Supporting and Contextualizing Pediatric ECMO Decision-Making Using a Person-Centered Framework.

AbstractThere is a critical need to establish a space to engage in careful deliberation amid exciting, important, necessary, and groundbreaking technological and clinical advances in pediatric medicine. Extracorporeal membrane oxygenation (ECMO) is one such technology that began in pediatric settings nearly 50 years ago. And while not void of medical and ethical examination, both the symbolic progression of medicine that ECMO embodies and its multidimensional challenges to patient care require more than an intellectual exercise. What we illustrate, then, is a person-centered framework that incorporates the philosophy and practice of palliative care and care-based ethical approaches. This person-centered framework is valuable for identifying and understanding challenges central to ECMO, guides collaborative decision-making, and recognizes the value of relationships within and between patients, families, healthcare teams, and others who impact and are impacted by ECMO. Specifically, this person-centered approach enables caregivers to provide compassionate and effective support in critical, and often urgent, situations where conflicts may emerge among healthcare team members, families, and other decision makers. By reflecting on three cases based on actual situations, we apply our person-centered framework and identify those aspects that were utilized in and informed this project. We aim to fill a current gap in the pediatric ECMO literature by presenting a person-centered framework that promotes caregiving relationships among hospitalized critically ill children, families, and the healthcare team and is supported through the philosophy and practice of palliative care and clinical ethics.

Intracranial pressure/cerebral perfusion pressure-targeted management of life-threatening intracranial hypertension complicating diabetic ketoacidosis-associated cerebral edema: a case report.

Symptomatic cerebral edema from diabetic ketoacidosis occurs infrequently but carries a high rate of mortality and morbidity owing to complications from intracranial hypertension. Treatment options are limited but include hyperosmolar therapy with mannitol or hypertonic saline, tracheal intubation for airway protection, and hyperventilation via mechanical ventilation. We describe here the successful use of an intracranial pressure/cerebral perfusion pressure-targeted management strategy through ventriculostomy catheter placement with intracranial pressure monitoring and cerebrospinal fluid drainage, hyperosmolar therapy with hypertonic saline, and controlled hyperventilation to treat life-threatening complications of cerebral edema in a pediatric patient with severe diabetic ketoacidosis.

A normal capillary refill time of ≤ 2 seconds is associated with superior vena cava oxygen saturations of ≥ 70%.

OBJECTIVE: To test the hypothesis that a normal capillary refill time (CRT) ≤ 2 seconds is associated with superior vena cava oxygen saturation (ScvO2) ≥ 70% in critically ill children. STUDY DESIGN: Two-year, prospective study in a tertiary-level pediatric intensive care unit. Whenever ScvO2 measurements were obtained, central (forehead/sternum) and peripheral (finger/toe) CRTs were concomitantly assessed. RESULTS: Central and peripheral CRTs ≤ 2 seconds were both associated with ScvO2 ≥ 70% (P < .01). Sensitivity/specificity analyses revealed that central CRT ≤ 2 seconds demonstrated a sensitivity of 84.4%, specificity of 71.4%, positive predictive value of 93.1%, and negative predictive value of 50.0% in predicting ScvO2 ≥ 70%. Peripheral CRT ≤ 2 seconds had a sensitivity of 71.9%, specificity of 85.7%, positive predictive value of 95.8%, and negative predictive value of 40.0% in predicting ScvO2 ≥ 70%. CONCLUSIONS: A normal CRT ≤ 2 seconds can be predictive of ScvO2 ≥ 70%. Our study corroborates the recommendations of the Pediatric Advanced Life Support curricula targeting a normal CRT ≤ 2 seconds as a therapeutic endpoint for goal-directed shock resuscitation. This clinical target remains particularly relevant in community hospitals when the ability to obtain central venous catheter access may be limited and ScvO2 data unavailable.