All this monitoring…what's necessary, what's not?

Exposure to surgery is associated with better long-term outcomes in patients admitted to Swedish intensive care units

BACKGROUND

Long-term outcomes of patients admitted to intensive care units (ICUs) after surgery are unknown. We investigated the long-term effects of surgical exposure prior to ICU admission.

METHODS

Registry-based cohort study. The adjusted effect of surgical exposure for mortality was examined using Cox regression. Secondary analysis with conditional logistic regression in a case-control subpopulation matched for age, gender, and Simplified Acute Physiology Score III (SAPS3) was also conducted.

RESULTS

72 242 adult patients (56.9% males, median age 66 years [IQR 50-76]), admitted to Swedish ICUs in 3-year (2012-2014) were followed for a median of 2026 days (IQR 1745-2293). Cardiovascular diseases (17.5%), respiratory diseases (15.8%), trauma (11.2%), and infections (11.4%) were the leading causes for ICU admission. Mortality at longest follow-up was 49.4%. Age; SAPS3; admissions due to malignancies, respiratory, cardiovascular and renal diseases; and transfer to another ICU were associated with increased mortality. Surgical exposure prior to ICU admission (adjusted hazard ratio [aHR] 0.90; 95% CI 0.87-0.94; P < .001), admissions from the operation theatre (aHR 0.94; CI 0.90-0.99; P = .022) or post-anaesthesia care unit (aHR 0.92; CI 0.87-0.97; P = .003) were associated with decreased mortality. Conditional logistic regression confirmed the association between surgical exposure and decreased mortality (adjusted odds ratio 0.82; CI 0.75-0.91; P < .001).

CONCLUSIONS

Long-term ICU mortality was associated with known risk factors such as age and SAPS3. Transfer to other ICUs also appeared to be a risk factor and requires further investigation. Prior surgical exposure was associated with better outcomes, a noteworthy observation given limited ICU admissions after surgery in Sweden.

Near-infrared Spectroscopy in Transport With a Patient in Multi-factorial Shock

A 14-year-old male with a history of repaired truncus arteriosus presented to an outside hospital emergency room in respiratory distress. The triage report to the transport referral center included the following vital signs: temperature of 36.6°C, respiratory rate (RR) of 26 breaths/min, heart rate (HR) of 144 beats/min, and blood pressure (BP) of 113/52 mm Hg with peripheral capillary oxygen saturation (SpO₂) of 95% on 4 L via an OxyMask (SouthMedic, Barrie, Ontario, Canada). Additional information indicated severe right ventricle to pulmonary artery conduit stenosis; anuria for 2 days; and cool, mottled extremities. The transport team was dispatched via helicopter. The vital signs upon arrival were as follows: temperature of 36.5°C, HR of 153 beats/min, RR of 48 breaths/min, BP of 81/52, mean arterial pressure of 62, and SpO₂ of 96% on 8 L via an OxyMask. Physical assessment revealed the patient was alert and oriented, tachypneic, tachycardic, and displaying poor perfusion. An epinephrine drip was initiated while the patient was being prepared for transport. Near-infrared spectroscopy (NIRS) was initiated with cerebral NIRS of 71% and renal NIRS of 39%. The epinephrine drip was escalated, and norepinephrine was initiated and titrated up for continued poor perfusion and low renal NIRS. Vitals at the transfer of care at the receiving facility were HR of 142 beats/min, BP of 91/51 mm Hg, RR of 56 breaths/min, SpO₂ of 99%, and cerebral NIRS of 75% and renal NIRS of 53%. The patient required mechanical circulatory support shortly after admission. NIRS monitoring was used to help measure perfusion and reassess interventions made during transport.

An Update on End-Tidal CO2 Monitoring

End-tidal CO2 (ETCO2) monitoring is not a new modality in the pediatric emergency department (PED) and emergency department. It is the standard of care during certain procedures such as intubations and sedations and can be used in variety of clinical situations. However, ETCO2 may be underused in the PED setting. The implementation of ETCO2 monitoring may be accomplished many ways, but a foundation of capnography principles specifically in ventilation, cardiac output, and current literature regarding its application is essential to successful implementation. It is the intention of this article to briefly review the principles of ETCO2 monitoring and its clinical applications in the PED setting.

Transthoracic intracardiac catheters in pediatric cardiac patients: A single-center experience

BACKGROUND

Transthoracic intracardiac catheters are frequently inserted in children during congenital heart surgery for monitoring and vascular access purposes. Their use entails a small potential risk.

AIM

We aimed to evaluate both catheter-associated morbidities related to maintenance and removal of transthoracic intracardiac catheters in pediatric cardiac patients, and predictors for catheter-associated adverse events.

METHODS

Single-center retrospective cohort study of prospectively collected data of children aged 0-14 years receiving a transthoracic intracardiac catheter inserted in the operating room during 7 consecutive years at the University Children's Hospital Zurich.

RESULTS

A total of 115 transthoracic intracardiac catheters were placed in 112 patients: 45 right atrial, 68 left atrial, and 2 pulmonary artery catheters. Five catheters (4.3%) had to be removed due to catheter-associated adverse events (infection, 2; nonfunction, 2; and leakage 1). After catheter removal, 19% of patients suffered adverse events, these were minor in 16 (14%) and serious in 6 (5.1%) (symptomatic bleeding in four (3.5%) patients, pericardial tamponade leading to death in one (0.8%), and tension pneumothorax in one (0.8%)). Catheter position in the right atrium and the need for platelet transfusion prior to removal were risk factors for adverse events.

CONCLUSIONS

Transthoracic intracardiac catheters are useful in the management of specific patient groups with complex congenital heart defects. Adverse events do occur; most of them do not require intervention. The insertion technique plays an important role in avoiding adverse events. Strict guidelines for the use and removal of transthoracic intracardiac catheters are required. Low platelet count should delay catheter removal. The wealth of information and therapeutic options offered by these catheters appear to outweigh the associated potential adverse events in this specific patient group.

Vasoactive Drugs and Hemodynamic Monitoring in Pediatric Cardiac Intensive Care: An Italian Survey

BACKGROUND

Little is known about practitioner preference, the availability of technology, and variability in practice with respect to hemodynamic monitoring and vasoactive drug use after congenital heart surgery. The aim of this study was to characterize current hospital practices related to the management of low cardiac output syndrome (LCOS) across Italy.

METHODS

We issued a 22-item questionnaire to 14 Italian hospitals performing pediatric cardiac surgery.

RESULTS

Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature, arterial lactate, and blood gas analysis were identified as routine in hemodynamic monitoring. With regard to advanced hemodynamic monitoring, pulmonary arterial catheter and transpulmonary thermodilution were available in 43% of the centers, uncalibrated pulse contour methods in 29% of the centers, and transesophageal/transthoracic echocardiograms in all of the centers. Dopamine added to milrinone was the most frequent drug regimen for LCOS prevention after cardiopulmonary bypass. Overall, 86% of centers used milrinone alone as the initial treatment for LCOS with elevated systemic vascular resistances and levosimendan, the second preferred choice. In cases of LCOS with low vascular resistance, epinephrine was the first choice (10 centers), dopamine was the second choice (4 centers), followed by vasopressin and norepinephrine (3 centers). For treatment of LCOS with elevated pulmonary resistances, milrinone was the first choice (eight centers), followed by inhaled nitric oxide (five centers).

CONCLUSIONS

The survey shows that advanced hemodynamic monitoring is rarely performed. The most commonly used vasoactive drugs are milrinone, levosimendan, dopamine, epinephrine, vasopressin, and norepinephrine. Guidelines on the topic are warranted.