Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda
Communication; Ethics; Extracorporeal Membrane Oxygenation; Critical care; ECLS
Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.
Clark JD; Baden HP; Berkman ER; Bourget E; Brogan TV; Di Gennaro JL; Doorenbos AZ; McMullan DM; Roberts JS; Turnbull JM; Wilfond BS; Lewis-Newby M
Frontiers in Pediatrics
2022
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.3389/fped.2022.896232" target="_blank" rel="noreferrer noopener">10.3389/fped.2022.896232</a>
An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers
Consultation; Extracorporeal membrane oxygenation; Pediatric palliative care; Survey
Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective(s): Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Method(s): Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Result(s): Of 291 eligible respondents, 48% (n=140) completed the survey and 16% (n=47) answered an open-ended question. Benefits included support in decision-making (n=98; 70%) and identification of goals of care (n=89; 64%). Barriers included perception of giving up on families (n=59; 42%) and poor acceptability by other team members (n=58; 41%). Respondents endorsed communication with the primary ICU team before (n=122; 87%) and after (n=129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusion(s): Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.
Delgado-Corcoran C; Wawrzynski SE; Mansfield KJ; Flaherty B; DeCourcey DD; Moore D; Cook LJ; Ullrich CK; Olson LM
Journal of Palliative Medicine
2022
<a href="http://doi.org/10.1089/jpm.2021.0452" target="_blank" rel="noreferrer noopener">10.1089/jpm.2021.0452</a>
A Communication Guide for Pediatric Extracorporeal Membrane Oxygenation
child; terminal care; communication; critical care; decision making; Extracorporeal membrane oxygenation
Decision-making surrounding extracorporeal membrane oxygenation initiation and decannulation has become a key challenge in critical care. Nuanced communication skills and transparent discussions about prognosis are imperative during this lifesaving, yet high-risk and burdensome intervention. Serious illness conversation guides are proving beneficial for patients, families and staff to communicate uncertainty and facilitate shared decision-making toward goal-concordant care. While the literature emphasizes the imperative to provide guidance for clinicians, no practical guide exists for communicating serious illness and prognostic uncertainty when managing children supported with extracorporeal membrane oxygenation and their families. To address this gap, we propose a structured conversation guide for critical early timepoints during pediatric extracorporeal membrane oxygenation support relevant for all cannulations and subsequent iterative discussions toward decannulation. The overarching approach defines extracorporeal membrane oxygenation as a bridge or temporary support device, part of a larger therapeutic effort toward a specific goal or goals. The Day 0 talk at extracorporeal membrane oxygenation initiation is brief, disclosing the serious nature of needing this level of support, and sets clear expectations toward a goal. The Day 1 talk provides further details about benefits and burdens of extracorporeal membrane oxygenation, cultivates prognostic awareness about potential outcomes and elicits families' goals of care with iterative discussions about how extracorporeal membrane oxygenation may promote these goals. If extracorporeal membrane oxygenation is no longer effective to achieve the intended goal, recommendations are provided for discontinuation of support. When death is anticipated or possible, end-of-life planning, contingencies, and escalation limits should be discussed. The communication framework presented can be adapted to unique institutional and clinical settings. Future research is required to investigate utility and potential barriers to implementation. We anticipate that structured conversations during extracorporeal membrane oxygenation support will facilitate clear expectations toward a common treatment goal, foster therapeutic relationships, ensure clinician alignment and consistent language, mitigate communication gaps, support bereavement, and minimize conflict.
Moynihan KM; Purol N; Alexander PMA; Wolfe J; October TW
Pediatric Critical Care Medicine
2021
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/pcc.0000000000002758" target="_blank" rel="noreferrer noopener">10.1097/pcc.0000000000002758</a>
Decision-Making, Ethics, and End-of-Life Care in Pediatric Extracorporeal Membrane Oxygenation: A Comprehensive Narrative Review
child; terminal care; ethics; decision-making; communication; Extracorporeal membrane oxygenation
OBJECTIVES: Pediatric extracorporeal membrane oxygenation is associated with significant morbidity and mortality. We sought to summarize literature on communication and decision-making, end-of-life care, and ethical issues to identify recommended approaches and highlight knowledge gaps. DATA SOURCES: PubMed, Embase, Web of Science, and Cochrane Library. STUDY SELECTION: We reviewed published articles (1972-2020) which examined three pediatric extracorporeal membrane oxygenation domains: 1) decision-making or communication between clinicians and patients/families, 2) ethical issues, or 3) end-of-life care. DATA EXTRACTION: Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. DATA SYNTHESIS: Of 2,581 publications screened, we identified one systematic review and 35 descriptive studies. No practical guides exist for communication and decision-making in pediatric extracorporeal membrane oxygenation. Conversation principles and parent/clinician perspectives are described. Ethical issues related to consent, initiation, discontinuation, resource allocation, and research. No patient-level synthesis of ethical issues or end-of-life care in pediatric extracorporeal membrane oxygenation was identified. CONCLUSIONS: Despite numerous ethical issues reported surrounding pediatric extracorporeal membrane oxygenation, we found limited patient-level research and no practical guides for communicating with families or managing extracorporeal membrane oxygenation discontinuation.
Moynihan KM; Dorste A; Siegel BD; Rabinowitz EJ; McReynolds A; October TW
Pediatric Critical Care Medicine
2021
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/pcc.0000000000002766" target="_blank" rel="noreferrer noopener">10.1097/pcc.0000000000002766</a>
Complications and mortality of venovenous extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure: a systematic review and meta-analysis
Humans; Infant Newborn; Survival Rate; Pneumothorax/etiology; Systematic reviews; Meta-analysis; Neonate; Extracorporeal membrane oxygenation; Extracorporeal Membrane Oxygenation/adverse effects/mortality; Hypertension/etiology; Observational Studies as Topic; Respiratory Distress Syndrome Newborn/mortality/therapy; Respiratory failure
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. To systematically evaluate the complications and mortality of venovenous ECMO (VV ECMO) in the treatment of neonatal respiratory failure, we performed a systematic review and meta-analysis of all the related studies. METHODS: PubMed, Embase, and Cochrane Library were searched. The retrieval period was from the establishment of the database to February 2019. Two investigators independently screened articles according to the inclusion and exclusion criteria. The quality of article was assessed by the Newcastle-Ottawa scale (NOS). The meta-analysis was performed by Stata 15.0 software. RESULTS: Four observational studies were included, with a total of 347 newborns. VV ECMO was used for neonates with refractory respiratory failure unresponsive to maximal medical therapy. Median ages of the newborns at cannulation were 43.2 h, 23 h, 19 h, and 71 h in the included four studies, respectively. The overall mortality at hospital charge was 12% (5-18%) with a heterogeneity of I(2) = 73.8% (p = 0.01). Two studies reported mortality during ECMO and after decannulation, with 10% (0.8-19.2%) and 6.1% (2.6-9.6%), respectively. The most common complications associated with VV ECMO were: pneumothorax (20.6%), hypertension (20.4%), cannula dysfunction (20.2%), seizure (14.9%), renal failure requiring hemofiltration (14.7%), infectious complications (10.3%), thrombi (7.4%), intracranial hemorrhage or infarction (6.6%), hemolysis (5.3%), cannula site bleeding (4.4%), gastrointestinal bleeding (3.7%), oxygenator failure (2.8%), other bleeding events (2.8%), brain death (1.9%), and myocardial stun (0.9%). CONCLUSION: The overall mortality at discharge of VV ECMO in the treatment of neonatal respiratory failure was 12%. Although complications are frequent, the survival rate during hospitalization is still high. Further larger samples, and higher quality of randomized controlled trials (RCTs) are needed to clarify the efficacy and safety of this technique in the treatment of neonatal respiratory failure.
Xiong J; Zhang L; Bao L
BMC Pulmonary Medicine
2020
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1186/s12890-020-1144-8" target="_blank" rel="noreferrer noopener">10.1186/s12890-020-1144-8</a>
Pediatric cardiopulmonary resuscitation: advances in science, techniques, and outcomes
Child; Humans; infant; Prognosis; Extracorporeal Membrane Oxygenation; Life Support Care; Magnetic Resonance Imaging; Animals; Blood Pressure; Regional Blood Flow; Vascular Resistance; quality of life; Newborn; Premature; cardiopulmonary resuscitation; S100 Proteins/blood; Heart Arrest/epidemiology/mortality/physiopathology/therapy; Nerve Growth Factors/blood; No-Reflow Phenomenon/physiopathology; Ventricular Fibrillation/epidemiology/physiopathology
More than 25% of children survive to hospital discharge after in-hospital cardiac arrests, and 5% to 10% survive after out-of-hospital cardiac arrests. This review of pediatric cardiopulmonary resuscitation addresses the epidemiology of pediatric cardiac arrests, mechanisms of coronary blood flow during cardiopulmonary resuscitation, the 4 phases of cardiac arrest resuscitation, appropriate interventions during each phase, special resuscitation circumstances, extracorporeal membrane oxygenation cardiopulmonary resuscitation, and quality of cardiopulmonary resuscitation. The key elements of pathophysiology that impact and match the timing, intensity, duration, and variability of the hypoxic-ischemic insult to evidence-based interventions are reviewed. Exciting discoveries in basic and applied-science laboratories are now relevant for specific subpopulations of pediatric cardiac arrest victims and circumstances (eg, ventricular fibrillation, neonates, congenital heart disease, extracorporeal cardiopulmonary resuscitation). Improving the quality of interventions is increasingly recognized as a key factor for improving outcomes. Evolving training strategies include simulation training, just-in-time and just-in-place training, and crisis-team training. The difficult issue of when to discontinue resuscitative efforts is addressed. Outcomes from pediatric cardiac arrests are improving. Advances in resuscitation science and state-of-the-art implementation techniques provide the opportunity for further improvement in outcomes among children after cardiac arrest.
2008
Topjian AA; Berg RA; Nadkarni VM
Pediatrics
2008
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1542/peds.2007-3313" target="_blank" rel="noreferrer">10.1542/peds.2007-3313</a>
Open lung biopsy in neonatal and paediatric patients referred for extracorporeal membrane oxygenation (ECMO)
Child; Humans; infant; Extracorporeal Membrane Oxygenation; infant; referral and consultation; Newborn; retrospective studies; Heart Defects; Safety; Biopsy/methods; Congenital/pathology; Hyperplasia/pathology; Lung/pathology; Respiratory Insufficiency/pathology/surgery/therapy; Thoracotomy/methods
BACKGROUND: This study was undertaken to determine the usefulness, safety, and most appropriate timing of open lung biopsy in infants and children considered for and on extracorporeal membrane oxygenation (ECMO) for respiratory failure. METHODS: A retrospective review of children referred for consideration of and placed on ECMO in our institution in the period 1996-2002. RESULTS: 506 patients were referred, 15 (3%) of whom underwent antemortem open lung biopsy (eight neonatal, four paediatric, and three cardiac patients). In the neonatal group open lung biopsy contributed to clinical decision making in all patients. Four neonates had a fatal lung dysplasia (three alveolar capillary dysplasia and one surfactant protein B deficiency) and treatment was withdrawn. Of the other four neonates, two had pulmonary hypoplasia, one had pulmonary lymphangiectasia, and one had meconium aspiration with mild barotrauma. Treatment was continued in these four patients and two survived. In the paediatric group the biopsies were of clinical relevance in two infants with pertussis who had lung infarction on biopsy in whom treatment was withdrawn. In the other two paediatric patients the biopsies were equivocal, treatment was continued, but both patients died. In the cardiac group, who presented perioperatively with pulmonary hypertension, the biopsies excluded a fatal lung dysplasia and severe pulmonary vascular disease but all three infants died. One patient had non-fatal bleeding complications. CONCLUSION: Open lung biopsy is clinically most useful when performed to diagnose fatal lung dysplasias in neonates and to confirm the presence of viable lung tissue in patients with acute lung injury due to pertussis infection.
2004
Inwald D; Brown K; Gensini F; Malone M; Goldman A
Thorax
2004
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1136/thx.2003.010793" target="_blank" rel="noreferrer">10.1136/thx.2003.010793</a>
A report of four cases of acute, severe pulmonary hemorrhage in infancy and support with extracorporeal membrane oxygenation
Female; Humans; Male; Extracorporeal Membrane Oxygenation; Respiration; Severity of Illness Index; Acute Disease; infant; Artificial; Hemorrhage/complications/therapy; Lung Diseases/complications/therapy; Respiratory Insufficiency/etiology/therapy
Introduction
Pulmonary hemorrhage is an uncommon event in infants. It has been described most commonly in the sick premature neonate, older child, or adolescent with chronic cardiopulmonary disease. Acute idiopathic pulmonary hemorrhage in previously healthy infants has, to our knowledge, been reported only rarely. During the past 5 years we have successfully treated 4 infants with sever respiratory failure secondary to acute idiopathic pulmonary hemorrhage. Two of these patients were managed with the conventional therapy of mechanical ventilation, while the other two were successfully managed with extracorporeal membrane oxygenation (ECMO) after failure of conventional mechanical ventilation. In this report we review the current literature on this unusual pediatric problem and describe the use of ECMO as a modality in supporting patients after an acute pulmonary hemorrhage.
Siden HB; Sanders GM; Moler FW
Pediatric Pulmonology
1994
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Journal Article
<a href="http://doi.org/10.1002/ppul.1950180512" target="_blank" rel="noreferrer noopener">10.1002/ppul.1950180512</a>