A Multicenter Retrospective Evaluation of Specialized Laboratory Investigations in the Workup of Pediatric Patients With New-Onset Supraventricular Tachycardia.

INTRODUCTION: Specialized laboratory evaluation of supraventricular tachycardia in children may occur, but the utility is unknown. The study objectives are to assess the type, frequency, and results of specialized laboratory testing performed in pediatric patients presenting with new-onset supraventricular tachycardia. We hypothesized that when specialized laboratory testing occurs (particularly for cardiac failure, toxicologic, inflammatory, and thyroid diseases), the results are generally within normal limits. METHODS: This is a retrospective descriptive study using an electronic health record database (TriNetX, Inc). We collected and evaluated the following data of subjects aged younger than 18 years with a first-time supraventricular tachycardia diagnosis: demographics, diagnostic codes, deaths, and laboratory codes/results (natriuretic peptide B, natriuretic peptide B prohormone N-terminal, troponin I, toxicology testing, inflammatory markers, and thyroid studies). RESULTS: A total of 621 subjects (524 [84.4%] without laboratory testing, 97 [15.6%] with laboratory testing) were included. Thyroid studies (65 [10.5%]) were the most frequent laboratory study performed followed by cardiovascular specific studies (35 [5.6%]), inflammatory markers (21 [3.4%]), and toxicology tests (10 [1.6%]) (P = .002). Obtained laboratory testing was more frequent with older subjects, females, and need for emergency, hospital, and critical care services. DISCUSSION: Cardiac-specific and noncardiac laboratory testing is frequently ordered for pediatric patients who present with supraventricular tachycardia. Thyroid studies were the most common laboratory testing ordered, but abnormal results only occurred in less than a quarter of subjects. These findings may highlight a quality improvement opportunity for emergency nurses and practitioners in the practice of obtaining laboratory tests to better reflect high-value evidence-based care for this vulnerable population.

PICU Passport: Pilot study of a handheld resident curriculum.

BACKGROUND: To explore the impact of an educational tool designed to streamline resident learning during their pediatric intensive care (PICU) rotations. METHODS: Topics and procedures were chosen for inclusion based on national requirements for pediatric residents. Residents received a PICU Passport at the beginning of their rotations. PICU faculty were provided learning objectives for each topic. Residents and faculty were surveyed before and after starting use of the Passport. RESULTS: Twenty-two residents pre-Passport and 38 residents post-Passport were compared. Residents were more satisfied with their educational experiences (27 % vs. 79 %; P < 0.001), more likely to report faculty targeted teaching towards knowledge gaps (5 % vs. 63 %; P < 0.001) and felt more empowered to ask faculty to discuss specific topics (27 % vs. 76 %; P = 0.002). The median number of teaching sessions increased from 3 to 10 (Z = 4.2; P < 0.001). Most residents (73 %) felt the Passport helped them keep track of their learning and identify gaps in their knowledge. CONCLUSIONS: The PICU Passport helps residents keep track of their learning and identify gaps in their knowledge. Passport use increases resident satisfaction with education during their PICU rotation and empowers residents to ask PICU faculty to address specific knowledge gaps.

Impact of a Severe Rocky Mountain Spotted Fever Case on Treatment Practices at an Academic Institution Within a Nonendemic Area.

INTRODUCTION: Rocky Mountain spotted fever (RMSF) is a bacterial disease associated with morbidity and mortality when untreated. The primary study objectives are to describe clinician diagnostic and treatment practices in a nonendemic area after the occurrence of an unrecognized severe pediatric presumed RMSF case (index case). We hypothesized that inpatient diagnostic testing frequency and initiation of empiric treatment will increase after the index case. METHODS: We performed a retrospective chart review of patients aged less than 18 y evaluated for RMSF at Penn State Hershey Children's Hospital between 2010 and 2019. We divided the study population into 2 groups (preindex and postindex) and evaluated patient characteristics, RMSF testing completion, and timing of doxycycline administration. RESULTS: Fifty-four patients (14 [26%] preindex and 40 [74%] postindex) were included. Age (median [25th percentile, 75th percentile]) decreased from 14.5 y (8.6, 16) preindex to 8.3 y (3.6, 14) postindex. Twelve (86%) preindex and 31 (78%) postindex patients received empiric doxycycline (P=0.70). Four years after the index case, a decrease in empiric and urgent initiation of doxycycline administration was noted. One case of severe RMSF was diagnosed 4 y after the index case. CONCLUSIONS: Our study found that inpatient RMSF testing increased after the index case, but not all patients received empiric treatment. This may represent an underappreciation of RMSF severity even after a recent devastating case. We suggest that when severe rare but possibly reversible diseases, such as RMSF occur, all clinicians are educated on the diagnostic and treatment approach to reduce the morbidity and mortality risk.

Assessing and Improving Documentation of Pediatric Brain Death Determination within an Electronic Health Record.

BACKGROUND/OBJECTIVE: Pediatric brain death determination (BDD) can be subject to interprovider variability of documentation, resulting in diagnosis credibility. The aim of this study was to describe our approach to assessing pediatric BDD documentation and documentation variation in the electronic health record (EHR). METHODS: This was a single institution cross-sectional review of pediatric patients younger than 18 years determined to meet brain death criteria. We assessed electronic documentation and evaluated for the presence of contributing factors that can interfere with the brain death documentation based on our institutional brain death evaluation policy (core body temperature, systolic blood pressure within an acceptable range, sedative/analgesic drug effects, and neuromuscular blockade). RESULTS: In total, 33 pediatric brain death patients were identified. This review revealed pediatric BDD documentation consistency (n, %) as follows: performance of the first pediatric brain death clinical examination with temperature above 36°C (27, 81.8%), systolic blood pressure above the defined range (29, 87.9%), more than 24 hours following admission (28, 84.8%); performance of the second pediatric brain death clinical examination with temperature above 36°C (32, 97%), more than 12 hours following the first examination (26, 89.7%); and ensuring sedative infusions were discontinued within the recommended cutoff period prior to pediatric BDD (28, 84.8%). Clinical neurologic examinations were fully documented. CONCLUSIONS: Pediatric BDD is a rare process subject to documentation omissions and error. Our findings highlight the variability of pediatric BDD electronic documentation among different providers and specialties at our institution. An approach to improving pediatric BDD documentation may start with completing a standardized electronic brain death document.

Assessing pulmonary arterial hypertension in infants with severe chronic lung disease of infancy: a role for a pulmonary artery catheter?

The treatment of pulmonary arterial hypertension (PAH) associated with chronic lung disease of infancy (CLDI) is becoming commonplace. However, an optimal approach to the monitoring of this treatment has not been clearly established, and data suggest that such therapy may not be without risk. This study assessed the feasibility and safety of pulmonary artery catheter (PAC) placement and its role in the management of PAH associated with CLDI. The medical records of 12 infants with CLDI requiring chronic mechanical ventilation who underwent PAC monitoring were reviewed. Data analyzed included demographics, hemodynamic data, PAH pharmacological therapy, respiratory support, echocardiographic data, sedation level, complications related to PAC use, and mortality. In this analysis, PAC placement and monitoring was found to be feasible, appeared safe, and was associated with the ability to wean inspired oxygen, decrease sedation, and titrate PAH therapy without untoward effect. However, no definitive conclusions can be drawn from this report given its small sample size and uncontrolled, retrospective design. It is hoped that these data will renew interest in PAC monitoring for CLDI and foster prospective study where its true value can be ascertained.

Impact of the COVID-19 Pandemic on Diagnostic Frequency of Febrile Seizures: An Electronic Health Record Database Observational Study.

Background and Purpose: Febrile seizures are common in children and are associated with viral infection. Mitigation strategies implemented during the coronavirus disease 2019 (COVID-19) pandemic have slowed the spread of all viral illnesses potentially impacting febrile seizure frequency. The objective of this study is to assess the impact of COVID-19 mitigation strategies on the diagnostic frequency of febrile seizures. Methods: This was a retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects aged 0 to 5 years of age reported to have a febrile seizure diagnosis. After the query, the study population was divided into 2 groups [pre-COVID-19 (April 1st, 2019 until March 31st, 2020) and COVID-19 (April 1st, 2020 until March 31st, 2021). We analyzed the following data: age, sex, race, diagnostic, medication, and procedural codes. Results: During the pre-COVID time frame, emergency or inpatient encounters made up 688,704 subjects aged 0 to 5 years in the TriNetx database, while in the COVID-19 pandemic time frame, it made up of 368 627 subjects. Febrile seizure diagnosis frequency decreased by 36.1% [2696 during COVID-19 vs 7462 during the pre-COVID-19] and a higher proportion of status epilepticus was coded [72 (2.7%) vs 120 (1.6%)] (P < .001) during the COVID-19 pandemic. Hospitalization, lumbar puncture, critical care services, mechanical ventilation procedural codes were similar between the 2 cohorts. Antimicrobial use was higher in the pre-COVID-19 pandemic group [424 (15.7%) vs 1603 (21.5%)] (P < .001). Conclusions: Less children were diagnosed with febrile seizures during the COVID-19 pandemic, but a higher proportion were coded to have the complex subtype. The medical interventions required with the exception of antimicrobial use was similar. Further study is needed regarding mitigation strategies and its impact on pediatric diseases associated with viruses.

Frequency and Results of Pregnancy Screening in Critically Ill Adolescents in Multiple Health Care Organizations.

PURPOSE: Adolescent females may undergo pregnancy screening while receiving critical care services, but the frequency and results are unknown. The objectives of this study are to evaluate patient characteristics, pregnancy screening frequency, and rate of positive pregnancy screens in adolescent females of childbearing age who require critical care services. We hypothesize that when adolescent pregnancy screening is performed in the critical care setting, it occurs in a higher frequency in older subjects. METHODS: This is a multicenter retrospective observational cohort study utilizing TriNetX, an electronic health record database. The following electronic health record data were collected and evaluated in adolescent females aged 12-18 years and billed for critical care services: age, race, ethnicity, diagnostic codes, selected radiology and surgical procedure codes, number of deaths, pregnancy screening laboratory codes, and pregnancy screening results. RESULTS: A total of 5,241 subjects (2,242 [42.8%] subjects for whom pregnancy screen was noted and 2,999 [57.2%] subjects for whom it was not noted) were included in this study. Subjects aged 15-18 years (odds ratio = 1.56, 95% confidence interval = 1.38-1.77, p value < .0001) and had Hispanic or Latina ethnicity (odds ratio = 1.46, 95% confidence interval = 1.28-1.66, p value < .0001) had a higher association with pregnancy screening. A positive pregnancy screen was identified in 18 (0.8%) subjects. DISCUSSION: In our study, positive pregnancy screens were infrequent, not all subjects were screened, and there was an association between pregnancy screening and ethnicity. Because of the potential for screening bias, this study suggests that clinicians should strongly consider routine pregnancy screening for all females of childbearing age and that hospital policies should require this type of screening.

Factors Influencing Pregnancy Screening in the Pediatric Intensive Care Unit.

STUDY OBJECTIVE: The objective of this study was to determine the rate of incidental pregnancy, pregnancy screening frequency, and factors associated with pregnancy screening in the pediatric intensive care unit (PICU). DESIGN: A cross-sectional, descriptive study. SETTING: The research was conducted at Penn State Health Children's Hospital evaluating PICU admissions between January 1, 2011, and January 31, 2019. PARTICIPANTS: Female adolescents 14-21 years of age who were admitted to the PICU. INTERVENTIONS: The study population was divided into 2 groups (Presence and Non-Presence of Pregnancy Screening), and data were collected from the electronic health record. MAIN OUTCOME MEASURES: We evaluated for patient characteristics and for presence and results of urine pregnancy screening. RESULTS: A total of 431 patients were included in the study. Of these, 275 patients (63.8%) had a pregnancy screen performed. No patients with incidental pregnancy were found. There was a statistically significant relationship between pregnancy screening and patient age, type of admission, and origin of transfer (P < .01). Analysis of secondary diagnoses (co-morbidities) indicated lower screening rates in patients with developmental delay, cerebral palsy, and/or mental retardation (15, 5.5%) [p < 0.0001] and chromosomal abnormalities (9, 3.3%) [p =0.021]. CONCLUSION: Incidental pregnancy is uncommon in female adolescents of childbearing age who are admitted to the PICU, but not all patients were screened, thus potentially jeopardizing maternal and fetal care. Clinicians should consider routine pregnancy screening of female patients of childbearing age admitted to the PICU and should be cognizant of individual factors that could preclude screening prior to or during their presentation.

Evaluation of Febrile Seizure Diagnoses Associated With COVID-19.

BACKGROUND/OBJECTIVES: Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be associated with febrile seizures, but the overall frequency and outcomes are unknown. The objectives of this study are to (1) determine the frequency of pediatric subjects diagnosed with febrile seizures and COVID-19, (2) evaluate patient characteristics, and (3) describe the treatments (medications and need for invasive mechanical ventilation) applied. METHODS: This was a retrospective study utilizing TriNetX electronic health record data. We included subjects ranging from 0 to 5 years of age with a diagnosis of febrile seizures (R56.00, R56.01) and COVID-19 (U07.1). We extracted the following data: age, race, ethnicity, diagnostic codes, medications, laboratory results, and procedures. RESULTS: During this study period, 8854 pediatric subjects aged 0-5 years were diagnosed with COVID-19 among 34 health care organizations and 44 (0.5%) were also diagnosed with febrile seizures (simple, 30 [68.2%]; complex, 14 [31.8%]). The median age was 1.5 years (1, 2), there were no reported epilepsy diagnoses, and a proportion required hospitalization (11; 25.0%) and critical care services (4; 9.1%). CONCLUSIONS: COVID-19 infections in children can be associated with febrile seizures. In our study, 0.5% of COVID-19 subjects were diagnosed with febrile seizures and approximately 9% of subjects were reported to require critical care services. Febrile seizures, although serious, are not a commonly diagnosed neurologic manifestation of COVID-19.

A Randomized Clinical Trial of Perfusion Modalities in Pediatric Congenital Heart Surgery Patients.

BACKGROUND: The objective of this randomized clinical trial was to investigate the effects of perfusion modalities on cerebral hemodynamics, vital organ injury, quantified by the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score, and clinical outcomes in risk-stratified congenital cardiac surgery patients. METHODS: This randomized clinical trial included 159 consecutive congenital cardiac surgery patients in whom pulsatile (n = 83) or nonpulsatile (n = 76) perfusion was used. Cerebral hemodynamics were assessed using transcranial Doppler ultrasound. Multiple organ injury was quantified using the PELOD-2 score at 24, 48, and 72 hours. Clinical outcomes, including intubation time, intensive care unit length of stay (LOS), hospital LOS, and mortality, were also evaluated. RESULTS: The Pulsatility Index at the middle cerebral artery and in the arterial line during aortic cross-clamping was consistently better maintained in the pulsatile group. Demographics and cardiopulmonary bypass characteristics were similar between the 2 groups. While risk stratification with The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Categories was similar between the groups, Mortality Categories 1 to 3 demonstrated more patients than Mortality Categories 4 and 5. There were no differences in clinical outcomes between the groups. The PELOD-2 scores showed a progressive improvement from 24 hours to 72 hours, but the results were not statistically different between the groups. CONCLUSIONS: The Pulsatillity Index for the pulsatile group demonstrated a more physiologic pattern compared with the nonpulsatile group. While pulsatile perfusion did not increase plasma-free hemoglobin levels or microemboli delivery, it also did not demonstrate any improvements in clinical outcomes or PELOD-2 scores, suggesting that while pulsatile perfusion is a safe method, it not a "magic bullet" for congenital cardiac operations.

Impact of Pediatric Intensive Care Unit Preadmission Huddle on Perceptions of Interprofessional Communication About Patient Safety.

BACKGROUND: Preadmission discussions in the study institution's pediatric intensive care unit are not standardized and admission plans were thought to be disjointed, leading to a perceived lack of organization and preparation for the arrival of a critically ill child. OBJECTIVE: To evaluate the impact of a new, formalized preadmission pediatric intensive care unit interdisciplinary huddle on clinician perceptions of interprofessional communication. The hypothesis was that preadmission huddles would improve unit clinicians' perceptions of interprofessional communication. METHODS: Interprofessional pediatric intensive care unit clinicians (physicians, advanced practice providers, nurses, and respiratory therapists) completed surveys before and 7 months after preadmission interdisciplinary huddle implementation. Huddle compliance and perceptions of interprofessional communication in the unit were evaluated. RESULTS: Of 265 eligible pediatric intensive care unit admissions, 69 huddles (26.0%) occurred. The postintervention survey revealed increased odds (odds ratio [95% CI]) of responding "strongly agree" or "agree" to questions about the opportunity to "communicate effectively with health care team members" (2.42 [1.10-5.34]), "respond to feedback from health care team members" (2.54 [1.23-5.24]), and "convey knowledge to other health care team members" (2.71 [1.31-5.61]) before an admission. DISCUSSION: This study introduced a formalized huddle that improved pediatric intensive care unit clinicians' perceived communication with other health care team members in the preadmission period. CONCLUSIONS: Future studies are needed to determine if this perceived improvement in communication significantly affects health care outcomes of critically ill children or if these results are generalizable to other pediatric intensive care unit settings.

Challenges With Implementation of a Respiratory Therapist-Driven Protocol of Spontaneous Breathing Trials in the Pediatric ICU.

BACKGROUND: Timely ventilator liberation is crucial in the pediatric ICU. In many pediatric ICUs, the decision to initiate weaning is driven by the physician, which may lead to delays in ventilator liberation. The objectives of this quality improvement project were to develop and implement a respiratory therapist (RT)-led protocol for screening for spontaneous breathing trial (SBT) readiness, to test protocol feasibility, and to evaluate its impact on SBT timing. METHODS: A retrospective chart review was performed on all intubated patients in the pediatric ICU for 18 months prior to protocol institution. An RT-driven protocol was developed and implemented, enabling consistent screening for SBT readiness. When criteria were met, an SBT was initiated after order placement. The difference in the timing of the first SBT between physician-directed screening and the RT-driven protocol was evaluated. RESULTS: A total of 219 subjects were included in this project (128 pre-intervention; 91 intervention). Baseline demographic data, including mortality risk and endotracheal tube size, were similar in both groups. The time of the first SBT (median [25th, 75th percentile]) was not significantly different between the intervention and preintervention groups (39.5 [25.3, 85.2] vs 42.6 [26.4, 81.3], respectively). There was no difference in mechanical ventilation duration, or length of hospital and ICU stay. The odds of being placed on noninvasive respiratory support were higher in the intervention group at 1 h (odds ratio [95% CI]: 2.29 [1.10, 4.78], P = .03) and 12 h (odds ratio 2.53 [1.23, 5.20], P = .01) postextubation, but the odds of re-intubation did not reach statistical significance (odds ratio 2.60 [0.73, 9.27], P = .14). RT adherence with patient screening was 56.4%. CONCLUSIONS: An RT-driven protocol was successfully introduced in an academic pediatric ICU. However, it did not impact time of SBT initiation, potentially due to the difficulty in maintaining adherence over time. RT-driven protocols require further study.

Epoprostenol and home mechanical ventilation for pulmonary hypertension associated with chronic lung disease.

Pulmonary hypertension (PH) can be associated with bronchopulmonary dysplasia (BPD) of infancy, and mortality in these pediatric patients is high without aggressive medical treatment. Continuous intravenous epoprostenol (prostacyclin) was shown to lower pulmonary artery pressures (PAP) in children with idiopathic pulmonary arterial hypertension (PAH), formerly referred to as primary pulmonary hypertension. We report on the first case of long-term home ventilation in combination with chronic intravenous epoprostenol in a child with severe pulmonary hypertension associated with chronic lung disease. This aggressive combination resulted in significant improvement in pulmonary artery pressures, substantial improvement in quality of life, and eventual discontinuation of home ventilation.

Dexmedetomidine for Sedation during Withdrawal of Support.

Agents used to control end-of-life suffering are associated with troublesome side effects. The use of dexmedetomidine for sedation during withdrawal of support in pediatrics is not yet described. An adolescent female with progressive and irreversible pulmonary deterioration was admitted. Despite weeks of therapy, she did not tolerate weaning of supplemental oxygen or continuous bilevel positive airway pressure. Given her condition and the perception that she was suffering, the family requested withdrawal of support. Despite opioids and benzodiazepines, she appeared to be uncomfortable after support was withdrawn. Ketamine was initiated. Relief from ketamine was brief, and its use was associated with a "wide-eyed" look that was distressing to the family. Ketamine was discontinued and a dexmedetomidine infusion was initiated. The patient's level of comfort improved greatly. The child died peacefully 24 hours after initiating dexmedetomidine from her underlying disease rather than the effects of the sedative.

Administration of the first dose of palivizumab immunoprophylaxis against respiratory syncytial virus in infants before hospital discharge: what is the evidence for its benefit?

BACKGROUND: Palivizumab is 1 of 2 agents used to prevent severe lower respiratory tract disease due to respiratory syncytial virus (RSV) infection. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend administering the first dose of RSV immunoprophylaxis to eligible infants before hospital discharge. Unfortunately, third-party payers frequently do not separately reimburse administration of this therapy to hospitalized infants. OBJECTIVE: Because palivizumab is commonly used to provide RSV immunoprophylaxis, we systematically reviewed all published data on this drug to determine whether the evidence supports the recommendation of administering the first dose before hospital discharge. METHODS: MEDLINE was searched for all articles published in English from January 1, 1996, to October 31, 2003, using the search terms palivizumab and Synagis, and the following data were extracted onto a standardized form: author(s), year of publication, study design, patient population, sample size, criteria used for administration of RSV prophylaxis, location of palivizumab prophylaxis (inpatient or outpatient), parental satisfaction with administration of prophylaxis, incidence of RSV infection, and hospitalization rates for RSV. All selected publications were reviewed to determine whether they reported differences in the incidence of RSV infection or hospitalization in patients who received palivizumab before discharge compared with those who received it after discharge. Only those publications that specifically documented administration of the first dose of palivizumab before hospital discharge were included in the final analysis. RESULTS: Six of the 166 studies reviewed met the selection criteria. Although all 6 studies reported reduced RSV hospitalization rates with palivizumab prophylaxis, no study directly compared inpatient and outpatient administration with regard to parental satisfaction or rates of RSV infection or hospitalization. Furthermore, based on the data in these studies, it was not possible to detect any differences in parental satisfaction or rates of RSV infection or hospitalization between the 2 locations of administration. CONCLUSIONS: Based on our literature review, there is no evidence to support the recommendation that palivizumab be administered before hospital discharge in every infant who meets the criteria for RSV immunoprophylaxis. Eligible infants may be given the initial dose of RSV prophylaxis as outpatients, reducing the cost to institutions that currently provide palivizumab before hospital discharge.

Magnesium sulfate for control of muscle rigidity and spasms and avoidance of mechanical ventilation in pediatric tetanus.

OBJECTIVE: To describe the use of intravenous magnesium sulfate for the control of muscle spasms and severe generalized rigidity in a child with moderate to severe tetanus without the need for prolonged deep sedation, mechanical ventilation, or neuromuscular blockade. DESIGN: Case report. SETTING: Pediatric intensive care unit in a tertiary care, university-based children's hospital. INTERVENTIONS: A continuous infusion of magnesium sulfate. MEASUREMENTS AND MAIN RESULTS: We describe a 12-yr-old child with moderate to severe tetanus who was treated with a continuous infusion of magnesium sulfate to control painful muscle spasms and severe generalized rigidity initially refractory to moderate sedation. Muscle spasms and severe generalized rigidity were improved with magnesium sulfate. No adverse effects associated with the use of magnesium sulfate were noted during the monitoring of cardiovascular and respiratory function, reflexes, and serum magnesium concentrations. CONCLUSIONS: An infusion of magnesium sulfate can be utilized to treat muscle spasms and severe generalized rigidity without the need for deep sedation, mechanical ventilation, or neuromuscular blockade. We recommend that magnesium sulfate be considered in the armamentarium of therapeutics utilized to treat muscle spasms and rigidity associated with tetanus, provided the patient's neurologic, cardiovascular, and respiratory status can be closely monitored in the pediatric intensive care unit.

Jading in the pediatric intensive care unit: Implications for healthcare providers of medically complex children.

OBJECTIVE: To discuss the phenomenon of jading within the context of the pediatric intensive care unit. DESIGN: Drawing from their experience, the authors describe and then discuss a clinical scenario readily recognizable by pediatric intensive care unit practitioners: a child whose care requires the expenditure of a large amount of energy and resources, provides seemingly little reward, and leads to jading of the PICU staff. CONCLUSION: Jading describes a process of exhaustion whereby apathy, cynicism, and callousness replace the drive to be responsive, to make a difference, and to care. The issue of jading has become an increasing area of concern in the pediatric intensive care unit, due in part to recurring, prolonged admissions, combined with the perception, at times, that continued medical care is fruitless. With a better understanding of the phenomenon of jading, and by reconsidering their own responses, pediatric intensive care unit practitioners can avoid becoming jaded.

A prospective assessment of the effect of aminophylline therapy on urine output and inflammation in critically ill children.

BACKGROUND: Aminophylline, an established bronchodilator, is also purported to be an effective diuretic and anti-inflammatory agent. However, the data to support these contentions are scant. We conducted a prospective, open-label, single arm, single center study to assess the hypothesis that aminophylline increases urine output and decreases inflammation in critically ill children. METHODS: Children less than 18 years of age admitted to the pediatric intensive care unit who were prescribed aminophylline over a 24-h period were eligible for study. The use and dosing of aminophylline was independent of the study and was at the discretion of the clinical team. Data analyzed consisted of demographics, diagnoses, medications, and markers of pulmonary function, renal function, and inflammation. Data were collected at baseline and at 24-h after aminophylline initiation with primary outcomes of change in urine output and inflammatory cytokine concentrations. RESULTS: Thirty-five patients were studied. Urine output increased significantly with aminophylline use [median increase 0.5 mL/kg/h (IQR: -0.3, 1.3), p = 0.05] while blood urea nitrogen and creatinine concentrations remained unchanged. Among patients with elevated C-reactive protein concentrations, levels of both interleukin-6 (IL-6) and IL-10 decreased at 24 h of aminophylline therapy. There were no significant differences in pulmonary compliance or resistance among patients invasively ventilated at both time points. Side effects of aminophylline were detected in 7 of 35 patients. CONCLUSION: Although no definitive conclusions can be drawn from this study, aminophylline may be a useful diuretic and effective anti-inflammatory medication in critically ill children. Given the incidence of side effects, the small sample size and the uncontrolled study design, further study is needed to inform the appropriate use of aminophylline in these children.

Care goals and decisions for children referred to a pediatric palliative care program.

OBJECTIVE: To describe goals of care for children with complex, life-limiting conditions and to assess the variables that may influence these goals. METHODS: Goals of care were elicited from the parents and children with complex, life-limiting conditions during initial palliative care consultation. Data abstracted included: diagnoses, demographics, time from diagnosis until initial palliative care consult, spirituality status, resuscitative status, and disposition at discharge. Goals of care were categorized into one of four quality-of-life domains: 1) physical health and independence, 2) psychological and spiritual, 3) social, and 4) environment. Summary statistics were prepared and comparisons were made between the four categories of goals. Descriptive statistics were utilized to explore potential associations with a decision to pursue full medical support. RESULTS: One hundred and forty goals of care were obtained from 50 patients/parents. The median patient age was 4.6 years. Thirty-seven patients had significant cognitive delay/impairment. Neuromuscular disorders accounted for more than half of the diagnoses. Forty-nine patients identified at least one goal pertaining to physical health and independence. This was significantly more than any other category (p < 0.0001). Thirty-three of the 50 patients (66%) opted for full medical support at the time of initial consult. CONCLUSIONS: Children with complex, life-limiting conditions and their families referred to a palliative care service commonly verbalize goals related to health maintenance and independence. Anticipating this expectation may foster communication and improve patient care.