Corina Noje

Hemorrhagic and Ischemic Stroke in Children With Cancer

BACKGROUND Adult survivors of childhood cancer have an increased risk of cerebrovascular disease; little is known about early stroke risk in childhood cancer. Our objectives were to assess stroke prevalence in children with cancer, to establish cancer and stroke type, and to determine if modifiable risk factors for stroke were present. METHODS Children with stroke and cancer were compared with all children seen for cancer at a single institution between 2000 and 2009. An International Classification of Disease, 9th version, code search and search of existing pediatric oncology and stroke databases identified children <18 years with ischemic stroke, intracerebral hemorrhage, and cerebral sinovenous thrombosis. RESULTS Of 1411 children with cancer, 15 had a stroke (1.1%, 95% CI: 0.6-1.7%). Stroke classifications were seven intracerebral hemorrhages, five ischemic strokes (one of which was followed by intracerebral hemorrhage), and three sinovenous thromboses. Stroke occurred at a median of 5 months after cancer diagnosis. Ten children with strokes had hematologic malignancies and five had brain tumors. Thirteen patients died poststroke, eight because of withdrawal of care. White blood cell count ≥48,000/mm3 was found in four children, all with intracerebral hemorrhage. Five of seven children with intracerebral hemorrhage had platelets <50,000/mm3. CONCLUSIONS Stroke has a prevalence of approximately 1% in children with cancer. Hemorrhagic stroke and ischemic stroke occur with approximately equal frequency; children with leukemia and brain tumors are at greatest risk.

Pulmonary Hypertension Therapy and a Systematic Review of Efficacy and Safety of PDE-5 Inhibitors

This systematic review underscores the need for effective therapies for pediatric PH. Data indicate improved oxygenation and hemodynamics in children with PH on PDE5 inhibitors. Pulmonary hypertension (PH) is a syndrome that is of growing concern to pediatricians worldwide. Recent data led to concerns about the safety of phosphodiesterase type 5 (PDE5) inhibitors in children and a US Food and Drug Administration safety advisory. Our objective is to provide insight into therapies for PH in children and to systematically review the comparative effectiveness and safety of PDE5 inhibitors in the management of pediatric patients with PH. We searched the following databases through February 2015: Medline, Embase, SCOPUS, and the Cochrane Central Register of Controlled Trials. We included studies that examined PDE5 inhibitor use in children with PH. Allowed comparators were either no medication or other classes of medication for management of PH. Study inclusion was via a 2-stage process with 2 reviewers and a predesigned form. Of 1270 papers identified by the literature search, 21 were included: 8 randomized controlled trials and 13 observational studies (9 retrospective, 4 prospective). There is strong evidence that PDE5 inhibitor use improves echocardiography measurements, cardiac catheterization parameters, and oxygenation compared with baseline or placebo in pediatric patients with PH. Evidence suggests that low- and moderate-dose sildenafil are safe regimens for children. There are a relatively small number of randomized controlled trials that address use of PDE5 inhibitors in pediatric patients with PH. PDE5 inhibitors are effective agents for cardiovascular and oxygenation end points in pediatric PH and important components of a multimodal pharmacotherapeutic approach to this growing challenge. Additional studies are needed to define optimal PH therapy in childhood.

Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home: A Case Series

Objectives: To present our single-center’s experience with three palliative critical care transports home from the PICU for terminal extubation. Design: We performed a retrospective chart review of patients transported between January 1, 2012, and December 31, 2014. Setting: All cases were identified from our institutional pediatric transport database. Patients: Patients were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home for terminal extubation and end-of-life care according to their families’ wishes. Interventions: Patients underwent palliative care transport home for terminal extubation. Measurements and Main Results: The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified, and home hospice care was arranged pretransfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families’ wishes for withdrawal of life support and death at home. As such, all three cases presented similar logistic challenges, including establishing do-not-resuscitate status pretransport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. Conclusions: Although a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses.

Interhospital Transport of Children Undergoing Cardiopulmonary Resuscitation: A Practical and Ethical Dilemma

Objectives: To discuss risks and benefits of interhospital transport of children in cardiac arrest undergoing cardiopulmonary resuscitation. Design: Narrative review. Results: Not applicable. Conclusions: Transporting children in cardiac arrest with ongoing cardiopulmonary resuscitation between hospitals is potentially lifesaving if it enables access to resources such as extracorporeal support, but may risk transport personnel safety. Research is needed to optimize outcomes of patients transported with ongoing cardiopulmonary resuscitation and reduce risks to the staff caring for them.

933: DEVELOPMENT OF A PEDIATRIC TRANSPORT TRIAGE TOOL

Learning Objectives: A modified Pediatric Early Warning Score (PEWS) for transport has been successfully used to assess illness severity, but not to guide transport decision making. Many transport teams are composed of a group of providers with varied experience. In an effort to standardize triage practices, we developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of transport mode and team configuration in order to improve care for children during transport. Methods: PT3 was created for pediatric transport, incorporating objective evaluation of neurologic, cardiovascular and respiratory (NCR) systems along with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team configuration not captured by NCR systems alone. A scoring algorithm was developed to guide transport mode and team configuration. Transport data were collected before and after PT3 initiation at a single tertiary center over an 18 month period. Transport mode, team configuration, complications during transport and disposition after transport [pediatric emergency department (PED), direct admission to pediatric ward or ICU (PICU)] were recorded. Results: We reviewed 4,391 inbound pediatric transport calls. Mean number of monthly transport calls (p=0.2) and initial patient disposition (PED p=0.2, PICU p=0.65) were not significantly different preand post-PT3 implementation. There were no differences in mean number of monthly medic (p=0.26), nurse (p=0.36), and physician level (p=0.49) calls, nor in transport mode (ground p=0.16, air p=0.5) utilized preand post-PT3. Need to upgrade team configuration or mode during transport was uncommon and not significantly different in preand post-PT3. No adverse patient safety events occurred with PT3 use. Conclusions: PT3 represents an objective triage tool to reduce variability in transport planning. PT3 did not result in increased resource utilization, or frequency of observed adverse outcomes. Transport teams with various staffing options and multiple modes of transport may benefit from such an objective assessment tool.