OBJECTIVE: To determine if pediatric procedural sedation-provider medical specialty affects major complication rates when sedation-providers are part of an organized sedation service. METHODS: The 38 self-selected members of the Pediatric Sedation Research Consortium prospectively collected data under institutional review board approval. Demographic data, primary and coexisting illness, procedure, medications used, outcomes, airway interventions, provider specialty, and adverse events were reported on a self-audited, Web-based data collection tool. Major complications were defined as aspiration, death, cardiac arrest, unplanned hospital admission or level-of-care increase, or emergency anesthesia consultation. Event rates per 10 000 sedations, 95% confidence intervals, and odds ratios were calculated using anesthesiologists as the reference group and were then adjusted for age, emergency status, American Society of Anesthesiologists physical status > 2, nil per os for solids, propofol use, and clustering by site. RESULTS: Between July 1, 2004, and December 31, 2008, 131 751 pediatric procedural sedation cases were recorded; there were 122 major complications and no deaths. Major complication rates and 95% confidence intervals per 10 000 sedations were as follows: anesthesiologists, 7.6 (4.6–12.8); emergency medicine, 7.8 (5.5–11.2); intensivist, 9.6 (7.3–12.6); pediatrician, 12.4 (6.9–20.4); and other, 10.2 (5.1–18.3). There was no statistical difference (P > .05) among provider's complication rates before or after adjustment for potential confounding variables. CONCLUSIONS: In our sedation services consortium, pediatric procedural sedation performed outside the operating room is unlikely to yield serious adverse outcomes. Within this framework, no differences were evident in either the adjusted or unadjusted rates of major complications among different pediatric specialists.

Procedural sedation/anesthesia outside the operating room for a variety of procedures is well described with an overall low adverse event rate in certain settings. Adverse event associated with procedural sedation/anesthesia outside the operating room for gastrointestinal procedures have been described, albeit in small, single-center studies with wide variance in outcomes. Predictors of such outcomes are unclear. We aimed to estimate the prevalence of adverse event in children undergoing procedural sedation/anesthesia outside the operating room for esophagogastroduodenoscopy, colonoscopy, or both to identify predictors of adverse event. Retrospective analysis of Pediatric Sedation Research Consortium database, a large data repository of pediatric patients aged 21 years old or younger undergoing procedural sedation/anesthesia outside the operating room during September 2007 to November 2011. Twenty-two of the 40 centers provided data pertaining to the procedure of interest. None. Primary outcome variable is any adverse event. Independent variables include: age (five groups), sex, American Societyof Anaesthesiologists status, procedure (esophagogastroduodenoscopy, colonoscopy, or both), provider responsible, medication used, location, and presence of coexisting medical conditions. Descriptive statistics used to summarize the data. Using multivariablelogistic regression model, odds ratio, 95% CI) were computed. A total of 12,030 procedures were performed (esophagogastroduodenoscopy, 7,970; colonoscopy, 1,378; and both, 2,682). A total of 96.9% of patients received propofol. Eighty-three percent were performed in a sedation unit. Prevalence of adverse event was 4.8%. The most common adverse event were persistent desaturations (1.5%), airway obstruction (1%), cough (0.9%), and laryngospasm (0.6%). No deaths or CPR occurred. Infants and children aged 5 years old or younger had a higher adverse event rate than older children (15.8%, 7.8% vs 4%). Regression analysis revealed age 5 years old or younger, American Society of Anaesthesiologists greater than or equal to 2, esophagogastroduodenoscopy ± colonoscopy, and coexisting medical conditions of obesity and lower airway disease were independent predictors of higher adverse event. Overall prevalence of any adverse event was 4.8%. Independent predictors of adverse events in procedural sedation/anesthesia outside the operating room in pediatric esophagogastroduodenoscopy/colonoscopy onoscopy were identified. Recognition of such risk factors may enable optimization of procedural sedation.

Sickle cell nephropathy is characterized by proteinuria that starts in childhood and may lead to renal failure. Microalbuminuria is used as a marker of glomerular damage. There are no data on the extent and type of proteinuria other than microalbuminuria in children with sickle cell disease (SCD). Our goal was characterization of glomerular permselectivity and tubular proteinuria in children with SCD. The improved characterization will allow earlier recognition and prevention of renal damage. Thirty-two stable patients with haemoglobin SS (HbSS) (15 boys and 17 girls, age 9.57 +/- 5.45 years, 8 months to 19 years) were investigated. All patients had normal renal function and tested negative for proteinuria with a dipstick method. Markers of glomerular permselectivity used were albumin (marker of charge selectivity and less severe pore-size selectivity) and immunoglobulin G (IgG, marker of more severe pore-size selectivity). The marker of tubular injury used was retinol-binding protein (RBP, marker of proximal tubular dysfunction). These proteins were measured in urine spot samples using nephelometry. We did not include a control group as values in healthy subjects were previously published. Total protein excretion was elevated in 41% (13/32) of all patients and, of these 13 patients, 38.5% (5/13) had increased microalbuminuria, 15% (2/13) had increased excretion of RBP and 23% (3/13) had increased excretion of IgG. Increased total proteinuria that was not detected by testing for microalbuminuria was found in 61.5% (8/13) of patients. The youngest patient was 3 years old. Increased microalbuminuria was present in 25% (8/32) of all patients and was detected as early as 4 years of age. Of these, 62% (5/8) also had increased total protein excretion and 62% (5/8) also had increased IgG excretion. A total of 62.5% were older than 10 years. RBP excretion was elevated in 16% (5/32) of patients, all of whom were 7-14 years old. None of these patients had increased microalbuminuria or increased excretion of IgG. IgG excretion was elevated in 16% (5/32) of patients and was accompanied by increased microalbuminuria. All patients with increased IgG excretion were > or = 13 years old. We found a weak positive correlation between microalbuminuria and age (0.323, P = 0.07). We did not find a significant correlation between any type of proteinuria and disease morbidity. Ten of the thirty-two patients received hydroxyurea treatment and 60% (6/10) had no proteinuria. Twelve of the thirty-two patients received chronic exchange transfusions and 42% (5/12) had no proteinuria. We found early glomerular selectivity damage in children with SCD, which is secondary to both size-selectivity and charge-selectivity impairment. Microalbuminuria alone does not adequately detect early renal damage in children with SCD. Proximal tubular dysfunction is seen in younger children and is independent of glomerular damage. We suggest that children with SCD be tested for both total protein and IgG excretion in the urine in addition to albumin. Knowing the extent and type of renal damage may allow earlier recognition of renal injury and prompt earlier initiation of preventive therapies.

Objectives: Family and medical provider perceptions of communication barriers within the PICU are poorly understood. We designed a qualitative study to characterize the perspective of families and medical providers of critically ill children regarding communication barriers. The identified barriers may be used to direct efforts to improve communication.Design: Semi-structured interviews were conducted from August 2017 to January 2018. Interviews were audio recorded and professionally transcribed verbatim.Setting: A PICU at a tertiary care academic center.Patients: Forty-two families whose children were admitted to the PICU (excluding patients receiving end-of-life care or with protective services involvement) and 12 PICU staff members, including nurses, residents, fellows, and attending’s.Interventions: None.Measurements and Main Results: An interprofessional team of a physician, nurse manager, and medical student coded the transcripts. Interviewing continued until thematic saturation was reached. Codes were organized into common themes using a modified constant comparative method. The families interviewed represented 16 previously healthy children, and 26 children with a chronic health condition. Staff interviewed included three residents, three fellows, three attending intensivists, and three nurses. Participants’ perceptions and experiences of barriers to communication included the following: 1) Communication breakdowns related to coordination of care among several services, 2) Family-centered rounds are insufficient for effective communication, 3) Undervaluing the knowledge of families of children with chronic health conditions or special needs, and 4) Communication breakdowns occur across provider hand-offs. Theme 3 was identified by families, but not by providers.Conclusions: Families and medical providers both identified several barriers to communication. However, only families identified the barrier “Undervaluing the knowledge of families with chronically ill children.” Future work should explore these barriers and the discrepancy in perception between providers and families to determine if there are interventions that improve both family satisfaction and patient care.