Pediatrics
-
Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED). ⋯ A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.
-
Not many large studies have reported the true impact of lower-grade intraventricular hemorrhages in preterm infants. We studied the neurodevelopmental outcomes of extremely preterm infants in relation to the severity of intraventricular hemorrhage. ⋯ Grade I-II IVH, even with no documented white matter injury or other late ultrasound abnormalities, is associated with adverse neurodevelopmental outcomes in extremely preterm infants.
-
Doctors have no ethical obligation to provide futile treatment. This has been true since the time of Hippocrates who warned physicians not to treat patients who were "overmastered by their disease." This principle remains valid today but, as the Society for Critical Care Medicine notes, it is difficult to identify treatment as absolutely futile in all but a few clinical situations. Far more common, they note, are "treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit." These, they say, "may be considered inappropriate and hence inadvisable, but should not be labeled futile." So what should doctors do when they have a case that seems close to the futility threshold but does not, perhaps, quite cross it? In such cases, is it appropriate to make unilateral decisions to withhold life-sustaining treatment even if the family objects? Or should treatment be provided knowing that it might cause pain and suffering to an infant with no likelihood of benefit? To address these questions, we present a case of an extremely premature infant with a giant omphalocele and ask 3 neonatologists, Dr Dalia Feltman of Evanston Hospital, Dr Theophil Stokes of the Walter Reed Medical Center, and Dr Jennifer Kett, a neonatologist and fellow in bioethics at Seattle Children's Hospital, to comment.
-
Current practice guidelines recommend administration of surfactant at or soon after birth in preterm infants with respiratory distress syndrome. However, recent multicenter randomized controlled trials indicate that early use of continuous positive airway pressure with subsequent selective surfactant administration in extremely preterm infants results in lower rates of bronchopulmonary dysplasia/death when compared with treatment with prophylactic or early surfactant therapy. Continuous positive airway pressure started at or soon after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants.
-
In recent years, the focus on patient safety and housestaff supervision has led to a steady increase in institutions providing 24/7 in-hospital (also known as in-house, henceforth referred to as IH) coverage by pediatric intensivists. Effects of this increased attending physician presence on education of pediatric housestaff have not been studied. We hypothesized that IH coverage would decrease perceived autonomy of housestaff and negatively affect their preparedness to be independent attending physicians on completion of training. ⋯ Pediatric intensivists and housestaff express concern regarding the preparation of housestaff training in a 24/7 IH attending model. An important priority for institutions using or considering a 24/7 IH attending coverage model is the balance between adequate housestaff supervision and autonomy.