1
|
Sam AE, Weber Z, Peña A, Henderson C, King JM, Carr NR. A pilot study to evaluate clinical factors associated with iron and ferritin elevations during pediatric extracorporeal membrane oxygenation. Perfusion 2024; 39:585-592. [PMID: 36725017 DOI: 10.1177/02676591231154750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Elevations in serum ferritin and serum iron occur during pediatric extracorporeal membrane oxygenation (ECMO). Previous reports attribute the elevation to frequent red blood cell transfusions and/or hemolysis. Chronic transfusion can cause iron deposition in tissues leading to multisystem organ dysfunction. This study aims identify clinical factors associated with elevated ferritin and iron in pediatric ECMO patients, along with post-decannulation magnetic resonance imaging (MRI) assessment of iron deposition in liver and brain.Methods: Prospective, pilot study, using descriptive statistics to investigate potential associations between patient characteristics, serum ferritin and iron levels, and post-decannulation hepatic and basal ganglia iron deposition.Results: In this study, nine patients (100%) had elevated serum ferritin levels during ECMO. High ferritin levels were more common with veno-arterial than with veno-venous cannulation (p = 0.026) and were also associated with high plasma free hemoglobin levels (p < 0.001). Five patients presented with elevated serum iron levels. High serum iron levels were associated with higher daily (p = 0.016) and cumulative transfusion volumes (p = 0.013) as well ECMO duration beyond 7 days. MRI scans were performed on three patients with no evidence of abnormal iron deposition detected in the liver or brain.Conclusions: This pilot study shows that during pediatric ECMO, elevations in serum ferritin and serum iron occur and those elevations may be related to the cannulation modality, ECMO duration, amount of hemolysis, and volume of red blood cell transfusions. Further investigation is warranted to fully understand the implications of elevated serum iron and ferritin in pediatric ECMO.
Collapse
Affiliation(s)
- Ashley E Sam
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Zachary Weber
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- National Capital Consortium, Bethesda, MD, USA
| | - Alejandra Peña
- University Medical Center, Lubbock, TX, USA
- University of Texas Health Science Center San Antonio Joe and Teresa Lozano Long School of Medicine, San Antonio, TX, USA
| | - Cody Henderson
- Children's Hospital of San Antonio, San Antonio, TX, USA
| | | | - Nicholas R Carr
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
2
|
Sam AE, Hamele MT, Matos RI, Fagiana AM, Borgman MA, Maddry JK, Schauer SG. A Descriptive Analysis of Pediatric Transports Throughout the U.S. Indo-Pacific Command. Mil Med 2021; 186:e743-e748. [PMID: 33216936 PMCID: PMC8246610 DOI: 10.1093/milmed/usaa506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/07/2020] [Accepted: 11/16/2020] [Indexed: 12/03/2022] Open
Abstract
Background The U.S. Indo-Pacific Command (INDOPACOM) has over 375,000 military personnel, civilian employees, and their dependents. Routine pediatric care is available in theater, but pediatric subspecialty, surgical, and intensive care often require patient movement. Transfer is frequently performed by military air evacuation teams and intermittently augmented by civilian services. Pediatric care requires special training and equipment, yet most transports are staffed by non-pediatric specialists. We seek to describe the epidemiology of pediatric transport missions in INDOPACOM. Methods A retrospective review of all patients less than 18 years old transported within INDOPACOM and logged into the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from June 2008 through June 2018 was conducted. Data are reported using descriptive statistics. Patients were categorized into four age groups: neonatal (<31 days), infant (31-364 days), young children (1 to <8 years), and older children (8-17 years). Results During the study period, 687 out of 4,217 (16.3%) transports were children. Median age was 4 years (interquartile range 6 months to 8 years) and 654 patients (95.2%) were transported via military fixed-wing aircraft. There were 219 (31.9%) neonates, 162 (23.6%) infants, 133 (19.4%) young children, and 173 (25.2%) older children. Most common diagnoses encountered were respiratory, cardiac, or abdominal, although older children had a higher percentage of psychiatric diagnoses (28%). Mechanical ventilation was used in 118 (17.2%) patients, and 75 (63.6%) of these patients were neonates. Conclusions Within TRAC2ES, nearly one in six encounters were patients aged <18 years, with neonates or infants representing nearly one of three pediatric encounters. Slightly more than one in six pediatric patients required intubation for transport. The data suggest the need for appropriately trained transport teams and equipment be provided to support these missions.
Collapse
Affiliation(s)
- Ashley E Sam
- San Antonio Uniformed Services Education Consortium, Department of Pediatrics, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA.,59th Medical Wing, JBSA-Lackland, TX 78236, USA
| | - Mitchell T Hamele
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI 96859, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Renée I Matos
- San Antonio Uniformed Services Education Consortium, Department of Pediatrics, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA.,59th Medical Wing, JBSA-Lackland, TX 78236, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Angela M Fagiana
- San Antonio Uniformed Services Education Consortium, Department of Pediatrics, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Matthew A Borgman
- San Antonio Uniformed Services Education Consortium, Department of Pediatrics, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Joseph K Maddry
- 59th Medical Wing, JBSA-Lackland, TX 78236, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,US Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
| | - Steven G Schauer
- 59th Medical Wing, JBSA-Lackland, TX 78236, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,US Army Institute of Surgical Research, JBSA-Fort Sam Houston, TX 78234, USA
| |
Collapse
|
3
|
Penney SW, O'Hara-Wood SN, McFarlan LM, Slaughter RP, Cox CS, Gibbons AN, Sam AE, Matos RI. A Quality Improvement Initiative to Reduce Unnecessary Rapid Responses Using Early Warning Scores. Pediatrics 2021; 147:peds.2019-1947. [PMID: 33547251 DOI: 10.1542/peds.2019-1947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The Pediatric Early Warning Score (PEWS) is an evidence-based tool that allows early collaborative assessment and intervention for a rapid response team (RRT) activation. The goal of our quality improvement initiative was to reduce the percentage of unnecessary RRT activations by 50% over 2 years without increasing PICU transfers or compromising patient safety and timely evaluation. METHODS A PEWS system replaced preexisting vital signs-based pediatric RRT criteria and was modified through plan-do-study-act cycles. Unnecessary RRT activations, total RRT activation rate, transfers to the PICU, total clinical interventions performed per RRT, and missed RRT activation rate were compared between intervention periods. Likert scale surveys were administered to measure satisfaction with each modification. RESULTS There was a significant decrease in the percentage of unnecessary RRT activations from 33% to 3.5% after the implementation of the PEWS and modified-PEWS systems (P < .05). The RRT activation rate decreased from 22.6 to 13.3 RRT activations per 1000 patient care days after implementation of the PEWS and modified-PEWS systems (P < .05), without changes in PICU transfer rates. Physicians reported that the PEWS system improved nursing communication and accuracy of RRT criteria (P < .05). Nursing reported that the PEWS system improved patient management and clinical autonomy (P < .05). CONCLUSIONS The PEWS systems have been an effective means of identifying deteriorating pediatric patients and reducing unnecessary RRT activations. The new system fosters collaboration and communication at the bedside to prevent acute deterioration, perform timely interventions, and ultimately improve patient safety and outcomes.
Collapse
Affiliation(s)
- Scott W Penney
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Scarlett N O'Hara-Wood
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Lisa M McFarlan
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Robert P Slaughter
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Carla S Cox
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Amber N Gibbons
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Ashley E Sam
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Renée I Matos
- San Antonio Uniformed Services Health Education Consortium, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| |
Collapse
|