Exploring the Necessity of Routine Daily Chest X-rays for Mechanically Ventilated Patients in the Pediatric Intensive Care Unit: An Integrative Review.

PROBLEM: In the PICU of a university teaching hospital, daily chest X-rays (CXR) are performed on all intubated and non-invasive ventilation-assisted patients, even when the patient is stable with no changes in clinical status. Inconsistent practice was identified with PICUs globally. This review aims to address the risk-benefit balance of clinical value, outcomes, cost, and radiation exposure when performing routine daily CXRs in the PICU. ELIGIBILITY CRITERIA: CINAHL, Medline, and Embase (Ovid) were searched for relevant articles within the last ten years (2009 to 2019). Articles involving routine daily CXR on adult patients were included due to limited pediatric research. SAMPLE: 18 articles were included in this review which evaluated the necessity of routine daily CXR protocol in the ICU setting and the risks of radiation exposure (pediatric n = 5, adult n = 10, both n = 3). RESULTS: When comparing the routine daily to on-demand CXR ordering protocols, there was no difference noted in clinical outcomes including mortality, complications, length of stay in hospital or ICU, and number of ventilator days. The on-demand CXR protocol decreased the number of CXRs per patient, which thereby decreased radiation exposure for patients, decreasing their risk of potential toxicity and malignancy. CONCLUSION: Routine daily CXR protocols are no longer recommended due to lack of clinical value, similar outcomes, increased cost, and since it places patients at risk for undue radiation exposure. IMPLICATIONS: Further studies should evaluate clinical and physical exam findings that would trigger ordering a CXR in order to optimize their diagnostic value in the pediatric setting.

Model-based decision making and model-free learning.

Free will is anything but free. With it comes the onus of choice: not only what to do, but which inner voice to listen to - our 'automatic' response system, which some consider 'impulsive' or 'irrational', or our supposedly more rational deliberative one. Rather than a devil and angel sitting on our shoulders, research suggests that we have two decision-making systems residing in the brain, in our basal ganglia. Neither system is the devil and neither is irrational. They both have our best interests at heart and aim to suggest the best course of action calculated through rational algorithms. However, the algorithms they use are qualitatively different and do not always agree on which action is optimal. The rivalry between habitual, fast action and deliberative, purposeful action is an ongoing one.