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Zhou S, Yang Y, Wang L, Liu H, Wang X, Ouyang C, Pan J, Hu X. Study on the trend of congenital heart disease inpatient costs and its influencing factors in economically underdeveloped areas of China, 2015-2020: a case study of Gansu Province. Front Public Health 2024; 12:1303515. [PMID: 38362209 PMCID: PMC10867958 DOI: 10.3389/fpubh.2024.1303515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/05/2024] [Indexed: 02/17/2024] Open
Abstract
Background Economic data on congenital heart disease are scarce in economically underdeveloped areas of China. Therefore, this study aimed to shed light on the level and changing trend of congenital heart disease inpatients' economic burden in underdeveloped areas. Method This study used a multi-stage stratified cluster sampling method to select 11,055 inpatients with congenital heart disease from 197 medical and health institutions in Gansu Province. Their medical records and expenses were obtained from the Hospital Information System. Univariate analysis was conducted using the rank sum test and Spearman rank correlation. Quantile regression and random forest were used to analyze the influencing factors. Results From 2015 to 2020, the average length of stay for congenital heart disease patients in Gansu Province was 10.09 days, with an average inpatient cost of USD 3,274.57. During this period, the average inpatient costs per time increased from USD 3,214.85 to USD 3,403.41, while the average daily inpatient costs increased from USD 330.05 to USD 376.56. The average out-of-pocket costs per time decreased from USD 2,305.96 to USD 754.77. The main factors that affected the inpatient costs included length of stay, cardiac procedure, proportion of medications, age, and hospital level. Conclusion Congenital heart disease causes a significant economic burden on both families and society. Therefore, to further reduce the patient's financial burden, the length of stay should be reasonably reduced, and the rational distribution of medical resources should be continuously promoted to ensure equitable access to healthcare services.
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Affiliation(s)
| | | | | | | | | | | | | | - Xiaobin Hu
- Institute of Epidemiology and Health Statistics, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
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Asfari A, Borasino S, Mendoza E, Hock KM, Huskey JL, Rahman AKMF, Zaccagni H, Byrnes JW. Risk factors for long post-operative hospital stays after cardiopulmonary bypass surgery in full-term neonates. Cardiol Young 2023; 33:2487-2492. [PMID: 36924162 DOI: 10.1017/s1047951123000379] [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: 03/18/2023]
Abstract
BACKGROUND Long hospital stays for neonates following cardiac surgery can be detrimental to short- and long-term outcomes. Furthermore, it can impact resource allocation within heart centres' daily operations. We aimed to explore multiple clinical variables and complications that can influence and predict the post-operative hospital length of stay. METHODS We conducted a retrospective observational review of the full-term neonates (<30 days old) who had cardiac surgery in a tertiary paediatric cardiac surgery centre - assessment of multiple clinical variables and their association with post-operative hospital length of stay. RESULTS A total of 273 neonates were screened with a mortality rate of 8%. The survivors (number = 251) were analysed; 83% had at least one complication. The median post-operative hospital length of stay was 19.5 days (interquartile range 10.5, 31.6 days). The median post-operative hospital length of stay was significantly different among patients with complications (21.5 days, 10.5, 34.6 days) versus the no-complication group (14 days, 9.6, 19.5 days), p < 0.01. Among the non-modifiable variables, gastrostomy, tracheostomy, syndromes, and single ventricle physiology are significantly associated with longer post-operative hospital length of stay. Among the modifiable variables, deep vein thrombosis and cardiac arrest were associated with extended post-operative hospital length of stay. CONCLUSIONS Complications following cardiac surgery can be associated with longer hospital stay. Some complications are modifiable. Deep vein thrombosis and cardiac arrest are among the complications that were associated with longer hospital stay and offer a direct opportunity for prevention which may be reflected in better outcomes and shorter hospital stay.
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Affiliation(s)
- Ahmed Asfari
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Santiago Borasino
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Erika Mendoza
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristal M Hock
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jordan L Huskey
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A K M Fazlur Rahman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hayden Zaccagni
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jonathan W Byrnes
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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3
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Vogt A, Meyer S, Schäfers HJ, Weise JJ, Wagenpfeil S, Abdul-Khaliq H, Poryo M. Standardized Treatment and Diagnostic Approach to Reduce Disease burden in the early postoperative phase in children with congenital heart defects-STANDARD study: a pilot randomized controlled trial. Eur J Pediatr 2023; 182:5325-5340. [PMID: 37733115 PMCID: PMC10746759 DOI: 10.1007/s00431-023-05191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/08/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
To explore the effect of a daily goal checklist on pediatric cardiac intensive care unit (PCICU) length of stay (LOS) after congenital heart surgery. This study is a prospective randomized single-center study. Group characteristics were as follows: STANDARD group: n = 30, 36.7% female, median age 0.9 years; control group: n = 33, 36.4% female, median age 1.1 years. Invasive ventilation time, STAT categories, mean vasoactive-inotropic score (VIS)24h, maximal (max.) VIS24h, mean VIS24-48h, max. VIS24-48h, VIS category, number of sedatives, analgesics, diuretics, number of deployed diagnostic modalities, morbidities, and mortality did not differ between both groups. Median PCICU LOS was 96.0 h (STANDARD group) versus 101.5 h (control group) (p = 0.63). In the overall cohort, univariate regression analysis identified age at surgery (b = -0.02), STAT category (b = 18.3), severity of CHD (b = 40.6), mean VIS24h (b = 3.5), max. VIS24h (b = 2.2), mean VIS24-48h (b = 6.5), and VIS category (b = 13.8) as significant parameters for prolonged PCICU LOS. In multivariate regression analysis, age at surgery (b = -0.2), severity of CHD (b = 44.0), and mean VIS24h (b = 6.7) were of significance. Within the STANDARD sub-group, univariate regression analysis determined STAT category (b = 32.3), severity of CHD (b = 70.0), mean VIS24h (b = 5.0), mean VIS24-48h (b = 5.9), number of defined goals (b = 2.6), number of achieved goals (b = 3.3), number of not achieved goals (b = 10.8), and number of unevaluated goals (b = 7.0) as significant parameters for prolonged PCICU LOS. Multivariate regression analysis identified the number of defined goals (b = 2.5) and the number of unevaluated goals (b = -3.0) to be significant parameters. Conclusion: The structured realization and recording of daily goals is of advantage in patients following pediatric cardiac surgery by reducing PCICU LOS. What is known: • Communication errors are the most frequent reasons for adverse events in intensive care unit patients. • Improved communication can be achieved by discussion and documentation of the patients' goals during daily rounds. What is new: • In the overall cohort age at surgery, severity of congenital heart defect and mean vasoactive inotropic score within the first 24 hours had significant impact on pediatric cardiac intensive care unit (PCICU) length of stay (LOS). • In the intervention group, the number of defined goals and the number of unevaluated goals were significant parameters for prolonged PCICU LOS.
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Affiliation(s)
- Antonia Vogt
- Medical School, University of Saarland, Homburg/Saar, Germany
| | - Sascha Meyer
- Franz-Lust Klinik für Kinder- und Jugendmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Julius Johannes Weise
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, Kirrberger Straße, Building 9, D-66421, Homburg/Saar, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Kirrberger Straße, Building 9, D-66421, Homburg/Saar, Germany.
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Sperotto F, Gearhart A, Hoskote A, Alexander PMA, Barreto JA, Habet V, Valencia E, Thiagarajan RR. Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review. Eur J Pediatr 2023; 182:4289-4308. [PMID: 37336847 PMCID: PMC10909121 DOI: 10.1007/s00431-023-05055-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Victoria Habet
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Zürn C, Hübner D, Ziesenitz VC, Höhn R, Schuler L, Schlange T, Gorenflo M, Kari FA, Kroll J, Loukanov T, Klemm R, Stiller B. Model-driven survival prediction after congenital heart surgery. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad089. [PMID: 37279735 PMCID: PMC10493173 DOI: 10.1093/icvts/ivad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/03/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The objective of the study was to improve postoperative risk assessment in congenital heart surgery by developing a machine-learning model based on readily available peri- and postoperative parameters. METHODS Our bicentric retrospective data analysis from January 2014 to December 2019 of established risk parameters for dismal outcome was used to train and test a model to predict postoperative survival within the first 30 days. The Freiburg training data consisted of 780 procedures; the Heidelberg test data comprised 985 procedures. STAT mortality score, age, aortic cross-clamp time and postoperative lactate values over 24 h were considered. RESULTS Our model showed an area under the curve (AUC) of 94.86%, specificity of 89.48% and sensitivity of 85.00%, resulting in 3 false negatives and 99 false positives.The STAT mortality score and the aortic cross-clamp time each showed a statistically highly significant impact on postoperative mortality. Interestingly, a child's age was barely statistically significant. Postoperative lactate values indicated an increased mortality risk if they were either constantly at a high level or low during the first 8 h postoperatively with an increase afterwards.When considering parameters available before, at the end of and 24 h after surgery, the predictive power of the complete model achieved the highest AUC. This, compared to the already high predictive power alone (AUC 88.9%) of the STAT mortality score, translates to an error reduction of 53.5%. CONCLUSIONS Our model predicts postoperative survival after congenital heart surgery with great accuracy. Compared with preoperative risk assessments, our postoperative risk assessment reduces prediction error by half. Heightened awareness of high-risk patients should improve preventive measures and thus patient safety.
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Affiliation(s)
- Christoph Zürn
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - David Hübner
- Machine learning for medical applications, Averbis GmbH, Freiburg, Germany
| | - Victoria C Ziesenitz
- Department of Paediatric Cardiology and Congenital Heart Disease Center for Child and Adolescent Health, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - René Höhn
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Lena Schuler
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tim Schlange
- Faculty of Psychology, Ruhr University, Bochum, Germany
| | - Matthias Gorenflo
- Department of Paediatric Cardiology and Congenital Heart Disease Center for Child and Adolescent Health, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tsvetomir Loukanov
- Department of Cardiothoracic Surgery, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - Rolf Klemm
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Stevens H, Gallant J, Foster J, Horne D, Krmpotic K. Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study. J Pediatr Intensive Care 2023; 12:167-172. [PMID: 37565014 PMCID: PMC10411109 DOI: 10.1055/s-0041-1730933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/21/2021] [Indexed: 10/21/2022] Open
Abstract
High-flow nasal cannula (HFNC) therapy is commonly used in the pediatric intensive care unit (PICU) for postextubation respiratory support. This hypothesis-generating retrospective cohort study aimed to compare postextubation PICU length of stay in infants extubated to HFNC and low flow oxygen (LF) in PICU following cardiac surgery. Of 136 infants (newborn to 1 year) who were intubated and mechanically ventilated in PICU following cardiac surgery, 72 (53%) were extubated to HFNC and 64 (47%) to LF. Compared with patients extubated to LF, those extubated to HFNC had significantly longer durations of cardiopulmonary bypass (152 vs. 109 minutes; p = 0.002), aortic cross-clamp (90 vs. 63 minutes; p = 0.003), and invasive mechanical ventilation (3.2 vs. 1.6 days; p < 0.001), although demographic and preoperative clinical variables were similar. No significant difference was observed in postextubation PICU length of stay between HFNC and LF groups in unadjusted analysis (3.3 vs. 2.6 days, respectively; p = 0.19) and after controlling for potential confounding variables (F [1,125] = 0.17, p = 0.68, R 2 = 0.16). Escalation of therapy was similar between HFNC and LF groups (8.3 vs. 14.1%; p = 0.41). HFNC was effective as rescue therapy for six patients in the LF group requiring escalation of therapy. Need for reintubation was similar between HFNC and LF groups (8.3 vs. 4.7%; p = 0.5). Although extubation to HFNC was associated with a trend toward longer postextubation PICU length of stay and was successfully used as rescue therapy for several infants extubated to LF, our results must be interpreted with caution given the limitations of our study.
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Affiliation(s)
- Hannah Stevens
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Julien Gallant
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada
| | - Jennifer Foster
- Faculty of Medicine, Dalhousie University, Halifax, Canada
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada
- Department of Critical Care, Dalhousie University, Halifax, Canada
| | - David Horne
- Faculty of Medicine, Dalhousie University, Halifax, Canada
- Division of Pediatric Congenital Cardiac Surgery, IWK Health, Halifax, Canada
- Department of Surgery, Dalhousie University, Halifax, Canada
| | - Kristina Krmpotic
- Faculty of Medicine, Dalhousie University, Halifax, Canada
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada
- Department of Critical Care, Dalhousie University, Halifax, Canada
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7
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Benscoter AL, Alten JA, Atreya MR, Cooper DS, Byrnes JW, Nelson DP, Ollberding NJ, Wong HR. Biomarker-based risk model to predict persistent multiple organ dysfunctions after congenital heart surgery: a prospective observational cohort study. Crit Care 2023; 27:193. [PMID: 37210541 PMCID: PMC10199562 DOI: 10.1186/s13054-023-04494-7] [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: 01/17/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is an important cause of post-operative morbidity and mortality for children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Dysregulated inflammation is widely regarded as a key contributor to bypass-related MODS pathobiology, with considerable overlap of pathways associated with septic shock. The pediatric sepsis biomarker risk model (PERSEVERE) is comprised of seven protein biomarkers of inflammation and reliably predicts baseline risk of mortality and organ dysfunction among critically ill children with septic shock. We aimed to determine if PERSEVERE biomarkers and clinical data could be combined to derive a new model to assess the risk of persistent CPB-related MODS in the early post-operative period. METHODS This study included 306 patients < 18 years old admitted to a pediatric cardiac ICU after surgery requiring cardiopulmonary bypass (CPB) for congenital heart disease. Persistent MODS, defined as dysfunction of two or more organ systems on postoperative day 5, was the primary outcome. PERSEVERE biomarkers were collected 4 and 12 h after CPB. Classification and regression tree methodology were used to derive a model to assess the risk of persistent MODS. RESULTS The optimal model containing interleukin-8 (IL-8), chemokine ligand 3 (CCL3), and age as predictor variables had an area under the receiver operating characteristic curve (AUROC) of 0.86 (0.81-0.91) for differentiating those with or without persistent MODS and a negative predictive value of 99% (95-100). Ten-fold cross-validation of the model yielded a corrected AUROC of 0.75 (0.68-0.84). CONCLUSIONS We present a novel risk prediction model to assess the risk for development of multiple organ dysfunction after pediatric cardiac surgery requiring CPB. Pending prospective validation, our model may facilitate identification of a high-risk cohort to direct interventions and studies aimed at improving outcomes via mitigation of post-operative organ dysfunction.
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Affiliation(s)
- Alexis L Benscoter
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
| | - Jeffrey A Alten
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Mihir R Atreya
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - David S Cooper
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Jonathan W Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David P Nelson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Hector R Wong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
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Abstract
OBJECTIVES Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions. DATA SOURCES Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021. STUDY SELECTION We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening. DATA EXTRACTION We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed. DATA SYNTHESIS Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18). CONCLUSIONS Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.
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Parent and Provider Perspectives on Primary Continuity Intensivists and Nurses for Long-Stay Pediatric Intensive Care Unit Patients. Ann Am Thorac Soc 2023; 20:269-278. [PMID: 36322431 DOI: 10.1513/annalsats.202205-379oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Rationale: Primary continuity intensivists and nurses for long-stay patients (LSPs) in pediatric intensive care units (PICUs) are understudied strategies used to mitigate the fragmented care of typical rotating care models. Objectives: To investigate the advantages and disadvantages of primary continuity intensivists and nurses for LSPs as perceived by their parents and PICU providers. Methods: We conducted a prospective cross-sectional mixed-methods study of the perspectives of parents whose children were admitted to a PICU for >10 days and had one or more complex chronic conditions regarding the care provided by their PICU intensivists and nurses. As part of a trial, patients had been randomized to care provided by a rotating on-service intensivist who changed weekly and by PICU nurses who changed every 12 hours (usual care group) or to care provided by the same on-service intensivist plus a primary continuity intensivist and primary nurses (primary group). In addition, PICU providers (intensivists, fellows, and nurses) were queried for their perspectives on primary intensivists and nurses. Novel questionnaires, assessed for content and face validity and for readability, were used. The parental questionnaire involved indicating their degree of agreement with 16 statements about their children's care. The provider questionnaire involved rating potential advantages of primary continuity intensivists and nurses and estimating the frequency of disadvantages. Descriptive statistics and divergent stack bar charts were used; parents' and providers' responses were compared, stratified by their children's group (usual care or primary) and provider role, respectively. Results: The parental response rate was 71% (120 completed questionnaires). For 10 of 16 statements, parents whose children had primary continuity intensivists and nurses indicated significantly more positive perceptions of care (e.g., communication, listening, decision making, problems due to changing providers). The provider response rate was 61% (117 completed questionnaires); more than 80% believed that primary intensivists and nurses were highly or very highly beneficial for LSPs. Providers perceived more benefits for patients/families (e.g., informational continuity, facilitating and expediting decision making) than for staff/institutions (e.g., staff satisfaction). Providers reported associated stress, expenditure of time and effort, and decreased staffing flexibility with primary practices. Conclusions: Perceived benefits of primary continuity intensivists and nurses by both parents and providers support more widespread adoption and study of these continuity strategies.
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10
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Sperotto F, Daverio M, Amigoni A, Gregori D, Dorste A, Allan C, Thiagarajan RR. Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2256178. [PMID: 36763356 PMCID: PMC9918886 DOI: 10.1001/jamanetworkopen.2022.56178] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
IMPORTANCE Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population. OBJECTIVE To investigate incidence, trends, and factors associated with IHCA and mortality in children with cardiac disease in the ICU. DATA SOURCES A systematic review was conducted using PubMed, Web of Science, EMBASE, and CINAHL, from inception to September 2021. STUDY SELECTION Observational studies on IHCA in pediatric ICU patients with cardiac disease were selected (age cutoffs in studies varied from age ≤18 y to age ≤21 y). DATA EXTRACTION AND SYNTHESIS Quality of studies was assessed using the National Institutes of Health Quality Assessment Tools. Data on incidence, mortality, and factors associated with IHCA or mortality were extracted by 2 independent observers. Random-effects meta-analysis was used to compute pooled proportions and pooled ORs. Metaregression, adjusted for type of study and diagnostic category, was used to evaluate trends in incidence and mortality. MAIN OUTCOMES AND MEASURES Primary outcomes were incidence of IHCA and in-hospital mortality. Secondary outcomes were proportions of patients who underwent extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) and those who did not achieve return of spontaneous circulation (ROSC). RESULTS Of the 2574 studies identified, 25 were included in the systematic review (131 724 patients) and 18 in the meta-analysis. Five percent (95% CI, 4%-6%) of children with cardiac disease in the ICU experienced IHCA. The pooled in-hospital mortality among children who experienced IHCA was 51% (95% CI, 42%-59%). Thirty-nine percent (95% CI, 29%-51%) did not achieve ROSC; in centers with ECMO, 22% (95% CI, 14%-33%) underwent ECPR, whereas 22% (95% CI, 12%-38%) were unable to be resuscitated. Both incidence of IHCA and associated in-hospital mortality decreased significantly in the last 20 years (both P for trend < .001), whereas the proportion of patients not achieving ROSC did not significantly change (P for trend = .90). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, prearrest mechanical ventilation or ECMO, and higher surgical complexity were associated with increased incidence of IHCA and mortality odds. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found that 5% of children with cardiac disease in the ICU experienced IHCA. Decreasing trends in IHCA incidence and mortality suggest that education on preventive interventions, use of ECMO, and post-arrest care may have been effective; however, there remains a crucial need for developing resuscitation strategies specific to children with cardiac disease.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Laboratories of Epidemiological Methods and Biostatistics, Department of Environmental Medicine and Public Health, University of Padova, Italy
| | - Anna Dorste
- Boston Children’s Hospital Library, Boston Children’s Hospital, Boston, Massachusetts
| | - Catherine Allan
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi R. Thiagarajan
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Leland BD, Wocial LD, Madrigal VN, Moon MM, Ramey-Hunt C, Walter JK, Baird JD, Edwards JD. Group Concept Mapping Conceptualizes High-Quality Care for Long-Stay Pediatric Intensive Care Unit Patients and Families. J Pediatr 2023; 252:48-55.e1. [PMID: 35973447 PMCID: PMC9772094 DOI: 10.1016/j.jpeds.2022.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe and conceptualize high-quality care for long-stay pediatric intensive care unit (PICU) patients using group concept mapping (GCM). STUDY DESIGN We convened an expert panel to elucidate domains of high-quality care for this growing patient population for which transitory care models fail to meet their needs. Thirty-one healthcare professionals and 7 parents of patients with previous prolonged PICU hospitalizations comprised a diverse, interprofessional multidisciplinary panel. Participants completed the prompt "For PICU patients and families experiencing prolonged lengths of stay, high quality care from the medical team includes ______", with unlimited free text responses. Responses were synthesized into individual statements, then panelists sorted them by idea similarity and rated them by perceived importance. Statement analysis using GCM software through GroupWisdom generated nonoverlapping clusters representing domains of high-quality care. RESULTS Participants submitted 265 prompt responses representing 313 unique ideas, resulting in 78 final statements for sorting and rating. The resultant cluster map best representing the data contained 8 domains: (1) Family-Centered Care and Shared Decision Making, (2) Humanizing the Patient, (3) Clinician Supports and Resources, (4) Multidisciplinary Coordination of Care, (5) Family Well-Being, (6) Anticipatory Guidance and Care Planning, (7) Communication, and (8) Continuity of Care. CONCLUSIONS GCM empowered a panel of healthcare professionals and parents to explicitly describe and conceptualize high-quality care for patients and families experiencing prolonged PICU stays. This information will aid the effort to address shortcomings of transitory PICU care models.
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Affiliation(s)
- Brian D Leland
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN.
| | - Lucia D Wocial
- John J. Lynch, MD Center for Ethics, MedStar Washington Hospital Center, Washington, DC
| | - Vanessa N Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC; Pediatric Ethics Program, Children's National Hospital, Washington, DC
| | - Michelle M Moon
- Palliative Care and Symptom Management, Swedish Health Systems, Issaquah, WA
| | - Cheryl Ramey-Hunt
- Integrated Care Management, Case Management, and Social Work, Indiana University Health & Riley Hospital for Children, Indianapolis, IN
| | - Jennifer K Walter
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Pediatric Advanced Care Team, Justin Michael Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer D Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, CA
| | - Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY
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12
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Read J, Ridout D, Johnson S, Hoskote A, Sheehan K, Wellman P, Jones A, Wray J, Brown K. Postoperative morbidities with infant cardiac surgery and toddlers' neurodevelopment. Arch Dis Child 2022; 107:922-928. [PMID: 35793944 DOI: 10.1136/archdischild-2021-322756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the relationship between morbidities after infant cardiac surgery and neurodevelopment and behaviour at age 2-3 years. DESIGN/SETTING A prospective cohort follow-up study, in four paediatric cardiac centres. We excluded children with known syndromes. Home-based neurodevelopmental assessments using the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) were undertaken in 81 children and secondary outcome measures of development and behaviour were completed by parents. A further 41 families completed the secondary outcome measures remotely. RESULTS Children were grouped as multiple morbidities/extracorporeal life support (ECLS) (n=19), single morbidities (n=36) and no morbidities (n=59). Group comparisons found that children with multiple morbidities/ECLS, compared with no morbidities, had: (a) lower adjusted mean scores for core Bayley-III composites (none reached the level of statistical significance), with mean differences of cognitive -6.1 (95% CI -12.4 to 0.1) p=0.06, language -9.1 (95% CI -18.6 to 0.3) p=0.06 and motor -4.4 (95% CI -12.0 to 3.1) p=25; (b) greater adjusted odds of at least one low or borderline Bayley-III composite result 4.0 (95% CI 1.0 to 16.0) (p=0.05); (c) greater adjusted risk of an abnormal Ages and Stages Questionnaire (ASQ) result 5.3 (95% CI 1.3 to 21.1) (p=0.03) and a borderline ASQ result 4.9 (95% CI 1.0 to 25.0) (p=0.05); and no difference in the risk of an abnormal Strengths and Difficulties Questionnaire result 1.7 (95% CI 0.3 to 10.4) p=0.58. These outcomes were not statistically different between the single morbidity and no morbidity groups. CONCLUSIONS Children who experience multiple morbidities/ECLS after infant heart surgery are at a greater risk of neurodevelopmental difficulties than their peers who had no complications and should be prioritised for neurodevelopmental follow-up.
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Affiliation(s)
- Julie Read
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Deborah Ridout
- Paediatric Epidemiology Biostatistics, University College London Institute of Child Health, London, UK
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
| | - Karen Sheehan
- Department of Paediatric Cardiology, Bristol Royal Children's Hospital, Bristol, UK
| | - Paul Wellman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Alison Jones
- Department of Paediatric Intensive Care, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Katherine Brown
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
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13
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Blood pressure variability during pediatric cardiac surgery is associated with acute kidney injury. Pediatr Nephrol 2022; 37:871-879. [PMID: 34436673 DOI: 10.1007/s00467-021-05234-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Blood pressure variability (BPV), defined as the degree of variation between discrete blood pressure readings, is associated with poor outcomes in acute care settings. Acute kidney injury (AKI) is a common and serious postoperative complication of cardiac surgery with cardiopulmonary bypass (CPB) in children. No studies have yet assessed the association between intraoperative BPV during cardiac surgery with CPB and the development of AKI in children. METHODS A retrospective chart review of children undergoing cardiac surgery with CPB was performed. Intraoperative BPV was calculated using average real variability (ARV) and standard deviation (SD). Multiple regression models were used to examine the association between BPV and outcomes of AKI, hospital and intensive care unit (PICU) length of stay, and length of mechanical ventilation. RESULTS Among 231 patients (58% males, median age 8.6 months) reviewed, 51.5% developed AKI (47.9% Stage I, 41.2% Stage II, 10.9% Stage III). In adjusted models, systolic and diastolic ARV were associated with development of any stage AKI (OR 1.40, 95% CI 1.08-1.8 and OR 1.4, 95% CI 1.05-1.8, respectively). Greater diastolic SD was associated with longer PICU length of stay (β 0.94, 95% CI 0.62-1.2). When stratified by age, greater systolic ARV and SD were associated with AKI in infants ≤ 12 months, but there was no relationship in children > 12 months. CONCLUSIONS Greater BPV during cardiac surgery with CPB was associated with development of postoperative AKI in infants, suggesting that BPV is a potentially modifiable risk factor for AKI in this high-risk population.
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14
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Edwards JD, Williams EP, Wagman EK, McHale BL, Malone CT, Kernie SG. A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses. J Intensive Care Med 2022; 37:1580-1586. [PMID: 35350919 DOI: 10.1177/08850666221090421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for >10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized-half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.
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Affiliation(s)
- Jeffrey D Edwards
- Section of Pediatric Critical Care, Department of Pediatrics, 21611Columbia University Vagelos College of Physician and Surgeons, New York, New York, USA
| | - Erin P Williams
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA.,21611Columbia University Vagelos College of Physician and Surgeons, New York, New York, USA
| | - Elizabeth K Wagman
- Emory College of Arts and Sciences, 1371Emory University, Atlanta, Georgia, USA
| | - Brittany L McHale
- 25065NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Caryn T Malone
- 25065NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Steven G Kernie
- 25065NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
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15
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Ishaque S, Akhtar S, Ladak AA, Martins RS, Memon MKY, Kazmi AR, Mahmood F, Haque AU. Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country. Acute Crit Care 2022; 37:217-223. [PMID: 35172530 PMCID: PMC9184984 DOI: 10.4266/acc.2020.00990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Arrhythmias are known complication after surgery for congenital heart disease (CHD). This study aimed to identify and discuss their immediate prevalence, diagnosis and management at a tertiary care hospital in Pakistan. Methods A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (<18 years old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected. Results Amongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker. Conclusions More than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia.
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16
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Parikh KJ, Fundora MP, Sasaki N, Rossi AF, Burke RP, Sasaki J. Use of aortic arch measurements in evaluating significant arch hypoplasia in neonates with coarctation. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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17
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Outcomes of home mechanical ventilation with tracheostomy after congenital heart surgery. Cardiol Young 2021; 31:1484-1488. [PMID: 33941304 DOI: 10.1017/s1047951121001657] [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: 11/05/2022]
Abstract
OBJECTIVE After congenital heart surgery, some patients may need long-term mechanical ventilation because of chronic respiratory failure. In this study, we analysed outcomes of the patients who need tracheostomy and home mechanical ventilation. METHODS Amongst 1343 patients who underwent congenital heart surgery between January, 2014 and June, 2018, 45 needed tracheostomy and HMV. The median age of these patients was 6.4 months (12 days-6.5 years). Nineteen patients underwent palliation while 26 patients underwent total repair. Post-operative diaphragm plication was performed in five patients (11%). Median duration of mechanical ventilation before tracheostomy was 32 days (8-154 days). The patients were followed up with their home ventilators in ward and at home. Mean follow-up time was 36.24 ± 11.61 months. RESULTS The median duration of ICU stay after tracheostomy was 27 days (range 2-93 days). Follow-up time in ward was median 30 days (2-156 days). A total of 12 patients (26.6%) were separated from the ventilator and underwent decannulation during hospital stay. Thirty-two patients (71.1%) were discharged home with home ventilator support. Of them, 15 patients (46.9%) were separated from the respiratory support in median of 6 weeks (1 week-11 months) and decannulations were performed. Total mortality was 31.1%. in which four patients are still HMV dependent. There was no significant difference for decannulation between total repair and palliation patients. CONCLUSION HMV via tracheostomy is a useful option for the treatment of children who are dependent on long-term ventilation after congenital heart surgery although there are potential risks.
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18
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Beken S, Akbulut BB, Albayrak E, Güner B, Ünlü Y, Temur B, Aydin S, Ödemiş E, Erek E, Korkmaz A. Evaluation of neonatal acute kidney injury after critical congenital heart disease surgery. Pediatr Nephrol 2021; 36:1923-1929. [PMID: 33492453 DOI: 10.1007/s00467-020-04890-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/11/2020] [Accepted: 12/02/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of congenital heart diseases (CHDs) after cardiac surgery. This study aimed to define the frequency and critical course, risk factors and short-term outcomes of AKI in postoperative CHD neonates. METHODS Postoperatively followed term CHD newborn infants were enrolled in the study. Infants with congenital anomalies of the urinary tract and other major congenital anomalies were excluded. Neonatal modified KDIGO criteria were used to assess AKI. RESULTS A total of 199 postoperatively followed newborn infants were included in the study. Acute kidney injury was detected in 71 (35.6%) patients. Of these patients, 24 (33.8%) were in stage 1, 14 (19.7%) in stage 2, and 33 (46.5%) in stage 3. Acute kidney injury occurred within the first week (median 1 day [IQR 1-2 days]) of cardiac surgery in 93% of the patients. The duration of invasive respiratory support and extracorporeal membrane oxygenation (ECMO) and mortality were significantly higher in stage 3 patients. Higher vasoactive-inotropic score (OR, 1.02; 95% CI, 1.0-1.04; p = 0.008) and receiving ECMO (OR, 7.9; 95% CI, 2.6-24.4; p = 0.001) were associated with risk for the development of AKI. The mortality rate was 52.1% in the AKI (+) patients, and having AKI (OR 7.1; 95% CI, 3.5-14.18) was significantly associated with mortality. CONCLUSION Acute kidney injury, a common early complication after critical neonatal CHD cardiac surgery, is associated with increased morbidity and mortality. Stage 3 AKI is associated with significantly higher mortality rates.
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Affiliation(s)
- Serdar Beken
- Department of Pediatrics, Neonatology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey.
| | - Burcu Bulum Akbulut
- Department of Pediatrics, Pediatric Nephrology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Eda Albayrak
- Neonatal Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University, Atakent Hospital, İstanbul, Turkey
| | - Bengisu Güner
- Department of Pediatrics, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Yasemin Ünlü
- Neonatal Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University, Atakent Hospital, İstanbul, Turkey
| | - Bahar Temur
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Selim Aydin
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Ender Ödemiş
- Department of Pediatrics Pediatric Cardiology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Ersin Erek
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Ayşe Korkmaz
- Department of Pediatrics, Neonatology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey
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Temsah MH, Abouammoh N, Al-Eyadhy A, AlRuthia Y, Hassounah M, Alsohime F, Alhaboob A, Almazyad M, Alabdulhafid M, Aljamaan F, Alhasan K, Jamal A. Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study. Risk Manag Healthc Policy 2021; 14:2625-2636. [PMID: 34188573 PMCID: PMC8235993 DOI: 10.2147/rmhp.s311100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022] Open
Abstract
Background Several factors influence patients’ length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs). Methods This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units’ leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days. Results Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million). Conclusion If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.
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Affiliation(s)
- Mohamad-Hani Temsah
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Noura Abouammoh
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Marwah Hassounah
- Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Alsohime
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ali Alhaboob
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Almazyad
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Majed Alabdulhafid
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Fadi Aljamaan
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Amr Jamal
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.,Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Evidence-Based Health Care & Knowledge Translation Research Chair, King Saud University, Riyadh, Saudi Arabia
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20
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Spinner JA, Denfield SW, Puri K, Morris SA, Costello JM, Moffett BS, Wang Y, Shekerdemian LS, Tunuguntla HP, Price JF, Heinle JS, Adachi I, Dreyer WJ, Cabrera AG. Hospital outcomes for pediatric heart transplant recipients undergoing tracheostomy: A multi-institutional analysis. Pediatr Transplant 2021; 25:e13904. [PMID: 33179431 DOI: 10.1111/petr.13904] [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: 08/26/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 11/28/2022]
Abstract
Tracheostomy is associated with increased mortality and resource utilization in children with CHD. However, the prevalence and hospital outcomes of tracheostomy in children with HTx are not known. We describe the prevalence and compare the post-HTx hospital outcomes of pediatric patients with Pre-TT and Post-TT to those without tracheostomy. A multi-institutional retrospective cohort study was performed using the Pediatric Health Information System database. Hospital mortality, mediastinitis, LOS, and costs were compared among patients with Pre-TT, Post-TT, and no tracheostomy. Pre-TT was identified in 29 (1.1%) and Post-TT was identified in 41 (1.6%) of 2603 index HTx hospitalizations. Patients with Pre-TT were younger and more likely to have CHD, a non-cardiac birth defect, or an airway anomaly compared to those without Pre-TT. Pre-TT was not independently associated with increased post-HTx in-hospital mortality. Age at HTx < 1 year, CHD, and Post-TT were associated with increased in-hospital mortality. Pre-TT that occurred during the HTx hospitalization and Post-TT were associated with increased resource utilization. Tracheostomy was not associated with mediastinitis.
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Affiliation(s)
- Joseph A Spinner
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Susan W Denfield
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Kriti Puri
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Shaine A Morris
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - John M Costello
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC, USA
| | - Brady S Moffett
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Yunfei Wang
- Department of Pediatrics, Cardiovascular Research Core - Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Lara S Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Hari P Tunuguntla
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Jack F Price
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - William J Dreyer
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Antonio G Cabrera
- Division of Pediatric Cardiology, Department of Pediatrics/Primary Children's Hospital Heart Center, University of Utah, Salt Lake City, UT, USA
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21
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The multisystem nature of isomerism: left isomerism complicated by Abernethy malformation and portopulmonary hypertension. Cardiol Young 2021; 31:532-540. [PMID: 33731242 DOI: 10.1017/s1047951121000809] [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] [Indexed: 01/22/2023]
Abstract
Isomerism, also referred to as "heterotaxy" is a complex set of anatomic and functional perturbations. One of the most obvious manifestations of isomerism is the disturbance of organ arrangement, such that the thoracic organs are no longer asymmetric on the left and right. We report the case of a 14-year-old female in whom exercise-induced dyspnea led to a late diagnosis of left isomerism complicated by Abernethy malformation and portopulmonary hypertension. A comprehensive evaluation revealed two anatomic left lungs and hyparterial bronchi, bilateral left atria, an interrupted inferior caval vein with azygos continuation, multiple spleens, sinus node dysfunction, hepatic hypertrophy with focal nodular hyperplasia, and absence of the portal vein. Pulmonary vasodilator therapy was initiated resulting in clinical improvement. This case exhibits unique features including a late diagnosis of isomerism with Abernethy malformation and portopulmonary hypertension. The patient's presentation, medical workup, and future treatment emphasise the importance of multidisciplinary care in children with complex multisystem disease. We review the multiple cardiac and extracardiac manifestations of isomerism.
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22
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Goulet J, Audrit H, Tinawi S, Laguë-Beauvais M, De Guise E. Relationship between depression, community integration and life satisfaction following mild traumatic brain injury. Brain Inj 2021; 35:751-759. [PMID: 33780305 DOI: 10.1080/02699052.2021.1906950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Compared to studies on moderate and severe traumatic brain injury (TBI), less literature exists concerning the consequences of mild traumatic brain injury (mTBI) on community integration and life satisfaction, especially in the early phase of recovery. Moreover, a better understanding of the variables that contribute to community integration and life satisfaction is still needed. The aim of the study was to assess the association of mood, fatigue and post-concussive symptoms with community integration and life satisfaction early following mTBI.Research method: A total of 85 participants aged between 18 and 61 years who sustained mTBI were included. Participants answered web-based questionnaires measuring anxiety and depression symptoms, fatigue, post-concussive symptoms, community integration and life satisfaction in the first three months post mTBI.Results: Post-concussive symptoms, fatigue and anxiety were not associated with community integration or life satisfaction. However, depressive symptoms were negatively associated with community integration and life satisfaction.Conclusions: Among all acute post-concussive symptoms following mTBI, depressive symptoms seem to have strongest relationship with community integration and life satisfaction. Acute psychological intervention targeting these symptoms is strongly recommended.
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Affiliation(s)
- Justine Goulet
- Department of Psychology, University of Montreal, Montreal, Quebec, Canada.,Centre De Recherche Interdisciplinaire En Réadaptation Du Montréal Métropolitain (CRIR), Montreal, Quebec, Canada
| | - Hélène Audrit
- Department of Psychology, University of Montreal, Montreal, Quebec, Canada.,Centre De Recherche Interdisciplinaire En Réadaptation Du Montréal Métropolitain (CRIR), Montreal, Quebec, Canada
| | - Simon Tinawi
- McGill University Health Centre, Traumatic Brain Injury Program, Montreal, Quebec, Canada
| | - Maude Laguë-Beauvais
- McGill University Health Centre, Traumatic Brain Injury Program, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
| | - Elaine De Guise
- Department of Psychology, University of Montreal, Montreal, Quebec, Canada.,Centre De Recherche Interdisciplinaire En Réadaptation Du Montréal Métropolitain (CRIR), Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Canada.,Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
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23
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Bai L, Feng Z, Zhao J, Guo S, Tong Y, Jin Y, Zhang P, Gao P, Li Y, Liu J. Risk Factors and Long-Term Prognosis for Chylothorax After Total Cavopulmonary Connection in Children: A Retrospective Study From a Single Center. Front Pediatr 2021; 9:744019. [PMID: 34869101 PMCID: PMC8637757 DOI: 10.3389/fped.2021.744019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/06/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Chylothorax is a severe complication after total cavopulmonary connection (TCPC) in children. This study was performed to evaluate the incidence, risk factors, and short- and long-term prognosis for chylothorax. Methods: We retrospectively reviewed the electronic records of patients who underwent TCPC between January 2008 and December 2020 in Fuwai Hospital. Patients were divided into two groups based on the occurrence of post-operative chylothorax. Univariate and multivariate analyses were performed to identify risk factors, and long-term survival was estimated by the Kaplan-Meier method. Results: Of 386 patients included in our study, chylothorax occurred in 60 patients (15.5%). Compared with the non-chylothorax group, the prevalence of prolonged intensive care unit (ICU) stay (p = 0.000) and post-operative hospital stay (p = 0.000) were greater in patients with chylothorax. Post-operative adverse events in terms of infection (p = 0.002), ascites (p = 0.001), prolonged pleural effusion (p = 0.000), and diaphragmatic paralysis (p = 0.026) were more frequent in chylothorax patients. The median follow-up duration was 4.0 (2.0, 6.8) years. The chylothorax group had significantly lower survival rates at 1 year (92.4 vs. 99.3%, p < 0.001) and 10 years (84.6 vs. 91.6%, p < 0.001), respectively. Having a right dominant ventricle [odds ratio (OR) = 2.711, 95% confidence interval (CI) = 1.285-5.721, p = 0.009] and a higher peak central venous pressure (CVP) on post-operative day (POD) 0 (OR = 1.116, 95% CI = 1.011-1.233, p = 0.030) were the risk factors for the development of chylothorax after TCPC operation. Conclusion: The incidence of chylothorax in patients undergoing TCPC is lower than previously reported but is associated with poor early- and long-term survival. Having a right dominant ventricle and a higher peak CVP on POD 0 are the risk factors for chylothorax after TCPC operation.
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Affiliation(s)
- Liting Bai
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyi Feng
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ju Zhao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengwen Guo
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuanyuan Tong
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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24
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Wu K, Meng B, Wang Y, Zhou X, Zhang S, Ding Y. Impact of miniaturized cardiopulmonary bypass circuits on ultrafiltration during congenital heart surgery. Perfusion 2020; 36:832-838. [PMID: 33140696 DOI: 10.1177/0267659120967206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate whether the miniaturized cardiopulmonary bypass (CPB) system decreased the usage of ultrafiltration (UF), and to explore whether the non-UF with miniaturized CPB strategy could get good clinical results during congenital heart surgery. METHODS We performed a retrospective analysis of all patients undergoing congenital heart surgery with CPB at Shenzhen Children's Hospital from 1 May 2015 to 30 September 2019. We classified patients to UF with miniaturized CPB group, non-UF with miniaturized CPB group, UF with conventional CPB group and non-UF with conventional CPB group. RESULTS Of the 2145 patients, 721 (33.6%) were in the conventional CPB group, and 1424 (66.4%) were in the miniaturized CPB group. The UF rate was significantly lower in the miniaturized CPB group compared with that in the conventional CPB group (12.5% vs. 76.8%, p < 0.001). Compared with patients in the other groups, patients in the non-UF with miniaturized CPB group had a shorter postoperative MV time (p < 0.05), and a shorter length of stay in the ICU (p < 0.001) and hospital (p < 0.001). The age of children in the UF with miniaturized CPB group was relatively younger (median: 1.5 months, IQR: 0.3-4.6 months), and the preoperative weight was relatively lower (median: 3.9 kg, IQR: 3.2-5.4 kg). Moreover, this group of children had a relatively longer postoperative MV time and length of stay in the ICU and hospital. CONCLUSION The miniaturized CPB system could decrease the usage of UF. Good results were achieved in children who did not use UF based on the miniaturized CPB circuit system during congenital heart surgery.
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Affiliation(s)
- Keye Wu
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Baoying Meng
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Yuanxiang Wang
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Xing Zhou
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Sheshe Zhang
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Yiqun Ding
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
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25
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Hudson E, Brown K, Pagel C, Wray J, Barron D, Rodrigues W, Stoica S, Tibby SM, Tsang V, Ridout D, Morris S. Costs of postoperative morbidity following paediatric cardiac surgery: observational study. Arch Dis Child 2020; 105:1068-1074. [PMID: 32381518 PMCID: PMC7588404 DOI: 10.1136/archdischild-2019-318499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/27/2020] [Accepted: 04/11/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Early mortality rates for paediatric cardiac surgery have fallen due to advancements in care. Alternative indicators of care quality are needed. Postoperative morbidities are of particular interest. However, while health impacts have been reported, associated costs are unknown. Our objective was to calculate the costs of postoperative morbidities following paediatric cardiac surgery. DESIGN Two methods of data collection were integrated into the main study: (1) case-matched cohort study of children with and without predetermined morbidities; (2) incidence rates of morbidity, measured prospectively. SETTING Five specialist paediatric cardiac surgery centres, accounting for half of UK patients. PATIENTS Cohort study included 666 children (340 with morbidities). Incidence rates were measured in 3090 consecutive procedures. METHODS Risk-adjusted regression modelling to determine marginal effects of morbidities on per-patient costs. Calculation of costs for hospital providers according to incidence rates. Extrapolation using mandatory audit data to report annual financial burden for the health service. OUTCOME MEASURES Impact of postoperative morbidities on per-patient costs, hospital costs and UK health service costs. RESULTS Seven of the 10 morbidity categories resulted in significant costs, with mean (95% CI) additional costs ranging from £7483 (£3-£17 289) to £66 784 (£40 609-£103 539) per patient. On average all morbidities combined increased hospital costs by 22.3%. Total burden to the UK health service exceeded £21 million each year. CONCLUSION Postoperative morbidities are associated with a significant financial burden. Our findings could aid clinical teams and hospital providers to account for costs and contextualise quality improvement initiatives.
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Affiliation(s)
- Emma Hudson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katherine Brown
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College of London, London, UK,Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - David Barron
- Department of Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Warren Rodrigues
- Paediatric Intensive care Unit, NHS Greater Glasgow and Clyde Inverclyde Royal Hospital, Glasgow, UK
| | - Serban Stoica
- Department of Cardiac Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Shane M Tibby
- Department of Paediatric Intensive Care, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Victor Tsang
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Paediatric Epidemiology Biostatistics, Institute of Child Health, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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26
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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27
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Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
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28
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Lisanti AJ, Vittner D, Medoff-Cooper B, Fogel J, Wernovsky G, Butler S. Individualized Family-Centered Developmental Care: An Essential Model to Address the Unique Needs of Infants With Congenital Heart Disease. J Cardiovasc Nurs 2020; 34:85-93. [PMID: 30303895 PMCID: PMC6283700 DOI: 10.1097/jcn.0000000000000546] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants born with critical congenital heart disease (cCHD) who require surgical intervention in the newborn period are often hospitalized in a cardiac intensive care unit (CICU). Cardiac surgery and the CICU environment are traumatic to infants and their families. Infants are exposed to overwhelming stress, which can result in increased pain, physiologic instability, behavioral disorganization, disrupted attachment, and altered brain development. Individualized Family-centered Developmental Care (IFDC) is a model that can address the unique needs and developmental challenges of infants with cCHD. PURPOSE The purpose of this article is to (1) clearly describe the uniqueness of the infant with cCHD, including the medical, neurological, and parental challenges, and (2) propose methods to apply IFDC to support recovery of infants with cCHD in the CICU. CONCLUSIONS The experiences in the CICU shape the developing brain and alter recovery and healing, thus adversely impacting development. Individualized Family-centered Developmental Care is a promising model of care that nurses can integrate into the CICU to promote neuroprotection and development. Nurses can effectively integrate IFDC into the CICU by understanding the unique characteristics of infants with cCHD and applying IFDC interventions that include both maturity and recovery perspectives. CLINICAL IMPLICATIONS The incorporation of IFDC interventions is essential for the infant with cCHD and should be a standard of care. Applying IFDC with a recovery perspective in all aspects of caregiving will provide opportunities for individualization of care and parent engagement, allowing infants in the CICU to recover from surgery while supporting both short- and long-term neurodevelopment.
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Affiliation(s)
- Amy Jo Lisanti
- Amy Lisanti, PhD, RN, CCNS, CCRN-K NRSA Postdoctoral Fellow, University of Pennsylvania School of Nursing; and Clinical Nurse Specialist/Nurse Scientist, Cardiac Nursing at Children's Hospital of Philadelphia, Pennsylvania. Dorothy Vittner, PhD, RN Nurse Scientist, Connecticut Children's Medical Center, Hartford; and Faculty, School of Nursing and an Assistant Professor, University of Connecticut School of Nursing, Storrs. Barbara Medoff-Cooper, PhD, RN Professor, Univeristy of Pennsylvania School of Nursing, Philadelphia. Jennifer Fogel, M.S.CCC-SLP/L Pediatric Speech Language Pathologist, Advocate Children's Hospital, Oak Lawn, Illinois. Gil Wernovsky, MD Senior Consultant in Cardiac Critical Care and Pediatric Cardiology, Children's National Health System, Washington, District of Columbia. Samantha Butler, PhD Developmental and Clinical Psychologist Director, Boston Children's; and Assistant Professor in Psychiatry, Harvard Medical School, Boston, Massachusetts
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Ciociola EC, Kumar KR, Zimmerman KO, Thompson EJ, Harward M, Sullivan LN, Turek JW, Hornik CP. Association between preoperative respiratory support and outcomes in paediatric cardiac surgery. Cardiol Young 2020; 30:66-73. [PMID: 31771666 PMCID: PMC7018562 DOI: 10.1017/s1047951119002786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preoperative mechanical ventilation is associated with morbidity and mortality following CHD surgery, but prior studies lack a comprehensive analysis of how preoperative respiratory support mode and timing affects outcomes. METHODS We retrospectively collected data on children <18 years of age undergoing cardiac surgery at an academic tertiary care medical centre. Using multivariable regression, we examined the association between modes of preoperative respiratory support (nasal cannula, high-flow nasal cannula/noninvasive ventilation, or invasive mechanical ventilation), escalation of preoperative respiratory support, and invasive mechanical ventilation on the day of surgery for three outcomes: operative mortality, postoperative length of stay, and postoperative complications. We repeated our analysis in a subcohort of neonates. RESULTS A total of 701 children underwent 800 surgical procedures, and 40% received preoperative respiratory support. Among neonates, 243 patients underwent 253 surgical procedures, and 79% received preoperative respiratory support. In multivariable analysis, all modes of preoperative respiratory support, escalation in preoperative respiratory support, and invasive mechanical ventilation on the day of surgery were associated with increased odds of prolonged length of stay in children and neonates. Children (odds ratio = 3.69, 95% CI 1.2-11.4) and neonates (odds ratio = 8.97, 95% CI 1.31-61.14) on high-flow nasal cannula/noninvasive ventilation had increased odds of operative mortality compared to those on room air. CONCLUSION Preoperative respiratory support is associated with prolonged length of stay and mortality following CHD surgery. Knowing how preoperative respiratory support affects outcomes may help guide surgical timing, inform prognostic conversations, and improve risk stratification models.
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Affiliation(s)
- Elizabeth C. Ciociola
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Karan R. Kumar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth J. Thompson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Melissa Harward
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Laura N. Sullivan
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W. Turek
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Brown KL, Ridout D, Pagel C, Wray J, Anderson D, Barron DJ, Cassidy J, Davis PJ, Rodrigues W, Stoica S, Tibby S, Utley M, Tsang VT. Incidence and risk factors for important early morbidities associated with pediatric cardiac surgery in a UK population. J Thorac Cardiovasc Surg 2019; 158:1185-1196.e7. [DOI: 10.1016/j.jtcvs.2019.03.139] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 11/29/2022]
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Mehmood A, Nadeem RN, Kabbani MS, Khan AH, Hijazi O, Ismail SR, Shath G, Eng WW, Jawed S. Impact of Cardiopulmonary Bypass and Aorta Cross Clamp Time on the Length of Mechanical Ventilation after Cardiac Surgery among Children: A Saudi Arabian Experience. Cureus 2019; 11:e5333. [PMID: 31598440 PMCID: PMC6778048 DOI: 10.7759/cureus.5333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/06/2019] [Indexed: 11/05/2022] Open
Abstract
Aim Several factors determine the perioperative outcome besides the nature of the congenital heart defect. Prolonged mechanical ventilation (PMV) is a major factor that determines mortality, length of stay (LOS), residual disability, and other functional outcomes. We aim to determine the clinical variables predicting PMV and LOS in hospital, and specifically the impact from the duration of cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC). Method We conducted a retrospective review of the medical records of 413 children consecutively admitted to the Pediatric Cardiac Intensive Care Unit (PCICU) in one year at a single center. We collected demographic information (e.g., age, gender, and weight), perioperative variables, clinical outcomes, length of mechanical ventilation, high-frequency ventilator use, and mortality. We used logistic regression to analyze the data. PMV was defined as mechanical ventilation for longer than seven days. Results A total of 410 records were included in our study. We found no statistically significant association between CPB time and mechanical ventilation days. Forty-seven children had PMV, 362 did not have PMV. We found no statistically significant association between CPB time and mechanical ventilation days after adjusting for covariates. Reanalyzing the data with PMV defined as longer than four days produced the same results. Using a regression model to assess the variables via the least absolute shrinkage and selection operator for feature selection, we found no statistically significant association between ACC time and mechanical ventilation days after adjusting for covariates. Conclusion According to our results, CPB and ACC time are not associated with PMV or prolonged hospital LOS.
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Affiliation(s)
| | | | - M S Kabbani
- Cardiac Sciences, King Abdulaziz Medical City, National Guard Hospital Health Affairs, Riyadh, SAU
| | - Altaf H Khan
- Bioinformatics, King Abdulaziz Medical City, National Guard Hospital Health Affairs, Riyadh, SAU
| | - Omar Hijazi
- Cardiac Sciences, King Abdulaziz Medical City, National Guard Hospital Health Affairs, Riyadh, SAU
| | - Sameh R Ismail
- Cardiac Sciences, King Abdulaziz Medical City, National Guard Hospital Health Affairs, Riyadh, SAU
| | - Ghassan Shath
- Cardiac Sciences, King Abdulaziz Medical City, National Guard Hospital Health Affairs, Riyadh, SAU
| | - Winston W Eng
- Miscellaneous, Performance Center, Omnicell, Inc., Pittsburgh, USA
| | - Shafaq Jawed
- Surgery, Jinnah Sindh Medical University, Karachi, PAK
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Lu C, Yu L, Wei J, Chen J, Zhuang J, Wang S. Predictors of postoperative outcomes in infants with low birth weight undergoing congenital heart surgery: a retrospective observational study. Ther Clin Risk Manag 2019; 15:851-860. [PMID: 31371972 PMCID: PMC6628950 DOI: 10.2147/tcrm.s206147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/27/2019] [Indexed: 11/23/2022] Open
Abstract
Background Despite improvements in neonatal cardiac surgery and postoperative care, hospitalized death for infants with low birth weight remains high. Objective This study sought to identify predictors of postoperative outcomes in low-birth-weight infants undergoing congenital heart surgery and establish nomograms to predict postoperative intensive-care unit (ICU) stay. Methods From June 2009 to June 2018, a retrospective review of 114 infants with low birth weight (≤2.5 kg) undergoing congenital heart surgery was conducted at Guangdong Provincial People’s Hospital. Purely surgical ligation of patent ductus arteriosus was excluded from this study. A total of 26 clinical variables were chosen for univariate, multivariate, and Cox regression analysis, and 14 variables were analyzed as predictors of postoperative outcomes. Nomograms were established to predict risk of postoperative cardiac ICU (CICU) stay, postoperative neonatal ICU (NICU) stay, and total ICU length of stay in infants with cardiac diseases. Results Two variables were independent predictors in multiple logistic regression analysis of hospitalized death: operation weight and Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery (STAT) risk categories. Six variables were independent predictors in the Cox model of postoperative ICU length of stay, including sex, prematurity, birth weight, preoperative stay time in NICU, diagnostic classification, and STAT risk categories. We calculated concordance-index values to estimate the discriminative ability of models of risk of postoperative CICU stay, postoperative NICU stay, and total ICU length of stay, with values of 0.758 (95% CI 0.696–0.820), 0.604 (95% CI 0.525–0.682), and 0.716 (95% CI 0.657–0.776), which indicated the possibility of true-positive results. Conclusion Our findings might help clinicians predict postoperative outcomes and optimize therapeutic strategies.
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Affiliation(s)
- Chao Lu
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Lina Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Jinfeng Wei
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jimei Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Sheng Wang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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The Inadequate Oxygen Delivery Index and Low Cardiac Output Syndrome Score As Predictors of Adverse Events Associated With Low Cardiac Output Syndrome Early After Cardiac Bypass. Pediatr Crit Care Med 2019; 20:737-743. [PMID: 31033863 DOI: 10.1097/pcc.0000000000001960] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of two scoring systems, the inadequate oxygen delivery index, a risk analytics algorithm (Etiometry, Boston, MA) and the Low Cardiac Output Syndrome Score, in predicting adverse events recognized as indicative of low cardiac output syndrome within 72 hours of surgery. DESIGN A retrospective observational pair-matched study. SETTING Tertiary pediatric cardiac ICU. PATIENTS Children undergoing cardiac bypass for congenital heart defects. Cases experienced an adverse event linked to low cardiac output syndrome in the 72 hours following surgery (extracorporeal membrane oxygenation, renal replacement therapy, cardiopulmonary resuscitation, and necrotizing enterocolitis) and were matched with a control patient on criteria of procedure, diagnosis, and age who experienced no such event. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of a total 536 bypass operations in the study period, 38 patients experienced one of the defined events. Twenty-eight cases were included in the study after removing patients who suffered an event after 72 hours or who had insufficient data. Clinical and laboratory data were collected to derive scores for the first 12 hours after surgery. The inadequate oxygen delivery index was calculated by Etiometry using vital signs and laboratory data. A modified Low Cardiac Output Syndrome Score was calculated from clinical and therapeutic markers. The mean inadequate oxygen delivery and modified Low Cardiac Output Syndrome Score were compared within each matched pair using the Wilcoxon signed-rank test. Inadequate oxygen delivery correctly differentiated adverse events in 13 of 28 matched pairs, with no evidence of inadequate oxygen delivery being higher in cases (p = 0.71). Modified Low Cardiac Output Syndrome Score correctly differentiated adverse events in 23 of 28 matched pairs, with strong evidence of a raised score in low cardiac output syndrome cases (p < 0.01). CONCLUSIONS Although inadequate oxygen delivery is an Food and Drug Administration approved indicator of risk for low mixed venous oxygen saturation, early postoperative average values were not linked with medium-term adverse events. The indicators included in the modified Low Cardiac Output Syndrome Score had a much stronger association with the specified adverse events.
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Knaup E, Nosaka N, Yorifuji T, Tsukahara K, Naito H, Tsukahara H, Nakao A. Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score. J Intensive Care 2019; 7:38. [PMID: 31384469 PMCID: PMC6664501 DOI: 10.1186/s40560-019-0392-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022] Open
Abstract
Background The length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission. Methods We performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017. Results Overall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%). Conclusions Pediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission. Electronic supplementary material The online version of this article (10.1186/s40560-019-0392-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily Knaup
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Nobuyuki Nosaka
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,3Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Takashi Yorifuji
- 4Department of Human Ecology, Graduate School of Environmental and Life Science, Okayama University, Okayama, Japan
| | - Kohei Tsukahara
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hiromichi Naito
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hirokazu Tsukahara
- 2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Atsunori Nakao
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Timing of Fontan Completion in Children with Functionally Univentricular Hearts and Isomerism: The Impact of Age, Weight, and Pre-Fontan Arterial Oxygen Saturation. Pediatr Cardiol 2019; 40:753-761. [PMID: 30671646 DOI: 10.1007/s00246-019-02060-z] [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: 10/16/2018] [Accepted: 01/16/2019] [Indexed: 10/27/2022]
Abstract
Isomerism, or heterotaxy, impacts morbidity and mortality after various stages of univentricular palliation. Timing of Fontan completing in these patients based on preoperative factors has not been investigated previously. The aim of this study was to determine the impact of preoperative factors on various outcomes including length of hospital stay and duration of chest tubes. A cross-sectional study was conducted. Patients with isomerism having undergone Fontan at the Children's Hospital of Wisconsin between 1998 and 2014 were identified. Preoperative, operative, and postoperative data were collected on these patients. Linear regression analysis was conducted to determine preoperative characteristics associated with various postoperative outcomes. Receiver operator curve analysis was also performed to determine the sensitivity and specificity of age and pre-Fontan arterial oxygen saturation in predicting increased length of hospitalization and increased duration of chest tubes. Younger age and lower pre-Fontan arterial oxygen saturation were associated with increased length of hospitalization while younger age, lower pre-Fontan arterial oxygen saturation, interrupted inferior caval vein, and worse pre-Fontan atrioventricular valve regurgitation were associated with increased length of chest tubes. Age, arterial oxygen saturation, pulmonary arteriovenous malformations, interruption of the inferior caval vein, and atrioventricular valve regurgitation should all be taken into consideration when timing Fontan completion in patients with isomerism. Arterial oxygen saturations between 82 and 84% with an approximate age of 3 years appear to be a time at which it is reasonable to consider Fontan in patients with isomerism.
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Zhang C, Meng B, Wu K, Ding Y. Comparison of two cardiopulmonary bypass strategies with a miniaturized tubing system: a propensity score-based analysis. Perfusion 2019; 34:460-466. [PMID: 30739569 DOI: 10.1177/0267659118825395] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The existing cardiopulmonary bypass tubing system has already been significantly improved in our hospital by reducing the priming volume; thus, we further employed a new cardiopulmonary bypass strategy in children based on a miniaturized cardiopulmonary bypass circuit. We aimed to compare the effectiveness of new and conventional strategies by analyzing the outcomes after congenital heart surgery. METHODS We performed a database analysis of all patients undergoing congenital heart surgery with cardiopulmonary bypass at Shenzhen Children's Hospital from 1 May 2015 to 30 June 2017. Propensity score matching was used to adjust for significant covariates, and multivariable regression models and stratified analysis were used to assess the association of cardiopulmonary bypass strategy with outcomes. RESULTS Of 925 total patients, 55.35% were in the conventional strategy group and 44.65% were in the new strategy group. After propensity score matching, there were 610 patients in total, with 305 patients in each group. In the multivariable regression models, the cardiopulmonary bypass strategy was not significantly associated with successful early extubation (p > 0.05), reintubation (p > 0.05), or nasal continuous positive airway pressure (p > 0.05) rates. The new strategy group had fewer hospital stays (p = 0.04) and intensive care unit stays (p < 0.05) compared with patients who underwent conventional strategy. The difference remained statistically significant (p < 0.05) when The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category was <3. CONCLUSION The implementation of a new cardiopulmonary bypass strategy, with selective ultrafiltration based on a miniaturized cardiopulmonary bypass circuit system, was safe and effective for children who underwent congenital heart surgery in a Chinese hospital. The new cardiopulmonary bypass strategy was associated with fewer hospital and intensive care unit stays.
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Affiliation(s)
- Cheng Zhang
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Baoying Meng
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Keye Wu
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Yiqun Ding
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
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Changing Risk of In-Hospital Cardiac Arrest in Children Following Cardiac Surgery in Victoria, Australia, 2007-2016. Heart Lung Circ 2018; 28:1904-1912. [PMID: 30591395 DOI: 10.1016/j.hlc.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/18/2018] [Accepted: 11/02/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Reported incidence of in hospital cardiac arrest (IHCA) after paediatric cardiac surgery varies between 3-4% in high income countries and this risk may have changed over time. We sought to examine this trend in detail. METHODS A retrospective observational study of 3,781 children who underwent 4,938 cardiac surgeries between 1 January 2007 and 31 December 2016 in a tertiary children's hospital. IHCA was defined as cessation of cardiac mechanical activity requiring cardiac massage for ≥1minute. Surgical complexity was categorised using risk adjusted congenital heart surgery (RACHS-1) category. Poisson regression was used to analyse trends for every two-year period. RESULTS There were a total of 211 (4.3%) IHCA events after surgery. These patients were younger, more likely to have had a premature birth, have a chromosomal or genetic syndrome association and have a high surgical complexity. Overall, there was a 52% reduction in IHCA rate over 10 years: reducing from 5.4 /100 surgeries in 2007-08 to 2.6/100 surgeries in 2015-16 (p-trend=<0.001). The reduction was mainly seen in low-to-moderate risk categories (RACHS-1 categories 1-4) and not in high risk categories (RACHS-1 category 5-6). Children in high risk categories were 13.6 times more likely to experience an IHCA (compared to low risk categories). Overall hospital mortality for children suffering IHCA decreased from 42.5/100 patients in 2007-08 to 11.1/100 patients in 2015-16 (p-trend=0.037). CONCLUSIONS The IHCA rate following cardiac surgery has more than halved over the last decade; children who experience IHCA also have lower mortality than in previous years. High risk procedures still have a substantial rate of IHCA and efforts are needed to minimise the burden further in this population.
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Fahlbusch FB, Heinlein T, Rauh M, Dittrich S, Cesnjevar R, Moosmann J, Nadal J, Schmid M, Muench F, Schroth M, Rascher W, Topf HG. Influence of factor XIII activity on post-operative transfusion in congenital cardiac surgery-A retrospective analysis. PLoS One 2018; 13:e0199240. [PMID: 29990321 PMCID: PMC6038983 DOI: 10.1371/journal.pone.0199240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/25/2018] [Indexed: 12/16/2022] Open
Abstract
Objectives Coagulation factor XIII (FXIII) plays a key role in fibrin clot stabilization—an essential process for wound healing following cardiothoracic surgery. However, FXIII deficiency as a risk for post-operative bleeding in pediatric cardiac surgery involving cardiopulmonary bypass (CPB) for congenital heart disease (CHD) is controversially discussed. Thus, as primary outcome measures, we analyzed the association of pre-operative FXIII activity and post-operative chest tube drainage (CTD) loss with transfusion requirements post-operatively. Secondary outcomes included the influence of cyanosis and sex on transfusion. Methods Our retrospective analysis (2009–2010) encompassed a single center series of 76 cardio-surgical cases with CPB (0–17 years, mean age 5.61 years) that were post-operatively admitted to our pediatric intensive care unit (PICU). The observational period was 48 hours after cardiac surgery. Blood cell counts and coagulation status, including FXIII activity were routinely performed pre- and post-operatively. The administered amount of blood products and volume expanders was recorded electronically, along with the amount of CTD loss. Uni- and multivariate logistic regression analysis was performed to calculate the associations (odds ratios) of variables with post-operative transfusion needs. Results FXIII activities remained stable following CPB surgery. There was no association of pre- and post-operative FXIII activities and transfusion of blood products or volume expanders in the first 48 hours after surgery. Similarly, FXIII showed no association with CTD loss. Cyanosis and female sex were associated with transfusion rates. Conclusions Although essentially involved in wound healing and clotting after surgery, FXIII activity does not serve as a valid predictor of post-operative transfusion need.
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Affiliation(s)
- Fabian B Fahlbusch
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Heinlein
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Manfred Rauh
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Robert Cesnjevar
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Moosmann
- Department of Pediatric Cardiology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jennifer Nadal
- Institute of Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital, Bonn, Germany
| | - Matthias Schmid
- Institute of Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital, Bonn, Germany
| | - Frank Muench
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Schroth
- Cnopf'sche Kinderklinik, Diakonie Neuendettelsau, Nürnberg, Germany
| | - Wolfgang Rascher
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Hans-Georg Topf
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Anwar S, Singh GK, Miller J, Sharma M, Manning P, Billadello JJ, Eghtesady P, Woodard PK. 3D Printing is a Transformative Technology in Congenital Heart Disease. JACC Basic Transl Sci 2018; 3:294-312. [PMID: 30062215 PMCID: PMC6059001 DOI: 10.1016/j.jacbts.2017.10.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/08/2017] [Accepted: 10/11/2017] [Indexed: 12/26/2022]
Abstract
Survival in congenital heart disease has steadily improved since 1938, when Dr. Robert Gross successfully ligated for the first time a patent ductus arteriosus in a 7-year-old child. To continue the gains made over the past 80 years, transformative changes with broad impact are needed in management of congenital heart disease. Three-dimensional printing is an emerging technology that is fundamentally affecting patient care, research, trainee education, and interactions among medical teams, patients, and caregivers. This paper first reviews key clinical cases where the technology has affected patient care. It then discusses 3-dimensional printing in trainee education. Thereafter, the role of this technology in communication with multidisciplinary teams, patients, and caregivers is described. Finally, the paper reviews translational technologies on the horizon that promise to take this nascent field even further.
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Key Words
- 3D printing
- 3D, three-dimensional
- ACHD, adults with congenital heart disease
- APC, aortopulmonary collaterals
- ASD, atrial septal defect
- CHD, congenital heart disease
- CT, computed tomography
- DORV, double outlet right ventricle
- MAPCAs, multiple aortopulmonary collaterals
- MRI, magnetic resonance imaging
- OR, operating room
- VSD, ventricular septal defect
- cardiac imaging
- cardiothoracic surgery
- congenital heart disease
- simulation
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Affiliation(s)
- Shafkat Anwar
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Gautam K. Singh
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jacob Miller
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Monica Sharma
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Manning
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joseph J. Billadello
- Division of Cardiovascular Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Pirooz Eghtesady
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Pamela K. Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Factors Affecting the Length of Stay in the Intensive Care Unit: Our Clinical Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9438046. [PMID: 29750174 PMCID: PMC5884409 DOI: 10.1155/2018/9438046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/28/2017] [Accepted: 02/18/2018] [Indexed: 11/17/2022]
Abstract
Background and Aim Long hospital days in intensive care unit (ICU) due to life-threatening diseases are increasing in the world. The primary goal in ICU is to decrease length of stay in order to improve the quality of medical care and reduce cost. The aim of our study is to identify and categorize the factors associated with prolonged stays in ICU. Materials and Method We retrospectively analyzed 3925 patients. We obtained the patients' demographic, clinical, diagnostic, and physiologic variables; mortality; lengths of stay by examining the intensive care unit database records. Results The mean age of the study was 61.6 ± 18.9 years. The average length of stay in intensive care unit was 10.2 ± 25.2 days. The most common cause of hospitalization was because of multiple diseases (19.5%). The length of stay was positively correlated with urea, creatinine, and sodium. It was negatively correlated with uric acid and hematocrit levels. Length of stay was significantly higher in patients not operated on than in patients operated on (p < 0.001). Conclusion Our study showed a significantly increased length of stay in patients with cardiovascular system diseases, multiple diseases, nervous system diseases, and cerebrovascular diseases. Moreover we showed that when urea, creatinine, and sodium values increase, in parallel the length of stay increases.
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Kaskinen AK, Kirjavainen T, Rautiainen P, Martelius L, Andersson S, Pitkänen OM. Ventilator-derived dynamic respiratory system compliance: Comparison with static compliance in children. Respir Physiol Neurobiol 2018; 249:32-34. [DOI: 10.1016/j.resp.2017.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/11/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
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Janai AR, Bellinghausen W, Turton E, Bevilacqua C, Zakhary W, Kostelka M, Bakhtiary F, Hambsch J, Daehnert I, Loeffelbein F, Ender J. Retrospective study of complete atrioventricular canal defects: Anesthetic and perioperative challenges. Ann Card Anaesth 2018; 21:15-21. [PMID: 29336386 PMCID: PMC5791481 DOI: 10.4103/aca.aca_110_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. Design: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. Setting: A single-center study at a university affiliated heart center. Participants: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. Methods: Primary and staged biventricular repair of complete AV canal defects. Measurements and main results: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. Conclusion: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.
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Affiliation(s)
- Aniruddha Ramesh Janai
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Wilfried Bellinghausen
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Edwin Turton
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Carmine Bevilacqua
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Waseem Zakhary
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Martin Kostelka
- Department of Clinic for Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Farhad Bakhtiary
- Department of Clinic for Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Joerg Hambsch
- Department of Clinic for Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Ingo Daehnert
- Department of Clinic for Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Florian Loeffelbein
- Department of Clinic for Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
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Corno AF, Bostock C, Chiles SD, Wright J, Tala MTJ, Mimic B, Cvetkovic M. Comparison of Early Outcomes for Normothermic and Hypothermic Cardiopulmonary Bypass in Children Undergoing Congenital Heart Surgery. Front Pediatr 2018; 6:219. [PMID: 30175089 PMCID: PMC6108179 DOI: 10.3389/fped.2018.00219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: Comparison of early outcomes of normothermic cardiopulmonary bypass (N-CPB, ≥35°C) with hypothermic cardiopulmonary bypass (H-CPB, 28-34°C) for congenital heart defects. Methods: Data from 99 patients <2 years operated with N-CPB (n = 48) or H-CPB (n = 51) were retrospectively reviewed: aortic X-clamping and CPB duration, vasoactive inotropic score (VIS), arterial lactate, pH and base excess, urine output, extubation, PICU stay, transfusion requirements, chest drain losses, costs of transfusions, and costs of PICU stay. Results: The two groups were homogeneous for diagnosis, risk factors, surgery and demographic variables: N-CPB age 7.7 ± 6.1 months, weight 6.2 ± 2.4 kg, and H-CPB age 6.6 ± 6.5 months, weight 6.1 ± 2.4 kg. There were no hospital deaths in either group. VIS in N-CPB was lower than H-CPB on PICU arrival (9.7 ± 5.9 vs. 13.4 ± 7.9, P < 0.005), after 4 h (7.0 ± 5.2 vs. 11.1 ± 7.3, P < 0.001) and 24 h (2.8 ± 3.6 vs. 5.6 ± 5.6, P < 0.003); arterial pH was better at PICU arrival (7.33 ± 0.09 vs. 7.30 ± 0.09, P = 0.046) after 4 h (7.35 ± 0.07 vs. 7.32 ± 0.07, P = 0.022) and after 24 h (7.37 ± 0.05 vs. 7.35 ± 0.05, P = 0.01). Extubation was earlier in N-CPB than in H-CPB (22 ± 27 vs. 48 ± 57 h, P = 0.003) as PICU discharge (61 ± 46 h vs. 87 ± 69 h, P = 0.021). Transfusion requirements in operating room were lower in N-CPB vs. H-CPB for RBC, FFP, cryoprecipitate, and platelets, while during the first 24 h in PICU were lower only for cryoprecipitate and platelets. Chest drain losses (mL/kg) on PICU arrival, after 4 and 24 h were lower with N-CPB vs. H-CPB (respectively 1.5 ± 1.4 vs. 2.5 ± 2.7, P = 0.013, 7.8 ± 6.0 vs. 10.9 ± 8.7, P = 0.025, and 23.0 ± 12.0 vs. 27.9 ± 15.2, P = 0.043). Tranexamic acid infusion was required in 7/48 (14.6%) patients with N-CPB vs. 18/51(= 35.3%) in H-CPB (P = 0.009). The average total costs/patient of blood and blood products (RBC, FFP, cryoprecipitate, platelets) were lower in N-CPB vs. H-CPB for both the first 24 h after surgery (£204 ± 169 vs. £306 ± 254, P = 0.011) as well as during the total duration of PICU stay (£239 ± 193 vs. £427 ± 337, P = 0.001). The average cost/patient/day of stay in PICU was lower in N-CPB than in H-CPB (£4,067 ± 3,067 vs. £5,800 ± 4,600, P = 0.021). Conclusions: N-CPB may reduce inotropic and respiratory support, shorten PICU stay, and decrease peri-operative transfusion requirements, with subsequent costs reduction, compared to H-CPB. Future studies are needed to validate and support wider use of N-CPB.
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Affiliation(s)
- Antonio F Corno
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom.,Cardiovascular Research Center, University of Leicester, Leicester, United Kingdom
| | - Claire Bostock
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Simon D Chiles
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Joanna Wright
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maria-Teresa Jn Tala
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Branko Mimic
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Mirjana Cvetkovic
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
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Factors Associated with the Need for, and the Impact of, Extracorporeal Membrane Oxygenation in Children with Congenital Heart Disease during Admissions for Cardiac Surgery. CHILDREN-BASEL 2017; 4:children4110101. [PMID: 29165381 PMCID: PMC5704135 DOI: 10.3390/children4110101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/02/2017] [Accepted: 11/15/2017] [Indexed: 12/21/2022]
Abstract
Introduction: This study aimed to determine factors associated with the need for extracorporeal membrane oxygenation (ECMO) in children with congenital heart disease (CHD) during admission for cardiac surgery (CS). A secondary aim was to determine how ECMO impacted length, cost, and mortality of the admission. Methods: Data from the Kids’ Inpatient Database (KIDS) were utilized. Admissions with CHD under 18 years of age with cardiac surgery were included. Need for ECMO in these admissions was then identified. Univariate analysis was conducted to compare characteristics between admissions with and without ECMO. Regression analyses were conducted to determine what factors were independently associated with ECMO and whether ECMO independently impacted admission characteristics. Results: A total of 46,176 admissions with CHD and CS were included in the final analysis. Of these, 798 (1.7%) required ECMO. Median age of ECMO admissions was 0.5 years. The following were associated with ECMO: decreased age, heart failure, acute kidney injury, arrhythmia, double outlet right ventricle, atrioventricular septal defect, transposition, Ebstein anomaly, hypoplastic left heart syndrome, common arterial trunk, tetralogy of Fallot, coronary anomaly, valvuloplasty, repair of total anomalous pulmonary venous connection, arterial switch, RV to PA conduit placement, and heart transplant (p < 0.01). ECMO independently increased length of stay by 17.8 days, cost of stay by approximately $415,917, and inpatient mortality 22-fold. Conclusion: Only a small proportion of CHD patients undergoing CS require ECMO, although these patients require increased resource utilization and have high mortality. Specific cardiac lesions, cardiac surgeries, and comorbidities are associated with increased need for ECMO.
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Kashyap A, Turek JW, Wagner SJ, Felderman L, Jaggers EA, Gruber PJ, Edens RE. Development of a Pediatric Cardiac Mechanical Support Program. Artif Organs 2017; 42:444-451. [PMID: 29105103 DOI: 10.1111/aor.12963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 03/21/2017] [Accepted: 04/12/2017] [Indexed: 02/01/2023]
Abstract
The development of a pediatric cardiac support program is a complex, multidisciplinary project. This study describes the University of Iowa Congenital Heart Program's experience from its inception to the present. In, we examine those specific factors that have led to substantial improvements in the program, additionally identifying where further gains can be made. We retrospectively reviewed all pediatric patients who received mechanical cardiac support at the University of Iowa from the inception of the program in 1991. In total, 29 patients received mechanical support between December 1991 and December 2015 and are included in the study. Twelve patients received continuous flow devices and 17 patients received pulsatile flow devices. Median age at implant was 12.8 years (range 0.1-18.2 years). Median weight at implant was 40.5 kg (3.2-123.4 kg). Factors examined included: operating room (OR) time, intensive care unit and hospital length of stay, intubation days, blood product usage, pre- and post-operative bilirubin, creatinine, natriuretic peptide B (NPPB), and device implanted. Categorical and continuous variables were compared using Chi-squared and Wilcoxon rank-sum tests, respectively. Of the 29 patients who received mechanical support, 17 (58.6%) were discharged home, 11 (37.9%) died during their hospitalization, and 1 (3.5%) remains hospitalized. Median length of ventricular assist device support was 59.5 days (range 1-653 days). Between December 1991 and December 2011, in-hospital mortality was 64.3%. Following this period, significant changes were made to patient management with in-hospital mortality decreasing to 13.3% between February 2013 and December 2015. Comparison between deceased and living patients revealed several significant factors including: median number of packed red blood cells transfused, 8 versus 4 units (P = 0.048), median OR time, 396 versus 299 min (P = 0.003), and device implanted. During the early stages of the mechanical support program, higher than expected mortality rates prompted changes in the management of pediatric cardiac patients, specifically, the development of a dedicated management team. These changes significantly improved outcomes and we suggest can be used as a model for similar cardiac support programs, especially in smaller volume programs.
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Affiliation(s)
- Abhishek Kashyap
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Joseph W Turek
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Samantha J Wagner
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.,Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Laura Felderman
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Elizabeth A Jaggers
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Peter J Gruber
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.,Departments of Surgery, Stem Cell Biology, and Regenerative Medicine, University of Southern California, Los Angeles, CA, USA
| | - R Erik Edens
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Kosiv KA, Gossett JM, Bai S, Collins RT. Congenital Heart Surgery on In-Hospital Mortality in Trisomy 13 and 18. Pediatrics 2017; 140:peds.2017-0772. [PMID: 29046387 DOI: 10.1542/peds.2017-0772] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Congenital heart disease (CHD) is common in trisomy 13 (T13) and trisomy 18 (T18), but surgical repair has not been offered in most centers. Data on outcomes of congenital heart surgery (CHS) for T13 and T18 are lacking. We sought to determine the impact of CHS on in-hospital mortality in T13 and T18. METHODS Data from the 2004 to 2015 Pediatric Health Information System database were used to identify inpatients with T13 or T18 and CHD. Data were restricted to newborns with T13 or T18 admitted at ≤14 days of age. Hospital readmissions were examined to analyze longer-term in-hospital mortality. In-hospital mortality and length of stay were compared between infants with and without CHD and with and without CHS. RESULTS The study cohort included 1020 infants with T18 and 648 infants with T13. CHD was present in 91% of infants with T18 and 86% of infants with T13. CHS was performed in 7% of each group. In-hospital mortality was decreased in those who underwent CHS (64% lower in T18 [P <.001]; 45% lower in T13 [P = .003]) and remained decreased throughout the 24 months of follow-up. In-hospital mortality was decreased in infants with higher weight, female sex, and older age at admission. CONCLUSIONS CHS is associated with decreased in-hospital mortality in T18 and T13. These results suggest CHS may be beneficial in select cases.
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Affiliation(s)
| | | | | | - R Thomas Collins
- Departments of Pediatrics and .,Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Abstract
OBJECTIVES The postsurgical care of children with congenital heart disease may be complicated by the need for cardiorespiratory support, including tracheostomy. The variation of the use of tracheostomy across multiple pediatric cardiac surgical centers has not been defined. We describe multicenter variation in the use of tracheostomy in children undergoing congenital heart surgery. DESIGN We retrospectively analyzed a multicenter cohort. SETTING Pediatric Health Information Systems database retrospective cohort. PATIENTS Children less than 18 years who underwent both tracheostomy and cardiac surgery (1/04-6/14). INTERVENTIONS Univariate and multivariate statistics were performed, stratifying by high (≥ 75th percentile) and low (≤ 25th percentile) tracheostomy volume and adjusting for patient characteristics in multivariate models. MEASUREMENTS AND MAIN RESULTS Out of 123,510 hospitalizations involving cardiac surgery, 1,292 tracheostomies (1.2%) were performed (46 hospitals). The rate of tracheostomy placement ranged from 0.3% to 2.5% with no difference in the rate of tracheostomy placement between high and low tracheostomy use centers (p = 0.8). The median time to tracheostomy was 63 days (interquartile range, 36-100), and there was no difference between high- and low-tracheostomy centers. High-tracheostomy centers had $420,000 lower hospital charges than low-volume centers (p = 0.03). Tracheostomy day greater than the median (63 d), Risk Adjustment for Congenital Heart Surgery-1 score 6, and extracorporeal membrane oxygenation were significantly associated with adjusted increased odds of mortality. Later hospital day of tracheostomy was associated with a $13,000/d increase in total hospital charges (p < 0.001). CONCLUSIONS Variation in the usage of tracheostomy in infants and children undergoing congenital heart surgery exists across the country. High-tracheostomy centers had lower hospital charges. Late tracheostomy placement, higher congenital heart disease surgical risk, and extracorporeal membrane oxygenation use are independent predictors of in-hospital mortality in this population.
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Shapiro MC, Henderson CM, Hutton N, Boss RD. Defining Pediatric Chronic Critical Illness for Clinical Care, Research, and Policy. Hosp Pediatr 2017; 7:236-244. [PMID: 28351944 DOI: 10.1542/hpeds.2016-0107] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronically critically ill pediatric patients represent an emerging population in NICUs and PICUs. Chronic critical illness has been recognized and defined in the adult population, but the same attention has not been systematically applied to pediatrics. This article reviews what is currently known about pediatric chronic critical illness, highlighting the unique aspects of chronic critical illness in infants and children, including specific considerations of prognosis, outcomes, and decision-making. We propose a definition that incorporates NICU versus PICU stays, recurrent ICU admissions, dependence on life-sustaining technology, multiorgan dysfunction, underlying medical complexity, and the developmental implications of congenital versus acquired conditions. We propose a research agenda, highlighting existing knowledge gaps and targeting areas of improvement in clinical care, research, and policy.
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Affiliation(s)
- Miriam C Shapiro
- Johns Hopkins University School of Medicine, Baltimore, Maryland; .,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- University of Mississippi Medical Center, Jackson, Mississippi; and.,Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Nancy Hutton
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
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Healthcare Disparities in Outcomes of a Metropolitan Congenital Heart Surgery Center: The Effect of Clinical and Socioeconomic Factors. J Racial Ethn Health Disparities 2017; 5:410-421. [PMID: 28849382 DOI: 10.1007/s40615-017-0384-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study is to identify the impact of demographic, socioeconomic, and clinical factors on congenital heart surgery outcomes. STUDY DESIGN This retrospective cohort study included 234 congenital heart surgery patients from 2011 through 2015, in a racially/ethnically diverse metropolitan children's hospital. Outcomes included length of stay (LOS), age at first echocardiogram, length of mechanical ventilation, and incidence of complications. RESULTS Compared to others, black children underwent their first echocardiogram at a later age (median 23 versus 2 days, p = 0.014) and were more likely to be diagnosed with congenital heart disease in the emergency room (p = 0.026). Hispanic children were more likely to have major non-cardiac congenital anomalies (p = 0.045). Increased LOS during elective admissions was associated with higher surgical complexity (STAT category 4 and 5 Estimate 3.905 days, p = 0.001), compared to STAT category 1, and number of complications (Estimate = 2.306 days per complication, p < 0.001). Increased LOS in non-elective admissions was associated with the number of complex chronic conditions (Estimate = 15.446 days, p = 0.045) and the number of complications (Estimate = 11.591 days per complication, p < 0.001). However, in multivariate analysis, race and ethnicity was not associated with increased LOS or age at first echocardiogram. CONCLUSION In this diverse setting, race/ethnicity was not associated with increased LOS, age at first echocardiogram, length of ventilation, or complications. Surgical complexity, chronic conditions, and complications were associated with increased LOS. We discuss some interventions to reduce disparities in congenital heart surgery outcomes.
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