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Pringle CP, Filipp SL, Morrison WE, Fainberg NA, Aczon MD, Avesar M, Burkiewicz KF, Chandnani HK, Hsu SC, Laksana E, Ledbetter DR, McCrory MC, Morrow KR, Noguchi AE, O'Brien CE, Ojha A, Ross PA, Shah S, Shah JK, Siegel LB, Tripathi S, Wetzel RC, Zhou AX, Winter MC. Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study. Crit Care Med 2024; 52:396-406. [PMID: 37889228 PMCID: PMC10922051 DOI: 10.1097/ccm.0000000000006101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN Secondary analysis of multicenter retrospective cohort study. SETTING Ten PICUs in the United States between 2009 and 2021. PATIENTS Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.
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Affiliation(s)
- Charlene P Pringle
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
| | - Stephanie L Filipp
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
| | - Wynne E Morrison
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia Philadelphia, PA
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
- KPMG Lighthouse, Dallas, TX
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
- Michigan State University College of Human Medicine, East Lansing, MI
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Nina A Fainberg
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
| | - Melissa D Aczon
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Michael Avesar
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Kimberly F Burkiewicz
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Harsha K Chandnani
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Stephanie C Hsu
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
| | - Eugene Laksana
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | | | - Michael C McCrory
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
| | - Katie R Morrow
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anna E Noguchi
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin E O'Brien
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Apoorva Ojha
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Sareen Shah
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jui K Shah
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Linda B Siegel
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Randall C Wetzel
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Alice X Zhou
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Iten R, O'Connor M, Gill FJ. Palliative care for infants with life-limiting conditions: integrative review. BMJ Support Palliat Care 2023:spcare-2023-004435. [PMID: 38123923 DOI: 10.1136/spcare-2023-004435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Infants with life-limiting conditions are a heterogeneous population. Palliative care for infants is delivered in a diverse range of healthcare settings and by interdisciplinary primary healthcare teams, which may not involve specialist palliative care service consultation. OBJECTIVE To synthesise the literature for how palliative care is delivered for infants aged less than 12 months with life-limiting conditions. METHODS An integrative review design. MEDLINE, CINAHL, ProQuest, Cochrane, Joanna Briggs Institute and EMBASE were searched for research published in English language, from 2010 to 2022, and peer reviewed. Critical appraisal was completed for 26 patient case series, 9 qualitative, 5 cross-sectional and 1 quality improvement study. Data analysis involved deductive content analysis and narrative approach to summarise the synthesised results. RESULTS 37 articles met the eligibility for inclusion. Two models of palliative care delivery were examined, demonstrating differences in care received and experiences of families and health professionals. Health professionals reported lack of palliative care education, challenges for delivering palliative care in intensive care settings and barriers to advance care planning including prognostic uncertainty and transitioning to end-of-life care. Families reported positive experiences with specialist palliative care services and challenges engaging in advance care planning discussions. CONCLUSION There are complex issues surrounding the provision of palliative care for infants. Optimal palliative care should encompass a collaborative and coordinated approach between the primary healthcare teams and specialist palliative care services and prioritisation of palliative care education for nurses and physicians involved in providing palliative care to infants.
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Affiliation(s)
- Rebecca Iten
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | | | - Fenella J Gill
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
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