Pediatr Crit Care Me
-
Pediatr Crit Care Me · Nov 2011
Pediatric intensive care unit family conferences: one mode of communication for discussing end-of-life care decisions.
To examine clinicians' and parents' reflections on pediatric intensive care unit family conferences in the context of discussion about end-of-life care decision making. ⋯ Pediatric intensive care unit clinicians in this study perceive family conferences as having an important role in end-of-life care decision making. The paucity of data from parents, an important finding itself, limits our ability to comment on parents' perceptions of family conferences. Prospective research of pediatric intensive care unit family conferences, with specific attention to parents' experiences and to all aspects of family conferences, including pre- and postconference events, should seek to understand the role and impact of this mode of communication on end-of-life care decision making and to determine the need for improvement to family conferences.
-
Pediatr Crit Care Me · Nov 2011
Neonatal and pediatric regionalized systems in pediatric emergency mass critical care.
Improved health outcomes are associated with neonatal and pediatric critical care in well-organized, cohesive, regionalized systems that are prepared to support and rehabilitate critically ill victims of a mass casualty event. However, present systems lack adequate surge capacity for neonatal and pediatric mass critical care. In this document, we outline the present reality and suggest alternative approaches. ⋯ States and regions (facilitated by federal partners) should review current emergency operations and devise appropriate plans to address the population-based needs of infants and children in large-scale disasters. Action at the state, regional, and federal levels should address legal, operational, and information systems to provide effective pediatric mass critical care through: 1) predisaster/mass casualty planning, management, and assessment with input from child health professionals; 2) close cooperation, agreements, public-private partnerships, and unique delivery systems; and 3) use of existing public health data to assess pediatric populations at risk and to model graded response plans based on increasing patient volume and acuity.
-
Pediatr Crit Care Me · Nov 2011
Red blood cell-coupled tissue plasminogen activator prevents impairment of cerebral vasodilatory responses through inhibition of c-Jun-N-terminal kinase and potentiation of p38 mitogen-activated protein kinase after cerebral photothrombosis in the newborn pig.
Pediatric ischemic stroke is a poorly understood, yet clinically important, problem. The sole approved treatment for acute stroke is tissue-type plasminogen activator. However, tissue plasminogen activator vasoactivity aggravates hypoxia/ischemia-induced impairment of cerebrovasodilation in response to hypercapnia and hypotension in newborn pigs. Mitogen-activated protein kinase (a family of 3 kinases, extracellular signal-related kinase, p38, and c-Jun-N-terminal kinase) is upregulated after hypoxia/ischemia. Coupling of tissue plasminogen activator to red blood cells prevented hypoxia/ischemia-induced impairment of dilation and suppressed extracellular signal-related kinase mitogen-activated protein kinase activation. This study investigated the differential roles of mitogen-activated protein kinase isoforms in the effects of red blood cells-tissue plasminogen activator on cerebrovasodilation in a translationally relevant injury model, photothrombosis. ⋯ These data indicate that in addition to restoring perfusion, red blood cells-tissue plasminogen activator prevents impairment of cerebrovasodilation after photothrombotic injury through blockade of c-Jun-N-terminal kinase and potentiation of p38 mitogen-activated protein kinase. These data suggest tissue plasminogen activator coupling to red blood cells offers a novel approach to increase the benefit/risk ratio of thrombolytic therapy to treat central nervous system ischemic disorders.
-
Pediatr Crit Care Me · Nov 2011
Lung aeration during ventilation after recruitment guided by tidal elimination of carbon dioxide and dynamic compliance was better than after end-tidal carbon dioxide targeted ventilation: a computed tomography study in surfactant-depleted piglets.
To test the hypothesis that tidal elimination of carbon dioxide and dynamic compliance guided lung recruitment and positive end-expiratory pressure titration in surfactant-depleted piglets result in improved aeration (repeated computed tomography scans) and reduced ventilation pressures compared to those of a control group with conventional end-tidal carbon dioxide targeted ventilation. ⋯ Aeration was significantly better after recruitment and positive end-expiratory pressure titration than in a control group managed by "conventional" end-tidal carbon dioxide targeted ventilation. An increase of the end-inspiratory pressure above the tidal elimination of carbon dioxide peak/plateau did not result in an increased amount of normally aerated lung. A recruitment maneuver resulted in a lower ventilatory amplitude for achieving a target tidal volume and better dynamic compliance at the end of the study period compared to those of the control group.