More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

Objective Children undergoing cardiac surgery with cardiopulmonary bypass (CPB) are susceptible to additional inflammatory and immunogenic insults from blood transfusions. We hypothesize that washing red blood cells (RBC) and platelets transfused to these patients will reduce post-operative transfusion-related immune modulation and inflammation. Design Prospective randomized controlled clinical trial. Setting University hospital pediatric cardiac intensive care unit. Patients Children from birth to 17 years old undergoing cardiac surgery with CPB. Interventions Children were randomized to an unwashed or washed RBC and platelet transfusion protocol for their surgery and postoperative care. All blood was leukoreduced, irradiated, and ABO identical. Plasma was obtained for laboratory analysis: pre-op, immediately, six and 12 hours after CPB. Primary outcome was the 12-hour post-CPB interleukin (IL)-6: IL-10 ratio. Secondary measures were IL levels, C-reactive protein (CRP), and clinical outcomes. Measurements and main results 162 subjects were studied, 81 per group. 34 subjects (17 per group) did not receive any blood transfusions. Storage duration of blood products was similar between groups. Among transfused subjects, the 12-hour IL ratio was significantly lower in the washed group (3.8 v. 4.8; p=0.04) secondary to lower IL-6 levels (post-CPB: 65 v.100 pg/ml; p = 0.06; 6 hour: 89 v.152 pg/ml; p = 0.02; 12-hour: 84 v.122 pg/ml; p = 0.09). Post-operative CRP was lower in subjects receiving washed blood (38 v. 43 mg/L; p = 0.03). There was a numerical, but not statistically significant decrease in total blood product transfusions (203 v. 260) and mortality (2 v. 6 deaths) in the washed group compared to the unwashed group. Conclusions Washed blood transfusions in cardiac surgery reduced inflammatory biomarkers, number of transfusions, donor exposures, and were associated with a non-significant trend towards reduced mortality. A larger study powered to test for clinical outcomes is needed to determine whether these laboratory findings are clinically significant.

Children with single-ventricle physiology do not benefit from a liberal transfusion strategy after cavopulmonary connection. A restrictive red blood cell transfusion strategy decreases the number of transfusions, donor exposures, and potential risks in these children. Larger studies with clinical outcome measures are needed to determine the transfusion threshold for children post cardiac repair or palliation for congenital heart disease.

Infants undergoing cardiac operation can be managed with a conservative RBC transfusion strategy. Clinical indications should help guide the decision for RBC transfusion even in this uniquely vulnerable population. Larger multicenter trials are needed to confirm these results, and focus on the highest risk patients would be of great interest.

The BIS monitor can be a useful monitoring guide for the titration of propofol by physicians who are competent in airway and hemodynamic management, to achieve deep sedation for children undergoing painful procedures.

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Objective To evaluate whether transfusion of cell saver salvaged, stored at the bedside for up to 24 hours, would decrease the number of post-operative allogeneic RBC transfusions and donor exposures, and possibly improve clinical outcomes. Design Prospective, randomized, controlled, clinical trial. Setting Pediatric cardiac intensive care unit. Patients Infants <20kg (n = 106) presenting for cardiac surgery with cardiopulmonary bypass. Interventions Subjects were randomized to a cell saver transfusion group where cell saver blood was available for transfusion up to 24 hours post-collection, or to a control group. Cell saver subjects received cell saver blood for volume replacement and/or RBC transfusions. Control subjects received crystalloid or albumin for volume replacement and RBCs for anemia. Blood product transfusions, donor exposures, and clinical outcomes were compared between groups. Measurements and Main Results Children randomized to the cell saver group had significantly fewer RBC transfusions (cell saver: 0.19 ± 0.44 v. control: 0.75 ± 1.2; p = 0.003) and coagulant product transfusions in the first 48 hours post-op (cell saver: 0.09 ± 0.45 v. control: 0.62 ± 1.4; p = 0.013), and significantly fewer donor exposures (cell saver: 0.60 ± 1.4 v. control: 2.3 ± 4.8; p =0.019). This difference persisted over the first week post-op, but did not reach statistical significance (cell saver: 0.64 ± 1.24 v. control: 1.1 ± 1.4; p =0.07). There were no significant clinical outcome differences. Conclusion Cell saver blood can be safely stored at the bedside for immediate transfusion for 24 hours post-collection. Administration of cell saver blood significantly reduces the number of RBC and coagulant product transfusions and donor exposures in the immediate post-operative period. Reduction of blood product transfusions has the potential to reduce transfusion-associated complications and decrease post-operative morbidity. Larger studies are needed to determine whether this transfusion strategy will improve clinical outcomes.

Educational GapClinicians need to recognize the signs and symptoms of dehydration to safely restore fluid and electrolytes.Objectives After completing this article, readers should be able to:1. Understand that the signs and symptoms of dehydration are related to changes in extracellular fluid volume.2. Recognize the different clinical and laboratory abnormalities in isonatremic, hyponatremic, and hypernatremic dehydration.3. Know how to manage isonatremic dehydration.4. Know how to manage hyponatremic dehydration.5. Know how to manage hypernatremic dehydration.6. Recognize how to avoid as well as treat complications of fluid and sodium repletion.7. Understand which patients are candidates for oral rehydration.8. Know the proper fluids and methods for oral rehydration.