Using Ultrasound to Improve Intravenous Access in Patients with Difficult IV Access in the Pediatric Emergency Department

Presenter: Lee Ginton, MD

Difficult intravenous (IV) access in the pediatric emergency department (ED) can contribute to pain, anxiety, delays in care, and prolonged length of stay.

At one institution, pediatric patients with cerebral palsy (CP) and complex congenital heart disease (CHD) requiring open cardiac surgery had higher rates of failed IV attempts (24.9% vs. 15.2%) and longer mean time to IV placement (50.5 vs. 41.4 minutes) than other ED patients between January 2024 and March 2025. A quality improvement (QI) initiative therefore aimed to increase ultrasound-guided IV (USGIV) placement in this high-risk group from 9% to 30% over 12 months. Interventions included an early-identification clinical guideline, education for nursing and physician teams, expansion of nurse USGIV credentialing, and performance feedback through iterative Plan-Do-Study-Act (PDSA) cycles. USGIV utilization increased from 9% to 15%, while first-attempt IV success remained at 84%, with a positive upward trend. Mean room-to-IV time and ED length of stay were unchanged at 102 minutes and 350 minutes, respectively.

The initiative increased USGIV use without observed changes in IV access time or ED length of stay, with further work planned to support sustainability.

Decreasing Chest X-rays in Asthma Patients in a Pediatric Emergency Department

Presenter: Amanda Leng Smith, MD

Chest radiographs (CXRs) are not routinely recommended for children with asthma exacerbations unless features such as significant hypoxia, focal abnormalities, prolonged illness, or severe distress are present.

In a pediatric emergency department (ED), CXR use remained high, prompting a quality improvement initiative to reduce utilization from 36% to 26% within 12 months. Interventions included updating the hospital asthma pathway, educating ED providers, introducing electronic health record (EHR) clinical decision support when residents ordered CXRs, and providing individual audit-feedback. Although the target was not reached within 12 months, continued Plan-Do-Study-Act (PDSA) cycles were associated with a modest reduction in overall CXR use from 36% to 33%. Among discharged patients, use decreased from 24% to 21.5%, while use among admitted patients declined from 74% to 60%. Mean time to CXR order remained 109 minutes. Since data collection began, 5 patients returned to the ED with a subsequent positive CXR, and no increase in positive inpatient CXRs was observed.

The ongoing initiative suggests that pathway optimization, EHR decision support, and audit-feedback can reduce CXR utilization while maintaining monitoring of potential missed bacterial pneumonia.

Significant Complications of a Massive Intentional Ibuprofen Overdose: A Case Report

Presenter: Alex Bryant, MD, MPH

Severe morbidity and mortality after ibuprofen overdose are uncommon, and extracorporeal support has rarely been described.

A 16-year-old male with bipolar depression developed severe toxicity after intentional ingestion of “a few bottles” of ibuprofen, with no reported co-ingestions other than cannabinoids detected on toxicology. He initially developed agitation, diaphoresis, clonus, seizure, and anion gap metabolic acidosis (venous pH 7.16, pvCO2 49, bicarbonate 24, lactate 10, anion gap 16), requiring intubation. His serum ibuprofen concentration was 620 mcg/mL 11 hours after ingestion. Progressive shock and high-output renal failure (Cr 2.54) prompted veno-arterial extracorporeal membrane oxygenation (ECMO), therapeutic plasma exchange, and continuous renal replacement therapy (CRRT). Gastric hemorrhage required exploratory laparotomy, which removed 4 liters of blood with intact ibuprofen pills. ECMO was discontinued on hospital day 3, while CRRT continued through day 11. Subsequent complications included pediatric acute respiratory distress syndrome and pulmonary hemorrhage. He was extubated on day 14 and discharged to rehabilitation on day 36 without reported neurologic sequelae.

This case expands the reported experience with severe ibuprofen toxicity and multimodal extracorporeal management.

The Current Landscape of Pediatric Critical Illness Follow-Up Programs in the United States: Growth, Heterogeneity, and the Need for Best Practices

Presenter: Jane Whitney, MD, MSCE

Recognition of Post-Intensive Care Syndrome in pediatrics (PICS-p) has increased, prompting the development of dedicated pediatric intensive care unit (PICU) follow-up programs, although their structures and care models remain poorly defined.

An electronic adaptive survey conducted from 2024–2026 included 59 respondents representing 44 unique institutions. PICU follow-up programs were operating at 12 (27.3%) institutions and planned at 5 (11.4%). Eligibility varied, with 2 (16.7%) programs accepting all PICU survivors, while others focused on acquired brain injury (3, 25%), acute respiratory failure (1, 8.3%), or extracorporeal membrane oxygenation (ECMO) survivors (1, 8.3%). Care was delivered in person (10, 83.3%), by video (7, 58.3%), or by phone (6, 50%), with substantial variation in visit structure and program leadership. Only 5 programs (41.7%) used standardized PICS-p assessments. Among 32 respondents assessing barriers, financial support was the most frequently reported challenge (17, 53.1%), followed by hospital/department support (9, 28.1%) and clinic space (10, 31.3%).

The findings demonstrate considerable heterogeneity and support collaborative development of best practices for PICU follow-up care.

Early Predictors of Outcomes in Pediatric Sepsis: The Role of The Primary Source of Infection

Presenter: Daniel A. Arrioja Azuaje, BS

Sepsis outcomes in children may vary according to the primary source of infection, in addition to illness severity and comorbidity burden.

This single-institution retrospective cohort included 652 patient encounters among children aged 0–18 years admitted to the pediatric intensive care unit (PICU) from 9/1/2018 to 8/31/2024 who met Phoenix Criteria (score ≥2) within 24 hours. Lower respiratory tract infection (LRTI) was the most common source (49%), followed by intra-abdominal infection (12%), urinary tract infection (UTI; 12%), and sepsis not otherwise specified (10%). Overall, 42% had an unfavorable outcome. These patients had higher Phoenix Scores (PS; median 5 vs 3) and Pediatric Comorbidity Index (PCI; median 12 vs 8) and were more likely to require cardiopulmonary resuscitation (CPR) at presentation (69% vs 31%).

Multivariable analysis identified higher PS (OR 1.22), PCI (OR 1.07), CPR (OR 3.53), recurrent UTI (OR 2.00), intra-abdominal infection (OR 2.38), and bacteremia (OR 2.35) as independently associated with unfavorable outcomes. Increasing PS, PCI, and CPR were associated with progressively higher odds of unfavorable outcomes across infection sites.

American Academy of Pediatrics (AAP) National Conference & Exhibition 2026, October 2–6, San Diego, California