Palliative extubation: five-year experience in a pediatric hospital

Affonseca, Carolina de Araújo; Carvalho, Luís Fernando Andrade de; Quinet, Renata de Pinho Barroso; Guimarães, Maíla Cristina da Cunha; Cury, Verônica Ferreira; Rotta, Alexandre Tellechea

doi:10.1016/j.jped.2019.07.005

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Original articles • J. Pediatr. (Rio J.) 96 (5) • Sep-Oct 2020 • https://doi.org/10.1016/j.jped.2019.07.005 copy

Palliative extubation: five-year experience in a pediatric hospital^☆ ☆ Please cite this article as: Affonseca CA, Carvalho LF, Quinet RP, Guimarães MC, Cury VF, Rotta AT. Palliative extubation: a five-year experience in a pediatric hospital. J Pediatr (Rio J). 2020;96:652-9. , ^☆☆ ☆☆ Stydy conducted at Hospital Infantil João Paulo II, Belo Horizonte, MG, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To present the characteristics of pediatric patients with chronic and irreversible diseases submitted to palliative extubation.

Method:

This is a descriptive analysis of a series of patients admitted to a public pediatric hospital, with chronic and irreversible diseases, permanently dependent on ventilatory support, who underwent palliative extubation between April 2014 and May 2019. The following information was collected from the medical records: demographic data, diagnosis, duration and type of mechanical ventilation; date, time, and place of palliative extubation; medications used; symptoms observed; and hospital outcome.

Results:

A total of 19 patients with a mean age of 2.2 years were submitted to palliative extubation. 68.4% of extubations were performed in the ICU; 11 patients (57.9%) died in the hospital. The time between mechanical ventilation withdrawal and in-hospital death ranged from 15 minutes to five days. Thirteen patients used an orotracheal tube and the others used tracheostomy. The main symptoms were dyspnea and pain, and the main drugs used to control symptoms were opioids and benzodiazepines.

Conclusions:

It was not possible to identify predictors of in-hospital death after ventilatory support withdrawal. Palliative extubation requires specialized care, with the presence and availability of a multidisciplinary team with adequate training in symptom control and palliative care.

KEYWORDS
Palliative extubation; Palliative ventilatory withdrawal; Palliative care; End-of-life care; Ethics; Children

Patient	Age (years)	Gender	Main diagnosis	Secondary diagnosis	Hospital length of stay prior to extubation (days)	Duration of MV (days)	Place where the procedure was performed	Airway device	In-hospital outcome	Time between palliative extubation and in-hospital or at-home death (days)
1	0.8	F	Congenital toxoplasmosis	Hydrocephalus/microphthalmia	4	3	Isolated bed	Orotracheal tube	Discharge	92
2	1.4	F	Microcephaly of unknown cause	Heart disease/uveitis	37	35	ICU	Orotracheal tube	Death	1
3	2.6	F	Nonketotic hyperglycinemia	Apnea/sepsis	13	4	ICU	Orotracheal tube	Discharge	50
4	0.3	M	Neurodegenerative disease	Spastic quadriparesis/Seizures/Cortical atrophy	35	12	ICU	Orotracheal tube	Death	2
5	2.4	F	Nonketotic hyperglycinemia	Respiratory failure	13	12	ICU	Orotracheal tube	Discharge	796
6	2.5	F	Glutaric aciduria type 1	Refractory seizures	111	11	ICU	Tracheostomy	Death	1
7	0.2	M	HIE	Dandy Walker Sd/West Sd/Heart Disease/cataracts	133	133	Isolated bed	Tracheostomy	Discharge	214
8	5.1	M	Lowe syndrome	Multiple organ failure	9	10	ICU	Orotracheal tube	Death	0
9	9.5	M	Unspecified CNS disease	Tracheobronchitis	12	8	ICU	Orotracheal tube	Death	0
10	1.0	F	HIE	Preterm birth	34	382	Infirmary	Tracheostomy	Death	5
11	0.3	F	Trisomy 18	SGA,LW	85	83	Infirmary	Tracheostomy	Death	0
12	0.5	M	Mitochondrial Myopathy	HIE	2278	2267	Isolated bed	Tracheostomy	Death	0
13	2.2	M	Microcephaly of unknown cause	Seizures	14	12	ICU	Orotracheal tube	Discharge	-
14	3.0	M	Microcephaly of unknown cause	Seizures	94	13	ICU	Orotracheal tube	Discharge	-
15	0.7	F	AME type 1	Respiratory failure	22	106	ICU	Orotracheal tube	Death	0
16	3.7	F	HIE	Pneumonia/ARDS/PIVH grade IV	60	60	ICU	Orotracheal tube	Discharge	-
17	0.77	F	Congenital Amyoplasia	Short bowel syndrome/malnutrition	50	31	ICU	Orotracheal tube	Death	3
18	0.96	F	SMA type 1	Respiratory failure	95	88	UTI	Orotracheal tube	Death	0
19	4.17	M	HIE	Seizures	1	1267	Infirmary	Tracheostomy	Discharge	-

Variables	In-hospital death
Variables	Yes	No
Procedure performed (p = 0.60)
Orotracheal tube removal - n (%)	7 (53.8)	6 (46.2)
Tracheostomy disconnected from the MV - n (%)	4 (80.0)	2 (20.0)
Time of ventilatory support until mechanical ventilation withdrawal (p = 0.26)
higher or equal (>=)30 days - n (%)	7 (70.0)	3 (30.0)
<30 days - n (%)	4 (44.4)	5 (55.6)
Respiratory support after extubation (p = 0.36)
Yes - n (%)	6 (50.0)	6 (50.0)
No - n (%)	5 (71.4)	2 (28.6)
FiO₂ before extubation (p = 0.60)
0.40 - n (%)	7 (53.8)	6 (46.2)
higher or equal (>=) 0.40 - n (%)	4 (66.7)	2 (33.3)
PIP/ PS before extubation (p = 0.20)
<15 cmH₂O- n (%)	5 (45.5)	6 (54.5)
Higher or equal (>=) 15 cmH₂0 - n (%)	6 (75.0)	2 (25.0)

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E-mail: jped@jped.com.br

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[1] * Corresponding author. E-mails: Corresponding authors. carolina.affonseca@yahoo.com (C.A. Affonseca), veronica.cury@fhemig.mg.gov.br (V.F. Cury).

Age in years - median (IQR)	2.2 (0.80-3.56)
Female gender - n (%)	11 (57.9)
Place where palliative extubation was performed
ICU - n (%)	13 (68.4)
Ward - n (%)	3 (15.8)
Isolated Bed - n (%)	3 (15.8)
Performed procedure
Orotracheal tube removal - n (%)	13 (68.4)
Tracheostomy disconnection from MV - n (%)	6 (31.6)
Time of ventilatory support until withdrawal of mechanical ventilation (days)
Median (IQR)	31 (11.5-97)
Time from decision-making until withdrawal of mechanical ventilation (days)
Median (IQR)	1 (0-4.5)
Outcome
Death - n (%)	11 (57.9)
Hospital discharge - n (%)	8 (42.1)

Symptoms	n(%)
None	8 (42.1)
Dyspnea	9 (47.4)
Dyspnea and pain	2 (10.5)
Medications in the 24 hours after extubation
Opioids	11 (57.9)
Opioids and Benzodiazepines	5 (26.3)
None	3 (15.8)
Respiratory support after extubation
Nasal catheter	6 (31.6)
Face mask	4 (21.0)
NIV	2 (10.5)
None	7 (36.9)