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Hollander SA, Wujcik K, Schmidt J, Liu E, Lin A, Dykes J, Good J, Brown M, Rosenthal D. Home Milrinone in Pediatric Hospice Care of Children with Heart Failure. J Pain Symptom Manage 2023; 65:216-221. [PMID: 36417945 DOI: 10.1016/j.jpainsymman.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT The symptom profile of children dying from cardiac disease, especially heart failure, differs from those with cancer and other non-cardiac conditions. Treatment with vasoactive infusions at home may be a superior therapy for symptom control for these patients, rather than traditional pain and anxiety management with morphine and benzodiazepines. OBJECTIVES We report our experience using outpatient milrinone in children receiving hospice care for end-stage heart failure. METHODS Retrospective review of a contemporary cohort of all patients at Lucile Packard Children's Hospital, Stanford who were discharged on intravenous milrinone and hospice care between 2008 and 2021. Clinical data, including cardiac diagnosis, milrinone dose and route of administration, total milrinone days, symptoms reported, rehospitalization rates, concurrent therapies and complications were analyzed. RESULTS Among 8 patients, median duration of home milrinone infusion was 191 (33, 572) days with the longest support duration 1,054 days. All (100%) patients were also receiving diuretics at the time of death. Five (63%) were receiving no other pain control medications until the active phase of dying. From milrinone initiation to last outpatient assessment, a reduction in the number of patients reporting respiratory discomfort, abdominal pain, weight loss/lack of appetite, and fatigue was observed. Six (75%) died at home. CONCLUSION We used milrinone with oral diuretics effectively for symptom control in children with heart failure on palliative care. Our experience was that this combination can be used safely in the outpatient setting for long-term use without the addition of opiates, benzodiazepines, or supplemental oxygen in most cases.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA.
| | - Kari Wujcik
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Julie Schmidt
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Esther Liu
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Aileen Lin
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - John Dykes
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Julie Good
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - Michelle Brown
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
| | - David Rosenthal
- Department of Pediatrics (Cardiology) (S.A.H., J.D., D.R.), Stanford University, Palo Alto, California, USA; Solid Organ Transplant Services (K.W., J.S.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pediatric Pulmonary Hypertension Service (E.L.), Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA; Pulmonary Hypertension Service (A.L.), Stanford University, Palo Alto, California, USA; Department of Anesthesiology (J.G.), Perioperative and Pain Medicine (and by courtesy, Pediatrics), Stanford University, Palo Alto, California, USA; Departments of Psychiatry & Palliative Care (M.B.), Stanford University/, Palo Alto, California, USA
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Hamad A, Ng C, Alade K, D'Amico B, Morales-Perez L, Price J, Leung SK. Diagnosing Acute Heart Failure in the Pediatric Emergency Department Using Point-of-Care Ultrasound. J Emerg Med 2021; 61:e18-e25. [PMID: 34092442 DOI: 10.1016/j.jemermed.2021.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/23/2021] [Accepted: 03/17/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute heart failure (AHF) in children is associated with significant disease burden with high rates of morbidity, mortality, and resource utilization. These children often present to the emergency department with clinical features that mimic common childhood illnesses. Cardiac point-of-care ultrasound (POCUS) can be an effective tool for rapidly identifying abnormal cardiac function. CASE REPORTS This case series documents 10 children presenting with AHF between 2016 and 2019 and demonstrates how pediatric emergency physicians used cardiac POCUS to expedite their diagnosis, management, and disposition. All cardiac POCUS was performed before comprehensive echocardiograms were completed. One case is described in detail; the other cases are summarized in a Table. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition of AHF is critical to reduce pediatric morbidity and mortality. With proper training, cardiac POCUS can be an effective adjunct and should be considered for the early diagnosis and treatment of infants and children with AHF.
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Affiliation(s)
- Alia Hamad
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Carrie Ng
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Kiyetta Alade
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Beth D'Amico
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Liliana Morales-Perez
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jack Price
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Stephanie K Leung
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Ren M, Miller PC, Schlame M, Phoon CKL. A critical appraisal of the tafazzin knockdown mouse model of Barth syndrome: what have we learned about pathogenesis and potential treatments? Am J Physiol Heart Circ Physiol 2019; 317:H1183-H1193. [PMID: 31603701 DOI: 10.1152/ajpheart.00504.2019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pediatric heart failure remains poorly understood, distinct in many aspects from adult heart failure. Limited data point to roles of altered mitochondrial functioning and, in particular, changes in mitochondrial lipids, especially cardiolipin. Barth syndrome is a mitochondrial disorder caused by tafazzin mutations that lead to abnormal cardiolipin profiles. Patients are afflicted by cardiomyopathy, skeletal myopathy, neutropenia, and growth delay. A mouse model of Barth syndrome was developed a decade ago, which relies on a doxycycline-inducible short hairpin RNA to knock down expression of tafazzin mRNA (TAZKD). Our objective was to review published data from the TAZKD mouse to determine its contributions to our pathogenetic understanding of, and potential treatment strategies for, Barth syndrome. In regard to the clinical syndrome, the reported physiological, biochemical, and ultrastructural abnormalities of the mouse model mirror those in Barth patients. Using this model, the peroxisome proliferator-activated receptor pan-agonist bezafibrate has been suggested as potential therapy because it ameliorated the cardiomyopathy in TAZKD mice, while increasing mitochondrial biogenesis. A clinical trial is now underway to test bezafibrate in Barth syndrome patients. Thus the TAZKD mouse model of Barth syndrome has led to important insights into disease pathogenesis and therapeutic targets, which can potentially translate to pediatric heart failure.
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Affiliation(s)
- Mindong Ren
- Department of Anesthesiology, New York University School of Medicine, New York, New York.,Department of Cell Biology, New York University School of Medicine, New York, New York
| | - Paighton C Miller
- Department of Pediatrics, Division of Pediatric Cardiology, New York University School of Medicine, New York, New York
| | - Michael Schlame
- Department of Anesthesiology, New York University School of Medicine, New York, New York.,Department of Cell Biology, New York University School of Medicine, New York, New York
| | - Colin K L Phoon
- Department of Pediatrics, Division of Pediatric Cardiology, New York University School of Medicine, New York, New York
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