Stephen Jacobe

Levosimendan for low cardiac output: a pediatric experience.

This was a retrospective observational study in a pediatric intensive care unit, in which 19 patients received levosimendan. There were no adverse events attributable to levosimendan and no instances where the clinical condition worsened after administration. Arterial lactate levels decreased significantly following levosimendan administration during cardiopulmonary bypass for anticipated low cardiac output. In those with established low cardiac output, trends toward improved hemodynamics were seen, with heart rate reduction, an increase in mean blood pressure, a reduction in arterial lactate, and reduced conventional inotrope use. Levosimendan was safely used in a small number of pediatric patients with established low cardiac output state who demonstrated improved hemodynamics and tissue perfusion, with a tendency to reduced conventional inotrope usage, and this warrants its evaluation as an inotrope in the pediatric population.

Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature

Objectives:  To examine withdrawal and limitation of life‐sustaining treatment (WLST) in an Australian paediatric intensive care unit (PICU) and to compare this experience with published data from other countries.

The Mortality Index for Neonatal Transportation Score: A New Mortality Prediction Model for Retrieved Neonates

Objective. To develop a mortality prediction score for retrieved neonates based on the information given at the first telephone contact with a retrieval service. Methods. Data from the New South Wales Newborn and Pediatric Emergency Transport Service database were examined. Analysis was performed with the results for 2504 infants (median gestational age: 36 weeks; range: 24–43 weeks) who were <72 hours of age at the time of referral and whose outcome (neonatal death or survival) was known. The study population was divided randomly into 2 halves, the derivation and validation cohorts. Univariate analysis was performed to identify variables in the derivation cohort related to neonatal death. The variables were entered into a multivariate logistic regression analysis with neonatal death as the outcome. Receiver operator characteristic (ROC) curves were constructed with the regression model and data from the derivation cohort and then the validation cohort. The results were used to generate an integer-based score, the Mortality Index for Neonatal Transportation (MINT) score. ROC curves were constructed to assess the ability of the MINT score to predict perinatal and neonatal death. Results. A 7-variable (Apgar score at 1 minute, birth weight, presence of a congenital anomaly, and infant’s age, pH, arterial partial pressure of oxygen, and heart rate at the time of the call) model was constructed that generated areas under ROC curves of 0.82 and 0.83 for the derivation and validation cohorts, respectively. The 7 variables were then used to generate the MINT score, which gave areas under ROC curves of 0.80 for both neonatal and perinatal death. Conclusion. Data collected at the first telephone contact by the referring hospital with a regionalized transport service can identify neonates at the greatest risk of dying.

End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine

End-of-life care in the intensive care unit (ICU) was identified as an objective in a series of Task Forces developed by the World Federation of Societies of Intensive and Critical Care Medicine Council in 2014. The objective was to develop a generic statement about current knowledge and to identify challenges relevant to the global community that may inform regional and local initiatives. An updated summary of published statements on end-of-life care in the ICU from national Societies is presented, highlighting commonalities and differences within and between international regions. The complexity of end-of-life care in the ICU, particularly relating to withholding and withdrawing life-sustaining treatment while ensuring the alleviation of suffering, within different ethical and cultural environments is recognized. Although no single statement can therefore be regarded as a criterion standard applicable to all countries and societies, the World Federation of Societies of Intensive and Critical Care Medicine endorses and encourages the role of Member Societies to lead the debate regarding end-of-life care in the ICU within each country and to take a leading role in developing national guidelines and recommendations within each country.

Five-year Analysis of Operative Mortality and Neonatal Outcomes in Congenital Heart Disease

BACKGROUND We sought to compare overall mortality with neonatal outcomes over a five year period to define risk factors for mortality and service development priorities. METHODS A retrospective cohort study of surgical outcomes following repair or palliation of structural congenital heart defects January 2005-2010. We defined mortality according to contemporary international guidelines and classified surgical procedures using the Risk Adjustment in Congenital Heart Surgery (RACHS-1) score. The effect of age and weight at operation on mortality and annual variation in case-complexity and surgeon case-mix were assessed. Subgroup analysis was performed in patients who were ≤30 days at operation (neonates). RESULTS Overall mortality within 30 days of operation or prior to hospital discharge was 1.3 and 1.9%, respectively. Mortality was higher in neonates (6.8%) and low birth weight infants (≤2.5kg) (12.1%). Mortality was similar in bypass versus non-bypass procedures (odds ratio 0.74, p=0.425). Annual mortality rates were consistent despite a marked increase in case-complexity. Neonates overall required longer periods of intensive care support and were more likely to suffer serious complications compared to older children. Age, weight and RACHS-1 score were independent risk factors for mortality on multivariate analysis. In neonates undergoing bypass procedures, only RACHS-1 score was a significant risk factor. CONCLUSIONS This study provides an accurate and contemporary audit of mortality risk associated with congenital heart surgery. Outcomes compare favourably to international benchmarks but highlight the risks of morbidity and mortality associated with neonatal cardiac surgery.

Gaining consent for publication in difficult cases involving children

Two years ago four paediatricians and an ethicist submitted to the BMJ a case study as an ethical debate which the BMJ decided not to publish because the authors had not obtained the consent of the patient’s parents for publication. The authors submitted it elsewhere, and the article was published last year. Here the authors explain why they think the BMJ should have published despite the lack of consent; the editor of the journal that did publish the case study explains why he did so (doi: 10.1136/bmj.a1233); and two members of the BMJ’s ethics committee explain why they recommended not to publish it (doi: 10.1136/bmj.a1232). An accompanying editorial explains why English law would now not allow the BMJ to publish it without consent, even if we thought it reasonable to do so.

Hypoplastic left heart syndrome in context

Abstract:  Hypoplastic left heart syndrome is a rare condition requiring major cardiac surgery during the neonatal period to sustain life, with subsequent procedures culminating in completion of the Fontan circulation – the common pathway for all ‘single ventricle’ conditions. Algorithms for care of these children are now well defined with predictable medium‐term outcomes with the majority achieving a Fontan circulation. Hypoplastic left heart syndrome is one of a group of conditions that require complex surgery as a neonate and require a similar perioperative approach. Antenatal diagnosis is common in this patient subgroup, and there is a significant body of work that can be drawn on to inform parental choice.

Diagnosing death: Diagnosing death

At 7:05 pm, Michael – not his real name – aged 2 was found by his mother unconscious, cyanosed and ‘lifeless’, after choking on a piece of apple. He was in asystole when the paramedics arrived at 7:13 pm. They administered three doses of adrenaline, intubated the trachea after removing some apple fragments and performed cardiopulmonary resuscitation (CPR). In the Emergency Department he received three further doses of adrenaline and ongoing external cardiac massage. There was no response and resuscitation efforts were halted at 7:53 pm by the Emergency Physician. With no signs of life and no palpable pulse, Michael was declared dead.

Early outcomes from a new regional programme for the surgical management of hypoplastic left heart syndrome

Early survival and quality of outcome after surgery for hypoplastic left heart syndrome (HLHS) are influenced by patient‐specific factors, the quality of surgery and perioperative care. Some skills are common to the care of other complex neonatal presentations but integrating this expertise is a key challenge for new programmes. We began offering surgery for HLHS from 2006 and provided a regional service from January 2009 and report early outcomes.