A Catholic Perspective on COVID-19.

It took nearly two thousand years for society to recognize the Hippocratic insistence that "the doctor knows best"1 was an inadequate approach to medical decisionmaking. Today, patient-centered medicine has come to understand that the individual patient has a significant role in the decisionmaking process.2.

Diagnostic Yield of Cardiac Biomarker Testing in Predicting Cardiac Disease and Multisystem Inflammatory Syndrome in Children in the Pandemic Era.

OBJECTIVES: This study aimed to assess whether elevations in cardiac biomarkers are associated with pediatric cardiac diagnoses in the era of COVID-19 and multisystem inflammatory syndrome in children (MIS-C). STUDY DESIGN: This single-center retrospective study analyzed children with a troponin drawn in the emergency department or inpatient unit between April 21 and December 31, 2020. The primary outcome was the presence of a cardiac diagnosis or MIS-C. Relationships among demographics, complaint, cardiac diagnostics, and cardiac biomarkers were analyzed. RESULTS: Four hundred eighty-six patients (mean ± SD; age 13.1 ± 7.8 years; 46.7% women) met inclusion criteria, for whom a cardiac diagnosis (excluding MIS-C) was made in 27 (5.6%) patients, with MIS-C diagnosed in 14 (2.9%) patients. The sensitivity and specificity of an elevated initial high-sensitivity troponin T (hsTropT) value (>14 ng/L) in predicting the composite outcome of a cardiac diagnosis or MIS-C were 54% and 89%, respectively. Four percent of patients with negative initial troponin values were found to have a cardiac diagnosis or MIS-C. Multivariable regression analysis demonstrated that elevated hsTropT (>14 ng/L; odds ratio [OR] [95% confidence interval]: 4.9 [1.70-14.0]) and elevated N-terminal pro B-type natriuretic peptide values (>500 pg/mL; 6.4 [2.01-20.1]) were associated with increased odds of a cardiac diagnosis or MIS-C. CONCLUSIONS: Children with elevated cardiac biomarkers have increased odds of a cardiac diagnosis or MIS-C and warrant workup regardless of indication for testing. Although a negative hsTropT may reassure providers, further investigation is critical in developing algorithms to reliably exclude cardiac disease.

Distinguishing Features of Patients Evaluated for Multisystem Inflammatory Syndrome in Children.

OBJECTIVES: Given the significant overlap of multisystem inflammatory syndrome in children (MIS-C) with other common childhood illnesses presenting to the emergency department, extensive workup of this syndrome has become necessary. Nevertheless, little has been published on the factors differentiating MIS-C from other conditions in the acute care setting. We investigated differences in presentation and laboratory studies between suspected versus confirmed MIS-C patients. METHODS: This was a retrospective cohort study on patients 21 years or younger undergoing investigation for possible MIS-C at a single institution between April 21 and July 1, 2020. The primary outcome was diagnosis of MIS-C or an alternative final diagnosis. Clinical features and laboratory findings from initial presentation were collected and analyzed. RESULTS: A total of 106 patients (median, 4 years; 55.7% male) were included, of whom 17 (16%) of 106 met the criteria for MIS-C. Multisystem inflammatory syndrome in children patients were significantly more likely to report a coronavirus disease 2019 exposure (odds ratio (OR), 13.17 [3.87-44.9]), have gastrointestinal symptoms (OR, 3.81 [1.02-14.19]), and have a significantly higher odds of having abnormal laboratory values including high-sensitivity troponin T (OR, 13 [4.0-42.2]), N-terminal B-type natriuretic peptide (OR, 8.4 [2.3-30.1]), D-dimer (OR, 13 [1.6-103]), and ferritin (OR, 7.8 [2.2-27.2]). There were also differences between groups in inflammatory markers: C-reactive protein (median, 134.45 mg/L vs 12.6 mg/L; P < 0.05) and procalcitonin (1.71 ng/mL vs 0.14 ng/mL; P < 0.001). CONCLUSIONS: Higher elevations in key laboratory studies may help to distinguish between MIS-C patients and non-MIS-C patients presenting to the emergency department.

Standardized Volume Dosing Protocol of 23.4% Hypertonic Saline for Pediatric Critical Care: Initial Experience.

Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but the concentration, dosing and administration of HTS in pediatrics is variable. With emerging pediatric experience of 23.4% HTS, a standard volume dose approach may be helpful. Objective: To describe initial experience with a standardized 23.4% HTS weight-based volume dosing protocol of 10, 20, or 30 mL in the pediatric intensive care unit. Methods: Standard volume doses of 23.4% HTS were developed from weight dosing equivalents of 3% HTS. Pre and post sodium and intracranial pressure (ICP) measurements were compared with paired t-test or Wilcoxon rank-sum test. The site of administration and complications were noted. Results: A total of 16 pediatric patients received 37 doses of 23.4% HTS, with the smallest patient weighing 11 kg. For protocol compliance, 17 doses (46%) followed recommended dosing, 19 were less volume than recommended (51%), and 1 dose (3%) was more than recommended. Mean increase in sodium was 3.5 mEq/L (95% CI = 2-5 mEq/L); P < 0.0001. The median decrease in ICP was 10.5 mm Hg (interquartile range [IQR] 8.3-19.5) for a 37% (IQR 25%-64%) reduction. Most doses were administered through central venous access, although peripheral intravenous administrations occurred in 4 patients without complication. Conclusion and Relevance: Three standard-volume dose options of 23.4% HTS based on weight increases sodium and reduces ICP in pediatric patients. Standard-volume doses may simplify weight-based dosing, storage and administration for pediatric emergencies, although the optimum dose, and safety of 23.4% HTS in children remains unknown.

From Death to Life: Ethical Issues in Postmortem Sperm Retrieval as a Source of New Life.

This paper examines and critiques the ethical issues in postmortem sperm retrieval and the use of postmortem sperm to create new life. The article was occasioned by the recent request of the parents of a West Point cadet who died in a skiing accident at the Academy to retrieve and use his sperm to honor his memory and perpetuate the family name. The request occasioned national media attention. A trial court judge in New York in a two-page order authorized both the retrieval and use of the postmortem sperm.

Conjoined Twins Separation Leading to the Death of One Twin: An Expanded Ethical Analysis of Issues Facing the ICU Team.

A recent case of conjoined twins required multiple hospitalizations in the pediatric intensive care unit and led to a difficult situation confronting staff regarding the potential separation where surgery would result in the death of one twin. The hospital ethics committee was consulted. A systematic approach was utilized to examine medical standards, historical precedents, and various ethical and legal frameworks. The ethics committee believed that either proceeding with or forgoing attempted separation surgery would be ethically acceptable. We share our reasoning and lessons learned for others facing this situation in the future.

Impact of Pediatric Intensive Care Unit Admission on Family Financial Status and Productivity: A Pilot Study.

OBJECTIVE: A child's pediatric intensive care unit (PICU) admission may have wide-ranging family implications. We assessed nonmedical out-of-pocket expenses (NMOOPEs) and disruptions in work and normal life for parents with a child admitted to the PICU for at least 2 days with acute, new onset, or exacerbation of a critical condition. DESIGN: We conducted a prospective, single-center study; administered a daily verbal response survey on NMOOPEs; stratified families by annual income (<$50 999, $51-99 000, >$100 000); and calculated daily expenditures (DEs), estimated daily budgets (DBs), and percentage of NMOOPEs (%DE/DB). We used a modified caregiver version of the Work Productivity and Activity Impairment Scale to assess the impact of PICU admission on work-related and normal life activities. SETTING: The PICU in an academic, tertiary medical center in the United States. PATIENTS: Patients admitted to PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study included 38 families, with median length of PICU stay of 3 days (range 3-13). The mean total NMOOPE was $127 ± $107 (range $5-$511). Financial impact of DB in the 3 annual income groups ranged from 0% to 136% (median 36%), 5% to 18% (median 10%), and 4% to 39% (median 16%), respectively. Total work absenteeism for cohort was 78 days. High levels of distraction were reported in working families, and normal daily activities were interrupted or suspended. CONCLUSIONS: PICU hospitalization results in a range of direct NMOOPEs of varying burden on families and additional work productivity impact. Further research to understand the array of financial implications on families and additional mitigation strategies are needed.

Building a Bridge Between Pediatric Anesthesiologists and Pediatric Intensive Care.

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields.

Parent Participation in Pediatric Intensive Care Unit Rounds via Telemedicine: Feasibility and Impact.

OBJECTIVES: To evaluate feasibility and impact of telemedicine for remote parent participation in pediatric intensive care unit (PICU) rounds when parents are unable to be present at their child's bedside. STUDY DESIGN: Parents of patients admitted to a 14-bed PICU were approached, and those unable to attend rounds were eligible subjects. Nurse and physician caregivers were also surveyed. Parents received an iPad (Apple Inc, Cupertino, California) with an application enabling audio-video connectivity with the care team. At a predetermined time for bedside rounds with the PICU team, parents entered a virtual meeting room to participate. Following each telemedicine encounter, participants (parent, physician, nurse) completed a brief survey rating satisfaction (0?=?not satisfied, 10?=?completely satisfied) and disruption (0?=?no disruption at all, 10?=?very disruptive). RESULTS: A total of 153 surveys were completed following 51 telemedicine encounters involving 13 patients. Parents of enrolled patients cited work demands (62%), care for other dependents (46%), and transportation difficulties (31%) as reasons for study participation. The median levels of satisfaction and disruption were 10 (range 5-10) and 0 (range 0-5), respectively. All parents reported that telemedicine encounters had a positive effect on their level of reassurance regarding their child's care and improved communication with the care team. CONCLUSIONS: This proof-of-concept study indicates that remote parent participation in PICU rounds is feasible, enhances parent-provider communication, and offers parents reassurance. Providers reported a high level of satisfaction with minimal disruption. Technological advancements to streamline teleconferencing workflow are needed to ensure program sustainability.

Effect of Transition From a Unit-Based Team to External Transport Team for a Pediatric Critical Care Unit.

OBJECTIVE: Pediatric hospitals must consider staff, training, and direct costs required to maintain a pediatric specialized transport team, balanced with indirect potential benefits of marketing and referral volume. The effect of transitioning a unit-based transport team to an external service on the pediatric intensive care unit (PICU) is unknown, but information is needed as hospital systems focus on population management. We examined the impact on PICU transports after transition to an external transport vendor. METHODS: Single-center retrospective review performed of PICU admissions, referrals, and transfers during baseline, post-, and maintenance period with a total of 9-year follow-up. Transfer volume was analyzed during pre-, post-, and maintenance phase with descriptive statistics and statistical process control charts from 1999 to 2012. RESULTS: Total PICU admissions increased with an annual growth rate of 3.7%, with mean annual 626 admissions prior to implementation to the mean of 890 admissions at the end of period, P < .001. The proportion of transport to total admissions decreased from 27% to 21%, but mean annual transports were unchanged, 175 to 183, P = .6, and mean referrals were similar, 186 to 203, P = .8. Seasonal changes in transport volume remained as a predominant source of variability. Annual transport refusals increased initially in the postimplementation phase, mean 11 versus 33, P < .03, but similar to baseline in the maintenance phase, mean 20/year, P = .07. Patient refusals were due to bed and staffing constraints, with 7% due to the lack of transport vendor availability. CONCLUSION: In a transition to a regional transport service, PICU transport volume was maintained in the long-term follow-up and total PICU admissions increased. Further research on the direct and indirect impact of transport regionalization is needed to determine the optimal cost-benefit and quality of care as health-care systems focus on population management.

Cardiovascular Effects of Continuous Dexmedetomidine Infusion Without a Loading Dose in the Pediatric Intensive Care Unit.

BACKGROUND: Use of dexmedetomidine in pediatric critical care is common, despite lack of prospective studies on its hemodynamic effects. OBJECTIVE: To describe cardiovascular effects in critically ill children treated with a constant continuous infusion of dexmedetomidine without a loading dose at highest Food and Drug Administration-approved adult dose. METHODS: Prospective, pilot study of 17 patients with dexmedetomidine infused at a rate of 0.7 µg/kg/h for 6 to 24 hours. Heart rate (HR) and blood pressure (BP) values over time were analyzed by a random effects mixed model. RESULTS: Patients with median age of 1.6 years (1 month to 17 years) and median weight of 11.8 kg (2.8-84 kg) received an infusion for a mean of 16 ± 7.2 hours. There were no cardiac conduction abnormalities. One patient required discontinuation of infusion for predetermined low HR termination criteria at hour 13 of infusion; there was no clinical compromise and it coincided with planned extubation. Decreased HR of 20% from baseline was found in 35% of patients. The mean HR reduction was largest at hour 13 of infusion with a decrease of 13 ± 17 bpm from baseline, but HR changes over time were not statistically significant. Blood pressure effects included a decrease in 12% and an increase in 29%. There was a small but statistically significant increase in systolic BP of 0.4 mm Hg/h of infusion, P < .001. CONCLUSION: A continuous infusion of 0.7 µg/kg/h of dexmedetomidine without a loading dose for up to 24 hours in critically ill children had tolerable effects on HR and BP.

Potassium abnormalities in a pediatric intensive care unit: frequency and severity.

BACKGROUND: Potassium abnormalities are common in critically ill patients. We describe the spectrum of potassium abnormalities in our tertiary-level pediatric intensive care unit (PICU). METHODS: Retrospective observational cohort of all the patients admitted to a single-center tertiary PICU over a 1-year period. Medical records and laboratory results were obtained through a central electronic data repository. RESULTS: A total of 512 patients had a potassium measurement. Of a total of 4484 potassium measurements, one-third had abnormal values. Hypokalemia affected 40% of the admissions. Mild hypokalemia (3-3.4 mmol/L) affected 24% of the admissions. Moderate or severe hypokalemia (K <3.0 mmol/L) affected 16% of the admissions. Hyperkalemia affected 29% of the admissions. Mild hyperkalemia (5.1-6.0 mmol/L) affected 17% of the admissions. Moderate or severe hyperkalemia (>6.0 mmol/L) affected 12%. Hemolysis affected 2% of all the samples and 24% of hyperkalemic values. On univariate analysis, severity of hypokalemia was associated with mortality (odds ratio 2.2, P = .003). CONCLUSIONS: Mild potassium abnormalities are common in the PICU. Repeating hemolyzed hyperkalemic samples may be beneficial. Guidance in monitoring frequencies of potassium abnormalities in pediatric critical care is needed.