Browsing by Author "Barbaro, Ryan P."

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    Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)
    (Wolters Kluwer, 2023) Emeriaud, Guillaume; López-Fernández, Yolanda M.; Iyer, Narayan Prabhu; Bembea, Melania M.; Agulnik, Asya; Barbaro, Ryan P.; Baudin, Florent; Bhalla, Anoopindar; de Carvalho, Werther Brunow; Carroll, Christopher L.; Cheifetz, Ira M.; Chisti, Mohammod J.; Cruces, Pablo; Curley, Martha A. Q.; Dahmer, Mary K.; Dalton, Heidi J.; Erickson, Simon J.; Essouri, Sandrine; Fernández, Analía; Flori, Heidi R.; Grunwell, Jocelyn R.; Jouvet, Philippe; Killien, Elizabeth Y.; Kneyber, Martin C. J.; Kudchadkar, Sapna R.; Korang, Steven Kwasi; Lee, Jan Hau; Macrae, Duncan J.; Maddux, Aline; Alapont, Vicent Modesto I.; Morrow, Brenda M.; Nadkarni, Vinay M.; Napolitano, Natalie; Newth, Christopher J. L.; Pons-Odena, Martí; Quasney, Michael W.; Rajapreyar, Prakadeshwari; Rambaud, Jerome; Randolph, Adrienne G.; Rimensberger, Peter; Rowan, Courtney M.; Sanchez-Pinto, L. Nelson; Sapru, Anil; Sauthier, Michael; Shein, Steve L.; Smith, Lincoln S.; Steffen, Katerine; Takeuchi, Muneyuki; Thomas, Neal J.; Tse, Sze Man; Valentine, Stacey; Ward, Shan; Watson, R. Scott; Yehya, Nadir; Zimmerman, Jerry J.; Khemani, Robinder G.; Pediatrics, School of Medicine
    Objectives: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. Design: International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. Setting: Not applicable. Patients: Patients with or at risk for PARDS. Interventions: None. Measurements and main results: Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. Conclusions: PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.
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    Tracheostomy and Long-Term Mechanical Ventilation in Children after Veno-Venous Extracorporeal Membrane Oxygenation
    (Wiley, 2021-09) Mallory, Palen P.; Barbaro, Ryan P.; Bembea, Melania M.; Bridges, Brian C.; Chima, Ranjit S.; Kilbaugh, Todd J.; Potera, Renee M.; Rosner, Elizabeth A.; Sandhu, Hitesh S.; Slaven, James E.; Tarquinio, Keiko M.; Cheifetz, Ira M.; Friedman, Matthew L.; Biostatistics, School of Public Health
    Objective Our objective is to characterize the incidence of tracheostomy placement and of new requirement for long-term mechanical ventilation after extracorporeal membrane oxygenation (ECMO) among children with acute respiratory failure. We examine whether an association exists between demographics, pre-ECMO and ECMO clinical factors, and the placement of a tracheostomy or need for long-term mechanical ventilation. Methods A retrospective multicenter cohort study was conducted at 10 quaternary care pediatric academic centers, including children supported with veno-venous (V-V) ECMO from 2011 to 2016. Results Among 202 patients, 136 (67%) survived to ICU discharge. All tracheostomies were placed after ECMO decannulation, in 22 patients, with 19 of those surviving to ICU discharge (14% of survivors). Twelve patients (9% of survivors) were discharged on long-term mechanical ventilation. Tracheostomy placement and discharge on home ventilation were not associated with pre-ECMO severity of illness or pre-existing chronic illness. Patients who received a tracheostomy were older and weighed more than patients who did not receive a tracheostomy, although this association did not exist among patients discharged on home ventilation. ECMO duration was longer in those who received a tracheostomy compared to those who did not, as well as for those discharged on home ventilation, compared to those who were not. Conclusion The 14% rate for tracheostomy placement and 9% rate for discharge on long-term mechanical ventilation after V-V ECMO are important patient centered findings. This work informs anticipatory guidance provided to families of patients requiring prolonged respiratory ECMO support, and lays the foundation for future research. This article is protected by copyright. All rights reserved.
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    Tracheostomy Practices and Outcomes in Children during Respiratory ECMO
    (Wolters Kluwer, 2022-04) Kohne, Joseph G.; MacLaren, Graeme; Rider, Erica; Carr, Benjamin; Mallory, Palen; Gebremariam, Acham; Friedman, Matthew L.; Barbaro, Ryan P.; Pediatrics, School of Medicine
    Objectives: Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making. Design: Retrospective cohort study Setting: ECMO centers contributing to the Extracorporeal Life Support Organization (ELSO) Registry Patients: Children birth to 18 years who received ECMO support for 7 days or greater for respiratory failure from January 1st 2015 to December 31st 2019. Interventions: None Measurements and Main Results: 3685 children received at least seven days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (IQR 9.3-19.9), and in-hospital mortality was 38.7% (1426/3685). A tracheostomy was placed during ECMO support in 94/3685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR 6.3-25.9) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR 13.0-58.7); in-hospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age 15.8 years (IQR 4.7-15.5) versus 11.7 years (IQR 11.5-17.3); p-value=0.002) and more likely to have been supported on VV-ECMO (84% vs 52%, p=0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared to 19/44 (43%) of those who received a tracheostomy at 14 days or later (p=0.03). Conclusions: Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a “secondary” strategy for prolonged ECMO support.
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    Veno-Venous Extracorporeal Membrane Oxygenation for Children With Cancer or Hematopoietic Cell Transplant: A Ten Center Cohort
    (Wolters Kluwer, 2021) Bridges, Brian C.; Kilbaugh, Todd J.; Barbaro, Ryan P.; Bembea, Melania M.; Chima, Ranjit S.; Potera, Renee M.; Rosner, Elizabeth A.; Sandhu, Hitesh S.; Slaven, James E.; Tarquinio, Keiko M.; Cheifetz, Ira M.; Rowan, Courtney M.; Friedman, Matthew L.; Biostatistics, School of Public Health
    We performed a multi-center retrospective cohort study of children aged 14 days to 18 years in the United States from 2011 to 2016 with cancer or hematopoietic cell transplant (HCT) who were supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO). We compared the outcomes of children with oncological diagnoses or HCT supported with V-V ECMO to other children who have received V-V ECMO support. In this cohort of 204 patients supported with V-V ECMO, 30 (15%) had a diagnosis of cancer or a history of HCT. There were 21 patients who had oncological diagnoses without HCT and 9 children were post-HCT. The oncology/HCT group had a higher overall ICU mortality (67% vs. 28%, p<0.001), mortality on ECMO (43% vs 21%, p<0.01), and ICU mortality among ECMO survivors (35% vs 8%, p<0.01). The oncology/HCT group had a higher rate of conversion to veno-arterial (V-A) ECMO (23% vs. 9%, p=0.02) (RR 2.5, 95% CI 1.1–5.6). Children with cancer or HCT were older (6.6 years vs 2.9 years, p=0.02) and had higher creatinine levels (0.65 mg/dL vs 0.4 mg/dL, p=0.04) but were similar to the rest of the cohort for other pre-ECMO variables. For post-HCT patients, survival was significantly worse for those whose indication for HCT was cancer or immunodeficiency (0/6) as compared to other nonmalignant indications (3/3) (p=0.01).