Select one of our projects below (listed a-z) to learn more.
CPCCRN has undertaken several preliminary studies to gain knowledge that will help us to develop and test a framework for conducting physician-parent follow-up meetings after a child's death in the PICU. We have used our research findings along with relevant literature on physician-parent communication to create a framework for physician-parent follow-up meetings after a child's death in the PICU. We are currently pilot testing this newly developed framework to refine its components and assess feasibility of implementation across CPCCRN sites.
The Parent Bereavement Study is a multicenter pilot study of video-recorded physician-parent follow-up meetings using the CPCCRN framework. Results of the pilot test will be used to assess the feasibility of the framework and to refine the framework prior to conducting a randomized controlled trial of the effect of physician-parent follow-up meetings on parental bereavement outcomes. This study has been completed and the results are being prepared for publication.
- A framework for conducting follow-up meetings with parents after a child's death in the pediatric intensive care unit (Meert 2011 PMC3285236)
The CPCCRN Core Data Project (CCDP) obtains descriptive information about all Pediatric Intensive Care Unit (PICU) discharges from the network Clinical Centers, based primarily on Clinical Center hospital administrative databases, and creates a database to be used by the CPCCRN investigators and the NICHD. The project provides pilot and descriptive data necessary for hypothesis generation, study design, preliminary power analyses, and recruitment projections for studies under development by the CPCCRN. The CCDP is a valuable resource to the CPCCRN and helps stimulate new research protocols, identify potential need for non-network partners to access additional patient populations, and provide a descriptive understanding of the critically ill infants and children cared for within the network.
Status asthmaticus is the most common medical emergency in children today and is responsible for nearly half a million hospital admissions annually. Despite evidence that asthma hospitalizations are decreasing, asthma mortality is not.
In order to gain a better understanding of status asthmaticus, its treatment, and its overall outcomes, each PICU research team within the Collaborative Pediatric Critical Care Research Network (CPCCRN) examined its admissions records in detail for children ages 1 year to 18 years old, over the last 5 years for any instances of deaths resulting from a diagnosis of asthma (fatal asthma). Post-mortem data was reviewed where available. In addition, the medical records for children intubated and mechanically ventilated for asthma (near-fatal asthma) were analyzed.
This review and abstraction has enabled CPCCRN investigators to quantify the current variability of critical asthma treatment and has helped us to identify additional medical problems, such as organ failure and the relatively high intubation rate for African-American children that occurred during the patient’s near-fatal illness. Data from this study will inform development of prospective studies investigating the management of critical asthma.
- Critical care for pediatric asthma: Wide care variability and challenges for study (Bratton 2012 PMC Journal - in process)
- Fatal and Near-Fatal Asthma in Children: The Critical Care Perspective (Newth 2012 PMC Journal - in process)
Despite high coverage for childhood vaccination, pertussis causes substantial morbidity and mortality in U.S. children, especially among young infants. Although pertussis is a well-known precipitant of critical illness, especially in infants, several gaps of knowledge about critical pertussis (pertussis associated with a PICU admission) exist. Understanding the morbidity and cost burden of severe pertussis, will inform national prevention strategies as adequate U.S. data do not exist, generate hypotheses, and help prioritize research.
Among children <18 years of age with pertussis who require hospitalization in the PICU, the aims of this multicenter study are to 1) characterize the acute course during the PICU admission; 2) assess reported health status and family impact following PICU discharge; 3) assess developmental sequelae and quality of life among infants who were less than 12 months of gestational age at time of PICU admission 12-months following PICU discharge; and 4) assess risk factors associated with developmental sequelae in infants.
A prospective cohort of children with critical pertussis will be identified through the National Institute for Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network (CPCCRN) and other PICU sites utilizing existing national research infrastructure. With enhanced PICU surveillance, approximately 250 critical pertussis case-children will be enrolled. Eligible pertussis cases will be defined using study case definitions. Demographic and clinical information will be collected through chart abstraction and parental interview. Six months after hospital discharge, health status will be assessed through questionnaire administered by mail survey. Among infants <12 months of gestational age at the time of PICU admission, developmental sequelae survivor outcomes will be evaluated with the validated Mullen Scales of Early Learning and potential risk factors for sequelae assessed through univariate and multivariable analyses.
- Protocol: Critical Pertussis in U.S. Children: Severe Morbidity, Sequelae, and Mortality: A Prospective Cohort Study
- The Collaborative Pediatric Critical Care Research Network (CPCCRN) Critical Pertussis Study: Collaborative research in pediatric critical care medicine (Burr 2011 PMC3439849)
This study, entitled “Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA),” evaluates whether regulating the body temperature will improve the outcome for children after cardiac arrest. There is a separate trial for children who arrest in the hospital (THAPCA-IH) and children who arrest out of the hospital (THAPCA-OH). The goal of these two randomized trials is to determine if therapeutic hypothermia improves survival with good neurobehavioral outcome in children who have had a cardiac arrest. Fever commonly occurs after cardiac arrest and is associated with worse outcome (death or brain damage). It is not known whether therapeutic hypothermia is superior to simply preventing elevated body temperature by keeping it in a normal range (normothermia). The trials are funded by the National Heart, Lung and Blood Institute (NHLBI) to enroll approximately 850 subjects at the CPCCRN centers and 27 additional sites throughout the United States and Canada. Enrollment began in September 2009. The trials are registered at ClinicalTrials.gov. For further information, visit the THAPCA website at www.thapca.org.
- In-hospital versus out-of-hospital pediatric cardiac arrest: A multicenter cohort study (Moler 2009 PMC2711020)
- Multicenter cohort study of in-hospital pediatric cardiac arrest (Meert 2009 PMC2741542)
- Multicenter cohort study of out-of-hospital pediatric cardiac arrest (Moler 2011 PMC3297020)
- Therapeutic Hypothermia after Pediatric Cardiac Arrest Trial: The Vanguard Phase Experience and Implications for other Trials (Pemberton 2013 PMC Journal - in process)
- Early Oxygenation and Ventilation Measurements After Pediatric Cardiac Arrest: Lack of Association with Outcome - Bennett 2013
- Rationale, Timeline, Study Design and Protocol Overview of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trials (Moler 2013 PMC Journal - in process)
- Early Lactate Elevations following Resuscitation from Pediatric Cardiac Arrest are Associated with Increased Mortality - Topjian
The purpose of this study is to evaluate a strategy for ventilator management (ventilator management protocol) that was developed in adult intensive care units for patients with Acute Lung Injury (ALI) or Acute Respiratory Distress Syndrome (ARDS). The goal is to evaluate the extent to which this ventilator management protocol needs to be changed to make it acceptable for use in the pediatric ICU. We are evaluating the size and scale (granularity) of the data input into the protocol and the granularity of recommendations for changes to ventilator settings. A ventilator management protocol that is scaled for pediatric use could support future research studies in the CPCCRN network and in other PICUs. The project is supported by Award Number R21HD061870 from the Eunice Kennedy Shriver National Institute Of Child Health & Human Development.
- Weaning and extubation readiness in pediatric patients (Newth 2009 PMC2849975)
- Variability in usual care mechanical ventilation for pediatric acute lung injury: the potential benefit of a lung protective computer protocol (Khemani 2011 PMC Journal - in process)
Critical care in general and pediatric critical care in particular, has developed excellent measures of severity of illness calibrated to mortality. However, severity may be reflected in subsequent morbidity as well as survival. A major challenge of critical care outcomes research is the development of methodologies that predict the full range of outcomes from normal through the range of morbidities as well as death. Critical care mortality prediction models are highly dependent on physiological system dysfunctions such as cardiovascular, neurological, respiratory, renal, metabolic, and hematological dysfunction. Yet the same dysfunction may result in intermediate and/or long-term functional status changes. ICU therapies such as steroid use and mechanical ventilation are associated with long-term sequelae including myopathy and chronic lung disease. It is logical to postulate that morbidity related to the progression of injury resulting from physiologic dysfunction such that, in the context of critical care, morbidity is an intermediate outcome between complete recovery and death.
TOPICC is a prospective observational cohort study where a probability sample of all patients under 18 years of age, who are admitted to all non-neonatal CPCCRN PICUs, will be selected. The final sample size is estimated at 10,000 patients. The estimated duration of the study is two years. During this time, the project will seek to determine the optimal time window in which to collect data elements representing the initial medical and physiological condition of PICU patients at the time of admission to the PICU. Also, investigators aim to derive and validate a predictor of three or more outcome states following pediatric intensive care; specifically death, survival with reduced functional status, and survival with normal or unchanged functional status. The ultimate goal of this study is to develop and validate a new predictive instrument to measure quality of care provided to children in PICUs across the country. This instrument will facilitate comparisons in quality of care and help inform the development of new interventions aimed at improving the quality of pediatric critical care.
- The ideal time interval for critical care severity-of-illness assesment (Pollack 2013 PMC Journal - in process)
Bleeding and thrombosis represent major adverse events during extracorporeal membrane oxygenation (ECMO). Complications resulting from these events can lead to death or need for long term rehabilitation support. Despite the increasing use of extracorporeal support and new technology which makes it simpler and potentially safer to apply, little scientific information regarding the predictors of bleeding or thrombosis exist.
This project will seek to describe the incidence of bleeding and thrombosis in ECMO patients at CPCCRN sites, describe current anticoagulation monitoring practices and seek evidence of association between bleeding and thrombotic complications, laboratory coagulation measurements, patient characteristics, ECMO circuitry and adherence to center-specific ECMO management protocols. The ultimate goal of this research is to eliminate bleeding and thrombotic complications during ECMO and improve outcome for these patients.
Informaticists at the Data Coordinating Center (DCC) have devised a way to use grid based technology, originally developed by the National Cancer Institute (NCI), to electronically collect and transfer data from the electronic medical record (EHR). The DCC has developed virtual machines, that contain the entire required software and a server, to be implemented at each CPCCRN site. Site ‘picuGrid’ implementation requires ongoing and extensive collaboration among the DCC picuGrid team, the site’s CPCCRN Research Team, and most importantly, the site’s information technology management and personnel. After successful implementation of the picuGrid, future network studies can be accomplished more efficiently because data will be electronically transferred to the DCC, rather than manually abstracted from the EHR by research coordinators. The EHR data transfer is approved by our Institutional Review Board, and the DCC has provided a Business Associate Agreement to cover HIPAA related issues. The exciting future of this project is to enable laboratory test results and other clinical information to be handled in a similar fashion, subject to IRB approval, for individual research projects.
Cardiac arrests in children are a major public health problem. Thousands of children in the USA are treated in pediatric intensive care units (ICUs) with cardiopulmonary resuscitation (CPR) each year for sudden in-hospital cardiac arrest. Neurological outcomes following these in-hospital PICU CPR events are often abnormal. As children with neurological deficits following in-hospital CPR are a major burden for families and society, improving neurological outcomes through superior blood flow during CPR is an important clinical goal.
High-fidelity hemodynamic data will be obtained during qualifying CPR Events in the ICU, and then analyzed by pediatric cardiopulmonary resuscitation field experts. This investigation aims to obtain evidentiary support to associate hemodynamics (arterial diastolic pressure and end tidal carbon dioxide) during CPR with outcomes in those children who suffer an arrest within CPCCRN ICUs.
- Rate of pediatric ICU versus ward cardiopulmonary resucitation events: Are ward CPR events becoming "Never Events"?
The objective of the first phase of the CPCCRN Bereavement studies was to investigate parents’ perspectives on the desirability, content, and conditions of a Physician-Parent conference after their child’s death in the Pediatric Intensive Care Unit. Audio recorded telephone interviews were conducted with 56 parents of 48 children. All of the children died in the PICU of one of the CPCCRN children’s hospitals 3 to 12 months before the study. Only seven (13%) parents had a scheduled meeting with any physician to discuss their child’s death; 33 (59%) wanted to meet with their child’s intensive care physician. Of these, 27 (82%) were willing to return to the hospital to meet. Topics that parents wanted to discuss included the chronology of events leading to PICU admission and death, cause of death, treatment, autopsy, genetic risk, medical documents, withdrawal of life support, ways to help others, bereavement support, and what to tell family. Parents sought reassurance and the opportunity to voice complaints and express gratitude. The conclusion was reached that many bereaved parents want to meet with the intensive care physician after their child’s death. Parents seek to gain information and emotional support, and to give feedback about their PICU experience.
- Parents' Perspective Regarding a Physician-Parent Conference after Their Child's Death in the Pediatric Intensive Care Unit (Meert 2007 PMC1993355)
- Parents' perspectives on physician-parent communication near the time of a child's death in the pediatric intensive care unit (Meert 2008 PMC3198033)
- Accounting for medical communication: Parents' perceptions of communicative roles and responsibilities in the pediatric intensive care unit (Gordon 2009 PMC3277327)
This study was designed to investigate the extent of complicated grief symptoms and associated risk factors among parents whose child died in a PICU. This study was carried out by way of surveys conducted over the phone or sent in the mail at 6 months and 18 months after the child’s death. One hundred thirty-eight parents of 106 children completed surveys at 6 and 18 months. Potential risk factors including demographic and clinical variables as well as parent psychosocial characteristics, such as attachment style, caregiving style, grief avoidance, and social support were assessed. The 6-month survey results showed that parents experienced high levels of complicated grief symptoms 6 months after their child’s death in the PICU. The 18-month survey results showed that complicated grief symptoms decreased among parents between 6 and 18 months after their child’s death in the PICU; however, high symptom levels persists for some. A better understanding of the trajectory of complicated grief will allow parents at risk for persistent distress to receive professional support.
- Complicated Grief and Associated Risk Factors Among Parents Following a Child's Death in the Pediatric Intensive Care Unit (Meert 2010 PMC3279721)
- Follow-Up Study of Complicated Grief among Parents Eighteen Months after a Child's Death in the Pediatric Intensive Care Unit (Meert 2011 PMC3037801)
The previous phases of the Bereavement Study have shown that parents of children who die in the PICU often desire a follow-up meeting with the PICU physician. Research regarding physicians’ perspectives on the content and conditions of follow-up meetings is lacking. Such data are needed to develop a framework for conducting physician-parent follow-up conferences. It was hypothesized that PICU physicians have variable experience conducting follow-up meetings with bereaved parents.
The objective of this study was to describe physicians’ experience with and attitudes toward follow-up meetings after a child’s death. Semi-structured audio-recorded telephone interviews were conducted with PICU attending physicians and fellows from the CPCCRN affiliated children’s hospitals. Interviews were transcribed verbatim and analyzed using standard qualitative methods. Meeting content included discussing autopsy, hospital course, diagnosis, genetic risk, parent questions, family coping, and bereavement services; providing reassurance; expressing sympathy; and receiving feedback from parents. Barriers to follow-up meetings included time, scheduling, distance, transportation, language, cultural issues, physician willingness, and lack of systematic meeting initiation. Of the 60 physicians that were interviewed, 19 (32%) reported never having previously participated in a follow-up conference. Fifty-four (90%) of all physicians interviewed reported that follow-up meetings should be routinely offered. PICU physicians have a wide range of experience conducting follow-up meetings with bereaved parents. These data, along with parents' perspectives described in prior research, provide a basis for developing a framework for follow-up conferences after a child’s death.
- Physicians' experiences and perspectives regarding follow-up meetings with parents after a child's death in the pediatric intensive care unit (Meert 2011 PMC3327296)
Although the therapeutic use of corticosteroids has long existed there still remains a lack of consensus regarding the target population for corticosteroid replacement therapy. This is due, in large part, to the time consuming method of free cortisol assessment called equilibrium dialysis isolation. Cortisol Quantification Investigation (CQI) was a prospective, observational cohort study that assessed baseline total and free serum cortisol concentrations in a convenience sample of critically ill children exhibiting a spectrum of illness severity. The goal was to determine whether plasma ultrafiltration can be used in place of equilibrium dialysis by comparing the measured free cortisol following each fractionation method. If successful, this would make rapid (within hours) free cortisol measurements feasible in future CPCCRN studies.
This study was conducted on 165 critically ill children across the spectrum of illness severity. Analyses determined that centrifugal ultrafiltration fractionated free cortisol was fast and results correlated highly with equilibrium dialysis fractionated free cortisol. This study ascertains that real-time free cortisol quantification is feasible to potentially help guide future research to enhance clinical decision making for cortisol replacement therapy in the pediatric intensive care unit.
Despite use of CDC recommended preventive strategies, nosocomial infection / sepsis occurs in up to 40% of children requiring long stay intensive care. Since lymphopenia and protein malnutrition are known risk factors, we evaluated whether directed nutraceutical supplements would reduce nosocomial infection / sepsis. A multicenter randomized double-blinded comparative trial was conducted to determine if enteral zinc, selenium, glutamine and IV metoclopramide (ZSGM) would reduce nosocomial infection / sepsis compared with enteral whey protein (WHEY) and IV placebo, when administered for up to 28 days of Pediatric Intensive Care Unit (PICU) stay. This study has been completed and the results have been published.
- Rationale and Design of the Pediatric Critical Illness Stress-Induced Immune Suppression (CRISIS) Prevention Trial (Carcillo 2009 PMC2918276)
- Is "rescue" therapy ethical in randomized controlled trials? (Holubkov 2009 PMC3259684)
- The randomized comparative pediatric critical illness stress-induced immune suppression (CRISIS) prevention trial (Carcillo 2012 PMC3302948)
- The role of the Data and Safety Monitoring Board in a clinical trial: The CRISIS Study (Holubkov 2013 PMC Journal - in process)
The purpose of the FSS (Functional Status Scale) study was to create a functional status outcome measure for large outcome studies that is well defined, quantitative, rapid, reliable, minimally dependent on subjective assessments, and applicable to hospitalized pediatric patients across a wide range of ages and inpatient environments. This study was designed with the intention that, if successful, FSS would be used throughout the world of pediatric medicine as an assessment tool.
Functional Status Scale (FSS) domains of functioning included mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status, categorized from normal (Score=1) to very severe dysfunction (score=5). The Adaptive Behavior Assessment System II (ABAS II) established construct validity and calibration within domains. Seven CPCCRN institutions provided PICU patients within 24 hours before or after PICU discharge, high-risk non-PICU patients within 24 hours after admission, and technology-dependent children. Primary care nurses completed the ABAS II.
A total of 836 children, with a mean FSS score of 10.3 (SD: 4.4), were studied. Eighteen percent had the minimal possible FSS score of 6, 44% had FSS scores of ≥ 10, 14% had FSS scores of ≥ 15, and 6% had FSS scores of ≥ 20. Each FSS domain was associated with mean ABAS II scores (P < .0001). Cells in each domain were collapsed and reweighted, which improved correlations with ABAS II scores (P < .001 for improvements). Discrimination was very good for moderate and severe dysfunction (ABAS II categories) and improved with FSS weighting. Intraclass correlations of original and weighted total FSS scores were 0.95 and 0.94, respectively.
The FSS study met all objectives and was determined to be well suited for large outcome studies.
To reduce pain, anxiety, or agitation critically ill children routinely receive opioids for analgesia and sedation in the pediatric intensive care unit (PICU). Routine use of opioid therapy often leads to tolerance and dependence. The objective of this prospective, observational study is to estimate the incidence and risk factors for opioid tolerance in critically ill children and describe analgesic practices in the PICU. Significant variability in clinical practices related to opioid analgesia in PICUs makes it difficult to launch scientific efforts for reducing the complications of opioid therapy or testing key hypotheses in this area. This study has been completed and the results published.
- Opioid Analgesia in Mechanically Ventilated Children: Results From the Multicenter Measuring Opioid Tolerance Induced by Fentanyl Study (Anand 2013 PMC Journal - in process)