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Safety of therapeutic hypothermia in children on veno-arterial extracorporeal membrane oxygenation after cardiac surgery. Cardiol Young 2015; 25:1367-73. [PMID: 25723254 DOI: 10.1017/s1047951115000116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the use of therapeutic hypothermia in patients receiving extracorporeal membrane oxygenation after paediatric cardiac surgery is associated with increased complication rates. METHODS We undertook a retrospective study to compare the complication rates and clinical course of children after cardiac surgery in two groups – extracorporeal membrane oxygenation without therapeutic hypothermia (group 1) and extracorporeal membrane oxygenation with therapeutic hypothermia (group 2). Therapeutic hypothermia was performed via the extracorporeal membrane oxygenation circuit heater-cooler device. RESULTS A total of 96 patients were included in this study (59 in group 1 and 37 in group 2). Complications were comparable between group 1 and group 2, except that more patients with therapeutic hypothermia had hypertension while on extracorporeal membrane oxygenation. Therapeutic hypothermia was not independently associated with in-hospital mortality (adjusted odds ratio 1.16, 95% CI: 0.33-4.03; p=0.82). CONCLUSION Therapeutic hypothermia can be safely provided to children on extracorporeal membrane oxygenation after cardiac surgery without an increase in complication rates.
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Abstract
BACKGROUND Therapeutic hypothermia (TH) has been shown to be effective in resuscitation of some adults following cardiac arrest and infants with hypoxic ischemic encephalopathy, but has not been well studied in children. OBJECTIVES The purpose of this systematic review/meta-analysis was to examine mortality, neurologic outcomes, and adverse events in children following use of TH. RESULTS A search of PubMed, the Cumulative Index to Nursing and Allied Health Literature, and the Institute for Scientific Information's Web of Knowledge from 1946 to 2014 yielded 6 studies (3 retrospective and 3 prospective cohort studies) that met our inclusion criteria. Quantitative synthesis of mortality following TH (136 subjects) was 44% (95% confidence interval, 32-57) with 28% (95% confidence interval, 11-53) of survivors (42 subjects) demonstrating poor neurologic outcome. The most frequently reported adverse events were electrolyte imbalances and pneumonia. CONCLUSIONS Evidence is insufficient to support the advantage of TH compared with normothermia in pediatric resuscitation. The adverse event profile appears to be different than that reported in adults. Further studies are needed before TH may be considered a standard protocol for children after cardiac arrest.
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Nakagawa TA, Ashwal S, Mathur M, Mysore M. Clinical report—Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics 2011; 128:e720-40. [PMID: 21873704 DOI: 10.1542/peds.2011-1511] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To review and revise the 1987 pediatric brain death guidelines. METHODS Relevant literature was reviewed. Recommendations were developed using the GRADE system. CONCLUSIONS AND RECOMMENDATIONS (1) Determination of brain death in term newborns, infants and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants less than 37 weeks gestational age are not included in this guideline. (2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. (3) Two examinations including apnea testing with each examination separated by an observation period are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hours for term newborns (37 weeks gestational age) to 30 days of age, and 12 hours for infants and chi (> 30 days to 18 years) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function following cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination. (4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco(2) 20 mm Hg above the baseline and ≥ 60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. (5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be us d to assist the clinician in making the diagnosis of brain death (i) when components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient; (ii) if there is uncertainty about the results of the neurologic examination; (iii) if a medication effect may be present; or (iv) to reduce the inter-examination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed and components that can be completed must remain consistent with brain death. In this instance the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. (6) Death is declared when the above criteria are fulfilled.
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Kirkham F. Cardiac arrest and post resuscitation of the brain. Eur J Paediatr Neurol 2011; 15:379-89. [PMID: 21640621 DOI: 10.1016/j.ejpn.2011.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 04/17/2011] [Indexed: 10/18/2022]
Abstract
Primary out-of-hospital cardiac arrest in childhood is rare but survival is a little better for children than for adults, although the prognosis for infants is very poor. Hypoxic-ischaemic encephalopathy after in-hospital cardiac arrest in children undergoing complicated treatment for previously untreatable conditions is now a common problem and is probably increasing. An additional ischaemic insult worsens the prognosis for other encephalopathies, such as that occurring after accidental or non-accidental head injury. For near-drowning, the prognosis is often good, provided that cardiopulmonary resuscitation (CPR) is commenced immediately, and the child gasps within 40 minutes of rescue and regains consciousness soon afterwards. The prognosis is much worse for the nearly drowned child admitted to casualty or the emergency room deeply unconscious with fixed dilated pupils, requiring continuing CPR and with an arterial pH <7, especially if there is little recovery by the time of admission to the intensive care unit. The use of adrenaline, sodium bicarbonate and calcium appears to worsen prognosis. Neurophysiology, specifically serial electroencephalography and evoked potentials, is the most useful tool prognostically, although neuroimaging and biomarkers may play a role. In a series of 89 patients studied after cardiac arrest in three London centres between 1982 and 1985, 39% recovered consciousness within one month. Twenty seven percent died a cardiac death whilst in coma, and the outcome in the remainder was either brain death or vegetative state. EEG and initial pH were the best predictors of outcome in this study. Seizures affected one third and were associated with deterioration and worse outcome. The advent of extracorporeal membrane oxygenation (ECMO) and the positive results of hypothermia trials in neonates and adults have rekindled interest in timely management of this important group of patients.
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Guidelines for the determination of brain death in infants and children: An update of the 1987 Task Force recommendations*. Crit Care Med 2011; 39:2139-55. [DOI: 10.1097/ccm.0b013e31821f0d4f] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Schlunt ML, Wang L. Hypothermia and pediatric cardiac arrest. J Emerg Trauma Shock 2011; 3:277-81. [PMID: 20930973 PMCID: PMC2938494 DOI: 10.4103/0974-2700.66533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 04/24/2010] [Indexed: 12/27/2022] Open
Abstract
The survival outcome following pediatric cardiac arrest still remains poor. Survival to hospital discharge ranges anywhere from 0 to 38% when considering both out-of-hospital and in-hospital arrests, with up to 50% of the survivors having neurologic injury. The use of mild induced hypothermia has not been definitively proven to improve outcomes following pediatric cardiac arrest. This may be due to the lack of consensus regarding target temperature, best method of cooling, optimal duration of cooling and identifying the patient population who will receive the greatest benefit. We review the current applications of induced hypothermia in pediatric patients following cardiac arrest after searching the current literature through Pubmed and Ovid journal databases. We put forth compiled recommendations/guidelines for initiating hypothermia therapy, its maintenance, associated monitoring and suggested adjunctive therapies to produce favorable neurologic and survival outcomes.
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Affiliation(s)
- Michelle L Schlunt
- Department of Anesthesiology, Loma Linda University School of Medicine, California, USA
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Inamasu J, Nakatsukasa M, Suzuki M, Miyatake S. Therapeutic hypothermia for out-of-hospital cardiac arrest: an update for neurosurgeons. World Neurosurg 2011; 74:120-8. [PMID: 21300001 DOI: 10.1016/j.wneu.2010.02.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 02/20/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Neurosurgeons have been familiar with the idea that hypothermia is protective against various types of brain injuries, including traumatic brain injury (TBI). Recent randomized controlled trials, however, have failed to demonstrate the efficacy of therapeutic hypothermia (TH) in patients with TBI. On the other hand, TH becomes popular in the treatment of out-of-hospital cardiac arrest (OHCA) survivors, after randomized controlled trials have shown that survival rate and functional outcome is improved with the use of TH in selected patients. We believe that knowledge on the recent progress in TH for OHCA is useful for neurosurgeons, because feedback of information obtained in the treatment of OHCA may revitalize the interest in TH for neurosurgical disorders, particularly TBI. METHODS A review of the literature was conducted with the use of PubMed. RESULTS Various cooling techniques and devices have been developed and trialed in the treatment of OHCA survivors, including prehospital cooling with bolus ice-cold saline, endovascular cooling catheters, and new generation surface cooling devices, some of which have already been known to neurosurgeons. The efficacy of these new methods and devices has been demonstrated in many preliminary studies, and phase III trials are also expected. CONCLUSIONS Neurosurgeons and critical care medicine physicians pursue the same goal of rescuing the brain from the secondary injury despite the difference in etiology (focal trauma vs. global ischemia), with the presumption that earlier and faster implementation of TH will result in better outcome. Thoughtful application of knowledge and techniques obtained in OHCA to TBI under a rigorously controlled situation will make a small, but significant difference in the outcome of TBI victims.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan.
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Abstract
PURPOSE OF REVIEW Severe traumatic brain injury (TBI) is the most common cause of death and disability in pediatric trauma. This review looks at the strategies to treat TBI in a temporal fashion. We examine the targets for resuscitation from field triage to definitive care in the pediatric ICU. RECENT FINDINGS Guidelines for the management of pediatric TBI exist. The themes of contemporary clinical research have been compliance with these guidelines and refinement of treatment recommendations developing a more sophisticated understanding of the pathophysiology of the injured brain. In the field, the aim has been to achieve routine compliance with the resuscitation goals. In the hospital, efforts have been directed at improving our ability to monitor the injured brain, developing techniques that limit brain swelling, and customizing brain perfusion. SUMMARY As our understanding of pediatric TBI evolves, the ambition is that age-specific and perhaps individual brain injury strategies based upon feedback from continuous monitors will be defined. In addition, vogue methods such as hypothermia, hypertonic saline, and aggressive surgical decompression may prove to impact brain swelling and outcomes.
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Mencía S, Berroya A, López-Herce J, Botrán M, Urbano J, Carrillo A. [Effects of induced hypothermia in critically ill children]. Med Intensiva 2010; 34:363-9. [PMID: 20207445 DOI: 10.1016/j.medin.2010.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 01/14/2010] [Accepted: 01/17/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the efficacy of induced hypothermia (IH) in children, its effect on hemodynamic, hematological, and biochemical parameters and its side effects. DESIGN Retrospective, observational study. SETTING Pediatric intensive care unit. PATIENTS Pediatric patients requiring induced hypothermia. INTERVENTIONS None. DATA COLLECTED The following variables were recorded prior to the initiation of IH and after 4, 24, 48, 72, and 120 hours: heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), diuresis, dose of inotropic, sedative, and muscle relaxant drugs, fluid balance, hematocrit, white cell count, white cell differential percentages, platelet count, blood levels of glucose, sodium, and potassium, C reactive protein, lactate, coagulation times, pressure ulcers, shivering, infections and death. RESULTS Thirty-one patients with a mean age of 20 months (SD: 39.8) were included in the study. The mean duration of IH was 3.97 days (range: 1 to 11 days). Among the IH effects, there was a significant fall in heart rate, with no changes in SBP, DBP, or diuresis. The blood tests revealed a progressive and significant fall in platelet count and an increase in C reactive protein levels. The fall in hematocrit and glucose and lactate levels was not significant. Positive cultures were detected in 25.8% of the patients during IH, most commonly from the bronchial aspirate (65%). CONCLUSIONS Induced hypothermia can be useful in some critically ill children. Tolerance is generally good and there are usually few side effects, which can be controlled through appropriate monitoring.
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Affiliation(s)
- S Mencía
- Sección de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España.
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Abstract
OBJECTIVE Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. DESIGN Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007). SETTING A rural, level I trauma center. PATIENTS One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days. CONCLUSIONS Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.
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Willson DF, Dean JM, Meert KL, Newth CJL, Anand KJS, Berger J, Harrison R, Zimmerman J, Carcillo J, Pollack M, Holubkov R, Jenkins TL, Nicholson C. Collaborative pediatric critical care research network: looking back and moving forward. Pediatr Crit Care Med 2010; 11:1-6. [PMID: 19794321 PMCID: PMC3293213 DOI: 10.1097/pcc.0b013e3181c01302] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To update the pediatric critical care community on the progress of the Collaborative Pediatric Critical Care Research Network and plans for the future. SETTING The six sites, seven hospitals of the Collaborative Pediatric Critical Care Research Network. RESULTS From the time of its inception in August 2005, the Network has engaged in a number of observational and interventional trials, several of which are ongoing. Additional studies are in the planning stages. To date, these studies have resulted in the publication of six manuscripts and five abstracts, with five additional manuscripts accepted and in press. CONCLUSION The Network remains committed to its stated goal "to initiate a multicentered program designed to investigate the safety and efficacy of treatment and management strategies to care for critically ill children, as well as the pathophysiologic basis of critical illness and injury in childhood."
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Affiliation(s)
- Douglas F Willson
- Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, VA, USA.
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Abstract
PURPOSE OF REVIEW The field of pediatric cardiac arrest experienced recent advances secondary to multicenter collaborations. This review summarizes developments during the last year and identifies areas for further research. RECENT FINDINGS A large retrospective review demonstrated important differences in cause, severity, and outcome of in-hospital vs. out-of-hospital pediatric cardiac arrest. This distinction is relevant to interpretation of retrospective studies that may not distinguish between these entities, and in planning therapeutic clinical trials. Hypothermia was further evaluated as a treatment strategy after neonatal hypoxia and leaders in the field of neonatology recommend universal use of hypothermia in term neonates at risk. In infants and children after cardiac arrest, there are inadequate data to make a specific recommendation. Two retrospective studies evaluating hypothermia in children after cardiac arrest found that it tended to be administered more frequently to sicker patients. However, similar or worse outcomes of patients treated with hypothermia were observed. Use of extracorporeal membrane oxygenation is another emerging area of research in pediatric cardiac arrest, and surprisingly good outcomes have been seen with this modality in some cases. SUMMARY Therapeutic hypothermia and extracorporeal membrane oxygenation continue to be the only treatment modalities over and above conventional care for pediatric cardiac arrest. New approaches to monitoring, treatment, and rehabilitation after cardiac arrest remain to be explored.
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Abstract
Therapeutic hypothermia for 12 to 24 hrs following resuscitation from out-of-hospital cardiac arrest is now recommended by the American Heart Association for the treatment of neurological injury when the initial cardiac rhythm is ventricular fibrillation. However, the role of therapeutic hypothermia is uncertain when the initial cardiac rhythm is asystole or pulseless electrical activity, or when the cardiac arrest is primarily due to a noncardiac cause, such as asphyxia or drug overdose. Given that survival rate in these latter conditions is very low, it is unlikely that clinical trials will be undertaken to test the efficacy of therapeutic hypothermia in this setting because of the very large sample size that would be required to detect a significant difference in outcomes. Therefore, in patients with anoxic brain injury after nonventricular fibrillation cardiac arrest, clinicians will need to balance the possible benefit of therapeutic hypothermia with the possible side effects of this therapy. Given that the side effects of therapeutic hypothermia are generally easily managed in the critical care setting, and there is benefit for anoxic brain injury demonstrated in laboratory studies, consideration may be given to treat comatose post-cardiac arrest patients with therapeutic hypothermia in this setting. Because the induction of therapeutic hypothermia has become more feasible with the development of simple intravenous cooling techniques and specialized equipment for improved temperature control in the critical care unit, it is expected that therapeutic hypothermia will become more widely used in the management of anoxic neurological injury whatever the presenting cardiac rhythm.
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Doherty DR, Parshuram CS, Gaboury I, Hoskote A, Lacroix J, Tucci M, Joffe A, Choong K, Farrell R, Bohn DJ, Hutchison JS. Hypothermia therapy after pediatric cardiac arrest. Circulation 2009; 119:1492-500. [PMID: 19273725 DOI: 10.1161/circulationaha.108.791384] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypothermia therapy improves mortality and functional outcome after cardiac arrest and birth asphyxia in adults and newborns. The effect of hypothermia therapy in infants and children with cardiac arrest is unknown. METHODS AND RESULTS A 2-year, retrospective, 5-center study was conducted, and 222 patients with cardiac arrest were identified. Seventy-nine (35.6%) of these patients met eligibility criteria for the study (age >40 weeks postconception and <18 years, cardiac arrest >3 minutes in duration, survival for > or = 12 hours after return of circulation, and no birth asphyxia). Twenty-nine (36.7%) of these 79 patients received hypothermia therapy and were cooled to 33.7+/-1.3 degrees C for 20.8+/-11.9 hours. Hypothermia therapy was associated with higher mortality (P=0.009), greater duration of cardiac arrest (P=0.005), more resuscitative interventions (P<0.001), higher postresuscitation lactate levels (P<0.001), and use of extracorporeal membrane oxygenation (P<0.001). When adjustment was made for duration of cardiac arrest, use of extracorporeal membrane oxygenation, and propensity scores by use of a logistic regression model, no statistically significant differences in mortality were found (P=0.502) between patients treated with hypothermia therapy and those treated with normothermia. Also, no differences in hypothermia-related adverse events were found between groups. CONCLUSIONS Hypothermia therapy was used in resuscitation scenarios that are associated with greater risk of poor outcome. In an adjusted analysis, the effectiveness of hypothermia therapy was neither supported nor refuted. A randomized controlled trial is needed to rigorously evaluate the benefits and harms of hypothermia therapy after pediatric cardiac arrest.
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Affiliation(s)
- Dermot R Doherty
- Department of Anaesthesia, Division of Pediatric Intensive Care, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
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Fink EL, Beers SR, Russell ML, Bell MJ. Acute brain injury and therapeutic hypothermia in the PICU: A rehabilitation perspective. J Pediatr Rehabil Med 2009; 2:309-19. [PMID: 21791822 PMCID: PMC3235956 DOI: 10.3233/prm-2009-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Acquired brain injury from traumatic brain injury, cardiac arrest (CA), stroke, and central nervous system infection is a leading cause of morbidity and mortality in the pediatric population and reason for admission to inpatient rehabilitation. Therapeutic hypothermia is the only intervention shown to have efficacy from bench to bedside in improving neurological outcome after birth asphyxia and adult arrhythmia-induced CA, thought to be due to its multiple mechanisms of action. Research to determine if therapeutic hypothermia should be applied to other causes of brain injury and how to best apply it is underway in children and adults. Changes in clinical practice in the hospitalized brain-injured child may have effects on rehabilitation referral practices, goals and strategies of therapies offered, and may increase the degree of complex medical problems seen in children referred to inpatient rehabilitation.
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Affiliation(s)
- Ericka L. Fink
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Faculty Pavilion, 2nd floor, Pittsburgh, PA, USA
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh, Oxford Building, Rm. 724, Pittsburgh, PA, USA
| | - Mary Louise Russell
- Department of Children’s Rehabilitation Services, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, 2nd floor, Pittsburgh, PA, USA
| | - Michael J. Bell
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Faculty Pavilion, 2nd floor, Pittsburgh, PA, USA
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