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Background and Aims

Children with life-limiting conditions (LLCs) are a large proportion of those admitted to PICU. We examined end-of-life (EOL) practices in our unit, comparing previously healthy children to those with LLCs.

Methods

Retrospective comparative study of children who died between 2008 and 2018 at a tertiary PICU. Data collected included demographic data, pre-existing medical history (categorized as previous healthy or as having LLCs), admission reason, severity of illness, treatments in the last 48 hours of life and mode of death. Conversations regarding goals of care as well as end of life practices were also recorded.

Results

357 patients died during the study period. 63% had LLCs. Previously healthy children were most likely to die from brain death (35%), whereas death was mostly following limitation or withdrawal of life-sustaining treatment in children with LLCs (84%, p<0.001). 93% of families had EOL psycho-social support.

Although 48.9% of children with LLCs had previous admissions to PICU, only 12.9% had prior advanced care planning and 8.9% had palliative care team involvement.

There were significant differences in time to initiation of EOL conversations between previously healthy patients and those with LLCs, occurring more quickly in the first group (p<0.0001).

Conclusions

Differences exist in how children with and without LLCs die in PICU, with a higher proportion of limitation/withdrawal of treatment in the group of children with LLCs. Initiation of EOL conversations occurred significantly later in children with LLCs. This may provide opportunities for future interventions to improve end-of-life care in PICU.

Background and Aims

In France, Claeys-Leonetti Law of 2016 authorizes deep and continuous sedation maintained until death (DCSUD). There are no French pediatric studies evaluating practice in pediatric intensive care unit (PICU) since then. We seek to highlight differences in practice since the passing of the law.

Methods

Our study is monocentric and retrospective. It was conducted in the PICU of Children’s Hospital of Lyon between 2010 and 2019. We included all children for whom it has been discussed to withdraw a treatment.

Results

82 patients with a withdrawing treatment decision were included : 51 patients before and 31 after the law. At the time of discontinuation, sedative doses were more frequently increased (18.4% vs 37%, p = 0.044) without changing the scale of doses increase. The most common sedative drug, Midazolam, remains administrated at 2.26 mg.kg^-1.h^-1 on average. Moreover, symptom assessment is performed for more patients (68% vs 90.3%, p = 0.023), at least 3 times a day almost systematically (74.3% vs 96.4%, p < 0.001). There is still a lack of traceability of procedures, particularly with regard to the sedative use. Nevertheless, the participation of an external consultant and a nurse in the decision-making meetings becomes systematic.

Conclusions

There has been little changes in sedative practice since the Claeys-Leonetti Law in PICU for withdrawing treatment. Whether it is due to the practice of deep sedation prior to the law or to a lack of knowledge of the law calls for further investigation.

Background and Aims

Medical advancements have resulted in a growing population of children with chronic underlying diseases who often require prolonged PICU admissions and frequent readmissions. To emphasize this change in the PICU population, we describe time trends and the burden of long duration admissions and frequent readmissions on the Dutch PICU capacity over the course of 15 years.

Methods

Data of all patients (0-17 years), admitted to 8 Dutch PICUs between 2003 and 2017, were extracted from the national PICU registry. Long stay was defined as an admission of ≥30 days, frequent flyers as ≥3 readmissions within the first year after discharge.

Results

A total of 47,424 critically ill children were admitted on 69,047 occasions and accounted for 386,525 cumulative admission days. Mortality decreased from 5.5% (2003) to 2.9% (2017). Long stayers (2.7% of the admissions) accounted for 33% of PICU bed occupancy days. Long stayers were younger (median 5 months) compared to the overall population (median 27 months) at admission.

Frequent flyers (2.1% of unique patients) accounted for 13% of PICU bed occupancy days. No time trends were observed between 2003 and 2017 for number of long stayers and frequent flyers nor for accounted PICU occupancy days.

Conclusions

Although a very small proportion of the total PICU population, both long stayers and frequent flyers comprise up to 40% of PICU bed occupancy days, creating substantial burden on healthcare systems. Between 2003 and 2017 mortality decreased, but number of long stayers, frequent flyers and their burden on PICU capacity remained constant.

On behalf of PICE registry

Background and Aims

Pediatric patients with acute leukemia (AL) are a high-risk population for infection and life-threatening conditions that require PICU admission, which carries an increase of the mortality rate. Studies predicting mortality among patients with AL without an history of HSCT are scarce. We investigated their clinical and epidemiological characteristics to determine prognostic factors for mortality.

Methods

Retrospective single-center analytic-observational study conducted from January 2011-December 2018 in a tertiary-care center. AL patients from 28 days-18 years admitted to the PICU were included, excluding those with history of HSCT or CAR T-cell therapy. We collected epidemiological and clinical characteristics, laboratory and microbiology results and outcome of the patients.

Results

Forty-three patients required urgent PICU admission (21.2%, 35 lymphocytic AL and 8 myeloid AL) in 63 episodes. Main reasons were sepsis (21, 33.3%), hyperleukocytosis (12, 19%), respiratory failure (11, 17.5%) and seizures (8, 12.7%). Nineteen patients (30.2%) required inotropic support while mechanical ventilation (MV) was used in 15 patients (23.8%). Three patients died during the PICU admission (3/63, 4.7%). Survival at 60^th day was 90.7%. Gram-negative sepsis was independently associated to 60^th mortality (OR 13.5, 95%CI 1.4-130.2, p=0.024) in the multivariate analysis. Readmission to the PICU was not a risk factor for mortality at day 60.

Conclusions

In our population, the main cause of PICU admission in patients with AL was infection, which was associated with more severity and longer length of stay. Gram-negative sepsis was predictor of mortality.

Background and Aims

To evaluate the clinical and demographical characteristics of pediatric patients with chronic and irreversible diseases who went through palliative extubation.

Methods

Descriptive analysis of a case series of pediatric patients admitted in a public pediatric hospital in Brazil, with chronic and irreversible diseases, permanently dependent on ventilatory support, who went through palliative extubation between April 2014 and December 2019. The following information was collected from the medical records: demographic data, diagnosis, duration and type of mechanical ventilation; date, time, and place of palliative extubation; medications used; symptoms observed; and hospital outcome.

Results

In this 5 years experience, after the multidisciplinary team’s consensus and creation of the care plan jointly with the family, 24 patients with a mean age of 3.4 years experienced palliative extubation. 17 (70,8%) of extubations were performed in the ICU, 4 at the pediatric ward and 3 at isolated beds;16 patients (66.7%) died inside the hospital, 8 had hospital discharge. 16 patients had an orotracheal tube and the others a tracheostomy. The time between mechanical ventilation withdrawal and in-hospital death vary from 15 minutes to 54 days. The main symptoms were dyspnea, pain and agitation. The main drugs used to control symptoms were opioids and benzodiazepines.

Conclusions

Palliative extubation requires specialized care, with the presence and availability of a multidisciplinary team with adequate training in symptom control and palliative care. The present study is limited by the small sample size, which may explain why it was not possible to identify predictors of survival time after ventilatory support withdrawal.