Analysis of enacted difficult conversations in neonatal intensive care.

OBJECTIVE: To analyze the communicative contributions of interdisciplinary professionals and family members in enacted difficult conversations in neonatal intensive care. STUDY DESIGN: Physicians, nurses, social workers, and chaplains (n=50) who attended the Program to Enhance Relational and Communication Skills, participated in a scenario of a preterm infant with severe complications enacted by actors portraying family members. Twenty-four family meetings were videotaped and analyzed with the Roter Interaction Analysis System (RIAS). RESULT: Practitioners talked more than actor-family members (70 vs 30%). Physicians provided more biomedical information than psychosocial professionals (P<0.001), and less psychosocial information than nurses, and social workers and chaplains (P<0.05; P<0.001). Social workers and chaplains asked more psychosocial questions than physicians and nurses (MD=P<0.005; RN=P<0.05), focused more on family's opinion and understanding (MD=P<0.01; RN=P<0.001), and more frequently expressed agreement and approval than physicians (P<0.05). No differences were found across disciplines in providing emotional support. CONCLUSION: Findings suggest the importance of an interdisciplinary approach and highlight areas for improvement such as using silence, asking psychosocial questions and eliciting family perspectives that are associated with family satisfaction.

End-of-life care in the pediatric intensive care unit after the forgoing of life-sustaining treatment.

OBJECTIVE: To describe the attitudes and practice of clinicians in providing sedation and analgesia to dying patients as life-sustaining treatment is withdrawn. STUDY DESIGN: Prospective case series of 53 consecutive patients who died after the withdrawal of life-sustaining treatment in the pediatric intensive care unit at three teaching hospitals in Boston. Data on the reasons why medications were given were obtained from a self-administered anonymous questionnaire completed by the critical care physician and nurse for each case. Data on what medications were given were obtained from a review of the medical record. RESULTS: Sedatives and/or analgesics were administered to 47 (89%) patients who died after the withdrawal of life-sustaining treatment. Patients who were comatose were less likely to receive these medications. Physicians and nurses cited treatment of pain, anxiety, and air hunger as the most common reasons, and hastening death as the least common reason, for administration of these medications. Hastening death was viewed as an "acceptable, unintended side effect" of terminal care by 91% of physician-nurse matched pairs. The mean dose of sedatives and analgesics administered nearly doubled as life-support was withdrawn, and the degree of escalation in dose did not correlate with clinician's views on hastening death. CONCLUSION: Clinicians frequently escalate the dose of sedatives or analgesics to dying patients as life-sustaining treatment is withdrawn, citing patient-centered reasons as their principle justification. Hastening death is seen as an unintended consequence of appropriate care. A large majority of physicians and nurses agreed with patient management and were satisfied with the care provided. Care of the dying patient after the forgoing of life-sustaining treatment remains underanalyzed and needs more rigorous examination by the critical care community.

Moral and ethical dilemmas in critically ill newborns: a 20-year follow-up survey of Massachusetts pediatricians.

OBJECTIVE: To replicate the 1987 survey, referring to the original 1977 study, regarding opinions about treatment for critically ill neonates. STUDY DESIGN: A long-term follow-up survey of American Academy of Pediatrics Massachusetts membership, maintaining the 1987 instrument, was initiated. RESULTS: A notable demographic shift in respondents from a majority of male practitioners in 1977 (89.6%), to 73% in 1987, to more equal numbers of men and women in 1997 (55% and 45%, respectively; p < 0.001; 1987 vs 1997) was apparent. Pediatricians' attitude changes over the 20-year period were relatively modest and were statistically associated with active medical intervention. In 1997, 75% of respondents rejected review committees as mediators, a marked change from 1987. Regardless of healthcare maintenance organization affiliations, 95% indicated that restrictive fiscal policies would not affect decision-making. CONCLUSION: This study indicates stability and consensus in pediatricians' attitudes toward active intervention for critically ill neonates compared with 1977 and 1987 surveys and reveals several claims to professional autonomy.

The use of sedation and muscle relaxation in the ventilated infant.

The use of sedation, muscle relaxation, or analgesia in the management of ventilated neonates has been controversial. Many neonatologists face a difficult decision on whether or not to use a muscle relaxant on a ventilated infant. This article reviews neonatal physiology and pharmacology, drug administration, absorption, distribution, and certain selected sedatives and analgesics. The muscle relaxants, financial issues, and family issues are also discussed.

Outcome of pediatric intensive care at six centers in Mexico and Ecuador.

OBJECTIVE: To improve understanding of the causes of morbidity and mortality among critically ill children in the countries studied. DESIGN: Survey of hospital records between 1992 and 1994. SETTING: Six pediatric intensive care units (ICUs) (four ICUs in Mexico City and two ICUs in Ecuador). PATIENTS: Consecutive patients (n = 1,061) admitted to the units studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mortality rate for low-risk patients (pediatric Risk of Mortality [PRISM] score of < or = 10, n = 701) was more than four times the rate predicted by the PRISM score (8.1% vs. 1.8%, p < .001), with an additional 11.3% of this group incurring major morbidity. The mortality rate for moderate-risk patients (PRISM scores of 11 to 20, n = 232) was more than twice predicted (28% vs. 12%, p < .001). For low-risk patients, death was significantly associated with tracheal intubation, central venous cannulation, pneumonia, age of < 2 months, use of more than two antibiotics, and nonsurgical diagnosis (after controlling for PRISM score). Central venous cannulation and tracheal intubation in the lower-risk groups were performed more commonly in units in Mexico than in one comparison unit in the United States (p < .001). CONCLUSIONS: For six pediatric ICUs in Mexico and Ecuador, mortality was significantly higher than predicted among lower-risk patients. Tracheal intubation, central catheters, pneumonia, sepsis, and nonsurgical status were associated with poor outcome for low-risk groups. We speculate that reducing the use of invasive central catheters and endotracheal intubation for lower-risk patients, coupled with improved infection control, could lower mortality rates in the population studied.

Failure to clinically predict NICU hearing loss.

Neonatal intensive care unit (NICU) survivors demonstrate handicapping sensorineural hearing loss up to 50 times more frequently than normal newborns, yet little is known about the etiology of the hearing loss. Theoretically, accurate identification and triage of a particular infant based on a clinical profile would be useful. Forty NICU graduates of The Massachusetts General Hospital were selected for a detailed retrospective chart review evaluating prenatal, perinatal, and NICU medical conditions and treatment. Twenty-three patients identified with hearing loss and 17 infants with normal hearing were compared clinically. Univariate and multivariate analysis was performed on a subpopulation of patients (20 with hearing loss and 16 with normal hearing). A history of ventilation was associated with hearing loss (P = .0023), but this factor was not absolute. No other clinical parameters were convincingly linked to hearing loss. We conclude that reliance on risk factors is an inadequate clinical method to select a patient for a hearing test and that each NICU survivor deserves audiometric evaluation.

Enhancing communication. The physician and family in the pediatric intensive care unit.

How well does the intensivist communicate with the parents of critically ill children? The authors' experience suggests that this process can be enhanced in a number of ways. The article reviews methods to improve communication by emphasizing the importance of the first meeting, trust, and understanding parental needs and coping mechanisms.

Ultrafilterable hypomagnesemia in neonates admitted to the neonatal intensive care unit.

OBJECTIVE: To evaluate the frequency and clinical correlates of ultrafilterable hypomagnesemia in neonates admitted to the neonatal intensive care unit (ICU). DESIGN: Prospective, observational study. SETTING: Massachusetts General Hospital and Mount Auburn Hospital. PATIENTS: A total of 117 patients (84 neonatal ICU patients and 33 normal newborns) studied over a 2-yr period of time. MEASUREMENTS: Blood samples were collected during the first 48 hrs after admission. The concentrations of magnesium (total and ultrafilterable), ionized calcium, parathyroid hormone, electrolytes, glucose and arterial blood gases were determined. RESULTS: Ultrafilterable circulating magnesium concentrations were determined in 74 of 84 neonatal ICU patients. On admission to the neonatal ICU, 23 (31.1%) of 74 neonates had ultrafilterable hypomagnesemia; two (2.7%) of 74 patients had ultrafilterable hypermagnesemia. Neonatal ICU patients had significantly lower (p < .001) ultrafilterable magnesium concentrations compared with normal neonates. Hypomagnesemic ICU patients required mechanical ventilatory support more frequently than did normomagnesemic ICU neonates (p < .05). Ionized hypocalcemia was a common finding in our patients (34 [42%] of 81). However, ultrafilterable hypomagnesemia was not statistically associated with ionized hypocalcemia (p > .05). Despite the below normal serum concentrations of ultrafilterable magnesium observed in our study, there was no impairment in parathyroid hormone secretion. CONCLUSIONS: Ultrafilterable hypomagnesemia is a common finding in neonates admitted to the ICU. Ultrafilterable hypomagnesemia is associated with the need for mechanical ventilation. To our knowledge, this is the first report of ultrafilterable magnesium concentrations in normal and sick neonates.

Pediatric intensive care training: confronting the dark side.

PURPOSE: To describe the dark side of pediatric intensive care fellowship training and offer educational approaches for understanding feelings of fallibility, anger, frustration, and loss. DATA SOURCES: Listening and observing fellows in the courses of their pediatric intensive care training and later careers. STUDY SELECTION: Studies that discussed pediatric residency and fellowship training, especially in the context of intensive care. DATA EXTRACTION: From group meetings, unit conferences, rounds, individual discussions, and child psychiatric consultations. RESULTS OF DATA SYNTHESIS: Pediatric intensive care unit (ICU) fellows gain a sense of mastery from the nature of their work: complex, technological, and frequently lifesaving. They face the usual personal stresses of extended training, including long work hours, limited financial resources, and relative isolation from family and friends. Pediatric ICU fellows confront deeper, "dark" feelings regarding their own high expectations, fallibility, anger, sense of loss, frustration, limited control, and the need to work closely with tense, grieving families. If the dark side is not acknowledged, fellows, team members, and faculty are likely to experience anger, detachment, and depression that may extend beyond work into their personal lives. CONCLUSIONS: Since the dark side is expected, normal, and inevitable, fellowship training programs should help fellows cope with and understand these feelings. Such understanding requires a sense of trust among intensive care staff and can be gained through group discussions, mentorship, specific team conferences, and child psychiatric consultation.

Pediatric airway control and ventilation.

Emphasis on a clear airway is a primary requisite for effective CPR. Airway control in the trauma victim needs special consideration of the possibility of associated cervical vertebrae and spinal cord injury; thus, modification of the patient positioning for transport is essential. Emphasis on visualization of chest movement is the most important factor in assessing adequacy of ventilation. Experience in the use of bag-valve-mask devices requires appropriate instruction and on-going practice. Small bag volume devices limit the ability to provide adequate tidal volumes and prolong inspiratory times. Tracheal intubation provides optimal airway management. In-field use of this procedure will depend upon the skill and experience of the operator. Validation of correctness of tracheal tube placement is critical; seeing the tube pass the glottic opening on laryngoscopy, bilateral and equal chest movement, auscultation of breath sounds in the chest. Methods to measure end-tidal CO2 as a valuable check for tube position is a useful adjunct but must not be relied upon. Foreign body management continues to be controversial and remains unchanged for the present; ie, the infant < 1 year of age the recommendations are back blows followed by chest thrusts. Above 1 year of age, abdominal thrusts (Heimlich maneuver) is recommended.

Hormonal responses to surgical stress in children.

The hormonal responses to surgical stress in adults are well characterized. We hypothesized that children have age-related differences in the "stress responses" to surgery. To test this hypothesis we prospectively studied 98 children (aged 2 to 20 years) undergoing elective surgical procedures under general anesthesia. Preoperative and postoperative (1 hour postoperation) blood samples were obtained and serum prolactin and cortisol concentrations were measured. Patient data were stratified by patient age and length of operation. All patients had significant (P < .05) increases in serum cortisol and prolactin concentrations 1 hour postoperatively as compared with preoperative values. However, there were no significant differences in prolactin and cortisol responses to surgery based on the age, anesthetic technique, or length of operation. Females had higher mean (+/- SD) serum prolactin concentrations (78.41 +/- 62.23 micrograms/L) as compared with males postoperatively (39.8 +/- 21.75 micrograms/L) (P < .05). We conclude the following: (1) children have significant increases in circulating prolactin and cortisol concentrations following surgery and anesthesia, and that those increases are not affected by age, length of surgery, or anesthetic technique; and (2) females have greater prolactin responses to surgery and anesthesia than males.

Undergraduate education in critical care medicine.

OBJECTIVE: To review the current status and future needs of medical students with respect to education in critical care medicine. DATA SOURCES: Literature review and questionnaire administered at the 1990 Educational and Scientific Symposium of the Society of Critical Care Medicine. MEASUREMENTS AND MAIN RESULTS: Medical students are presently not required to master even the basic aspects of critical care medicine before licensing. The results of the questionnaire demonstrated that critical care medicine professionals believe a critical care core curriculum should be established and its completion should be made a requirement for graduation from medical school. A reference set of critical care medicine learning objectives and a strategy for their implementation are presented. CONCLUSIONS: There is a gap between what student physicians are required to learn and what they need to know to effectively initiate critical care interventions and to appropriately refer patients to ICUs. This gap can and should be remedied with wide implementation of a critical care core curriculum.

Ethical dilemmas in pediatric critical care.

Advances in the area of pediatric medicine during the past few years have presented ethical dilemmas for the physician to consider. This article discusses the ethical principles upon which clinical reasoning and judgments can be made.