Prediction and Comparison of Fentanyl Infusion Pharmacokinetics in Obese and Nonobese Children Objectives: To compare fentanyl infusion pharmacokinetic variables in obese children and nonobese children. Design: A pharmacokinetic simulation study. Setting: We used a semi-physiologically based pharmacokinetic model to generate fentanyl pharmacokinetic variables. Subjects: Simulations of pharmacokinetic variables were based on historical inpatient demographic data in less than 18-year-olds. Interventions: Obese children were defined as children less than 2 years with weight-for-length greater than or equal to 97.7th percentile or body mass index-for-age greater than or equal to 95th percentile for greater than or equal to 2–17-year-olds. Measurements and Main Results: Overall, 4,376 patients were included, with 807 (18.4%) classified as obese children. The majority (52.9%) were male, with a median age of 8.1 years (interquartile range, 4.3–13.0 yr). The differences in total clearance (CLS), volume of distribution at steady-state values, weight-normalized CLS, and weight-normalized volume of distribution at steady state were assessed in obese children and nonobese children. Multivariable analyses indicated that obesity was significantly associated with a higher CLS in obese children greater than 6-year-olds (p < 0.0375). However, there was an 11–30% decrease in weight-normalized CLS in obese children versus nonobese children in all age groups (p < 0.05). Both volume of distribution at steady state and weight-normalized volume of distribution at steady state increased significantly in obese children compared with nonobese children (p < 0.05). Fentanyl plasma concentration-time profiles of obese children and nonobese children pairs (ages 4, 9, and 15) receiving 1 µg/kg/hr using total body weight were also compared. Steady-state concentrations of the obese children using similar weight-based dosing increased by 25%, 77%, and 44% in comparison to nonobese children 4-, 9-, and 15-year-olds, respectively. Time to steady state and elimination half-lives were two- to four-fold longer in obese children. An additional simulation was conducted for 15-year-old obese children and nonobese children using a fixed dose of 50 µg/hr and it provided similar pharmacokinetic profiles. Conclusions: CLS may increase less than proportional to weight in obese children greater than 6-year-olds, while volume of distribution at steady state increases more than proportional to weight in all obese children compared with nonobese children. Weight-based dosing in obese children may cause an increase in steady-state concentration while prolonging the time to steady state. Exploring alternative dosing strategies for obese children is warranted. 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). Platform Presentation at the Society of Critical Care Medicine 46th Critical Care Congress in Honolulu, HI, January 2017. Drs. Miller’s and Johnson’s institutions received funding from American Society of Health System Pharmacists. Dr. Skrepnek’s institution received funding from AbbVie, Purdue Pharma, Otsuka, Gilead, and Amgen. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Sin Yin Lim, PharmD, Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, 1110 N. Stonewall Ave., CPB 216, Oklahoma City, OK 73117. E-mail: sinyin-lim@ouhsc.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Vacuum-Assisted Closure for the Treatment of Deep Sternal Wound Infection After Pediatric Cardiac Surgery Objectives: Vacuum-assisted closure is being increasingly used to treat deep sternal wound infection following cardiac surgery, but most of the data refer to adults. This study investigated the safety and efficacy of vacuum-assisted closure in pediatric patients. Design: Retrospective file review. Setting: Tertiary pediatric medical center. Patients: All children with deep sternal wound infection treated with vacuum-assisted closure in 2003–2016. Interventions: Epidemiological, clinical, and microbiological data were collected from the medical records. Measurements and Main Results: The cohort included 50 patients (0.9% of cardiac patients operated during the study period) of median age 6.5 months (interquartile range, 2–12.75 mo; range, 1 wk to 14 yr) and median weight 5.1 kg (interquartile range, 4–9.75 kg). The most frequent heart defects were tetralogy of Fallot (22%) and ventricular septal defect (20%); 38% of patients had cyanotic heart disease. Deep sternal wound infections appeared a median of 10 days postoperatively (interquartile range, 7–14 d; range 3–100 d). Vacuum-assisted closure was applied a median of 13 days postoperatively (interquartile range, 10–18.5 d; range, 5–103 d) for a median duration of 10 days (interquartile range, 7–13.25 d; range, 1–21 d). Wound cultures were positive in 48 patients (96%); most isolates were Gram-positive (76%). The main bacterial pathogen was methicillin-susceptible Staphylococcus aureus (61%). Most patients were treated with cloxacillin for a median of 38 days (interquartile range, 28–42 d; range, 9–189 d). There were no statistically significant differences in clinical or treatment characteristics between bacteremic (56%) and nonbacteremic patients. Compared with older patients, infants less than 3 months old (36%) had a significantly longer hospitalization time (41 vs 25 d; p = 0.001) and higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category (3 vs 2; p = 0.003). All cases except one (contact dermatitis) were uneventful. In 10 patients, wounds were closed surgically after vacuum-assisted closure. Two patients required a pectoralis flap, both treated before 2005. One of the two deaths was infection-related. Conclusions: Vacuum-assisted closure is a feasible treatment option of deep sternal wound infection after pediatric cardiac surgery and was not associated with independent morbidity. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: itzhakl@clalit.org.il ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Population-Based Epidemiology and Outcomes of Acute Kidney Injury in Critically Ill Children Objectives: We describe the epidemiology, characteristics, risk factors, and incremental risks associated with acute kidney injury in critically ill children at a population-level. Design: Population-based retrospective cohort study. Setting: PICUs in Alberta, Canada. Patients: All children admitted to PICUs in Alberta, Canada between January 1, 2015, and December 31, 2015. Interventions: None. Measurements and Main Results: A total of 1,017 patients were included. Acute kidney injury developed in 308 patients (30.3%; 95% CI, 28.1–33.8%) and severe acute kidney injury (Kidney Disease: Improving Global Outcomes stage 2 and 3) developed in 124 patients (12.2%; 95% CI, 10.3–14.4%). Incidence rates for critical illness-associated acute kidney injury and severe acute kidney injury were 34 (95% CI, 30.3–38.0) and 14 (95% CI, 11.38–16.38) per 100,000 children-year, respectively. Severe acute kidney injury incidence rates were greater in males (incidence rate ratio, 1.55; 95% CI, 1.08–2.33) and infants younger than 1 year old (incidence rate ratio, 14.77; 95% CI, 10.36–21.07). Thirty-two patients (3.1%) did not survive to PICU discharge. The acute kidney injury-associated PICU mortality rate was 2.3 (95% CI, 1.4–3.5) per 100,000 children-year. In multivariate analysis, severe acute kidney injury was associated with greater PICU mortality (odds ratio, 11.93; 95% CI, 4.68–30.42) and 1-year mortality (odds ratio, 5.50; 95% CI, 2.76–10.96). Severe acute kidney injury was further associated with greater duration of mechanical ventilation, duration of vasoactive support, and lengths of PICU and hospital stay. Conclusions: The population-level burden of acute kidney injury and its attributable risks are considerable among critically ill children. These findings emphasize the need for enhanced surveillance for acute kidney injury, identification of modifiable risks, and evaluation of interventional strategies. 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, grant from the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta. Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: bagshaw@ualberta.ca ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

New-Onset Refractory Status Epilepticus in Children: Etiologies, Treatments, and Outcomes Objectives: To elucidate etiologies, treatment, functional and neurocognitive outcomes of children with new-onset refractory status epilepticus. Design: A single-center retrospective study. Setting: A tertiary care children’s hospital. Patients: All patients between 1 month and 21 years old admitted with new-onset refractory status epilepticus between January 2004 and July 2017. Interventions: None. Measurements and Main Results: Clinical presentation, laboratory data, imaging studies, and treatments were collected during hospitalization. Outcomes were assessed at hospital discharge and follow-up in the outpatient neurology clinic based on functional and neurocognitive outcomes as well as development of epilepsy. A total of 674 unique patients presented with status epilepticus of which 40 had new-onset refractory status epilepticus. Patients were classified into either refractory status epilepticus or super-refractory status epilepticus. The etiology of most children with new-onset refractory status epilepticus remained cryptogenic. The most common identified etiology was viral (20%). None of the patients had a contributory positive neuronal antibody test. Several treatments were tried including immunotherapy which was used in half of the patients. Five patients died (12.5%) during the acute phase of their disease, with four lost to follow-up. Twenty out of the remaining 31 patients (65%) developed epilepsy and 18 (58%) had persistent neurocognitive impairment. There was no statistical significant difference in various outcome measures and various etiologies, patients’ characteristics, and treatments. Conclusions: In this single-center cohort, more than half of the children with new-onset refractory status epilepticus did not have an identifiable etiology. Unlike adult patients, the presence of positive neuronal antibody syndrome was rare. There was no difference in outcome between those with or without an identifiable etiology. As expected, patients with super-refractory status epilepticus had worse functional and neurocognitive outcomes. More standardized diagnostic and treatment algorithms are needed along with prospective multicenter studies. Current affiliation for Dr. Husari: Department of Neurology, Johns Hopkins University, Baltimore, MD. Current affiliation for Dr. Labiner: Child Neurology Consultants of Austin, Austin, TX. Current affiliation for Mr. Huang: Children’s Medical Center Dallas, Dallas, TX. Current affiliation for Dr. Said: Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX. This study was conducted at the University of Texas Southwestern Medical Center. Drs. Husari and Said were involved in study concept and design, as well as critical revision of the article for important intellectual content. Drs. Husari and Labiner were involved in acquisition, analysis, or interpretation of data and drafting of the article. Mr. Huang and Dr. Husari were involved in statistical analysis. 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, institutional award (Service Package Award) grant from Children’s HealthSM—Children Medical Center to cover the statistical consultation and analysis. Dr. Husari’s institution received funding from Children’s Health—Children Medical Center. Dr. Said’s institution received funding from an internal grant from Children’s Health Dallas (called the Service Package Grant) for the amount of $4,225 for Statistical Consultation and Analysis, and she disclosed that she serves on the Professional Advisory Board of the Epilepsy Foundation of Texas (volunteer, unpaid position). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: kshusari@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Association of Duration of Hypotension With Survival After Pediatric Cardiac Arrest Objectives: To evaluate the association of a single episode of hypotension and burden of hypotension with survival to hospital discharge following resuscitation from pediatric cardiac arrest. Design: Retrospective cohort study. Setting: Single-center PICU. Patients: Patients between 1 day and 18 years old who had a cardiac arrest, received chest compressions for more than 2 minutes, had return of spontaneous circulation for more than 20 minutes, and survived to receive postresuscitation care in the ICU. Interventions: None. Measurement and Main Results: One-hundred sixteen patients were evaluable. Hypotension, defined as systolic blood pressure less than the fifth percentile for age and sex, occurred in 37 patients (32%) within the first 6 hours and 64 (55%) within 72 hours of postresuscitation ICU care. There was no significant difference in survival to discharge for patients who had a single episode of hypotension within 6 hours (51% vs 69%; p = 0.06) or within 72 hours (56% vs 73%; p = 0.06). Burden of hypotension was defined as the percentage of hypotension measurements that were below the fifth percentile. After controlling for patient and cardiac arrest event characteristics, a higher burden of hypotension within the first 72 hours of ICU postresuscitation care was associated with decreased discharge survival (adjusted odds ratio = 0.67 per 10% increase in hypotension burden; 95% CI, 0.48–0.86; p = 0.006). Conclusions: After successful resuscitation from pediatric cardiac arrest, systolic hypotension was common (55%). A higher burden of postresuscitation hypotension within the first 72 hours of ICU postresuscitation care was associated with significantly decreased discharge survival, after accounting for potential confounders including number of doses of epinephrine, arrest location, and arrest etiology due to airway obstruction or trauma. Dr. Topjian’s institution received funding from the National Institutes of Health (NIH); she received funding from expert testimony; and she received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: laverrieree@email.chop.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Necrotizing Enterocolitis and Associated Mortality in Neonates With Congenital Heart Disease: A Multi-Institutional Study Objective: There are scarce data about the prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. The purpose of this study is to provide a multi-institutional description and comparison of the overall prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. Design: Retrospective multi-institutional study. Setting: The Pediatric Health Information System database. Patients: Neonates with congenital heart disease between 2004 and 2014. Interventions: None. Measurements and Main Results: The primary study measure is the prevalence of necrotizing enterocolitis. Secondary measures include in-hospital mortality, hospital charges, ICU length of stay, hospital length of stay, and 30-day readmission. The prevalence of necrotizing enterocolitis was 3.7% (1,448/38,770) and varied significantly among different congenital heart disease diagnoses. The lowest prevalence of necrotizing enterocolitis was in transposition of the great arteries (n = 104, 2.1%). Compared with transposition of the great arteries, necrotizing enterocolitis occurred more frequently in neonates with hypoplastic left heart syndrome (odds ratio, 2.7; 95% CI, 2.1–3.3), truncus arteriosus (odds ratio, 2.6; 95% CI, 1.9–3.5), common ventricle (odds ratio, 2.1; 95% CI, 1.5–2.8), and aortic arch obstruction (odds ratio, 1.4; 95% CI, 1.1–1.7). Prematurity is a significant risk factor for necrotizing enterocolitis and for mortality in neonates with necrotizing enterocolitis, conferring varying risk by cardiac diagnosis. Unadjusted mortality associated with necrotizing enterocolitis was 24.4% (vs 11.8% in neonates without necrotizing enterocolitis; p < 0.001), and necrotizing enterocolitis increased the adjusted mortality in neonates with transposition of the great arteries (odds ratio, 2.5; 95% CI, 1.5–4.4), aortic arch obstruction (odds ratio, 1.8; 95% CI, 1.3–2.6), and tetralogy of Fallot (odds ratio, 1.6; 95% CI, 1.1–2.4). Necrotizing enterocolitis was associated with increased hospital charges (p < 0.0001), ICU length of stay (p = 0.001), and length of stay (p = 0.001). Conclusions: The prevalence of necrotizing enterocolitis among neonates with congenital heart disease is 3.7% and is associated with increased in-hospital mortality, length of stay, and hospital charges. The prevalence and associated mortality of necrotizing enterocolitis in congenital heart disease vary among different heart defects. Dr. Spinner assisted with data analysis, drafted the initial article, and reviewed and revised the final article. Dr. Morris assisted with data analysis, and critically reviewed and revised the article. Drs. Nandi, Costarino, Marino, and Rossano critically reviewed and revised the article. Dr. Shamszad conceptualized and designed the study, collected the data, performed data analysis, and reviewed and revised the article. Dr. Morris received funding from Guidepoint (consulting). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: shamszadp@email.chop.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Assessment of the Independent and Synergistic Effects of Fluid Overload and Acute Kidney Injury on Outcomes of Critically Ill Children Objectives: Evaluate the independent and synergistic associations of fluid overload and acute kidney injury with outcome in critically ill pediatric patients. Design: Secondary analysis of the Acute Kidney Injury in Children Expected by Renal Angina and Urinary Biomarkers (NCT01735162) prospective observational study. Setting: Single-center quaternary level PICU. Patients: One-hundred forty-nine children 3 months to 25 years old with predicted PICU length of stay greater than 48 hours, and an indwelling urinary catheter enrolled (September 2012 to March 2014). Acute kidney injury (defined by creatinine or urine output on day 3) and fluid overload (≥ 20% on day 3) were used as outcome variables and risk factors for ICU endpoints assessed at 28 days. Interventions: None. Measurements and Main Results: Acute kidney injury and fluid overload occurred in 19.4% and 24.2% respectively. Both acute kidney injury and fluid overload were associated with longer ICU length of stay but neither maintained significance after multivariate regression. Delineation into unique fluid overload/acute kidney injury classifications demonstrated that fluid overload+ patients experienced a longer ICU and hospital length of stay and higher rate of mortality compared with fluid overload– patients, regardless of acute kidney injury status. Fluid overload+/acute kidney injury– patients had increased odds of death (p = 0.013). After correction for severity of illness, ICU length of stay remained significantly longer in fluid overload+/acute kidney injury+ patients compared with patients without both classifications (17.4; 95% CI, 11.0–23.7 vs 8.8; 95% CI, 7.3–10.9; p = 0.05). Correction of acute kidney injury classification for net fluid balance led to acute kidney injury class switching in 29 patients and strengthened the association with increased mechanical ventilation and ICU length of stay on bivariate analysis, but reduced the increased risk conferred by fluid overload for mortality. Conclusions: The current study suggests the effects of significant fluid accumulation may be delineable from the effects of acute kidney injury. Concurrent fluid overload and acute kidney injury significantly worsen outcome. Correction of acute kidney injury assessment for net fluid balance may refine diagnosis and unmask acute kidney injury associated with deleterious downstream sequelae. The unique effects of fluid overload and acute kidney injury on outcome in critically ill patients warrant further study. 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). Database support was provided from the Center for Clinical and Translational Science Training Grant Support (8UL1-TR000077). Dr. Gist received support for article research from the National Institutes of Health. Dr. Menon was sponsored in the Cincinnati Children’s Hospital Medical Center’s Acute Care Nephrology Fellowship through a grant from Gambro Renal Products. Dr. Basu received funding from BioPorto Diagnostics and Baxter Healthcare. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: rajit.basu@choa.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Fluid Overload in Pediatric Severe Traumatic Brain Injury Objective: Pediatric traumatic brain injury is a major public health problem in the United States. Hypertonic saline therapy is a well-established treatment in patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) who have intracranial hypertension. In children, fluid overload is associated with increased mortality, ventilator duration, and length of PICU stay, even when controlling for severity of illness. This study reports prevalence of fluid overload in pediatric patients with severe traumatic brain injury treated with 3% hypertonic saline and effect on clinical outcomes. Design: Single-center retrospective chart review. Setting: PICUs at two tertiary children’s hospitals. Patients: One hundred thirty-eight patients with traumatic brain injury with postresuscitation Glasgow Coma Scale less than or equal to 8 who received hypertonic saline from September 1, 2010, to February 28, 2016, and intracranial pressure monitoring and survived at least 24 hours from admission. Interventions: None. Measurements and Main Results: We used fluid balance percentage greater than or equal to 10% as our definition of fluid overload. Ninety-one percent of patients less than 1 year old had fluid overload on day 10 of admission compared with 47% of patients greater than 1 year. Fluid overloaded patients did not have increased mortality, acute kidney injury, PICU length of stay, or ventilator days. Hypertonic saline was not the cause of fluid overload in these patients. Conclusions: Patients with severe traumatic brain injury do have high rates of fluid overload. However, fluid overload did not contribute to mortality, longer days on the ventilator, increased risk of acute kidney injury, or increased PICU length of stay. Dr. Williamson received $1,500 in internal grant support from the Department of Anesthesiology at Emory University for an unrelated project. Dr. Paden received multiple patents (both issued and pending) and multiple grants, all of which are not related to this project. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: caseystulce@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers Objectives: The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. Design: Electronic-mail recruitment with survey of expert centers using web-based questionnaire. Setting: Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. Patients: None. Interventions: None. Measurements and Main Results: A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. Conclusions: At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices. The Executive Committee of the Pediatric Neurocritical Care Research Group (PNCRG) includes: the Chair (Michelle Schober, 2018-2020), a past Chair (Courtney Robertson, 2016-2018), Secretary/Treasurer (Jonathan Kurz, 2019-2021), the Chair of the Scientific Review Committee (Jose Pineda, 2018-2020) and two Councilors (senior level leaders, Mark Wainwright and Mike Bell). 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. Appavu’s institution received funding from American Heart Association and Moberg ICU Solutions. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: kerri.larovere@childrens.harvard.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU Objectives: To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. Design: Prospective pre/post observational study. Setting: A large single-center noncardiac PICU in North America. Patients: All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018. Interventions: Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement. Measurements and Main Results: Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34–0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31–0.96) while adjusting for tracheal intubation indications and device. Conclusions: Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children. Supported, in part, by grant from the Agency for Healthcare Research and Quality (AHRQ) R03HS021583, AHRQ R18HS022464, R18HS024511 and Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia. Ms. Napolitano’s, Ms. Craig’s, and Dr. Nishisaki’s institutions received funding from Agency for Healthcare Research and Quality (AHRQ) R03HS021583, AHRQ R18HS022464, and R18HS024511. Ms. Napolitano’s and Ms. Craig’s institutions received funding from Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia. Ms. Napolitano and Drs. Nadkarni and Nishisaki are supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development R21 HD089151 and AHRQ R18HS024511. Ms. Napolitano disclosed off-label product use of simple nasal cannula with higher flow ranges than recommended by the manufacturer; and she disclosed that she has research relationships and consulting relationships with Draeger, Actuated Medical, Smiths Medical, Vero Biotech, Philips/Respironics, and Aerogen. Ms. Snyder disclosed that she received compensation from American Association of Critical-Care Nursing (presenting at National Training Institute in 2017) and Springer Publishing for writing a chapter on pediatric sepsis. Dr. Branca received support for article research from AHRQ R03HS021583, AHRQ R18HS022464, and R18HS024511. Dr. Nishisaki received support for article research from the AHRQ. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: napolitanon@email.chop.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies