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Ash A, Ryerson L, Anand V, Conway J, Foshaug R, Slim G, Naimi I, Eckersley L. Use of a Postoperative Care Management Pathway Reduces the Incidence of Chylothorax Post-Fontan Palliation. Pediatr Cardiol 2024:10.1007/s00246-024-03494-w. [PMID: 38858264 DOI: 10.1007/s00246-024-03494-w] [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] [Received: 02/13/2024] [Accepted: 04/08/2024] [Indexed: 06/12/2024]
Abstract
Pleural effusions and chylothorax are challenging morbidities post-Fontan palliation. We sought to evaluate the efficacy of our Fontan Care Pathway (FCP) in reducing the incidence of post-operative chylothorax and Time to Chest Tube Removal (TTCTR), and to determine risk factors associated with longer TTCTR. Between 2016 and 2022 our institutional approach to post-Fontan care fell into three categories: Group 1 (n = 36): no standardized approach; Group 2 (n = 30): a prophylactic chylothorax diet (fat content < 5%); Group 3 (n = 57): the FCP (a chylothorax diet, fluid restriction, supplemental O2 and aggressive diuresis). The incidence of chylothorax and TTCTR was compared between groups. Predictors of TTCTR were analyzed using linear regression modelling, adjusting for covariates. Chylothorax rate decreased in Group 3 compared to Groups 1 and 2 (9% vs. 28% and 33% respectively, p = 0.011), without alteration in TTCTR. Univariate factors associated with median TTCTR included chylothorax (+ 13.7 days, p = 0.001), additional procedures at time of Fontan (+ 2.4 days per procedure p = 0.017), Fontan revision or takedown (+ 11.7 days, p = 0.018) and minor/major complications (+ 5.1, p = 0.01 and + 15.8, p < 0.001, respectively). On multivariable analysis, chylothorax (+ 6.5 days, p = 0.005) and major complications (+ 15.8 days, p = 0.001) were associated with increased TTCTR. When chylothorax was excluded from multivariable analysis, the FCP showed a significant decrease in TTCTR (- 3.3 days, p = 0.034). A bundled therapy approach was associated with reduced laboratory confirmed chylothorax post-Fontan, whereas diet change alone was not. Additional studies in this area, with larger sample sizes are warranted.
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Affiliation(s)
- Alanna Ash
- Department of Nursing, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada
- Division of Cardiology, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
| | - Lindsay Ryerson
- Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada
- Division of Critical Care, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
| | - Vijay Anand
- Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada
- Division of Critical Care, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
| | - Jennifer Conway
- Division of Cardiology, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
- Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada
| | - Rae Foshaug
- Division of Cardiology, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
| | - George Slim
- Division of Cardiology, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
- Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada
| | - Iman Naimi
- Division of Cardiology, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada
- Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada
| | - Luke Eckersley
- Division of Cardiology, Stollery Children's Hospital, 8440 112 Street, Edmonton, AB, T6G2B7, Canada.
- Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G1C9, Canada.
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Rahmath MRK, Bhat AN, Lone RA, Kamal RY. Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery. Asian Cardiovasc Thorac Ann 2024; 32:186-193. [PMID: 38659299 DOI: 10.1177/02184923241249198] [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] [Indexed: 04/26/2024]
Abstract
OBJECTIVE A single centre experience with chylothorax in post cardiac surgical patients. METHODS Retrospective review. RESULTS Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)]. SUMMARY In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.
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Affiliation(s)
| | - Akhlaque N Bhat
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reyaz A Lone
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reema Y Kamal
- Pediatric Cardiology, Pediatrics, Hamad Medical Corporation, Doha, Qatar
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Kerstein JS, Klepper CM, Finnan EG, Mills KI. Nutrition for critically ill children with congenital heart disease. Nutr Clin Pract 2023; 38 Suppl 2:S158-S173. [PMID: 37721463 DOI: 10.1002/ncp.11046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/19/2023] Open
Abstract
Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.
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Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| | - Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Emily G Finnan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
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Fogg KL, Trauth A, Horsley M, Vichayavilas P, Winder M, Bailly DK, Gordon EE. Nutritional management of postoperative chylothorax in children with CHD. Cardiol Young 2023; 33:1663-1671. [PMID: 36177859 DOI: 10.1017/s1047951122003109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Chylothorax after congenital cardiac surgery is associated with increased risk of malnutrition. Nutritional management following chylothorax diagnosis varies across sites and patient populations, and a standardised approach has not been disseminated. The aim of this review article is to provide contemporary recommendations related to nutritional management of chylothorax to minimise risk of malnutrition. METHODS The management guidelines were developed by consensus across four dietitians, one nurse practitioner, and two physicians with a cumulative 52 years of experience caring for children with CHD. A PubMed database search for relevant literature included the terms chylothorax, paediatric, postoperative, CHD, chylothorax management, growth failure, and malnutrition. RESULTS Fat-modified diets and nil per os therapies for all paediatric patients (<18 years of age) following cardiac surgery are highlighted in this review. Specific emphasis on strategies for treatment, duration of therapies, optimisation of nutrition including nutrition-focused lab monitoring, and supplementation strategies are provided. CONCLUSIONS Our deliverable is a clinically useful guide for the nutritional management of chylothorax following paediatric cardiac surgery.
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Affiliation(s)
- Kristi L Fogg
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Amiee Trauth
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Melissa Winder
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Erin E Gordon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX, USA
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Cox V, Hart S, Hersey D, Gauntt J, Carrillo S, McConnell P, Simsic J. Quality Report: Postoperative Guideline Implementation Reduces Length of Stay after Fontan Procedure. Pediatr Qual Saf 2023; 8:e661. [PMID: 38571741 PMCID: PMC10990373 DOI: 10.1097/pq9.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/10/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely. Methods We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions. Results One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86). Conclusion Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.
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Affiliation(s)
- Virginia Cox
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
| | - Stephen Hart
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
| | - Diane Hersey
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
| | - Jennifer Gauntt
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
| | - Sergio Carrillo
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
| | - Patrick McConnell
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
| | - Janet Simsic
- From The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio
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Linnane N, Kenny DP, Hijazi ZM. Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies. Expert Rev Cardiovasc Ther 2023; 21:329-336. [PMID: 37114439 DOI: 10.1080/14779072.2023.2208862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognising this risk and with the introduction risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced. AREA COVERED This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then novel low risk strategies are discussed for low weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed. EXPERT OPINION There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding inherent bias when assessing risk will be key to continuing this improvement.
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Affiliation(s)
- N Linnane
- Department of Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - D P Kenny
- Department of Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Royal College of Surgeons, Dublin, Ireland
| | - Z M Hijazi
- Department of Cardiovascular Diseases, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine, New York, NY, USA
- Jordan University, Amman, Jordan
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Heinisch PP, Metz P, Staehler H, Mayr B, Vodiskar J, Strbad M, Ruf B, Ewert P, Hager A, Hörer J, Ono M. Pleural and mediastinal effusions after the extracardiac total cavopulmonary connection: Risk factors and impact on outcome. Front Cardiovasc Med 2022; 9:1026445. [DOI: 10.3389/fcvm.2022.1026445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundThis study investigated the volume and duration of pleural and mediastinal effusions following extracardiac total cavopulmonary connection, as well as preoperative risk factors and their impact on outcome.Materials and methodsA total of 210 patients who underwent extracardiac total cavopulmonary connection at our center between 2012 and 2020 were included in this study. Postoperative daily amount of pleural and mediastinal drainage were collected and factors influencing duration and amount of effusions were analyzed. The impact of effusions on adverse events was analyzed.ResultsMedian age at extracardiac total cavopulmonary connection was 2.2 (interquartile range, 1.8–2.7) years with median weight of 11.6 (10.7–13.0) kg. Overall duration of drainage after extracardiac total cavopulmonary connection was 9 (6–17) days. The total volume of mediastinal, right pleural, and left pleural drainage was 18.8 (11.9–36.7), 64.4 (27.4–125.9), and 13.6 (0.0–53.5) mL/kg, respectively. Hypoplastic left heart syndrome (p = 0.004) and end-diastolic pressure (p = 0.044) were associated with high volume of drainages, and hypoplastic left heart syndrome (p = 0.007), presence of aortopulmonary collaterals (p = 0.002), and high end-diastolic pressure (p = 0.023) were associated with long duration of drainages. Dextrocardia was associated with higher volume (p < 0.001) and longer duration (p = 0.006) of left pleural drainage. Duration of drainage was associated with adverse events following extracardiac total cavopulmonary connection (p = 0.015).ConclusionVolume and duration of pleural and mediastinal effusions following extracardiac total cavopulmonary connection were related with hypoplastic left heart syndrome, aortopulmonary collaterals, and end-diastolic pressure. The duration of drainage for effusions was a risk factor for adverse events after total cavopulmonary connection.
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Gill K, Rivera E, Flores NO, AlAshi A, Rossi A, Sasaki J. Postoperative Inhaled Nitric Oxide Use and Early Outcomes after Fontan Surgery Completion. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1756308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
AbstractA considerable number of patients after the Fontan operation require prolonged hospitalization due to significant perioperative morbidities. The early postoperative morbidity can be attributed to elevated pulmonary vascular resistance. We hypothesized that the postoperative outcomes would improve with the routine use of inhaled nitric oxide (iNO) to decrease pulmonary vascular resistance. From January 2015 to November 2017 (Group 1), 37 patients underwent Fontan operation, and from December 2017 to December 2019 (Group 2), 34 patients underwent Fontan operation. All patients in Group 2 received iNO in the immediate perioperative period as part of a standardized postoperative pathway. There was no statistically significant difference in demographics or single ventricle subtype between the two groups. All patients underwent an extracardiac Fontan, and Group 2 had a higher number of fenestration (p< 0.01). Pre-Fontan hemodynamics showed no statistically significant difference in Glenn pressure, transpulmonary gradient, or systemic arterial and venous saturation. Both groups had a median length of stay of 13 days (p = 0.5), median chest tube placement of 7 days (p = 0.5), and there was no statistically significant difference in major complications. Readmission within 1 month of discharge occurred in five patients in Group 1 and six patients in Group 2 (p = 0.7). Routine use of iNO in the early postoperative period after Fontan operation did not reduce the length of stay, chest tube duration, rate of complications, or readmission.
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Affiliation(s)
- Kamalvir Gill
- Division of Cardiology, The Hospital for Sick Children, Toronto, Canada
| | - Estefania Rivera
- Department of Cardiology, Nicklaus Children's Hospital, Miami, Florida, United States
| | - Nicolas Ortiz Flores
- Department of Cardiology, Nicklaus Children's Hospital, Miami, Florida, United States
| | - Amro AlAshi
- Department of Pediatrics, Herbert Wertheim School of Medicine, Florida International University, Miami, Florida, United States
| | - Anthony Rossi
- Department of Cardiology, Nicklaus Children's Hospital, Miami, Florida, United States
| | - Jun Sasaki
- Division of Pediatric Critical Care Medicine and Pediatric Cardiology, Weill Cornell Medicine/New York-Presbyterian Komansky Children's Hospital, New York, United States
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Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD. Cardiol Young 2022; 32:1202-1209. [PMID: 35792060 DOI: 10.1017/s1047951122001871] [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: 11/06/2022]
Abstract
OBJECTIVE A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap. METHODS Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. "Consensus" was defined as ≥ 80% of responses as "agree" or "strongly agree" to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not. RESULTS The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for "low" and "high" volume patients, and timing and duration of fat-modified diet. All recommendations achieved "consensus" (agreement >80%) by the workgroup (range 81-100%). Ex vivo simulations demonstrated good understanding by developers (range 94-100%) and non-developers (73%-100%). CONCLUSIONS The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.
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Katz AJ, Lion RP, Martens T, Newcombe J, Razzouk A, Shih W, Amirnovin R, Gordon BM. Pediatric Surgical Pulmonary Valve Replacement Outcomes After Implementation of a Clinical Pathway. World J Pediatr Congenit Heart Surg 2022; 13:420-425. [PMID: 35757942 DOI: 10.1177/21501351221098127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Standardization of perioperative care can reduce resource utilization while improving patient outcomes. We sought to describe our outcomes after the implementation of a perioperative clinical pathway for pediatric patients undergoing elective surgical pulmonary valve replacement and compare these results to previously published national benchmarks. METHODS A retrospective single-center descriptive study was conducted of all pediatric patients who underwent surgical pulmonary valve replacement from 2017 through 2020, after the implementation of a clinical pathway. Outcomes included hospital length of stay and 30-day reintervention, readmission, and mortality. RESULTS Thirty-three patients (55% female, median age 11 [7, 13] years, 32 [23, 44] kg) were included in the study. Most common diagnosis and indication for surgery was Tetralogy of Fallot (61%) with pulmonary valve insufficiency (88%). All patients had prior cardiac surgery. Median hospital length of stay was 2 [2, 2] days, and longest length of stay was three days. There were no 30-day readmissions, reinterventions, or mortalities. Median follow-up time was 19 [9, 31] months. CONCLUSIONS Formalization of a perioperative surgical pulmonary valve replacement clinical pathway can safely promote short hospital length of stay without any short-term readmissions or reinterventions, especially when compared with previously published benchmarks. Such formalization enables the dissemination of best practices to other institutions to reduce hospital length of stay and limit costs.
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Affiliation(s)
- Alex J Katz
- Department of Pediatrics, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Richard P Lion
- Department of Pediatrics, Division of Critical Care, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Timothy Martens
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Jennifer Newcombe
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anees Razzouk
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Wendy Shih
- School of Public Health, 4608Loma Linda University, Loma Linda, CA, USA
| | - Rambod Amirnovin
- Department of Pediatrics, Division of Critical Care, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Brent M Gordon
- Department of Pediatrics, Division of Cardiology, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
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Abstract
A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.
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12
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Tran DD, Le TN, Dang VHT, Vo HL. Predictors of Prolonged Pleural Effusion After the Extracardiac Fontan Procedure: A 8-Year Single-Center Experience in Resource-Scare Setting. Pediatr Cardiol 2021; 42:89-99. [PMID: 32970244 DOI: 10.1007/s00246-020-02457-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
To date, despite improvement in survival rate following a Fontan operation, postoperative prolonged pleural effusion (PPE) has still remained a confounding complication of this procedure, which significantly contributes to morbidity and prolonged hospitalization. Our study aims to investigate risk factors associated with PPE after the extracardiac Fontan operation. From August 2012 to December 2019, we obtained clinical data from the medical records of 145 consecutive patients who were diagnosed with single-ventricle lesions and received an extracardiac Fontan operation at the E Hospital (Hanoi, Vietnam). PPE was defined as the need for a chest tube for > 14 days. Patients were divided into two groups, those with PPE (n = 29, 20.00%) and those without PPE (n = 116, 80.00%). During the pre-Fontan evaluation, significant differences between two groups were observed in PPE (p = 0.00), chylothorax (p = 0.045), pleurodesis (p = 0.045), position of thoracic and abdominal organs (p = 0.018), atrioventricular (AV) valve regurgitation (p = 0.030), and large aortapulmonary circulation (p = 0.041). During the Fontan evaluation, significant differences among two groups were seen in aortic cross-clamp time (p = 0.04), cardiopulmonary bypass time (p = 0.014), and mean pulmonary artery pressure (PAP) at Fontan (p = 0.0072). In multivariable analysis with logistic regression, a reduced model including independent predictors for PPE was found to be the NYHA class III (OR 4.93, 95% CI 1.19-20.50, p = 0.028), double-outlet right ventricle (DORV) with transposition of great arteries (TGA) (OR 31.00, 95% CI 1.35-711.63, p = 0.032), AV valve regurgitation (OR 70.73, 95% CI 3.28-1523.28, p = 0.007), ventricle-to-pulmonary artery shunt (OR 8.29, 95% CI 1.60-42.78, p = 0.012), PAI (OR 0.98, 95% CI 0.97-0.99, p = 0.002) at pre-Fontan, while, at Fontan, high PAP (OR 1.24, 95% CI 1.01-1.53, p = 0.046) was an independent predictor for PPE. In conclusion, the incidence of PPE was relatively low. The NYHA class III, primary anatomical diagnosis of DORV with TGA, pre-Fontan AV valve regurgitation, the existence of pre-Fontan ventricle-to-pulmonary artery shunt, low pulmonary artery index (PAI), and high PAP in the operation were identified as independent risk factors to predict PPE following a Fontan operation. As prior studies also investigated various risk factors influencing PPE, a preventive strategy that targets these factors combined with previous identified other risk factors might reduce the PPE incidence.
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Affiliation(s)
- Dai Dac Tran
- Cardiovascular Center, E Hospital, Hanoi, 100000, Vietnam.,School of Medicine and Pharmacy, Vietnam National University, Hanoi, 100000, Vietnam
| | - Thanh Ngoc Le
- Cardiovascular Center, E Hospital, Hanoi, 100000, Vietnam.,School of Medicine and Pharmacy, Vietnam National University, Hanoi, 100000, Vietnam
| | - Van Hai Thi Dang
- Department of Pediatrics, Hanoi Medical University, Hanoi, 100000, Vietnam.,National Children's Hospital, Hanoi, 100000, Vietnam
| | - Hoang-Long Vo
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam.
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13
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Abstract
INTRODUCTION The Fontan procedure is the final stage of surgical palliation for the children with functionally single ventricle anatomy. The post-operative medical management of this patient population can be variable and hospital length of stay prolonged. The purpose of this quality improvement project was to determine if the implementation of an evidence-based clinical pathway for post-operative management of the Fontan patient at a large Midwestern academic paediatric medical centre would standardise care and decrease length of stay. MATERIALS AND METHODS The clinical pathway was developed using key components from three published pathways for the Fontan procedure from other paediatric institutions across the United States. Components of the clinical pathway included (1) supplemental oxygen until pleural drainage tubes are removed, (2) fluid restriction to 80% daily maintenance and a prescribed low-fat diet, (3) aggressive and standardised diuretic therapy while inpatient and (4) central venous access. The pathway was trialed using Plan-Do-Study-Act cycles in 2016, implemented in 2017 and sustained in 2018-2019. A retrospective electronic medical record review was performed to compare key outcomes from pre-pathway (2014-2015, 37 patients) with post-pathway implementation (2017-2018, 30 patients). RESULTS Adherence to the pathway was nearly 100% with a statistically significant decrease in length of stay from 12 to 9 days (p = 0.007) and no increase in readmissions. CONCLUSION Standardising care can improve clinical and financial outcomes for the Fontan patient population without negatively impacting quality of care, thus providing a positive benefit to the healthcare institution, industry and patient.
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14
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Ergün S, Yıldız O, Ayyıldız P, Çilsal E, Öztürk E, Onan İS, Güzeltaş A, Haydin S. Parameters affecting pleural drainage and management strategy after Fontan operation. J Card Surg 2020; 35:1556-1562. [DOI: 10.1111/jocs.14691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Servet Ergün
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
- Vocational School of Health Services Istanbul Aydın Universty Istanbul Turkey
| | - Okan Yıldız
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Pelin Ayyıldız
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Erman Çilsal
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - İsmihan Selen Onan
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Alper Güzeltaş
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Sertaç Haydin
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
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15
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Cantinotti M, Giordano R, Marchese P, Franchi E, Viacava C, Pak V, Murzi B, Arcieri L, Poli V, Federici D, Koestenberger M, Assanta N. Retrosternal Clots After Fontan Surgery by Systematic Evaluation With Transthoracic Ultrasound. J Cardiothorac Vasc Anesth 2020; 34:951-955. [DOI: 10.1053/j.jvca.2019.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/01/2019] [Accepted: 11/08/2019] [Indexed: 11/11/2022]
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16
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Prophylactic Opening of the Pleural Cavity for Postoperative Drainage is a Risk Factor for Prolonged Pleural Effusion After a Fontan Operation. Pediatr Cardiol 2019; 40:1609-1617. [PMID: 31468062 DOI: 10.1007/s00246-019-02194-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
Postoperative prolonged pleural effusion (PPE) remains a confounding problem after a Fontan operation. We aimed to describe the risk factors for PPE after a Fontan operation and to clarify the impact of prophylactic opening of the pleural cavity (POPC) for drainage tube insertion on PPE. We retrospectively reviewed the medical charts of 50 consecutive patients who underwent a Fontan operation at our institution. POPC for postoperative drainage was performed based on each surgeon's preference. Patients were divided into three groups for analysis: group A (n = 12), no opening; group B (n = 14), unilateral opening; and group C (n = 24), bilateral opening. At the time of surgery, the median age of our patient group was 26 months, with a median body weight of 10.5 kg. The volume of pleural effusion tended to be lower in group A than in groups B and C (p = 0.08). The median duration of drainage was significantly shorter (p = 0.03) in group A (3 days) than in group B (4 days) or C (5 days). Overall, 12 patients required chest tube drainage for ≥ 7 days. Multivariate analysis revealed POPC (p = 0.01) and postoperative water balance (p = 0.03) as independent predictors of PPE. POPC and postoperative water balance are risk factors for PPE after a Fontan operation. Therefore, avoiding POPC for postoperative drainage may reduce the risk of postoperative pleural effusion and morbidities associated with PPE after a Fontan operation.
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17
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Koski TK, Suominen PK, Raissadati A, Knihtilä HM, Ojala TH, Salminen JT. The effect of sildenafil on pleural and peritoneal effusions after the TCPC operation. Acta Anaesthesiol Scand 2019; 63:1384-1389. [PMID: 31271655 DOI: 10.1111/aas.13431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/21/2019] [Accepted: 06/15/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND We evaluated whether the administration of sildenafil in children undergoing the TCPC operation shortened the interval from the operation to the removal of the pleural and peritoneal drains. METHODS We retrospectively reviewed the data of 122 patients who had undergone the TCPC operation between 2004 and 2014. Patients were divided into two groups on the basis of their treatments. Sildenafil was orally administered pre-operatively in the morning of the procedure or within 24 hours after the TCPC operation to the sildenafil group (n = 48), which was compared to a control group (n = 60). Fourteen patients were excluded from the study. RESULTS The primary outcome measure was the time from the operation to the removal of the drains. The study groups had similar demographics. The median [interquartile range] time for the removal of drains (sildenafil group 11 [8-19] vs control group 11 [7-16] d, P = .532) was comparable between the groups. The median [interquartile range] fluid balance on the first post-operative day was significantly higher (P = .001) in the sildenafil group compared with controls (47 [12-103] vs 7 [-6-67] mL kg-1 ). The first post-operative day fluid balance was a significant predictor for a prolonged need for drains in the multivariate analysis. CONCLUSIONS Sildenafil administration, pre-operatively or within 24 hours after the TCPC operation, did not reduce the required time for pleural and peritoneal drains but was associated with a significantly higher positive fluid balance.
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Affiliation(s)
- Tapio K. Koski
- Department of Anesthesia and Intensive Care Children's Hospital, Helsinki University Hospital Helsinki Finland
| | - Pertti K. Suominen
- Department of Anesthesia and Intensive Care Children's Hospital, Helsinki University Hospital Helsinki Finland
| | - Alireza Raissadati
- Faculty of Medicine University of Helsinki Helsinki Finland
- Department of Pediatric Cardiology Children's Hospital, Helsinki University Hospital Helsinki Finland
| | | | - Tiina H. Ojala
- Faculty of Medicine University of Helsinki Helsinki Finland
- Department of Pediatric Cardiology Children's Hospital, Helsinki University Hospital Helsinki Finland
| | - Jukka T. Salminen
- Department of Pediatric Cardiac Surgery Children's Hospital, Helsinki University Hospital Helsinki Finland
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18
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Predicted clinical factors associated with the intensive care unit length of stay after total cavopulmonary connection. J Thorac Cardiovasc Surg 2019; 157:2005-2013.e3. [DOI: 10.1016/j.jtcvs.2018.10.144] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 11/23/2022]
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19
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Ono M, Georgiev S, Burri M, Mayr B, Cleuziou J, Strbad M, Balling G, Hager A, Hörer J, Lange R. Early extubation improves outcome following extracardiac total cavopulmonary connection. Interact Cardiovasc Thorac Surg 2019; 29:85-92. [DOI: 10.1093/icvts/ivz010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/28/2018] [Accepted: 01/03/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to investigate the impact of an early extubation strategy on the outcome following extracardiac total cavopulmonary connection.
METHODS
From 1999 through 2017, 458 patients underwent extracardiac total cavopulmonary connection; 257 (56%) patients were managed with an early extubation strategy adopted in 2009 (group A). Their outcome was compared with those of 201 (44%) patients treated before 2009 (group B). In group A, the outcome of unstable patients, defined as >75th percentile for volume administered and inotrope scores, was compared with those of stable patients.
RESULTS
Ventilation time (median: 4 h vs 16 h, P < 0.001), fluid volume administered during the first 24 h (mean: 110 ml/kg vs 164 ml/kg, P = 0.003), chest tube duration (median: 3 days vs 4 days, P = 0.028) and length of intensive care unit stay (median: 6 days vs 7 days, P = 0.001) were less in group A than in group B. The reintubation rate (7% vs 6%, P = 0.547) and early mortality (0.8% vs 1.5%, P = 0.465) were similar between groups. The 80 unstable group A patients received more inotropic support (P < 0.001) and fluid volume (P < 0.001) than stable patients, but the ventilation time (6 h vs 5 h, P = 0.220), the reintubation rate (10% vs 6%, P = 0.283) and the length of intensive care unit stay (7 days vs 6 days, P = 0.590) were similar. In unstable patients, mean arterial pressure before extubation was significantly lower than stable patients (P = 0.001). However, mean arterial pressure in unstable patients increased significantly (P < 0.001) soon after extubation, and became similar to the value in stable patients.
CONCLUSIONS
Early extubation following extracardiac total cavopulmonary connection improves postoperative haemodynamics and recovery regardless of the initial haemodynamic status.
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Affiliation(s)
- Masamichi Ono
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Stanimir Georgiev
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Technische Universität München, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Benedikt Mayr
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Martina Strbad
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Gunter Balling
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital Heart Disease, Marie Lannelongue Hospital, Les Plessis-Robinson, France
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Center Munich, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research, Munich, Germany
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20
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Mah KE, Cooper DS. Commentary: Fontan survivor-outwit, outlast, outplay but do not overstay (your welcome). J Thorac Cardiovasc Surg 2019; 157:2014-2015. [PMID: 30685179 DOI: 10.1016/j.jtcvs.2018.11.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; The Heart Institute, Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; The Heart Institute, Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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21
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Kumar KR, Hornik CP. Commentary: Singling out single ventricles after Fontan. J Thorac Cardiovasc Surg 2018; 157:2016-2017. [PMID: 30553591 DOI: 10.1016/j.jtcvs.2018.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Karan R Kumar
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Christoph P Hornik
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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22
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Patterson T, Hehir DA, Buelow M, Simpson PM, Mitchell ME, Zhang L, Eslami M, Murkowski K, Scott JP. Hemodynamic Profile of Acute Kidney Injury Following the Fontan Procedure: Impact of Renal Perfusion Pressure. World J Pediatr Congenit Heart Surg 2017; 8:367-375. [PMID: 28520545 DOI: 10.1177/2150135117701376] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is common following cardiopulmonary bypass. Fontan completion may result in systemic venous hypertension and low cardiac output, reducing renal perfusion pressure (RPP) and further increasing the risk of AKI. We investigated the incidence and risk factors for post-Fontan AKI. METHODS Single-center retrospective study of children undergoing Fontan completion from 2005 to 2012. Demographic and hemodynamic variables were assessed for association with AKI. Subgroup analysis was performed on patients with high-grade AKI (creatinine increase of ≥2.0 × baseline). Vital sign data were collected hourly for the first postoperative day. RESULTS A total of 186 patients underwent Fontan at 3.1 (2.5-3.8) years of age and 13.5 kg (12.2-15.1). Acute kidney injury occurred in 97 (52%) patients, with high-grade AKI in 52 (28%). Univariate analysis identified reduced RPP in patients with AKI compared to those without AKI, 50 (45-56) mm Hg versus 58 (54-61) mm Hg ( P < .0001), due to lower mean arterial blood pressure, 63 (60-69) versus 70 (66-73) mm Hg ( P < .0001), and higher central venous pressure, 14 (12-16) versus 13 (11-14) mm Hg, ( p < .0001). Multivariable logistic regression and classification tree analyses further identified elements of RPP as significant predictors of AKI, especially high-grade AKI. Postoperative intubation was linked to AKI development. Patients with AKI had decreased postoperative urine output with increased colloid requirements, duration of chest tube insertion, and hospital length of stay. CONCLUSION Acute kidney injury occurs frequently following the Fontan procedure. Associated factors include reduced RPP, high colloid requirements, and postoperative intubation. Targeted hemodynamic interventions may serve to reduce the incidence of post-Fontan AKI.
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Affiliation(s)
| | - David A Hehir
- 2 AI Dupont Hospital for Children, Nemours Cardiac Center, Wilmington, DE, USA
| | - Matthew Buelow
- 3 Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Pippa M Simpson
- 4 Division of Quantitative Health Sciences, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael E Mitchell
- 5 Section of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Liyun Zhang
- 4 Division of Quantitative Health Sciences, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mehdi Eslami
- 1 Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen Murkowski
- 6 Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- 7 Sections of Pediatric Anesthesiology and Pediatric Critical Care, Departments of Anesthesiology and Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
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Sunstrom RE, Langley SM. Reply: To PMID 25442983. Ann Thorac Surg 2015; 100:1973-4. [PMID: 26522565 DOI: 10.1016/j.athoracsur.2015.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 06/29/2015] [Accepted: 07/06/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Rachel E Sunstrom
- Doernbecher Children's Hospital, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR97239.
| | - Stephen M Langley
- St. Joseph's Children's Hospital of Tampa, Department of Cardiothoracic Surgery, Tampa, FL
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24
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Corno AF, Aung YM. Portland Protocol: Conclusions Are Not Justified by the Content of the Article. Ann Thorac Surg 2015; 100:1972-3. [PMID: 26522563 DOI: 10.1016/j.athoracsur.2015.04.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Antonio F Corno
- East Midlands Congenital Heart Center, Glenfield Hospital, Leicester, LE3 9QP, United Kingdom.
| | - Yee Mon Aung
- East Midlands Congenital Heart Center, Glenfield Hospital, Leicester, LE3 9QP, United Kingdom
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25
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Pike NA, Okuhara CA, Toyama J, Gross BP, Wells WJ, Starnes VA. Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol. J Thorac Cardiovasc Surg 2015; 150:481-7. [DOI: 10.1016/j.jtcvs.2015.06.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/09/2015] [Accepted: 06/14/2015] [Indexed: 10/23/2022]
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