (95% CI, 6–7 d) versus 9 days (7–10 d) in the intervention and standard care groups, respectively (p = 0.002; log-rank test). At any random time, children in the intervention group were about 1.9-fold more likely to have their pressure injury completely healed than those in the standard care group (hazard ratio 1.86; 95% CI, 1.21–2.87). There were no allergic reactions or secondary wound infections in the intervention group. Conclusions: The use of medicated honey dressings decreased the time to wound healing in critically ill children with pressure injuries. There were no allergic reactions or secondary bacterial infections in any of these children. ClinicalTrials.gov ID: NCT03391310 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by HARD Manufacturing-WFPICCS Pediatric Critical Care Research Grant'-10000 USD. Drs. Sankar's, AV's, Rameshkumar's, Mahadevan's, and Kabra's institutions received funding from WFPICCS HARD Manufacturing Pediatric Critical Care Research Grant. Dr. Sankar's institution also received funding from the Department of Science and Technology and the Indian Council of Medical Research. Dr. Lodha disclosed off-label product use of medicated honey dressings for pressure ulcers in critically ill children For information regarding this article, E-mail: jhumaji@gmail.com ©2020The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies


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