Palliative care, resuscitation status, and end-of-life considerations in pediatric anesthesia.

PURPOSE OF REVIEW: To familiarize pediatric anesthesiologists with primary palliative care procedural communication skills and recommendations for discussions involving complex medical decision-making or advance care planning, such as discussions about resuscitation status. RECENT FINDINGS: Recent publications highlight the benefits of pediatric palliative care (PPC) for seriously ill patients and their families, and how PPC principles might be applied to perioperative communication and decision-making. Both prospective and retrospective reports reveal improved quality of life, symptom management, and avoidance of unnecessary interventions when PPC is introduced early for a child with serious illness. SUMMARY: Pediatric anesthesiologists will, at some point, care for a child with serious illness who would benefit from PPC. It is important that all members of the perioperative care team are familiar with primary PPC procedural communication skills and models for approaching discussions about goals of care, shared decision-making, and advance care planning. Pediatric anesthesiologists should be incorporated as early as possible in team discussions about potential procedures requiring sedation for seriously ill children.

Optically Activated Delayed Fluorescence through Control of Cyanine Dye Photophysics.

Merocyanine 540 fluorescence can be enhanced by optically depopulating dark photoisomer states to regenerate the fluorescence-generating manifold of the all-trans isomer. Here, we utilize a competing modulation route, long-wavelength coexcitation of the trans triplet population to not only modulate fluorescence through enhanced ground-state recovery but also generate optically activated delayed fluorescence (OADF) with longer-wavelength co-illumination. Such OADF (∼580 nm) is directly observed with pulsed fluorescence excitation at 532 nm, followed by long-wavelength (637 nm) continuous wave depopulation of the photogenerated triplet by repopulating the emissive S1 state. Such reverse intersystem crossing (RISC) results in ns-lived fluorescence delayed by several microseconds after the initial primary excitation pulse and the prompt 1 ns-lived fluorescence that it induces. The dark state from which OADF is generated decays more rapidly with increased secondary laser intensity, as the optically induced RISC rate increases. This first OADF from organic dyes is observed, as the red secondary laser excites ∼580 nm, <1 ns-lived fluorescence from the previously optically prepared ∼1 µs-lived triplet state. This sequential two-photon, repumped fluorescence yields background-free collection with potential for new high-sensitivity fluorescence imaging schemes.

Are Children's Hospitals Doing Enough to Address the Climate Crisis?

INTRODUCTION: The warming of our planet matters to the health, well-being, and future of every child. 1 Due to the nature of infants' and children's biological systems and cognitive immaturity, they are more vulnerable to the effects of climate change and air pollution. 1,2 The U.S. healthcare sector itself contributes to the problem and accounts for 8.5% of U.S. greenhouse gas emissions (GHGe). 3 These emissions come directly from hospital operations, indirectly from purchased energy, and the largest category, termed scope 3 emissions, includes purchased goods and services, employee commuting, and waste management. 4 Reducing GHGe can also improve hospitals' operating efficiency and promote healthcare resiliency. 1.

Attempting to Define Clinical Productivity Metrics among Pediatric Palliative Care Services at Academic Children's Hospitals.

Introduction: Pediatric palliative care (PPC) programs have grown in size and number at academic children's hospitals in the United States for the past 20 years. Little is known about the relationships between program workforce staffing, billing and coding practices, clinical service requirements for billing providers, and sustainability of program models for billing providers. Methods: The authors contacted a convenience sample of 10 PPC program leaders at academic children's hospitals in the United States. Program leaders were asked to provide information about billing provider full-time equivalent (FTE) staffing, billing and coding practices, and productivity metrics for a three-month period, from January 1 to March 31, 2017. Results: Ten programs participated in the convenience sample survey, and seven provided information about billing and coding practices. For the seven programs that provided evaluation and management data, calculated estimate of mean work Relative Value Unit (wRVU) production per 1.0 FTE per year was 1626. Calculated estimate of consultations per 1.0 FTE per month was 15. Calculated estimate of total clinical encounters per 1.0 FTE per month was 70. Conclusions: The relationships between PPC billing provider productivity and clinical workload are complex and vary widely among a convenience sample of academic PPC programs. Given the high burnout rates in the field, efforts should be made to more clearly define these relationships to promote sustainability of both billing and nonbilling PPC providers.

Methadone prolongs cardiac conduction in young patients with cancer-related pain.

OBJECTIVE: Methadone prolongs cardiac conduction, from mild corrected QT (QTc) prolongation to torsades de pointes and ventricular fibrillation, in adults. However, methadone use for pain and its effects on cardiac conduction have not been investigated in pediatric populations. METHODS: A retrospective review of QTc intervals in patients receiving methadone analgesia was conducted. Medical records from a 4-year period (September 2006 to October 2010) at a pediatric oncology institution were reviewed, and correlations were tested between cardiac conduction and methadone dosage and duration of therapy, electrolyte levels, renal and hepatic dysfunction, and concurrent medications. RESULTS: Of the 61 patients who received methadone, 37 met our inclusion criteria and underwent 137 electrocardiograms (ECGs). During methadone treatment, the mean QTc was longer than that at baseline (446.5 vs 437.55 ms). The mean methadone dose was 27.0±24.3 mg/d (range, 5-125 mg/d; median, 20 mg/d) or 0.47±0.45 mg/kg per day (range, 0.05-2.25 mg/kg per day; median, 0.37 mg/kg per day), and the mean duration of therapy was 49 days. The authors identified a correlation between automated and manual ECG readings by two cardiologists (Pearson r=0.649; p<0.0001), but the authors found no correlations between methadone dose or duration and concurrent QTc-prolonging medications, sex, age, electrolyte abnormalities, or renal or hepatic dysfunction. CONCLUSION: At a clinically effective analgesic dose, methadone dosage and duration were not correlated with QTc prolongation, even in the presence of other risk factors, suggesting that methadone use may be safe in pediatric populations. The correlation between automated and manual ECG readings suggests that automated ECG readings are reliable for monitoring cardiac conductivity during the reported methadone-dosage regimens.

Tailoring cyanine dark states for improved optically modulated fluorescence recovery.

Cyanine dyes are well-known for their bright fluorescence and utility in biological imaging. However, cyanines also readily photoisomerize to produce nonemissive dark states. Co-illumination with a secondary, red-shifted light source on-resonance with the longer wavelength absorbing dark state reverses the photoisomerization and returns the cyanine dye to the fluorescent manifold, increasing steady-state fluorescence intensity. Modulation of this secondary light source dynamically alters emission intensity, drastically improving detection sensitivity and facilitating fluorescence signals to be recovered from an otherwise overwhelming background. Red and near-IR emitting cyanine derivatives have been synthesized with varying alkyl chain lengths and halogen substituents to alter dual-laser fluorescence enhancement. Photophysical properties and enhancement with dual laser modulation were coupled with density functional calculations to characterize substituent effects on dark state photophysics, potentially improving detection in high background biological environments.