Editor’s Choice Articles for August

There are three excellent Editor’s Choice articles for the August 2023 issue of Pediatric Critical Care Medicine (PCCM). First, a much-awaited report from the Society of Critical Care Medicine (SCCM) ICU liberation campaign focused on a bundle of six quality improvement (QI) initiatives in the PICU. Second, a study to better understand physician experiences with families as they respond to the potential diagnosis of their child’s death by neurologic criteria (DNC). Third, a multidisciplinary evaluation of an algorithm for testing practices and approach to differential diagnosis in PICU patients with new fever or instability. The PCCM Connections for Readers focuses on practices during life support with extracorporeal membrane oxygenation (ECMO). WHAT HAVE WE LEARNED FROM THE SCCM ICU LIBERATION BUNDLE WHEN CARING FOR PEDIATRIC PATIENTS? Lin JC, Srivastava A, Malone S, et al; Society of Critical Care Medicine’s Pediatric ICU Liberation Campaign Collaborative: Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative (1). SCCM’s six-component ABCDEF (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention, and management; Early mobility and exercise; Family engagement and empowerment) “Bundle” creates management goals aimed at optimizing pediatric care and family participation during critical illness. We have the benefit of the 2022 SCCM clinical practice guidelines (CPG) on “prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility” (2). The new SCCM report extends the CPG by addressing PICU-wide and individual feasibility and outcomes associated with CPG implementation. Readers, please note that PCCM has published other reports about implementing QI-related bundles of care (3–6) and, in this context, the new article is extensive and wide-reaching. The SCCM ABCDEF bundle was implemented in 632 patients, during 6,252 days of PICU care, when there were 47 deaths. The accompanying editorial makes us pause for thought and reflect on the current findings (7). Overall, the pediatric SCCM ABCDEF study is important, it must be read, and we clearly need to make refinements to our clinical research in this area. WHAT IS TO BE LEARNED FROM REFUSALS TO ALLOW EXAMINATION FOR DETERMINATION OF DNC IN CHILDREN? Paquette ED, Ross LF, Chavez J, Frader JE: Refusals of the Determination of Death by Neurologic Criteria: A Mixed Methods Study of Physician Perspectives on Refusals Cases (8). My second Editor’s Choice article is about physician perspectives of parent/family refusals at the time of determination of DNC. By way of background, start with the contemporary international literature (2020 to 2023) on determination of death. For example, review the 2020 World Brain Death Project report (9) and the 2023 CPG for a brain-based definition of death in children and adults in Canada (10). Then consider the work about the public’s understanding of the definition and determination of death. There is a 2022 scoping review (11), a 2023 national survey of public opinion in Canada (12), and a 2023 report of interviews in family members with relatives dying after determination of DNC (13). Despite these detailed articles on families at the time of death, we have heard little about physicians and their decision-making when families refuse testing for the determination of DNC (14). PCCM publishes a report about refusals to allow examination for determination of DNC from an online survey of 80 pediatric intensivists and neurologists, with detailed phone interviews in 12 of the respondents. The clinicians describe their approaches when managing refusals, and the impact of these decisions on their medical teams. This work echoes previous PCCM publications on the topics of therapeutic alliance between parents and physicians (15) and communications about prognosis (16–18). Our editorial writer also adds to our understanding with more context about the United States 1980 Uniform Determination of Death Act, the case of Jahi McMath, and a personal view (19). WHAT ABOUT SYSTEMATIZING AN APPROACH IN PICU PATIENTS WITH NEW FEVER OR INSTABILITY? Sick-Samuels AC, Booth LD, Milstone M, et al: A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability (20). My final Editor’s Choice article returns to the topic of QI in the PICU (1). Over 2021 to 2023, the QI themes of antibiotic stewardship (21–23), bacterial investigations (24,25), and diagnostic accuracy (26,27), have had extended coverage in PCCM, and all this material is worth reviewing. Now, in this latest QI report (20), the authors follow PCCM’s guidance on reporting QI studies (28,29) and describe their pre- versus postimplementation findings (4,290 versus 2,843) of an algorithm for PICU patients with new fever or clinical instability. There is an accompanying editorial (30); also read another relevant article and editorial about serial tracheal aspirate cultures in the PICU (31,32). “PCCM CONNECTIONS” FOR READERS This month’s special topic for educational review is life support with ECMO. There are five articles about ECMO in the August 2023 issue (33–37): an extracorporeal life support organization database study of neonates undergoing life support with either centrifugal or conventional roller pumps (33); two articles on outcomes in specific patient populations, with one about status asthmaticus (34) and the other about neonates with congenital diaphragmatic hernia (35); and, last, two articles about acute care during life support–a literature review of nutrition (36) and an electroencephalography study of seizure identification (37). Finally, another highlight for me in the narrative essay series is the article entitled “The Exchange” (38).

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