Ajit Sarnaik

Differences in medical therapy goals for children with severe traumatic brain injury-an international study.

Objectives: To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury. Design: A survey of the goals from representatives of the international centers. Setting: Thirty-two pediatric traumatic brain injury centers in the United States, United Kingdom, France, and Spain. Patients: None. Interventions: None. Measurements and Main Results: A survey instrument was developed that required free-form responses from the centers regarding their usual practice goals for topics of intracranial hypertension therapies, hypoxia/ischemia prevention and detection, and metabolic support. Cerebrospinal fluid diversion strategies varied both across centers and within centers, with roughly equal proportion of centers adopting a strategy of continuous cerebrospinal fluid diversion and a strategy of no cerebrospinal fluid diversion. Use of mannitol and hypertonic saline for hyperosmolar therapies was widespread among centers (90.1% and 96.9%, respectively). Of centers using hypertonic saline, 3% saline preparations were the most common but many other concentrations were in common use. Routine hyperventilation was not reported as a standard goal and 31.3% of centers currently use PbO2 monitoring for cerebral hypoxia. The time to start nutritional support and glucose administration varied widely, with nutritional support beginning before 96 hours and glucose administration being started earlier in most centers. Conclusions: There were marked differences in medical goals for children with severe traumatic brain injury across our international consortium, and these differences seemed to be greatest in areas with the weakest evidence in the literature. Future studies that determine the superiority of the various medical therapies outlined within our survey would be a significant advance for the pediatric neurotrauma field and may lead to new standards of care and improved study designs for clinical trials.

Ethical issues in pediatric intensive care in developing countries: Combining western technology and eastern wisdom

Application of traditional ethical principles in developing countries may not, indeed should not, conform to the western philosophy and ideology. The principle of distributive justice is of utmost importance when critical resources are scarce. There is no ethical imperative, nor is one followed even in the most advanced countries, that every citizen is entitled to the very best available care. However, a society must establish a uniform code of ethics that can be applied nationally, whereby all citizens are eligible for a minimum acceptable level of care. The traditional principles of autonomy, beneficence, nonmaleficence and justice are still applicable in structuring an ethical framework that is most suited for the country’s needs and resources

Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury

Objectives: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. Design: First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial—a comparative effectiveness study using an observational, cohort study design. Setting: PICUs in tertiary children’s hospitals in United States and abroad. Patients: Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ⩽ 8; intracranial pressure monitoring). Interventions: None. Measurements and Main Results: Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%). Conclusions: In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

Neonatal and Pediatric Organ Donation: Ethical Perspectives and Implications for Policy

The lifesaving processes of organ donation and transplantation in neonatology and pediatrics carry important ethical considerations. The medical community must balance the principles of autonomy, non-maleficence, beneficence, and justice to ensure the best interest of the potential donor and to provide equitable benefit to society. Accordingly, the US Organ Procurement and Transplantation Network (OPTN) has established procedures for the ethical allocation of organs depending on several donor-specific and recipient-specific factors. To maximize the availability of transplantable organs and opportunities for dying patients and families to donate, the US government has mandated that hospitals refer potential donors in a timely manner. Expedient investigation and diagnosis of brain death where applicable are also crucial, especially in neonates. Empowering trained individuals from organ procurement organizations to discuss organ donation with families has also increased rates of consent. Other efforts to increase organ supply include recovery from donors who die by circulatory criteria (DCDD) in addition to donation after brain death (DBD), and from neonates born with immediately lethal conditions such as anencephaly. Ethical considerations in DCDD compared to DBD include a potential conflict of interest between the dying patient and others who may benefit from the organs, and the precision of the declaration of death of the donor. Most clinicians and ethicists believe in the appropriateness of the Dead Donor Rule, which states that vital organs should only be recovered from people who have died. The medical community can maximize the interests of organ donors and recipients by observing the Dead Donor Rule and acknowledging the ethical considerations in organ donation.

Bronchoscopy with N-acetylcysteine lavage in severe respiratory failure from pertussis infection.

Pertussis is an illness that causes significant morbidity and mortality, especially in infants younger than 3 months old. In the most severe cases, it can cause pneumonia, respiratory failure, acute respiratory distress syndrome, pulmonary hypertension, and death. There are reports of using rescue extracorporeal membrane oxygenation (ECMO) as a rescue therapy. However, the mortality of ECMO with pertussis is higher than with other causes of pediatric respiratory failure. We report here the case of a 2-month-old boy with severe respiratory failure and pulmonary hypertension who satisfied ECMO criteria but was successfully treated with repeated bronchoscopy with instillation of N-acetylcysteine. Our patient’s respiratory failure was refractory to multiple therapies that have shown benefit in pediatric hypoxemic respiratory failure, including open lung strategies, prone positioning, intratracheal surfactant, and inhaled nitric oxide. Although pulmonary hypertension is a key factor in most cases of fatal pertussis, the adverse effects of hyperinflation and air leaks were more important in this patient’s clinical course. Because bronchiolar obstruction from inflammatory, mucous, and airway epithelial debris can be seen in severe pertussis, a regimen of repeated therapeutic bronchoscopy was initiated, and thick, inspissated secretions were retrieved. The patient’s airway obstruction gradually resolved, and he eventually recovered with minimal sequelae.

Recognizing and Managing Cardiogenic Shock

Cardiogenic shock is an acute state of end-organ hypoperfusion following cardiac failure. This occurs mainly due to primary pump failure with or without contributions from inadequate preload and afterload. The consequence of cardiogenic shock is hypoxia at the cellular level resulting in loss of function.

High Frequency Jet Ventilation in Respiratory Failure Secondary to Respiratory Syncytial Virus Infection: A Case Series

Objective To describe the utility of high frequency jet ventilation (HFJV) as a rescue therapy in patients with respiratory failure secondary to respiratory syncytial virus (RSV) that was refractory to conventional mechanical ventilation (CMV). Design Descriptive study by retrospective review. Setting Pediatric intensive care unit at a tertiary care children’s hospital. Patients Infants on mechanical ventilation for respiratory failure due to RSV. Interventions Use of HFJV. Main Results Eleven patients were placed on HFJV. There was sustained improvement in ventilation on HFJV with a mean decrease in PCO2 of 9 mmHg at 24 h and 11 mmHg at 72 h. There were no significant changes in oxygenation by oxygenation index. No patients required extracorporeal support or suffered pneumothorax, pneumomediastinum, or subcutaneous emphysema. Ten out of 11 (91%) patients survived to discharge from the hospital. Conclusion High frequency jet ventilation may represent an alternative therapy for RSV-induced respiratory failure that is refractory to CMV.

The Use of Independent Lung Ventilation for Unilateral Pulmonary Hemorrhage

Independent Lung Ventilation (ILV) has been used in the critical care setting as a rescue therapy for differential lung disease. The purpose of anatomic separation of the lungs is to prevent blood, purulent secretions, or other debris from one lung from contaminating the other lung. Physiologic separation of the lungs allows different ventilator strategies to be applied to each lung. We report the case of the successful use of ILV in a man with congenital heart disease with severe right sided pulmonary hemorrhage in which the left lung was relatively disease-free. By use of high-pressure “open-lung” strategies applied to the right lung and moderate settings on the left lung, we were able to achieve recruitment of the right lung without over-distention and injury to the left lung. ILV can be considered in the critical care setting in patients with respiratory failure involving widely differential disease between the two lungs.