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Abdelhadi RA, Bouma S, Bairdain S, Wolff J, Legro A, Plogsted S, Guenter P, Resnick H, Slaughter-Acey JC, Corkins MR. Characteristics of Hospitalized Children With a Diagnosis of Malnutrition. JPEN J Parenter Enteral Nutr 2016; 40:623-35. [DOI: 10.1177/0148607116633800] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/21/2016] [Indexed: 12/17/2022]
Affiliation(s)
| | - Sandra Bouma
- University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | | | - Jodi Wolff
- Rainbow Babies and Children’s Hospital, Solon, Ohio, USA
| | - Amanda Legro
- Miller Children’s and Women’s Hospital, Long Beach, California, USA
| | | | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Helaine Resnick
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Jaime C. Slaughter-Acey
- College of Nursing & Health Professions School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Mark R. Corkins
- University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Hehir DA, Easley RB, Byrnes J. Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia. World J Pediatr Congenit Heart Surg 2016; 7:199-209. [PMID: 26957404 DOI: 10.1177/2150135115615847] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.
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Affiliation(s)
- David A Hehir
- Nemours Cardiac Center, AI Dupont Hospital for Children, Thomas Jefferson Medical College, Philadelphia, PA, USA
| | - R Blaine Easley
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jonathan Byrnes
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Current outcomes of the bi-directional cavopulmonary anastomosis in single ventricle patients: analysis of risk factors for morbidity and mortality, and suitability for Fontan completion. Cardiol Young 2016; 26:288-97. [PMID: 25704070 DOI: 10.1017/s1047951115000153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The bi-directional cavopulmonary anastomosis forms an essential staging procedure for univentricular hearts. This review aims to identify risk factors for morbidity, mortality, and suitability for Fontan completion. METHODS A total of 114 patients undergoing cavopulmonary anastomosis between 1992 and 2012 were reviewed to assess primary - mortality and survival to Fontan completion - and secondary outcome endpoints - re-intubation, new drain, and ICU stay. Median age and weight were 8 months and 6.9 kg, respectively. In 83% of patients, 1-3 interventions had preceded. Norwood-type procedures became more prevalent over time. RESULTS Extubation occurred after a median of 4 hours, median ICU stay was 2 days; 10 patients (8.8%) needed re-intubation and 18 received a new drain. Higher central venous pressure and transpulmonary gradient were risk factors for new drain insertion (p<0.01). Higher pre-operative pulmonary pressure correlated with increased inotropic support and prolonged intubation (p=0.01). Need for re-intubation was significantly affected by younger age at operation (p=0.01). Hospital and pre-Fontan mortality were 11.4 and 5.3%, respectively. Operative mortality was independently affected by younger age (p=0.013), lower weight (p=0.02), longer bypass time (p=0.04), and re-intubation (p=0.004). Interstage mortality was mainly influenced by moderate ventricular function (p=0.03); 82% of survivors underwent or are candidates for Fontan completion. CONCLUSION The cavopulmonary anastomosis remains associated with adverse outcomes. Age at operation decreases with rising prevalence of complex univentricular hearts. Considering the important impact of re-intubation on hospital mortality, peri-operative management should focus on optimising cardio-respiratory status. Once this selection step is taken, successful Fontan completion can be expected, provided that ventricular function is maintained.
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Ugonabo N, Hirsch-Romano JC, Uzark K. The role of home monitoring in interstage management of infants following the Norwood procedure. World J Pediatr Congenit Heart Surg 2015; 6:266-73. [PMID: 25870346 DOI: 10.1177/2150135114563771] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although outcomes for infants with complex single ventricle heart defects have steadily improved in recent decades, there is still a significant risk for mortality and morbidity during the interstage period between stage 1 Norwood hospitalization discharge and stage 2 palliation. Home monitoring programs, which involve parental surveillance of daily weight and oxygen saturations during the interstage period, have been shown to significantly improve survival rates. This article describes the potential risk factors or causes of interstage mortality and reviews the role of home monitoring in early detection and potential prevention of adverse outcomes.
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Affiliation(s)
- Nkem Ugonabo
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer C Hirsch-Romano
- Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI, USA
| | - Karen Uzark
- Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI, USA
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Oster ME, Ehrlich A, King E, Petit CJ, Clabby M, Smith S, Glanville M, Anderson J, Darbie L, Beekman RH. Association of Interstage Home Monitoring With Mortality, Readmissions, and Weight Gain: A Multicenter Study from the National Pediatric Cardiology Quality Improvement Collaborative. Circulation 2015; 132:502-8. [PMID: 26260497 DOI: 10.1161/circulationaha.114.014107] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 05/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Daily home monitoring of oxygen saturation and weight has been reported to improve outcomes for patients with single-ventricle heart disease during the period between stage I palliation and stage II palliation. However, these studies have been limited to single institutions and used historical control subjects. Our objective was to determine the association of various interstage home monitoring strategies with outcomes using a multicenter cohort with contemporary control subjects. METHODS AND RESULTS We performed a retrospective cohort study using prospectively collected data from the National Pediatric Cardiology Quality Improvement Collaborative from 2008 to 2012. We compared interstage mortality, unscheduled readmissions, and change in weight-for-age Z score for various home monitoring strategies of oxygen saturation (n=494) or weight (n=472), adjusting for sex, syndrome, tricuspid regurgitation, arch obstruction, and shunt type. Overall interstage mortality was 8.1%, and 47% had ≥1 unscheduled readmission. We did not find any associations of home oxygen saturation or weight monitoring with mortality or readmission. Although there was no difference in weight-for-age Z score for daily (0.33±0.12) versus weekly (0.34±0.18, P=0.98) weight monitoring, daily home weight monitoring was superior to no home weight monitoring (-0.15±0.18; P<0.01). CONCLUSIONS Home weight monitoring is associated with improved weight gain during the interstage period, but we did not find any benefits in other clinical outcomes for either home oxygen saturation monitoring or home weight monitoring.
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Affiliation(s)
- Matthew E Oster
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.).
| | - Alexandra Ehrlich
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Eileen King
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Christopher J Petit
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Martha Clabby
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Sherry Smith
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Michelle Glanville
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Jeffrey Anderson
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Lynn Darbie
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Robert H Beekman
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
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Hill GD, Hehir DA, Bartz PJ, Rudd NA, Frommelt MA, Slicker J, Tanem J, Frontier K, Xiang Q, Wang T, Tweddell JS, Ghanayem NS. Effect of feeding modality on interstage growth after stage I palliation: a report from the National Pediatric Cardiology Quality Improvement Collaborative. J Thorac Cardiovasc Surg 2014; 148:1534-9. [PMID: 24607373 DOI: 10.1016/j.jtcvs.2014.02.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/30/2013] [Accepted: 02/03/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Achieving adequate growth after stage 1 palliation for children with single-ventricle heart defects often requires supplemental nutrition through enteral tubes. Significant practice variability exists between centers in the choice of feeding tube. The impact of feeding modality on the growth of patients with a single ventricle after stage 1 palliation was examined using the multiinstitutional National Pediatric Cardiology Quality Improvement Collaborative data registry. METHODS Characteristics of patients were compared by feeding modality, defined as oral only, nasogastric tube only, oral and nasogastric tube, gastrostomy tube only, and oral and gastrostomy tube. The impact of feeding modality on change in weight for age z-score during the interstage period, from stage 1 palliation discharge to stage 2 palliation, was evaluated by multivariable linear regression, adjusting for important patient characteristics and postoperative morbidities. RESULTS In this cohort of 465 patients, all groups demonstrated improved weight for age z-score during the interstage period with a mean increase of 0.3±0.8. In multivariable analysis, feeding modality was not associated with differences in the change in weight for age z-score during the interstage period (P=.72). Risk factors for poor growth were a diagnosis of hypoplastic left heart syndrome (P=.003), vocal cord injury (P=.007), and lower target caloric goal at discharge (P=.001). CONCLUSIONS In this large multicenter cohort, interstage growth improved for all groups and did not differ by feeding modality. With appropriate caloric goals and interstage monitoring, adequate growth may be achieved regardless of feeding modality and therefore local comfort and complication risk should dictate feeding modality.
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Affiliation(s)
- Garick D Hill
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
| | - David A Hehir
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Peter J Bartz
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Michele A Frommelt
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Julie Slicker
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jena Tanem
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Katherine Frontier
- Division of Speech and Audiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Qun Xiang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - Tao Wang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
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