Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society (Part Two) Objectives: To make recommendations on improving understanding of bleeding and thrombosis with pediatric extracorporeal life support including future research directions. Data Sources: Evaluation of literature and consensus conferences of pediatric critical care and extracorporeal life support experts. Study Selection: A team of 10 experts with pediatric cardiac and extracorporeal membrane oxygenation experience and expertise met through the Pediatric Cardiac Intensive Care Society to review current knowledge and make recommendations for future research to establish “best practice” for anticoagulation management related to extracorporeal life support. Data Extraction/Data Synthesis: This white paper focuses on clinical understanding and limitations of current strategies to monitor anticoagulation. For each test of anticoagulation, limitations of current knowledge are addressed and future research directions suggested. Conclusions: No consensus on best practice for anticoagulation monitoring exists. Structured scientific evaluation to answer questions regarding anticoagulation monitoring and bleeding and thrombotic events should occur in multicenter studies using standardized approaches and well-defined endpoints. Outcomes related to need for component change, blood product administration, healthcare outcome, and economic assessment should be incorporated into studies. All centers should report data on patient receiving extracorporeal life support to a registry. The work for this project occurred during monthly phone meetings and at each of the institutions listed above for the authors. 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. Reddy’s institution received funding from the National Institutes of Health and the American Heart Association. Dr. Thiagarajan’s institution received funding from Bristol Myers Squibb and Pfizer. Dr. Dalton received funding from Innovative Extracorporeal Membrane Oxygenation (ECMO) Concepts (consultant), and she disclosed off-label product use of ECMO. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jamiepenk@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

The Occurrence and Risk Factors of Inappropriately Deep Tip Position of Microcuff Pediatric Endotracheal Tube During PICU Stay: A Retrospective Cohort Pilot Study Objectives: Cuffed endotracheal tubes are being used increasingly for pediatric patients on mechanical ventilation. Appropriate placement of the tube tip for Microcuff (Kimberley-Clark, Roswell, GA) pediatric endotracheal tube is guided by the intubation depth mark on the device. However, inappropriately deep tip position is sometimes observed during PICU stay. The purpose of this study was to assess the occurrence and risk factors of inappropriately deep tip position of Microcuff pediatric endotracheal tube during PICU stay. Design: A retrospective cohort study. Setting: The PICU at the National Center for Child Health and Development, one of the largest tertiary pediatric hospitals in Japan. Patients: All patients on mechanical ventilation with Microcuff pediatric endotracheal tube admitted between February 1, 2015, and July 31, 2016, were enrolled. Interventions: None. Measurements and Main Results: The primary outcome was the occurrence of inappropriately deep tip position, defined as a position of the tube tip less than 5 mm above the carina on a chest radiograph. There were 179 cases (157 patients) requiring mechanical ventilation with Microcuff pediatric endotracheal tube during the study period. An inappropriately deep tip position was found in 42 cases (23.5%), including bronchial intubation in 13 cases (7.3%). In multivariate analysis, height in cm (odds ratio, 0.93; p < 0.001), history of abdominal disease or previous abdominal surgery (odds ratio, 4.38; p = 0.004), and oversized endotracheal tube (odds ratio, 2.93; p = 0.042) were found to be independent risk factors. Conclusions: The occurrence of inappropriately deep tip position of Microcuff pediatric endotracheal tube during PICU stay was 23.5%. The possibility of an inappropriately deep tip position should be considered whenever patients with the above risk factors, a history of abdominal disease or previous abdominal surgery, and small children are treated or when oversized endotracheal tubes are used. Dr. Matsuoka reviewed the electronic health records and wrote the draft of the article. Dr. Ide conceptualized and designed the study, supervised the review of the patient data, and wrote the final article. Dr. Matsudo co-reviewed the patients’ chest radiographs. Dr. Kobayashi supervised the data analysis. Drs. Nishimura and Nakagawa conceptualized and designed the study. All the authors read and approved the final article. 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: ide-k@ncchd.go.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Methods Used to Maximize Follow-up: Lessons Learned From the Therapeutic Hypothermia After Pediatric Cardiac Arrest Trials Objectives: To describe telephone interview completion rates among 12-month cardiac arrest survivors enrolled in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials, identify key characteristics of the completed follow-up interviews at both 3- and 12-month postcardiac arrest, and describe strategies implemented to promote follow-up. Setting: Centralized telephone follow-up interviews. Design: Retrospective report of data collected for Therapeutic Hypothermia after Pediatric Cardiac Arrest trials, and summary of strategies used to maximize follow-up completion. Patients: Twelve-month survivors (n = 251) from 39 Therapeutic Hypothermia after Pediatric Cardiac Arrest PICU sites in the United States, Canada, and United Kingdom. Interventions: Not applicable. Measurements and Main Results: The 3- and 12-month telephone interviews included completion of the Vineland Adaptive Behavior Scales, Second Edition. Vineland Adaptive Behavior Scales, Second Edition data were available on 96% of 3-month survivors (242/251) and 95% of 12-month survivors (239/251) with no differences in demographics between those with and without completed Vineland Adaptive Behavior Scales, Second Edition. At 12 months, a substantial minority of interviews were completed with caregivers other than parents (10%), after calls attempts were made on 6 or more days (18%), and during evenings/weekends (17%). Strategies included emphasizing the relationship between study teams and participants, ongoing communication between study team members across sites, promoting site engagement during the study’s final year, and withholding payment for work associated with the primary outcome until work had been completed. Conclusions: It is feasible to use telephone follow-up interviews to successfully collect detailed neurobehavioral outcome about children following pediatric cardiac arrest. Future studies should consider availability of the telephone interviewer to conduct calls at times convenient for families, using a range of respondents, ongoing engagement with site teams, and site payment related to primary outcome completion. 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. 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). Additional members of the Therapeutic Hypothermia after Pediatric Cardiac Arrest trial investigators are listed in Supplemental Appendix 1 (Supplemental Digital Content 2, http://links.lww.com/PCC/B50). Supported, in part, by the National Heart, Lung, and Blood Institute grants HL094345 (to Dr. Moler) and HL094339 (to Dr. Dean). Supported, in part, from the following federal planning grants contributed to the planning of the Therapeutic Hypothermia after Pediatric Cardiac Arrest trials: HD044955 and HD050531 (to Dr. Moler). Additional in part support from the following research networks: Pediatric Emergency Care Applied Research Network from cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008; and the Collaborative Pediatric Critical Care Research Network from cooperative agreements U10HD500009, U10HD050096, U10HD049981, U10HD049945, U10HD049983, U10HD050012, and U01HD049934. Site support from P30HD040677, UL1TR000003UL1, RR 024986, and UL1 TR 000433. Dr. Moler’s, Mr. Page’s, and Drs. Meert’s, Holubkov’s, and Slomine’s institution received funding from the National Institutes of Health (NIH). Ms. Gildea’s and Drs. Dean’s and Christensen’s institution received funding from the National Heart, Lung, and Blood Institute. All authors received support for article research from the NIH. For information regarding this article, E-mail: Slomine@kennedykrieger.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Volume Guaranteed Ventilation During Neonatal Transport Objectives: To compare tidal volumes, inflating pressures and other ventilator variables of infants receiving synchronized intermitted mandatory ventilation with volume guarantee during emergency neonatal transport with those of infants receiving synchronized intermitted mandatory ventilation without volume guarantee. Design: Retrospective observational study. Setting: A regional neonatal emergency transport service. Patients: We enrolled 77 infants undergoing emergency neonatal transfer. Forty-five infants were ventilated with synchronized intermittent mandatory ventilation with volume guarantee and 32 with synchronized intermitted mandatory ventilation without volume guarantee. Interventions: Infants received synchronized intermitted mandatory ventilation with or without volume guarantee during interhospital emergency neonatal transport using a Fabian + nCPAP evolution neonatal ventilator (Software Version: 4.0.1; Acutronic Medical Instruments, Hirzel, Switzerland). Measurements and Main Results: We downloaded detailed ventilator data with 0.5 Hz sampling rate. We analyzed data with the Python computer language and its data science packages. The mean expiratory tidal volume of inflations was lower and less variable in infants ventilated with volume guarantee than in babies ventilated without volume guarantee (group median 4.8 vs 6.0 mL/kg; p = 0.001). Babies ventilated with synchronized intermittent mandatory ventilation with volume guarantee had on average lower and more variable peak inflating pressures than babies ventilated without volume guarantee (group median 15.5 vs 19.5 cm H2O;p = 0.0004). With volume guarantee, a lower proportion of the total minute ventilation was attributed to ventilator inflations rather than to spontaneous breaths between inflations (group median 66% vs 83%; p = 0.02). With volume guarantee, babies had fewer inflations with tidal volumes greater than 6 mL/kg and greater than 8 mL/kg (group medians 3% vs 44% and 0% vs 7%, respectively; p = 0.0001). The larger tidal volumes in the non-volume guarantee group were not associated with significant hypocapnia except in one case. Conclusions: During neonatal transport, synchronized intermittent mandatory ventilation with volume guarantee ventilation reduced the occurrence of excessive tidal volumes, but it was associated with larger contribution of spontaneous breaths to minute ventilation compared with synchronized intermitted mandatory ventilation without volume guarantee. This work was performed at Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge, CB2 0QQ, United Kingdom and Neonatal Emergency and Transport Service of the Peter Cerny Foundation, 53 Bókay János Street, Budapest, 1083 Hungary. 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. Kovacs received funding from Sanofi Hungary and Syreon Research Institute. Dr. Szilagyi received funding from Peter Cerny Ambulance Service for Curing Sick Babies. Dr. Morley received funding from ACUTRONIC Medical (consultant for neonatal resuscitation research, but not for any aspect of their ventilators). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: gusztav.belteki@addenbrookes.nhs.uk ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Survival and Cardiopulmonary Resuscitation Hemodynamics Following Cardiac Arrest in Children With Surgical Compared to Medical Heart Disease Objectives: To assess the association of diastolic blood pressure cutoffs (≥ 25 mm Hg in infants and ≥ 30 mm Hg in children) during cardiopulmonary resuscitation with return of spontaneous circulation and survival in surgical cardiac versus medical cardiac patients. Secondarily, we assessed whether these diastolic blood pressure targets were feasible to achieve and associated with outcome in physiology unique to congenital heart disease (single ventricle infants, open chest), and influenced outcomes when extracorporeal cardiopulmonary resuscitation was deployed. Design: Multicenter, prospective, observational cohort analysis. Setting: Tertiary PICU and cardiac ICUs within the Collaborative Pediatric Critical Care Research Network. Patients: Patients with invasive arterial catheters during cardiopulmonary resuscitation and surgical cardiac or medical cardiac illness category. Interventions: None. Measurements and Main Results: Hemodynamic waveforms during cardiopulmonary resuscitation were analyzed on 113 patients, 88 surgical cardiac and 25 medical cardiac. A similar percent of surgical cardiac (51/88; 58%) and medical cardiac (17/25; 68%) patients reached the diastolic blood pressure targets (p = 0.488). Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients (p = 0.018), but not medical cardiac patients (p = 0.359). Fifty-three percent (16/30) of patients with single ventricles attained the target diastolic blood pressure. In patients with an open chest at the start of chest compressions, 11 of 20 (55%) attained the target diastolic blood pressure. In the 33 extracorporeal cardiopulmonary resuscitation patients, 16 patients (48%) met the diastolic blood pressure target with no difference between survivors and nonsurvivors (p = 0.296). Conclusions: During resuscitation in an ICU, with invasive monitoring in place, diastolic blood pressure targets of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children can be achieved in patients with both surgical and medical heart disease. Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients, but not medical cardiac patients. Diastolic blood pressure targets were feasible to achieve in 1) single ventricle patients, 2) open chest physiology, and 3) extracorporeal cardiopulmonary resuscitation patients. A complete list of Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network members are listed in the Acknowledgments section. 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). Supported, in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services: UG1HD050096, UG1HD049981, UG1HD049983, UG1HD063108, UG1HD083171, UG1HD083166, UG1HD083170, U10HD050012, U10HD063106, U10HD063114, and U01HD049934. Drs. Yates’s, Berger’s, and Carcillo’s institutions received funding from the National Institutes of Child Health and Human Development. Drs. Yates, Reeder, Meert, Berger, Wessel, Newth, Carcillo, McQuillen, Harrison, Moler, Pollack, Carpenter, Dean, Nadkarni, and Berg received support for article research from the National Institutes of Health (NIH). Dr. Sutton’s institution received funding from National Heart, Lung, and Blood Institute R01 to study cardiopulmonary resuscitation quality improvement bundle; he received funding from Zoll Medical (speaking honoraria); and he disclosed he is a volunteer for the American Heart Association (AHA), is the Chair for AHA’s Get with the Guidelines Resuscitation Pediatric Research Task Force, and was an author for the 2015 and 2018 Pediatric Advanced Life Support Guidelines. Drs. Reeder’s, Meert’s, Wessel’s, Harrison’s, Moler’s, Pollack’s, Dean’s, and Berg’s institutions received funding from the NIH. Dr. Berger’s institution received funding from Association for Pediatric Pulmonary Hypertension and Actelion Pharmaceutical. 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: Andrew.yates@nationwidechildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Compassionate Discharges from the PICU: Retraction No abstract available

Effects of Healthcare-Associated Infections on Length of PICU Stay and Mortality Objectives: To identify the effects of healthcare-associated infections on length of PICU stay and mortality. Design: Retrospective, single-center, observational study. Setting: PICU of a tertiary children’s hospital. Patients: Consecutive patients who stayed greater than 48 hours in the PICU between January 2013 and December 2017. Interventions: None. Measurements and Main Results: Data were retrospectively collected from medical records. We identified occurrences of common healthcare-associated infections, including bloodstream infection, pneumonia, and urinary tract infection, defined according to the 2008 definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the effects of each healthcare-associated infection on length of PICU stay and PICU mortality using multivariable analysis. Among 1,622 admissions with a PICU stay greater than 48 hours, the median age was 299 days and male patients comprised 51% of admissions. The primary diagnostic categories were cardiovascular (58% of admissions), respiratory (21%), gastrointestinal (8%), and neurologic/muscular (6%). The median length of PICU stay was 6 days, and the PICU mortality rate was 2.5%. A total of 167 healthcare-associated infections were identified, including 67 bloodstream infections (40%), 43 pneumonias (26%), and 57 urinary tract infections (34%). There were 152 admissions with at least one healthcare-associated infection (9.4% of admissions with a stay > 48 hr). On multivariable analysis, although each healthcare-associated infection was not significantly associated with mortality, bloodstream infection was associated with an extra length of PICU stay of 10.2 days (95% CI, 7.9–12.6 d), pneumonia 14.2 days (11.3–17.2 d), and urinary tract infection 6.5 days (4.0–9.0 d). Accordingly, 9.7% of patient-days were due to these three healthcare-associated infections among patients with a stay greater than 48 hours. Conclusions: Although healthcare-associated infections were not associated with PICU mortality, they were associated with extra length of PICU stay. As 9.7% of patient-days were due to healthcare-associated infections, robust prevention efforts are warranted. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: hatachi@wch.opho.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Hospital-Acquired Pressure Injuries in Children With Congenital Heart Disease: Prevalence and Associated Factors Objectives: To explore the prevalence, location, and clinical factors associated with hospital-acquired pressure injuries among pediatric patients with congenital heart disease. Design: Secondary analysis of data from a multicenter prospective cohort study of pediatric pressure injury risk, including patients with congenital heart disease. Setting: Eight acute care academic pediatric hospitals. Patients: Patients were preterm to 21 years old with congenital heart disease and on bed rest for at least 24 hours after hospital admission with a medical device attached to or traversing the skin or mucous membrane. Interventions: None. Measurements and Main Results: Patients were evaluated for a maximum of eight observations during a 4-week period to identify Braden QD risk and pressure injury development. Hospital-acquired pressure injuries were staged according to the National Pressure Ulcer Advisory Panel guidelines. Stepwise logistic regression was used to explore risk factors associated with hospital-acquired pressure injuries development, accounting for site as a cluster variable using generalized estimating equations. Overall, 279 pediatric cardiac patients provided 919 observations (median, 2 per patient [interquartile range, 2–5 per patient]). Thirty-eight hospital-acquired pressure injuries occurred in 27 patients (9.7%). Most injuries (28/38 [74%]) were related to medical devices. The most common medical devices that caused injury were oxygen saturation probes. The remaining hospital-acquired pressure injuries were immobility-related pressure injuries (10/38 [26%]) located primarily on the buttock, sacrum, or coccyx (5/10 [50%]). In multivariable analyses, being non-Hispanic white (odds ratio, 3.54; 95% CI, 2.15–5.84), experiencing operating room time greater than 4 hours (odds ratio, 2.91; 95% CI, 1.13–7.49), having oxygen saturation levels less than 85% (odds ratio, 2.65; 95% CI, 1.01–6.96), and having worse Braden QD scores (odds ratio, 1.25 per 1 point increase; 95% CI, 1.17–1.34) were significantly associated with hospital-acquired pressure injuries development. Conclusions: In this multicenter observational study of pediatric patients with congenital heart disease, we describe a hospital-acquired pressure injury prevalence of 9.7% with approximately 75% of injuries related to medical devices. These data can be used to inform practice and target interventions to decrease pressure injury risk and prevent pressure injuries in this vulnerable pediatric population. The Braden QD Study Group members include as follows: Martha A. Q. Curley, RN, PhD, Natalie R. Hasbani, MPH, Sandy M. Quigley, RN, MSN, Judith J. Stellar, RN, MSN, Tracy A. Pasek, RN, DNP, Stacey S. Shelley, RN, MSN, Lindyce A. Kulik, RN, MS, Tracy B. Chamblee, RN, PhD, Mary Anne Dilloway, RN, BS, Catherine N. Caillouette, RN, MS, Margaret A. McCabe, RN, PhD, and David Wypij, PhD. 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). Ms. Kulik’s and Ms. Quigley’s institution received funding from the Wound, Ostomy and Continence Nurses Society and the Program for Patient Safety and Quality, Boston Children’s Hospital. Ms. Kulik’s and Drs. Wypij’s and Curley’s institutions received funding from institution received funding from American Association of Critical-Care Nurses. Ms. Stellar received funding from Proctor and Gamble (one-time consultation, unrelated to the study). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: lindyce.kulik@childrens.harvard.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Bioactive Oxylipins in Infants and Children With Congenital Heart Disease Undergoing Pediatric Cardiopulmonary Bypass Objectives: To determine the production of 9-hydroxyoctadecadienoic acid and 13-hydroxyoctadecadienoic acid during cardiopulmonary bypass in infants and children undergoing cardiac surgery, evaluate their relationship with increase in cell-free plasma hemoglobin, provide evidence of bioactivity through markers of inflammation and vasoactivity (WBC count, milrinone use, vasoactive-inotropic score), and examine their association with overall clinical burden (ICU/hospital length of stay and mechanical ventilation duration). Design: Prospective observational study. Setting: Twelve-bed cardiac ICU in a university-affiliated children’s hospital. Patients: Children were prospectively enrolled during their preoperative clinic appointments with the following criteria: greater than 1 month to less than 18 years old, procedures requiring cardiopulmonary bypass Interventions: None. Measurements and Main Results: Plasma was collected at the start and end of cardiopulmonary bypass in 34 patients. 9-hydroxyoctadecadienoic acid, 13-hydroxyoctadecadienoic acid, plasma hemoglobin, and WBC increased. 9:13-hydroxyoctadecadienoic acid at the start of cardiopulmonary bypass was associated with vasoactive-inotropic score at 2–24 hours postcardiopulmonary bypass (R2 = 0.25; p < 0.01), milrinone use (R2 = 0.17; p < 0.05), and WBC (R2 = 0.12; p < 0.05). 9:13-hydroxyoctadecadienoic acid at the end of cardiopulmonary bypass was associated with vasoactive-inotropic score at 2–24 hours (R2 = 0.17; p < 0.05), 24–48 hours postcardiopulmonary bypass (R2 = 0.12; p < 0.05), and milrinone use (R2 = 0.19; p < 0.05). 9:13-hydroxyoctadecadienoic acid at the start and end of cardiopulmonary bypass were associated with the changes in plasma hemoglobin (R2 = 0.21 and R2 = 0.23; p < 0.01). The changes in plasma hemoglobin was associated with milrinone use (R2 = 0.36; p < 0.001) and vasoactive-inotropic score less than 2 hours (R2 = 0.22; p < 0.01), 2–24 hours (R2 = 0.24; p < 0.01), and 24–48 hours (R2 = 0.48; p < 0.001) postcardiopulmonary bypass. Cardiopulmonary bypass duration, 9:13-hydroxyoctadecadienoic acid at start of cardiopulmonary bypass, and plasma hemoglobin may be risk factors for high vasoactive-inotropic score. Cardiopulmonary bypass duration, changes in plasma hemoglobin, 9:13-hydroxyoctadecadienoic acid, and vasoactive-inotropic score correlate with ICU and hospital length of stay and/mechanical ventilation days. Conclusions: In low-risk pediatric patients undergoing cardiopulmonary bypass, 9:13-hydroxyoctadecadienoic acid was associated with changes in plasma hemoglobin, vasoactive-inotropic score, and WBC count, and may be a risk factor for high vasoactive-inotropic score, indicating possible inflammatory and vasoactive effects. Further studies are warranted to delineate the role of hydroxyoctadecadienoic acids and plasma hemoglobin in cardiopulmonary bypass-related dysfunction and to explore hydroxyoctadecadienoic acid production as a potential therapeutic target. 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. Kim-Campbell was supported by the Ann E. Thompson Fellow Scholarship Award; UL1 TR000005 (University of Pittsburgh Clinical and Translational Science Institute), the Vascular Medicine Institute, the Hemophilia Center of Western Pennsylvania, and the Institute for Transfusion Medicine; and the National Institutes of Health (NIH) (T32HD040686 and 1K12HL109068). Dr. Bayir is supported by grants from the NIH (NS084604 and NS061817). Drs. Kim-Campbell, Callaway, and Bayir received support for article research from the NIH. Dr. Ritov disclosed work for hire. Dr. Kochanek received funding from the Society of Critical Care Medicine for acting as Editor-in-Chief of Pediatric Critical Care Medicine. Dr. Callaway’s institution received funding from National Heart, Lung, and Blood Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: nahmah.kimcampbell@chp.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Evaluation of Pediatric Cardiac ICU Advanced Practice Provider Education and Practice Variation Objectives: The education, training, and scope of practice of cardiac ICU advanced practice providers is highly variable. A survey was administered to cardiac ICU advanced practice providers to examine specific variations in orientation format, competency assessment during and at the end of orientation, and scope of clinical practice to determine gaps in resources and need for standardization. Design: This study was a cross-sectional descriptive study utilizing survey responses. Setting: Pediatric cardiac ICUs in the United States. Subjects: The survey was delivered to a convenience sample of advanced practice providers currently practicing in pediatric cardiac ICUs. Interventions: A list of pediatric cardiothoracic surgery programs was generated from the Society of Thoracic Surgery database. A self-administered, electronic survey was delivered via email to advanced practice providers at those institutions. Descriptive data were compared using a chi-square test or Fisher exact test depending on the normalcy of data. Continuous data were compared using a Student t test or Mann-Whitney U test. Measurements and Main Results: Eighty-three of 157 advanced practice providers responded (53% response rate, representing 36 institutions [35% of institutions]). Sixty-five percent of respondents started as new graduates. Ninety-three to one-hundred percent obtain a history and physical, order/interpret laboratory, develop management plans, order/titrate medications, and respiratory support. Ability to perform invasive procedures was highly variable but more likely for those in a dedicated cardiac ICU. Seventy-seven percent were oriented by another advanced practice provider, with a duration of orientation less than 4 months (66%). Fifty percent of advanced practice providers had no guidelines in place to guide learning/competency during orientation. Sixty-seven percent were not evaluated in any way on their knowledge or skills during or at the end of orientation. Orientation was rated as poor/fair by the majority of respondents for electrophysiology (58%) and echocardiography (69%). Seventy-one percent rated orientation as moderately effective or less. Respondents stated they would benefit from more structured didactic education with clear objectives, standardized management guidelines, and more simulation/procedural practice. Eighty-five percent were very/extremely supportive of a standardized cardiac ICU advanced practice provider curriculum. Conclusions: Orientation for cardiac ICU advanced practice providers is highly variable, content depends on the institution/preceptor, and competency is not objectively defined or measured. A cardiac ICU advanced practice provider curriculum is needed to standardize education and promote the highest level of advanced practice provider practice. 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. Address requests for reprints to: Lindsey Justice, DNP, APRN, CPNP-AC, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, 45229. E-mail: Lindsey.Justice@cchmc.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies