Pediatr Crit Care Me
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Pediatr Crit Care Me · Aug 2018
Observational StudyCharacterization of the Glucocorticoid Receptor in Children Undergoing Cardiac Surgery.
Postoperative administration of corticosteroids is common practice for managing catecholamine refractory low cardiac output syndrome. Since corticosteroid activity is dependent on the glucocorticoid receptor, we sought to characterize glucocorticoid receptor levels in children undergoing cardiac surgery and examined the association between glucocorticoid receptor levels and cardiovascular dysfunction. ⋯ Increasing glucocorticoid receptor levels in peripheral WBCs of children undergoing cardiac surgery are associated with a longer time to being inotrope free. Cortisol levels minimally increased during the study duration. These results suggest that exposure to high-dose perioperative corticosteroids may suppress the hypothalamic-pituitary-adrenal axis leading to increase in glucocorticoid receptor levels in response to a low cortisol environment. Further studies are required to better delineate the interplay between glucocorticoid receptor levels, cortisol levels, corticosteroid exposure, and postoperative inotropic requirements.
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Pediatr Crit Care Me · Aug 2018
Observational StudyCorrected QT Interval Prolongation in Hospitalized Pediatric Patients Receiving Methadone.
Methadone is often used in pediatric patients to prevent or treat opioid withdrawal after prolonged sedation. Prolonged corrected QT interval is an important adverse effect of methadone because it can progress to torsades de pointes, a potentially fatal dysrhythmia. The prevalence of corrected QT interval prolongation and contributing risk factors are not well defined in hospitalized pediatric patients receiving methadone. The study purpose was to identify the frequency and risk factors of corrected QT interval prolongation in hospitalized pediatric patients receiving methadone. ⋯ In hospitalized pediatric patients receiving methadone, corrected QT interval prolongation was common, but no episodes of torsades de pointes were documented. Risk factors that have been identified in adults were not associated with prolongation in our study population.
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To examine the circumstance of death in the PICU in the setting of ongoing curative or life-prolonging goals. ⋯ Merging curative interventions and optimal end-of-life care is possible, important, and can be enabled when clinicians use creativity, explore possibilities, remain open minded, and maintain flexibility in the provision of critical care medicine. When faced with real and perceived barriers in providing optimal end-of-life care, particularly when curative goals of care are prioritized despite a very poor prognosis, tensions and conflict may arise. Through an intentional exploration of self and others' perspectives, values, and goals, and working toward finding commonality in order to align with each other, conflict in end-of-life care may lessen, allowing the central focus to remain on providing optimal support for the dying child and their family.
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To describe practical considerations related to discussions about death or possible death of a critically ill child. ⋯ Timely conversations about death as a possible outcome of PICU care are an important part of high-quality ICU care. Not all patients "require" these conversations; however, identifying patients for whom conversations are indicated should be an active process. Informed conversations require preparation to provide the best available objective information. Information should include distillation of local experience, incorporate the patients' clinical trajectory, the potential impact(s) of alternate treatments, describe possible modes of death, and acknowledge the extent of uncertainty. We suggest the more factual understanding of risk of death should be initially separated from the more inherent value-laden treatment recommendations and decisions. Gathering and sharing of collective knowledge, conduct of additional investigations, and time can increase the factual content of risk of death discussions. Timely and sensitive delivery of this best available knowledge then provides foundation for high-quality treatment recommendations and decision-making.
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Pediatr Crit Care Me · Aug 2018
Admission Hyperoxia Is a Risk Factor for Mortality in Pediatric Intensive Care.
To determine whether the association between hyperoxia and increased risk-adjusted mortality in adult intensive care patients is also observed in a pediatric intensive care population. ⋯ In this single-center study, hyperoxia at admission to the PICU was highly correlated with increased risk-adjusted mortality. Further investigation of these observations in a large multicenter cohort is warranted.