Duke Childrens Hospital

Durham, NC, United States

Duke Childrens Hospital

Durham, NC, United States

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Rehder K.J.,Duke Childrens Hospital | Turner D.A.,Duke Childrens Hospital | Cheifetz I.M.,Duke Childrens Hospital
Pediatric Critical Care Medicine | Year: 2013

Objective: To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure. Data Source: A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations. Study Selection: Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxy-genation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation. Data Extraction: Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygen-ation utilization, and ancillary therapies. Data Synthesis: Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained. Conclusions: Despite a large number of published extracorpo-real membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients. Copyright © 2013 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.


Rehder K.J.,Duke Childrens Hospital
Expert review of respiratory medicine | Year: 2012

Extracorporeal membrane oxygenation (ECMO) is an important rescue therapy for patients with cardiac and/or respiratory failure, with a growing body of literature supporting its use. Despite widespread use of ECMO, there remains a paucity of data on optimal management strategies for ECMO patients. Management of ECMO patients involves an understanding of the complex interaction between this technology and the critically ill patients being supported. ECMO providers typically rely on a combination of consensus guidelines and institutional experience to make management decisions. Substantial controversy continues to exist regarding many elements of ECMO management, including seemingly straightforward decisions such as the initial implementation of this technology. In addition, there are multiple providers involved in the management of ECMO patients who must be co-ordinated for this supportive therapy to be most effective. This manuscript provides an overview of current techniques for treating respiratory ECMO patients.


Frazier M.D.,Marshall University | Cheifetz I.M.,Duke Childrens Hospital
Paediatric Respiratory Reviews | Year: 2010

Helium-oxygen (heliox) gas mixtures have been studied for over 70 years as an adjunctive therapy for airway obstruction in a variety of respiratory diseases. The medical use of heliox is based on the physical properties of helium as its low density makes it advantageous in promoting more efficient flow through narrowed passages. Clinical evidence of the efficacy of heliox in treating paediatric respiratory diseases is increasing in the medical literature. This article consists of a comprehensive review of the literature investigating the utility of heliox in the treatment of paediatric respiratory disorders, including upper and lower airway obstruction, mechanical ventilation, and aerosol delivery. © 2009 Elsevier Ltd. All rights reserved.


Abdelsalam M.,Suez Chest Hospital | Cheifetz I.M.,Duke Childrens Hospital
Respiratory Care | Year: 2010

Permissive hypoxemia is a lung-protective strategy that aims to provide a patient with severe acute respiratory distress syndrome (ARDS) a level of oxygen delivery that is adequate to avoid tissue hypoxia while minimizing the detrimental effects of the often toxic ventilatory support required to maintain normal arterial oxygenation. However, in many patients with severe ARDS it can be difficult to achieve a balance between maintaining adequate tissue oxygenation and avoiding ventilator- induced lung injury (VILI). A potential strategy for the management of such patients involves goal-oriented manipulation of cardiac output and, if necessary, hemoglobin concentration, to compensate for hypoxemia and maintain a normal (but not supranormal) value of oxygen delivery. Although it has not yet been studied, this approach is theorized to improve clinical outcomes of critically ill patients with severe ARDS. We stress that the goal of this article is not to convince the reader that this approach is necessarily correct, as data are clearly lacking, but rather to provide a basis for continued thought, discussion, and potential research. © 2010 Daedalus Enterprises.


Cheifetz I.M.,Duke Childrens Hospital
Respiratory Care | Year: 2011

The data available to guide clinical management of acute lung injury and acute respiratory distress syndrome are much more limited for infants and children than for adult patients. This paper reviews the available medical data and the pertinent physiology on the management of pediatric patients with acute lung injury. With the collaboration of multicenter investigation networks, definitive pediatric data may be on the horizon to better guide our clinical practice. © 2011 Daedalus Enterprises.


Cheifetz I.M.,Duke Childrens Hospital
Respiratory Care | Year: 2011

As the basis for this paper, it must be acknowledged that children are not simply small adults. But this acknowledgment must go further: infants are not simply small adolescents. As data for pediatric mechanical ventilation, in general, and the management for pediatric acute lung injury, more specifically, are very limited, the pediatric critical care clinician must closely assess the available adult data and evaluate its application for infants and children. Given the hurdles in studying pediatric acute lung injury and acute respiratory distress syndrome, clinicians involved with the care of critically ill infants and children are left with extrapolation of data from the neonatal and adult populations, reliance on the limited available pediatric data, careful assessment of the applicable physiologic and pathophysiologic principles, and/or reliance on their own experience and their colleagues' experience. Hopefully, with the collaboration of multicenter investigator networks, additional and definitive pediatric data may be on the horizon. In the meantime, sharing data between adult and pediatric populations seems to be an essential approach to the management of critically ill patients. © 2011 Daedalus Enterprises.


Rehder K.J.,Duke Childrens Hospital | Cheifetz I.M.,Duke Childrens Hospital | Willson D.F.,Childrens Hospital of Richmond | Turner D.A.,Duke Childrens Hospital
Pediatrics | Year: 2014

BACKGROUND: In recent years, the focus on patient safety and housestaff supervision has led to a steady increase in institutions providing 24/7 in-hospital (also known as in-house, henceforth referred to as IH) coverage by pediatric intensivists. Effects of this increased attending physician presence on education of pediatric housestaff have not been studied. We hypothesized that IH coverage would decrease perceived autonomy of housestaff and negatively affect their preparedness to be independent attending physicians on completion of training. METHODS: A secure, anonymous, Web-based survey was sent to pediatric intensivists in the United States and Canada, and pediatric critical care fellows and pediatric residents at academic centers across the United States. Questions focused on perceptions of IH coverage and housestaff educational experience. RESULTS: We report 1323 responses from 147 institutions (center response rate 74%). Although 96% of respondents stated that the PICU provides "a good educational experience," only 50% of pediatric intensivists and 67% of housestaff feel that housestaff are prepared for independent practice after training in an IH model. Compared with those training in home-call models, respondents currently working in IH models have more favorable perceptions of the effects of IH coverage on housestaff autonomy (P < .0001), supervision (P < .0001), and preparation for independent practice (P < .0001). CONCLUSIONS: Pediatric intensivists and housestaff express concern regarding the preparation of housestaff training in a 24/7 IH attending model. An important priority for institutions using or considering a 24/7 IH attending coverage model is the balance between adequate housestaff supervision and autonomy. Copyright © 2014 by the American Academy of Pediatrics.


Cheifetz I.M.,Duke University | Cheifetz I.M.,Duke Childrens Hospital
Pediatric Clinics of North America | Year: 2013

This article focuses on the respiratory management and monitoring of pediatric acute lung injury (ALI) as a specific cause for respiratory failure. Definitive, randomized, controlled trials in pediatrics to guide optimal ventilatory management are few. The only adjunct therapy that has been proved to improve clinical outcome is low tidal volume ventilation, but only in adult patients. Careful monitoring of the patient's respiratory status with airway graphic analysis and capnography can be helpful. Definitive data are needed in the pediatric population to assist in the care of infants, children, and adolescents with ALI to improve survival and functional outcome. © 2013 Elsevier Inc.


Rabinovich C.E.,Duke Childrens Hospital
Current Opinion in Rheumatology | Year: 2011

Purpose of Review: To update the current understanding of the risk factors for poor outcomes in juvenile idiopathic arthritis-related uveitis. In addition, current therapies, both traditional and biological, are reviewed. Recent Findings: Male sex, independent of age or antinuclear antibody status, is associated with increased ocular morbidity. Having anterior chamber inflammation on first exam increases the risk of developing vision-threatening eye complications. Presence of one complication increases the risk of developing another. Risk of cataract development associated with topical glucocorticoid use is better defined. Longer duration of remission on therapy has been found to decrease the risk of disease flare after discontinuation of methotrexate. Recent studies of both nonbiological and biological therapies for arthritis-related uveitis are discussed. Summary: With a better understanding of risk factors associated with the ocular morbidity of uveitis associated with juvenile idiopathic arthritis, aggressive therapies can be targeted for improved visual outcomes. Alternative treatments to avoid long-term corticosteroid use include the use of antimetabolites and biological therapies. More prospective comparator studies and/or use of multicenter databases are needed to better understand best treatments. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Turner D.A.,Duke Childrens Hospital
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies | Year: 2013

To describe the teaching and evaluation modalities used by pediatric critical care medicine training programs in the areas of professionalism and communication. Cross-sectional national survey. Pediatric critical care medicine fellowship programs. Pediatric critical care medicine program directors. None. Survey response rate was 67% of program directors in the United States, representing educators for 73% of current pediatric critical care medicine fellows. Respondents had a median of 4 years experience, with a median of seven fellows and 12 teaching faculty in their program. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication. However, six of the eight (75%) required elements of communication evaluated were not specifically taught by all programs. Faculty role modeling was the most commonly used technique to teach professionalism in 44% of the content areas evaluated, and didactics was the technique used in 44% of other professionalism content areas. Thirteen of the 16 required elements of professionalism (81%) were not taught by all programs. Evaluations by members of the healthcare team were used for assessment for both competencies. The use of a specific teaching technique was not related to program size, program director experience, or training in medical education. A wide range of techniques are currently used within pediatric critical care medicine to teach communication and professionalism, but there are a number of required elements that are not specifically taught by fellowship programs. These areas of deficiency represent opportunities for future investigation and improved education in the important competencies of communication and professionalism.

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