1
|
Mack C, Mailo J, Ofosu D, Hinai AA, Keto-Lambert D, Soril LJJ, van Manen M, Castro-Codesal M. Tracheostomy and long-term invasive ventilation decision-making in children: A scoping review. Pediatr Pulmonol 2024; 59:1153-1164. [PMID: 38289099 DOI: 10.1002/ppul.26884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/01/2023] [Accepted: 01/14/2024] [Indexed: 04/30/2024]
Abstract
An increasing number of children are surviving critical illnesses requiring tracheostomy/long-term ventilation (LTV). This scoping review seeks to collate the available evidence on decision-making for tracheostomy/LTV in children. Systematic searches of electronic databases and websites were conducted for articles and reports. Inclusion criteria included: (1) children 0-18 years old; (2) described use of tracheostomy or tracheostomy/LTV; and (3) information on recommendations for tracheostomy decision-making or decision-making experiences of family-caregivers or health care providers. Articles not written in English were excluded. Of the 4463 records identified through database search and other methods, a total of 84 articles, 2 dissertations, 1 book chapter, 3 consensus statement/society guidelines, and 8 pieces of grey literature were included. Main thematic domains identified were: (1) legal and moral standards for decision-making; (2) decision-making models, roles of decision-makers, and decisional aids towards a shared decision-making model; (3) experiences and perspectives of decision-makers; (4) health system and society considerations; and (5) conflict resolution and legal considerations. A high degree of uncertainty and complexity is involved in tracheostomy/LTV decision-making. There is a need for a standardized decision-support process that is consistent with a child's best interests and shared decision-making. Strategies for optimizing communication and mechanism for managing disputes are needed.
Collapse
Affiliation(s)
- Cheryl Mack
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Janette Mailo
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Ofosu
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Alreem A Hinai
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Diana Keto-Lambert
- Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley J J Soril
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Medicine Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Michael van Manen
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|
2
|
Char DS, Hollander SA, Feudtner C. Compassionate Deactivation of Ventricular Assist Devices in Children with Heart Failure. ASAIO J 2021; 67:1187-1188. [PMID: 34352820 DOI: 10.1097/mat.0000000000001545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Danton S Char
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology, Center for Biomedical Ethics, Stanford University School of Medicine
| | - Seth A Hollander
- Pediatric Heart Failure & Transplantation Section, Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine
| | - Chris Feudtner
- The Department of Medical Ethics, The Children's Hospital of Philadelphia
- Departments of Pediatrics, Medical Ethics and Healthcare Policy, The Perelman School of Medicine, The University of Pennsylvania
| |
Collapse
|
3
|
Joong A, Gossett JG, Blume ED, Thrush P, Pahl E, Mongé MC, Backer CL, Patel A. Variability in clinical decision-making for ventricular assist device implantation in pediatrics. Pediatr Transplant 2020; 24:e13840. [PMID: 33070459 DOI: 10.1111/petr.13840] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/03/2020] [Accepted: 08/12/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Minimal data exist on clinical decision-making in VAD implantation in pediatrics. This study aims to identify areas of consensus/variability among pediatric VAD physicians in determining eligibility and factors that guide decision-making. METHODS An 88-item survey with clinical vignettes was sent to 132 pediatric HT cardiologists and surgeons at 37 centers. Summary statistics are presented for the variables assessed. RESULTS Total respondents were 65 (72% cardiologists, 28% surgeons) whose centers implanted 1-5 (34%), 6-10 (40%), or >10 (26%) VADs in the past year. Consensus varied by patients' age, diagnosis, and Pedimacs profile. Highest agreement to offer VAD (97%) was a mechanically ventilated teenager with dilated cardiomyopathy. Patients stable on inotropes were less likely offered VAD (11%-25%). SV infant with Pedimacs profile 2 had the most varied responses: 37% offered VAD; estimated survival ranged from 15% to 90%. Variables considered for VAD eligibility included mild developmental delays (100% offered VAD), moderate-severe behavioral concerns (46%), cancer in remission >2 years (100%), active malignancy with good prognosis (68%) or uncertain prognosis (36%), and BMI >35 (74%) or <15 (69%). Most respondents (91%) would consider destination therapy VADs in pediatrics, though not currently feasible at 1/3 of centers. Factors with greatest influence on decision-making included HT candidacy, families' goals of care, and risks of complications. CONCLUSIONS Significant variation exists among pediatric VAD physicians when determining VAD eligibility and estimating survival, which can lead to differences in access to emerging technologies across institutions. Further work is needed to understand and mitigate these differences.
Collapse
Affiliation(s)
- Anna Joong
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeffrey G Gossett
- Division of Pediatric Cardiology, Benioff Children's Hospital, University of San Francisco California, San Francisco, CA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip Thrush
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elfriede Pahl
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael C Mongé
- Division of Pediatric Cardiovascular Surgery, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK Healthcare Kentucky Children's Hospital, Lexington, KY, USA
| | - Angira Patel
- Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| |
Collapse
|
4
|
Tunuguntla H, Conway J, Villa C, Rapoport A, Jeewa A. Destination-Therapy Ventricular Assist Device in Children: "The Future Is Now". Can J Cardiol 2019; 36:216-222. [PMID: 31924452 DOI: 10.1016/j.cjca.2019.10.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 01/16/2023] Open
Abstract
Durable ventricular assist devices (VADs) have significantly improved survival to transplantation among children with advanced stages of heart failure. The fundamental goals of VAD therapy include decreasing mortality, minimizing adverse events, and improving quality of life. As the pediatric VAD experience has evolved with reduced device related complications and improved survival, VAD therapy is being considered not only as a bridge to transplantation (BTT) but also as a bridge to decision (BTD) and as destination therapy (DT). Data regarding pediatric DT VAD are limited to anecdotal or case reports of children being supported for long periods with VADs and by default being classified as DT VAD. This article reviews current trends in the use of DT VAD and adverse events in children vs adults on VAD, and provides a framework for patient selection with the use of a multidisciplinary approach including palliative care. The general approach to determining DT VAD candidacy should include: 1) a reasonable success that the patient will survive the peri- and postoperative state; and 2) a high likelihood that the patient will be able to be discharged out of hospital and have adequate caregiver support. Patients with muscular dystrophy and failing Fontan physiology are examples of pediatric populations for whom DT VAD may be considered and which require unique considerations.
Collapse
Affiliation(s)
- Hari Tunuguntla
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Conway
- Department of Paediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Chet Villa
- Pediatric Cardiology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Adam Rapoport
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aamir Jeewa
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Char D, Hollander SA. The Decision to Withdraw in Children With Ventricular Assist Devices. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:61-62. [PMID: 31543046 DOI: 10.1080/15265161.2018.1563655] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|
6
|
Hyotala K. Caring for Pediatric Heart Failure Patients With Long-Term Mechanical Circulatory Support. Crit Care Nurse 2019; 38:44-56. [PMID: 30275063 DOI: 10.4037/ccn2018313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Pediatric cardiac failure is a significant problem that may be caused by cardiomyopathy, myocarditis, or congenital defects that cannot be surgically repaired. Long-term mechanical circulatory support (LTMCS) devices provide hemodynamic support for patients in heart failure as a bridge to heart transplant and, sometimes, cardiac recovery or destination therapy. Critical care nurses must have a comprehensive understanding of LTMCS device function and keen assessment skills to detect signs of impaired perfusion and device failure. Nurses should anticipate postoperative interventions, prevent adverse events, and be prepared to respond during emergencies. Patient care should be family centered and nurses must strive to maximize patients' quality of life throughout device implantation. This article provides a basic guide to caring for pediatric patients receiving LTMCS, including specific information regarding 4 devices that are often used for pediatric heart failure: Berlin Heart EXCOR, SynCardia Total Artificial Heart, HeartWare HVAD, and HeartMate II.
Collapse
Affiliation(s)
- Kari Hyotala
- Kari Hyotala is a nurse practitioner in the pediatric intensive care unit at Cook Children's Medical Center in Fort Worth, Texas.
| |
Collapse
|
7
|
Buddhe S, Cripe L, Friedland-Little J, Kertesz N, Eghtesady P, Finder J, Hor K, Judge DP, Kinnett K, McNally EM, Raman S, Thompson WR, Wagner KR, Olson AK. Cardiac Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S72-S81. [PMID: 30275251 PMCID: PMC6566852 DOI: 10.1542/peds.2018-0333i] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) results in a progressive cardiomyopathy that produces significant morbidity and mortality. To improve the quality of life in patients with DMD, cardiac care is focused on surveillance and management, with the goal of slowing the onset and progression of heart failure complications. The current article is intended to be an expanded review on the cardiac management data used to inform the 2018 DMD Care Considerations recommendations as well as be a discussion on clinical controversies and future management directions. The new cardiac guidance includes changes regarding noninvasive imaging surveillance of cardiac function and pharmacologic therapy. Many emerging therapies lack sufficient evidence-based data to be recommended in the 2018 DMD Care Considerations. These are discussed in the present article as clinical controversies and future directions. Important emerging therapies include new heart failure medications, mechanical circulatory support with ventricular assist devices, heart transplantation, and internal cardiac defibrillators. Future research studies should be focused on the risks and benefits of these advanced therapies in patients with DMD. We conclude this review with a brief discussion on the relationship between the heart and the recently developed medications that are used to directly target the absence of dystrophin in DMD.
Collapse
Affiliation(s)
- Sujatha Buddhe
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Linda Cripe
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Joshua Friedland-Little
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Naomi Kertesz
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Pirooz Eghtesady
- St Louis Children’s Hospital and School of Medicine, Washington University, St Louis, Missouri
| | - Jonathan Finder
- Children’s Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kan Hor
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Daniel P. Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Hackensack, New Jersey
| | | | | | | | - Kathryn R. Wagner
- Kennedy Krieger institute, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Aaron K. Olson
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
8
|
Mechanical circulatory support challenges in pediatric and (adult) congenital heart disease. Curr Opin Organ Transplant 2018; 23:301-307. [DOI: 10.1097/mot.0000000000000522] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
9
|
[Extracorporeal life support and heart-lung transplant in children]. Presse Med 2018; 47:611-619. [PMID: 29580908 DOI: 10.1016/j.lpm.2018.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 11/22/2022] Open
Abstract
Extracorporeal life support and heart and/or lung transplant are the last resort in children with end-stage cardiac and/or pulmonary failure and short-term life threaten. Currently, circulatory support is used as a bridge to recovery or as a bridge to transplant but not as a destination therapy. The Excor Berlin Heart is the long-lasting external pneumatic ventricular assist system that is currently available from infancy to adulthood. Long-term prognosis after pediatric cardiac and/or pulmonary transplant is conditioned by the occurrence of graft failure, coronary disease of the cardiac graft, viral infections and bronchiolitis obliterans of the pulmonary graft, the incidence of which increase with time. The scarcity of grafts and the risk of acute rejection due to lack of compliance with immunosuppressive treatment require the transplant specialized teams to choose the best candidates according to psychosocial and biological criteria. The next expected developments concern mainly long-term ventricular assistance with systems that allow for greater autonomy and a return to the child's home.
Collapse
|
10
|
Magnus D, Char D. CPR and Ventricular Assist Devices: The Challenge of Prolonging Life Without Guaranteeing Health. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:1-2. [PMID: 28112616 DOI: 10.1080/15265161.2016.1276752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|
11
|
Influence of Transplant Center Procedural Volume on Survival Outcomes of Heart Transplantation for Children Bridged with Mechanical Circulatory Support. Pediatr Cardiol 2017; 38:280-288. [PMID: 27882424 DOI: 10.1007/s00246-016-1510-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
Transplant center expertise improves survival after heart transplant (HTx) but it is unknown whether center expertise ameliorates risk associated with mechanical circulatory support (MCS) bridge to transplantation. This study investigated whether center HTx volume reduced survival disparities among pediatric HTx patients bridged with extracorporeal membrane oxygenation (ECMO), left ventricular assist device (LVAD), or no MCS. Patients ≤18 years of age receiving first-time HTx between 2005 and 2015 were identified in the United Network of Organ Sharing registry. Center volume was the total number of HTx during the study period, classified into tertiles. The primary outcome was 1 year post-transplant survival, and MCS type was interacted with center volume in Cox proportional hazards regression. The study cohort included 4131 patients, of whom 719 were supported with LVAD and 230 with ECMO. In small centers (≤133 HTx over study period), patients bridged with ECMO had increased post-transplant mortality hazard compared to patients bridged with LVAD (HR 0.29, 95% CI 0.12, 0.71; p = 0.006) and patients with no MCS (HR 0.33, 95% CI 0.19, 0.57; p < 0.001). Interactions of MCS type with medium or large center volume were not statistically significant, and the same differences in survival by MCS type were observed in medium- or large-volume centers (136-208 or ≥214 HTx over the study period). Post-HTx survival disadvantage of pediatric patients bridged with ECMO persisted regardless of transplant program volume. The role of institutional ECMO expertise outside the transplant setting for improving outcomes of ECMO bridge to HTx should be explored.
Collapse
|
12
|
Affiliation(s)
- Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| |
Collapse
|