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

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