Introduction: Neuromuscular blockade (NMB) use in pediatric ICUs prevents movement, decreases ventilator dysynchrony, and metabolic demand. While helpful in septic shock and intracranial hypertension, overuse is linked to myopathy, prolonged ventilation, exposure keratopathy, and pressure ulcers. Review of limited pediatric studies suggests a correlation between cumulative NMB dose and prolonged recovery. Pediatric critical care fellows led a QI project to reduce cumulative NMB exposure by 10% in patients on NMB infusions for >24hrs in our quaternary pediatric ICU from February to August 2025. Methods: We created cause-and-effect and key driver diagrams and surveyed attendings and advanced practice providers (APPs) to understand NMB practices and perceptions. Primary outcome was cumulative NMB exposure per patient in mg/kg; process measures included Train-of-Four (TOF) monitoring and rate of NMB holidays (>1hr); the balancing measure was unplanned extubations on infusions. We used Plan-Do-Study-Act (PDSA) cycles. Interventions involved focused education for prescribers—physicians, APPs, and residents—via presentations and onboarding. Nurses were educated on NMB use and monitoring; TOF monitor availability increased. Posters were placed in workrooms. EMR interventions weren’t feasible within our timeline. Results: Pre-intervention surveys showed a gap between perceived and documented NMB holiday practices. During our baseline period (July-Dec ’24), 110 (68%) patients were on rocuronium, 23 (14%) on cisatracurium, and 29 (18%) on vecuronium. From Feb-Jun’25, cumulative rocuronium dose rose slightly from a median of 7.8 to 8.6 mg/kg/day per rocuronium exposure. NMB holiday rate increased from 15% at baseline to 25% during the last 3 months, associated with project team presence on units. Documented TOF fluctuated around 2.1% of NMB patients. Unplanned extubations were not due to lack of NMB. Conclusions: Patient census, acuity, and NMB indications variability may impact cumulative exposure. We identified a need to improve process measures to improve outcomes. Future work will target optimizing best practices for TOF monitoring and NMB holidays to decrease NMB-associated morbidity. EMR-based interventions not reliant on individuals will be needed for long-term impact.

Introduction: Encephalitis, acute inflammation of the brain, correlates with systemic complications, prolonged ICU stays, and high mortality. Cerebrovascular disease (CVD) involves reduced blood flow to the brain. The impact of CVD on outcomes of critically-ill encephalitis patients has not been well characterized. We hypothesized that compromised cerebrovascular integrity in CVD exacerbates the impact of cerebral inflammation and critical illness. Methods: We used publicly available data to conduct a population-based cohort study of adults admitted to intensive care units of acute care hospitals in Texas from 2016 through 2022 with encephalitis. Transfers, elective admissions, and discharges against medical advice were excluded. The population was identified using International Classification of Diseases, Tenth Revisions, Clinical Modification (ICD-10-CM) codes selected from Clinical Classification Software Refined Category NVS002: Encephalitis. CVD was identified using ICD-10-CM codes G45x, G46x, I60x-I69X, and H340x. The outcome was short-term mortality. Overlap propensity score weighting was applied with results expressed as adjusted risk ratio and 95% confidence interval (aRR [95% CI]). Results: Of 6,576 hospitalizations included in the study, 1,496 (23%) had CVD. Hospitalizations with CVD were older (48% vs 38% aged ≥ 65 years), had higher Deyo comorbidity index (mean[SD] 2.3 [2.2] vs 2.1 [2.4]), and more often required invasive mechanical ventilation (38% vs 28%). Patients with CVD had a higher rate of short-term mortality (28% vs 17%). Hospital length of stay was longer for CVD patients (mean[SD] 19[19] days vs 16[19] days). All covariates balanced exactly after overlap weighting. Within the overlap population, CVD remained associated with mortality (26% vs 22%) and (aRR 1.2 [95% CI 1.1 to 1.3]). Similar results were observed on sensitivity analyses for older patients, patients using invasive mechanical ventilation, and those more severely ill. Conclusions: Although CVD patients were older, had higher burden of comorbidities, and were at greater risk of death, after risk adjustment, preexisting CVD was still found to significantly and independently increase the risk of death in critically ill patients with encephalitis. These findings can help with early risk stratification.

Introduction: Death certificates are the primary source for estimating the population-level burden of sepsis mortality, while ICD codes are often used to identify sepsis deaths in hospital claims data. Based on ICD codes, sepsis is present in up to 1 in 2 hospital decedents in the United States. A prior study comparing the number of sepsis decedents in hospital claims data and death certificates showed markedly lower figures among the latter, but the findings are dated and different ICD coding approaches were used for claims and death certificate data. We evaluated the contemporary concordance of similarly coded sepsis diagnosis between population-level hospital claims data and death certificates. Methods: We used a statewide dataset to identify all in-hospital decedents aged ≥18 years in Texas and the corresponding aggregate inpatient death certificate data from CDC WONDER during 2020-2023. An identical, previously reported ICD-10 code-based taxonomy was used to identify sepsis in claims data and death certificates. Normal approximation was used to estimate the rate difference [RD] and rate ratio [RR] in the frequency of sepsis diagnosis overall and in demographic and COVID-19 diagnosis strata, and for their comparisons across categories within examined strata. Results: There were 282,958 decedents in claims data and 321,660 in death certificates, with 136,886 (48.4%) and 67,212 (20.9%) reporting sepsis, respectively (RD 27.5% [95% CI 27.2-27.8]; RR 2.32 [95% CI 2.30-2.33]). RD in the frequency of sepsis diagnosis between claims data and death certificates ranged from 23.0% (non-COVID-19) to 41.6% (COVID-19), with corresponding RR 2.04 and 3.49, respectively. RD in the frequency of sepsis diagnosis between claims data and death certificates and their RR varied across the examined strata categories, being highest among decedents aged 18-44 years (vs ≥65 years), males (vs females), Hispanics (vs Whites), and those with COVID-19 (vs non-COVID-19). Conclusions: Death certificates substantially underestimated the burden of sepsis-associated mortality among hospital decedents, when compared to hospital claims data in Texas, with the use of an identical ICD code-based algorithm. The gaps in the frequency of sepsis diagnosis were greater among younger decedents, males, Hispanics, and those with COVID-19.

Introduction: Fiber-containing (FC) enteral nutrition (EN) has been shown to decrease diarrhea and gastrointestinal complications in patients who are hemodynamically stable. However, in hemodynamically unstable patients requiring vasopressors, fiber may increase the risk of gastrointestinal mucosal injury and bowel ischemia. The purpose of this study was to assess EN tolerance and the incidence of adverse events in patients receiving either FC or fiber-free (FF) EN while on vasopressors. Methods: This was a single-center, retrospective cohort study of patients admitted to the intensive care unit from January 1, 2022, through December 31, 2024, who received EN and concomitant vasopressors. Patients who received FC EN were compared to those who received FF EN. Outcomes included doses of nutrition provided, incidence of bowel ischemia, feeding intolerance, and other adverse events. Results: A total of 35 patients were included, with 19 patients in the FC group and 16 patients in the FF group. All patients received norepinephrine, with 6 patients (31.6%) in the FC group and 2 patients (12.5%) in the FF group receiving additional vasopressors. In the FC group, 5 patients (26.3%) experienced abdominal distention compared to 4 patients (25%) in the FF group (OR 0.93, 95% CI 0.20 to 4.29, p >.9). Five patients (26.3%) in the FC group had diarrhea or constipation compared to 3 patients (18.8%) in the FF group (OR 0.65, 95% CI 0.13 to 3.26, p =.7). Four patients (21.1%) in the FC group developed aspiration compared to 2 patients (12.5%) in the FF group (OR 0.54, 95% CI 0.08 to 3.40, p =.7). Three patients (15.8%) in the FC group developed an ileus compared to no patients in the FF group (OR 0.14, 95% CI 0.01 to 2.99, p =.2). One patient (5.3%) in the FC group experienced bowel ischemia compared to no patients in the FF group (OR 0.37, 95% CI 0.01 to 9.82, p >.9). There were no significant differences in the number of calories or amount of protein provided to each group. Conclusions: While limitations must be considered, this study did not indicate harm associated with fiber in patients receiving EN while on vasopressors. These results may help generate hypotheses for future studies for a more comprehensive evaluation.

Introduction: Older adults can be difficult to recruit for research studies in the intensive care unit (ICU). Our objective was to evaluate consent rates in a study of older ICU survivors in which consent was obtained during the ICU hospitalization, analyze barriers to consent, and describe strategies to address these challenges and increase consent rates. Methods: The LANTERN study is a longitudinal study in which older adults are approached for consent during their ICU stay. Participants complete an in-hospital interview, a home visit, and 6 monthly follow-up calls. We identified 1,053 potential participants between 1/2024-7/2025. Outcomes included “consented” or “not consented,” with the latter category further divided into “refused,” “approached, but patient/proxy did not consent before discharge,” and “missed (not approached).” We described demographic characteristics by outcome category using means and standard deviations for continuous variables and proportions for categorical variables. Reasons for refusing consent were qualitatively analyzed. Modifiable barriers to consent were identified, and strategies were generated to address them. Results: The mean (standard deviation [SD]) age was 76.5 (7.3) years, 567 (54%) were female, and 161 (15%) identified as Black. Of 1,053 eligible patients, 351 consented, 458 refused, 201 were approached but did not consent before discharge, and 43 were missed. Reasons for refusal were grouped into 15 categories; the three most common were lack of interest (n=116, 25.3%), too much going on/feeling overwhelmed (n=100, 21.8%), and medical reasons, such as poor prognosis or feeling too tired (n=68, 14.8%). Among these, modifiable reasons included missing patients, concerns about the home visit, and feeling too tired. Strategies to improve consent rates included hiring more staff, offering phone visits in lieu of home visits, and approaching patients closer to discharge. In the first half of 2025, we consented an average of 25 patients/month compared to 15 patients/month in 2024. Conclusions: We found that critically ill older adults face several barriers to research participation, including modifiable factors which may be addressed with flexibility in follow-up and timing of approach. These findings may help inform strategies for recruitment and future study design.

Introduction: Iatrogenic Withdrawal Syndrome affects over 100,000 children annually, particularly following mechanical ventilation termination. Current nursing-based screening is time-consuming and episodic, limited by staffing availability. We developed and validated a computable phenotype using standard electronic health record variables to identify withdrawal through autonomic dysregulation patterns and medication histories. Methods: This single-center, retrospective and prospective multi-cohort study included PICU patients from 2012-2025. Training/testing cohorts comprised 2,100 patients (2012-2023), with prospective validation in 400 patients (2023-2025). Inclusion criteria: extubation from mechanical ventilation and Withdrawal Assessment Tool (WAT-1) evaluation. Data were organized into 4-hour epochs. Variables included vital signs metrics (average, maximum, minimum, measurement frequency) and opioid/sedative exposures (cumulative dose, prior 4-hour dosage, average 4-hour dose). WAT-1 scores ≥3 defined withdrawal. Machine learning utilized XGBoost algorithm. Results: Test cohort performance: AUROC 0.87, AUPRC 0.62, calibration curve R2 0.96 (slope 1.08, intercept -0.02). Prospective validation maintained performance despite lower withdrawal prevalence: AUROC 0.85, AUPRC 0.35, calibration R2 0.93 (slope 1.19, intercept -0.09). Pearson’s correlation between computable phenotype risk and WAT-1 scores: r = 0.95 (p < 0.05). Prediction accuracy exceeded 87% at high/low WAT-1 values and ranged 54.8-73.3% near diagnostic thresholds. Conclusions: We successfully developed and validated a novel machine learning computable phenotype using standard EHR data for pediatric ICU withdrawal risk identification. This objective, personalized approach demonstrated clinically suitable performance metrics with potential for real-time monitoring while reducing nursing administrative burden. The model’s reliance on autonomic dysregulation indicators and medication profiles enables continuous, automated withdrawal surveillance in critically ill children.

Introduction: NIV is beneficial for many forms of ventilatory failure. NIV benefits may be realized in austere environments and during transport by use of a PV with NIV capabilities. We evaluated the ASI of 4 PVs set to provide NIV with varying Leak (Lk), Pressure Support (PS), and physiologic conditions. Methods: Four PVs (Sparrow Robust, Inovytec; 731 EMV+, Zoll; T1, Hamilton; V60, Philips) were set to deliver NIV to an ASL5000 simulator (Ingmar) at 192 conditions based on physiology (normal (C=60, R=5) and COPD (C=70, Ri=20, Re=35), inspiratory effort (Insp) (Low=-3, Norm=-7, High=-15), Lk, and PS (5 and 10) at a rate of 15, Ti 1.0, and PEEP of 5. Each PV used default settings for trigger, rise time, and exp cycle. Lk conditions were characterized by Lk flow at P of 5 and 15 cmH2O: Lk0=no additional Lk, Lk1=constant Lk (14.4, 27.9), L3=Lk during inspiration only >7.5 via water column (< 1,17.0), and L2=both L1+L3 (14.6, e14.6/i46.11). Each PV used a recommended circuit, and data/waveforms were collected for 2 min after 30 sec stabilization. ASI was determined by analysis of waveforms of 25 breaths at each condition by 2 raters. Five AS types were defined: Missed Trigger (MT) = no breath delivery during Ti, Delayed Trigger (DT) = breath initiated > 300ms following start of effort (SOE), Auto Trigger (AT)= any breath initiated prior to SOE + breaths initiated during Ti without visible evidence of trigger, Premature Cycle (PC) and Delayed Cycle (DC) = vent cycle off > 300ms prior to or following end of Insp effort, respectively. ASI for each PV was compared for all conditions and specific to conditions related to physiology, Insp effort, Lk setting, and PSV level. Results: Conditions with 0% ASI for each PV were: V60 68 (35%), T1 64 (33%), 731 44 (23%), Sparrow 20 (10%). The ASI for all 192 conditions [ASI (COPD ASI, NORM ASI)] for each PV was: T1 37% (64%, 11%); V60 39% (65%, 13%); 731 68% (79%, 58%); Sparrow 69%, (88%, 49%). The most common ASI type for each PV was: V60 DT (24%), T1 DT (24%), 731 AT (34%), Sparrow MT (44%). COPD, low effort, and Lk2 conditions had the highest ASI; PS had minimal effect on ASI. Conclusions: NIV performance varies greatly among PVs. T1 and V60 had the lowest ASI. The 731 and Sparrow had high ASI, and their NIV use should be limited with COPD, low Insp effort, and high Lk.

Introduction: Phenobarbital (PHB) has emerged as a first-line therapy for alcohol withdrawal syndrome (AWS), but the ideal dosing strategy and administration route is unclear. Intravenous (IV) PHB has a rapid onset and may require closer monitoring for adverse effects compared to the slower onset of intramuscular (IM) PHB. This study examined differences in efficacy, safety, and resource utilization when PHB is administered IV versus IM for AWS. Methods: This single-center, retrospective, observational study included adult patients presenting to an Emergency Department (ED) between January 2022 and August 2023 who received at least one parenteral PHB dose using the institution’s AWS order set. Patients were excluded if they were pregnant, switched PHB route or left against medical advice prior to completion of PHB load, or if their encounter occurred within five days of prior PHB therapy. The institutional PHB protocol includes a 6 or 10 mg/kg loading dose, divided for administration over one hour for IV or nine hours for IM. Dose and route are selected by the provider. Outcomes including hospital length of stay (LOS), safety endpoints, and supplemental doses given within nine hours of protocol initiation were compared between those treated with IV versus IM PHB. Results: This analysis included 198 patient encounters (IV n=97, IM n=101). No difference was found for hospital LOS between IV and IM groups (3.9 days for each group, p=0.739) or for any pre-specified subgroup. Safety outcomes of intubation, sedation, hemodynamic instability, respiratory depression, or rescue medication use were rare and similar between groups. The IV group received significantly more supplemental PHB than IM group (0.94 mg/kg vs 0.25 mg/kg, p< 0.001), with 51.5% of IV patients receiving any supplemental PHB compared to 14.9% of IM patients. Conclusions: We did not identify safety or efficacy differences between patients receiving IV versus IM loads of PHB for AWS, but the faster onset of IV may have allowed for identification of breakthrough symptoms requiring supplemental doses. This study adds to the safety of PHB as first-line therapy for AWS and emphasizes the need for a streamlined IV dosing regimen for severe AWS to preserve nursing resources and overcome operational limitations in the busy ED setting.