Editorials
of stay using a national database from 2000 through 2009. Am J Cardiol 2013; 111:1792–1799 3. Ghanayem NS, Allen KR, Tabbutt S, et al; Pediatric Heart Network Investigators: Interstage mortality after the Norwood procedure: Results of the multicenter Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144:896–906 4. Dean PN, Hillman DG, McHugh KE, et al: Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011; 128:e1181–e1186 5. Wypij D, Newburger JW, Rappaport LA, et al: The effect of duration of deep hypothermic circulatory arrest in infant heart surgery on late neurodevelopment: The Boston Circulatory Arrest Trial. J Thorac Cardiovasc Surg 2003; 126:1397–1403 6. Culbert EL, Ashburn DA, Cullen-Dean G, et al; Congenital Heart Surgeons Society: Quality of life of children after repair of transposition of the great arteries. Circulation 2003; 108:857–862 7. Marino BS, Tomlinson RS, Drotar D, et al: Quality-of-life concerns differ among patients, parents, and medical providers in children and
adolescents with congenital and acquired heart disease. Pediatrics 2009; 123:e708–e715 8. Mellion K, Uzark K, Cassedy A, et al; Pediatric Cardiac Quality of Life Inventory Testing Study Consortium: Health-related quality of life outcomes in children and adolescents with congenital heart disease. J Pediatr 2014; 164:781.e1–788.e1 9. Pasquali SK, Marshall JL, He X, et al: Variation in congenital heart surgery costs across hospitals. Pediatrics 2014; 133:e553–e560 10. Delgado-Corcoran C, Bodily S, Frank DU, et al: Reducing Blood Testing in Pediatric Patients After Heart Surgery: A Quality Improvement Project. Pediatr Crit Care Med 2014; 15:756–761 11. Choi S, Kaufman J: Quality and performance improvement challenges for the congenital heart center. In: Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care. Da Cruz EM, Ivy D, Jaggers J (Eds). London, UK, Springer Verlag, 2014, pp 3351–3366 12. Tweddell JS, Ghanayem NS, Hoffman GM: All this monitoring…what’s necessary, what’s not? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:81–90
Palliative Care in the ICU: Together We Can Make a Greater Difference* Joseph R. Custer, MD Department of Pediatrics and Pediatric Critical Care Medicine Directory Respiratory Care C.S. Mott Children’s Hospital University of Michigan Hospital and Health Systems University of Michigan Ann Arbor, MI
W
e read with interest the IPAL-ICU (Improving Palliative Care in the ICU) report in this issue of Pediatric Critical Care Medicine (1). How shall we as critical care educators, bedside caregivers, and investigators regard palliative care? Palliative care is undeniably part of the intensivists’ tool kit. A segment of our care that most of us, I would assume, regard as a nearly sacred obligation to family and patient. The IPALICU report suggests that it is time for intensivists to pause and reflect on the role of palliative care in “our” units. Are palliative care specialists (yet) another consult? Do we merely delegate this aspect of care to another team? Do we intensivists recognize a need for colleagues with expertise in this important area of our daily work? Do we regard pediatric palliative care specialists as partners in care? Do we recognize our limitations in this area of our care and develop core competencies for continuing education and training programs?
*See also p. 762. Key Words: critical care; doctor-patient communication; palliative care; pediatrics Dr. Custer served as board member for Here 4U Inc. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000242
784
www.pccmjournal.org
“Palliative care aims to prevent and relieve suffering by controlling symptoms and to provide other support to patients and families in order to maintain and improve their quality of living … palliative care may be applied to all stages of illness, whether terminal or not (2).” The Academy of Pediatrics recommends that palliative care begin early in the trajectory of acute and chronic disease (3). Clearly, integration of palliative care into daily PICU practice improves care and satisfaction with care (4, 5). Intensive care specialists might carefully consider the implications presented in the section titled “Communication and Decision Making.” Parents and our patients face immeasurable stress. In this time of unimaginable concern, parents must make family and patient life-altering decisions. How do we lead them through this hour of greatest need (6, 7)? The art of critical care lies not alone in knowledge or wisdom or technical skill. It is relatively easy to be a physician; it is difficult to be a good one. Good physicians are outstanding communicators as caregivers, team leaders, mentors, and teachers. The lay press and our own literature have criticized the medical profession for failing to communicate with empathy and compassion. Yet those of us involved in training programs from Medical School through residency through fellowship recognize that this is a skill more easily recognized than taught (8). Conflicts in the conduct of ICU are inevitable. Conflicts inevitably arise with multiple caregivers caring for a child with complex conditions over time. Failure to communicate increases family anxiety and promotes conflict (9). A palliative care specialist can function as an ombudsman for families seeking to resolve differences with a diverse team of organ system specialists and multiple intensivists on a care team. This can be conceived of as redefinition of goals of care for patient and healthcare team. Trained intensivists (in an October 2014 • Volume 15 • Number 8
Editorials
integrative model) would recognize the need for early attention if not intervention in conflict resolution. Palliative care specialists, working with intensive care teams, can provide consistent communication over long hospital stays involving many practitioners and several hierarchies. The combination of palliative care specialist expertise working in concert with a team of intensivists would have its greatest effect in sustaining and promoting continuity of care. A nuance in critical care is its compartmentalization. Intensivists are “onservice” or “off-service.” Work hour restriction, academic and administrative duties, and the essential need for an array of organ system specialists have contributed to fragmented and discontinuous care. At its core, critical care is a trust-based business, a people business. We have faith in our training and skills, we trust our teammates, but we must earn the trust of the patients and families we care for. Trust is hard to come by when a patient’s care might involve many physicians from several disciplines. (One of my favorite parents describes consultations as drive by shootings!). Supporting families through challenging decisions is a hallmark of family-centered care. We all would honor the importance of the concept, but it is one thing to do it and another to do it well. Family-centered care is an important value, but metrics to measure the quality of satisfaction are yet to be developed (10). Core competency for trainee and practitioner will include the ability to communicate with empathy and compassion and identify family goals, spiritual and psychosocial needs, information sharing ability, and conflict resolution (11). The IPAL report suggests that another, perhaps underappreciated, aspect of intensive care is conflict resolution. The ability to resolve conflict is a valuable, perhaps transparent trait of successful intensivists. We have conflicts with other professionals, families, and patients. Accomplishment of conflict resolution improves satisfaction with care. Palliative care as a specialty could conceivably be a source of conflict for some of us who (excuse the generalization, but we know who we are) are control “junkies” and have difficulty asking for and receiving help from a consultative team. Palliative care specialists might provide a listening, nonjudgmental ear for families working through a redefinition in goals of care. Intensivists with skills in palliative care would perhaps better anticipate the need for a third-party arbitrator be that a palliative care specialist or an Ethics Committee Consultation (12). Anxiety, depression, and posttraumatic stress are common consequences of intensive care. Patients and families (and I would wager trainees and clinicians) are subject to stresses. Many of these stresses and strains are not acknowledged. Institutionally, we should not disown our patients following hospitalization in our units. To complete the circle of care begun at admission, we owe our families recognition of these symptoms and early intervention. An aspect of good palliative care will be the ability to identify the large number of our families at risk for acute stress-related disorders. The report summarizes randomized, controlled data from our adult colleagues, substantiating the claim that these symptoms can be reduced (13, 14). The report has implications for graduate medical education. Communication skills are lacking in trainee education. Pediatric Critical Care Medicine
There is room for improvement for all of us, be it veteran or rookie. Basic communication skills can be taught and learned (15, 16). Barriers have been identified for learners. Only a few templates for career path development exist. In the near future, trainees will enter fellowship having had a very different learning experience than that of previous generations of trainees. Medical education is evolving. Soon our trainees will have been in “tracks” as medical students and residents. Palliative care curricular content and education methodology will need to adapt to the new learner (17). How then will palliative care be integrated into a pediatric critical care core curriculum? This endeavor will require palliative care specialists to work hand in hand with critical care and medical educators in the design of training program content. Palliative care must necessarily be an integrated skill learned as part of a critical care fellowship, with accompanying metrics for professional growth and achievement of competency. One can foresee palliative care with-in intensive care training evolve as an “academic” track leading to professional and academic career focus (18, 19). 1. Palliative care is a unique specialty. Partnership with pediatric critical care will improve care for our patients and families. Metrics for quality care require refinement. 2. Palliative care, with an emphasis on communication, conflict resolution, is an essential skill and element of training and competency for pediatric critical care training programs. 3. Palliative care as an investigative field within critical care is a fertile area for study. Education models, metrics, and outcomes all will be areas of research for both fields. 4. Palliative care will evolve as an area of focus and scholarly activity for some pediatric critical care personnel. 5. Dual boarding in these specialties should be considered for a select few trainees.
REFERENCES
1. Boss R, Nelson J, Weissman D, et al: Integrating Palliative Care Into the PICU: A Report From the Improving Palliative Care in the ICU Advisory board. Pediatr Crit Care Med 2014; 15:762–767 2. Lanken PN, Terry PB, Delisser HM, et al; ATS End-of-Life Care Task Force: An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912–927 3. American Academy of Pediatrics Policy Statement: Pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatrics 2013; 132:966–972 4. Truog RD, Campbell ML, Curtis JR, et al; American Academy of Critical Care Medicine: Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 2008; 36:953–963 5. Liben S, Papadatou D, Wolfe J: Paediatric palliative care: Challenges and emerging ideas. Lancet 2008; 371:852–864 6. Studdert DM, Burns JP, Mello MM, et al: Nature of conflict in the care of pediatric intensive care patients with prolonged stay. Pediatrics 2003; 112:553–558 7. Studdert DM, Mello MM, Burns JP, et al: Conflict in the care of patients with prolonged stay in the ICU: Types, sources, and predictors. Intensive Care Med 2003; 29:1489–1497 8. Azoulay E, Chevret S, Leleu G, et al: Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000; 28:3044–3049 www.pccmjournal.org
785
Editorials 9. Azoulay E, Pochard F, Chevret S, et al; French FAMIREA Group: Meeting the needs of intensive care unit patient families: A multicenter study. Am J Respir Crit Care Med 2001; 163:135–139 10. Meert KL, Templin TN: Validity of family satisfaction measures: An ongoing process. Pediatr Crit Care Med 2013; 14:826–827 11. Lanken PN, Terry PB, Delisser HM, et al; ATS End-of-Life Care Task Force: An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912–927 12. Feudtner C, Nathanson PG: Pediatric palliative care and pediatric medical ethics: Effects opportunities and challenges. Pediatrics 2014; 133(Suppl 1):S1–S7 13. Nelson LP, Gold JI: Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: A review. Pediatr Crit Care Med 2012; 13:338–347 14. Davidson JP: Family response to critical illness: Post intensive care syndrome-family. Crit Care Med 2012; 40:618–624
15. Yuen JK, Mehta SS, Roberts JE, et al: A brief educational intervention to teach residents shared decision making in the intensive care unit. J Palliat Med 2013; 16:531–536 16. Curtis JR, Back AL, Ford DW, et al: Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA 2013; 310:2271–2281 17. Kamel G, Paniagua M, Uppalapati A: Palliative care in the intensive care unit: Are residents well trained to provide optimal care to critically ill patients? Am J Hosp Palliat Care 2014 May 30. [Epub ahead of print] 18. Schiffman JD, Chamberlain LJ, Palmer L, et al: Introduction of a pediatric palliative care curriculum for pediatric residents. J Palliat Med 2008; 11:164–170 19. Danis M, Federman D, Fins JJ, et al: Incorporating palliative care into critical care education: Principles, challenges, and opportunities. Crit Care Med 1999; 27:2005–2013
How We Measure Anticoagulation Is Just As Important (Maybe More Important) As How We Anticoagulate* Robert I. Parker, MD Department of Pediatrics Stony Brook Children’s Hospital State University of New York at Stony Brook School of Medicine Stony Brook, NY
U
p until recently, the continuous infusion of unfractionated heparin (UFH) has been the “gold standard” for acute anticoagulation therapy for both children and adults (1, 2). Historically, dose monitoring of patients receiving UFH has been with the activated partial thromboplastin time (aPTT), commonly referred to as the “PTT.” The therapeutic range for the aPTT was set at 1.5–2.5 times the patient’s pretherapy baseline and rigorously validated in a clinical study by Hirsh and colleagues (3). Subsequently, this range for aPTT values was shown to correspond to a plasma heparin concentration of 0.2–0.4 U/mL and later to an anti-Xa activity of 0.3–0.7 U/mL (1). Although the aPTT has historically been the preferred monitoring test for assessment of UFH dosing, the aPTT demonstrates a high degree of intra- and interpatient variability, which often results in the need for increased blood tests for monitoring and multiple dose modifications.
*See also p. e340. Key Words: anti-Xa; anticoagulation monitoring; antithrombin III concentrates; unfractionated heparin The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000189
786
www.pccmjournal.org
Factors that contribute to this variability include patient age, body habitus, levels of other plasma proteins (e.g., factor VIII and fibrinogen), and plasma anti-thrombin-III (antithrombin) level (2, 4–8). This test variability and subsequent need for additional blood sampling is particularly problematic in pediatric patients owing to the desire to limit the volume of blood taken for tests and restrictions on venous access (9, 10). Consequently, many clinical laboratories and clinicians have substituted the anti-Xa assay for UFH monitoring. Although the anti-Xa assay has been shown to reduce test variability and result in fewer monitoring blood tests (11), the anti-Xa assay does not measure the antithrombin-mediated thrombin (activated factor II [FIIa]) inhibition produced by UFH and may thereby give an incomplete (potentially misleading) assessment of anticoagulation (8, 12, 13). In this issue of Pediatric Critical Care Medicine, Ryerson et al (14) report on the effect of commercially available antithrombin concentrate infusions in achieving and maintaining aPTT and/or anti-Xa values in the desired target range during therapeutic anticoagulation of children with UFH. The authors found that administration of antithrombin concentrates (ATCs) to children with antithrombin plasma levels less than 0.5 U/mL who were receiving UFH for therapeutic anticoagulation resulted in a statistically significant reduction in the dose of UFH required to achieve a target anti-Xa level. Of interest, however, was the observation that the benefit of ATC infusion was strongest in the younger patients (i.e., 3 mo old) patients. In children less than 12 months old, ATC infusion resulted in an increase in anti-Xa levels from 0.21 to 0.47 U/mL (p < 0.001), whereas October 2014 • Volume 15 • Number 8
of stay using a national database from 2000 through 2009. Am J Cardiol 2013; 111:1792–1799 3. Ghanayem NS, Allen KR, Tabbutt S, et al; Pediatric Heart Network Investigators: Interstage mortality after the Norwood procedure: Results of the multicenter Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144:896–906 4. Dean PN, Hillman DG, McHugh KE, et al: Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011; 128:e1181–e1186 5. Wypij D, Newburger JW, Rappaport LA, et al: The effect of duration of deep hypothermic circulatory arrest in infant heart surgery on late neurodevelopment: The Boston Circulatory Arrest Trial. J Thorac Cardiovasc Surg 2003; 126:1397–1403 6. Culbert EL, Ashburn DA, Cullen-Dean G, et al; Congenital Heart Surgeons Society: Quality of life of children after repair of transposition of the great arteries. Circulation 2003; 108:857–862 7. Marino BS, Tomlinson RS, Drotar D, et al: Quality-of-life concerns differ among patients, parents, and medical providers in children and
adolescents with congenital and acquired heart disease. Pediatrics 2009; 123:e708–e715 8. Mellion K, Uzark K, Cassedy A, et al; Pediatric Cardiac Quality of Life Inventory Testing Study Consortium: Health-related quality of life outcomes in children and adolescents with congenital heart disease. J Pediatr 2014; 164:781.e1–788.e1 9. Pasquali SK, Marshall JL, He X, et al: Variation in congenital heart surgery costs across hospitals. Pediatrics 2014; 133:e553–e560 10. Delgado-Corcoran C, Bodily S, Frank DU, et al: Reducing Blood Testing in Pediatric Patients After Heart Surgery: A Quality Improvement Project. Pediatr Crit Care Med 2014; 15:756–761 11. Choi S, Kaufman J: Quality and performance improvement challenges for the congenital heart center. In: Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care. Da Cruz EM, Ivy D, Jaggers J (Eds). London, UK, Springer Verlag, 2014, pp 3351–3366 12. Tweddell JS, Ghanayem NS, Hoffman GM: All this monitoring…what’s necessary, what’s not? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:81–90
Palliative Care in the ICU: Together We Can Make a Greater Difference* Joseph R. Custer, MD Department of Pediatrics and Pediatric Critical Care Medicine Directory Respiratory Care C.S. Mott Children’s Hospital University of Michigan Hospital and Health Systems University of Michigan Ann Arbor, MI
W
e read with interest the IPAL-ICU (Improving Palliative Care in the ICU) report in this issue of Pediatric Critical Care Medicine (1). How shall we as critical care educators, bedside caregivers, and investigators regard palliative care? Palliative care is undeniably part of the intensivists’ tool kit. A segment of our care that most of us, I would assume, regard as a nearly sacred obligation to family and patient. The IPALICU report suggests that it is time for intensivists to pause and reflect on the role of palliative care in “our” units. Are palliative care specialists (yet) another consult? Do we merely delegate this aspect of care to another team? Do we intensivists recognize a need for colleagues with expertise in this important area of our daily work? Do we regard pediatric palliative care specialists as partners in care? Do we recognize our limitations in this area of our care and develop core competencies for continuing education and training programs?
*See also p. 762. Key Words: critical care; doctor-patient communication; palliative care; pediatrics Dr. Custer served as board member for Here 4U Inc. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000242
784
www.pccmjournal.org
“Palliative care aims to prevent and relieve suffering by controlling symptoms and to provide other support to patients and families in order to maintain and improve their quality of living … palliative care may be applied to all stages of illness, whether terminal or not (2).” The Academy of Pediatrics recommends that palliative care begin early in the trajectory of acute and chronic disease (3). Clearly, integration of palliative care into daily PICU practice improves care and satisfaction with care (4, 5). Intensive care specialists might carefully consider the implications presented in the section titled “Communication and Decision Making.” Parents and our patients face immeasurable stress. In this time of unimaginable concern, parents must make family and patient life-altering decisions. How do we lead them through this hour of greatest need (6, 7)? The art of critical care lies not alone in knowledge or wisdom or technical skill. It is relatively easy to be a physician; it is difficult to be a good one. Good physicians are outstanding communicators as caregivers, team leaders, mentors, and teachers. The lay press and our own literature have criticized the medical profession for failing to communicate with empathy and compassion. Yet those of us involved in training programs from Medical School through residency through fellowship recognize that this is a skill more easily recognized than taught (8). Conflicts in the conduct of ICU are inevitable. Conflicts inevitably arise with multiple caregivers caring for a child with complex conditions over time. Failure to communicate increases family anxiety and promotes conflict (9). A palliative care specialist can function as an ombudsman for families seeking to resolve differences with a diverse team of organ system specialists and multiple intensivists on a care team. This can be conceived of as redefinition of goals of care for patient and healthcare team. Trained intensivists (in an October 2014 • Volume 15 • Number 8
Editorials
integrative model) would recognize the need for early attention if not intervention in conflict resolution. Palliative care specialists, working with intensive care teams, can provide consistent communication over long hospital stays involving many practitioners and several hierarchies. The combination of palliative care specialist expertise working in concert with a team of intensivists would have its greatest effect in sustaining and promoting continuity of care. A nuance in critical care is its compartmentalization. Intensivists are “onservice” or “off-service.” Work hour restriction, academic and administrative duties, and the essential need for an array of organ system specialists have contributed to fragmented and discontinuous care. At its core, critical care is a trust-based business, a people business. We have faith in our training and skills, we trust our teammates, but we must earn the trust of the patients and families we care for. Trust is hard to come by when a patient’s care might involve many physicians from several disciplines. (One of my favorite parents describes consultations as drive by shootings!). Supporting families through challenging decisions is a hallmark of family-centered care. We all would honor the importance of the concept, but it is one thing to do it and another to do it well. Family-centered care is an important value, but metrics to measure the quality of satisfaction are yet to be developed (10). Core competency for trainee and practitioner will include the ability to communicate with empathy and compassion and identify family goals, spiritual and psychosocial needs, information sharing ability, and conflict resolution (11). The IPAL report suggests that another, perhaps underappreciated, aspect of intensive care is conflict resolution. The ability to resolve conflict is a valuable, perhaps transparent trait of successful intensivists. We have conflicts with other professionals, families, and patients. Accomplishment of conflict resolution improves satisfaction with care. Palliative care as a specialty could conceivably be a source of conflict for some of us who (excuse the generalization, but we know who we are) are control “junkies” and have difficulty asking for and receiving help from a consultative team. Palliative care specialists might provide a listening, nonjudgmental ear for families working through a redefinition in goals of care. Intensivists with skills in palliative care would perhaps better anticipate the need for a third-party arbitrator be that a palliative care specialist or an Ethics Committee Consultation (12). Anxiety, depression, and posttraumatic stress are common consequences of intensive care. Patients and families (and I would wager trainees and clinicians) are subject to stresses. Many of these stresses and strains are not acknowledged. Institutionally, we should not disown our patients following hospitalization in our units. To complete the circle of care begun at admission, we owe our families recognition of these symptoms and early intervention. An aspect of good palliative care will be the ability to identify the large number of our families at risk for acute stress-related disorders. The report summarizes randomized, controlled data from our adult colleagues, substantiating the claim that these symptoms can be reduced (13, 14). The report has implications for graduate medical education. Communication skills are lacking in trainee education. Pediatric Critical Care Medicine
There is room for improvement for all of us, be it veteran or rookie. Basic communication skills can be taught and learned (15, 16). Barriers have been identified for learners. Only a few templates for career path development exist. In the near future, trainees will enter fellowship having had a very different learning experience than that of previous generations of trainees. Medical education is evolving. Soon our trainees will have been in “tracks” as medical students and residents. Palliative care curricular content and education methodology will need to adapt to the new learner (17). How then will palliative care be integrated into a pediatric critical care core curriculum? This endeavor will require palliative care specialists to work hand in hand with critical care and medical educators in the design of training program content. Palliative care must necessarily be an integrated skill learned as part of a critical care fellowship, with accompanying metrics for professional growth and achievement of competency. One can foresee palliative care with-in intensive care training evolve as an “academic” track leading to professional and academic career focus (18, 19). 1. Palliative care is a unique specialty. Partnership with pediatric critical care will improve care for our patients and families. Metrics for quality care require refinement. 2. Palliative care, with an emphasis on communication, conflict resolution, is an essential skill and element of training and competency for pediatric critical care training programs. 3. Palliative care as an investigative field within critical care is a fertile area for study. Education models, metrics, and outcomes all will be areas of research for both fields. 4. Palliative care will evolve as an area of focus and scholarly activity for some pediatric critical care personnel. 5. Dual boarding in these specialties should be considered for a select few trainees.
REFERENCES
1. Boss R, Nelson J, Weissman D, et al: Integrating Palliative Care Into the PICU: A Report From the Improving Palliative Care in the ICU Advisory board. Pediatr Crit Care Med 2014; 15:762–767 2. Lanken PN, Terry PB, Delisser HM, et al; ATS End-of-Life Care Task Force: An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912–927 3. American Academy of Pediatrics Policy Statement: Pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatrics 2013; 132:966–972 4. Truog RD, Campbell ML, Curtis JR, et al; American Academy of Critical Care Medicine: Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 2008; 36:953–963 5. Liben S, Papadatou D, Wolfe J: Paediatric palliative care: Challenges and emerging ideas. Lancet 2008; 371:852–864 6. Studdert DM, Burns JP, Mello MM, et al: Nature of conflict in the care of pediatric intensive care patients with prolonged stay. Pediatrics 2003; 112:553–558 7. Studdert DM, Mello MM, Burns JP, et al: Conflict in the care of patients with prolonged stay in the ICU: Types, sources, and predictors. Intensive Care Med 2003; 29:1489–1497 8. Azoulay E, Chevret S, Leleu G, et al: Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000; 28:3044–3049 www.pccmjournal.org
785
Editorials 9. Azoulay E, Pochard F, Chevret S, et al; French FAMIREA Group: Meeting the needs of intensive care unit patient families: A multicenter study. Am J Respir Crit Care Med 2001; 163:135–139 10. Meert KL, Templin TN: Validity of family satisfaction measures: An ongoing process. Pediatr Crit Care Med 2013; 14:826–827 11. Lanken PN, Terry PB, Delisser HM, et al; ATS End-of-Life Care Task Force: An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912–927 12. Feudtner C, Nathanson PG: Pediatric palliative care and pediatric medical ethics: Effects opportunities and challenges. Pediatrics 2014; 133(Suppl 1):S1–S7 13. Nelson LP, Gold JI: Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: A review. Pediatr Crit Care Med 2012; 13:338–347 14. Davidson JP: Family response to critical illness: Post intensive care syndrome-family. Crit Care Med 2012; 40:618–624
15. Yuen JK, Mehta SS, Roberts JE, et al: A brief educational intervention to teach residents shared decision making in the intensive care unit. J Palliat Med 2013; 16:531–536 16. Curtis JR, Back AL, Ford DW, et al: Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA 2013; 310:2271–2281 17. Kamel G, Paniagua M, Uppalapati A: Palliative care in the intensive care unit: Are residents well trained to provide optimal care to critically ill patients? Am J Hosp Palliat Care 2014 May 30. [Epub ahead of print] 18. Schiffman JD, Chamberlain LJ, Palmer L, et al: Introduction of a pediatric palliative care curriculum for pediatric residents. J Palliat Med 2008; 11:164–170 19. Danis M, Federman D, Fins JJ, et al: Incorporating palliative care into critical care education: Principles, challenges, and opportunities. Crit Care Med 1999; 27:2005–2013
How We Measure Anticoagulation Is Just As Important (Maybe More Important) As How We Anticoagulate* Robert I. Parker, MD Department of Pediatrics Stony Brook Children’s Hospital State University of New York at Stony Brook School of Medicine Stony Brook, NY
U
p until recently, the continuous infusion of unfractionated heparin (UFH) has been the “gold standard” for acute anticoagulation therapy for both children and adults (1, 2). Historically, dose monitoring of patients receiving UFH has been with the activated partial thromboplastin time (aPTT), commonly referred to as the “PTT.” The therapeutic range for the aPTT was set at 1.5–2.5 times the patient’s pretherapy baseline and rigorously validated in a clinical study by Hirsh and colleagues (3). Subsequently, this range for aPTT values was shown to correspond to a plasma heparin concentration of 0.2–0.4 U/mL and later to an anti-Xa activity of 0.3–0.7 U/mL (1). Although the aPTT has historically been the preferred monitoring test for assessment of UFH dosing, the aPTT demonstrates a high degree of intra- and interpatient variability, which often results in the need for increased blood tests for monitoring and multiple dose modifications.
*See also p. e340. Key Words: anti-Xa; anticoagulation monitoring; antithrombin III concentrates; unfractionated heparin The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000189
786
www.pccmjournal.org
Factors that contribute to this variability include patient age, body habitus, levels of other plasma proteins (e.g., factor VIII and fibrinogen), and plasma anti-thrombin-III (antithrombin) level (2, 4–8). This test variability and subsequent need for additional blood sampling is particularly problematic in pediatric patients owing to the desire to limit the volume of blood taken for tests and restrictions on venous access (9, 10). Consequently, many clinical laboratories and clinicians have substituted the anti-Xa assay for UFH monitoring. Although the anti-Xa assay has been shown to reduce test variability and result in fewer monitoring blood tests (11), the anti-Xa assay does not measure the antithrombin-mediated thrombin (activated factor II [FIIa]) inhibition produced by UFH and may thereby give an incomplete (potentially misleading) assessment of anticoagulation (8, 12, 13). In this issue of Pediatric Critical Care Medicine, Ryerson et al (14) report on the effect of commercially available antithrombin concentrate infusions in achieving and maintaining aPTT and/or anti-Xa values in the desired target range during therapeutic anticoagulation of children with UFH. The authors found that administration of antithrombin concentrates (ATCs) to children with antithrombin plasma levels less than 0.5 U/mL who were receiving UFH for therapeutic anticoagulation resulted in a statistically significant reduction in the dose of UFH required to achieve a target anti-Xa level. Of interest, however, was the observation that the benefit of ATC infusion was strongest in the younger patients (i.e., 3 mo old) patients. In children less than 12 months old, ATC infusion resulted in an increase in anti-Xa levels from 0.21 to 0.47 U/mL (p < 0.001), whereas October 2014 • Volume 15 • Number 8
