Perceptions by Families of Emergency Medical Service Interventions During Imminent Pediatric Out-of-Hospital Death.

OBJECTIVE: To understand how family members view the ways Emergency Medical Services (EMS) and other first responders interact with distressed family members during an intervention involving a recent or impending pediatric death. METHODS: In depth interviews with 11 grieving parents of young children and survey results from 4 additional grieving parents of adult children were conducted as part of a larger study on effective ways for EMS providers to interact with distressed family members during a pediatric death in the field. The responses were analyzed using qualitative content analyses. RESULTS: Family reactions to the crisis and the professional response by first responders were critical to family coping and getting necessary support. There were several critical competencies identified to help the family cope including: (1) that first responders provide excellent and expeditious care with seamless coordination, (2) allowing family to witness the resuscitation including the attempts to save the child's life, and (3) providing ongoing communication. Whether the child is removed from the scene or not, keeping the family apprised of what is happening and why is critical. Giving tangible forms of support by calling friends, family, and clergy, along with allowing the family time with the child after death, giving emotional support, and follow-up gestures all help families cope. CONCLUSION: The study generated hypothetical ways for first responders to interact with distressed family members during an OOH pediatric death.

Compassionate Options for Pediatric EMS (COPE): Addressing Communication Skills.

INTRODUCTION: Each year, 16,000 children suffer cardiopulmonary arrest, and in one urban study, 2% of pediatric EMS calls were attributed to pediatric arrests. This indicates a need for enhanced educational options for prehospital providers that address how to communicate to families in these difficult situations. In response, our team developed a cellular phone digital application (app) designed to assist EMS providers in self-debriefing these events, thereby improving their communication skills. The goal of this study was to pilot the app using a simulation-based investigative methodology. METHODS: Video and didactic app content was generated using themes developed from a series of EMS focus groups and evaluated using volunteer EMS providers assessed during two identical nonaccidental trauma simulations. Intervention groups interacted with the app as a team between assessments, and control groups debriefed during that period as they normally would. Communication performance and gap analyses were measured using the Gap-Kalamazoo Consensus Statement Assessment Form. RESULTS: A total of 148 subjects divided into 38 subject groups (18 intervention groups and 20 control groups) were assessed. Comparison of initial intervention group and control group scores showed no statistically significant difference in performance (2.9/5 vs. 3.0/5; p = 0.33). Comparisons made during the second assessment revealed a statistically significant improvement in the intervention group scores, with a moderate to large effect size (3.1/5 control vs. 4.0/5 intervention; p < 0.001, r = 0.69, absolute value). Gap analysis data showed a similar pattern, with gaps of -0.6 and -0.5 (values suggesting team self-over-appraisal of communication abilities) present in both control and intervention groups (p = 0.515) at the initial assessment. This gap persisted in the control group at the time of the second assessment (-0.8), but was significantly reduced (0.04) in the intervention group (p = 0.013, r = 0.41, absolute value). CONCLUSION: These results suggest that an EMS-centric app containing guiding information regarding compassionate communication skills can be effectively used by EMS providers to self-debrief after difficult events in the absence of a live facilitator, significantly altering their near-term communication patterns. Gap analysis data further imply that engaging with the app in a group context positively impacts the accuracy of each team's self-perception.

Family Centered Practice During Pediatric Death in an Out of Hospital Setting.

OBJECTIVE: To understand effective ways for EMS providers to interact with distressed family members during a field intervention involving a recent or impending out-of-hospital (OOH) pediatric death. METHODS: Eight focus groups with 98 EMS providers were conducted in urban and rural settings between November 2013 and March 2014. Sixty-eight providers also completed a short questionnaire about a specific event including demographics. Seventy-eight percent of providers were males, 13% were either African American or Hispanic, and the average number of years in EMS was 16 years. They were asked how team members managed the family during the response to a dying child, what was most helpful for families whose child suddenly and unexpectedly was dead in the OOH setting, and what follow up efforts with the family were effective. RESULTS: The professional response by the EMS team was critical to family coping and getting necessary support. There were several critical competencies identified to help the family cope including: (1) that EMS provide excellent and expeditious care with seamless coordination, (2) allowing family to witness the resuscitation including the attempts to save the child's life, and (3) providing ongoing communication. Whether the child is removed from the scene or not, keeping the family appraised of what is happening and why is critical. Exclusion of families from the process in cases of suspected child abuse is not warranted. Giving tangible forms of support by calling friends, family, and clergy, along with allowing the family time with the child after death, giving emotional support, and follow-up gestures all help families cope. CONCLUSION: The study revealed effective ways for EMS providers to interact with distressed family members during an OOH pediatric death.

Detection and elimination of microemboli related to cardiopulmonary bypass.

BACKGROUND: Neurobehavioral impairment is a common complication of coronary bypass surgery. Cerebral microemboli during cardiopulmonary bypass (CPB) are a principal mechanism of cognitive injury. The aim of this work was to study the occurrence of cerebral embolism during CPB and to evaluate the effectiveness of evidence-based CPB circuit component and process changes on the exposure of the patient to emboli. METHODS AND RESULTS: M-Mode Doppler was used to detect emboli in the inflow and outflow of cardiopulmonary circuit and in the right and left middle cerebral arteries. Doppler signals were merged into a single display to allow real-time associations between discrete clinical techniques and emboli detection. One hundred sixty-nine isolated coronary artery bypass grafting (CABG) patients were studied between 2002 and 2008. There was no statistical difference in median microemboli detected in the inflow of the CPB circuit, (Phase I, 931; Phase II, 1214; Phase III, 1253; Phase IV, 1125; F [3,158]=0.8, P=0.96). Significant changes occurred in median microemboli detected in the outflow of the CPB circuit across phases, (Phase I, 702; Phase II, 572; Phase III, 596; Phase IV, 85; F [3,157]=13.1, P<0.001). Significant changes also occurred in median microemboli detected in the brain across phases, (Phase I, 604; Phase II, 429; Phase III, 407; Phase IV, 138; F [3,153]=14.4, P<0.001). Changes in the cardiopulmonary bypass circuit were associated with an 87.9% (702 versus 85) reduction in median microemboli in the outflow of the CPB circuit (P<0.001), and a 77.2% (604 versus 146) reduction in microemboli in the brain (P<0.001). CONCLUSIONS: Changes in CPB techniques and circuit components, including filter size and type of pump, resulted in a reduction in more than 75% of cerebral microemboli.

Highest core temperature during cardiopulmonary bypass and rate of mediastinitis.

Temperature control during cardiopulmonary bypass (CPB) may be related to rates of bacterial infection. We assessed the relationship between highest core temperature during CPB and rates of mediastinitis in 6955 consecutive isolated coronary artery bypass graft (CABG) procedures in northern New England. The overall rate of mediastinitis was 1.1%. The association between highest core temperature and mediastinitis was different for diabetics than for nondiabetics. A multivariate model showed that there was a significant interaction between diabetes and temperature in their association with mediastinitis (p=0.015). Diabetic patients showed higher rates of mediastinitis as highest core temperature increased, from 0.7% in the < or = 37 degrees C group to 3.3% in the > or = 38 degrees C group (p(trend) = 0.002). Adjusted rates were similar. Nondiabetic patients did not show this trend (p(trend) = 0.998). Among diabetic patients, a peak core body temperature > 37.9 degrees C during CPB is a significant risk factor for development of mediastinitis. Avoidance of higher temperatures during CPB may lower the risk of mediastinitis for diabetic patients undergoing CABG surgery.

A method for identifying mechanisms of neurologic injury from cardiac surgery.

BACKGROUND: A method for linking discrete surgical and perfusion-related processes of care with cerebral emboli, cerebral oxyhemoglobin desaturation, and hemodynamic changes may offer opportunities for reducing overall neurologic injury for patients undergoing cardiac surgery. METHODS: An intensive intraoperative neurologic and physiologic monitoring approach was developed and implemented. Mechanisms likely to produce embolic (cerebral emboli), hypoperfusion (oxyhemoglobin desaturation), and hypotensive (hemodynamic changes) neurologic injuries were monitored and synchronized with the occurrence of surgical and perfusion clinical events/techniques using a case video. RESULTS: The system was tested among 32 cardiac surgery patients. Emboli were measured in the cerebral arteries and outflow of the cardiopulmonary bypass circuit among nearly 75% and 85% of patients, respectively. Oxyhemoglobin desaturation was measured among nearly 70% of patients. Hemodynamic information was recorded in 100% of patients. CONCLUSIONS: We developed and successfully implemented a method for detailed real-time associations between processes of clinical care and precursors of neurologic injury. Knowledge of this linkage will result in the redesign of clinical care to reduce a patient's risk of neurologic injury.

Lowest core body temperature and adverse outcomes associated with coronary artery bypass surgery.

To examine the effect of lowest core body temperature on adverse outcomes associated with coronary artery bypass graft (CABG) surgery, data were collected on 7134 isolated CABG procedures carried out in New England from 1997 to 2000. Excluded from the analysis were patients with pump times < 60 and > 120 min and those operated upon using continuous warm cardioplegia. Data for lowest core temperature were divided into quartiles for analysis ( < 31.4 degrees C, 31.5-33.1 degrees C, 33.2-34.3 degrees C, and 2 34.4 degrees C). Patients with lower core body temperature on cardiopulmonary bypass (CPB) had higher in-hospital mortality rates. Crude mortality rates were 2.9% in the < or = 31.4 degrees C group, 2.1% in the 31.5-33.1 degrees C group, 1.3% in the 33.2-34.3 degrees C group and 1.2% in the > or = 34.4 degrees C group. The trend toward higher mortality as core temperature decreased was statistically significant (P(trend) < 0.001). Adjustment for differences in patient and disease characteristics did not significantly change the results and the test of trend remained significant (p < 0.001). Rates of perioperative stroke were somewhat lower in the colder groups. Rates in the two colder groups were 0.9% compared with 1.6% and 1.4% in the warmer groups (P(trend) = 0.082). This remained a marginal but significant trend after adjustment for possible confounding factors (p = 0.044). Low core body temperatures on CPB are associated with higher rates of in-hospital mortality among isolated CABG patients. Rates of intra- or postoperative use of an intra-aortic balloon pump are also higher with lower core temperatures. We concluded that temperature management strategy during CABG surgery has an important effect on patient outcomes.

Repair of hypoplastic left heart syndrome of a 4.25-kg Jehovah's witness.

The care of patients who refuse homologous transfusions has challenged cardiac surgery teams to refine blood conservation techniques and question standard transfusion practices. We cared for a newborn child with hypoplastic left heart syndrome (HLHS) whose parents refused to give consent to care for the child that involved the transfusion of homologous blood. A Norwood Stage I procedure was planned with the understanding that transfusions would be avoided, if possible. A court order was obtained that specified the conditions under which the attending physicians would transfuse the newborn. The birth weight of the patient was 4.25 kg. A low prime cardiopulmonary bypass (CPB) circuit and aggressive blood conservation techniques that included modified ultrafiltration (MUF) allowed the completion of the repair and CPB portion of the operation without the use of blood. The lowest hematocrit during CPB was 20%. After an unsuccessful attempt to separate from CPB, blood was transfused. Recovery was consistent for HLHS patients following Norwood Stage I. However, at 1 month postoperatively, the patient did require a shunt reduction for pulmonary overcirculation. Norwood Stage II repair was completed at age 4 months without donor blood. The key to a successful outcome is a well-thoughtout plan by the surgeon, anesthesiologist and perfusionist. This plan should include careful monitoring of the patient's oxygenation and cardiovascular status.

A 10-year review of pediatric perfusion practice in North America.

In December 1999, 145 North American pediatric open-heart institutions were mailed an updated survey as a follow-up of two earlier surveys, 1989 and 1994. The survey consisted of 81 questions pertaining to demographics, equipment, techniques and patient monitoring. This survey, following a similar format of the two earlier surveys, provides a 10-year review encompassing both new and founded practices performed during the conduct of pediatric cardiopulmonary bypass. Responses were received from 83 hospitals, for a 57% response rate. Of the respondents, 72 were active pediatric open-heart centers, 67% performing both adult and pediatric cardiac surgery and 33% performing pediatric surgery exclusively. The mean number of pediatric cases performed in 1999 was 169, compared to 101 cases in 1989 and 145 cases in 1993. Of the 72 respondents, 51% were performing greater than 100 cases/year, whereas 3% of centers were performing under 25 cases/year. As the decade progressed, bubble oxygenators were completely replaced by their membrane counterpart. The use of ultrafiltration, reported first in the 1989 survey, has risen by over 30%. The use of colloids in the prime, specifically 25% albumin, has increased in use from 34% in 1989 to 85% in 1999. Rewarming gradients are used by 100% of respondents with a mean gradient of 9.4 degrees C between the patient and water bath. Myocardial protection has seen an increase of close to 20% in the use of blood cardioplegia. The use of safety devices is also on the rise with more centers using level detectors (79%), bubble detectors (88%) and arterial line filters (96%). Centers relying on the use of cardiac assist devices have increased by 25% since 1989. Results of this survey suggest a movement toward a higher volume of cases being performed at fewer centers. While some diversity is seen, movement toward greater homogeneity, first noted in the 1994 survey, continues in 1999.