Pediatric Critical Care Medicine

When a Child Dies in the PICU: Practice Recommendations From a Qualitative Study of Bereaved Parents Objectives: Around the world, the PICU is one of the most common sites for hospitalized children to die. Although ensuring the best possible care experience for these children and their families is important, clear recommendations for end-of-life and bereavement care, arising from the parents themselves, remain limited within current literature. This report aims to describe bereaved parents' recommendations for improvements in end-of-life care and bereavement follow-up when a child dies in intensive care. Design: Thematic analysis of incidental data from a larger grounded theory study. Setting: Four Australian PICUs. Subjects: Twenty-six bereaved parents participated in audio-recorded, semi-structured interviews in 2015–2016. Interviews explored their experiences of having a child die in intensive care and their experiences of end-of-life care and bereavement follow-up. Data pertaining to this report were analyzed via thematic analysis. Interventions: None. Measurements and Main Results: Bereaved parents identified several areas for care delivery and improvement across three time periods: during hospitalization; during the dying phase; and during bereavement. During hospitalization, parents' recommendations focused on improved communication, changes to the physical environment, better self-care resources, and provision of family support. During the dying phase, parents suggested private, demedicalized rooms, familiar staff members, and support to leave the hospital. Recommendations for care after death focused mainly on the provision of ongoing support from the hospital or local bereavement services, as well as improved information delivery. Conclusions: Findings from this study offer many concrete recommendations for improvements in care both during and after a child's death. These recommendations range from simple practice changes to larger organizational modifications, offering many potential avenues for change and improvement both on an individual healthcare provider level and within individual PICUs. Supported, in part, by grant from the Australian College of Critical Care Nurses Novice Researcher Grant, and the Australian College of Children and Young People's Nurses Sister Mary Dorothea Sheehan Scholarship. Dr. Butler received support for article research from Australian College of Critical Care Nurses Novice Researcher Grant, Australian College of Children and Young People's Nurses Sister Mary Dorothea Sheehan Scholarship, and Australian Government Research Training Program Stipend (formerly Australian Postgraduate Award). Dr. Copnell received funding from the Australian College of Critical Care Nurses. Dr. Hall disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: Ashleigh.butler@ucl.ac.uk ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Evaluating the Practice of Repositioning Endotracheal Tubes in Neonates and Children Based on Radiographic Location Objectives: Chest radiographs are commonly performed in the ICU setting to confirm the position of the endotracheal tube. The purpose of this study was to evaluate the practice and accuracy of repositioning endotracheal tubes in the pediatric population based on chest radiograph. Design: Retrospective review of patient's medical record and chest radiograph. Setting: Single-institution, academic children's hospital. Patients: PICU and cardiothoracic ICU patients who had repositioning of their endotracheal tube from September 1, 2016, to September 1, 2017. Measurements and Main Results: Chest radiograph before and after endotracheal tube repositioning were examined measuring the distance from the endotracheal tube tip to carina. A total of 183 endotracheal tube repositionings were assessed. Twenty-nine percent of endotracheal tube repositionings resulted in a persistently malpositioned endotracheal tube, requiring another intervention. For intended endotracheal tube repositioning of ± 2.0 cm, the actual change measured compared to intended adjustment was a median of 0.7 cm (interquartile range, 0.35–1.1 cm). For intended ± 1.5 cm, the median difference was 0.4 cm (interquartile range, 0.16–0.90 cm). For intended ± 1.0 cm, the median difference was 0.5 cm (interquartile range, 0.20–0.90 cm). For intended ± 0.5 cm, the median difference was 0.3 cm (interquartile range, 0.2–0.88 cm). When the head was malpositioned the difference from intended endotracheal tube repositioning to actual was median 0.70 cm (interquartile range, 0.40–1.1 cm), this was significantly higher than when the head was in a good position Conclusions: When repositioning endotracheal tubes based on chest radiograph, there is a significant difference between intended and actual adjustment with great variability. Avoiding very small repositionings (± 0.5 cm) and standardizing head position prior to daily chest radiograph may reduce these errors. Dr. Newth received funding from Philips Research North America. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: danielim@usc.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Plasma Neutrophil Gelatinase-Associated Lipocalin Is Associated With Acute Kidney Injury and Clinical Outcomes in Neonates Undergoing Cardiopulmonary Bypass Objectives: Acute kidney injury is a frequent complication following neonatal cardiac surgery and is associated with significant morbidity and mortality. The objectives of this study were to determine if plasma neutrophil gelatinase-associated lipocalin levels were associated with acute kidney injury and clinical outcomes in neonates with congenital heart disease undergoing cardiopulmonary bypass. Design: Retrospective single-center observational study. Setting: A pediatric cardiac ICU within a tertiary-care academic hospital. Patients: Patients age less than 30 days undergoing cardiac surgery requiring cardiopulmonary bypass. Interventions: None. Measurements and Main Results: Plasma neutrophil gelatinase-associated lipocalin peaked at 12 hours postcardiopulmonary bypass and more than doubled compared with preoperative levels. Higher preoperative and 24-hour postoperative neutrophil gelatinase-associated lipocalin levels were associated with acute kidney injury (r = 0.30, r = 0.49), longer duration of mechanical ventilation (r = 0.40, r = 0.51), ICU (r = 0.32, r = 0.33) and hospital lengths of stay (r = 0.28, r = 0.32), and total hospital charges (r = 0.35, r = 0.30; all p values < 0.05). Conclusions: Both preoperative and 24-hour postoperative plasma neutrophil gelatinase-associated lipocalin levels are associated with acute kidney injury and worse clinical outcomes in neonates undergoing cardiac surgery. Plasma neutrophil gelatinase-associated lipocalin levels may have a role in risk stratification for predicting postoperative renal dysfunction as well as providing a potential clinical trajectory in the postoperative period. This work is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or National Institutes of Health. Supported, in part, by grants HL112968 and HL00726041 from the National Heart, Lung, and Blood Institute as well as a Career Development Award from the American College of Cardiology Foundation/Pfizer Scholarship. Drs. Schroeder and Graham received support for article research from the National Institutes of Health (NIH). Dr. Buckley's institution received funding from Grifols and National Heart, Lung, and Blood Institute (NHLBI) grant (awarded to Dr. Graham to the institution). Dr. Stroud received funding from the NIH. Dr. Graham's institution received funding from the NIH/NHLBI and the American College of Cardiology Foundation, and he received funding from Bayer Pharmaceuticals (research consultant). The remaining authors have disclosed that they do not have any potential conflicts of interest. Clinical Trial Registry Number: NCT00934843. IRB Details: Study Pro00063112, approved January 12, 2017. For information regarding this article, E-mail: schroedl@musc.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Ventricular-Arterial Coupling in Children and Infants With Congenital Heart Disease After Cardiopulmonary Bypass Surgery: Observational Study Objectives: Ventricular-arterial coupling represents the interaction between the left ventricle and the arterial system. Ventricular-arterial coupling is measured as the ratio between arterial elastance and ventricular end-systolic elastance. Scant information is available in critically ill children about these variables. The aim of this study was to prospectively assess ventricular-arterial coupling after pediatric cardiac surgery and evaluate its association with other commonly recorded hemodynamic parameters. Design: Single-center retrospective observational study. Setting: Pediatric cardiac surgery operating room. Patients: Children undergoing corrective cardiac surgery. Interventions: Hemodynamic monitoring with transesophageal echocardiography. Measurements and Main Results: Twenty-seven patients with biventricular congenital heart disease, who underwent elective cardiac surgery with cardiopulmonary bypass, were enrolled before operating room discharge. Chen single-beat modified method was applied to calculate ventricular-arterial coupling. The median arterial elastance and end-systolic elastance values were 5.9 mm Hg/mL (2.2–9.3 mm Hg/mL) and 4.3 mm Hg/mL (1.9–8.3 mm Hg/mL), respectively. The median ventricular-arterial coupling was 1.2 (1.1–1.6). End-systolic elastance differences between patients with a ventricular-arterial coupling below (low ventricular-arterial coupling) and above (high ventricular-arterial coupling) the median value were –5.2 (95% CI, –6.28 to –0.7; p = 0.008). Differently, arterial elastance differences were –2.1 (95% CI, –5.7 to 1.6; p = 0.19). Ventricular-arterial coupling showed a significant association with pre-ejection time (r, 0.44; p = 0.02), total ejection time (r, –0.41; p = 0.003), cardiac cycle efficiency (r, –0.46; p = 0.02), maximal delta pressure over delta time (r, –0.44; p = 0.02), ejection fraction (r, –0.57; p = 0.01), and systemic vascular resistances indexed (0.56; p = 0.003). After adjustment, total ejection time (p = 0.001), pre-ejection time (p = 0.02), and ejection fraction (p = 0.001) remained independently associated with ventricular-arterial coupling. Conclusions: Median ventricular-arterial coupling values in children after cardiac surgery appear high (above 1). Uncoupling was particularly evident in high ventricular-arterial coupling patients who showed the lowest end-systolic elastance values (but not significantly different arterial elastance values) compared with low ventricular-arterial coupling. Ventricular-arterial coupling appears to be inversely proportional to pre-ejection time, total ejection time, and ejection fraction. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: zaccaria.ricci@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Changes in Anesthetic and Postoperative Sedation–Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study Objectives: The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. Design: Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. Setting: Five children's hospitals. Patients: A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). Interventions: None. Measurements and Main Results: Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02–5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. Conclusions: The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Research reported in this publication was conducted as an ancillary study of the Pediatric Heart Network supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Numbers HL068270, HL068290, HL109673, HL109737, HL109741, HL109741, HL109743, HL109777, HL109778, HL109781, HL109816, and HL109818. This investigation was also supported by the University of Utah Population Health Research Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764). Drs. Amula, Vener, Presson, and Nicolson received support for article research from the National Institutes of Health (NIH). Dr. Amula's institution received funding from the NIH. Dr. Vener's institution received funding from NIH (Pediatric Heart Network). Dr. Riegger's institution received funding from the Pediatric Heart Network, and she received support for article research from Pediatric Heart Network. Dr. Presson disclosed that this investigation was supported by the University of Utah Population Health Research Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: venu.amula@hsc.utah.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

A Pilot Evaluation of a Capacitance-Based Automatic Urinometer in a Pediatric Intensive Care Setting Objectives: To compare a modified capacitance-based automatic urinometer to a manual urinometer, with regard to precision of measurement and to evaluate the staff's opinion regarding the automatic urinometer. Design: Prospective observational cohort study. Setting: PICU at Astrid Lindgren's Children Hospital in Solna, Sweden. Patients: Twelve children weighing up to 10 kg with an indwelling urinary catheter in place before enrollment. Interventions: Measurement of hourly diuresis using either an automatic urinometer or manual urinometer. Measurements and Main Results: Hourly diuresis was measured with an automatic urinometer (n = 127; Sippi; Observe Medical Nordic AB, Gothenburg, Sweden) or an manual urinometer (n = 83; Unometer Safeti Plus; Convatec, Lejre, Denmark) and thereafter validated with a measuring cylinder. The absolute mean bias was –1.1 mL for the automatic urinometer (CI, –0.6 to –1.5) and –0.6 mL (CI, ± 0.0 to –1.2) for the manual urinometer (p = 0.21). The SDs were 2.6 and 2.8 mL, respectively. User evaluation comparing the automatic urinometer with the manual urinometer concerning the ease of use was made with a questionnaire (n = 18). The majority of staff preferred the automatic urinometer to the manual urinometer in terms of ease of use, learning, and handling. Conclusions: The two urinometers were comparable in performance for children weighing up to 10 kg. Taking into account the overwhelming staff satisfaction with the automatic urinometer and benefits in less well-staffed wards as well as lack of temporal deviation, the modified automatic urinometer may be considered for clinical use in the PICU. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Dr. Wetterfall disclosed that the company that manufactures the automatic urinometer loaned the investigators the two urinometers used in the study, free of charge. The remaining authors have disclosed that they do not have any potential conflicts of interest. Ethical permission was obtained for this study by the regional ethical review board in Stockholm (approval number 2015/666-32). Address requests for reprints to: Martin Slettengren, MD, Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 77, Stockholm, Sweden. E-mail: martin.slettengren@sll.se ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Characteristics and Outcomes of Pediatric Patients Supported With Ventricular Assist Device—A Multi-Institutional Analysis Objectives: The use of ventricular assist devices for pediatric patients with heart failure is increasing, but is associated with significant morbidity and mortality. Our objectives were to describe the admission outcomes and resource utilization of pediatric patients supported with ventricular assist devices, utilizing a multicenter database. Data Sources: Pediatric Health Information System database (comprising 49 nonprofit children's hospitals). Study Selection: Retrospective cohort analysis of the database from January 2006 to September 2015 for all admissions less than or equal to 21 years old with ventricular assist device implantation. Data Extraction: The primary outcome was hospital mortality. The secondary outcomes were hospital length of stay and adjusted cost. Data Synthesis: We analyzed 744 ventricular assist device implantations (740 patients), 422 (57%) males, and 363 (49%) non-Hispanic white. Median age at admission was 5.9 years (interquartile range, 0.9–13.5 yr), and median length of stay was 69 days (interquartile range, 36–122 d). The overall hospital mortality was 188 (25%), whereas 395 (53%) were transplanted and 141 (19%) were discharged on ventricular assist device. Extracorporeal membrane oxygenation was used, in addition to ventricular assist device, in 340 (46%). The majority of ventricular assist device implantations (453, 61%) were from 2011 to 2015 (compared to 2006–2010). More patients discharged on ventricular assist device from 2011 to 2015 (23% vs 13% in 2006–2010; p = 0.001). There was no difference in median age, mortality, length of stay, or adjusted costs between these time periods. On multivariable analysis, underlying congenital heart disease, renal failure, liver congestion, sepsis, cerebrovascular accident, and extracorporeal membrane oxygenation were associated with hospital mortality. Sepsis and ventricular assist device replacement/repair were associated with higher adjusted cost and longer length of stay. Conclusions: The pediatric ventricular assist device experience continues to grow, with a significant increase in the number of patients undergoing ventricular assist device implantation and a higher proportion being discharged from hospital on ventricular assist device support in recent years. Underlying congenital heart disease, renal failure, sepsis, cerebrovascular accident, and extracorporeal membrane oxygenation are significantly associated with hospital mortality. Dr. Puri carried out the initial analyses, drafted the initial article, and reviewed and revised the article. Dr. Anders conceptualized and designed the study, coordinated data collection, and reviewed and revised the article. Drs. Causey and Moffett coordinated and completed the data collection, and reviewed and revised the article. Dr. Wang supervised the analysis and critically reviewed the article. Drs. Tume, Cabrera, Heinle, and Shekerdemian supervised analysis, and critically reviewed and revised the article. All authors approved the final article as submitted and agree to be accountable for all aspects of the work. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Dr. Cabrera's institution received funding from Novartis, and he disclosed off-label product use of continuous flow device use in children. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: kriti.puri@bcm.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Age-Specific Distribution of Diagnosis and Outcomes of Children Admitted to ICUs: A Population-Based Cohort Study Objectives: Although several studies have reported outcome data on critically ill children, detailed reports by age are not available. We aimed to evaluate the age-specific estimates of trends in causes of diagnosis, procedures, and outcomes of pediatric admissions to ICUs in a national representative sample. Design: A population-based retrospective cohort study. Setting: Three hundred forty-four hospitals in South Korea. Patients: All pediatric admissions to ICUs in Korea from August 1, 2009, to September 30, 2014, were covered by the Korean National Health Insurance Corporation, with virtually complete coverage of the pediatric population in Korea. Patients less than 18 years with at least one ICUs admission between August 1, 2009, and September 30, 2014. We excluded neonatal admissions (< 28 days), neonatal ICUs, and admissions for health status other than a disease or injury. The final sample size was 38,684 admissions from 32,443 pediatric patients. Intervention: None. Measurements and Main Results: The overall age-standardized admission rate for pediatric patients was 75.9 admissions per 100,000 person-years. The most common primary diagnosis of admissions was congenital malformation (10,897 admissions, 28.2%), with marked differences by age at admission (5,712 admissions [54.8%] in infants, 3,994 admissions [24.6%] in children, and 1,191 admissions [9.9%] in adolescents). Injury was the most common primary diagnosis in adolescents (3,248 admissions, 27.1%). The overall in-hospital mortality was 2,234 (5.8%) with relatively minor variations across age. Neoplasms and circulatory and neurologic diseases had both high frequency of admissions and high in-hospital mortality. Conclusions: Admission patterns, diagnosis, management, and outcomes of pediatric patients admitted to ICUs varied by age groups. Strategies to improve critical care qualities of pediatric patients need to be based on the differences of age and may need to be targeted at specific age groups. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: joongbum.cho@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Nutritional Status Deterioration Occurs Frequently During Children's ICU Stay Objectives: Malnutrition and faltering growth at PICU admission have been related to suboptimal outcomes. However, little is known about nutritional status deterioration during PICU stay, as critical illness is characterized by a profound and complex metabolism shift, which affects energy requirements and protein turnover. We aim to describe faltering growth occurrence during PICU stay. Design: Single-center prospective observational study. Setting: Twenty-three-bed general PICU, Lyon, France. Patients: All critically ill children 0–18 years old with length of stay longer than 5 days were included (September 2013–December 2015). Interventions: Weight and height/length were measured at admission, and weight was monitored during PICU stay, in order to calculate body mass index for age z score. Faltering growth was defined as body mass index z score decline over PICU stay. Children admitted during the first year of the study and who presented with faltering growth were followed after PICU discharge for 3 months. Measurements and Main Results: We analyzed 579 admissions. Of them, 10.2% presented a body mass index z score decline greater than 1 SD and 27.8% greater than 0.5. Admission severity risk scores and prolonged PICU stay accounted for 4% of the variability in nutritional status deterioration. Follow-up of post-PICU discharge nutritional status showed recovery within 3 months in most patients. Conclusions: Nutritional deterioration is frequent and often intense in critically ill children with length of stay greater than 5 days. Future research should focus on how targeted nutritional therapies can minimize PICU faltering growth and improve post-PICU rehabilitation. Drs. Valla, Ginhoux, Cour-Andlauer, and Javouhey designed the study, collected, and participated to interpretation of data. Drs. Ford-Chessel, Gervet, and Ms. Giraud helped to design the study and to collect data. Drs. Baudin and Gaillard Le Roux helped designing and analyzing the data. Dr. Tume participated to interpretation of data and provided English editing of the article. All authors were involved in writing the article and had final approval of the submitted and published versions. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). This study was conducted with the financial support of ACTICLAN 2011 grant (sponsored by Fresenius Kabi, on behalf of the French speaking nutrition scientific society [SFNEP]) and Association Lyonnaise de logistique post hospitalière grant. In addition, this study was conducted with the support of the "Centre d'Investigation Clinique pédiatrique" des Hospices Civils de Lyon, with the precious help of Behaa Krefa. Dr. Valla reports personal fees from Baxter, personal fees and nonfinancial support from Nutricia. Dr. Valla's institution received funding from Fresenius Kabi and Association Lyonnaise de logistique post hospitalière, and he received funding from Baxter and Nutricia. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work was performed in Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France. For information regarding this article, E-mail: Frederic.valla@chu-lyon.fr ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Tracheal Size and Morphology on the Reconstructed CT Imaging Objectives: To characterize the real size and morphology of tracheas in childhood for the optimal selection of endotracheal tube. Design: A retrospective cohort study of pediatric patients who received CT scan of the cervical spine from July 2011 to March 2018. Cross-sectional CT images vertical to trachea were reconstructed and the accurate tracheal diameters were measured. The validity of the traditional age-based formula for predicting the endotracheal tube size was assessed for the best fit to trachea. Setting: Tertiary Emergency and Critical Care Center of Kyushu University Hospital. Patients: Children, who are 1 month to 15 years old, received CT scan of the cervical spine. Interventions: None. Measurements and Main Results: We enrolled 86 children with median age of 53 months. The cross-sectional shape of pediatric trachea was circular at the cricoid level and elliptical at the infraglottic level. The narrowest part of pediatric trachea was the transverse diameter at the infraglottic level at any age. Significant positive correlation between age and the narrowest diameter was observed. When compared the transverse diameter at the infraglottic level with the outer diameter of endotracheal tubes, uncuffed endotracheal tubes selection based on the traditional age-based formula ran a significant risk of oversized endotracheal intubation until 10 years old compared with cuffed endotracheal tubes selection (60.0% vs 23.8%; p < 0.05). Conclusions: These findings indicate the safety and efficacy of cuffed endotracheal tubes in infants and children and the reconsideration for the airway management in pediatric anesthesia and intensive care. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Drs. Maki and Baba disclosed work for hire. The remaining authors disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: ystmmtmr@pediatr.med.kyushu-u.ac.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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alsfakia@gmail.com