RESUMO
The purposes of this review are to describe differences between palliative care for adult patients and palliative care for pediatric patients, both generally and in the intensive care unit; to highlight ethical considerations for pediatric intensive care unit patients by using illustrative cases; and to examine the impact of these ethical considerations on decision-making for children and their families.
Assuntos
Unidades de Terapia Intensiva Pediátrica , Cuidados Paliativos , Humanos , Cuidados Paliativos/ética , Criança , Masculino , Feminino , Adolescente , Pré-Escolar , Lactente , Adulto , Tomada de Decisões/ética , Recém-NascidoRESUMO
Multisystem inflammatory syndrome in children (MIS-C) is a serious, sometimes life-threatening late complication of coronavirus disease 2019 (COVID-19) with multiorgan involvement and evidence of immune activation. The pathogenesis of MIS-C is not known, nor is the pathogenesis of the severe organ damage that is the hallmark of MIS-C. Human herpesvirus 6 (HHV-6), the virus responsible for roseola, is a ubiquitous herpesvirus that causes close to universal infection by the age of 3 years. HHV-6 remains latent for life and can be activated during inflammatory states, by other viruses, and by host cell apoptosis. HHV-6 has been associated with end-organ diseases, including hepatitis, carditis, and encephalitis. In addition, â¼1% of people have inherited chromosomally integrated human herpesvirus 6 (iciHHV-6), which is HHV-6 that has been integrated into chromosomal telomeric regions and is transmitted through the germ line. iciHHV-6 can be reactivated and has been associated with altered immune responses. We report here a case of MIS-C in which an initial high HHV-6 DNA polymerase chain reaction viral load assay prompted testing for iciHHV-6, which yielded a positive result. Additional research may be warranted to determine if iciHHV-6 is commonly observed in patients with MIS-C and, if so, whether it may play a part in MIS-C pathogenesis.
Assuntos
COVID-19/virologia , Herpesvirus Humano 6 , Infecções por Roseolovirus/virologia , Síndrome de Resposta Inflamatória Sistêmica/virologia , Teste de Ácido Nucleico para COVID-19 , Criança , DNA Viral/isolamento & purificação , Herpesvirus Humano 6/genética , Herpesvirus Humano 6/isolamento & purificação , Humanos , Masculino , Reação em Cadeia da Polimerase , Telômero/virologia , Carga Viral , Latência ViralRESUMO
OBJECTIVE: To evaluate bispectral index technology in critically ill children and compare its performance to standard clinical assessment of sedation level. DESIGN: Prospective convenience sample. SETTING: Multidisciplinary 16-bed pediatric intensive care unit at a large, urban, university-affiliated children's hospital. PATIENTS: Thirty-one pediatric intensive care unit patients requiring mechanical ventilation and sedation. MEASUREMENTS AND MAIN RESULTS: Intubated, sedated, pediatric intensive care unit patients were evaluated for their level of sedation by using bispectral index (BIS) and the COMFORT scale twice daily for up to 5 days. The lowest and highest BIS measurements and their corresponding COMFORT scale measurements were selected from each subject. The mean BIS and COMFORT scale measurements were 62.4 +/- 2.6 and 18 +/- 0.6, respectively; however the individual measurements were only moderately correlated. The BIS values were categorized into very deep (<40), deep (41-60), moderate (61-80), and light (>80) levels of sedation. The corresponding COMFORT scale mean measurements in each category were 15.8 +/- 0.6, 16.2 +/- 0.6, 18.1 +/- 1.3, and 22.3 +/- 1.4 (R(2) =.89). CONCLUSIONS: BIS measurements evaluated in clinically relevant ranges compare favorably with a standard assessment of the level of sedation. However, comparisons of BIS and COMFORT scale measurements at isolated moments during a prolonged pediatric intensive care unit course of sedation were less correlated. BIS may be best used to identify and prevent oversedation of patients in the pediatric intensive care unit.