Editorials A 30-month prospective surveillance. Infect Control Hosp Epidemiol 2004; 25:753–758 9. Ibrahim EH, Mehringer L, Prentice D, et al: Early versus late enteral feeding of mechanically ventilated patients: Results of a clinical trial. JPEN J Parenter Enteral Nutr 2002; 26:174–181 10. Bigham MT, Amato R, Bondurrant P, et al: Ventilator-associated pneumonia in the pediatric intensive care unit: Characterizing the problem and implementing a sustainable solution. J Pediatr 2009; 154:582–587.e2 11. Cook DJ, Reeve BK, Guyatt GH, et al: Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. JAMA 1996; 275:308–314 12. Messori A, Trippoli S, Vaiani M, et al: Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: Meta-analysis of randomised controlled trials. BMJ 2000; 321:1103–1106 13. Yildizdas D, Yapicioglu H, Yilmaz HL: Occurrence of ventilator-associated pneumonia in mechanically ventilated pediatric intensive care patients during stress ulcer prophylaxis with sucralfate, ranitidine, and omeprazole. J Crit Care 2002; 17:240–245

14. Lopriore E, Markhorst DG, Gemke RJ: Ventilator-associated pneumonia and upper airway colonisation with Gram negative bacilli: The role of stress ulcer prophylaxis in children. Intensive Care Med 2002; 28:763–767 15. Costarino AT, Dai D, Feng R, et al: Gastric acid suppressant prophylaxis in pediatric intensive care: Current practice as reflected in a large administrative database. Pediatr Crit Care Med 2015; 16:605–612 16. Chaïbou M, Tucci M, Dugas MA, et al: Clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit: A prospective study. Pediatrics 1998; 102:933–938 17. Lacroix J, Nadeau D, Laberge S, et al: Frequency of upper gastrointestinal bleeding in a pediatric intensive care unit. Crit Care Med 1992; 20:35–42 18. Faisy C, Guerot E, Diehl JL, et al: Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med 2003; 29:1306–1313 19. Marik PE, Vasu T, Hirani A, et al: Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis. Crit Care Med 2010; 38:2222–2228

Together We Are Strong. Collaborative Learning as a Strategy for Implementing a New Standard of Care* Ehrenfried Schindler, DrMed Department of Pediatric Anesthesia Asklepios Klinik Sankt Augustin Sankt Augustin, Germany

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ay by day, new knowledge is being published in medical journals all over the world. Years later, new guidelines are extracted out of this knowledge or revised. Even more, time will pass until this knowledge changes daily clinical practice. Grol and Grimshaw (1) reported that in some countries at least 30–40% of the patients did not receive medical care according to the most recent scientific evidence, whereas 20% of the care was not needed or even harmful to the patients. What are the reasons why changes in daily clinical practice are implemented with such a delay? First, the introduction of new methods, therapies, standards of care, etc., in our daily practice is not directly rewarded. On the contrary, there are significant barriers to overcome including a lack of awareness, knowledge, seniority, control, and fear of “something” new to come. Second, the proof of superiority of new concepts takes time. No one can assure that new methods will have positive effects compared to the standard of care we are used to. Third, stakeholders may have to change their practice or habits too or even lose part of their livelihood or contribution to patient care. It is evident

*See also p. 939. Key Words: change management; collaborative learning; early extubation; fast track; pediatric cardiac anesthesia The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2016 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000926

Pediatric Critical Care Medicine

that the larger and more complex a system is the more difficult, it is implementing new therapies or strategy into daily practice. The report of Mahle et al (2) published in this issue of Pediatric Critical Care Medicine is an excellent example how the implementation of new standards could be achieved. They have transferred a technique coming from the manufacturing industry into the hospital. The concept of collaborative learning is based on the idea to bring lowperforming processes into line with the highest performing process. Based on his research, Vygotsky (3) highlighted that individuals were able to achieve higher levels of learning when working in groups together. Transferred to the current topic, Mahle et al (2) have used the basic principles of collaborative learning strategies and translated them for the use in our hospitals which are as follows: 1) communication, 2) sharing protocols, 3) site visits, and 4) face-to-face conversations to introduce a fast-track concept after pediatric cardiac surgery in five different hospitals compared to a so called “control group” of another five centers. The principle of fast tracking in surgery coming out of the adult “world,” and its basic principles and advantages are widely accepted (4–6). The mesh term “fast-track surgery” reveals more than 1,400 articles in PubMed, whereas “fast-track pediatric surgery” displayed only 36 articles. To my mind, the pediatric population is predestinated for fast-track programs. Children do not want to stay in hospitals. Pediatric cardiac surgery is a very good example of complex surgery, in complex patients cared by many different medical specialities. That might be the reason why the introduction of early extubation and fast-track concepts are even more difficult in this special group. Nevertheless, there are several studies showing excellent results of early extubation in pediatric cardiac surgery and that selected patients do even better when not being ventilated like Fontan or hemi-Fontan www.pccmjournal.org

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Editorials

patients (7–10). The findings of Mahle et al (2) showed that the following principles were found to be essential for successful early extubation in pediatric cardiac surgery in all five participating centers. They were as follows: 1) choice and dose of premedication and anesthetic agents that would allow for early extubation; 2) anesthesia with volatile anesthetic with low-dose opioids and to my mind the most important factor and 3) balanced sedation/analgesia in the early postoperative period. The only drawback I want to mention is that the advantages of the described collaborative learning strategy to translate new published findings into clinical practice more rapidly might not be as fast as suggested by the authors. To bring 10 different institutions together at one table, to set up protocols to organize site visits, and to ensure ongoing communication might be time consuming. The study is not able to prove that without collaboration the same change in practice would naturally occur in the same time interval. Nevertheless, the “collaborative learning approach” seems to be a promising tool for increasing the rate of successful early extubation and fast-track protocol even in complex patients without a change in reintubation rate in infants following cardiac surgery. It could also be a template for other complex topics like change of preoperative fasting protocols in children or introducing procedural sedation just to name two as examples.

REFERENCES

1. Grol R, Grimshaw J: From best evidence to best practice: Effective implementation of change in patients’ care. Lancet 2003; 362:1225–1230 2. Mahle WT, Nicolson SC, Hollenbeck-Pringle D, et al; for the Pediatric Heart Network Investigators: Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med 2016; 17:939–947 3. Vygotsky LS: Mind in Society: The Development of Higher Mental Process. Cambridge, MA, Harvard University Press, 1978 4. Agarwal BB, Chintamani, Agarwal S: Fast track surgery-minimizing side effects of surgery. Indian J Surg 2015; 77(Suppl 3):753–758 5. Ansari D, Gianotti L, Schröder J, et al: Fast-track surgery: Procedurespecific aspects and future direction. Langenbecks Arch Surg 2013; 398:29–37 6. Nanavati AJ, Prabhakar S: Fast-track surgery: Toward comprehensive peri-operative care. Anesth Essays Res 2014; 8:127–133 7. Mahle WT, Jacobs JP, Jacobs ML, et al: Early extubation after repair of tetralogy of Fallot and the Fontan procedure: An analysis of the society of thoracic surgeons congenital heart surgery database. Ann Thorac Surg 2016 May 9. [Epub ahead of print] 8. Mutsuga M, Quiñonez LG, Mackie AS, et al: Fast-track extubation after modified Fontan procedure. J Thorac Cardiovasc Surg 2012; 144:547–552 9. Alghamdi AA, Singh SK, Hamilton BC, et al: Early extubation after pediatric cardiac surgery: Systematic review, meta-analysis, and evidence-based recommendations. J Card Surg 2010; 25:586–595 10. Kawaguchi A, Liu Q, Coquet S, et al: Impact and challenges of a policy change to early track extubation in the operating room for Fontan. Pediatr Cardiol 2016 May 9. [Epub ahead of print]

Missing Messages of Clinical Pharmacologic Survey on Inotropic Drug Use in Neonatal Critical Care* Yun Cao, MD Ying Dong, MD Bo Sun, MD Neonatal Intensive Care Unit Department of Neonatology Children’s Hospital of Fudan University The Laboratory of Neonatal Medicine National Health and Family Planning Commission Shanghai, China

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he immaturity of cardiovascular system and disease status predispose newborn infants, both term and preterm, to low systemic blood flow during the first week of life and beyond, when various morbidities, including hypoxemic respiratory failure, patent ductus arteriosus (PDA), sepsis, necrotizing enterocolitis (NEC), hypoxic-ischemic injury, and persistent pulmonary hypertension of the

*See also p. 948. Key Words: dopamine; inotrope; neonate The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2016 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000916

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newborn (PPHN), are likely to occur. Hemodynamic instability is associated with increased morbidities and mortality in neonates, and the consequences, diagnosis, and treatment of hemodynamic instability are important issues in neonatology. Inotropes with dopamine as the representative drug are commonly used in neonatal ICUs (NICUs). However, pharmaceutical activity of most inotropic drugs in newborns especially the very immature ones is largely unknown, and alternative drugs for dopamine are yet to be identified in order to achieve the goal hemodynamic status with minimal adverse effects (1). In this issue of Pediatric Critical Care Medicine, Burns et al (2) conducted a retrospective survey of inotropic drug (dopamine, dobutamine, epinephrine, norepinephrine, milrinone, and levosimedan) use in a large sample of 974 neonates from a Norwegian Neonatal Network, corresponding to 2.7% and 0.27%, respectively, of a total of 36,397 NICU admissions and a nearly complete live birth population of 361,803 from 2009 to 2014. Given the population-based nature of this study, the results may be applicable to future studies on neonatal inotropic use and outcomes. The authors analyzed the use of inotropic drug in three groups categorized by neonatal maturation, as well as the timing and mode of drug application. Consistent with other studies (3–6), this study demonstrated dopamine to be the most commonly used drug in all gestational age (GA) groups, either as monotherapy or in combination October 2016 • Volume 17 • Number 10

Copyright © 2016 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited

Together We Are Strong. Collaborative Learning as a Strategy for Implementing a New Standard of Care.

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