The purpose of this study was to ( a) determine the frequency of diagnostic errors in pediatric cancer, ( b) categorize errors, and ( c) underscore themes associated with misdiagnosis. This is a retrospective cohort study at a tertiary children's hospital of 265 patients with new oncologic diagnoses. The diagnostic error rate was 28%. Compared with those with no diagnostic error, those in whom there was an error were more likely to have ( a) more visits before diagnosis ( P < .001), ( b) not been seen in an acute care setting ( P = .03), ( c) inappropriate treatment ( P < .001), and ( d) misinterpreted laboratory studies or imaging ( P < .001). Themes in diagnostic errors were lack of appropriate evaluation for persistent symptoms (47%), failure to recognize signs and symptoms suggestive of malignancy (45%), and misinterpretation of tests (8%). Clinicians should consider diagnostic evaluation for multiple visits for the same complaint or a constellation of signs and symptoms suggestive of malignancy.

Hypoxemic respiratory failure is a common problem in critical care. Current management strategies, including mechanical ventilation and extracorporeal membranous oxygenation, can be efficacious but these therapies put patients at risk for toxicities associated with invasive forms of support. Areas covered: In this manuscript, we discuss intravenous oxygen (IVO), a novel method to improve oxygen delivery that involves intravenous administration of a physiologic solution containing dissolved oxygen at hyperbaric concentrations. After a brief review of the physiology behind supersaturated fluids, we summarize the current evidence surrounding IVO. Expert commentary: Although not yet at the stage of clinical testing in the United States and Europe, IVO has been used safely in Asia. Furthermore, preliminary laboratory data have been encouraging, suggesting that IVO may play a role in the management of patients with hypoxemic respiratory failure in years to come. However, significantly more work needs to be done, including definitive evidence that such a therapy is safe, before it can be included in an intensivist's arsenal for hypoxemic respiratory failure.

BACKGROUND: Extubation failure is associated with increased duration of mechanical ventilation, length of hospital stay, and mortality. An elevated dead-space-to-tidal-volume ratio (V D /V T) has been proposed as a predictor of successful extubation in children. We hypothesized that a higher V D /V T value would be associated with extubation failure and higher postextubation respiratory support. METHODS: This was a prospective, observational, cohort study. All subjects were < 18 y old and were extubated in the pediatric multidisciplinary ICU or the cardiac ICU at an academic medical center from June 2016 through March 2017. Using arterial blood gas analysis and mainstream volumetric capnography, daily V D /V T measurements were obtained on intubated subjects using an automated algorithm. Respiratory support upon extubation was based on the clinical team's judgment and defined as low (ie, room air or nasal cannula) or high (ie, high-flow nasal cannula, CPAP, or bi-level positive airway pressure). Subjects were monitored for 48 h after extubation for escalation in respiratory support and need for re-intubation. RESULTS: Of 189 subjects included in the analysis, 166 were successfully extubated and 23 (12%) required re-intubation. There was no significant difference in final V D /V T between those who extubated successfully and those who failed extubation, with a median V D /V T of 0.28 (interquartile range [IQR] 0.20-0.37) vs 0.29 (IQR 0.21-0.33), respectively (P 5 .87). Those who received a high level of support upon extubation had a higher V D /V T than those who received a low level of support, with a median of 0.32 (IQR 0.23-0.39) vs 0.25 (IQR 0.16-0.30), respectively (P < .001). This association remained significant when controlling for age, duration of intubation, and cyanotic congenital heart disease (odds ratio 1.63, 95% CI 1.18-2.24). CONCLUSIONS: There was no significant relationship between V D /V T and extubation success, although V D /V T was associated with the level of respiratory support provided following extubation. Further studies should investigate whether the use of V D /V T can help reduce extubation failure rates with varying levels of postextubation respiratory support.

Highlights Abstract Introduction: Catheter-associated deep vein thrombosis (CADVT) in children has been recognized as a significant hospital-acquired condition. This study was undertaken to retrospectively analyze the impact of CADVT on outcomes and to identify risk factors for the development of deep vein thrombosis in children with central venous catheters. Methods: This was a single-center retrospective case-control study of patients with central venous catheters in a pediatric intensive care unit (ICU) from January 2014 to December 2018. Forty-one patients with central venous catheters who developed CADVT were compared with 100 random controls. Central venous catheter type, along with patient and disease-specific characteristics, were compared between the two groups by univariate and multivariate regression. Outcome comparison was made after adjusting for confounding variables. Results: Median time from insertion to the development of CADVT was 4 days (interquartile range, 2–9). Forty percent (16/40) of patients had a blood urea nitrogen greater than 20 mg/dL, and 86.6% (13/15) had a C-reactive protein greater than 1 mg/dL within 48 hours of development of CADVT. Central venous catheter duration (odds ratio [OR], 1.05), mechanical ventilation (OR, 7.49), and upper versus lower extremity site of the central venous catheter (OR, 0.324) were associated with the development of CADVT. Ultrasound guidance occurred significantly less in patients who developed CADVT (39.3% vs 70.7%); however, it was not independently associated with increased risk. Age, body mass index, mechanical ventilation, and severity of illness–adjusted hospital and ICU length of stay were significantly higher in patients who developed CADVT. Conclusions: CADVT is independently associated with worse outcomes. Ultrasound guidance and site selection are potential modifiable risk factors in the development of CADVT in pediatric patients. Future studies should target an effective chemoprophylaxis regimen.