Pediatrics
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Doctors have no ethical obligation to provide futile treatment. This has been true since the time of Hippocrates who warned physicians not to treat patients who were "overmastered by their disease." This principle remains valid today but, as the Society for Critical Care Medicine notes, it is difficult to identify treatment as absolutely futile in all but a few clinical situations. Far more common, they note, are "treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit." These, they say, "may be considered inappropriate and hence inadvisable, but should not be labeled futile." So what should doctors do when they have a case that seems close to the futility threshold but does not, perhaps, quite cross it? In such cases, is it appropriate to make unilateral decisions to withhold life-sustaining treatment even if the family objects? Or should treatment be provided knowing that it might cause pain and suffering to an infant with no likelihood of benefit? To address these questions, we present a case of an extremely premature infant with a giant omphalocele and ask 3 neonatologists, Dr Dalia Feltman of Evanston Hospital, Dr Theophil Stokes of the Walter Reed Medical Center, and Dr Jennifer Kett, a neonatologist and fellow in bioethics at Seattle Children's Hospital, to comment.
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Observational Study
Prospective evaluation of a clinical pathway for suspected appendicitis.
To evaluate the diagnostic accuracy of a clinical pathway for suspected appendicitis combining the Samuel's pediatric appendicitis score (PAS) and selective use of ultrasonography (US) as the primary imaging modality. ⋯ Our protocol demonstrates high sensitivity and specificity for diagnosis of appendicitis in children. Institutions should consider investing in resources that increase the availability of expertise in pediatric US. Standardization of care may decrease radiation exposure associated with use of computed tomography scans.
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Practice Guideline
Surfactant replacement therapy for preterm and term neonates with respiratory distress.
Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in preterm infants. Surfactant therapy substantially reduces mortality and respiratory morbidity for this population. ⋯ This statement summarizes the evidence regarding indications, administration, formulations, and outcomes for surfactant-replacement therapy. The clinical strategy of intubation, surfactant administration, and extubation to continuous positive airway pressure and the effect of continuous positive airway pressure on outcomes and surfactant use in preterm infants are also reviewed.
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Practice Guideline
Recognition and management of iatrogenically induced opioid dependence and withdrawal in children.
Opioids are often prescribed to children for pain relief related to procedures, acute injuries, and chronic conditions. Round-the-clock dosing of opioids can produce opioid dependence within 5 days. ⋯ Guidance on this subject is available only for adults and primarily for adults with substance use disorders. The guideline will summarize existing literature and provide readers with information currently not available in any single source specific for this vulnerable pediatric population.
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In recent years, the focus on patient safety and housestaff supervision has led to a steady increase in institutions providing 24/7 in-hospital (also known as in-house, henceforth referred to as IH) coverage by pediatric intensivists. Effects of this increased attending physician presence on education of pediatric housestaff have not been studied. We hypothesized that IH coverage would decrease perceived autonomy of housestaff and negatively affect their preparedness to be independent attending physicians on completion of training. ⋯ Pediatric intensivists and housestaff express concern regarding the preparation of housestaff training in a 24/7 IH attending model. An important priority for institutions using or considering a 24/7 IH attending coverage model is the balance between adequate housestaff supervision and autonomy.