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Yates AR, Naim MY, Reeder RW, Ahmed T, Banks RK, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yeh J, Zuppa AF, Sutton RM, Meert KL. Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021). Pediatr Crit Care Med 2024; 25:312-322. [PMID: 38088765 PMCID: PMC10994777 DOI: 10.1097/pcc.0000000000003423] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients. DESIGN Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497). SETTING Eighteen ICUs participated in ICU-RESUS. PATIENTS There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation. CONCLUSIONS We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.
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Affiliation(s)
- Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Justin Yeh
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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Zinna SS, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Cooper KK, Michael Dean J, Wesley Diddle J, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Hehir DA, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis. Resuscitation 2024; 194:110068. [PMID: 38052273 PMCID: PMC10843614 DOI: 10.1016/j.resuscitation.2023.110068] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
AIM Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes. METHODS AND RESULTS Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes. CONCLUSIONS Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.
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Affiliation(s)
- Shairbanu S Zinna
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
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3
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Federman M, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Kirkpatrick T, Maa T, Maitoza LA, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Naim MY. Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease. Pediatr Crit Care Med 2024; 25:4-14. [PMID: 37678381 PMCID: PMC10843749 DOI: 10.1097/pcc.0000000000003368] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease. DESIGN Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021). SETTING Eighteen PICUs. PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups. CONCLUSIONS In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.
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Affiliation(s)
- Myke Federman
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children’s Hospital, Delaware, Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, St. Louis, MO, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Theresa Kirkpatrick
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Laura A Maitoza
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Murray M Pollack
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children’s Hospital, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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4
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Takyi-Williams J, Leino AD, Li R, Downes KJ, Zuppa AF, Bwint A, Wen B, Sun D, Scheetz MH, Pai MP. Bioanalysis of six antibiotics from volumetric microsamples: a new tool for precision dosing in critically ill children. Bioanalysis 2024; 16:19-31. [PMID: 37991215 PMCID: PMC10718164 DOI: 10.4155/bio-2023-0171] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/02/2023] [Indexed: 11/23/2023] Open
Abstract
Background: Volumetric absorptive microsamples (VAMS) can support pharmacokinetic / pharmacodynamic studies. We present the bioanalytical method development for the simultaneous quantification of ampicillin, cefepime, ceftriaxone, meropenem, piperacillin, tazobactam, and vancomycin from VAMS. Methods & results: Optimal extraction, chromatographic, and mass spectrometry conditions were identified. Maximum extraction recoveries included 100 μl of water for rehydration and methanol for protein precipitation. Chromatographic separation used Phenomenex Kinetex™ Polar C18 column with a mobile phase comprising water/acetonitrile with formic acid and was fully validated. Hematocrit effects were only observed for vancomycin. Samples were stable for 90 days at -80°C except for meropenem, which was stable for 60 days. Conclusion: Multiple antibiotics can be assayed from a single VAMS sample to facilitate pharmacokinetic/pharmacodynamic studies.
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Affiliation(s)
| | - Abbie D Leino
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Ruiting Li
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Athena F Zuppa
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Amanda Bwint
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Bo Wen
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Duxin Sun
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | - Marc H Scheetz
- College of Pharmacy, Midwestern University, Downers Grove, IL 60515, USA
| | - Manjunath P Pai
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
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Osborne CM, Langelier C, Kamm J, Williamson K, Ambroggio L, Reeder RW, Locandro C, Kirk Harris J, Wagner BD, Maddux AB, Caldera S, Lyden A, Soesanto V, Simões EAF, Leroue MK, Carpenter TC, Hall MW, Zuppa AF, Carcillo JA, Meert KL, Pollack MM, McQuillen PS, Notterman DA, DeRisi J, Mourani PM. Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection. Pediatr Crit Care Med 2024; 25:e1-e11. [PMID: 37732845 PMCID: PMC10756702 DOI: 10.1097/pcc.0000000000003336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs). DESIGN This is an analysis of of a seven-center prospective cohort study. SETTING Seven PICUs within academic children's hospitals in the United States. PATIENTS Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours. INTERVENTIONS We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement. MEASUREMENTS AND MAIN RESULTS Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001). CONCLUSIONS Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.
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Affiliation(s)
- Christina M Osborne
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Charles Langelier
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, CA
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Lilliam Ambroggio
- Department of Epidemiology, University of Colorado School of Medicine, Aurora, CO
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - J Kirk Harris
- Department of Pediatrics, Section of Pulmonary Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Eric A F Simões
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew K Leroue
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Todd C Carpenter
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Athena F Zuppa
- Anesthesiology and Critical Care, Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joseph A Carcillo
- Department of Anesthesia and Critical Care Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kathleen L Meert
- Department of Pediatrics, Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Murray M Pollack
- Department of Pediatrics, Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | | | | | - Peter M Mourani
- Department of Pediatrics, Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR
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VanBuren JM, Hall M, Zuppa AF, Mourani PM, Carcillo J, Dean JM, Watt K, Holubkov R. The Design of Nested Adaptive Clinical Trials of Multiple Organ Dysfunction Syndrome Children in a Single Study. Pediatr Crit Care Med 2023; 24:e635-e646. [PMID: 37498156 PMCID: PMC10817996 DOI: 10.1097/pcc.0000000000003332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVES Describe the statistical design of the Personalized Immunomodulation in Sepsis-induced Multiple Organ Dysfunction Syndrome (MODS) (PRECISE) study. DESIGN Children with sepsis-induced MODS undergo real-time immune testing followed by assignment to an immunophenotype-specific study cohort. Interventional cohorts include the granulocyte macrophage-colony stimulating factor (GM-CSF) for the Reversal of Immunoparalysis in Pediatric Sepsis-induced MODS (GRACE)-2 trial, which uses the drug GM-CSF (or placebo) to reverse immunoparalysis; and the Targeted Reversal of Inflammation in Pediatric Sepsis-induced MODS (TRIPS) trial, which uses the drug anakinra (or placebo) to reverse systemic inflammation. Both trials have adaptive components and use a statistical framework in which frequent data monitoring assesses futility and efficacy, allowing potentially earlier stopping than traditional approaches. Prespecified simulation-based stopping boundaries are customized to each trial to preserve an overall one-sided type I error rate. The TRIPS trial also uses response-adaptive randomization, updating randomization allocation proportions to favor active arms that appear more efficacious based on accumulating data. SETTING Twenty-four U.S. academic PICUs. PATIENTS Septic children with specific immunologic derangements during ongoing dysfunction of at least two organs. INTERVENTIONS The GRACE-2 trial compares GM-CSF and placebo in children with immunoparalysis. The TRIPS trial compares four different doses of anakinra to placebo in children with moderate to severe systemic inflammation. MEASUREMENTS AND MAIN RESULTS Both trials assess primary efficacy using the sum of the daily pediatric logistic organ dysfunction-2 score over 28 days. Ranked summed scores, with mortality assigned the worst possible value, are compared between arms using the Wilcoxon Rank Sum test (GRACE-2) and a dose-response curve (TRIPS). We present simulation-based operating characteristics under several scenarios to demonstrate the behavior of the adaptive design. CONCLUSIONS The adaptive design incorporates innovative statistical features that allow for multiple active arms to be compared with placebo based on a child's personal immunophenotype. The design increases power and provides optimal operating characteristics compared with traditional conservative methods.
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Affiliation(s)
- John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Mark Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, Division of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh, Children's Hospital of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Kevin Watt
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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7
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Podd BS, Banks RK, Reeder R, Telford R, Holubkov R, Carcillo J, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Randolph AG. Early, Persistent Lymphopenia Is Associated With Prolonged Multiple Organ Failure and Mortality in Septic Children. Crit Care Med 2023; 51:1766-1776. [PMID: 37462434 DOI: 10.1097/ccm.0000000000005993] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Sepsis-associated immune suppression correlates with poor outcomes. Adult trials are evaluating immune support therapies. Limited data exist to support consideration of immunomodulation in pediatric sepsis. We tested the hypothesis that early, persistent lymphopenia predicts worse outcomes in pediatric severe sepsis. DESIGN Observational cohort comparing children with severe sepsis and early, persistent lymphopenia (absolute lymphocyte count < 1,000 cells/µL on 2 d between study days 0-5) to children without. The composite outcome was prolonged multiple organ dysfunction syndrome (MODS, organ dysfunction beyond day 7) or PICU mortality. SETTING Nine PICUs in the National Institutes of Health Collaborative Pediatric Critical Care Research Network between 2015 and 2017. PATIENTS Children with severe sepsis and indwelling arterial and/or central venous catheters. INTERVENTIONS Blood sampling and clinical data analysis. MEASUREMENTS AND MAIN RESULTS Among 401 pediatric patients with severe sepsis, 152 (38%) had persistent lymphopenia. These patients were older, had higher illness severity, and were more likely to have underlying comorbidities including solid organ transplant or malignancy. Persistent lymphopenia was associated with the composite outcome prolonged MODS or PICU mortality (66/152, 43% vs 45/249, 18%; p < 0.01) and its components prolonged MODS (59/152 [39%] vs 43/249 [17%]), and PICU mortality (32/152, 21% vs 12/249, 5%; p < 0.01) versus children without. After adjusting for baseline factors at enrollment, the presence of persistent lymphopenia was associated with an odds ratio of 2.98 (95% CI [1.85-4.02]; p < 0.01) for the composite outcome. Lymphocyte count trajectories showed that patients with persistent lymphopenia generally did not recover lymphocyte counts during the study, had lower nadir whole blood tumor necrosis factor-α response to lipopolysaccharide stimulation, and higher maximal inflammatory markers (C-reactive protein and ferritin) during days 0-3 ( p < 0.01). CONCLUSIONS Children with severe sepsis and persistent lymphopenia are at risk of prolonged MODS or PICU mortality. This evidence supports testing therapies for pediatric severe sepsis patients risk-stratified by early, persistent lymphopenia.
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Affiliation(s)
- Bradley S Podd
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Russell Telford
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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8
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Gardner MM, Hehir DA, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Topjian AA. Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study. Crit Care 2023; 27:388. [PMID: 37805481 PMCID: PMC10559632 DOI: 10.1186/s13054-023-04662-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge. METHODS We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes. RESULTS Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001). CONCLUSIONS Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.
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Affiliation(s)
- Monique M Gardner
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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9
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Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest. Resuscitation 2023; 191:109939. [PMID: 37625580 PMCID: PMC10528057 DOI: 10.1016/j.resuscitation.2023.109939] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
AIM To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest. METHODS This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status. RESULTS Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites. CONCLUSIONS Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Robert Bishop
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Heather A Wolfe
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
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10
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Cheung C, Kernan KF, Berg RA, Zuppa AF, Notterman DA, Pollack MM, Wessel D, Meert KL, Hall MW, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Banks RK, Reeder RW, Holubkov R, Carcillo JA, Fink EL. Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study. Pediatr Crit Care Med 2023; 24:840-848. [PMID: 37314247 PMCID: PMC10719421 DOI: 10.1097/pcc.0000000000003300] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure. DESIGN Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS). SETTING Nine tertiary care PICUs in the United States. PATIENTS Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC. CONCLUSIONS One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.
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Affiliation(s)
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F. Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Rick E. Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
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11
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Fan Z, Kernan KF, Qin Y, Canna S, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Park HJ, Carcillo JA. Hyperferritinemic sepsis, macrophage activation syndrome, and mortality in a pediatric research network: a causal inference analysis. Crit Care 2023; 27:347. [PMID: 37674218 PMCID: PMC10481565 DOI: 10.1186/s13054-023-04628-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND One of five global deaths are attributable to sepsis. Hyperferritinemic sepsis (> 500 ng/mL) is associated with increased mortality in single-center studies. Our pediatric research network's objective was to obtain rationale for designing anti-inflammatory clinical trials targeting hyperferritinemic sepsis. METHODS We assessed differences in 32 cytokines, immune depression (low whole blood ex vivo TNF response to endotoxin) and thrombotic microangiopathy (low ADAMTS13 activity) biomarkers, seven viral DNAemias, and macrophage activation syndrome (MAS) defined by combined hepatobiliary dysfunction and disseminated intravascular coagulation, and mortality in 117 children with hyperferritinemic sepsis (ferritin level > 500 ng/mL) compared to 280 children with sepsis without hyperferritinemia. Causal inference analysis of these 41 variables, MAS, and mortality was performed. RESULTS Mortality was increased in children with hyperferritinemic sepsis (27/117, 23% vs 16/280, 5.7%; Odds Ratio = 4.85, 95% CI [2.55-9.60]; z = 4.728; P-value < 0.0001). Hyperferritinemic sepsis had higher C-reactive protein, sCD163, IL-22, IL-18, IL-18 binding protein, MIG/CXCL9, IL-1β, IL-6, IL-8, IL-10, IL-17a, IFN-γ, IP10/CXCL10, MCP-1/CCL2, MIP-1α, MIP-1β, TNF, MCP-3, IL-2RA (sCD25), IL-16, M-CSF, and SCF levels; lower ADAMTS13 activity, sFasL, whole blood ex vivo TNF response to endotoxin, and TRAIL levels; more Adenovirus, BK virus, and multiple virus DNAemias; and more MAS (P-value < 0.05). Among these variables, only MCP-1/CCL2 (the monocyte chemoattractant protein), MAS, and ferritin levels were directly causally associated with mortality. MCP-1/CCL2 and hyperferritinemia showed direct causal association with depressed ex vivo whole blood TNF response to endotoxin. MCP-1/CCL2 was a mediator of MAS. MCP-1/CCL2 and MAS were mediators of hyperferritinemia. CONCLUSIONS These findings establish hyperferritinemic sepsis as a high-risk condition characterized by increased cytokinemia, viral DNAemia, thrombotic microangiopathy, immune depression, macrophage activation syndrome, and death. The causal analysis provides rationale for designing anti-inflammatory trials that reduce macrophage activation to improve survival and enhance infection clearance in pediatric hyperferritinemic sepsis.
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Affiliation(s)
- Zhenziang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Faculty Pavilion, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Yidi Qin
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott Canna
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - H J Park
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Faculty Pavilion, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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12
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Morgan RW, Reeder RW, Ahmed T, Bell MJ, Berger JT, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Himebauch AS, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial. Resuscitation 2023; 190:109897. [PMID: 37406760 PMCID: PMC10530491 DOI: 10.1016/j.resuscitation.2023.109897] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes. METHODS This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR. RESULTS Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups. CONCLUSIONS In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - John T Berger
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA; Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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13
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Downes KJ, Zuppa AF, Sharova A, Neely MN. Optimizing Vancomycin Therapy in Critically Ill Children: A Population Pharmacokinetics Study to Inform Vancomycin Area under the Curve Estimation Using Novel Biomarkers. Pharmaceutics 2023; 15:1336. [PMID: 37242578 PMCID: PMC10220925 DOI: 10.3390/pharmaceutics15051336] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Area under the curve (AUC)-directed vancomycin therapy is recommended, but Bayesian AUC estimation in critically ill children is difficult due to inadequate methods for estimating kidney function. We prospectively enrolled 50 critically ill children receiving IV vancomycin for suspected infection and divided them into model training (n = 30) and testing (n = 20) groups. We performed nonparametric population PK modeling in the training group using Pmetrics, evaluating novel urinary and plasma kidney biomarkers as covariates on vancomycin clearance. In this group, a two-compartment model best described the data. During covariate testing, cystatin C-based estimated glomerular filtration rate (eGFR) and urinary neutrophil gelatinase-associated lipocalin (NGAL; full model) improved model likelihood when included as covariates on clearance. We then used multiple-model optimization to define the optimal sampling times to estimate AUC24 for each subject in the model testing group and compared the Bayesian posterior AUC24 to AUC24 calculated using noncompartmental analysis from all measured concentrations for each subject. Our full model provided accurate and precise estimates of vancomycin AUC (bias 2.3%, imprecision 6.2%). However, AUC prediction was similar when using reduced models with only cystatin C-based eGFR (bias 1.8%, imprecision 7.0%) or creatinine-based eGFR (bias -2.4%, imprecision 6.2%) as covariates on clearance. All three model(s) facilitated accurate and precise estimation of vancomycin AUC in critically ill children.
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Affiliation(s)
- Kevin J. Downes
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Athena F. Zuppa
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Anna Sharova
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Michael N. Neely
- Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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14
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Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Michael Dean J, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, KirkpatrickN T, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Qunibi D, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes. Resuscitation 2023; 185:109673. [PMID: 36565948 PMCID: PMC10065910 DOI: 10.1016/j.resuscitation.2022.109673] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
AIM To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit. METHODS This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses. RESULTS Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency. CONCLUSIONS Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Theresa KirkpatrickN
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Danna Qunibi
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
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15
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Bailly DK, Reeder RW, Muszynski JA, Meert KL, Ankola AA, Alexander PM, Pollack MM, Moler FW, Berg RA, Carcillo J, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Dalton H, Zuppa AF. Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis. Perfusion 2023; 38:363-372. [PMID: 35220828 DOI: 10.1177/02676591211056562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, 14434University of Utah, Salt Lake, UT, USA
| | - Jennifer A Muszynski
- Division of Critical Care, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Center for Clinical and Translational Research, 2650The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen L Meert
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Cardiology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Peta Ma Alexander
- Department of Pediatrics, 14434Harvard Medical School, Boston, MA, USA
| | - Murray M Pollack
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Frank W Moler
- Department of Pediatrics and Communicable Diseases, 1259University of Michigan, Ann Arbor, MI, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Critical Care Medicine, 6619Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Berger
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Michael J Bell
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - J M Dean
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Carol Nicholson
- Trauma and Critical Illness Branch, 35040National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA.,35040National Institutes of Health, Bethesda, MD, USA
| | - Pamela Garcia-Filion
- Department of Biomedical Informatics, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David Wessel
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Sabrina Heidemann
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Allan Doctor
- Department of Pediatrics and Center for Blood Oxygen Transport and Hemostasis, 12264University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Rick Harrison
- Department of Pediatrics, 21785Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Heidi Dalton
- Department of Pediatrics and Heart and Vascular Institute, 3313Inova Fairfax Hospital, Fall Church, VA, USA
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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16
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Berg RA, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM. Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study. Crit Care Med 2023; 51:91-102. [PMID: 36519983 PMCID: PMC9970166 DOI: 10.1097/ccm.0000000000005715] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort. DESIGN Prospective observational study. SETTING Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020. PATIENTS Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051). CONCLUSIONS These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.
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Affiliation(s)
- Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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17
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Horvat CM, Fabio A, Nagin DS, Banks RK, Qin Y, Park HJ, Kernan KF, Canna SW, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Reeder RW, Sward K, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Mortality Risk in Pediatric Sepsis Based on C-reactive Protein and Ferritin Levels. Pediatr Crit Care Med 2022; 23:968-979. [PMID: 36178701 PMCID: PMC9722561 DOI: 10.1097/pcc.0000000000003074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Interest in using bedside C-reactive protein (CRP) and ferritin levels to identify patients with hyperinflammatory sepsis who might benefit from anti-inflammatory therapies has piqued with the COVID-19 pandemic experience. Our first objective was to identify patterns in CRP and ferritin trajectory among critically ill pediatric sepsis patients. We then examined the association between these different groups of patients in their inflammatory cytokine responses, systemic inflammation, and mortality risks. DATA SOURCES A prospective, observational cohort study. STUDY SELECTION Children with sepsis and organ failure in nine pediatric intensive care units in the United States. DATA EXTRACTION Two hundred and fifty-five children were enrolled. Five distinct clinical multi-trajectory groups were identified. Plasma CRP (mg/dL), ferritin (ng/mL), and 31 cytokine levels were measured at two timepoints during sepsis (median Day 2 and Day 5). Group-based multi-trajectory models (GBMTM) identified groups of children with distinct patterns of CRP and ferritin. DATA SYNTHESIS Group 1 had normal CRP and ferritin levels ( n = 8; 0% mortality); Group 2 had high CRP levels that became normal, with normal ferritin levels throughout ( n = 80; 5% mortality); Group 3 had high ferritin levels alone ( n = 16; 6% mortality); Group 4 had very high CRP levels, and high ferritin levels ( n = 121; 11% mortality); and Group 5 had very high CRP and very high ferritin levels ( n = 30; 40% mortality). Cytokine responses differed across the five groups, with ferritin levels correlated with macrophage inflammatory protein 1α levels and CRP levels reflective of many cytokines. CONCLUSIONS Bedside CRP and ferritin levels can be used together to distinguish groups of children with sepsis who have different systemic inflammation cytokine responses and mortality risks. These data suggest future potential value in personalized clinical trials with specific targets for anti-inflammatory therapies.
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Affiliation(s)
- Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Fabio
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S. Nagin
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | | | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A. Berg
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI., Central Michigan University, Mt Pleasant MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital Immune Surveillance Laboratory, and Nationwide Children’s Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Rick E. Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F. Zuppa
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
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18
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Cashen K, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fink EL, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Meert KL. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatr Crit Care Med 2022; 23:784-792. [PMID: 35880872 PMCID: PMC9529841 DOI: 10.1097/pcc.0000000000003045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). DESIGN Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. SETTING Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621). CONCLUSIONS In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Aisha H Frazier
- Department of Pediatrics, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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19
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Qin Y, Kernan KF, Fan Z, Park HJ, Kim S, Canna SW, Kellum JA, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Michael Dean J, Carcillo JA. Machine learning derivation of four computable 24-h pediatric sepsis phenotypes to facilitate enrollment in early personalized anti-inflammatory clinical trials. Crit Care 2022; 26:128. [PMID: 35526000 PMCID: PMC9077858 DOI: 10.1186/s13054-022-03977-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy-induced thrombocytopenia-associated multiple organ failure and hyperinflammatory macrophage activation syndrome are important causes of late pediatric sepsis mortality that are often missed or have delayed diagnosis. The National Institutes of General Medical Science sepsis research working group recommendations call for application of new research approaches in extant clinical data sets to improve efficiency of early trials of new sepsis therapies. Our objective is to apply machine learning approaches to derive computable 24-h sepsis phenotypes to facilitate personalized enrollment in early anti-inflammatory trials targeting these conditions. METHODS We applied consensus, k-means clustering analysis to our extant PHENOtyping sepsis-induced Multiple organ failure Study (PHENOMS) dataset of 404 children. 24-hour computable phenotypes are derived using 25 available bedside variables including C-reactive protein and ferritin. RESULTS Four computable phenotypes (PedSep-A, B, C, and D) are derived. Compared to all other phenotypes, PedSep-A patients (n = 135; 2% mortality) were younger and previously healthy, with the lowest C-reactive protein and ferritin levels, the highest lymphocyte and platelet counts, highest heart rate, and lowest creatinine (p < 0.05); PedSep-B patients (n = 102; 12% mortality) were most likely to be intubated and had the lowest Glasgow Coma Scale Score (p < 0.05); PedSep-C patients (n = 110; mortality 10%) had the highest temperature and Glasgow Coma Scale Score, least pulmonary failure, and lowest lymphocyte counts (p < 0.05); and PedSep-D patients (n = 56, 34% mortality) had the highest creatinine and number of organ failures, including renal, hepatic, and hematologic organ failure, with the lowest platelet counts (p < 0.05). PedSep-D had the highest likelihood of developing thrombocytopenia-associated multiple organ failure (Adj OR 47.51 95% CI [18.83-136.83], p < 0.0001) and macrophage activation syndrome (Adj OR 38.63 95% CI [13.26-137.75], p < 0.0001). CONCLUSIONS Four computable phenotypes are derived, with PedSep-D being optimal for enrollment in early personalized anti-inflammatory trials targeting thrombocytopenia-associated multiple organ failure and macrophage activation syndrome in pediatric sepsis. A computer tool for identification of individual patient membership ( www.pedsepsis.pitt.edu ) is provided. Reproducibility will be assessed at completion of two ongoing pediatric sepsis studies.
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Affiliation(s)
- Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Zhenjiang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Soyeon Kim
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott W Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Russell Banks
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Ron W Reeder
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Holubkov
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel A Notterman
- University of Utah, Salt Lake City, UT, USA
- Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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20
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Bamat NA, Thompson EJ, Greenberg RG, Lorch SA, Zuppa AF, Eichenwald EC, Tolia VN, Clark RH, Smith PB, Hornik CP, Lang JE, Laughon MM. Association between postmenstrual age and furosemide dosing practices in very preterm infants. J Perinatol 2022; 42:461-467. [PMID: 35075306 PMCID: PMC9007841 DOI: 10.1038/s41372-022-01320-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/17/2021] [Accepted: 01/14/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Furosemide renal clearance is slow after very preterm (VP) birth and increases with postnatal maturation. We compared furosemide dose frequency and total daily dose between postmenstrual age (PMA) groups in VP infants. STUDY DESIGN Observational cohort study of VP infants exposed to a repeated-dose course of furosemide in Pediatrix neonatal intensive care units (NICU) from 1997 to 2016. RESULTS We identified 6565 furosemide courses among 4638 infants. There were no statistically significant differences between PMA groups on the odds of receiving more frequent furosemide dosing. Furosemide courses initiated at <28 weeks PMA were associated with a higher total daily dose than those initiated at a later PMA. CONCLUSIONS Furosemide dosing practices in the NICU are similar across PMA groups, despite maturational changes in drug disposition. Research is needed to identify and test rational dosing strategies across the PMA spectrum for this commonly used but unproven pharmacotherapy.
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Affiliation(s)
- Nicolas A Bamat
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Scott A Lorch
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eric C Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Veeral N Tolia
- Department of Neonatology, Baylor University Medical Center, Dallas, TX, USA
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Reese H Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jason E Lang
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Matthew M Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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21
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Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, Burns C, Diddle JW, Federman M, Fernandez R, Franzon D, Frazier AH, Friess SH, Graham K, Hehir D, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, Morgan RW, Nadkarni VM, Naim MY, Palmer CA, Schneiter C, Sharron MP, Siems A, Srivastava N, Tabbutt S, Tilford B, Viteri S, Berg RA, Bell MJ, Carcillo JA, Carpenter TC, Dean JM, Fink EL, Hall M, McQuillen PS, Meert KL, Mourani PM, Notterman D, Pollack MM, Sapru A, Wessel D, Yates AR, Zuppa AF. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. JAMA 2022; 327:934-945. [PMID: 35258533 PMCID: PMC8905390 DOI: 10.1001/jama.2022.1738] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes. OBJECTIVE To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings. DESIGN, SETTING, AND PARTICIPANTS A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021). INTERVENTION During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge. RESULTS Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47). CONCLUSIONS AND RELEVANCE In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02837497.
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Affiliation(s)
| | | | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Aisha H Frazier
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - David Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Ashley Siems
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Michael J Bell
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
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22
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Thibault C, Moorthy GS, Vedar C, Naim MY, DiLiberto MA, Zuppa AF. Pharmacokinetics of Cefepime in Children on Extracorporeal Membrane Oxygenation: External Model Validation, Model Improvement and Dose Optimization. Pediatr Infect Dis J 2022; 41:217-223. [PMID: 34817416 DOI: 10.1097/inf.0000000000003371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cefepime is a first-line therapy for Gram-negative infections in children on extracorporeal membrane oxygenation. Cefepime pharmacokinetics (PK) in children on extracorporeal membrane oxygenation still needs to be better established. METHODS This was a prospective single-center PK study. A maximum of 12 PK samples per patient were collected in children <18 years old on extracorporeal membrane oxygenation who received clinically indicated cefepime. External validation of a previously published population PK model was performed by applying the model in a new data set. The predictive performance of the model was determined by calculating prediction errors. Because of poor predictive performance, a revised model was developed using NONMEM and a combined data set that included data from both studies. Dose-exposure simulations were performed using the final model. Optimal dosing was judged based on the ability to maintain free cefepime concentrations above the minimal inhibitory concentration (MIC) for 68% and 100% of the dosing interval. RESULTS Seventeen children contributed 105 PK samples. The mean (95% CI) and median (interquartile range) prediction errors were 33.7% (19.8-47.7) and 17.5% (-22.6 to 74.4). A combined data set was created, which included 33 children contributing 310 PK samples. The final improved 2-compartment model included weight and serum creatinine on clearance and oxygenator day and blood transfusion on volume of the central compartment. At an MIC of 8 mg/L, 50 mg/kg/dose every 8 hours reached target concentrations. CONCLUSIONS Dosing intervals of 8 hours were needed to reach adequate concentrations at an MIC of 8 mg/L. Longer dosing intervals were adequate with higher serum creatinine and lower MICs.
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Affiliation(s)
- Céline Thibault
- From the Department of Pediatrics, Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ganesh S Moorthy
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina Vedar
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine
| | - Mary Ann DiLiberto
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
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23
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Ellis DE, Hubbard RA, Willis AW, Zuppa AF, Zaoutis TE, Hennessy S. Comparative risk of serious hypoglycemia among persons dispensed a fluoroquinolone versus a non-fluoroquinolone antibiotic. Diabetes Res Clin Pract 2022; 185:109225. [PMID: 35122901 DOI: 10.1016/j.diabres.2022.109225] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/30/2021] [Accepted: 01/28/2022] [Indexed: 11/21/2022]
Abstract
AIM Fluoroquinolone antibiotics have been implicated in cases of metabolic adverse events. This study investigated the causal association between fluoroquinolones and serious hypoglycemia in those with and without diabetes. METHODS We conducted a propensity score-matched cohort study using Optum claims data. We included adults dispensed an oral fluoroquinolone or comparator antibiotic between January 2000 and September 2015 for specific infections of interest. The outcome was serious hypoglycemia, defined using a validated algorithm. Conditional logistic regression was used to estimate odds ratios (ORs) in diabetes and non-diabetes cohorts after matching on propensity scores fitted using confounding variables of interest. RESULTS Our cohort contained 119,112 individuals with diabetes and 917,867 individuals without diabetes exposed to a fluoroquinolone, matched 1:1 with a comparator. Matching produced balance (standardized mean difference < 0.1) on all variables included in the propensity score. The OR for the association between fluoroquinolones and serious hypoglycemia was 1.28 (95% confidence interval [CI]: 1.04-1.57) in the entire cohort, 1.30 (95% CI: 1.05-1.62) in individuals with diabetes, and 1.06 (95% CI: 0.53-2.13) in individuals without diabetes. CONCLUSION Fluoroquinolone users are at an increased risk of serious hypoglycemia relative to comparator antibiotic users. This association was evident only among persons diagnosed with diabetes.
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Affiliation(s)
- Darcy E Ellis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Athena F Zuppa
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Theoklis E Zaoutis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Tsitsiklis A, Osborne CM, Kamm J, Williamson K, Kalantar K, Dudas G, Caldera S, Lyden A, Tan M, Neff N, Soesanto V, Harris JK, Ambroggio L, Maddux AB, Carpenter TC, Reeder RW, Locandro C, Simões EAF, Leroue MK, Hall MW, Zuppa AF, Carcillo J, Meert KL, Sapru A, Pollack MM, McQuillen PS, Notterman DA, Dean JM, Zinter MS, Wagner BD, DeRisi JL, Mourani PM, Langelier CR. Lower respiratory tract infections in children requiring mechanical ventilation: a multicentre prospective surveillance study incorporating airway metagenomics. The Lancet Microbe 2022; 3:e284-e293. [PMID: 35544065 PMCID: PMC9446282 DOI: 10.1016/s2666-5247(21)00304-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alexandra Tsitsiklis
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Christina M Osborne
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | | | - Gytis Dudas
- Gothenburg Global Biodiversity Centre, Gothenburg, Sweden
| | - Saharai Caldera
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | | | - Norma Neff
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Todd C Carpenter
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chris Locandro
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric A F Simões
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew K Leroue
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Mark W Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Anil Sapru
- Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital and George Washington School of Medicine and Health Services, Washington, DC, USA
| | - Patrick S McQuillen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Matt S Zinter
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Charles R Langelier
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA.
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25
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Dahmer MK, Yang G, Zhang M, Quasney MW, Sapru A, Weeks HM, Sinha P, Curley MAQ, Delucchi KL, Calfee CS, Flori H, Matthay MA, Bateman ST, Berg MD, Borasino S, Bysani GK, Cowl AS, Bowens CD, Faustino VS, Fineman LD, Godshall AJ, Hirshberg EL, Kirby AL, McLaughlin GE, Medar SS, Oren PP, Schneider JB, Schwarz AJ, Shanley TP, Source LR, Truemper EJ, Vender Heyden MA, Wittmayer K, Zuppa AF, Wypij D. Identification of phenotypes in paediatric patients with acute respiratory distress syndrome: a latent class analysis. Lancet Respir Med 2022; 10:289-297. [PMID: 34883088 PMCID: PMC8897230 DOI: 10.1016/s2213-2600(21)00382-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous latent class analysis of adults with acute respiratory distress syndrome (ARDS) identified two phenotypes, distinguished by the degree of inflammation. We aimed to identify phenotypes in children with ARDS in whom developmental differences might be important, using a latent class analysis approach similar to that used in adults. METHODS This study was a secondary analysis of data aggregated from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial and the Genetic Variation and Biomarkers in Children with Acute Lung Injury (BALI) ancillary study. We used latent class analysis, which included demographic, clinical, and plasma biomarker variables, to identify paediatric ARDS (PARDS) phenotypes within a cohort of children included in the RESTORE and BALI studies. The association of phenotypes with clinically relevant outcomes and the performance of paediatric data in adult ARDS classification algorithms were also assessed. FINDINGS 304 children with PARDS were included in this secondary analysis. Using latent class analysis, a two-class model was a better fit for the cohort than a one-class model (p<0·001). Latent class analysis identified two classes: class 1 (181 [60%] of 304 patients with PARDS) and class 2 (123 [40%] of 304 patients with PARDS), referred to as phenotype 1 and 2 hereafter. Phenotype 2 was characterised by higher concentrations of inflammatory biomarkers, a higher incidence of vasopressor use, and more frequent diagnosis of sepsis, consistent with the adult hyperinflammatory phenotype. All levels of severity of PARDS were observed across both phenotypes. Children with the hyperinflammatory phenotype (phenotype 2) had worse clinical outcomes than those with the hypoinflammatory phenotype (phenotype 1), with a longer duration of mechanical ventilation (median 10·0 days [IQR 6·3-21·0] for phenotype 2 vs 6·6 days [4·1-10·8] for phenotype 1, p<0·0001), and higher incidence of mortality (17 [13·8%] of 123 patients vs four [2·2%] of 181 patients, p=0·0001). When using adult phenotype classification algorithms in children, the soluble tumour necrosis factor receptor-1 (sTNFr1), vasopressor use, and interleukin (IL)-6 variables gave an area under the curve (AUC) of 0·956, and the sTNFr1, vasopressor use, and IL-8 variables gave an AUC of 0·954, compared with the gold standard of latent class analysis. INTERPRETATION Latent class analysis identified two phenotypes in children with ARDS with characteristics similar to those in adults, including worse outcomes among patients with the hyperinflammatory phenotype. PARDS phenotypes should be considered in design and analysis of future clinical trials in children. FUNDING US National Institutes of Health.
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Affiliation(s)
- Mary K Dahmer
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michael W Quasney
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Heidi M. Weeks
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pratik Sinha
- Department of Anesthesia, Washington University, St. Louis, MO
| | - Martha AQ Curley
- Department of Family and Community Health (School of Nursing), Division of Anesthesia and Critical Care Medicine (Perelman School of Medicine) University of Pennsylvania, Philadelphia, PA; Research Institute; Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kevin L Delucchi
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA
| | - Heidi Flori
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
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26
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Vedar C, Bamat NA, Zuppa AF, Reilly ME, Moorthy GS. Development, validation, and implementation of an UHPLC-MS/MS method for the quantitation of furosemide in infant urine samples. Biomed Chromatogr 2022; 36:e5262. [PMID: 34648199 PMCID: PMC8881385 DOI: 10.1002/bmc.5262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/24/2021] [Accepted: 10/04/2021] [Indexed: 11/06/2022]
Abstract
Furosemide is a diuretic drug used to increase urine flow in order to reduce the amount of salt and water in the body. It is commonly utilized to treat preterm infants with chronic lung disease of prematurity. There is a need for a simple and reliable quantitation of furosemide in human urine. We have developed and validated an ultra-high performance liquid chromatography-tandem mass spectrometry method for furosemide quantitation in human urine with an assay range of 0.100-50.0 μg/ml. Sample preparation involved solid-phase extraction with 10 μl of urine. Intra-day accuracies and precisions for the quality control samples were 94.5-106 and 1.86-10.2%, respectively, while inter-day accuracies and precision were 99.2-102 and 3.38-7.41%, respectively. Recovery for furosemide had an average of 23.8%, with an average matrix effect of 101%. Furosemide was stable in human urine under the assay conditions. Stability for furosemide was shown at 1 week (room temperature, 4, -20 and -78°C), 6 months (-78°C), and through three freeze-thaw cycles. This robust assay demonstrates accurate and precise quantitation of furosemide in a small volume (10 μl) of human urine. It is currently being implemented in an ongoing pediatric clinical study.
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Affiliation(s)
- Christina Vedar
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Nicolas A. Bamat
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104,Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Athena F. Zuppa
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104,Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Megan E. Reilly
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Ganesh S. Moorthy
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104,Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104,Address correspondence to: Ganesh S. Moorthy, PhD, Center for Clinical Pharmacology, The Children’s Hospital of Philadelphia, 3615 Civic Center Blvd, ARC 516A, Philadelphia, PA 19104, Tel: 215 590 0142,
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27
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Stitt G, Dubinsky S, Edginton A, Huang YSV, Zuppa AF, Watt K, Downes K. Antimicrobial Dosing Recommendations in Pediatric Continuous Renal Replacement Therapy: A Critical Appraisal of Current Evidence. Front Pediatr 2022; 10:889958. [PMID: 35633961 PMCID: PMC9134108 DOI: 10.3389/fped.2022.889958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Continuous renal replacement therapy (CRRT) is commonly employed in critically ill children and is known to affect antimicrobial pharmacokinetics. There is a lack of readily available, evidence-based antimicrobial dosing recommendations in pediatric CRRT. This study aims to quantify commonly used antimicrobial drugs in pediatric CRRT and identify gaps between contemporary literature-based dosing recommendations and those presented in a frequently used dosing reference. METHODS The Pediatric Health Information System (PHIS) database was queried from July 1, 2018 through June 30, 2021 to identify admissions in which antimicrobials were billed on the same day as CRRT. Drugs of interest were selected if at least 10% of admission involved administration on at least one CRRT day, with additional clinically important antimicrobials selected by the authors. A comprehensive literature search was performed to identify antimicrobial pharmacokinetic (PK) studies in children for each selected drug. For identified articles, dosing recommendations were extracted and compared to those in a popular tertiary dosing reference (Lexi-Comp Online database). The level of agreement of the dosing recommendations was assessed. RESULTS 77 unique antimicrobial agents were identified amongst 812 admissions from 20 different PHIS hospitals. Fifteen antimicrobials were billed on the same day as CRRT in ≥10% of admissions, with 4 additional drugs deemed clinically relevant by the authors. Twenty PK studies were identified for these 19 drugs, and dosing recommendations were included in 8 (42.1%) of them. Seventeen agents (89.5%) had some type of CRRT-specific dosing guidance in Lexi-Comp, with only 1 directly based on a pediatric CRRT study. For the 8 agents with PK data available, Lexi-Comp recommendations matched primary literature dosing guidance in 3 (37.5%). Two (25%) lacked agreement between the Lexi-Comp and primary literature, and the remaining 3 (37.5%) had partial agreement with multiple dosing regimens suggested in the primary literature and at least one of these regimens recommended by Lexi-Comp. CONCLUSION Significant gaps exist in the data supporting antimicrobial dosing recommendations for children receiving CRRT. Future studies should focus on antimicrobial dosing in pediatric CRRT, emphasizing provision of robust data from which dosing recommendations can be promptly incorporated into tertiary dosing references.
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Affiliation(s)
- Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Samuel Dubinsky
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Yuan-Shung V Huang
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Kevin Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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28
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Thibault C, Zuppa AF. Dexmedetomidine in Children on Extracorporeal Membrane Oxygenation: Pharmacokinetic Data Exploration Using Previously Published Models. Front Pediatr 2022; 10:924829. [PMID: 35832579 PMCID: PMC9271626 DOI: 10.3389/fped.2022.924829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Dexmedetomidine is a sedative and analgesic increasingly used in children supported with extracorporeal membrane oxygenation (ECMO). No data is available to describe the pharmacokinetics (PK) of dexmedetomidine in this population. METHODS We performed a single-center prospective PK study. Children <18 years old, supported with ECMO, and on a dexmedetomidine infusion as part of their management were prospectively included. PK samples were collected. Dexmedetomidine dosing remained at the discretion of the clinical team. Six population PK models built in pediatrics were selected. Observed concentrations were compared with population predicted concentrations using the PK models. RESULTS Eight children contributed 30 PK samples. None of the PK models evaluated predicted the concentrations with acceptable precision and bias. Four of the six evaluated models overpredicted the concentrations. The addition of a correction factor on clearance improved models' fit. Two of the evaluated models were not applicable to our whole population age range because of their structure. CONCLUSION Most of the evaluated PK models overpredicted the concentrations, potentially indicating increased clearance on ECMO. Population PK models applicable to a broad spectrum of ages and pathologies are more practical in pediatric critical care settings but challenging to develop.
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Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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29
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Kernan KF, Ghaloul-Gonzalez L, Vockley J, Lamb J, Hollingshead D, Chandran U, Sethi R, Park HJ, Berg RA, Wessel D, Pollack MM, Meert KL, Hall MW, Newth CJL, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Prevalence of Pathogenic and Potentially Pathogenic Inborn Error of Immunity Associated Variants in Children with Severe Sepsis. J Clin Immunol 2022; 42:350-364. [PMID: 34973142 PMCID: PMC8720168 DOI: 10.1007/s10875-021-01183-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Purpose Our understanding of inborn errors of immunity is increasing; however, their contribution to pediatric sepsis is unknown. Methods We used whole-exome sequencing (WES) to characterize variants in genes related to monogenic immunologic disorders in 330 children admitted to intensive care for severe sepsis. We defined candidate variants as rare variants classified as pathogenic or potentially pathogenic in QIAGEN’s Human Gene Mutation Database or novel null variants in a disease-consistent inheritance pattern. We investigated variant correlation with infection and inflammatory phenotype. Results More than one in two children overall and three of four African American children had immunodeficiency-associated variants. Children with variants had increased odds of isolating a blood or urinary pathogen (blood: OR 2.82, 95% CI: 1.12–7.10, p = 0.023, urine: OR: 8.23, 95% CI: 1.06–64.11, p = 0.016) and demonstrating increased inflammation with hyperferritinemia (ferritin \documentclass[12pt]{minimal}
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\begin{document}$$\ge 500$$\end{document}≥500 ng/mL, OR: 2.16, 95% CI: 1.28–3.66, p = 0.004), lymphopenia (lymphocyte count < 1000/µL, OR: 1.66, 95% CI: 1.06 – 2.60, p = 0.027), thrombocytopenia (platelet count < 150,000/µL, OR: 1.76, 95% CI: 1.12–2.76, p = 0.013), and CRP greater than 10 mg/dl (OR: 1.71, 95% CI: 1.10–2.68, p = 0.017). They also had increased odds of requiring extracorporeal membrane oxygenation (ECMO, OR: 4.19, 95% CI: 1.21–14.5, p = 0.019). Conclusion Herein, we describe the genetic findings in this severe pediatric sepsis cohort and their microbiologic and immunologic significance, providing evidence for the phenotypic effect of these variants and rationale for screening children with life-threatening infections for potential inborn errors of immunity. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-021-01183-4.
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Affiliation(s)
- Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Janette Lamb
- Genomics Core Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Uma Chandran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahil Sethi
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Department of Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen L Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher J L Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
- Division of Pediatric Critical Care Medicine, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, MD, Baltimore, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University, CA, Palo Alto, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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Ellis DE, Hubbard RA, Willis AW, Zuppa AF, Zaoutis TE, Hennessy S. Comparing LASSO and random forest models for predicting neurological dysfunction among fluoroquinolone users. Pharmacoepidemiol Drug Saf 2021; 31:393-403. [PMID: 34881470 DOI: 10.1002/pds.5391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fluoroquinolones are associated with central (CNS) and peripheral (PNS) nervous system symptoms, and predicting the risk of these outcomes may have important clinical implications. Both LASSO and random forest are appealing modeling methods, yet it is not clear which method performs better for clinical risk prediction. PURPOSE To compare models developed using LASSO versus random forest for predicting neurological dysfunction among fluoroquinolone users. METHODS We developed and validated risk prediction models using claims data from a commercially insured population. The study cohort included adults dispensed an oral fluoroquinolone, and outcomes were CNS and PNS dysfunction. Model predictors included demographic variables, comorbidities and medications known to be associated with neurological symptoms, and several healthcare utilization predictors. We assessed the accuracy and calibration of these models using measures including AUC, calibration curves, and Brier scores. RESULTS The underlying cohort contained 16 533 (1.18%) individuals with CNS dysfunction and 46 995 (3.34%) individuals with PNS dysfunction during 120 days of follow-up. For CNS dysfunction, LASSO had an AUC of 0.81 (95% CI: 0.80, 0.82), while random forest had an AUC of 0.80 (95% CI: 0.80, 0.81). For PNS dysfunction, LASSO had an AUC of 0.75 (95% CI: 0.74, 0.76) versus an AUC of 0.73 (95% CI: 0.73, 0.74) for random forest. Both LASSO models had better calibration, with Brier scores 0.17 (LASSO) versus 0.20 (random forest) for CNS dysfunction and 0.20 (LASSO) versus 0.25 (random forest) for PNS dysfunction. CONCLUSIONS LASSO outperformed random forest in predicting CNS and PNS dysfunction among fluoroquinolone users, and should be considered for modeling when the cohort is modest in size, when the number of model predictors is modest, and when predictors are primarily binary.
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Affiliation(s)
- Darcy E Ellis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison W Willis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Athena F Zuppa
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theoklis E Zaoutis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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31
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Downes KJ, Zuppa AF, Sharova A, Gianchetti L, Duffey E, Goldstein SL, Neely M. 64. Novel Biomarkers Improve Estimation of Vancomycin Clearance in Critically Ill Children. Open Forum Infect Dis 2021. [PMCID: PMC8643886 DOI: 10.1093/ofid/ofab466.064] [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] [Indexed: 11/24/2022] Open
Abstract
Background There are a paucity of robust population PK (popPK) models to inform vancomycin (VAN) dosing in critically ill children. The majority of published models incorporate peak/trough data and rely on flawed estimates of renal function. We sought to develop a popPK model for IV VAN in critically ill children utilizing novel plasma and urinary biomarkers. Methods We conducted a prospective observational study of critically ill children prescribed VAN for a suspected infection in the CHOP pediatric ICU. Children < 1 year of age and those receiving ECMO or CRRT were excluded. Five VAN samples were collected from a single dosing interval for each subject. Plasma biomarkers (creatinine [Cr], cystatin C [CysC], NGAL) and urinary biomarkers (CysC, NGAL, KIM-1, osteopontin) were collected the morning of PK sampling; urinary biomarkers were corrected for urine creatinine. Nonparametric popPK modeling was performed using Pmetrics. The impact of renal function (GFR) on VAN clearance (CL) was estimated first, comparing model performance with each biomarker (Cr and plasma CysC). The influence of age, sex, additional biomarkers, PIM3 score, and receipt of vasopressors as covariates was then assessed for relevant PK parameters. Results 30 subjects completed the study. Median age was 10 years (range 1-17); 76% were male. The majority (90%) of children received VAN for suspected sepsis. PK sampling occurred at a median of 37.7 hours (range 24.6-94.8) into VAN treatment; 136 VAN samples were included. A 2-compartment model with fixed allometric scaling of 0.75 on clearances and 1 on volumes best described the data. CysC-based GFR as a covariate on VAN CL using the HOEK formula (GFR = -4.32 + (80.35/CysC)) resulted in the best model fit. Age and plasma NGAL were also informative on VAN CL in the final model (Figure 1). During model building, urinary NGAL was also associated with VAN CL (comparable to plasma NGAL) and outperformed Cr, although it was not retained in the final model. Figure 1. Final population PK model and parameter estimates. ![]()
Conclusion Plasma CysC is a better renal function estimate than Cr to inform VAN clearance in critically ill children. Urinary and plasma NGAL also improved estimation of VAN CL during popPK modeling. Novel biomarkers can better describe VAN exposures in critically ill children than reliance on Cr alone. Disclosures Kevin J. Downes, MD, Merck (Individual(s) Involved: Self): Grant/Research Support Stuart L. Goldstein, MD, Bioporto (Consultant, Grant/Research Support)
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Affiliation(s)
| | | | - Anna Sharova
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Emily Duffey
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Michael Neely
- Children Hospital Los Angeles, Los Angeles, California
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32
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Downes KJ, Tam D, Sharova A, Vedar C, Fitzgerald JC, Jawad AF, Moorthy GS, Zuppa AF. 1104. Comparison of Antibiotic Sampling Techniques: Predicting Plasma Vancomycin Concentrations Using Volumetric Absorptive Microsampling (VAMS) from Capillary and Venous/Arterial Whole Blood. Open Forum Infect Dis 2021. [PMCID: PMC8643864 DOI: 10.1093/ofid/ofab466.1298] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Therapeutic drug monitoring (TDM) is paramount to optimize the safety and efficacy of vancomycin (VAN). In children, TDM is challenged by difficulty in obtaining venous samples, impeding timely sampling. We assessed the ability of volumetric absorptive microsampling (VAMS) as a novel, whole blood sampling technique to predict plasma VAN concentrations in plasma.
Methods
We conducted a prospective pilot study among critically ill children prescribed VAN for clinical care. Coincident with VAN TDM in plasma (P), we collected 20 µL of capillary whole blood (C) and venous/arterial whole blood (V) using VAMS. Paired VAMS-P samples drawn >5 mins apart and VAMS samples with over- or under-loaded filter tip on visual inspection were excluded. Plasma concentrations were measured via chemiluminescent immunoassay in the Chemistry Laboratory. VAMS C and V concentrations were measured using LC/MS in the Bioanalytic Core Laboratory. Plasma concentrations were predicted from whole blood VAMS with Passing-Bablok regression using 3 methods: 1) uncorrected VAMS measures, 2) hematocrit-corrected VAMS, and 3) lab-corrected VAMS (Figure 1). We then assessed bias, imprecision, and accuracy of plasma predictions from VAMS (C and V) as compared to coincident P concentrations for each technique (Figure 1).
Figure 1. Methods for relating whole blood vancomycin concentrations collected via VAMS to plasma concentrations and measure to evaluate predictive performance.
Results
Paired samples were collected from 31 enrolled subjects (Figure 2), with a median age of 3.3 years (range 0.1-17.9). Measured P concentrations ranged from 4.6 - 54.9 mg/L. 11 C samples (29%) and 3 V samples (10%) were excluded due to collection issues. Prediction results are shown in Figure 3. The 3 prediction techniques had similar performance characteristics, with each method displaying minimal bias (-0.4-2.0%) and reasonable imprecision (13.7-20.2%). The accuracy of prediction of P concentrations using VAMS was better for V than C samples.
Figure 2. Flow diagram from sample collection to evaluation.
Abbreviations: C-P, capillary VAMS-plasma; V-P, venous/arterial VAMS-plasma; VAMS, volumetric absorptive microsampling.
Figure 3. Performance of 3 techniques to predict plasma vancomycin concentrations using whole blood collected via VAMS.
Conclusion
Our pilot highlights the challenges of using VAMS for TDM. Sample collection issues were common. When VAMS is used, education on collection techniques is imperative. The predictive performance of VAMS was modest and V sampling had higher accuracy than C, although our sample size was small. Larger studies will be needed to further evaluate the predictive performance of the regression equations derived by our study.
Disclosures
Kevin J. Downes, MD, Merck, Inc. (Grant/Research Support)
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Affiliation(s)
- Kevin J Downes
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Derrick Tam
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anna Sharova
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina Vedar
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Abbas F Jawad
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Athena F Zuppa
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Corbett B, Luz S, Sotuyo N, Pearson-Leary J, Moorthy GS, Zuppa AF, Bhatnagar S. FTY720 (Fingolimod), a modulator of sphingosine-1-phosphate receptors, increases baseline hypothalamic-pituitary adrenal axis activity and alters behaviors relevant to affect and anxiety. Physiol Behav 2021; 240:113556. [PMID: 34390688 DOI: 10.1016/j.physbeh.2021.113556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 05/04/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
FTY720 (fingolimod) is an analog of sphingosine, a ubiquitous sphingolipid. Phosphorylated FTY720 (FTY720-P) non-selectively binds to sphingosine-1-phosphate receptors (S1PRs) and regulates multiple cellular processes including cell proliferation, inflammation, and vascular remodeling. We recently demonstrated that S1PR3 expression in the medial prefrontal cortex (mPFC) of rats promotes stress resilience and that S1PR3 expression in blood may serve as a biomarker for PTSD. Here we investigate the effects of FTY720 in regulating the stress response. We found that single and repeated intraperitoneal injections of FTY720 increased baseline plasma adrenocorticotropic hormone (ACTH) and corticosterone concentrations. FTY720 reduced social anxiety- and despair-like behavior as assessed by increased social interaction time and reduced time spent immobile in the Porsolt forced swim test. In blood, FTY720 administration reduced lymphocyte and reticulocyte counts, but raised erythrocyte counts. FTY720 also reduced mRNA of angiopoietin 1, endothelin 1, plasminogen, TgfB2, Pdgfa, and Mmp2 in the medial prefrontal cortex, suggesting that FTY720 reduced vascular remodeling. The antidepressant-like and anxiolytic-like effects of FTY720 may be attributed to reduced vascular remodeling as increased stress-induced blood vessel density in the brain contributes to behavior associated with vulnerability in rats. Together, these results demonstrate that FTY720 regulates baseline HPA axis activity but reduces social anxiety and despair, providing further evidence that S1PRs are important and novel regulators of stress-related functions.
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Affiliation(s)
- Brian Corbett
- Center for Stress Neurobiology, Children's Hospital of Philadelphia, 3615 CIvic Center Blvd, ARC Suite 402, Philadelphia, Pennsylvania,19104-4399, USA
| | - Sandra Luz
- Center for Stress Neurobiology, Children's Hospital of Philadelphia, 3615 CIvic Center Blvd, ARC Suite 402, Philadelphia, Pennsylvania,19104-4399, USA
| | - Nathaniel Sotuyo
- Center for Stress Neurobiology, Children's Hospital of Philadelphia, 3615 CIvic Center Blvd, ARC Suite 402, Philadelphia, Pennsylvania,19104-4399, USA
| | - Jiah Pearson-Leary
- Center for Stress Neurobiology, Children's Hospital of Philadelphia, 3615 CIvic Center Blvd, ARC Suite 402, Philadelphia, Pennsylvania,19104-4399, USA
| | - Ganesh S Moorthy
- Center for Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Athena F Zuppa
- Center for Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Seema Bhatnagar
- Center for Stress Neurobiology, Children's Hospital of Philadelphia, 3615 CIvic Center Blvd, ARC Suite 402, Philadelphia, Pennsylvania,19104-4399, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Perry MA, Dawkins-Henry OS, Awojoodu RE, Blumenthal J, Asaro LA, Wypij D, Kudchadkar SR, Zuppa AF, Curley MA. Study protocol for a two-center test of a nurse-implemented chronotherapeutic restoring bundle in critically ill children: RESTORE Resilience (R 2). Contemp Clin Trials Commun 2021; 23:100840. [PMID: 34466711 PMCID: PMC8385396 DOI: 10.1016/j.conctc.2021.100840] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/03/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Often, pediatric intensive care environments are not conducive to healing the sick. Critically ill children experience disruptions in their circadian rhythms, which can contribute to delayed recovery and poor outcomes. We aim to test the hypothesis that children managed via RESTORE Resilience (R2), a nurse-implemented chronotherapeutic bundle, will experience restorative circadian rhythms compared to children receiving usual care. In this two-phased, prospective cohort study, two separate pediatric intensive care units in the United Sates will enroll a total of 20 baseline subjects followed by 40 intervention subjects, 6 months to less than 18 years of age, requiring invasive mechanical ventilation. During the intervention phase, we will implement the R2 bundle, which includes: (1) a focused effort to replicate the child's pre-hospitalization daily routine, (2) cycled day-night lighting and sound modulation, (3) minimal yet effective sedation (RESTORE), (4) nighttime fasting with bolus enteral daytime feedings, (5) early progressive mobility (PICU Up!), (6) continuity in nursing care, and (7) parent diaries. Our primary outcome is circadian activity ratio post-extubation. We hypothesize that children receiving R2 will experience restored circadian rhythms as evidenced by decreased nighttime activity while in the PICU. Our exploratory outcomes include salivary melatonin levels; electroencephalogram (EEG) slow-wave activity; R2 feasibility, adherence, and system barriers; levels of patient comfort; exposure to sedative medications; time to physiological stability; and parent perception of being well cared for. This paper describes the design, rationale, and implementation of R2. CLINICALTRIALSGOV IDENTIFIER NCT04695392.
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Key Words
- CINC, continuity in nursing care
- Circadian rhythm
- DARE, daytime activity ratio estimate
- DCC, Data Coordinating Center
- DMS, data management system
- EEG, electroencephalography
- FCCS, Family-Centered Care Scale
- ICU, intensive care unit
- Mechanical ventilation
- Nurse-implemented interventions
- PCPC, Pediatric Cerebral Performance Category
- PICU, pediatric intensive care unit
- POPC, Pediatric Overall Performance Category
- PRISM III-12, Pediatric Risk of Mortality III score from first 12 h in the PICU
- Pediatric critical care
- WAT-1, Withdrawal Assessment Tool-1
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Affiliation(s)
- Mallory A. Perry
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Ronke E. Awojoodu
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins Medicine, Baltimore, MD, USA
- University of Maryland Baltimore School of Nursing, Baltimore, MD, USA
| | - Jennifer Blumenthal
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa A. Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Athena F. Zuppa
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Martha A.Q. Curley
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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35
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Siems A, Banks R, Holubkov R, Meert KL, Bauerfeld C, Beyda D, Berg RA, Bulut Y, Burd RS, Carcillo J, Dean JM, Gradidge E, Hall MW, McQuillen PS, Mourani PM, Newth CJL, Notterman DA, Priestley MA, Sapru A, Wessel DL, Yates AR, Zuppa AF, Pollack MM. Structured Chart Review: Assessment of a Structured Chart Review Methodology. Hosp Pediatr 2021; 10:61-69. [PMID: 31879317 DOI: 10.1542/hpeds.2019-0225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability. METHODS A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability. RESULTS The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories. CONCLUSIONS A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.
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Affiliation(s)
- Ashley Siems
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Russell Banks
- School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Kathleen L Meert
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - Christian Bauerfeld
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Beyda
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yonca Bulut
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - Randall S Burd
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Joseph Carcillo
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - J Michael Dean
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Eleanor Gradidge
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- University of California, San Francisco and University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Peter M Mourani
- University of Colorado and Children's Hospital of Colorado, Denver, Colorado
| | - Christopher J L Newth
- Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California; and
| | | | | | - Anil Sapru
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - David L Wessel
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | | | - Athena F Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Murray M Pollack
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia;
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36
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Pais GM, Liu J, Avedissian SN, Hiner D, Xanthos T, Chalkias A, d'Aloja E, Locci E, Gilchrist A, Prozialeck WC, Rhodes NJ, Lodise TP, Fitzgerald JC, Downes KJ, Zuppa AF, Scheetz MH. Lack of synergistic nephrotoxicity between vancomycin and piperacillin/tazobactam in a rat model and a confirmatory cellular model. J Antimicrob Chemother 2021; 75:1228-1236. [PMID: 32011685 DOI: 10.1093/jac/dkz563] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vancomycin and piperacillin/tazobactam are reported in clinical studies to increase acute kidney injury (AKI). However, no clinical study has demonstrated synergistic toxicity, only that serum creatinine increases. OBJECTIVES To clarify the potential for synergistic toxicity between vancomycin, piperacillin/tazobactam and vancomycin + piperacillin/tazobactam treatments by quantifying kidney injury in a translational rat model of AKI and using cell studies. METHODS (i) Male Sprague-Dawley rats (n = 32) received saline, vancomycin 150 mg/kg/day intravenously, piperacillin/tazobactam 1400 mg/kg/day intraperitoneally or vancomycin + piperacillin/tazobactam for 3 days. Urinary biomarkers and histopathology were analysed. (ii) Cellular injury was assessed in NRK-52E cells using alamarBlue®. RESULTS Urinary output increased from Day -1 to Day 1 with vancomycin but only after Day 2 for vancomycin + piperacillin/tazobactam-treated rats. Plasma creatinine was elevated from baseline with vancomycin by Day 2 and only by Day 4 for vancomycin + piperacillin/tazobactam. Urinary KIM-1 and clusterin were increased with vancomycin from Day 1 versus controls (P < 0.001) and only on Day 3 with vancomycin + piperacillin/tazobactam (P < 0.001, KIM-1; P < 0.05, clusterin). The histopathology injury score was elevated only in the vancomycin group when compared with piperacillin/tazobactam as a control (P = 0.04) and generally not so with vancomycin + piperacillin/tazobactam. In NRK-52E cells, vancomycin induced cell death with high doses (IC50 48.76 mg/mL) but piperacillin/tazobactam did not, and vancomycin + piperacillin/tazobactam was similar to vancomycin. CONCLUSIONS All groups treated with vancomycin demonstrated AKI; however, vancomycin + piperacillin/tazobactam was not worse than vancomycin. Histopathology suggested that piperacillin/tazobactam did not worsen vancomycin-induced AKI and may even be protective.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Jiajun Liu
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Sean N Avedissian
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Danielle Hiner
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | | | | | - Ernesto d'Aloja
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Emanuela Locci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Annette Gilchrist
- Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA.,Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Walter C Prozialeck
- Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin J Downes
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Athena F Zuppa
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA.,Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
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37
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Ellis DE, Hubbard RA, Willis AW, Zuppa AF, Zaoutis TE, Hennessy S. Comparative neurological safety of fluoroquinolones versus therapeutic alternatives. Pharmacoepidemiol Drug Saf 2021; 30:797-805. [PMID: 33655544 PMCID: PMC10960267 DOI: 10.1002/pds.5219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fluoroquinolones, one of the most commonly prescribed antibiotic classes, have been implicated in cases of central nervous system (CNS) and peripheral nervous system (PNS) adverse events, which highlights the need for epidemiologic studies of the neurological safety of fluoroquinolones. PURPOSE To evaluate the safety of fluoroquinolones with regard to risk of diagnosed neurological dysfunction. METHODS We conducted a propensity score-matched inception cohort study using claims data from a commercially insured population. Our study included adults prescribed an oral fluoroquinolone or comparator antibiotic between January 2000 and September 2015 for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, uncomplicated urinary tract infection, or acute bronchitis. Our outcomes were CNS dysfunction, and four separate but complementary PNS dysfunction outcomes. Cox proportional hazards models were estimated after matching on propensity scores fitted using the variables age, sex, epilepsy, hereditary peripheral neuropathy, renal dysfunction, diabetes, gabapentinoid use, statin use, isoniazid use, and chemotherapy use. RESULTS Our cohort contained 976 568 individuals exposed to a fluoroquinolone antibiotic matched 1:1 with a comparator. Matching produced balance (standardized mean difference <0.1) on all variables included in the propensity score. The hazard ratio associated with fluoroquinolone exposure was 1.08 (95% confidence interval 1.05-1.11) for CNS dysfunction, and 1.09 (95% CI 1.07-1.11) for the most commonly occurring PNS dysfunction outcome. CONCLUSIONS Fluoroquinolone antibiotic use was associated with the development of neurological dysfunction versus comparator antibiotic use in the adult population.
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Affiliation(s)
- Darcy E. Ellis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison W. Willis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Athena F. Zuppa
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theoklis E. Zaoutis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Moorthy GS, Vedar C, Downes KJ, Fitzgerald JC, Scheetz MH, Zuppa AF. Microsampling Assays for Pharmacokinetic Analysis and Therapeutic Drug Monitoring of Antimicrobial Drugs in Children: A Critical Review. Ther Drug Monit 2021; 43:335-345. [PMID: 33278241 PMCID: PMC8119311 DOI: 10.1097/ftd.0000000000000845] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND With the increasing prevalence of multidrug resistant organisms, therapeutic drug monitoring (TDM) has become a common tool for assuring the safety and efficacy of antimicrobial drugs at higher doses. Microsampling techniques, including dried blood spotting (DBS) and volumetric absorptive microsampling (VAMS), are attractive tools for TDM and pediatric clinical research. For microsampling techniques to be a useful tool for TDM, it is necessary to establish the blood-plasma correlation and the therapeutic window of antimicrobial drugs in the blood. METHODS DBS involves the collection of small volumes of blood (30-50 µL per spot) on a filter paper, whereas VAMS allows the accurate and precise collection of a fixed volume of blood (10-30 µL) with microsampling devices. One of the major advantages of VAMS is that it reduces or eliminates the volumetric blood hematocrit (HCT) bias associated with DBS. Liquid chromatography with tandem mass spectrometry is a powerful tool for the accurate quantification of antimicrobial drugs from small volumes of blood specimens. RESULTS This review summarizes the recent liquid chromatography with tandem mass spectrometry assays that have used DBS and VAMS approaches for quantifying antimicrobial drugs. Sample collection, extraction, validation outcomes, including the interassay and intra-assay accuracy and precision, recovery, stability, and matrix effect, as well as the clinical application of these assays and their potential as tools of TDM are discussed herein. CONCLUSIONS Microsampling techniques, such as VAMS, provide an alternative approach to traditional plasma sample collection for TDM.
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Affiliation(s)
- Ganesh S. Moorthy
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Vedar
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin J. Downes
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Divisions of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Marc H. Scheetz
- Department of Pharmacy Practice and Pharmacology, Midwestern University, Downers Grove, IL, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Athena F. Zuppa
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Mourani PM, Sontag MK, Williamson KM, Harris JK, Reeder R, Locandro C, Carpenter TC, Maddux AB, Ziegler K, Simões EAF, Osborne CM, Ambroggio L, Leroue MK, Robertson CE, Langelier C, DeRisi JL, Kamm J, Hall MW, Zuppa AF, Carcillo J, Meert K, Sapru A, Pollack MM, McQuillen P, Notterman DA, Dean JM, Wagner BD. Temporal airway microbiome changes related to ventilator-associated pneumonia in children. Eur Respir J 2021; 57:13993003.01829-2020. [PMID: 33008935 DOI: 10.1183/13993003.01829-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
We sought to determine whether temporal changes in the lower airway microbiome are associated with ventilator-associated pneumonia (VAP) in children.Using a multicentre prospective study of children aged 31 days to 18 years requiring mechanical ventilation support for >72 h, daily tracheal aspirates were collected and analysed by sequencing of the 16S rRNA gene. VAP was assessed using 2008 Centers for Disease Control and Prevention paediatric criteria. The association between microbial factors and VAP was evaluated using joint longitudinal time-to-event modelling, matched case-control comparisons and unsupervised clustering.Out of 366 eligible subjects, 66 (15%) developed VAP at a median of 5 (interquartile range 3-5) days post intubation. At intubation, there was no difference in total bacterial load (TBL), but Shannon diversity and the relative abundance of Streptococcus, Lactobacillales and Prevotella were lower for VAP subjects versus non-VAP subjects. However, higher TBL on each sequential day was associated with a lower hazard (hazard ratio 0.39, 95% CI 0.23-0.64) for developing VAP, but sequential values of diversity were not associated with VAP. Similar findings were observed from the matched analysis and unsupervised clustering. The most common dominant VAP pathogens included Prevotella species (19%), Pseudomonas aeruginosa (14%) and Streptococcus mitis/pneumoniae (10%). Mycoplasma and Ureaplasma were also identified as dominant organisms in several subjects.In mechanically ventilated children, changes over time in microbial factors were marginally associated with VAP risk, although these changes were not suitable for predicting VAP in individual patients. These findings suggest that focusing exclusively on pathogen burden may not adequately inform VAP diagnosis.
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Affiliation(s)
- Peter M Mourani
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Marci K Sontag
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Kayla M Williamson
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron Reeder
- Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Todd C Carpenter
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Katherine Ziegler
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Eric A F Simões
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Christina M Osborne
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Matthew K Leroue
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles E Robertson
- Medicine, Division of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles Langelier
- Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA.,Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Joseph L DeRisi
- Chan Zuckerberg Biohub, San Francisco, CA, USA.,Dept of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Mark W Hall
- Dept of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Kathleen Meert
- Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Anil Sapru
- Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Pediatrics, Children's National Medical Center and George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Patrick McQuillen
- Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Brandie D Wagner
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
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Pinto NP, Berg RA, Zuppa AF, Newth CJ, Pollack MM, Meert KL, Hall MW, Quasney M, Sapru A, Carcillo JA, McQuillen PS, Mourani PM, Chima RS, Holubkov R, Nadkarni VM, Reeder RW, Zimmerman JJ. Improvement in Health-Related Quality of Life After Community Acquired Pediatric Septic Shock. Front Pediatr 2021; 9:675374. [PMID: 34490155 PMCID: PMC8416609 DOI: 10.3389/fped.2021.675374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Although some pediatric sepsis survivors experience worsening health-related quality of life (HRQL), many return to their pre-illness HRQL. Whether children can improve beyond baseline is not known. We examined a cohort of pediatric sepsis survivors to determine if those with baseline HRQL scores below the population mean could exhibit ≥10% improvement and evaluated factors associated with improvement. Methods: In this secondary analysis of the Life After Pediatric Sepsis Evaluation prospective study, children aged 1 month to 18 years admitted to 12 academic PICUs in the United States with community-acquired septic shock who survived to 3 months and had baseline HRQL scores ≤ 80 (i.e., excluding those with good baseline HRQL to allow for potential improvement) were included. HRQL was measured using the Pediatric Quality of Life Inventory or Stein-Jessop Functional Status Scale. Findings: One hundred and seventeen children were eligible. Sixty-one (52%) had ≥ 10% improvement in HRQL by 3 months. Lower pre-sepsis HRQL was associated with increased odds of improvement at 3 months [aOR = 1.08, 95% CI (1.04-1.11), p < 0.001] and 12 months [OR = 1.05, 95% CI (1.02-1.11), p = 0.005]. Improvement in HRQL was most prevalent at 3 month follow-up; at 12 month follow-up, improvement was more sustained among children without severe developmental delay compared to children with severe developmental delay. Interpretation: More than half of these children with community acquired septic shock experienced at least a 10% improvement in HRQL from baseline to 3 months. Children with severe developmental delay did not sustain this improvement at 12 month follow-up.
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Affiliation(s)
- Neethi P Pinto
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System, Washington, DC, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
| | - Michael Quasney
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, United States
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, Aurora, CO, United States
| | - Ranjit S Chima
- Division of Critical Care Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Jerry J Zimmerman
- Department of Pediatrics, Seattle Children's Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA, United States
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Moorthy GS, Lalley-Chareczko L, Koenig HC, Zuppa AF. Tenofovir Urine Assay to Monitor Adherence to HIV Pre-exposure Prophylaxis. ACTA ACUST UNITED AC 2020; 15:102-104. [PMID: 31713497 DOI: 10.2174/1574884714666191111125348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 04/13/2019] [Accepted: 07/07/2019] [Indexed: 11/22/2022]
Abstract
Tenofovir Disoproxil Fumarate (TDF) and tenofovir Alafenamide (TAF) are prodrugs of tenofovir and have excellent long-term efficacy and tolerability for the treatment of HIV. An objective marker of adherence to tenofovir-based therapy could be clinically useful in supporting adherence to TDF-based HIV pre-Exposure Prophylaxis (PrEP) in populations in whom, self-report has been shown to be unreliable, and could play a role in resource-limited settings to support HIV and hepatitis B treatment adherence. A semi-quantitative high-performance liquid chromatographymass spectrometry method for tenofovir quantification of urine samples was developed. This assay detects tenofovir concentration in log10 levels between 1 and 10,000 ng/mL, and was shown to distinguish between recent adherence and low/non-adherence to both TDF and TAF, with a concentration of >1000 ng/mL, highly predictive of medication ingestion in the last 24-48 hours. This assay was validated relative to other markers of adherence including dried blood spot and selfreport in a highly adherent population of PrEP patients, and tenofovir was shown to be stable at room temperature in urine for at least 14 days. The assay was successfully used in a clinical setting to maintain high PrEP adherence and retention in care of 50 young men who have sex with men (MSM) over 48 weeks, to assess PrEP adherence in youth with mental health conditions, and to monitor drug levels relative to plasma levels in a case study of chewed TDF/FTC (tenofovir/emtricitabine) for PrEP. Further studies are underway to implement the tenofovir urine assay to monitor adherence and pre-exposure prophylaxis, nationally and internationally.
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Affiliation(s)
- Ganesh S Moorthy
- Division of Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States,Department of Anesthesiology & Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States
| | | | - Helen C Koenig
- Division of Infectious Diseases, MacGregor Infectious Diseases Clinic, PCAM 4S Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Athena F Zuppa
- Division of Clinical Pharmacology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States
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Thibault C, Massey SL, Abend NS, Naim MY, Zoraian A, Zuppa AF. Population Pharmacokinetics of Phenobarbital in Neonates and Infants on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy. J Clin Pharmacol 2020; 61:378-387. [PMID: 32960986 DOI: 10.1002/jcph.1743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/25/2020] [Indexed: 01/20/2023]
Abstract
The objective of this study was to describe the pharmacokinetics (PK) of intravenous phenobarbital in neonates and infants on extracorporeal membrane oxygenation (ECMO) and to provide dosing recommendations in this population. We performed a retrospective single-center PK study of phenobarbital in neonates and infants on ECMO between January 1, 2014, and December 31, 2018. We developed a population PK model using nonlinear mixed-effects modeling, performed simulations using the final PK parameters, and determined optimal dosing based on attainment of peak and trough concentrations between 20 and 40 mg/L. We included 35 subjects with a median (range) age and weight of 14 days (1-154 days) and 3.4 kg (1.6-8.1 kg), respectively. A total of 194 samples were included in the analysis. Five children (14%) contributing 30 samples (16%) were supported by continuous venovenous hemodiafiltration (CVVHDF). A 1-compartment model best described the data. Typical clearance and volume of distribution for a 3.4-kg infant were 0.038 L/h and 3.83 L, respectively. Clearance increased with age and CVVHDF. Although on ECMO, phenobarbital clearance in children on CVVHDF was 6-fold higher than clearance in children without CVVHDF. In typical subjects, a loading dose of 30 mg/kg/dose followed by maintenance doses of 6-7 mg/kg/day administered as divided doses every 12 hours reached goal concentrations. Age did not impact dosing recommendations. However, higher doses were needed in children on CVVHDF. We strongly recommend therapeutic drug monitoring in children on renal replacement therapy (excluding slow continuous ultrafiltration) while on ECMO.
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Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexandra Zoraian
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Francoeur C, Welsh SS, Ichord R, Abend NS, Topjian AA, Zuppa AF. Assessment of midazolam pharmacokinetics in the treatment of status epilepticus. Seizure 2020; 81:310-314. [PMID: 32947180 DOI: 10.1016/j.seizure.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/27/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES Refractory status epilepticus (RSE) is often treated with midazolam boluses and continuous infusions, but there is considerable variability in dosing and efficacy. We aimed to evaluate the performance of a clinical midazolam dose escalation pathway for the treatment of pediatric RSE that was designed based on a novel midazolam pharmacokinetic model. DESIGN Prospective pharmacokinetic study of midazolam bolus and escalation of continuous midazolam infusion. SETTING Pediatric Intensive Care Unit in quaternary-care academic hospital. SUBJECTS Children between two months to seventeen years of age who received clinically-indicated midazolam infusion for treatment of RSE. INTERVENTION Blood sampled at regular intervals during treatment. Main study outcome measure was the accuracy of a pharmacokinetic model to predict serum midazolam concentrations. MEASUREMENTS AND MAIN RESULTS We analysed data from six subjects. Three subjects had serum midazolam concentrations close to those predicted by our initial model (accuracy 88.9-170.2 %) which incorporates body weight, hepatic function, and renal function. For the other three subjects, all of whom were receiving pre-existing chronic benzodiazepine therapy prior to the RSE episode, the model grossly overestimated serum concentrations (predictive error 420.3-722.5 %). Once the model was corrected for the impact of pre-existing chronic benzodiazepine use on clearance, predicted concentrations more closely reflected those measured in subjects. CONCLUSION We evaluated a clinical midazolam RSE treatment pathway but discovered that the model on which the pathway was based was not accurate for all patients. We therefore developed a novel pharmacokinetic midazolam model in children with RSE treated with continuous midazolam infusion. This model incorporates body weight, hepatic and renal function, and importantly, a correction factor for pre-existing chronic benzodiazepine use. Once validated, this model may guide dosing and drive the development of more effective treatment pathways for continuous midazolam in RSE.
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Affiliation(s)
- Conall Francoeur
- Department of Pediatrics, CHU de Québec - Université Laval Research Center, Canada.
| | - Sarah S Welsh
- Division of Pediatric Critical Care Medicine, Hasbro Children's Hospital, Providence, RI, United States
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicholas S Abend
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Downes KJ, Hayes M, Fitzgerald JC, Pais GM, Liu J, Zane NR, Goldstein SL, Scheetz MH, Zuppa AF. Mechanisms of antimicrobial-induced nephrotoxicity in children. J Antimicrob Chemother 2020; 75:1-13. [PMID: 31369087 PMCID: PMC6910165 DOI: 10.1093/jac/dkz325] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Drug-induced nephrotoxicity is responsible for 20% to 60% of cases of acute kidney injury in hospitalized patients and is associated with increased morbidity and mortality in both children and adults. Antimicrobials are one of the most common classes of medications prescribed globally and also among the most common causes of nephrotoxicity. A broad range of antimicrobial agents have been associated with nephrotoxicity, but the features of kidney injury vary based on the agent, its mechanism of injury and the site of toxicity within the kidney. Distinguishing nephrotoxicity caused by an antimicrobial agent from other potential inciting factors is important to facilitate both early recognition of drug toxicity and prompt cessation of an offending drug, as well as to avoid unnecessary discontinuation of an innocuous therapy. This review will detail the different types of antimicrobial-induced nephrotoxicity: acute tubular necrosis, acute interstitial nephritis and obstructive nephropathy. It will also describe the mechanism of injury caused by specific antimicrobial agents and classes (vancomycin, aminoglycosides, polymyxins, antivirals, amphotericin B), highlight the toxicodynamics of these drugs and provide guidance on administration or monitoring practices that can mitigate toxicity, when known. Particular attention will be paid to paediatric patients, when applicable, in whom nephrotoxin exposure is an often-underappreciated cause of kidney injury.
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Affiliation(s)
- Kevin J Downes
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Molly Hayes
- Antimicrobial Stewardship Program, Center for Healthcare Quality & Analytics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Jiajun Liu
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
- Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Zuppa AF, Nicolson SC, Wilder NS, Ibla JC, Gottlieb EA, Burns KM, Stylianou M, Trachtenberg F, Ni H, Skeen TH, Andropoulos DB. Results of a phase 1 multicentre investigation of dexmedetomidine bolus and infusion in corrective infant cardiac surgery. Br J Anaesth 2019; 123:839-852. [PMID: 31623840 PMCID: PMC6993105 DOI: 10.1016/j.bja.2019.06.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 06/01/2019] [Accepted: 06/19/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing. METHODS We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations. RESULTS Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1. CONCLUSIONS When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection. CLINICAL TRIALS REGISTRATION NCT01915277.
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Affiliation(s)
- Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole S Wilder
- Department of Anesthesiology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Juan C Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Gottlieb
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Kristin M Burns
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, Bethesda, MD, USA
| | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Hua Ni
- New England Research Institutes, Watertown, MA, USA
| | - Tera H Skeen
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Dean B Andropoulos
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
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Moorthy GS, Vedar C, Zane NR, Downes KJ, Prodell JL, DiLiberto MA, Zuppa AF. Development and validation of a volumetric absorptive microsampling- liquid chromatography mass spectrometry method for the analysis of cefepime in human whole blood: Application to pediatric pharmacokinetic study. J Pharm Biomed Anal 2019; 179:113002. [PMID: 31785929 DOI: 10.1016/j.jpba.2019.113002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 01/07/2023]
Abstract
Cefepime is a fourth-generation cephalosporin antibiotic with an extended spectrum of activity against many Gram-positive and Gram-negative bacteria. There is a growing need to develop sensitive, small volume assays, along with less invasive sample collection to facilitate pediatric pharmacokinetic clinical trials and therapeutic drug monitoring. The volumetric absorptive microsampling (VAMS™) approach provides an accurate and precise collection of a fixed volume of blood (10 μL), reducing or eliminating the volumetric blood hematocrit assay-bias associated with the dried blood spotting technique. We developed a high-performance liquid chromatographic method with tandem mass spectrometry detection for quantification of cefepime. Sample extraction from VAMS™ devices, followed by reversed-phase chromatographic separation and selective detection using tandem mass spectrometry with a 4 min runtime per sample was employed. Standard curves were linear between 0.1-100 μg/mL for cefepime. Intra- and inter-day accuracies were within 95.4-113% and precision (CV) was < 15 % based on a 3-day validation study. Recoveries ranged from 40.8 to 62.1% and the matrix effect was within 89.5-96.7% for cefepime. Cefepime was stable in human whole blood under assay conditions (3 h at room temperature, 24 h in autosampler post-extraction). Cefepime was also stable for at least 1 week (7 days) at 4 °C, 1 month (39 days) at -20 °C and 3 months (91 days) at -78 °C as dried microsamples. This assay provides an efficient quantitation of cefepime and was successfully implemented for the analysis of whole blood microsamples in a pediatric clinical trial.
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Affiliation(s)
- Ganesh S Moorthy
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States.
| | - Christina Vedar
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States
| | - Janice L Prodell
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Mary Ann DiLiberto
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
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Moorthy GS, Vedar C, DiLiberto MA, Zuppa AF. A patient-centric liquid chromatography-tandem mass spectrometry microsampling assay for analysis of cannabinoids in human whole blood: Application to pediatric pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2019; 1130-1131:121828. [PMID: 31670108 DOI: 10.1016/j.jchromb.2019.121828] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 01/07/2023]
Abstract
Medical cannabis is increasingly used for the treatment of various ailments in children and adults. Three major cannabinoids in cannabis are delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), and cannabinol (CBN). There is a growing need to develop and utilize a patient-centric blood microsampling methodology to enable clinical trials and facilitate therapeutic drug monitoring. We have employed the volumetric absorptive microsampling (VAMS™) devices that enables accurate and precise collection of a fixed volume (20 µL) of blood, minimizing the impact of hematocriton accurate quantitation. We developed an ultra-performance liquid chromatographic method with tandem mass spectrometry detection for the quantification of three cannabinoids (THC, CBD, and CBN) employing deuterium labelled internal standards (THC-D3, CBD-D3, and CBN-D3). Sample extraction of VAMS™ devices, followed by solid phase extraction, reverse phase chromatographic separation, and selective detection using tandem mass spectrometry with a 6-minute runtime per sample was developed. Standard curves were linear between 1 and 500 ng/mL for THC and 0.5-500 ng/mL for CBD and CBN. Intra-day accuracies were within 91.3-112% while inter-day accuracies were within 94.4-107% with both having precisions (CV (%)) of <13% based on quality control samples in a three day validation study for all three cannabinoids. Analytes were stable in human whole blood under assay conditions (60 h at room temperature and 24 h in autosampler post-extraction). Dried microsamples were stable for one week at 40 °C, two weeks (15 days) under different storage conditions (room temperature, 4, -20 and -78 °C), one month (29 days) at -20 and -78 °C and three months (68 days) at -78 °C. This assay provides an efficient quantitation of THC, CBD, and CBN in VAMS™ devices and is currently being implemented for pediatric clinical trials.
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Affiliation(s)
- Ganesh S Moorthy
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States; Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Christina Vedar
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States
| | - Mary Ann DiLiberto
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States; Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States; Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
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Boelig RC, Zuppa AF, Kraft WK, Caritis S. Pharmacokinetics of vaginal progesterone in pregnancy. Am J Obstet Gynecol 2019; 221:263.e1-263.e7. [PMID: 31211965 DOI: 10.1016/j.ajog.2019.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/23/2019] [Accepted: 06/10/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Characterization of pharmacokinetics is lacking for vaginal progesterone in pregnancy. Dosing of vaginal progesterone for preterm birth prevention has been empirical. Owing to pregnancy-related changes in vaginal and uterine blood flow, hepatic metabolism, renal clearance, and endogenously elevated serum progesterone, studies outside of pregnancy may not be applicable. The lack of the pharmacokinetics profile of vaginally administered progesterone in pregnancy limits the ability to define the exposure-response relationship needed to optimize dosing, which has implications for its use in research and clinical care regarding management of short cervix, prevention of recurrent preterm birth, and prevention of recurrent miscarriage. OBJECTIVE This was a study to establish the feasibility of using serum progesterone to establish basic pharmacokinetic parameters of vaginal progesterone in pregnancy for preterm birth prevention. STUDY DESIGN This is a prospective study of 6 low-risk singletons at 18 0/7 to 23 6/7 weeks' gestation with body mass index 20-40. Exclusion criteria were current vaginitis, abnormal Pap smear, prescription medication use, cervical length ≤25 mm, prior preterm birth, and contraindication to progesterone. Participants received a single dose of 200 mg micronized vaginal progesterone and serum progesterone levels were evaluated every 2 hours from 0 to 12 hours and then 24 hours post dose. Primary outcome was concentration/time profile of serum progesterone. RESULTS Median (range) maternal age was 27 (21.5-33.3) years, median body mass index was 26.5 (23.3-29.0) kg/m2, and median gestational age was 22.9 (21.0-23.4) weeks. Median baseline serum progesterone was 47 (40-52) ng/mL, median peak concentration was 54 (48-68) ng/mL, and median time to peak was 12 (4-15) hours. There was a trend in rising serum progesterone over baseline with a median change in peak concentration of 11 ng/mL and interquartile range of 2-22. Median percent change from baseline was an increase by 24% (interquartile range, 4%-53%). However, there was no clear elimination phase and the median area under the curve was 112 ng*h/mL with an interquartile range of -43 to 239. CONCLUSION Unlike in nonpregnant individuals, administration of vaginal progesterone in pregnant individuals only minimally impacts systemic exposure. There is a limited trend of rising serum progesterone over baseline levels, with significant inter-individual variability. Serum progesterone is unlikely to be a good candidate for establishing pharmacokinetics or dosing of vaginal progesterone in pregnancy for preterm birth prevention.
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Torgersen J, Bellamy SL, Ratshaa B, Han X, Mosepele M, Zuppa AF, Vujkovic M, Steenhoff AP, Bisson GP, Gross R. Impact of Efavirenz Metabolism on Loss to Care in Older HIV+ Africans. Eur J Drug Metab Pharmacokinet 2019; 44:179-187. [PMID: 30168000 DOI: 10.1007/s13318-018-0507-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE: Efavirenz is commonly used in Africa and is frequently associated with neurocognitive toxicity, which may compromise clinical outcomes. Older individuals are at increased risk for drug toxicity and clinical outcomes may be worse in older age, particularly among those individuals with cytochrome P450 (CYP) 2B6 polymorphisms associated with slower efavirenz metabolism. The aim of this study was to determine if the CYP2B6 polymorphisms differentially impacts loss to care in older people. METHODS We conducted a prospective cohort study of 914 treatment-naïve HIV+ adults initiating efavirenz-based antiretroviral treatment at public HIV clinics in Gaborone, Botswana between 2009 and 2013. Older age, defined as age ≥ 50 years, was the primary exposure and loss to care at 6 months was the primary outcome. Interaction between age and CYP2B6 516G>T and 983T>C polymorphisms, defined as extensive, intermediate, and slow metabolism, was assessed. Neurocognitive toxicity was measured using a symptom questionnaire. Age-stratified logistic regression was performed to identify factors associated with loss to care. RESULTS Older age was associated with loss to care (OR 1.95, 95% CI 1.30-2.92). Age modified the effect of CYP2B6 genotype on loss to care with older, slow metabolizers at over four-fold higher risk when compared to older, intermediate metabolizers (OR 4.06 95% CI 1.38-11.89); neurocognitive toxicity did not mediate this risk. CYP2B6 metabolism genotype did not increase risk of loss to care in younger participants. CONCLUSION Older age was associated with loss to care, especially among those with slow efavirenz metabolism. Understanding the relationship between older age and CYP2B6 genotype will be important to improving outcomes in an aging population initiating efavirenz-based ART in similar settings.
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Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3910 Powelton Ave., 2nd Floor, Philadelphia, PA, 19104, USA. .,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Scarlett L Bellamy
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | | | - Xiaoyan Han
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Athena F Zuppa
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marijana Vujkovic
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew P Steenhoff
- Botswana UPenn Partnership, Gaborone, Botswana.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory P Bisson
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3910 Powelton Ave., 2nd Floor, Philadelphia, PA, 19104, USA.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Gross
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3910 Powelton Ave., 2nd Floor, Philadelphia, PA, 19104, USA.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Topjian AA, Sutton RM, Reeder RW, Telford R, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA, Zuppa AF, Graham K, Twelves C, Diliberto MA, Landis WP, Tomanio E, Kwok J, Bell MJ, Abraham A, Sapru A, Alkhouli MF, Heidemann S, Pawluszka A, Hall MW, Steele L, Shanley TP, Weber M, Dalton HJ, Bell AL, Mourani PM, Malone K, Locandro C, Coleman W, Peterson A, Thelen J, Doctor A. The association of immediate post cardiac arrest diastolic hypertension and survival following pediatric cardiac arrest. Resuscitation 2019; 141:88-95. [PMID: 31176666 DOI: 10.1016/j.resuscitation.2019.05.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/20/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
AIM In-hospital cardiac arrest occurs in >5000 children each year in the US and almost half will not survive to discharge. Animal data demonstrate that an immediate post-resuscitation burst of hypertension is associated with improved survival. We aimed to determine if systolic and diastolic invasive arterial blood pressures immediately (0-20 min) after return of spontaneous circulation (ROSC) are associated with survival and neurologic outcomes at hospital discharge. METHODS This is a secondary analysis of the Pediatric Intensive Care Quality of CPR (PICqCPR) study of invasively measured blood pressures during intensive care unit CPR. Patients were eligible if they achieved ROSC and had at least one invasively measured blood pressure within the first 20 min following ROSC. Post-ROSC blood pressures were normalized for age, sex and height. "Immediate hypertension" was defined as at least one systolic or diastolic blood pressure >90th percentile. The primary outcome was survival to hospital discharge. RESULTS Of 102 children, 70 (68.6%) had at least one episode of immediate post-CPR diastolic hypertension. After controlling for pre-existing hypotension, duration of CPR, calcium administration, and first documented rhythm, patients with immediate post-CPR diastolic hypertension were more likely to survive to hospital discharge (79.3% vs. 54.5%; adjusted OR = 2.93; 95%CI, 1.16-7.69). CONCLUSIONS In this post hoc secondary analysis of the PICqCPR study, 68.6% of subjects had diastolic hypertension within 20 min of ROSC. Immediate post-ROSC hypertension was associated with increased odds of survival to discharge, even after adjusting for covariates of interest.
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Affiliation(s)
- Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States.
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Russell Telford
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - John T Berger
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
| | - Rick E Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, United States
| | - Frank W Moler
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States; Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Todd C Carpenter
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, United States
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Katherine Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Carolann Twelves
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary Ann Diliberto
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Elyse Tomanio
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States
| | - Jeni Kwok
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Michael J Bell
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States; Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Alan Abraham
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anil Sapru
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States; Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
| | - Mustafa F Alkhouli
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
| | - Sabrina Heidemann
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Ann Pawluszka
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Lisa Steele
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Thomas P Shanley
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, United States; Department of Pediatrics, Lurie Children's Hospital, Northwestern University, Chicago, IL, United States
| | - Monica Weber
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, United States
| | - Heidi J Dalton
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Aimee La Bell
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Peter M Mourani
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, United States
| | - Kathryn Malone
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, United States
| | - Christopher Locandro
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Whitney Coleman
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Alecia Peterson
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Julie Thelen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Allan Doctor
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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