Publications by authors named "Cindy Darnell-Bowens"

7 Publications

  • Page 1 of 1

Outcomes of Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis.

Crit Care Med 2021 04;49(4):682-692

University of Texas Southwestern Medical Center, Dallas, TX.

Objective: The goal of this work is to provide insight into survival and neurologic outcomes of pediatric patients supported with extracorporeal cardiopulmonary resuscitation.

Data Sources: A systematic search of Embase, PubMed, Cochrane, Scopus, Google Scholar, and Web of Science was performed from January 1990 to May 2020.

Study Selection: A comprehensive list of nonregistry studies with pediatric patients managed with extracorporeal cardiopulmonary resuscitation was included.

Data Extraction: Study characteristics and outcome estimates were extracted from each article.

Data Synthesis: Estimates were pooled using random-effects meta-analysis. Differences were estimated using subgroup meta-analysis and meta-regression. The Meta-analyses Of Observational Studies in Epidemiology guideline was followed and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation system. Twenty-eight studies (1,348 patients) were included. There was a steady increase in extracorporeal cardiopulmonary resuscitation occurrence rate from the 1990s until 2020. There were 32, 338, and 1,094 patients' articles published between 1990 and 2000, 2001 and 2010, and 2010 and 2020, respectively. More than 70% were cannulated for a primary cardiac arrest. Pediatric extracorporeal cardiopulmonary resuscitation patients had a 46% (CI 95% = 43-48%; p < 0.01) overall survival rate. The rate of survival with favorable neurologic outcome was 30% (CI 95% = 27-33%; p < 0.01).

Conclusions: The use of extracorporeal cardiopulmonary resuscitation is rapidly expanding, particularly for children with underlying cardiac disease. An overall survival of 46% and favorable neurologic outcomes add credence to this emerging therapy.
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April 2021

CPR during COVID-19: Use of Expert-driven Rapid Cycle Deliberate Practice to Implement PALS Guidelines.

Pediatr Qual Saf 2021 Jan-Feb;6(1):e374. Epub 2020 Dec 28.

Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Tex.

The American Heart Association (AHA) and other national institutions have endorsed modifications to resuscitation guidelines given the risk of healthcare workers' (HCWs) exposure to COVID-19. Institutional implementation of the COVID-19-focused guidelines requires both proof of feasibility and education of HCW. Pediatric critical care medical directors at The University of Texas Southwestern/Children's Health System of Texas (UTSW/CHST) created a guideline for the resuscitation of COVID-19 patients. The simulation team used in situ simulation to demonstrate guideline feasibility and to create educational materials.

Methods: A UTSW/CHST guideline incorporated COVID-19-focused AHA and other national organizational recommendations to fit the institutional needs. A high-fidelity in situ simulation helped test the feasibility and optimize the UTSW/CHST guideline. We developed a novel form of rapid cycle deliberate practice (RCDP), expert-driven RCDP, in which all simulation participants are experts, to debrief the simulation.

Results: In situ simulation with expert-driven RCDP demonstrated guideline feasibility in the resuscitation of a COVID-19 patient while balancing the protection of HCW. Expert-driven RCDP allowed for real-time alterations to the guideline during the simulation event. Video recording and dissemination of the simulation allowed for the education of over 300 staff on the new recommendations.

Conclusions: High-fidelity in situ simulation with expert-driven RCDP created a rapid consensus among expert critical care providers to develop the UTSW/CHST guideline and quickly adopt the new AHA recommendations. This debriefing method helped minimize the risk of HCW exposure by minimizing the number of required participants and time for simulation. We recommend using this distinctive, expert-driven RCDP debriefing method for expeditious testing of COVID-19-focused processes at other institutions. [link forthcoming].
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December 2020

Coagulation Profile Is Not a Predictor of Acute Cerebrovascular Events in Pediatric Extracorporeal Membrane Oxygenation Patients.

ASAIO J 2017 Nov/Dec;63(6):793-801

From the *Department of Pediatrics, Critical Care Division, University of Texas Southwestern Medical Center, Dallas, Texas; †Department of Pediatrics, Hematology-Oncology Division, University of Texas Southwestern Medical Center, Dallas, Texas; ‡Department of Pediatrics, Critical Care Division, University of Texas Health Science Center at Houston, Houston, Texas; §Department of Pediatrics, Neurology Division, University of Texas Southwestern Medical Center, Dallas, Texas; and ¶Trauma Services Children's Health Dallas, Dallas, Texas.

We performed a retrospective matched case-control study evaluating whether the traditional coagulation profile predicts cerebrovascular events in children on extracorporeal membrane oxygenation (ECMO) in a 71 bed intensive care unit at a tertiary children's hospital. Between 2009 and 2014, 241 neonates and children were initiated on ECMO. The cumulative 5 year incidence of intracranial hemorrhage and infarct was 9.2% and 7.9%, respectively. Thirty-six cases were individually matched 1:1 with control subjects based on age, primary diagnosis, ECMO type, cannulation site, and the presence of pre-ECMO coagulopathy. In-hospital mortality was higher among the cases compared with control subjects (78 vs. 22%, p < 0.01). The median laboratory values that assisted with heparin anticoagulation monitoring (activated clotting time, partial thromboplastin time, and antifactor Xa) and the laboratory data that assisted with blood product administration (platelet count, prothrombin time, fibrinogen, and d-dimer) during the 24 and 72 hour periods before the cerebrovascular event did not show any significant difference between the hemorrhage group and their controls or between the infarct group and their controls. The traditional coagulation profile did not predict acute cerebrovascular events in our cohort. Other markers of neurologic injury on ECMO are yet to be elucidated. Prospective studies to determine better predictors of cerebrovascular complications in pediatric ECMO patients are required.
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May 2018

Reducing Fresh Tracheostomy Decannulations Following Implementation of a Fresh Tracheostomy Guideline.

Crit Care Nurs Clin North Am 2017 Jun 22;29(2):131-141. Epub 2017 Mar 22.

Critical Care Division, Pediatrics, PICU, Children's Health, Children's Medical Center Dallas, 1935 Medical District Drive, Dallas, TX 75235, USA.

Pediatric patients undergoing tracheostomy placement are often medically fragile with multiple comorbidities. The complexity of these patients partnered with the risks of a newly placed tracheostomy necessitates a clear understanding of patient management and clinical competence. At our institution, a quality improvement initiative was formed with a focus on increasing the safety of these patients by developing a postoperative care guideline.
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June 2017

Successful engraftment after hematopoietic stem cell transplantation with infusion of donor stem cells through the extracorporeal membrane oxygenation circuit.

Indian J Crit Care Med 2016 Oct;20(10):617-619

Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern/Children's Health Dallas, TX, USA.

Wiskott-Aldrich syndrome (WAS) is a rare X-linked primary immunodeficiency due to mutations in the WAS gene expressed in hematopoietic cells. Hematopoietic stem cell transplantation (HSCT) is the treatment of choice when an appropriate human leukocyte antigen-matched donor is available. The use of the extracorporeal membrane oxygenation (ECMO) circuit to infuse donor cells for HSCT has not been previously published in the literature. We describe a case of a child who had successful engraftment after HSCT with infusion of the donor stem cells through the ECMO circuit.
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October 2016

A retrospective study of sedation and analgesic requirements of pediatric patients on extracorporeal membrane oxygenation (ECMO) from a single-center experience.

Perfusion 2017 Apr 11;32(3):183-191. Epub 2016 Oct 11.

1 Department of Pediatrics, Critical Care Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Introduction: The purpose of this study is to describe the sedative and analgesic requirements identifying factors associated with medication escalation in neonates and children supported on ECMO.

Method: Observational retrospective cohort study in a tertiary pediatric intensive care unit from June 2009 to June 2013.

Results: One hundred and sixty patients were included in the study. Fentanyl and midazolam were the first line agents used while on ECMO. Higher opiate requirements were associated with younger age (p=0.01), thoracic cannulation (p=0.002), the use of dexmedetomidine (p=0.007) and prolonged use of muscle relaxants (p=0.03). Higher benzodiazepine requirements were associated with younger age (p=0.01), respiratory failure (p=0.02) and the use of second line agents (p=0.002). One third of the patients required second line agents as adjuvants for comfort without a decrease in opiate and/or benzodiazepine requirements.

Conclusions: Providing comfort to subpopulations of pediatric ECMO patients seems to be more challenging. The use of second line agents did not improve comfort in our cohort. Prospective studies are required to optimize analgesia and sedation management in children on ECMO.
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April 2017