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Simulation is a popular and effective training modality in medical education across a variety of domains. Central venous catheterization (CVC) is commonly undertaken by trainees, and carries significant risk for patient harm when carried out incorrectly. Multiple studies have evaluated the efficacy of simulation-based training programs, in comparison with traditional training modalities, on learner and patient outcomes. In this review, we discuss relevant adult learning principles that support simulation-based CVC training, review the literature on simulation-based CVC training, and highlight the use of simulation-based CVC training programs at various institutions.

Background Opportunities to practice procedural skills in the clinical learning environment are decreasing, and faculty time to coach skills is limited, even in simulation-based training. Self-directed learning with hands-on practice early in a procedural skill course might help maximize the benefit of later faculty coaching and clinical experience. However, it may also lead to well-learned errors if learners lack critical guidance. The present study sought to investigate the effects of a hands-on, self-directed “study hall” for central line insertion among first-year residents. Methods Learner cohorts before vs. after introduction of the study hall ( n  = 49) were compared on their pre- and post-test performance of key procedural behaviors that were comparable across cohorts, with all learners receiving traditional instructor-led training between tests. Results Study hall participants spent a median of 116 min in hands-on practice (range 57–175). They scored higher at pre-test (44% vs. 27%, p  = .00; Cohen’s d  = 0.95) and at post-test (80% vs. 72%, p  = .02; Cohen’s d  = 0.69). A dose–response relationship was found, such that 2 h of study hall were roughly equivalent to the performance improvement seen with four clinical observations or supervised insertions of central lines. Conclusions Self-directed, hands-on “study hall” supported improved procedural skill learning in the context of limited faculty availability. Potential additional benefits make the approach worth further experimentation and evaluation.

Background Ultrasonography is increasingly used in pediatric surgery. Intraoperatively, ultrasonography can be used to confirm the preoperative diagnosis, guide the surgical approach, and enhance decision-making. We aimed to report our experience with intraoperative ultrasonography in different neonatal and pediatric procedures. So, a retrospective study was designed. It included all pediatric patients who had intraoperative ultrasound between January 2018 and October 2020 in a single center. Results We used intraoperative ultrasonography in 208 pediatric patients for various types of surgery. The authors compared ultrasound-guided central line insertion (n = 139) to the landmark method (n = 153). The number of trials was significantly lower in the ultrasound-guided method (P < 0.001). Conversion to cut-down was significantly lower with the ultrasound-guided technique (4 (2.8%) vs. 13 (8.5%); P = 0.047) and insertion-related complications were lower with ultrasound (0 vs 13 (8.5%); P < 0.001). We used ultrasound-guided sclerotherapy for cystic hygroma in 15 patients. Nine patients had successful treatment with a single injection (60%). Conclusion The application of intraoperative ultrasound in pediatric patients is increasing in our institution. The technique is safe and could effectively reduce central line insertion complications and enhance cystic hygroma sclerotherapy’s success with a single injection. Ultrasonography should be an essential part of residents’ and fellows’ training in pediatric surgery.

Background/Objectives: Preterm infants in the neonatal intensive care unit (NICU) are subjected to clinically essential painful procedures including peripherally inserted central catheter (PICC) placement. Pharmacological interventions are inconsistently used for procedural analgesia due to concerns of adverse events. Intranasal (IN) fentanyl is a promising pharmacological alternative that delivers rapid targeted analgesia. The objectives of this blinded randomized controlled trial (RCT) were to assess the feasibility of conducting a definitive RCT of IN fentanyl for PICC placement in preterm infants and evaluate the acceptability and adoption of IN fentanyl for procedural pain management in the NICU. Methods: Infants admitted to the NICU (Mount Sinai Hospital, Toronto) with a gestational age (GA) at birth < 32 weeks undergoing their first PICC placement were randomized to IN fentanyl or placebo as an add-on to standard of care. The primary feasibility outcomes were recruitment and completeness of data collection for pain assessment. The pre-specified targets were recruitment of 24 participants and at least 80% of video-recordings being suitable for pain assessment. Secondary outcomes were adverse events, and IN fentanyl acceptability and adoption by healthcare providers. (ClinicalTrials.gov ID NCT06590870). Results: Between August 2024 and January 2025, 16 parents/guardians were approached resulting in eight enrollments for a consent rate of 50% (95% CI 28, 72). The target recruitment of 24 participants was not achieved. Out of six infants that received study interventions, all video-recordings were suitable for pain assessment by outcome assessors with a success rate of 100% (95% CI 61, 100). There were no adverse events. Fifteen healthcare providers completed the survey and reported acceptability of IN fentanyl but barriers with its adoption in clinical practice. Conclusions: Major modifications to the recruitment strategy would be required to progress to a definitive RCT. Strategies facilitating IN fentanyl adoption for procedural analgesia in the NICU are needed.

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Cancers arising from germline DNA mismatch repair deficiency or polymerase proofreading deficiency (MMRD and PPD) in children harbour the highest mutational and microsatellite insertion–deletion (MS-indel) burden in humans. MMRD and PPD cancers are commonly lethal due to the inherent resistance to chemo-irradiation. Although immune checkpoint inhibitors (ICIs) have failed to benefit children in previous studies, we hypothesized that hypermutation caused by MMRD and PPD will improve outcomes following ICI treatment in these patients. Using an international consortium registry study, we report on the ICI treatment of 45 progressive or recurrent tumors from 38 patients. Durable objective responses were observed in most patients, culminating in a 3 year survival of 41.4%. High mutation burden predicted response for ultra-hypermutant cancers (>100 mutations per Mb) enriched for combined MMRD + PPD, while MS-indels predicted response in MMRD tumors with lower mutation burden (10–100 mutations per Mb). Furthermore, both mechanisms were associated with increased immune infiltration even in ‘immunologically cold’ tumors such as gliomas, contributing to the favorable response. Pseudo-progression (flare) was common and was associated with immune activation in the tumor microenvironment and systemically. Furthermore, patients with flare who continued ICI treatment achieved durable responses. This study demonstrates improved survival for patients with tumors not previously known to respond to ICI treatment, including central nervous system and synchronous cancers, and identifies the dual roles of mutation burden and MS-indels in predicting sustained response to immunotherapy. Hypermutation and microsatellite burden determine responses and long-term survival following PD-1 blockade in children and young adults with refractory cancers resulting from germline DNA replication repair deficiency.

Purpose Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children. Methods We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0–14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention’s National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting. Results A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70–3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05–4.61;  p  = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02–4.64;  p  = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable. Conclusions PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.

Background Central line–associated bloodstream infections (CLABSIs) remain a critical and possibly fatal outcome of hospitalization. Use of central venous catheter (CVC) bundles can considerably reduce CLABSI rates in hospitalized patients. However, despite widespread adoption of these bundles in hospitals worldwide, CLABSIs still remain prevalent. The aim of the present study was to determine whether longer duration of CVCs placement is related to CLABSIs in hospitalized adults, despite the implementation of preventive bundles. Also to analyse CLABSI pathogens distribution and antimicrobial resistance profiles in different time intervals of catheterization. Methods A retrospective study was performed among hospitalized patients who had a CVC inserted during a 24-month period (May 2017–May 2019) and developed CLABSIs. To evaluate the association between CVC placement duration and CLABSI events, we categorized events into three groups, each representing a 10-day time interval. Results A total of 59 CLABSI cases were identified among 9774 catheter/days. The CLABSI incidence rate per 1000 catheter/days was 4.80 for duration of catheterization up to 10 days, 5.92 for duration of 11–20 days, and 8.64 for duration > 20 days( p  = 0.007). The CLABSI incidence rate per 1000 catheter/days due to multidrug-resistant organisms (MDROs) among the three groups was 2.62 for catheter duration of up to 10 days, 3.83 for 11–20 days, and 3.46 for > 20 days ( p  = 0.14). Among CLABSIs, the most common microorganism identified was multidrug-resistant Acinetobacter baumannii , which accounted for 27.1% of the cases. There was no significant difference in the type of CLABSI pathogens isolated among the 3 groups. Conclusions Our findings suggest that duration of CVC placement remains an important risk factor for CLABSIs in hospitalized patients, even after the adoption of prevention bundles. The high prevalence of MDROs in our setting reflects the local epidemiology, highlighting a significant threat of urgent public health concern.

This document is an executive summary of the APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI). It describes key evidence-based care components of the Central Line Insertion and Maintenance Bundles and its implementation using the quality improvement methodology, namely the Plan-Do-Study-Act (PDSA) methodology involving multidisciplinary process and stakeholders. Monitoring of improvement over time with timely feedback to stakeholders is a key component to ensure the success of implementing best practices. A surveillance program is recommended to monitor outcomes and adherence to evidence-based central line insertion and maintenance practices (compliance rate) and identify quality improvement opportunities and strategically targeting interventions for the reduction of CLABSI.