Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study.

OBJECTIVE: Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN: Secondary analysis of multicenter retrospective cohort study. SETTING: Ten PICUs in the United States between 2009 and 2021. PATIENTS: Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS: Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.

Admission Functional Status is Associated With Intensivists Perception of Extracorporeal Membrane Oxygenation Candidacy for Pediatric Acute Respiratory Failure.

OBJECTIVES: To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure. DESIGN: Prospective, cross-sectional study. SETTING: Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022. SUBJECTS: Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio [OR] 0.18 [95% CI, 0.06-0.56], p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 [95% CI, 0.29-0.68], p < 0.0001). CONCLUSIONS: In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.

A Taxonomy of Objections to Brain Death Determination.

Family objections to evaluating a patient for death by neurologic criteria, or "brain death," are challenging for the family and the medical team. In this article, we categorize brain death evaluation refusals into a taxonomy: informational objections, emotional objections, and principled objections. We offer suggested approaches for clinicians to respond to refusals on the basis of the category. The category of objection may also be important in considering when accommodation of refusals should be considered. The goal in all such situations is to promote compassionate, ethical, and equitable care for the patient and family.

Integrating Palliative Care Into the ICU: From Core Competency to Consultative Expertise.

OBJECTIVES: To propose a model describing levels of integration of palliative care into the care of ICU patients. DATA SOURCES: Literature review and author opinion. CONCLUSIONS: All critical care team members should demonstrate and foster their core competencies in caring for patients with complex illness and uncertain prognosis, including at the end of life. We describe these core competencies of the ICU team member as "primary" palliative care skills. Some ICU team members will have special expertise in end-of-life care or symptom management and decision-making support and will serve as local experts within the ICU team as a resource to other team members. We call this skillset "secondary" palliative care. Some patients will benefit from the full range of expertise provided by a separate consulting team, with additional training, focused on caring for patients with palliative care needs across the full spectrum of patient locations within a health system. We term the skillset provided by such outside consultants "tertiary" palliative care. Solutions for meeting patients' palliative care needs will be unique within each system and individual institution, depending on available resources, history, and structures in place. Providers from multiple professions will usually contribute to meeting patient needs.

Parental Sources of Support and Guidance When Making Difficult Decisions in the Pediatric Intensive Care Unit.

OBJECTIVE: To assess sources of support and guidance on which parents rely when making difficult decisions in the pediatric intensive care unit and to evaluate associations of sources of support and guidance to anxiety, depression, and positive and negative affect. STUDY DESIGN: This was a prospective cohort study of 86 English-speaking parents of 75 children in the pediatric intensive care unit at The Children's Hospital of Philadelphia who were hospitalized greater than 72 hours. Parents completed standardized instruments and a novel sources of support and guidance assessment. RESULTS: Most parents chose physicians, nurses, friends, and extended family as their main sources of support and guidance when making a difficult decision. Descriptive analysis revealed a broad distribution for the sources of support and guidance items related to spirituality. Parents tended to fall into 1 of 2 groups when we used latent class analysis: the more-spiritual group (n = 47; 55%) highly ranked "what my child wants" (P = .023), spouses (P = .002), support groups (P = .003), church community (P < .001), spiritual leader (P < .001), higher power (P < .001), and prayer (P < .001) compared with the less-spiritual group (n = 39; 45%). The more-spiritual parents had greater positive affect scores (P = .005). Less-spiritual parents had greater depression scores (P = .043). CONCLUSIONS: Parents rely most on physicians, nurses, and friends and extended family when making difficult decisions for their critically ill child. Respondents tended to fall into 1 of 2 groups where the more-spiritual respondents were associated with greater positive affect and may be more resistant to depression.

The Development of Tracheal Intubation Proficiency Outside the Operating Suite During Pediatric Critical Care Medicine Fellowship Training: A Retrospective Cohort Study Using Cumulative Sum Analysis.

OBJECTIVE: Tracheal intubation is a core technical skill for pediatric critical care medicine fellows. Limited data exist to describe current pediatric critical care medicine fellow tracheal intubation skill acquisition through the training. We hypothesized that both overall and first-attempt tracheal intubation success rates by pediatric critical care medicine fellows improve over the course of training. DESIGN: Retrospective cohort study at a single large academic children's hospital. MATERIALS AND METHODS: The National Emergency Airway Registry for Children database and local QI database were merged for all tracheal intubations outside the Operating Suite by pediatric critical care medicine fellows from July 2011 to January 2015. Primary outcomes were tracheal intubation overall success (regardless of number of attempts) and first attempt success. Patient-level covariates were adjusted in multivariate analysis. Learning curves for each fellow were constructed by cumulative sum analysis. RESULTS: A total of 730 tracheal intubation courses performed by 33 fellows were included in the analysis. The unadjusted overall and first attempt success rates were 87% and 80% during the first 3 months of fellowship, respectively, and 95% and 73%, respectively, during the past 3 months of fellowship. Overall success, but not first attempt success, improved during fellowship training (odds ratio for each 3 months, 1.08; 95% CI, 1.01-1.17; p = 0.037) after adjusting for patient-level covariates. Large variance in fellow's tracheal intubation proficiency outside the operating suite was demonstrated with a median number of tracheal intubation equal to 26 (range, 19-54) to achieve a 90% overall success rate. All fellows who completed 3 years of training during the study period achieved an acceptable 90% overall tracheal intubation success rate. CONCLUSIONS: Tracheal intubation overall success improved significantly during the course of fellowship; however, the tracheal intubation first attempt success rates did not. Large variance existed in individual tracheal intubation performance over time. Further investigations on a larger scale across different training programs are necessary to clarify intensity and duration of the training to achieve tracheal intubation procedural competency.

Regoaling: a conceptual model of how parents of children with serious illness change medical care goals.

BACKGROUND: Parents of seriously ill children participate in making difficult medical decisions for their child. In some cases, parents face situations where their initial goals, such as curing the condition, may have become exceedingly unlikely. While some parents continue to pursue these goals, others relinquish their initial goals and generate new goals such as maintaining the child's quality of life. We call this process of transitioning from one set of goals to another regoaling. DISCUSSION: Regoaling involves factors that either promote or inhibit the regoaling process, including disengagement from goals, reengagement in new goals, positive and negative affect, and hopeful thinking. We examine these factors in the context of parental decision making for a seriously ill child, presenting a dynamic conceptual model of regoaling. This model highlights four research questions that will be empirically tested in an ongoing longitudinal study of medical decision making among parents of children with serious illness. Additionally, we consider potential clinical implications of regoaling for the practice of pediatric palliative care. SUMMARY: The psychosocial model of regoaling by parents of children with a serious illness predicts that parents who experience both positive and negative affect and hopeful patterns of thought will be more likely to relinquish one set of goals and pursue a new set of goals. A greater understanding of how parents undergo this transition may enable clinicians to better support them through this difficult process.

An under-recognized benefit of cardiopulmonary resuscitation: organ transplantation.

OBJECTIVE: For many patients who suffer cardiac arrest, cardiopulmonary resuscitation does not result in long-term survival. For some of these patients, the evolution to donation of organs becomes an option. Organ transplantation after cardiopulmonary resuscitation is not reported as an outcome of cardiopulmonary resuscitation and is therefore overlooked. We sought to determine the number and proportion of organs transplanted from donors who received cardiopulmonary resuscitation after a cardiac arrest in the United States and to compare survival of organs from donors who had cardiopulmonary resuscitation (cardiopulmonary resuscitation organs) versus donors who did not have resuscitation (noncardiopulmonary resuscitation organs). DATA SOURCE: We retrospectively analyzed a nationwide, population-based database of all organ donors and recipients from the United Network for Organ Sharing between July 1999 and June 2011. STUDY SELECTION: We queried the database for all organs from deceased donors between July 1999 and June 2011. Organs from living donors (n = 76,015), all organs with missing cardiopulmonary resuscitation data (n = 59), and organs procured following a circulatory determination of death (n = 12,030) were excluded. DATA EXTRACTION: We report donor demographic data and organ survival outcomes among organs from donors who received cardiopulmonary resuscitation (cardiopulmonary resuscitation organs) and donors who had not received cardiopulmonary resuscitation (noncardiopulmonary resuscitation organs). Graft survival of cardiopulmonary resuscitation organs versus noncardiopulmonary resuscitation organs was compared using Kaplan-Meier estimates and stratified log-rank test. DATA SYNTHESIS: In the United States, among the 224,076 organs donated by donors who were declared dead by neurologic criteria between 1999 and 2011, at least 12,351 organs (5.5%) were recovered from donors who received cardiopulmonary resuscitation. Graft survival of cardiopulmonary resuscitation organs was not significantly different than that of noncardiopulmonary resuscitation organs. CONCLUSIONS: At least 1,000 organs transplanted per year in the United States (> 5% of all organs transplanted from patients declared dead by neurologic criteria) are recovered from patients who received cardiopulmonary resuscitation. Organ recovery and successful transplantation is an unreported beneficial outcome of cardiopulmonary resuscitation.

Parental decision-making preferences in the pediatric intensive care unit.

OBJECTIVE: To assess parental decision-making preferences in the high-stress environment of the pediatric intensive care unit and test whether preferences vary with demographics, complex chronic conditions, prior admissions to the pediatric intensive care unit, and parental positive and negative emotional affect. DESIGN: Institutional Review Board-approved prospective cohort study conducted between December 2009 and April 2010. SETTING: Pediatric intensive care unit at The Children's Hospital of Philadelphia. PARTICIPANTS: Eighty-seven English-speaking parents of 75 children either <18 yrs of age or cognitively incapable of making their own decisions and who were hospitalized in the pediatric intensive care unit for >72 hrs. INTERVENTIONS: Parents were interviewed in person and completed standardized instruments that assessed decision-making preferences and parental affect. MEASUREMENTS AND MAIN RESULTS: The majority of parents in the analytic sample preferred shared decision making with their doctors (40.0%) or making the final decision/mostly making the final decision on their own (41.0%). None of the child and parent characteristics in the analytic sample were found to be significantly associated with the top decision-making preference. Using shared decision making as a reference category, we determined whether positive or negative affect scores were associated with preferring other decision-making options. We found that parents with higher positive affect were less likely to prefer self/mostly self (autonomous decision making). Increased positive affect was also associated with a reduced likelihood of preferring doctor/mostly doctor (delegating the decision), but not to a significant degree. CONCLUSIONS: Most parents in the pediatric intensive care unit prefer their role in decision making to be shared with their doctor or to have significant autonomy in the final decision. A sizeable minority, however, prefer decision-making delegation. Parental emotional affect has an association with decision-making preference.

The Bereaved Parent Needs Assessment: a new instrument to assess the needs of parents whose children died in the pediatric intensive care unit*.

OBJECTIVES: To evaluate the reliability and validity of the Bereaved Parent Needs Assessment, a new instrument to measure parents' needs and need fulfillment around the time of their child's death in the pediatric intensive care unit. We hypothesized that need fulfillment would be negatively related to complicated grief and positively related to quality of life during bereavement. DESIGN: Cross-sectional survey. SETTING: Five U.S. children's hospital pediatric intensive care units. SUBJECTS: Parents (n = 121) bereaved in a pediatric intensive care unit 6 months earlier. INTERVENTIONS: Surveys included the 68-item Bereaved Parent Needs Assessment, the Inventory of Complicated Grief, and the abbreviated version of the World Health Organization Quality of Life questionnaire. Each Bereaved Parent Needs Assessment item described a potential need and was rated on two scales: 1) a 5-point rating of importance (1 = not at all important, 5 = very important) and 2) a 5-point rating of fulfillment (1 = not at all met, 5 = completely met). Three composite scales were computed: 1) total importance (percentage of all needs rated ≥4 for importance), 2) total fulfillment (percentage of all needs rated ≥4 for fulfillment), and 3) percent fulfillment (percentage of important needs that were fulfilled). Internal consistency reliability was assessed by Cronbach's α and Spearman-Brown-corrected split-half reliability. Generalized estimating equations were used to test predictions between composite scales and the Inventory of Complicated Grief and World Health Organization Quality of Life questionnaire. MEASUREMENTS AND MAIN RESULTS: Two items had mean importance ratings <3, and 55 had mean ratings >4. Reliability of composite scores ranged from 0.92 to 0.94. Total fulfillment was negatively correlated with Inventory of Complicated Grief (r = -.29; p < .01) and positively correlated with World Health Organization Quality of Life questionnaire (r = .21; p < .05). Percent fulfillment was also significantly correlated with both outcomes. Adjusting for parent's age, education, and loss of an only child, percent fulfillment remained significantly correlated with Inventory of Complicated Grief but not with World Health Organization Quality of Life questionnaire. CONCLUSIONS: The Bereaved Parent Needs Assessment demonstrated reliability and validity to assess the needs of parents bereaved in the pediatric intensive care unit. Meeting parents' needs around the time of their child's death may promote adjustment to loss.

Change in regional (somatic) near-infrared spectroscopy is not a useful indicator of clinically detectable low cardiac output in children after surgery for congenital heart defects.

OBJECTIVE: Near-infrared spectroscopy correlation with low cardiac output has not been validated. Our objective was to determine role of splanchnic and/or renal oxygenation monitoring using near-infrared spectroscopy for detection of low cardiac output in children after surgery for congenital heart defects. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit of a tertiary care teaching hospital. PATIENTS: Children admitted to the pediatric intensive care unit after surgery for congenital heart defects. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We hypothesized that splanchnic and/or renal hypoxemia detected by near-infrared spectroscopy is a marker of low cardiac output after pediatric cardiac surgery. Patients admitted after cardiac surgery to the pediatric intensive care unit over a 10-month period underwent serial splanchnic and renal near-infrared spectroscopy measurements until extubation. Baseline near-infrared spectroscopy values were recorded in the first postoperative hour. A near-infrared spectroscopy event was a priori defined as ≥20% drop in splanchnic and/or renal oxygen saturation from baseline during any hour of the study. Low cardiac output was defined as metabolic acidosis (pH <7.25, lactate >2 mmol/L, or base excess ≤-5), oliguria (urine output <1 mL/kg/hr), or escalation of inotropic support. Receiver operating characteristic analysis was performed using near-infrared spectroscopy event as a diagnostic test for low cardiac output. Twenty children were enrolled: median age was 5 months; median Risk Adjustment for Congenital Heart Surgery category was 3 (1-6); median bypass and cross-clamp times were 120 mins (45-300 mins) and 88 mins (17-157 mins), respectively. Thirty-one episodes of low cardiac output and 273 near-infrared spectroscopy events were observed in 17 patients. The sensitivity and specificity of a near-infrared spectroscopy event as an indicator of low cardiac output were 48% (30%-66%) and 67% (64%-70%), respectively. On receiver operating characteristic analysis, neither splanchnic nor renal near-infrared spectroscopy event had a significant area under the curve for prediction of low cardiac output (area under the curve: splanchnic 0.45 [95% confidence interval 0.30-0.60], renal 0.51 [95% confidence interval 0.37-0.65]). CONCLUSIONS: Splanchnic and/or renal hypoxemia as detected by near-infrared spectroscopy may not be an accurate indicator of low cardiac output after surgery for congenital heart defects.