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Zhang H, Li G, Li Q, Zuo Y, Wang Q. Clinical characteristics and outcomes of patients who underwent neonatal cardiac surgery: ten years of experience in a tertiary surgery center. Eur J Med Res 2024; 29:144. [PMID: 38409131 PMCID: PMC10895745 DOI: 10.1186/s40001-024-01735-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE To evaluate the outcomes after neonatal cardiac surgery at our institute, and identify factors associated with operative mortality. METHODS We examined 224 neonates who underwent cardiac surgery at a single institution from 2013 to 2022. Relevant data, such as demographic information, operative details, and postoperative records, were gathered from medical and surgical records. Our primary focus was on the operative mortality. RESULTS Median age and weight at surgery were 12 (7-20) days and 3.4 (3.0-3.8) kg, respectively. Overall mortality was 14.3% (32/224). Mortality rates showed improvement over time (2013-2017 vs. 2018-2022), with rates decreasing from 21.9% to 10.6% (p = 0.023). ECMO use, extubation failure, lactate > 4.8 mmol/l and VIS > 15.5 on 24 h after operation were significantly associated with operative mortality, according to multivariate logistic regression analysis. Patients admitted to the cardiac intensive care unit (CICU) before surgery and those with prenatal diagnosis showed lower operative mortality. Median follow-up time of 192 hospital survivors was 28.0 (11.0-62.3) months. 10 patients experienced late deaths, and 7 patients required reinterventions after neonatal cardiac surgery. Risk factors for composite end-point of death and reintervention on multivariable analysis were: surgical period (HR = 0.230, 95% CI 0.081-0.654; p = 0.006), prolonged ventilation (HR = 4.792, 95% CI 1.296-16.177; p = 0.018) and STAT categories 3-5 (HR = 5.936, 95% CI 1.672-21.069; p = 0.006). CONCLUSIONS Our institution has observed improved surgical outcomes in neonatal cardiac surgery over the past five years with low mortality, but late death and reintervention remain necessary in some patients. The location and prenatal diagnosis prior to surgery may affect the outcomes of neonates undergoing congenital heart disease operations.
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Affiliation(s)
- Han Zhang
- Beijing Anzhen Hospital, Capital Medical University, 2 Anding Road, Beijing, 100029, China
| | - Gang Li
- Beijing Anzhen Hospital, Capital Medical University, 2 Anding Road, Beijing, 100029, China
| | - Qiangqiang Li
- Beijing Anzhen Hospital, Capital Medical University, 2 Anding Road, Beijing, 100029, China
| | - Yansong Zuo
- Beijing Anzhen Hospital, Capital Medical University, 2 Anding Road, Beijing, 100029, China
| | - Qiang Wang
- Beijing Anzhen Hospital, Capital Medical University, 2 Anding Road, Beijing, 100029, China.
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2
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Shentu J, Shi G, Zhang Q, Wen C, Zhang H, Zhu Z, Chen H. Surgical repair of neonatal total anomalous pulmonary venous connection: A single institutional experience with 241 cases. JTCVS OPEN 2023; 16:739-754. [PMID: 38204647 PMCID: PMC10774983 DOI: 10.1016/j.xjon.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 01/12/2024]
Abstract
Objective Challenges persist in surgery for neonatal total anomalous pulmonary venous connection (neoTAPVC), with the high mortality risk not mitigated over time. Methods A prospectively collected single-center database containing all neonates with TAPVC undergoing biventricular repair in 2012 to 2020 was retrospectively reviewed. The primary outcome was death or postoperative pulmonary venous obstruction (PPVO). Based on the preoperative admission location in our hospital, patients were classified into those being admitted to cardiac intensive care unit versus neonatal intensive care unit or general pediatric intensive care unit. Access to dedicated presurgical care (DPC) was defined as patients who were preoperatively admitted to the cardiac intensive care unit. Results Overall, 241 patients with a median age at surgery of 14 days (interquartile range [IQR], 9-21 days) were included. Anomalous return was supracardiac in 38.6%, cardiac in 26.1%, infracardiac in 28.6%, and mixed in 6.6%. Patients receiving DPC had better survival (96.3% vs 84.3%; P = .0028) and lower incidence of PPVO (15.2% vs 28.6%; P = .011) compared with those without DPC. Patients in the DPC group were less likely to undergo operation within 24 hours on presentation (27.1% vs 40.3%; P = .041), had improved lactate clearance (1.5 [IQR, 1.0-2.2] vs 2.8 [IQR, 1.8-4.1]; P < .001), and had lower incidence of postoperative pulmonary hypertension crisis (2.8% vs 18.7%; P < .001) compared with those in no-DPC group. After matching, no difference in PPVO could be observed in patients undergoing conventional versus sutureless repair (22.6% vs 12.9%; P = .29). Conclusions Access to DPC potentially improves outcomes in the neoTAPVC setting; freedom from PPVO were similar using conventional versus sutureless repair.
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Affiliation(s)
- Jin Shentu
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guocheng Shi
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qian Zhang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chen Wen
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Zhang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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3
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Myers AL, Fussell JJ, Moffatt ME, Boyer D, Ross R, Dammann CEL, Degnon L, Weiss P, Sauer C, Vinci RJ. The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children. J Pediatr 2023:13365. [PMID: 36894130 DOI: 10.1016/j.jpeds.2023.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. 65 Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. 66 The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. 67 In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.
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Affiliation(s)
- Angela L Myers
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Jill J Fussell
- Professor, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR
| | - Mary E Moffatt
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Debra Boyer
- DIO/Chief Medical Education Officer, Professor of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Robert Ross
- Children's Hospital of Michigan, Professor of Pediatrics, Central Michigan University College of Medicine, Detroit, MI
| | | | | | - Pnina Weiss
- Professor of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Cary Sauer
- Professor of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Robert J Vinci
- Professor of Pediatrics, Boston University School of Medicine, Boston, MA
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4
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Cardiovascular Critical Care in Children. Pediatr Clin North Am 2022; 69:403-413. [PMID: 35667753 DOI: 10.1016/j.pcl.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pediatric cardiac critical care has evolved with advances in congenital heart surgery, interventional cardiac catheterization, and diagnostic advances. Debate remains over the optimal location of care and training background despite data showing that systems established in collaboration with multidisciplinary experts in the care of children with congenital heart disease are associated with the best outcomes. Operative mortality is low, and preventing morbidity is the new focus of the future. Advances in screening and fetal diagnosis, mechanical circulatory support, and collaborative research and quality improvement initiatives are reviewed in this article.
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5
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Levy PT, Thomas AR, Wethall A, Perez D, Steurer M, Ball MK. Rethinking Congenital Heart Disease in Preterm Neonates. Neoreviews 2022; 23:e373-e387. [PMID: 35641458 DOI: 10.1542/neo.23-6-e373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Congenital heart disease (CHD) and prematurity are the leading causes of infant mortality in the United States. Importantly, the combination of prematurity and CHD results in a further increased risk of mortality and significant morbidity. The key factors in these adverse outcomes are not well understood, but likely include maternal-fetal environment, perinatal and neonatal elements, and challenging postnatal care. Preterm neonates with CHD are born with "double jeopardy": not only do they experience challenges related to immaturity of the lungs, brain, and other organs, but they also must undergo treatment for cardiac disease. The role of the neonatologist caring for preterm infants with CHD has changed with the evolution of the field of pediatric cardiac critical care. Increasingly, neonatologists invested in the cardiovascular care of the newborn with CHD engage at multiple stages in their course, including fetal consultation, delivery room management, preoperative care, and postoperative treatment. A more comprehensive understanding of prematurity and CHD may inform clinical practice and ultimately improve outcomes in preterm infants with CHD. In this review, we discuss the current evidence surrounding neonatal and cardiac outcomes in preterm infants with CHD; examine the prenatal, perinatal, and postnatal factors recognized to influence these outcomes; identify knowledge gaps; consider research and clinical opportunities; and highlight the ways in which a neonatologist can contribute to the care of preterm infants with CHD.
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Affiliation(s)
- Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Ashley Wethall
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Danielle Perez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Martina Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA.,Department of Epidemiology and Biostatistics, California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH
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6
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Goldshtrom N, Vasquez AM, Chaves DV, Bateman DA, Kalfa D, Levasseur S, Torres AJ, Bacha E, Krishnamurthy G. Outcomes after neonatal cardiac surgery: The impact of a dedicated neonatal cardiac program. J Thorac Cardiovasc Surg 2022; 165:2204-2211.e4. [PMID: 35927084 DOI: 10.1016/j.jtcvs.2022.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/26/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Prematurity is a risk factor for in-hospital mortality after cardiac surgery. The structure of intensive care unit models designed to deliver optimal care to neonates including those born preterm with critical congenital heart disease is unknown. The objective of this study was to evaluate in-hospital outcomes after cardiac surgery across gestational ages in an institution with a dedicated neonatal cardiac program. METHODS This study is a single-center, retrospective review of infants who underwent cardiac surgical interventions from our dedicated neonatal cardiac intensive care program between 2006 and 2017. We evaluated in-hospital mortality and morbidity rates across all gestational ages. RESULTS A total of 1238 subjects met inclusion criteria over a 11-year period. Overall in-hospital mortality after cardiac surgery was 6.1%. The mortality rate in very preterm infants (n = 68; <34 weeks' gestation at birth) was 17.6% (odds ratio, 3.52 [1.4-8.53]), versus 4.3% in full-term (n = 563; 39-40 weeks) referent/control infants. Very preterm infants with isolated congenital heart disease (without evidence of other affected organ systems) experienced a mortality rate of 10.5% after cardiac surgery. Neither the late preterm (34-36 6/7 weeks) nor the early term (37-38 6/7) groups had significantly increased odds of mortality compared with full-term infants. Seventy-eight percent of very preterm infants incurred a preoperative or postoperative complication (odds ratio, 4.78 [2.61-8.97]) compared with 35% of full-term infants. CONCLUSIONS In this study of a single center with a dedicated neonatal cardiac program, we report some of the lowest mortality and morbidity rates after cardiac surgery in preterm infants in the recent era. The potential survival advantage of this model is most striking for very preterm infants born with isolated congenital heart disease.
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7
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Hamrick SEG, Ball MK, Rajgarhia A, Johnson BA, DiGeronimo R, Levy PT. Integrated cardiac care models of neonates with congenital heart disease: the evolving role of the neonatologist. J Perinatol 2021; 41:1774-1776. [PMID: 34140645 DOI: 10.1038/s41372-021-01117-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/04/2021] [Accepted: 05/20/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Shannon E G Hamrick
- Division of Neonatology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Molly K Ball
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ayan Rajgarhia
- Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Beth Ann Johnson
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Philip T Levy
- Department of Pediatrics, Harvard Medical School and Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
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8
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Abstract
Congenital heart disease is a major public health concern in the United States. Outcomes of surgery for children with congenital heart disease have dramatically improved over the last several decades with current aggregate operative mortality rates approximating 3%, inclusive of all ages and defects. However, there remains significant variability among institutions, especially for higher-risk and more complex patients. As health care moves toward the quadruple aim of improving patient experience, improving the health of populations, lowering costs, and increasing satisfaction among providers, congenital heart surgery programs must evolve to meet the growing scrutiny, demands, and expectations of numerous stakeholders. Improved outcomes and reduced interinstitutional variability are achieved through prioritization of quality assurance and improvement.
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Affiliation(s)
- Timothy W Pettitt
- Department of Pediatric Cardiovascular Surgery, Children's Hospital of New Orleans, New Orleans, LA.,Department of Surgery, Louisiana State University Health Science Center, New Orleans, LA
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9
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Séguéla PE, Jalal Z, Thambo JB. Impact of dedicated perioperative care in neonatal cardiac surgery. J Thorac Dis 2019; 11:S223-S225. [PMID: 30997182 DOI: 10.21037/jtd.2019.02.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Pierre-Emmanuel Séguéla
- Pediatric and Congenital Cardiology Unit, Bordeaux University Hospital, Bordeaux, France.,IHU Lyric, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, F-33600 Pessac, France
| | - Zakaria Jalal
- Pediatric and Congenital Cardiology Unit, Bordeaux University Hospital, Bordeaux, France.,IHU Lyric, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, F-33600 Pessac, France
| | - Jean-Benoit Thambo
- Pediatric and Congenital Cardiology Unit, Bordeaux University Hospital, Bordeaux, France.,IHU Lyric, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, F-33600 Pessac, France
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10
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Wheeler DS, Dewan M, Maxwell A, Riley CL, Stalets EL. Staffing and workforce issues in the pediatric intensive care unit. Transl Pediatr 2018; 7:275-283. [PMID: 30460179 PMCID: PMC6212383 DOI: 10.21037/tp.2018.09.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Maxwell
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carley L Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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11
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Johnson JT, Wilkes JF, Menon SC, Tani LY, Weng HY, Marino BS, Pinto NM. Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery. J Thorac Cardiovasc Surg 2018; 155:2606-2614.e5. [PMID: 29550071 DOI: 10.1016/j.jtcvs.2018.01.100] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/26/2017] [Accepted: 01/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. METHODS We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. RESULTS Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. CONCLUSIONS Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery.
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Affiliation(s)
- Joyce T Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill.
| | - Jacob F Wilkes
- Intermountain Healthcare, Pediatric Clinical Program, Salt Lake City, Utah
| | - Shaji C Menon
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah at Primary Children's Hospital, Salt Lake City, Utah
| | - Lloyd Y Tani
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah at Primary Children's Hospital, Salt Lake City, Utah
| | - Hsin-Yi Weng
- Study Design and Biostatistics Center, University of Utah, School of Medicine, Salt Lake City, Utah
| | - Bradley S Marino
- Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nelangi M Pinto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah at Primary Children's Hospital, Salt Lake City, Utah
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12
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Bhaskar P, Rettiganti M, Gossett JM, Gupta P. Impact of intensive care unit attending physician training background on outcomes in children undergoing heart operations. Ann Pediatr Cardiol 2018; 11:48-55. [PMID: 29440830 PMCID: PMC5803977 DOI: 10.4103/apc.apc_99_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: The existing training pathways to become a pediatric cardiac intensivist are very variable with physicians coming from varied training backgrounds of pediatric critical care, pediatric cardiology, neonatology, or pediatric anesthesia. Aim: To evaluate the impact of cardiac Intensive Care Unit (ICU) attending physician training background on outcomes in children undergoing heart operations. Setting and Design: Patients in the age group from 1 day to 18 years undergoing heart operation at a Pediatric Health Information System database participating hospital were included (2010–2015). Patients and Methods: Based on the training background of majority of attending physicians in an ICU, the participating ICUs were divided into three groups: critical care medicine (CCM), cardiology, and indeterminate. Statistical Analysis: Multivariable logistic regression models were fitted to evaluate the association of ICU physician training background with study outcomes. Results: A total of 54,935 patients from 42 ICUs were included. Of these, 31,815 patients (58%) were treated in the CCM group (26 ICUs), 19,340 patients (35%) were treated in the cardiology group (12 ICUs), and 3780 patients (7%) were treated in the indeterminate group (4 ICUs). In adjusted models, no specific group based on ICU attending physician training background was associated with lower mortality (CCM vs. cardiology, odds ratio: 0.75, 95% confidence interval: 0.48–1.18), or lower incidence of cardiac arrest, or prolonged hospital length of stay, or prolonged mechanical ventilation. Conclusions: This large observational study did not demonstrate any impact of ICU attending training background on outcomes in children undergoing heart operations.
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Affiliation(s)
- Priya Bhaskar
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Mallikarjuna Rettiganti
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Jeffrey M Gossett
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Punkaj Gupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
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13
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Association of Freestanding Children's Hospitals With Outcomes in Children With Critical Illness. Crit Care Med 2017; 44:2131-2138. [PMID: 27513535 DOI: 10.1097/ccm.0000000000001961] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness. DESIGN Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score. SETTING Retrospective study from an existing national database, Virtual PICU Systems (LLC) database. PATIENTS Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p < 0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p < 0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p < 0.001; reintubation: 3.4% vs 3.8%, p < 0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001). CONCLUSIONS In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.
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14
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Carlo WF, Cnota JF, Dabal RJ, Anderson JB. Practice trends over time in the care of infants with hypoplastic left heart syndrome: A report from the National Pediatric Cardiology Quality Improvement Collaborative. CONGENIT HEART DIS 2017; 12:315-321. [PMID: 28121380 DOI: 10.1111/chd.12442] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 09/29/2016] [Accepted: 11/23/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) was established in 2008 to improve outcomes of hypoplastic left heart syndrome (HLHS) during the interstage period. They evaluated changes in patient variables and practice variation between early and late eras. DESIGN Data including demographic, operative, discharge, and follow-up variables from the first 100 patients (6/2008-1/2010) representing 18 centers were compared with the most recent 100 patients (1/2014-11/2014) from these same centers. RESULTS Prenatal diagnosis increased from 69% to 82% (P = .05). There were no differences in gestational age or weight at Norwood. A composite of any preoperative risk factor occurred more frequently in the early era (59% vs. 34%, P < .01). While mean age at Norwood was similar (8.3 vs. 6.6 days, P = .2), the standard deviation was significantly lower in the recent era (10.4-6.4 days, P = .04). Use of RV-PA conduit increased (67%-84%, P < .01). Rates of complete discharge communication with both the primary care physician (31%-97%, P < .01) and primary cardiologist (44%-97%, P < .01) increased substantially. There were limited changes in feeding strategies. Use of home monitoring program increased (76%-99%, P < .01) with all participants in the late era monitoring both oxygen saturation and weight. CONCLUSIONS Among NPC-QIC centers contributing patients to both eras, there were significant changes in preoperative risk factors, surgical strategy, discharge communication, and interstage care. Further study is required to determine an association between these changes and decreased mortality.
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Affiliation(s)
- Waldemar F Carlo
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - James F Cnota
- The Heart Institute, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Robert J Dabal
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
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Risk factors and outcomes of in-hospital cardiac arrest following pediatric heart operations of varying complexity. Resuscitation 2016; 105:1-7. [DOI: 10.1016/j.resuscitation.2016.04.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/05/2016] [Accepted: 04/25/2016] [Indexed: 11/22/2022]
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16
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Gupta P, Rettiganti M, Jeffries HE, Brundage N, Markovitz BP, Scanlon MC, Simsic JM. Association of 24/7 In-House Intensive Care Unit Attending Physician Coverage With Outcomes in Children Undergoing Heart Operations. Ann Thorac Surg 2016; 102:2052-2061. [PMID: 27324525 DOI: 10.1016/j.athoracsur.2016.04.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/05/2016] [Accepted: 04/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multicenter data regarding the around-the-clock (24/7) presence of an in-house critical care attending physician with outcomes in children undergoing cardiac operations are limited. METHODS Patients younger than 18 years of age who underwent operations (with or without cardiopulmonary bypass [CPB]) for congenital heart disease at 1 of the participating intensive care units (ICUs) in the Virtual PICU Systems (VPS, LLC) database were included (2009-2014). The study population was divided into 2 groups: the 24/7 group (14,737 patients; 32 hospitals), and the No 24/7 group (10,422 patients; 22 hospitals). Propensity-score matching was performed to match patients 1:1 in the 24/7 group and in the No 24/7 group. RESULTS Overall, 25,159 patients from 54 hospitals qualified for inclusion. By propensity matching, 9,072 patients (4,536 patient pairs) from 51 hospitals were matched 1:1 in the 2 groups. After matching, mortality at ICU discharge was lower among the patients treated in hospitals with 24/7 coverage (24/7 versus No 24/7, 2.8% versus 4.0%; p = 0.002). The use of extracorporeal membrane oxygenation (ECMO), the incidence of cardiac arrest, extubation within 48 hours after operation, the rate of reintubation, and the duration of arterial line and central venous line use after operation were significantly improved in the 24/7 group. When stratified by surgical complexity, survival benefits of 24/7 coverage persisted among patients undergoing both high-complexity and low-complexity operations. CONCLUSIONS The presence of 24-hour in-ICU attending physician coverage in children undergoing cardiac operations is associated with improved outcomes, including ICU mortality. It is possible that 24-hour in-ICU attending physician coverage may be a surrogate for other factors that may bias the results. Further study is warranted.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Mallikarjuna Rettiganti
- Section of Biostatistics, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Howard E Jeffries
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | | | - Barry P Markovitz
- Virtual PICU Systems, LLC, Los Angeles, California; Division of Critical Care Medicine, Department of Pediatrics and Anesthesiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Matthew C Scanlon
- Virtual PICU Systems, LLC, Los Angeles, California; Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Janet M Simsic
- Division of Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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17
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Nishijima DK, Monuteaux MC, Faraoni D, Goobie SM, Lee L, Galante J, Holmes JF, Kuppermann N. Tranexamic Acid Use in United States Children's Hospitals. J Emerg Med 2016; 50:868-874.e1. [PMID: 27017532 DOI: 10.1016/j.jemermed.2016.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/13/2016] [Accepted: 02/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of tranexamic acid (TXA) use for trauma and other conditions in children is unknown. OBJECTIVES The objective of this study was to describe the use of TXA in United States (US) children's hospitals for children in general, and specifically for trauma. METHODS We conducted a secondary analysis of a large, administrative database of 36 US children's hospitals. We included children <18 years of age who received TXA (based on pharmacy charge codes) between 2009 and 2013. Patients were grouped into the following diagnostic categories: trauma, congenital heart surgery, scoliosis surgery, craniosynostosis/craniofacial surgery, and other, based on the International Classification of Diseases, Ninth Revision principal procedure and diagnostic codes. TXA administration and dosage, in-hospital clinical variables, and diagnostic and procedure codes were documented. RESULTS A total of 35,478 pediatric encounters with a TXA charge were included in the study cohort. The proportions of children who received TXA were similar across the years 2009 to 2013. Only 110 encounters (0.31%) were for traumatic conditions. Congenital heart surgery accounted for more than one-half of the encounters (22,863; 64%). Overall, the median estimated weight-based dose of TXA was 22.4 mg/kg (interquartile range, 7.3-84.9 mg/kg). CONCLUSIONS We identified a wide frequency of use and range of doses of TXA for several diagnostic conditions in children. The use of TXA among injured children, however, appears to be rare despite its common use and efficacy among injured adults. Additional work is needed to identify appropriate indications for TXA and provide dosage guidelines among children with a variety of conditions, including trauma.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Michael C Monuteaux
- Division of Pediatric Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lois Lee
- Division of Pediatric Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph Galante
- Division of Trauma and Emergency Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, California
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California
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Gupta P, Rettiganti M, Gossett JM, Yeh JC, Jeffries HE, Rice TB, Wetzel RC. Risk factors for mechanical ventilation and reintubation after pediatric heart surgery. J Thorac Cardiovasc Surg 2016; 151:451-8.e3. [DOI: 10.1016/j.jtcvs.2015.09.080] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/08/2015] [Accepted: 09/12/2015] [Indexed: 11/25/2022]
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Gupta P, Rettiganti M. Association Between Extracorporeal Membrane Oxygenation Center Volume and Mortality Among Children With Heart Disease: Propensity and Risk Modeling. Pediatr Crit Care Med 2015; 16:868-74. [PMID: 26536546 DOI: 10.1097/pcc.0000000000000557] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To evaluate the relationship between extracorporeal membrane oxygenation center volume and mortality in children undergoing heart operations using propensity score matching in a multiinstitutional cohort. DESIGN Post hoc analysis of data from an existing national database, Pediatric Health Information System. Propensity score matching was performed to 1-1-1 match patients in low-volume (0-30 cases per year), medium-volume (31-50 cases per year), and high-volume (> 50 cases per year) categories. We tested the sensitivity of our findings by repeating the primary analyses using traditional statistical techniques (traditional regression-based methods and covariate adjustment using propensity score). SETTING Forty-two children's hospitals across the Unites States. PATIENTS Patients 18 years old or younger receiving extracorporeal membrane oxygenation before or after pediatric heart operation at a Pediatric Health Information System participating hospital (2004-2013) were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 3,502 from 42 hospitals qualified for inclusion. Using propensity score matching, 1,962 patients were matched 1-1-1 to compare the three volume categories (654 patients in each category). Overall mortality was 1,493 patients (43%). Before matching and adjustment, low- and medium-volume centers were associated with higher mortality (low versus high volume: unadjusted odds ratio, 1.99; 95% CI, 1.68-2.36; p < 0.001). After matching, there was no significant association between center volume and mortality in unadjusted and adjusted analyses (low versus high volume: unadjusted odds ratio, 1.06; 95% CI, 0.85-1.32; p = 0.62 and adjusted odds ratio, 0.97; 95% CI, 0.63-1.50; p = 0.90). This relationship remained similar for analyses using traditional statistical techniques (regression adjustment, low versus high volume: adjusted odds ratio, 1.23; 95% CI, 0.80-1.89; p = 0.35 and covariate adjustment using propensity score, low versus high volume: adjusted odds ratio, 1.16; 95% CI, 0.77-1.74; p = 0.49). CONCLUSIONS We demonstrated no relationship between extracorporeal membrane oxygenation center volume and mortality. Further analyses are needed to evaluate this relationship.
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Affiliation(s)
- Punkaj Gupta
- 1Division of Pediatrics, Department of Pediatrics, Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR. 2Biostatistics Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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