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Abdul-Khaliq H, Gomes D, Meyer S, von Kries R, Wagenpfeil S, Pfeifer J, Poryo M. Trends of mortality rate in patients with congenital heart defects in Germany-analysis of nationwide data of the Federal Statistical Office of Germany. Clin Res Cardiol 2024; 113:750-760. [PMID: 38436738 PMCID: PMC11026207 DOI: 10.1007/s00392-023-02370-6] [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: 01/28/2023] [Accepted: 12/30/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Congenital heart defects (CHD) are still associated with an increased morbidity and mortality. The aim of this study was to analyze trends of mortality rates in patients with CHD between 1998 and 2018 in Germany. METHODS Data of registered deaths with an underlying diagnosis of CHD were used to evaluate annual mortality between 1998 and 2018. Polynomial regressions were performed to assess annual changes in CHD-associated mortality rates by age groups. RESULTS During the 21-year study period, a total of 11,314 deaths were attributed to CHD with 50.9% of deaths in infants (age < 1 year) and 28.2% in neonates (age ≤ 28 days). The most frequent underlying CHDs associated with death were hypoplastic left heart syndrome (n = 1498, 13.2%), left ventricular outflow tract obstruction (n = 1009, 8.9%), atrial septal defects (n = 771, 6.8%), ventricular septal defects (n = 697, 6.2%), and tetralogy of Fallot (n = 673, 5.9%), and others (n = 6666, 58.9%). Among all patients, annual CHD-related mortality rates declined significantly between 1998 and 2010 (p < 0.0001), followed by a significant annual increase until 2018 (p < 0.0001). However, mortality rates in 2018 in all ages were significantly lower than in 1998. CONCLUSION Mortality in CHD patients decreased significantly between 1998 and 2010, but a substantial number of deaths still occurred and even significantly increased in the last 3 years of the observation period particularly in neonates and infants. This renewed slight increase in mortality rate during the last years was influenced mainly by high-risk neonates and infants. Assessment of factors influencing the mortality rate trends in association with CHD in Germany is urgently needed. Obligatory nationwide registration of death cases in relation to surgical and catheter interventions in CHD patients is necessary to provide additional valuable data on the outcome of CHD.
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Affiliation(s)
- Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, Kirrberger Straße, 66421, Homburg/Saar, Germany.
- Competence Network for Congenital Heart Defects, DZHK (German Centre for Cardiovascular Research), Berlin, Germany.
| | - Delphina Gomes
- Institute of Social Pediatrics and Adolescent Medicine, Division of Pediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Section of Intensive Care, Saarland University Medical Center, Homburg/Saar, Germany
| | - Rüdiger von Kries
- Institute of Social Pediatrics and Adolescent Medicine, Division of Pediatric Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jochen Pfeifer
- Department of Pediatric Cardiology, Saarland University Medical Center, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Kirrberger Straße, 66421, Homburg/Saar, Germany
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Mikulski MF, Linero A, Stromberg D, Affolter JT, Fraser CD, Mery CM, Lion RP. Analysis of haemodynamics surrounding blood transfusions after the arterial switch operation: a pilot study utilising real-time telemetry high-frequency data capture. Cardiol Young 2024:1-8. [PMID: 38450505 DOI: 10.1017/s104795112400009x] [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: 03/08/2024]
Abstract
BACKGROUND Packed red blood cell transfusions occur frequently after congenital heart surgery to augment haemodynamics, with limited understanding of efficacy. The goal of this study was to analyse the hemodynamic response to packed red blood cell transfusions in a single cohort, as "proof-of-concept" utilising high-frequency data capture of real-time telemetry monitoring. METHODS Retrospective review of patients after the arterial switch operation receiving packed red blood cell transfusions from 15 July 2020 to 15 July 2021. Hemodynamic parameters were collected from a high-frequency data capture system (SickbayTM) continuously recording vital signs from bedside monitors and analysed in 5-minute intervals up to 6 hours before, 4 hours during, and 6 hours after packed red blood cell transfusions-up to 57,600 vital signs per packed red blood cell transfusions. Variables related to oxygen balance included blood gas co-oximetry, lactate levels, near-infrared spectroscopy, and ventilator settings. Analgesic, sedative, and vasoactive infusions were also collected. RESULTS Six patients, at 8.5[IQR:5-22] days old and weighing 3.1[IQR:2.8-3.2]kg, received transfusions following the arterial switch operation. There were 10 packed red blood cell transfusions administered with a median dose of 10[IQR:10-15]mL/kg over 169[IQR:110-190]min; at median post-operative hour 36[IQR:10-40]. Significant increases in systolic and mean arterial blood pressures by 5-12.5% at 3 hours after packed red blood cell transfusions were observed, while renal near-infrared spectroscopy increased by 6.2% post-transfusion. No significant changes in ventilation, vasoactive support, or laboratory values related to oxygen balance were observed. CONCLUSIONS Packed red blood cell transfusions given after the arterial switch operation increased arterial blood pressure by 5-12.5% for 3 hours and renal near-infrared spectroscopy by 6.2%. High-frequency data capture systems can be leveraged to provide novel insights into the hemodynamic response to commonly used therapies such as packed red blood cell transfusions after paediatric cardiac surgery.
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Affiliation(s)
- Matthew F Mikulski
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Antonio Linero
- Department of Statistics and Data Sciences, College of Natural Sciences, The University of Texas at Austin, Austin, TX, USA
| | - Daniel Stromberg
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Jeremy T Affolter
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Richard P Lion
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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Long D, Anderson VA, Crossley L, Sood NT, Charles KR, MacDonald AD, Bora S, Pestell CF, Murrell K, Pride NA, Anderson PJ, Badawi N, Rose B, Baillie H, Masterson K, Chumbes Flores J, Sherring C, Raman S, Beca J, Erickson S, Festa M, Anderson BW, Venugopal P, Yim D, Andrews D, Cheung M, Brizard C, Gentles TL, Iyengar A, Nicholson I, Ayer J, Butt W, Schlapbach LJ, Gibbons KS. Longitudinal cohort study investigating neurodevelopmental and socioemotional outcomes in school-entry aged children after open heart surgery in Australia and New Zealand: the NITRIC follow-up study protocol. BMJ Open 2023; 13:e075429. [PMID: 37648380 PMCID: PMC10471882 DOI: 10.1136/bmjopen-2023-075429] [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: 05/08/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Despite growing awareness of neurodevelopmental impairments in children with congenital heart disease (CHD), there is a lack of large, longitudinal, population-based cohorts. Little is known about the contemporary neurodevelopmental profile and the emergence of specific impairments in children with CHD entering school. The performance of standardised screening tools to predict neurodevelopmental outcomes at school age in this high-risk population remains poorly understood. The NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial randomised 1371 children <2 years of age, investigating the effect of gaseous nitric oxide applied into the cardiopulmonary bypass oxygenator during heart surgery. The NITRIC follow-up study will follow this cohort annually until 5 years of age to assess outcomes related to cognition and socioemotional behaviour at school entry, identify risk factors for adverse outcomes and evaluate the performance of screening tools. METHODS AND ANALYSIS Approximately 1150 children from the NITRIC trial across five sites in Australia and New Zealand will be eligible. Follow-up assessments will occur in two stages: (1) annual online screening of global neurodevelopment, socioemotional and executive functioning, health-related quality of life and parenting stress at ages 2-5 years; and (2) face-to-face assessment at age 5 years assessing intellectual ability, attention, memory and processing speed; fine motor skills; language and communication; and socioemotional outcomes. Cognitive and socioemotional outcomes and trajectories of neurodevelopment will be described and demographic, clinical, genetic and environmental predictors of these outcomes will be explored. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Children's Health Queensland (HREC/20/QCHQ/70626) and New Zealand Health and Disability (21/NTA/83) Research Ethics Committees. The findings will inform the development of clinical decision tools and improve preventative and intervention strategies in children with CHD. Dissemination of the outcomes of the study is expected via publications in peer-reviewed journals, presentation at conferences, via social media, podcast presentations and medical education resources, and through CHD family partners. TRIAL REGISTRATION NUMBER The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as 'Gene Expression to Predict Long-Term Neurodevelopmental Outcome in Infants from the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) Study - A Multicentre Prospective Trial'. TRIAL REGISTRATION ACTRN12621000904875.
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Affiliation(s)
- Debbie Long
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Vicki A Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Psychology Service, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Louise Crossley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nikita Tuli Sood
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Karina R Charles
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Anna D MacDonald
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Samudragupta Bora
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Carmela F Pestell
- School of Psychological Science, University of Western Australia, Crawley, Western Australia, Australia
| | - Kathryn Murrell
- Consult Liaison Team, Starship Children's Hospital, Auckland, New Zealand
| | - Natalie A Pride
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Peter J Anderson
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
| | - Nadia Badawi
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Brian Rose
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Australian and New Zealand Fontan Advocacy Committee, HeartKids Australia Inc, Sydney, New South Wales, Australia
| | - Heidi Baillie
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Kate Masterson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jenipher Chumbes Flores
- Paediatric Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Claire Sherring
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Sainath Raman
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Benjamin W Anderson
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - Prem Venugopal
- School of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Cardiac Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Deane Yim
- Department of Paediatric Cardiology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - David Andrews
- Department of Cardiothoracic Surgery, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Michael Cheung
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Cardiology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Christian Brizard
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Cardiac Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Thomas L Gentles
- Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Ajay Iyengar
- Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Ian Nicholson
- Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Julian Ayer
- Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Warwick Butt
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zürich, Switzerland
| | - Kristen S Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
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Shimizu T, Kanazawa T, Sakura T, Shioji N, Shimizu K, Fukuhara R, Shinya T, Iwasaki T, Morimatsu H. Efficacy of prophylactic high-flow nasal cannula therapy for postoperative pulmonary complications after pediatric cardiac surgery: a prospective single-arm study. J Anesth 2023; 37:433-441. [PMID: 37058243 DOI: 10.1007/s00540-023-03187-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/26/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE This study investigated the incidence of postoperative pulmonary complications (PPC) when high-flow nasal cannula therapy (HFNC) is used prophylactically after pediatric cardiac surgery, and evaluated its efficacy. METHODS This was a single-arm prospective interventional study that was conducted in a tertiary teaching hospital with eight beds in the pediatric cardiac ICU after approval by the Ethics Committee. One-hundred children under the age of 48 months who were scheduled for cardiac surgery for congenital heart disease were recruited. HFNC was used for 24 h after extubation at a 2 L/kg/min flow rate. The primary outcome was the incidence of PPC within 48 h after extubation. PPC was defined as atelectasis and acute respiratory failure meeting certain criteria. We considered prophylactic HFNC as effective if the prevalence of PPC was < 10%, based on previous reports of reintubation rates of 6%-9% after pediatric cardiac surgery. RESULTS A total of 91 patients were finally included in the analysis. The incidence of PPC within 48 h after extubation was 18.7%, whereas atelectasis was observed in 13.2%, and acute respiratory failure in 8.8%. Reintubation rate within 48 h after extubation was 0%. CONCLUSIONS We found the incidence of PPC with prophylactic HFNC after planned extubation after pediatric cardiac surgery. However, the incidence was > 10%; therefore, we could not demonstrate its efficacy in this single-arm study. Further studies are needed to investigate whether the HFNC could be adapted as first-line oxygen therapy after pediatric cardiac surgery.
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Affiliation(s)
- Tatsuhiko Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
| | - Takanobu Sakura
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Naohiro Shioji
- Department of Anesthesia and Intensive Care, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | | | - Takayoshi Shinya
- Department of Community Medicine and Medical Science, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
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Acute Effects of Sodium Bicarbonate in Children with Congenital Heart Disease with Biventricular Circulation in Non-cardiac Arrest Situations. Pediatr Cardiol 2022; 43:1723-1727. [PMID: 35415814 DOI: 10.1007/s00246-022-02905-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
Despite the controversy, sodium bicarbonate is a commonly used medication in critically ill patients of all ages. There is a lack of data on the acute impact on hemodynamic parameters, biomarker indicators of cardiac output, and changes in vasoinotropic support after sodium bicarbonate therapy. In our retrospective study on children with biventricular circulation in pediatric cardiac intensive care unit receiving bicarbonate therapy: we analyzed its effects on arterial blood gases, heart rate, blood pressure (BP), central venous pressures (CVP), cerebral and renal near-infrared spectroscopy (NIRS), changes in vasoinotropic and ventilator changes before and after sodium bicarbonate administration. Thirty-one administrations of sodium bicarbonate in 23 patients with congenital heart disease without residual shunts were analyzed. The average age was 15.4 months, weight 7.7 kg, and the average bicarbonate dose was 1 meq/kg. There was an increase in arterial pH from 7.24 to 7.30 (p = 0.14) and bicarbonate changed from 18 to 20 mEq/L (p = 0.23). No clinically significant changes were found in the following parameters: heart rate (141 ± 20.1 to 136 ± 19), systolic BP (84 ± 17 to 86 ± 14 mmHg), diastolic BP (48 ± 12 to 49 ± 12 mmHg), cerebral NIRS (64 ± 12 to 65 ± 12), renal NIRS (80 ± 10 to 81 ± 7), CVP (9 ± 3 to 10 ± 4 mmHg), paCO2 (45 ± 26 to 42 ± 7 mmHg), paO2 (143 ± 78 to 127 ± 59 mmHg), serum lactate (2.2 ± 2.7 to 3.6 ± 3.8 mmol/L), and vasoinotropic score (7.5 ± 5.0 to 7.7 ± 4.7). Outside of a change in serum pH and bicarbonate levels no other significant changes were noted after sodium bicarbonate administration in children with congenital heart disease with fully septated, biventricular circulation. There was no improvement in systemic oxygen delivery.
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Abstract
BACKGROUND Targeted drug development efforts in patients with CHD are needed to standardise care, improve outcomes, and limit adverse events in the post-operative period. To identify major gaps in knowledge that can be addressed by drug development efforts and provide a rationale for current clinical practice, this review evaluates the evidence behind the most common medication classes used in the post-operative care of children with CHD undergoing cardiac surgery with cardiopulmonary bypass. METHODS We systematically searched PubMed and EMBASE from 2000 to 2019 using a controlled vocabulary and keywords related to diuretics, vasoactives, sedatives, analgesics, pulmonary vasodilators, coagulation system medications, antiarrhythmics, steroids, and other endocrine drugs. We included studies of drugs given post-operatively to children with CHD undergoing repair or palliation with cardiopulmonary bypass. RESULTS We identified a total of 127 studies with 51,573 total children across medication classes. Most studies were retrospective cohorts at single centres. There is significant age- and disease-related variability in drug disposition, efficacy, and safety. CONCLUSION In this study, we discovered major gaps in knowledge for each medication class and identified areas for future research. Advances in data collection through electronic health records, novel trial methods, and collaboration can aid drug development efforts in standardising care, improving outcomes, and limiting adverse events in the post-operative period.
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Inferior Vena Cava Collapsibility Index to Assess Central Venous Pressure in Perioperative Period Following Cardiac Surgery in Children. Pediatr Cardiol 2021; 42:560-568. [PMID: 33481045 DOI: 10.1007/s00246-020-02514-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
The inferior vena cava collapsibility index (IVCCI) is an ultrasound method used to assess central venous pressure (CVP). Our objective was to evaluate the correlation between IVCCI and CVP in children during the early period following surgery for congenital heart disease (CHD). Prospective study performed in a single tertiary care center. Patients ≤ 18 years old, who underwent cardiopulmonary bypass surgery for CHD, were enrolled. Ultrasound images of the inferior vena cava (IVC) were obtained at two time points; the first was within 2 h of arrival to the CICU and the second was 12-18 h from the first measurement. CVP measured by catheter placed during surgery was recorded within minutes of performing ultrasound. Maximum and minimum IVC diameters were measured by 2D images and M mode method. Seventy patients (47.1% males), with median age 7 months (IQR 4-47 months) and weight 6.9 kg (IQR 4.8-13.5 kg), were evaluated. The 2D IVCCI had inverse correlation with CVP in patients breathing spontaneously; r = - 0.76 (p < 0.01) and r = - 0.73 (p < 0.01), during the first and second measurements, respectively. The 2D IVCCI ≤ 0.24 had sensitivity, specificity, and negative predictive value of 94%, 79%, and 88.9% , respectively, to detect CVP ≥ 10 mmHg. No correlation was found between IVCCI and CVP during positive pressure ventilation. There is a significant inverse correlation between 2D IVCCI and CVP in spontaneously breathing children after surgery for CHD. Use of 2D IVCCI for monitoring CVP could reduce the frequency and duration of CVP catheters and their inherent complications.
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Krishnamoorthy V, Gadhinglajkar SV, Palanisamy N, Sreedhar R, Babu S, Dharan BS. Transthoracic intracardiac catheters in perioperative management of pediatric cardiac surgery patients: a single-center experience. Asian Cardiovasc Thorac Ann 2020; 29:735-742. [PMID: 33356353 DOI: 10.1177/0218492320983492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transthoracic intracardiac catheters inserted under direct vision in the pulmonary artery and left atrium during cardiac surgery play major roles in the management of patients with complex congenital heart disease. We aimed to analyze the utility of transthoracic intracardiac catheters in the perioperative management of pediatric cardiac surgery patients and review catheter-related morbidity. METHODS The computerized register of all pediatric cardiac surgery patients in whom transthoracic intracardiac catheters were inserted from 2012 to 2019 in a tertiary referral center were reviewed. RESULTS Transthoracic pulmonary artery and left atrial catheters were inserted in 89 and 71 patients, respectively. The most common indications for pulmonary artery and left atrial catheters were total anomalous pulmonary venous connection (52%) and total cavopulmonary connection (58%) respectively. The most common reason for elevated pulmonary artery and left atrial pressure after cardiopulmonary bypass was left ventricular dysfunction. Transthoracic pulmonary artery catheters helped in diagnosing pulmonary hypertensive crisis (29%), surgical decision-making (14%), and ventilator therapy (16%). Left atrial catheters helped in the diagnosis of left ventricular dysfunction (54%). The incidence of morbidity was 8.9% for transthoracic pulmonary artery catheters and 9.8% for left atrial catheters. CONCLUSION Transthoracic pulmonary artery catheters help in the diagnosis and management of pulmonary hypertensive crisis, for making perioperative surgical decisions, and during ventilator therapy. Transthoracic left atrial catheters help in the diagnosis of left ventricular dysfunction in the perioperative period. The diagnostic and treatment benefits provided by transthoracic intracardiac catheters outweigh the minor adverse events, supporting their continued use in the perioperative period.
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Affiliation(s)
- Vasanth Krishnamoorthy
- Division of Cardiothoracic & Vascular Anesthesia, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Shrinivas V Gadhinglajkar
- Division of Cardiothoracic & Vascular Anesthesia, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Nithiyanandan Palanisamy
- Division of Cardiothoracic & Vascular Anesthesia, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Rupa Sreedhar
- Division of Cardiothoracic & Vascular Anesthesia, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Saravana Babu
- Division of Cardiothoracic & Vascular Anesthesia, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Baiju S Dharan
- Department of Cardiothoracic & Vascular Surgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
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The effects of Vasoactive-Ventilation-Renal score on pediatric heart surgery. North Clin Istanb 2020; 7:329-334. [PMID: 33043256 PMCID: PMC7521093 DOI: 10.14744/nci.2020.77775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/14/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE: The effects of Vasoactive-Ventilation-Renal (VVR) score on the evaluation of pediatric heart surgery results were investigated in this study. METHODS: This retrospective study included children younger than 18 years of age who were operated for congenital heart disease between was July 1st- December 31st 2018. Patients who needed ECMO support at the first postoperative 72 hours were not included in the study group. The postoperative initial, 24th and 48th-hour Vasoactive-Inotrope Score (VIS) and VVR scores of all patients were calculated in the intensive care unit (ICU). The effects of these scores on lengthy ICU duration (PCILOS, duration more than the upper 25th percentile) and to the hospital mortality (before 30 days) were evaluated. RESULTS: There were 340 patients in this study. The median age was 12 months (1 day-18 years), and the median weight was 7 kg (2.5 -82 kg). 18% of the patients had single ventricle physiology. Total correction was performed in 88% of the patients. Median RACHS 1 score was 2 (1–6). PCILOS was>112 hours and total mortality was 4%. The 0th hour VVR ICU c index=0.73 (CI: 0.70–0.77), mortality c index=0.77 (CI: 0.69–0.85). VVR at 24th hour ICU c index=0.75 (CI: 0.71–0.79), mortality c index=0.86 (CI: 0.81–0.91). VVR at 48th-hour ICU c index=0.87 (CI: 0.82–0.92), mortality c index=0.92 (CI: 0.87–0.97). The VVR score at 48th-hour was a strong indicator for the prediction of both LICU duration (odds ratio [OR]: –1.44; p=0.001) and hospital mortality (OR: –1.28; p=0.001). CONCLUSION: The postoperative VVR score can be a strong determinant for the prediction of early clinical results in congenital heart disease patients, which were considerably a heterogeneous group.
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Comparison of End-of-Life Care Practices Between Children With Complex Chronic Conditions and Neonates Dying in an ICU Versus Non-ICUs: A Substudy of the Pediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) Project. Pediatr Crit Care Med 2020; 21:e236-e246. [PMID: 32091504 DOI: 10.1097/pcc.0000000000002259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe and compare characteristics of care provided at the end of life for children with chronic complex conditions and neonates who died in an ICU with those who died outside an ICU. DESIGN Substudy of a nation-wide retrospective chart review. SETTING Thirteen hospitals, including 14 pediatric and neonatal ICUs, two long-term institutions, and 10 community-based organizations in the three language regions of Switzerland. PATIENTS One hundred forty-nine children (0-18 yr) who died in the years 2011 or 2012. Causes of death were related to cardiac, neurologic, oncological, or neonatal conditions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical characteristics, therapeutic procedures, circumstances of death, and patterns of decisional processes were extracted from the medical charts. Ninety-three (62%) neonates (median age, 4 d) and children (median age, 23 mo) died in ICU, and 56 (38%) with a median age of 63 months outside ICU. Generally, ICU patients had more therapeutic and invasive procedures, compared with non-ICU patients. Changes in treatment plan in the last 4 weeks of life, such as do-not-resuscitate orders occurred in 40% of ICU patients and 25% of non-ICU patients (p < 0.001). In the ICU, when decision to withdraw life-sustaining treatment was made, time to death in children and newborns was 4:25 and 3:00, respectively. In institutions where it was available, involvement of specialized pediatric palliative care services was recorded in 15 ICU patients (43%) and in 18 non-ICU patients (78%) (p = 0.008). CONCLUSIONS This nation-wide study demonstrated that patients with a complex chronic condition who die in ICU, compared with those who die outside ICU, are characterized by fast changing care situations, including when to withdraw life-sustaining treatment. This highlights the importance of early effective communication and shared decision making among clinicians and families.
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Forman J, Beech R, Slugantz L, Donnellan A. A Review of Tetralogy of Fallot and Postoperative Management. Crit Care Nurs Clin North Am 2019; 31:315-328. [PMID: 31351553 DOI: 10.1016/j.cnc.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article discusses the anatomy and physiology of tetralogy of Fallot (TOF) and TOF variants. Indications for surgical repair, morbidity/mortalities, and surgical repair techniques are also reviewed. The article concludes with review of common postoperative complications and management strategies for arrhythmias, right ventricular dysfunction, low cardiac output, and residual defects.
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Affiliation(s)
- Johnna Forman
- Heinrich A. Werner Division of Pediatric Critical Care, University of Kentucky, Kentucky Children's Hospital, 800 Rose Street, MN 460, Lexington, KY 40536, USA.
| | - Rachel Beech
- Heinrich A. Werner Division of Pediatric Critical Care, University of Kentucky, Kentucky Children's Hospital, 800 Rose Street, MN 460, Lexington, KY 40536, USA
| | - Lucy Slugantz
- Pediatric Intensive Care Unit, University of Kentucky, Kentucky Children's Hospital, 800 Rose Street, MN 460, Lexington, KY 40536, USA
| | - Amy Donnellan
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 1002, Cincinnati, OH 45229, USA
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Abstract
OBJECTIVES Assess the effect of a simulation "boot camp" on the ability of pediatric nurse practitioners to identify and treat a low cardiac output state in postoperative patients with congenital heart disease. Additionally, assess the pediatric nurse practitioners' confidence and satisfaction with simulation training. DESIGN Prospective pre/post interventional pilot study. SETTING University simulation center. SUBJECTS Thirty acute care pediatric nurse practitioners from 13 academic medical centers in North America. INTERVENTIONS We conducted an expert opinion survey to guide curriculum development. The curriculum included didactic sessions, case studies, and high-fidelity simulation, based on high-complexity cases, congenital heart disease benchmark procedures, and a mix of lesion-specific postoperative complications. To cover multiple, high-complexity cases, we implemented Rapid Cycle Deliberate Practice method of teaching for selected simulation scenarios using an expert driven checklist. MEASUREMENTS AND MAIN RESULTS Knowledge was assessed with a pre-/posttest format (maximum score, 100%). A paired-sample t test showed a statistically significant increase in the posttest scores (mean [SD], pre test, 36.8% [14.3%] vs post test, 56.0% [15.8%]; p < 0.001). Time to recognize and treat an acute deterioration was evaluated through the use of selected high-fidelity simulation. Median time improved overall "time to task" across these scenarios. There was a significant increase in the proportion of clinically time-sensitive tasks completed within 5 minutes (pre, 60% [30/50] vs post, 86% [43/50]; p = 0.003] Confidence and satisfaction were evaluated with a validated tool ("Student Satisfaction and Self-Confidence in Learning"). Using a five-point Likert scale, the participants reported a high level of satisfaction (4.7 ± 0.30) and performance confidence (4.8 ± 0.31) with the simulation experience. CONCLUSIONS Although simulation boot camps have been used effectively for training physicians and educating critical care providers, this was a novel approach to educating pediatric nurse practitioners from multiple academic centers. The course improved overall knowledge, and the pediatric nurse practitioners reported satisfaction and confidence in the simulation experience.
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Abstract
UNLABELLED IntroductionDiagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU. METHODS Paediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015. RESULTS The response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient's condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors. CONCLUSIONS Paediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.
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Song IK, Kim EH, Lee JH, Kang P, Kim HS, Kim JT. Utility of Perioperative Lung Ultrasound in Pediatric Cardiac Surgery. Anesthesiology 2018; 128:718-727. [DOI: 10.1097/aln.0000000000002069] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
Pediatric cardiac patients are at risk for perioperative respiratory insufficiency. The objective of this study was to assess the utility of perioperative lung ultrasound examination in pediatric cardiac surgery.
Methods
In this randomized, controlled trial, children (5 yr old or younger) undergoing cardiac surgery were allocated into a control (n = 61) or intervention (n = 61) group. The control group received only lung ultrasound examinations at the end of surgery and 6 to 12 h after surgery. The intervention group received lung ultrasound examinations and an ultrasound-guided recruitment maneuver depending on ultrasound findings after inducing anesthesia, at the end of surgery, and 6 to 12 h after surgery. Primary outcomes were incidences of intra- and postoperative desaturation, and postoperative pulmonary complications. Multiple comparisons were corrected (P ≤ 0.017) in the primary outcome analysis.
Results
Of the 120 children included in the analysis, postoperative desaturation (64% vs. 27%; P < 0.001; odds ratio [OR], 0.210; 95% CI, 0.097 to 0.456) occurred more in the control group. The incidences of intraoperative desaturation (36% vs. 19%; P = 0.033; OR, 0.406; 95% CI, 0.176 to 0.939) and postoperative pulmonary complications (12% vs. 3%; P = 0.093; OR, 0.271; 95% CI, 0.054 to 1.361) were similar between the groups. Lung ultrasound scores were better in the intervention group than in the control group. Duration of mechanical ventilation was longer in the control group than in the intervention group (38 ± 43 vs. 26 ± 25 h; 95% CI of mean difference, 0 to 25; P = 0.048).
Conclusions
Perioperative lung ultrasound examination followed by ultrasound-guided recruitment maneuver helped decrease postoperative desaturation events and shorten the duration of mechanical ventilation in pediatric cardiac patients.
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Affiliation(s)
- In-Kyung Song
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Eun-Hee Kim
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Ji-Hyun Lee
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Pyoyoon Kang
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Hee-Soo Kim
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
| | - Jin-Tae Kim
- From the Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (I.-K.S.); and the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (E.-H.K., J.-H.L., P.K., H.-S.K., J.-T.K.)
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Olive MK, Owens GE. Current monitoring and innovative predictive modeling to improve care in the pediatric cardiac intensive care unit. Transl Pediatr 2018; 7:120-128. [PMID: 29770293 PMCID: PMC5938248 DOI: 10.21037/tp.2018.04.03] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The objectives of this review are (I) to describe the challenges associated with monitoring patients in the pediatric cardiac intensive care unit (PCICU) and (II) to discuss the use of innovative statistical and artificial intelligence (AI) software programs to attempt to predict significant clinical events. Patients cared for in the PCICU are clinically fragile and at risk for fatal decompensation. Current monitoring modalities are often ineffective, sometimes inaccurate, and fail to detect a deteriorating clinical status in a timely manner. Predictive models created by AI and machine learning may lead to earlier detection of patients at risk for clinical decompensation and thereby improve care for critically ill pediatric cardiac patients.
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Affiliation(s)
- Mary K Olive
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Gabe E Owens
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Murni IK, Musa NL. The Need for Specialized Pediatric Cardiac Critical Care Training Program in Limited Resource Settings. Front Pediatr 2018; 6:59. [PMID: 29594089 PMCID: PMC5861149 DOI: 10.3389/fped.2018.00059] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/27/2018] [Indexed: 12/30/2022] Open
Abstract
Congenital heart disease (CHD) is one of the major global health problems with the highest birth prevalence in low- and middle-income countries. In these populous countries, basic health services for the children with CHD, including surgery, are lacking. Even though surgery is performed, outcome after cardiac surgery is influenced by the quality of the postoperative management with a reported high morbidity and mortality. Henceforth, there is an urgent need for comprehensive interventions to provide high quality cardiac intensive care programs to improve the quality of pediatric cardiac surgery services in order to address high morbidity and mortality after cardiac surgery. The development and training of the health workers in the field of pediatric cardiac intensive care program is required. It is imperative to conduct this training prior to actual implementation of the program in limited resources settings.
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Affiliation(s)
- Indah K Murni
- Department of Pediatrics, Dr Sardjito Hospital, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ndidiamaka L Musa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, United States
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Abstract
In many parts of the world, mostly low- and middle-income countries, timely diagnosis and repair of congenital heart diseases (CHDs) is not feasible for a variety of reasons. In these regions, economic growth has enabled the development of cardiac units that manage patients with CHD presenting later than would be ideal, often after the window for early stabilisation - transposition of the great arteries, coarctation of the aorta - or for lower-risk surgery in infancy - left-to-right shunts or cyanotic conditions. As a result, patients may have suffered organ dysfunction, manifest signs of pulmonary vascular disease, or the sequelae of profound cyanosis and polycythaemia. Late presentation poses unique clinical and ethical challenges in decision making regarding operability or surgical candidacy, surgical strategy, and perioperative intensive care management.
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Beham K, Dave H, Kelly J, Frey B, Hug MI, Brotschi B. Transthoracic intracardiac catheters in pediatric cardiac patients: A single-center experience. Paediatr Anaesth 2017; 27:918-926. [PMID: 28707420 DOI: 10.1111/pan.13204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transthoracic intracardiac catheters are frequently inserted in children during congenital heart surgery for monitoring and vascular access purposes. Their use entails a small potential risk. AIM We aimed to evaluate both catheter-associated morbidities related to maintenance and removal of transthoracic intracardiac catheters in pediatric cardiac patients, and predictors for catheter-associated adverse events. METHODS Single-center retrospective cohort study of prospectively collected data of children aged 0-14 years receiving a transthoracic intracardiac catheter inserted in the operating room during 7 consecutive years at the University Children's Hospital Zurich. RESULTS A total of 115 transthoracic intracardiac catheters were placed in 112 patients: 45 right atrial, 68 left atrial, and 2 pulmonary artery catheters. Five catheters (4.3%) had to be removed due to catheter-associated adverse events (infection, 2; nonfunction, 2; and leakage 1). After catheter removal, 19% of patients suffered adverse events, these were minor in 16 (14%) and serious in 6 (5.1%) (symptomatic bleeding in four (3.5%) patients, pericardial tamponade leading to death in one (0.8%), and tension pneumothorax in one (0.8%)). Catheter position in the right atrium and the need for platelet transfusion prior to removal were risk factors for adverse events. CONCLUSIONS Transthoracic intracardiac catheters are useful in the management of specific patient groups with complex congenital heart defects. Adverse events do occur; most of them do not require intervention. The insertion technique plays an important role in avoiding adverse events. Strict guidelines for the use and removal of transthoracic intracardiac catheters are required. Low platelet count should delay catheter removal. The wealth of information and therapeutic options offered by these catheters appear to outweigh the associated potential adverse events in this specific patient group.
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Affiliation(s)
- Kristoffer Beham
- Department of Anesthesiology, Hospital of Uster, Uster, Switzerland
| | - Hitendu Dave
- Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Janet Kelly
- Department of Pediatric and Neonatal Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Bernhard Frey
- Department of Pediatric and Neonatal Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Maja I Hug
- Division of Pediatric Intensive Care, University Children's Hospital of Berne, Inselspital, Bern, Switzerland
| | - Barbara Brotschi
- Department of Pediatric and Neonatal Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
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Yousef N. To B or not to B; that might just be the question. The use of lung ultrasound in pediatric cardiac intensive care. Pediatr Pulmonol 2017; 52:421-422. [PMID: 27712035 DOI: 10.1002/ppul.23558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Nadya Yousef
- Department of Neonatal Intensive Care, Paris-Sud University Hospitals, AP-HP, Clamart, France
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Abstract
OBJECTIVE Use of hydrocortisone to treat refractory haemodynamic instability in patients recovering from surgery for congenital heart disease is common practice at many centres. We aimed to determine whether there is a relationship between total serum cortisol concentrations and haemodynamic response to this therapy. Material and methods We retrospectively reviewed patients <21 years who underwent cardiac surgery from 2011 to 2013, received hydrocortisone within 72 hours postoperatively, and had total serum cortisol measurements contemporaneous with its administration. Favourable responders were defined as patients in whom, at 24 hours after hydrocortisone initiation, either (1) systolic blood pressure was increased or unchanged and vasoactive-inotrope score was decreased or (2) systolic blood pressure increased by ⩾10% of baseline and vasoactive-inotrope score was unchanged. Variables were compared using t-tests or Mann-Whitney U tests as appropriate. RESULTS In total, 24 patients were reviewed, with a median age of 1.4 months and range of 0.1-232 months. Among them, 14 (58%) patients responded favourably to hydrocortisone. At 24 hours, the median change in vasoactive-inotrope score was -18% in favourable responders and +31% in those who did not respond favourably, p=0.001. The mean pre-hydrocortisone total serum cortisol in favourable responders was 17.4±10.9 µg/dl compared with 46.1±44.7 µg/dl in those who did not respond favourably, p=0.03. CONCLUSION Total serum cortisol obtained before initiation of hydrocortisone was significantly lower in patients who responded favourably to this therapy. Total serum cortisol may therefore be helpful in identifying children recovering from cardiac surgery who may or may not haemodynamically improve with hydrocortisone.
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Abstract
OBJECTIVES Viral respiratory infection is commonly considered a relative contraindication to elective cardiac surgery. We aimed to determine the frequency and outcomes of symptomatic viral respiratory infection in pediatric cardiac surgical patients. DESIGN Retrospective cohort study of children undergoing cardiac surgery. Symptomatic children were tested using a multiplex Polymerase Chain Reaction (respiratory virus polymerase chain reaction) panel capturing nine respiratory viruses. Tests performed between 72 prior to and 48 hours after PICU admission were included. Mortality, length of stay in PICU, and intubation duration were investigated as outcomes. SETTING Tertiary PICU providing state-wide pediatric cardiac services. PATIENTS Children less than 18 years admitted January 1, 2008 to November 29, 2014 for cardiac surgery. MEASUREMENTS AND MAIN RESULTS Respiratory virus polymerase chain reaction was positive in 73 (4.2%) of 1,737 pediatric cardiac surgical admissions, including 13 children with multiple viruses detected. Commonly detected viruses included rhino/enterovirus (48%), adenovirus (32%), parainfluenza virus 3 (10%), and respiratory syncytial virus (3%). Pediatric Index of Mortality 2, Aristotle scores, and cardiopulmonary bypass times were similar between virus positive and negative/untested cohorts. Respiratory virus polymerase chain reaction positive patients had a median 2.0 days greater PICU length of stay (p < 0.001) and longer intubation duration (p < 0.001). Multivariate analysis adjusting for age, Aristotle score, cardiopulmonary bypass duration, and need for preoperative PICU admission confirmed that virus positive patients had significantly greater intubation duration and PICU length of stay (p < 0.001). Virus positive patients were more likely to require PICU admission greater than 4 days (odds ratio, 3.5; 95% CI, 1.9-6.2) and more likely to require intubation greater than 48 hours (odds ratio, 2.5; 95% CI, 1.4-4.7). There was no difference in mortality. No association was found between coinfection and outcomes. CONCLUSIONS Pediatric cardiac surgical patients with a respiratory virus detected at PICU admission had prolonged postoperative recovery with increased length of stay and duration of intubation. Our results suggest that postponing cardiac surgery in children with symptomatic viral respiratory infection is appropriate, unless the benefits of early surgery outweigh the risk of prolonged ventilation and PICU stay.
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Liet JM, Barrière F, Gaillard-Le Roux B, Bourgoin P, Legrand A, Joram N. Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study. BMC Pediatr 2016; 16:180. [PMID: 27821162 PMCID: PMC5100099 DOI: 10.1186/s12887-016-0717-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/25/2016] [Indexed: 12/19/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a mode of assisted mechanical ventilation that delivers inspiratory pressure proportionally to the electrical activity of the diaphragm. To date, no pediatric study has focused on the effects of NAVA on hemodynamic parameters. This physiologic study with a randomized cross-over design compared hemodynamic parameters when NAVA or conventional ventilation (CV) was applied. Methods After a baseline period, infants received NAVA and CV in a randomized order during two consecutive 30-min periods. During the last 10 min of each period, respiratory and hemodynamic parameters were collected. No changes in PEEP, FiO2, sedation or inotropic doses were allowed during these two periods. The challenge was to keep minute volumes constant, with no changes in blood CO2 levels and in pH that may affect the results. Results Six infants who had undergone cardiac surgery (mean age 7.8 ± 4.1 months) were studied after parental consent. Four of them had low central venous oxygen saturation (ScvO2 < 65 %). The ventilatory settings resulted in similar minute volumes (1.7 ± 0.4 vs. 1.6 ± 0.6 ml/kg, P = 0.67) and in similar tidal volumes respectively with NAVA and with CV. There were no statistically significant differences on blood pH levels between the two modes of ventilation (7.32 ± 0.02 vs. 7.32 ± 0.04, P = 0.34). Ventilation with NAVA delivered lower peak inspiratory pressures than with CV: -32.7 % (95 % CI: -48.2 to –17.1 %, P = 0.04). With regard to hemodynamics, systolic arterial pressures were higher using NAVA: +8.4 % (95 % CI: +3.3 to +13.6 %, P = 0.03). There were no statistically significant differences on cardiac index between the two modes of ventilation. However, all children with a low baseline ScvO2 (<65 %) tended to increase their cardiac index with NAVA compared to CV: 2.03 ± 0.30 vs. 1.91 ± 0.39 L/min.m2 (median ± interquartile, P = 0.07). Conclusions This pilot study raises the hypothesis that NAVA could have beneficial effects on hemodynamics in children when compared to a conventional ventilatory mode that delivered identical PEEP and similar minute volumes. Trial registration ClinicalTrials.gov Identifier: NCT01490710. Date of registration: December 7, 2011.
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Affiliation(s)
- Jean-Michel Liet
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.
| | - François Barrière
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Bénédicte Gaillard-Le Roux
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Arnaud Legrand
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.,CIC-INSERM 1413, University of Nantes, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
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James C, Millar J, Horton S, Brizard C, Molesworth C, Butt W. Nitric oxide administration during paediatric cardiopulmonary bypass: a randomised controlled trial. Intensive Care Med 2016; 42:1744-1752. [DOI: 10.1007/s00134-016-4420-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/09/2016] [Indexed: 12/24/2022]
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Maher KO, Chang AC, Shin A, Hunt J, Wong HR. Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care. World J Pediatr Congenit Heart Surg 2016; 6:588-96. [PMID: 26467873 DOI: 10.1177/2150135115606087] [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] [Indexed: 01/18/2023]
Abstract
The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care.
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Affiliation(s)
- Kevin O Maher
- Children's Hospital of Atlanta, Cardiac Intensive Care Unit, Sibley Heart Center Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anthony C Chang
- Sharon Disney Lund Medical Intelligence and Innovation Institute (MI3), Children's Hospital of Orange County, Orange, CA, USA Honors Cooperative Program in Biomedical Informatics and Artificial Intelligence, Stanford School of Medicine, Stanford, CA, USA
| | - Andrew Shin
- Cardiac Intensive Care Unit, Lucille Packard Children's Hospital, Palo Alto, CA, USA Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliette Hunt
- Cardiac Intensive Care Unit, Children's Hospital of Orange County, Orange, CA, USA Department of Pediatrics, University of California at Irvine School of Medicine, Irvine, CA, USA
| | - Hector R Wong
- Pediatric Intensive Care Unit, Cincinnati Children's Hospital, Cincinnati, OH, USA Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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Miletic KG, Delius RE, Walters HL, Mastropietro CW. Prospective Validation of a Novel Vasoactive-Ventilation-Renal Score as a Predictor of Outcomes After Pediatric Cardiac Surgery. Ann Thorac Surg 2016; 101:1558-63. [PMID: 26872731 DOI: 10.1016/j.athoracsur.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND We sought to further validate the novel vasoactive-ventilation-renal (VVR) score in a prospective study of a heterogeneous cohort of children undergoing cardiac surgery that includes patients with single-ventricle anatomy and residual mixing lesions. METHODS We prospectively performed an observational study of all children less than 18 years of age who underwent surgery for congenital heart disease at our center from November 2013 to June 2014. We calculated VVR score as follows: vasoactive-inotrope score + ventilation index + (change in serum creatinine from baseline × 10). Admission, peak, and 48-hour measurements were recorded. Outcomes of interest were prolonged duration of mechanical ventilation and intensive care unit and hospital stays, represented by the upper 25% for all patients. Areas under the receiver-operating characteristic curves (AUC) were determined for all study timepoints and outcome variables. RESULTS Ninety-two patients were analyzed; their median age was 0.65 (range, 3 days to 17.9 years), and 17 (18%) had single-ventricle anatomy. The VVR measurements outperformed vasoactive-inotrope scores in isolation at all timepoints, with higher AUC values for all outcomes. Of the three timepoints assessed, the 48-hour VVR score most consistently predicted poor outcome, especially with regard to prolonged duration of mechanical ventilation (AUC 0.980) and prolonged intensive care unit stay (AUC 0.919). CONCLUSIONS In a heterogeneous population of children undergoing cardiac surgery, the 48-hour VVR score was a very strong predictor of outcomes, and outperformed the more traditional vasoactive-inotrope score. The VVR score, therefore, represents a novel and potentially powerful means of predicting clinical outcomes relatively early in the hospital course of these patients.
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Affiliation(s)
- Kyle G Miletic
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ralph E Delius
- Department of Surgery, Division of Cardiothoracic Surgery, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Henry L Walters
- Department of Surgery, Division of Cardiothoracic Surgery, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.
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Abstract
CHD is frequently associated with a genetic syndrome. These syndromes often present specific cardiovascular and non-cardiovascular co-morbidities that confer significant peri-operative risks affecting multiple organ systems. Although surgical outcomes have improved over time, these co-morbidities continue to contribute substantially to poor peri-operative mortality and morbidity outcomes. Peri-operative morbidity may have long-standing ramifications on neurodevelopment and overall health. Recognising the cardiovascular and non-cardiovascular risks associated with specific syndromic diagnoses will facilitate expectant management, early detection of clinical problems, and improved outcomes--for example, the development of syndrome-based protocols for peri-operative evaluation and prophylactic actions may improve outcomes for the more frequently encountered syndromes such as 22q11 deletion syndrome.
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Yuerek M, Rossano JW, Mascio CE, Shaddy RE. Postoperative management of heart failure in pediatric patients. Expert Rev Cardiovasc Ther 2015; 14:201-15. [PMID: 26560361 DOI: 10.1586/14779072.2016.1117388] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25-65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.
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Affiliation(s)
- Mahsun Yuerek
- a Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Joseph W Rossano
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Christopher E Mascio
- c Division of Pediatric Cardiothoracic Surgery, Department of Surgery , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Robert E Shaddy
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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Andrés AS, Miño CG, Diéguez EV, Boni L, Moreno JIC. Management of Specific Complications after Congenital Heart Surgery (I). ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ojped.2015.51011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Miletic KG, Spiering TJ, Delius RE, Walters HL, Mastropietro CW. Use of a novel vasoactive-ventilation-renal score to predict outcomes after paediatric cardiac surgery. Interact Cardiovasc Thorac Surg 2014; 20:289-95. [DOI: 10.1093/icvts/ivu409] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Oualha M, Urien S, Spreux-Varoquaux O, Bordessoule A, D'Agostino I, Pouard P, Tréluyer JM. Pharmacokinetics, hemodynamic and metabolic effects of epinephrine to prevent post-operative low cardiac output syndrome in children. Crit Care 2014; 18:R23. [PMID: 24456639 PMCID: PMC4056810 DOI: 10.1186/cc13707] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 01/09/2014] [Indexed: 11/16/2022] Open
Abstract
Introduction The response to exogenous epinephrine (Ep) is difficult to predict given the multitude of factors involved such as broad pharmacokinetic and pharmacodynamic between-subject variabilities, which may be more pronounced in children. We investigated the pharmacokinetics and pharmacodynamics of Ep, co-administered with milrinone, in children who underwent open heart surgical repair for congenital defects following cardiopulmonary bypass, including associated variability factors. Methods Thirty-nine children with a high risk of low cardiac output syndrome were prospectively enrolled. Ep pharmacokinetics, hemodynamic and metabolic effects were analyzed using the non-linear mixed effects modeling software MONOLIX. According to the final model, an Ep dosing simulation was suggested. Results Ep dosing infusions ranged from 0.01 to 0.23 μg.kg-1.min-1 in children whose weight ranged from 2.5 to 58 kg. A one-compartment open model with linear elimination adequately described the Ep concentration-time courses. Bodyweight (BW) was the main covariate influencing clearance (CL) and endogenous Ep production rate (q0) via an allometric relationship: CL(BWi) = θCL x (BWi)3/4 and q0(BWi) = θq0 x (BWi )3/4. The increase in heart rate (HR) and mean arterial pressure (MAP) as a function of Ep concentration were well described using an Emax model. The effect of age was significant on HR and MAP basal level parameters. Assuming that Ep stimulated the production rate of plasma glucose, the increases in plasma glucose and lactate levels were well described by turnover models without any significant effect of age, BW or exogenous glucose supply. Conclusions According to this population analysis, the developmental effects of BW and age explained a part of the pharmacokinetic and pharmacodynamics between-subject variabilities of Ep administration in critically ill children. This approach ultimately leads to a valuable Ep dosing simulation which should help clinicians to determine an appropriate a priori dosing regimen.
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Abstract
OBJECTIVE The specialty of pediatric cardiac critical care has undergone rapid scientific and clinical growth in the last 25 years. The Board of Directors of the Pediatric Cardiac Intensive Care Society assembled an updated list of sentinel references focused on the critical care of children with congenital and acquired heart disease. We encouraged board members to select articles that have influenced and informed their current practice or helped to establish the standard of care. The objective of this article is to provide clinicians with a compilation and brief summary of these updated 100 useful references. DATA SOURCES The list of 'One Hundred Useful References for Pediatric Cardiac Intensive Care' (2004) and relevant literature to the practice of cardiac intensive care. DATA SELECTION A subset of Pediatric Cardiac Intensive Care Society board members compiled the initial list of useful references in 2004, which served as the basis of the new updated list. Suggestions for relevant articles were submitted by the Pediatric Cardiac Intensive Care Society board members and selected pediatric cardiac intensivists with an interest in this project following the Society's meeting in 2010. Articles were considered for inclusion if they were named in the original list from 2004 or were suggested by Pediatric Cardiac Intensive Care Society board members and published before December 31, 2011. DATA EXTRACTION Following submission of the complete list by the Pediatric Cardiac Intensive Care Society board and contributing Society members, articles were complied by the two co-first authors (D.A., D.K.). The authors also performed Medline searches to ensure comprehensive inclusion of all relevant articles. The final list was then submitted to the Pediatric Cardiac Intensive Care Society board members, who ranked each publication. DATA SYNTHESIS Rankings were compiled and the top 100 articles with the highest scores were selected for inclusion in this publication. The two co-first authors (D.A., D.K.) reviewed all existing summaries and developed summaries of the newly submitted articles. CONCLUSIONS An updated compilation of 100 useful references for the critical care of children with congenital and acquired heart disease has been compiled and summarized here. Clinicians and trainees may wish to use this document as a reference for education in this complex and challenging subspecialty.
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Sasser WC, Robert SM, Carlo WF, Borasino S, Dabal RJ, Kirklin JK, Alten JA. Postoperative serum cortisol concentration and adrenal insufficiency in neonates undergoing open-heart surgery. World J Pediatr Congenit Heart Surg 2013; 3:214-20. [PMID: 23804777 DOI: 10.1177/2150135111431268] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND We sought to determine whether immediate postoperative serum cortisol concentration predicts adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass. We hypothesized that cortisol <10 µg/dL would be associated with increased catecholamine requirements and fluid resuscitation and would predict hemodynamic responsiveness to exogenous steroids. METHODS Retrospective study of 41 neonates was carried out for the levels of cortisol in the immediate postoperative period; of whom, 15 received steroids due to high levels of inotropic support. Laboratory and clinical outcomes were collected. RESULTS Median cortisol was 12 µg/dL (interquartile range: 5.2-27.4). Levels of cortisol <10 µg/dL was not associated with any clinical variable indicative of increased illness severity. Peak lactate (9.1 vs 11.8 mmol/L, P = .04) and maximum arteriovenous saturation difference ([Sao 2 - Svo 2] 28% vs 32%, P = .05) were both lower among patients with levels of cortisol <10 µg/dL. Six (40%) patients had a significant hemodynamic improvement within 24 hours after receiving steroids (responders), although there was no statistical difference between levels of cortisol in responders versus nonresponders. Level of cortisol was positively correlated with maximum lactate (P < .001), maximum Sao 2 - Svo 2 (P < .001), maximum inotrope score (P = .014), initial 24-hour fluid intake (P = .012), and time to negative fluid balance (P = .008) and was negatively correlated with initial 24-hour urine output (P < .001). CONCLUSIONS Low cortisol obtained in the immediate postoperative period is not associated with worse postoperative outcomes or predictive of steroid responsiveness. In contrast, elevated levels of cortisol are positively correlated with severity of illness. The use of an absolute cortisol threshold to identify adrenal insufficiency and/or guide steroid therapy in neonates after cardiac surgery is unjustified.
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Affiliation(s)
- William C Sasser
- Division of Critical Care, Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
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Georgiev S, Konstantinov G, Latcheva A, Mitev P, Mitev I, Lazarov S. Phrenic nerve injury after paediatric heart surgery: is aggressive plication of the diaphragm beneficial? Eur J Cardiothorac Surg 2013; 44:808-12. [DOI: 10.1093/ejcts/ezt110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lowry AW. Resuscitation and perioperative management of the high-risk single ventricle patient: first-stage palliation. CONGENIT HEART DIS 2013; 7:466-78. [PMID: 22985457 DOI: 10.1111/j.1747-0803.2012.00710.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Infants born with hypoplastic left heart syndrome or other lesions resulting in a single right ventricle face the highest risk of mortality among all forms of congenital heart disease. Before the modern era of surgical palliation, these conditions were universally lethal; recent refinements in surgical technique and perioperative management have translated into dramatic improvements in survival. Nonetheless, these infants remain at a high risk of morbidity and mortality, and an appreciation of single ventricle physiology is fundamental to the care of these high-risk patients. Herein, resuscitation and perioperative management of infants with hypoplastic left heart syndrome are reviewed. Basic neonatal and pediatric life support recommendations are summarized, and perioperative first-stage clinical management strategies are reviewed.
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Affiliation(s)
- Adam W Lowry
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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Penny DJ, Shekerdemian LS. The American Heart Association's recent scientific statement on cardiac critical care: implications for pediatric practice. CONGENIT HEART DIS 2012; 8:3-19. [PMID: 23280102 DOI: 10.1111/chd.12028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2012] [Indexed: 10/27/2022]
Abstract
A writing group sponsored by the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the Council on Quality of Care and Outcomes Research of The American Heart Association has recently formulated a roadmap to meet the changing needs of the patient with cardiovascular disease requiring critical care. Although this roadmap has been formulated primarily to address the care needs of the adult with critical cardiovascular disease, it contains useful lessons pertinent to the care of the patient with pediatric and congenital cardiovascular disease. In this document, we have examined The Statement and applied its framework to the evolving field of pediatric cardiac critical care.
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Affiliation(s)
- Daniel J Penny
- Division of Cardiology, Texas Children's Hospital, Houston, TX 77030, USA.
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Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes 2012; 6:42-9. [PMID: 23250980 DOI: 10.1161/circoutcomes.112.967968] [Citation(s) in RCA: 250] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite ongoing efforts to improve the quality of pediatric resuscitation, it remains unknown whether survival in children with in-hospital cardiac arrest has improved. METHODS AND RESULTS Between 2000 and 2009, we identified children (<18 years of age) with an in-hospital cardiac arrest at hospitals with >3 years of participation and >5 cases annually within the national Get With The Guidelines-Resuscitation registry. Multivariable logistic regression was used to examine temporal trends in survival to discharge. We also explored whether trends in survival were attributable to improvement in acute resuscitation or postresuscitation care and examined trends in neurological disability among survivors. Among 1031 children at 12 hospitals, the initial cardiac arrest rhythm was asystole and pulseless electrical activity in 874 children (84.8%) and ventricular fibrillation and pulseless ventricular tachycardia in 157 children (15.2%), with an increase in cardiac arrests due to pulseless electrical activity over time (P for trend <0.001). Risk-adjusted rates of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009 (adjusted rate ratio per year, 1.08; 95% confidence interval, 1.01-1.16; P for trend=0.02). Improvement in survival was driven largely by an improvement in acute resuscitation survival (risk-adjusted rates: 42.9% in 2000, 81.2% in 2009; adjusted rate ratio per year: 1.04; 95% confidence interval, 1.01-1.08; P for trend=0.006). Moreover, survival trends were not accompanied by higher rates of neurological disability among survivors over time (unadjusted P for trend=0.32), suggesting an overall increase in the number of survivors without neurological disability over time. CONCLUSIONS Rates of survival to hospital discharge in children with in-hospital cardiac arrests have improved over the past decade without higher rates of neurological disability among survivors.
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Affiliation(s)
- Saket Girotra
- University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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