The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

OBJECTIVES Hospitalized children are perceived to be increasingly medically complex, but no such trend has been documented. The objective of this study was to determine whether the proportion of pediatric inpatient use that is attributable to patients with a diagnosis of one or more complex chronic condition (CCC) has increased over time and to assess the degree to which CCC hospitalizations are associated with attributes that are consistent with heightened medical complexity. METHODS A retrospective observational study that used the 1997, 2000, 2003, and 2006 Kids Inpatient Databases examined US hospitalizations for children. Attributes of medical complexity included hospital admissions, length of stay, total charges, technology-assistance procedures, and mortality risk. RESULTS The proportion of inpatient pediatric admissions, days, and charges increased from 1997 to 2006 for any CCC and for every CCC group except hematology. CCCs accounted for 8.9% of US pediatric admissions in 1997 and 10.1% of admissions in 2006. These admissions used 22.7% to 26.1% of pediatric hospital days, used 37.1% to 40.6% of pediatric hospital charges, accounted for 41.9% to 43.2% of deaths, and (for 2006) used 73% to 92% of different forms of technology-assistance procedures. As the number of CCCs for a given admission increased, all markers of use increased. CONCLUSIONS CCC-associated hospitalizations compose an increasing proportion of inpatient care and resource use. Future research should seek to improve methods to identify the population of medically complex children, monitor their increasing inpatient use, and assess whether current systems of care are meeting their needs.

Survival among this cohort of adults with severe respiratory failure supported with ECMO was 50%. Advanced patient age, increased pre-ECMO ventilation duration, diagnosis category and complications while on ECMO were associated with mortality. Prospective studies are needed to evaluate the role of this complex support mode.

Background-Extracorporeal membrane oxygenation (ECMO) has been used to support cardiorespiratory function during pediatric cardiopulmonary resuscitation (CPR). We report on outcomes and predictors of in-hospital mortality after ECMO used to support CPR (E-CPR). Methods and Results-Outcomes for patients aged Ͻ18 years using E-CPR were analyzed with data from the Extracorporeal Life Support Organization, and predictors of in-hospital mortality were determined. Of 26 242 ECMO uses reported, 695 (2.6%) were for E-CPR (nϭ682 patients

Although the survival of pediatric patients with acute respiratory failure treated with extracorporeal membrane oxygenation has not changed, this treatment is currently offered to increasingly medically complex patients. Mechanical ventilation in excess of 2 wks before the initiation of extracorporeal membrane oxygenation is associated with decreased survival.

Object The aims of this study were to measure inpatient health care for pediatric hydrocephalus in the US; describe patient, hospital, and hospitalization characteristics for pediatric hydrocephalus inpatient care; and determine characteristics associated with death. Methods A cross-sectional study was performed using the 1997, 2000, and 2003 Healthcare Cost and Utilization Project Kids' Inpatient Databases (KID), nationally representative weighted data sets of hospital discharges for pediatric patients. A hydrocephalus-related hospitalization was classified as either cerebrospinal fluid (CSF) shunt–related (including initial placements, infections, malfunctions, or other) or non–CSF shunt–related. Patients > 18 years of age were excluded. The KID provided weighted estimates of 6.657, 6.597, and 6.732 million total discharges in the 3 study years. Results Each year there were 38,200–39,900 admissions, 391,000–433,000 hospital days, and total hospital charges of $1.4–2.0 billion for pediatric hydrocephalus. Hydrocephalus accounted for 0.6% of all pediatric hospital admissions in the US in 2003, but for 1.8% of all pediatric hospital days and 3.1% of all pediatric hospital charges. Over the study years, children admitted with hydrocephalus were older, had an increase in comorbidities, and were admitted more frequently to teaching hospitals. Compared with children who survived, those who died were more likely to be < 3 months of age and have a birth-related admission, have no insurance, have comorbidities, be transferred, and have a non–CSF shunt–related admission. Conclusions Children with hydrocephalus have a chronic illness and use a disproportionate share of hospital days and healthcare dollars in the US. Since 1997 they have increased in age and in number of comorbid conditions. For important changes in morbidity and mortality rates to be made, focused research efforts and funding are necessary.

No abstract

The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on "auto-resuscitation," we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.