Pediatric cardiac intensivists: are enough being trained?

OBJECTIVE: To determine both the number of cardiac intensivists being trained by member institutions of the Pediatric Cardiac Intensive Care Society and the perceived need for these professionals. DESIGN: Web-based survey of pediatric cardiac intensive care unit program directors. RESULTS: A total of 54 directors completed the survey (41% response rate). Twelve pediatric cardiac critical care fellowship positions are offered each year among the responding Pediatric Cardiac Intensive Care Society institutions in the United States and Canada-only six of the 12 positions were filled in the academic year 2002-2003. Cardiac intensivist recruitment was ongoing at 25 of the programs surveyed (46%). An additional 45 cardiac intensivists will be sought during the next 1-3 yrs and 36 during the subsequent 3- to 5-yr period. CONCLUSIONS: There is a discrepancy between the current and growing need for trained pediatric cardiac intensivists and the graduation rate of these professionals from teaching programs.     

The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients

OBJECTIVE: To develop and test the validity and reliability of the Withdrawal Assessment Tool-1 for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. DESIGN: Prospective psychometric evaluation. Pediatric critical care nurses assessed eligible at-risk pediatric patients for the presence of 19 withdrawal symptoms and rated the patient's overall withdrawal intensity using a Numeric Rating Scale where zero indicated no withdrawal and 10 indicated worst possible withdrawal. The 19 symptoms were derived from the Opioid and Benzodiazepine Withdrawal Score, the literature and expert opinion. SETTING: Two pediatric intensive care units in university-affiliated academic children's hospitals. PATIENTS: Eighty-three pediatric patients, median age 35 mos (interquartile range: 7 mos-10 yrs), recovering from acute respiratory failure who were being weaned from more than 5 days of continuous infusion or round-the-clock opioid and benzodiazepine administration. INTERVENTIONS: Repeated observations during analgesia and sedative weaning. A total of 1040 withdrawal symptom assessments were completed, with a median (interquartile range) of 11 (6-16) per patient over 6.6 (4.8-11) days. MEASUREMENTS AND MAIN RESULTS: Generalized linear modeling was used to analyze each symptom in relation to withdrawal intensity ratings, adjusted for site, subject, and age group. Symptoms with high redundancy or low levels of association with withdrawal intensity ratings were dropped, resulting in an 11-item (12-point) scale. Concurrent validity was indicated by high sensitivity (0.872) and specificity (0.880) for Withdrawal Assessment Tool-1 > 3 predicting Numeric Rating Scale > 4. Construct validity was supported by significant differences in drug exposure, length of treatment and weaning from sedation, length of mechanical ventilation and intensive care unit stay for patients with Withdrawal Assessment Tool-1 scores > 3 compared with those with lower scores. CONCLUSIONS: The Withdrawal Assessment Tool-1 shows excellent preliminary psychometric performance when used to assess clinically important withdrawal symptoms in the pediatric intensive care unit setting. Further psychometric evaluation in diverse at-risk groups is needed.     

Sedative, analgesic and muscle relaxant management in Spanish paediatric intensive care units

ObjectiveThe aim of the study was to define the strategies for the use and monitoring of sedative, analgesic, and muscle relaxant medication in Spanish paediatric intensive care units (PICU).Material and methodsA questionnaire with 102 questions was sent by e-mail to all Spanish PICUs.ResultsReplies were received from 36 of the 45 PICUs (80%). A written protocol for sedation and analgesia was used in 64%; this medication was adjusted according to the diagnosis and clinical status of the patient in 30% of the units. Midazolam was the most widely used drug for sedation, followed by ketamine and propofol. Fentanyl was the most widely used drug for analgesia, followed by paracetamol and metamizole. The combination of midazolam and fentanyl in continuous infusion was used most frequently in patients on mechanical ventilation (MV), followed by propofol. Scales to monitor sedation and analgesia were employed in 45% of PICUs, most used the Ramsay scale. The bispectral index (BIS) was used in 50% of PICUs. Muscle relaxants were administered to 26% of patients on MV; the most common indications for MV were head injury and severe respiratory disease. The principal methods for avoiding withdrawal syndrome were a progressive withdrawal of the drugs and morphine chloride.ConclusionsAlthough there is insufficient scientific evidence to determine the ideal drugs for sedation and analgesia in the critically ill child and the methods for monitoring and control, the production of guidelines and written treatment and monitoring protocols could help to improve the management and control of sedation and analgesia.     

The feasibility of implementing a communication skills training course in pediatric hematology/oncology fellowship

Communication skills are a competency highlighted by the Accreditation Council on Graduate Medical Education; yet, little is known about the frequency with which trainees receive formal training or what programs are willing to invest. We sought to answer this question and designed a program to address identified barriers. We surveyed pediatric fellowship program directors from all disciplines and, separately, pediatric hematology/oncology fellowship program directors to determine current use of formal communication skills training. At our institution, we piloted a standardized patient (SP)-based communication skills training program for pediatric hematology/oncology fellows. Twenty-seven pediatric hematology/oncology program directors and 44 pediatric program directors participated in the survey, of which 56% and 48%, respectively, reported having an established, formal communication skills training course. Multiple barriers to implementation of a communication skills course were identified, most notably time and cost. In the pilot program, 13 pediatric hematology/oncology fellows have participated, and 9 have completed all 3 years of training. Precourse assessment demonstrated fellows had limited comfort in various areas of communication. Following course completion, there was a significant increase in self-reported comfort and/or skill level in such areas of communication, including discussing a new diagnosis (p =.0004), telling a patient they are going to die (p =.005), discussing recurrent disease (p <.001), communicating a poor prognosis (p =.002), or responding to anger (p ≤.001). We have designed a concise communication skills training program, which addresses identified barriers and can feasibly be implemented in pediatric hematology/oncology fellowship.     

Sedation analgesia in pediatric intensive care

Provision of optimum comfort control to a critically ill child, in Pediatric Intensive Care Unit (PICU) requires a great degree of skill and planning and should be a prime concern for all practising paediatricians. Failure to provide adequate sedation and analgesia to control the stress response has been seen to be associated with increased complications and mortality. Sedation/analgesia in PICU is required both for, short term procedure and as an adjunct to pediatric intensive care. One has to identify the requirement whether sedation, analgesia or both. The ideal approach should be a sedative/hypnotic for sedation, an anxiolytic for anxiety, and an analgesic for pain. Threfore, it is essential, to provide the right drug for the problem at the right time in the right dosage. The drugs commonly used for sedation analgesia in PICU and their side effects have been described here.     

How and how well do pediatric radiology fellows learn ultrasound skills? A national survey

Background

Ultrasound (US) comprises a significant portion of pediatric imaging. Technical as well as interpretive skills in US imaging are consequently fundamental in training pediatric radiologists. Unfortunately, formalized technical education regarding US imaging in pediatric fellowships has lagged.

Objective

We surveyed pediatric fellows and program directors regarding US scanning education to improve this experience moving forward.

Materials and methods

We conducted an online survey from February 2011 to March 2011 of all United States pediatric radiology body imaging fellows and fellowship program directors. Questions posed to fellows assessed their educational US experiences during their residencies and fellowships. Directors were asked to evaluate US educational opportunities in their programs.

Results

Among the respondents, 43.9% of fellows undertook on-call US scanning without a sonographer during residency, 23.3% during fellowship; 41.8% of fellows and 58.6% of program directors reported that their fellowship had a dedicated curriculum to facilitate independent US scanning. Both fellows and program directors cited the volume of cases requiring immediate dictation as an obstacle to scanning. Fewer program directors than fellows identified lack of sufficient staffing as an obstacle, but more identified fellow disinterest. Program directors and fellows alike rated independent US scanning as highly important to pediatric radiologists’ future success.

Conclusion

Pediatric radiology fellowship directors and fellows agree that technical US skills are crucial to the practice of pediatric radiology. However, the groups identify different obstacles to training. As US instruction is developing in undergraduate medicine and subspecialists are acquiring point-of-care US skills, pediatric radiology education should address the obstacles to US training and formalize a curriculum at the fellowship level.     

A survey of pediatric intensive care services in Turkey

The aim of this study was to describe and assess the structure, organization, and staffing of pediatric intensive care services in Turkey. A survey was sent to major university and government hospitals. Out of the 40 hospitals stating to provide pediatric intensive care, 34 responded to the survey (85% response rate). In the majority (81.2%) of hospitals, pediatric intensive care was provided in single room units or within the pediatric ward. Unit size ranged from 1-16 beds with an average of 6.8 +/- 4.2 operational beds per unit. Much of the equipment and a sufficient number of specialists for pediatric intensive care unit (PICU) care were present in the surveyed hospitals. However, only 12 units had a pediatric intensivist on staff and few had special PICU nurses. Many hospitals in Turkey already have various equipment and specialists needed to support pediatric intensive care. Expansion of services and improved care could be achieved if more pediatric intensivists and nurses could be provided and services concentrated in fully equipped tertiary centers.     

The training of pediatric residents in the care of acutely ill and injured children

OBJECTIVES: To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. DESIGN: A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. SETTING AND PARTICIPANTS: Pediatric residency programs and their directors. MAIN OUTCOME MEASURES: Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). RESULTS: One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. CONCLUSIONS: Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.     

Pediatric emergency medicine fellowship training in the new millennium

OBJECTIVE Fellowship training in pediatric emergency medicine has been available since the early 1980s. Its availability increased rapidly in the late 1980s and early 1990s, but its growth has been much slower in recent years. In this report, we characterize and compare the training programs of today to those that existed 10 years ago. Our study deals with program content and design, focusing on five aspects of fellowship training: demographics, curriculum, clinical emergency department time, research, and benefits. The data gathered in this study are meant to assist programs, both new and old, in enhancing their fellowship training.METHODS A 43-question survey was mailed to all known pediatric emergency medicine fellowship program directors in March of 2000. Two additional attempts were made to obtain survey responses. Forty of the 50 program directors responded, for a response rate of 80%. Statistical analysis was performed, and the data were compared with data that were gathered in two previous studies of fellowship training programs conducted in 1988 and 1991.RESULTS Fellowship training in pediatric emergency medicine continues to grow but at a slower pace than previously experienced. The number of training programs has increased by 27% over the past 10 years; however, the number of first-year positions has only increased by 15%. Clinical fellow supervision has increased significantly over the years, likely as a result of changes in reimbursement. In 1990, 75% of fellows worked unsupervised in the emergency department versus 23% of first-year fellows, 56% of second-year fellows, and 74% of third-year fellows in the year 2000. The structure of the fellowship curriculum has become more standardized during the past 10 years, with numerous core rotations required by most programs. The percentage of programs offering protected research time has changed significantly over the years, with the amount of time increasing from 40% in 1988, to 95% in 1990, to 100% in 2000. The amount of clinical time has also increased with the transition to a 3-year program.CONCLUSIONS Pediatric emergency medicine continues to expand as a pediatric subspecialty but at a slower rate. During the previous decade, fellowship training has become more structured, with greater emphasis being placed on fellow supervision, standardization of education, and research. These data are meant to assist new as well as established fellowship programs with the development of their training curriculum.     

Correlation of the Bispectral Index Monitor with the COMFORT scale in the pediatric intensive care unit.

OBJECTIVE: The COMFORT scale is a commonly used observational scoring system to assess the level of sedation in ventilated children in pediatric intensive care units (PICUs). The bispectral index (BIS) monitor is a processed electroencephalographic parameter that noninvasively measures the hypnotic effect of anesthetic and sedative drugs on the brain. The objective of this study was to assess the degree of correlation between the COMFORT scale and the BIS monitor. DESIGN: A prospective study in a tertiary level PICU. RESULTS: A total of 75 children were enrolled in the study, resulting in 869 valid paired observations of BIS values and COMFORT scores. The median age was 10 months, with a range of 1 month to 12 yrs. The median COMFORT score was 11 (range, 8-40). The median BIS value was 52 (range, 0-98). In a repeated-measures analysis, the correlation coefficient between COMFORT scores and BIS values averaged over time was 0.61 (p < .0001). CONCLUSIONS: The BIS monitor may be a valid and useful monitor of the level of sedation of children in the PICU. We cannot expect perfect correlation between BIS values and observational scales because they measure different variables. The BIS monitor may be the best objective monitor currently available for children receiving neuromuscular blockade because it does not rely on subjective measures such as those used in the COMFORT scale. The ability of the BIS monitor to distinguish between very deep levels of sedation may be useful to prevent over-sedation of children in PICUs and to help clarify the appropriate target level of sedation for each child.     

东北及内蒙古地区儿科重症监护病房护士镇痛镇静护理行为现状调查及影响因素分析

目的通过横断面调查,了解东北及内蒙古地区儿科重症监护病房(pediatric intesive care unit,PICU)护士镇痛镇静护理行为现状并对其影响因素进行分析,为进一步构建规范化培训方案及研发标准化镇痛镇静护理流程提供参考依据。方法采用自行设计的PICU护士镇痛镇静护理知信行现状调查问卷对东北及内蒙古地区18家医院的435名PICU护士进行问卷调查。结果东北及内蒙古地区PICU护士镇痛镇静护理行为问卷平均得分为(70.54±13.63)分。不同年龄、护龄、PICU护龄、学历、职称,以及是否是重症专科护士、是否接受过镇痛镇静培训、有无护理镇痛镇静患儿经历,各组间护士的行为得分比较,差异均有统计学意义(均P<0.05)。护士是否接受过镇痛镇静相关培训、有无护理镇痛镇静患儿经历及对镇痛镇静的态度是影响PICU护士镇痛镇静行为的主要因素。结论东北及内蒙古地区PICU护士镇痛镇静护理行为尚有很大提升空间,PICU护士参加镇痛镇静相关培训次数越多、护理镇痛镇静患儿经历越丰富、镇痛镇静态度越积极,其临床护理实践能力越强。     

Pediatric Cardiology Boot Camp: Description and Evaluation of a Novel Intensive Training Program for Pediatric Cardiology Trainees

The transition from residency to subspecialty fellowship in a procedurally driven field such as pediatric cardiology is challenging for trainees. We describe and assess the educational value of a pediatric cardiology “boot camp” educational tool designed to help prepare trainees for cardiology fellowship. A two-day intensive training program was provided for pediatric cardiology fellows in July 2015 at a large fellowship training program. Hands-on experiences and simulations were provided in: anatomy, auscultation, echocardiography, catheterization, cardiovascular intensive care (CVICU), electrophysiology (EP), heart failure, and cardiac surgery. Knowledge-based exams as well as surveys were completed by each participant pre-training and post-training. Pre- and post-exam results were compared via paired t tests, and survey results were compared via Wilcoxon rank sum. A total of eight participants were included. After boot camp, there was a significant improvement between pre- and post-exam scores (PRE 54 ± 9 % vs. POST 85 ± 8 %; p ≤ 0.001). On pre-training survey, the most common concerns about starting fellowship included: CVICU emergencies, technical aspects of the catheterization/EP labs, using temporary and permanent pacemakers/implantable cardiac defibrillators (ICDs), and ECG interpretation. Comparing pre- and post-surveys, there was a statistically significant improvement in the participants comfort level in 33 of 36 (92 %) areas of assessment. All participants (8/8, 100 %) strongly agreed that the boot camp was a valuable learning experience and helped to alleviate anxieties about the start of fellowship. A pediatric cardiology boot camp experience at the start of cardiology fellowship can provide a strong foundation and serve as an educational springboard for pediatric cardiology fellows.     

What's New in Topical Anesthesia

Advances in topical anesthesia have brought improved products and drug delivery devices that reduce the time to effect. Although EMLA requires 45 to 60 minutes for effect, LMX4 and Synera are effective within 20 to 30 minutes. Placement at triage reduces the negative impact on ED flow. New commercially available devices can reduce the time to effect further to 5 minutes or less. Despite these advances, topical anesthetics are not being routinely used for minor skin-breaking procedures in EDs; a recent survey of pediatric emergency medicine fellowship directors reported that only 38% typically used topical anesthesia for routine IV cannulation [94]. With the current advances, topical anesthesia for nonemergent venipuncture and other venous access procedures should become routine in pediatric emergency care.     

Sedation and analgesia for critically ill children

Effective analgesia and sedation in the paediatric intensive care unit (PICU) encompasses the provision of physical comfort and caring for the psychological well-being of critically ill children. In the UK the most commonly used sedative and analgesic agents for critically ill children are midazolam and either morphine or fentanyl. Consensus clinical practice guidelines for the provision of sedation and analgesia in critically ill children were published in 2006 by the UK Paediatric Intensive Care Society, and an ESPNIC position statement on clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children was published in 2016: Despite this, considerable variation in practice persists. Pain experienced early in life may result in long-term changes in neurosensory function and there are also concerns that sedative and analgesic agents may themselves be associated with developmental neurotoxicity, particularly amongst neonates, and adverse psychological outcomes in survivors of critical care. Validated tools for assessment of withdrawal syndrome and delirium are available and this article will briefly discuss these and how to use them in clinical practice. The most important single factor in reducing avoidable psychological morbidity in survivors of PICU is to minimize the administered doses of sedative and analgesic agents.     

Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units.

The purpose of this study was to assess the use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units. The directors of 38 pediatric units and 31 neonatal units reported that analgesics were infrequently used for intravenous cannulation (10%), suprapubic bladder aspiration (8%), urethral catheterization (2%), or venipuncture (2%). Analgesics were used significantly more regularly in pediatric than in neonatal intensive care units for arterial line placement, bone marrow aspiration, central line placement, chest tube insertion, paracentesis, and lumbar puncture.     

Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training

PurposeTo describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees.MethodsWe conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training.ResultsForty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited “time” (55%, n = 136/243) most frequently as a barrier.ConclusionsOur needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.