e16 SECTION XV Pediatric Critical Care Board Review Questions 2 Which of the following statements is true regarding cardiac ultrasonography by intensivists in children? A It demonstrates good concorda[.]
e16 S E C T I O N XV Pediatric Critical Care: Board Review Questions Which of the following statements is true regarding cardiac ultrasonography by intensivists in children? A It demonstrates good concordance with studies performed and interpreted by expert echocardiographers B It is useful in cardiac arrest to determine the likelihood of failed return of spontaneous circulation (ROSC) if the heart is not moving C It is not affected by high intraabdominal pressure D When used for determining intravascular volume status, identical criteria for IVC measurement should be used for mechanically ventilated and spontaneously breathing patients Preferred response: A Rationale Cardiac ultrasonography by pediatric intensivists and emergency medicine physicians has demonstrated good concordance in terms of both interpretation and image acquisition with ICU ultrasound equipment Though adult cardiac arrest studies have demonstrated cardiac standstill may predict failure to achieve ROSC, recovery of cardiac function in children on ECMO initiated during CPR has also been described Increased intrathoracic pressure with mechanical ventilation affects the measurement of the inferior vena cava (IVC) for volume status assessment as well Accordingly, heart position is also affected by elevated intrathoracic or intraabdominal pressures due to position of the diaphragm and lungs in these clinical scenarios What is true regarding pulmonary ultrasound in critically ill children? A It demonstrates reduced visibility of lung parenchyma and pulmonary vascular structures as consolidation progresses B It is affected by changes in body composition, development, and size throughout the growth of a child C It is prone to artifactual findings, which should be ignored during interpretation of the image D It should be performed with a phased array transducer Preferred response: B Rationale The appearance of the lung changes throughout pediatric development as infant body water decreases and bones ossify Early in life, intrathoracic structures may be more visible because of less impedance from lung and bony structures Through late childhood into adolescence, ongoing growth affects available windows and the depth of visualization in patients A phased array transducer can visualize areas within the thorax and the pleural line; however, this is not optimal for visualizing pleural sliding because the field of view with this type of sector transducer is narrow near the skin Artifactual pulmonary ultrasound findings, such as B- and Z-lines, have been described as useful for assessing pediatric pulmonary pathology and should be incorporated into the assessment Consolidation of lung parenchyma increases visualization of structures due to less interference from air as it is excluded from the tissue B-lines are not apparent in pneumothorax due to separation of the visceral pleura from the chest wall Chapter 16: Patient- and Family-Centered Care in the Pediatric Intensive Care Unit High quality and collaborative communication includes: A Avoidance of conflict B Decreased used of empathetic statements C Explicit support of family decision making D Guarantee of positive outcome E Higher proportion of physician speech Preferred response: C Rationale Explicit support of family decision-making, higher proportion of family speech, increased use of empathetic statements and expressing nonabandonment are all elements of high quality communication that is associated with increased patient survival, family and patient satisfaction, and is protective against physician and nursing burnout Conflict is abundant in clinical practice It may be unavoidable Rather than side-stepping conflict, collaborative communication helps physicians identify conflict as an opportunity to develop a more complete understanding of the family’s differing perspectives Parental presence during invasive procedures and cardiopulmonary resuscitation has been shown to: A Complicate the ability of clinicians to teach trainees procedural skills B Increase the likelihood of adverse events C Increase parental emotional lability D Negatively impact physicians’ technical performance E Reduce parental anxiety surrounding their child’s care Preferred response: E Rationale Parental presence during invasive procedures and cardiopulmonary resuscitation is associated with improved satisfaction, better understanding, reduced anxiety, better coping, more emotional stability, and improved adjustment to a child’s death Parental presence during procedures or resuscitation has not been associated with negative impacts on technical performance, ability to teach, adverse events, or clinical decision making In general, what is the primary cause of stress in parents related to the admission of their child to an ICU? A They are concerned about the cost of care B They are afraid their child will die C They are stressed about being separated from their child D They are concerned their child will not be the same after leaving the hospital Preferred response: C Rationale The admission process can be frightening for the parents and child, especially when the admission is emergent or unplanned Every effort should be extended to help the parents acclimate to the new environment; they should be treated with compassion and courtesy, and time should be taken to meet their needs Parents report a loss of control, which can be unbearable when they are separated from their ill child To support the child and the parents, caregivers should invite the parents to be part of the admission process and enable them to remain with their child to the extent possible CHAPTER 136 Board Review Questions Chapter 17: Pediatric Critical Care Ethics The use of substituted judgment is most appropriate for decision-making on behalf of which of the following patients? A 18-month-old male with severe ARDS on ECLS B 7-year-old female with an accidental ingestion C 13-year-old male with 60% total body surface area burns who has been sedated and intubated since his accident D 16-year-old female with cystic fibrosis end-stage lung disease who is ventilated and sedated Preferred response: D Rationale The substituted judgment standard applies to situations in which the surrogate decision makers know what the patient would have wanted Very young children are unable to communicate what they want Even older children often have not have developed the ability to consider and verbalize their preferences about complex medical decisions prior to becoming incapacitated Therefore, utilization of the best interest standard (as opposed to substituted judgement) as the basis of surrogate decision-making is most common in pediatrics In situations where an older adolescent (commonly living with chronic medical conditions) has considered and conveyed their wishes to adults prior to the losing the ability to participate in decision-making, substituted judgment is appropriate to utilize in making surrogate medical decisions In all situations where the wishes of the patient are unknown, the best-interest standard is the most appropriate decision-making tool Which of the following statements regarding adolescent decisionmaking is true? A A 15-year-old patient can seek medical care for reproductive and mental health needs without parental consent B Adolescents are typically not developmentally ready to participate in discussions about their medical care C Adolescents are legally required to provide assent as part of the informed consent process D Pediatric patients designated as mature minors are still required to have adult caregiver consent for significant medical decisions Preferred response: A Rationale In pediatrics, parents or legal guardians must provide informed consent for non-adult children If children are years of age or older, their informed assent is desired but not legally required However, there are exceptions Adolescents who qualify as mature minors can provide consent for themselves Similarly, all states allow adolescents to provide consent for specific healthcare needs like reproductive health and mental health services after a certain age (usually 14 or 15) Regardless of legal decision-making authority, clinicians should strongly consider including adolescents in medical decisions and should work with adolescents and their families to achieve agreement whenever possible During an influenza outbreak, the PICU is running out of ventilators The MOST appropriate allocation strategy is: A Adhere to your institution’s predetermined standardized triage criteria B Perform a lottery C Prioritize neonates over older children since they have a longer life expectancy D Withdraw the ventilators from patients least likely to survive Preferred response: A e17 Rationale Allocation decisions for scarce resources are best made in advance, before a period of surge This prevents triage decisions from being made at individual bedsides and eliminates potential injustices Every institution should have a disaster plan in place to deal with surges—natural or manmade A 3-year-old girl suffered a cardiac arrest following cardiac surgery She has had minimal neurologic recovery She has been in the CICU for months with chronic critical illness Her parents adamantly demand that everything medically possible be done for her despite ongoing communication with the medical team Many members of the medical team are distressed at caring for this patient and advocate for withdrawal of life support The most appropriate response from the medical team is: A Allow distressed staff to refuse to care for the child B Continue to tell the family daily that their child is suffering and that life support should be withdrawn C Continue to support the family and the medical team, and engage the ethics consult service to apply a fair processbased approach to evaluate if continuing medical therapies is potentially inappropriate D The medical team should tell the family that life support will be withdrawn against their wishes Preferred response: C Rationale Clinicians cannot simply refuse to care for a child based on a claim of moral distress, or unilaterally withdraw life-support against a family’s wishes without a fair process The medical team should continue to support the family and staff through these challenging times, working diligently to maintain open lines of communication and trust with the family Which of the following is a true statement regarding the doctrine of informed consent? A Decisions must be voluntary and not subject to coercion, manipulation, or undue influence B It does not apply to decisions involving research C The patient needs to understand all the minutia of the treatment being discussed D The decision making should be shared with a competent medical provider Preferred response: A Rationale The doctrine of informed consent applies to both medical decisions and research Informed consent must satisfy four requirements that apply when surrogates provide permission as well as when consent is obtained directly from patients With disclosure, the clinician should supply the patient with sufficient information that a “reasonable person” would desire to be able to make an informed medical decision With understanding, the clinician should assess the patient’s understanding of the proposed course of action, the risks and benefits of that course of action, and any available alternatives along with the risks and benefits associated with those actions Understanding may be particularly impaired in the critical care setting where the high stakes and time pressures can impact the ability to achieve optimal understanding With capacity, the patient must meet legal requirements for competency, be able to understand the medical decision, form a reasonable judgment based on the consequences of the decision, and be e18 S E C T I O N XV Pediatric Critical Care: Board Review Questions able to communicate that decision to others Legally, children under the age of 18 are not considered competent for medical decision making with the exception of emancipated and mature minors Emancipated minors are considered competent based on characteristics that are defined by state law, but may include pregnancy, parenthood, or establishing financial independence Mature minors represent another category that is defined by state law whereby a minor, usually above a certain age, can be judged competent to make certain medical decisions Most states require a judge to make these determinations, and the judge may restrict the determination to the medical decisions at hand With voluntariness, decisions must be voluntary and not subject to coercion, manipulation, or undue influence Importantly, physicians should not withhold or deemphasize information in an effort to manipulate patients Which of the following is an important consideration that may justify seeking legal intervention to override a parent’s decision to refuse a medical therapy? A Mediation and negotiation efforts are initiated and conducted by the state courts B Parental authority is absolute and cannot be challenged legally by medical professionals C The intervention refused by the parent is one that is not commonly performed D The parent’s decision places the child at a significant risk of serious harm Preferred response: D Rationale In most situations, parents are granted wide latitude in the decisions they make on behalf of their children, and the law has respected those decisions except when they place the child’s health, well-being, or life in jeopardy Parental authority is not absolute, however, and when a parent or guardian fails to adequately guard the interests of a child, the decision may be challenged, and the state may intervene A clinician’s authority to interfere with parental decision making is limited Except in emergency situations where a child’s life is threatened imminently or a delay would result in significant suffering or risk to the child, the physician cannot anything to a child without the permission of the child’s parent or guardian Touching (physical examination, diagnostic testing, or administering a medication) without consent is generally considered battery under the law The clinician’s options include either tolerating the parents’ decision (while continuing to try to convince them to act otherwise) or involving a state agency to assume medical decision-making authority on behalf of the child Only the state can order a parent to comply with medical recommendations This can take different forms, but most frequently either includes involvement of child protective services (under a claim of medical neglect) or a court order Both of these options represent a serious challenge to parental authority, and parents will generally perceive them as disrespectful and adversarial Such action interferes with family autonomy, can adversely affect the family’s future interactions with medical professionals, and can negatively impact the emotional well-being of the child Neither should be undertaken without serious consideration Before initiating the involvement of state agencies to limit parental authority and override parental refusal, the clinician must establish that (1) the recommended course of action is likely to benefit the child in an important way, (2) the treatment is of proved efficacy with a reasonable likelihood of success, (3) the parent or surrogate’s decision to refuse intervention places the child at significant risk of serious harm in comparison to the recommendations of the healthcare team (applying the harm principle), and (4) all attempts at mediation and negotiation to find a mutually acceptable solution have been exhausted Chapter 18: Ethical Issues Around Death and Dying A 10-year old patient with recurrent acute myelogenous leukemia (AML) is now 10 days post-stem cell transplant and is admitted to the Pediatric Intensive Care Unit in critical condition from septic shock Despite maximal support, the patient continues to deteriorate from multiple organ failure, including acute respiratory distress syndrome (ARDS), ventricular dysfunction, hepatic failure and diffuse coagulopathy with bleeding from every orifice The patient’s parents now demand a trial of extracorporeal membrane oxygenation (ECMO) The most appropriate response to this request is: A Conduct a family meeting to discuss prognosis B Continue with current therapy C Consult hospital legal office D Provide a trial of ECMO E Write a unilateral DNR order Preferred response: A Rationale The parents have a long established legal and ethical right to make decisions for their child, but they may not demand therapy that the physician deems inappropriate However, before escalating the situation further, it is most appropriate to invest all necessary time and energy into listening to their concerns and fostering respectful communication by holding a family meeting as the next best step The parents and the attending physician have made the decision to withdraw life-sustaining treatment from the 10-yearold patient with recurrent AML, now one month post-stem cell transplant with progressive multiple organ failure Which of the following options reflects current thinking in medical ethics: A Neither withholding life-sustaining treatments nor withdrawing life-sustaining treatments is allowed without the assent of the 10-year old child in addition to the permission of the parents B There is no ethical distinction between withholding lifesustaining treatments and withdrawing life-sustaining treatments C Withdrawing life-sustaining treatments is more ethical than withholding life-sustaining treatments D Withholding life-sustaining treatments is more ethical than withdrawing life-sustaining treatments Preferred response: B Rationale There is no morally relevant or logically valid distinction between withholding and withdrawing life-sustaining treatments in mainstream bioethics or in the law in the United States They are considered to be the same CHAPTER 136 Board Review Questions e19 Chapter 19: Palliative Care in the Pediatric Intensive Care Unit legal repercussions should not prevent physicians from treating patients appropriately It is also generally accepted, and supported by a series of court cases, that any medical technology can be discontinued if it is no longer providing a benefit to the patient, no longer desired by the competent adult patient, or merely prolonging imminent death For children, parents are assumed to be the legal decision-makers except in unusual circumstances Typically, there is little controversy when parents and the medical team agree on goals of care, the withdrawal of technology that is no longer helpful, and the management of suffering The Doctrine of Double Effect is often used as an ethical justification for providing medications to treat pain and suffering at the end of life, since there is also a possibility that they will hasten death The components that make the unintended consequence justifiable include: The act itself (treating suffering) must be inherently good The agent intends the good effect (treating suffering) rather than the bad effect (hastening death) The good effect must outweigh the bad effect (e.g., hastening death by many years for mild pain would be unacceptable) Many add that the bad effect must not be a means to the good effect—meaning death is not used as the means to end suffering Practically, these arguments can shed light on what medications may or may not be acceptable to use at the end of life Medications that treat pain or other symptoms should be used in reasonable doses based on the patient’s prior exposure and expected tolerance and may be escalated rapidly as needed for untreated symptoms Medications that are unacceptable are those that would merely hasten the dying process without treating suffering (e.g., neuromuscular blockade, potassium chloride) In the vignette, it would be appropriate to give any of the sedative or opioid agents listed with an intent to treat pain or dyspnea, even if the respiratory drive might be suppressed or the intracranial pressure affected Vecuronium, however, would be inappropriate as the ventilator is being withdrawn since neuromuscular blockade would hasten death without treating suffering (and in fact would potentially make it difficult to detect distress) Agents that are considered to provide deep sedation (e.g., ketamine or propofol) are typically considered only when other agents have proven ineffective or when the patient is known to be very tolerant to less sedating agents, but their use can still be justified 1 12-year-old boy with a history of glioblastoma is in the ICU with respiratory failure and mental status changes An MRI of his brain is obtained and identifies extensive leptomeningeal spread of his tumor The oncology team has met with his parents to let them know there are no further cancer-directed therapies to offer The family and medical team decide that it is time to discontinue invasive interventions and focus on comfort, and begin to plan for a compassionate extubation Which of the following medications would be inappropriate to give as the ventilator is discontinued? A Hydromorphone B Ketamine C Lorazepam D Propofol E Vecuronium Preferred response: E You are caring for an 8-year-old boy with end-stage metastatic osteosarcoma, with extensive bony and lung metastases He was admitted to the PICU from home due to a pain crisis that could not be adequately controlled by his hospice team He is currently on a hydromorphone PCA (patient-controlled anesthesia), with both a basal rate and a demand dose You are escalating the dose aggressively, and he continues to complain of refractory pain, particularly in his right humerus and right scapula Which of the following adjunctive pain treatments would be LEAST appropriate in this setting? A Bisphosphonates B Epidural analgesia C Ketamine D Lidocaine patch E Steroids Preferred response: B Rationale There is long-standing legal and moral precedent that pain and suffering at the end of life can and should be treated, and fears of Rationale Steroids and bisphosphonates are important adjuvant therapies for bone pain that is refractory to opiates Ketamine would be a The decision is made to withdraw mechanical ventilation on a 10-year-old patient with recurrent AML, now one month post-stem cell transplant with progressive multiple organ failure and allow her to die Which of the following options reflects current thinking in medical ethics on the goal of administering sedatives and analgesics in this context: A To hasten the patient’s death B To relieve the parent’s anxiety C To relieve the team’s anxiety D To treat patient discomfort Preferred response: D Rationale The goal of administering these therapies is only to treat patient discomfort and not to hasten the dying process or treat concerns of family members or the team with medication to the patient The decision is made to withdraw mechanical ventilation on a 10-year-old patient with recurrent AML, now one month post-stem cell transplant with progressive multiple organ failure and allow her to die Which of the following might be indicated in this context? A Antisialagogue B Caffeine C Neuromuscular blocking agent D Potassium Preferred response: A Rationale Medications that have no comfort relieving properties, but will hasten the death of the patient, such as neuromuscular blocking agents, potassium, and calcium are contraindicated in this context Similarly, caffeine would work at odds with sedatives and analgesics in a patient in this context An antisialagogue might be indicated in this context to reduce the secretion burden in this patient being extubated from mechanical ventilation with the goal of allowing her to die e20 S E C T I O N XV Pediatric Critical Care: Board Review Questions reasonable addition to the hydromorphone PCA, given its distinct mechanism of action (NMDA-antagonist) and its potential to help alleviate any component of neuropathic pain Lidocaine patches can be useful adjuncts, particularly when the pain is highly localized to one or two areas Epidural analgesia can be an invaluable adjunctive therapy for refractory pain in end-stage cancer, as long as the site of pain is at the chest or below This patient’s site of pain (shoulder and scapula) would be inappropriately high to place an epidural catheter You are caring for a 2-year-old boy, formerly a 26-week premature infant, with chronic respiratory failure due to bronchopulmonary dysplasia, dependent on mechanical ventilation via a tracheostomy tube He also has global developmental delay and a seizure disorder He is admitted to the PICU with severe pneumonia, sepsis, and multiorgan dysfunction syndrome What is the best strategy to begin a discussion of limitation of interventions with the family? A Ask the family to share their understanding of their son’s current medical condition, as well as their values, hopes, and goals with regard to their son and his care B Impress upon the family that the severity of the child’s illness and poor overall prognosis not justify further aggressive life support given the child’s underlying developmental delay C Inform the family that the patient is not going to live through the night D Present a list of interventions and ask whether or not the family would like them performed Preferred response: A Rationale Discussions of this nature should always begin by allowing the family to articulate their understanding of the child’s current condition, as well as their hopes, values, and goals for their child overall After the clinician has heard this information, recommendations for or against various interventions can be made as they pertain to the family’s stated goals Although it is important to ensure that the family understands the severity of illness and poor prognosis, it is not appropriate to make a recommendation against continuing life support based only on the presence of developmental delay Physicians are poor at predicting the exact time of death for patients, so statements of certainty around death should be avoided Physicians should avoid presenting families with a “menu” of options for care; rather they should elicit the family’s goals and make recommendations for pursuing or limiting certain interventions based on their stated goals Physicians must avoid phrases such as “do everything,” as they are nonspecific and imply that “doing” is always the best course of action Which of the following is true of methadone use for symptom management? A It has a toxic metabolite that can accumulate and lead to seizures B It has a long and variable half-life, which can lead to accumulation over time C It is renally excreted and therefore should be avoided in patients with renal failure D It shortens the QT interval Preferred response: B Rationale The half-life of methadone varies from less than 10 hours to greater than 75 hours, depending on a variety of host factors It can easily accumulate as it is reaching steady state and lead to oversedation and even obtundation Therefore dosing and titration must be performed carefully Morphine is renally excreted and should be avoided in renal failure Meperidine has a toxic metabolite that can accumulate and lead to seizures Fentanyl is the only opiate available as a transdermal patch Methadone prolongs the QT interval, and a screening electrocardiogram should be considered prior to its initiation Chapter 20: Organ Donation Process and Management of the Organ Donor You are caring for a 4-week-old infant who had a prolonged cardiac arrest after being placed face down in the crib The child has sustained significant anoxic brain injury On the third hospital day, the infant has a Glasgow Coma Score of with fixed and dilated pupils The infant is mechanically ventilated and receiving a dopamine infusion of mg/kg/min Which statement is most correct about ongoing medical care for this infant? A Authorization for donation after circulatory death (DCD) should be obtained from the family during discussions and decisions about end-of-life care B Early referral for organ donation to the organ procurement organization (OPO) enhances recovery of organs for transplantation C Organs cannot be recovered from neonatal donors D The role of the pediatric intensivist ends after providing support for the family during end-of-life care and declaring death because of potential conflict of interest with organ donation Preferred response: B Rationale Early referral for organ donation to the organ procurement organization (OPO) is considered a best practice and enhances recovery of organs for transplantation Donor management should be viewed as a continuum of care provided by the pediatric intensivist and the critical care team from the time of admission to recovery of organs for transplantation Involvement of intensivists results in better donor management and recovery of more organs with better graft function following transplantation The discussions and decision to authorize organ donation after cardiac death (DCD) should only occur after an independent decision to withdraw medical support has been decided upon by the parents or legal guardian This firewall avoids the perceived ethical conflict that the patient is being allowed to die to recover organs Authorization must occur from parents or legal guardians ... to die Which of the following options reflects current thinking in medical ethics on the goal of administering sedatives and analgesics in this context: A To hasten the patient’s death B To relieve... are contraindicated in this context Similarly, caffeine would work at odds with sedatives and analgesics in a patient in this context An antisialagogue might be indicated in this context to reduce... parents B There is no ethical distinction between withholding lifesustaining treatments and withdrawing life-sustaining treatments C Withdrawing life-sustaining treatments is more ethical than withholding