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and practice of clinicians in providing sedation and analgesia to dying patients as life-sustaining treatment is withdrawn.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 The mean dose of sedatives and analgesics administered nearly doubled as life-support was withdrawn, and the degree of escalation in dose did not correlate with clinician's views on hastening death.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Clinicians frequently escalate the dose of sedatives or analgesics to dying patients as life-sustaining treatment is withdrawn, citing patient-centered reasons as their principle justification.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.

Renal and hemodynamic effects of dopamine in infants following cardiac surgery.

The renal and hemodynamic effects of dopamine were measured during the immediate postoperative period in six infants following repair of congenital cardiac defects. Dopamine was infused at rates of 5, 10, and 15 micrograms/kg/min. Cardiac index (CI) increased significantly at a dopamine infusion rate of 15 micrograms/kg/min. The glomerular filtration rate (GFR) and urine output increased at dopamine infusion rates of 5 and 10 micrograms/kg/min and returned to baseline at 15 micrograms/kg/min. No significant changes occurred in right atrial pressure (RAP), left atrial pressure (LAP), systemic artery pressure, systemic vascular resistance (SVR), or pulmonary vascular resistance (PVR). Heart rate (HR) increased slightly at a dopamine infusion rate of 15 micrograms/kg/min. Pulmonary artery pressure (PAP) increased significantly in only one patient. These data demonstrate that infants require high doses of dopamine to produce the hemodynamic effects seen in adults and that these higher doses may be used without adverse renal effects.

Pediatric resuscitation.

The key to successful resuscitation in children is aggressive intervention, including oxygenation, ventilation, volume expansion, other therapies directed at the cause, and close observation before cardiorespiratory arrest occurs. Prevention of arrests will have the most important impact on improving outcome. Once an arrest occurs, meticulous attention to the ABCs of resuscitation and to advanced life support guidelines may help lower mortality and morbidity rates in these tragic circumstances.

Ribavirin administration to infants receiving mechanical ventilation.

Aerosolized ribavirin was administered to 12 infants with bronchiolitis who were receiving mechanical ventilation. All patients had a history of cardiac or pulmonary disease and developed severe respiratory failure during their infection. We developed a method for ribavirin administration and patient monitoring that included timed circuit valve and tubing changes to avoid obstruction by precipitated drug, frequent endotracheal tube suctioning, and constant observation of the patient and ventilator. All patients were successfully treated. We conclude that ribavirin can be safely administered to infants receiving mechanical ventilation.

Correction of congenital diaphragmatic hernia in utero. IV. An early gestational fetal lamb model for pulmonary vascular morphometric analysis.

Infants born with congenital diaphragmatic hernia (CDH) often have specific pathologic abnormalities of the pulmonary microcirculation that result in high pulmonary vascular resistance and extrapulmonary right-to-left shunting after birth. In an attempt to make an animal model with similar vascular changes, we created CDH in fetal lambs at 60 to 63 days gestation, repaired some at 100 to 113 days gestation, and subsequently performed morphometric analysis of the pulmonary vasculature. Creation of CDH at this early gestational age resulted in a high fetal mortality rate. In the unrepaired CDH lambs, the pulmonary vascular abnormalities were more severe in the left lung. Similar to human CDH, diaphragmatic hernia in the fetal lamb resulted in a decrease in the total size of the pulmonary vascular bed, a decrease in the number of vessels per unit area lung, and increased muscularization of the arterial tree. Fetal surgical repair of CDH restored the pulmonary arterial bed towards normal.

Management of respiratory failure in infants with acute viral bronchiolitis.

Fifteen infants with acute viral bronchiolitis required mechanical ventilation. Infants were all aged less than 12 weeks and all had evidence of atelectasis or pneumonia on chest x-ray films. Respiratory syncytial virus was identified by immunofluorescence in 14 of 15 patients. Intubation and mechanical ventilation were initiated to reduce the work of breathing rather than to treat hypoxemia alone. Additional therapy included continuous positive airway pressure or positive end-expiratory pressure, sedation, aminophylline, diuretics, fluid restriction, and early feeding.

Diabetes insipidus accompanying brain death in children.

Diabetes insipidus (DI) developed in 14 of 16 children who satisfied criteria for brain death. The occurrence of DI after an hypoxic/ischemic insult may represent midbrain death and seems to be a clinically useful sign in the diagnosis of brain death in children. In two patients, DI resolved spontaneously; these patients and children without DI may have had small areas of residual cerebral blood flow and brain function. The onset or cessation of DI was temporally associated with the use of dopamine in three patients.

Apnea testing to confirm brain death in children.

The diagnosis of brain death requires absence of respiratory effort. Various protocols for apnea testing in adults have been reported; however, similar protocols have not been established for children. The technique of apneic oxygenation was used on 10 brain-dead children. PaO2 remained over 200 torr in all patients, and the mean PaCO2 increase was 4 torr/min. Five min of apneic oxygenation is a safe and effective means of evaluating respiratory activity in initially normocapnic children thought to be brain-dead.