Lara Nelson

Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: A review

Objective: To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families. Data Sources: Studies were identified through PubMed, MEDLINE, and Ovid. Study Selection: All descriptive, observational, and controlled studies with a focus on posttraumatic stress disorder and the pediatric intensive care unit were included. Data Extraction and Data Synthesis: Posttraumatic stress disorder rates in children following admission to the pediatric intensive care unit were between 5% and 28%, while rates of posttraumatic stress disorder symptoms were significantly higher, 35% to 62%. There have been inconsistencies noted across risk factors. Objective and subjective measurements of disease severity were intermittently positively associated with development of posttraumatic stress disorder. There was a positive relationship identified between the child’s symptoms of posttraumatic stress disorder and their parents’ symptoms. The biological mechanisms associated with the development of posttraumatic stress disorder in children admitted to the pediatric intensive care unit have yet to be explored. Studies in children following burn or other unintentional injury demonstrate potential relationships between adrenergic hormone levels and a diagnosis of posttraumatic stress disorder. Likewise genetic studies suggest the importance of the adrenergic system in this pathway. The rates of posttraumatic stress disorder in parents following their child’s admission to the pediatric intensive care unit ranged between 10.5% and 21%, with symptom rates approaching 84%. It has been suggested that mothers are at increased risk for the development of posttraumatic stress disorder compared to fathers. Objective and subjective measures of disease severity yielded mixed findings with regard to the development of posttraumatic stress disorder. Protective parental factors may include education or the opportunity to discuss the parents’ feelings during the admission. Conclusions: Following admission to the pediatric intensive care unit, both children and their parents have high rates of trauma exposure, both personally and secondary exposure via other children and their families, and subsequently are reporting significant rates of posttraumatic stress disorder. To effectively treat our patients, we must recognize the signs of posttraumatic stress disorder and strive to mitigate the negative effects.

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States

Introduction Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date. Methods We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use. Results Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7–12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5–5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2–6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%). Discussion Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Are we correctly diagnosing adrenal insufficiency or are we just spitting into the wind

Adrenal insufficiency continues to be a common and poorly understood associated feature of pediatric critical illness.(1,2) Incidence rates range widely from 30 to 88%. Part of the reason for this disparity is likely due to the variety of diagnostic strategies. Not only is there variability in the use of low- or high-dose corticotropin stimulation testing versus simple measurement of a baseline cortisol level, but the literature also points to the variance in results based on the use of total or free cortisol levels.(3,4) Normally 90% of cortisol is bound to cortisol binding globulin (CBG) or to albumin; however, the free form of cortisol is the active form. During critical illness there is a significant decrease in CBG and albumin leading to a drop in total cortisol, but not necessarily in free cortisol. The reduced total cortisol level may then inappropriately suggest adrenal insufficiency.(5)

790: IMPLEMENTATION OF A WITHDRAWAL PREVENTION PROTOCOL IN A PEDIATRIC CARDIAC ICU

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) pulmonary embolism (PE) were listed in the complication or diagnosis field, or prophylactic if neither DVT nor PE was indicated in either field. Results: Of the 1,970,117 patients identified, 23,558 (1.2%) received an IVC filter. Overall use of IVC filters decreased significantly from 2010–2012, sliding from 1.3% to 1.1% (P<0.001). This was not due to variation in venous thromboembolism (VTE) incidence, which remained constant at 1.1% for the yr examined. Likewise, therapeutic use of IVC filters remained constant at ~0.3% for each year of the study. However, use of prophylactic IVC filters significantly decreased from 1.0% to 0.8% (P<0.001) during the study period, which is nearly half of the previously reported 1.4% (Dossett et al. 2011. J of Trauma). Conclusions: In the US, prophylactic use of IVC filters has significantly decreased in recent years, suggesting widespread changes in practice patterns. This is a dramatic shift away from the upsurge in usage observed from 1993–2007. This reduction may be partially attributable to the 2008 CHEST guidelines which strongly recommend against IVC filters as thromboprophylaxis and starkly contrast the earlier and more liberal guidelines of both EAST and CHEST.

Palliative care in a neonatal intensive care unit

In this issue of Journal of Critical Care, Peng et al [1] present the results of a retrospective chart review of infants who received end-of-life care in a neonatal intensive care unit (NICU) during their last week of life. This article highlights the increasing importance of palliative care throughout the spectrum of medical care offered to patients, regardless of age. The authors recognize and highlight that palliation in the NICU is an understudied area. There are many misconceptions related to palliative care and a growing concern that this subspecialty, in particular, is associated with hastening the death process for a given patient. To the contrary, the goal for palliative care, according to the World Health Organization, is an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual [2]. Clearly, palliative care is not intended to quicken the dying process, but rather, to provide comfort and support for the patient and his/her family. The current article reported the signs and symptoms most common in infants during their last week of life in the NICU. Given that palliative care is reflective of patients with life-threatening illness, not exclusively terminal patients in their last week of life, this criterion is clearly limiting in scope and does not encompass the true spirit and/or intention of palliative care services in the NICU. Furthermore, a retrospective account of signs and symptoms of patients in their last week of life is an overly simplistic reporting of the findings. Many of the symptoms are those of the dying patient, for example, respiratory distress, desaturation and cyanosis, generalized edema, bradycardia, and oliguria, and should be recognized as the symptoms to initiate palliative care services for a given patient, if it has not already been done. Once a patient has been identified as needing palliative care services, one must further ascertain and treat the symptoms, which reflect patient and/or family suffering. For example, the

659: Comparing Stress Symptoms between Children with Chronic or Acute Illness while in the PICU

Introduction: Improved survival outcomes of pediatric critical illness have increased the number of children and parents exposed to the stressful environment of the pediatric intensive care unit (PICU). Studies have demonstrated an increased risk of posttraumatic stress disorder (PTSD) in children a