Cardiopulmonary Interactions

Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study

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.

Application of high-flow nasal cannula in fibreoptic bronchoscopy after congenital heart surgery: a retrospective cohort study

BACKGROUND

The purpose of this study was to compare the effectiveness and safety of high-flow nasal cannula (HFNC) and conventional oxygen therapy (COT) in fibreoptic bronchoscopy (FB) after congenital heart surgery (CHS) in children.

METHODS

We did a retrospective cohort study using patients from the electronic medical record system of Fujian Children's Hospital in China. The study population was children who underwent FB in the cardiac intensive care unit after CHS for 1 year (May 2021-May 2022). Children were classified into HFNC and COT groups according to their oxygen therapy during FB. The primary outcome was oxygenation indices during FB, including pulse oximeter oxygen saturation (SpO2) and transcutaneous oxygen tension (TcPO2) during FB. Secondary outcomes were the number of interruptions during FB and their causes, and complications after FB.

RESULTS

We identified 107 children from the electronic medical record system, and 102 children after CHS were finally included in the study (53 in the HFNC group and 49 in the COT group). During the FB examination, TcPO2 and SpO2 were significantly higher in the HFNC group than in the COT group (TcPO2: 90.3±9.3 vs 80.6±11.1 mm Hg; SpO2: 95.6±2.5 vs 92.1%±2.0%, p<0.001) and the transcutaneous carbon dioxide tension was significantly lower than in the COT group (39.6±3.0 vs 43.5±3.9 mm Hg, p<0.001). During the FB, a total of 20 children in the COT group had 24 interruptions, and 8 children in the HFNC group had 9 interruptions (p=0.001). In terms of postoperative complications, eight cases had complications in the COT group and four complications in the HFNC group (p=0.223).

CONCLUSIONS

Among children undergoing FB after CHS, the application of HFNC was associated with better oxygenation and fewer procedural interruptions compared with COT, without an increased risk of postoperative complications.

Impact of intravenous fluid administration on cardiac output and oxygenation during cardiopulmonary resuscitation

BACKGROUND

The effect of intravenous fluid (IVF) administration during cardiopulmonary resuscitation (CPR) is an unexplored factor that may improve cardiac output (CO) during CPR. The aim of this study was to determine the effect of IVF administration on CO and oxygenation during CPR.

METHODS

This experimental animal study was performed in a critical care animal laboratory. Twenty-two Landrace-Yorkshire female piglets weighing 27-37 kg were anesthetized, intubated, and placed on positive pressure ventilation. Irreversible cardiac arrest was induced with bupivacaine. CPR was performed with a LUCAS 3 mechanical compression device. Pigs were randomized into IVF or no-IVF groups. Pigs in the IVF group were given 20 mL/kg of Plasma-Lyte (Baxter International, Deerfield, IL USA), infused from 15 to 35 min of CPR. CPR was maintained for 50 min with serial measurements of CO obtained using ultrasound dilution technology and partial pressure of oxygen (PaO₂).

RESULTS

A mixed-effects repeated measures analysis of variance was used to compare within-group, and between-group mean changes in CO and PaO₂ over time. CO and PaO₂ for the piglets were measured at 10-min intervals during the 50 min of CPR. CO was greater in the IVF compared with the control group at all time points during and after the infusion of the IVF. Mean PaO₂ decreased with time; however, at no time was there a significant difference in PaO₂ between the IVF and control groups.

CONCLUSIONS

Administration of IVF during CPR resulted in a significant increase in CO during CPR both during and after the IVF infusion. There was no statistically significant decrease in PaO₂ between the IVF and control groups.

Pleural and transpulmonary pressures to tailor protective ventilation in children

This review aims to: (1) describe the rationale of pleural (P_PL) and transpulmonary (P_L) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on P_L in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (P_ES) and P_L measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. P_L corresponds to the difference between airway pressure and P_PL Oesophageal manometry allows measurement of P_ES, a good surrogate of P_PL, to estimate P_L directly at the bedside. Lung stress is the P_L, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with P_L and P_PL being key components. P_L-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory P_L (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory P_L value close to zero; (2) Protective ventilation based on end-inspiratory P_L (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20-25 cmH₂O; (3) P_PL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) P_PL or P_L measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, P_PL and P_L measurements may help to characterise how changes in PEEP affect P_PL and potentially haemodynamics. In the PICU, P_PL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of P_PL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, P_ES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate P_PL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. P_PL and P_L monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of P_L and multimodal respiratory monitoring may be worth to be evaluated in the future.

State-of-the-art management of the acutely unwell child

Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.

Anesthetic management using high-flow nasal cannula therapy during cardiac catheter examination of a neonate with hypoplastic left heart syndrome

Background

Sedation during cardiac catheter examination in neonates with complex congenital heart disease is challenging, as even the slightest change in the circulatory or respiratory status can lead to hemodynamic collapse. Here, we report a case wherein we achieved adequate sedation with a high-flow nasal cannula (HFNC) for catheter examination in a neonate with a congenital cardiac anomaly.

Case presentation

An 11-day-old boy with hypoplastic left heart syndrome was scheduled for a cardiac catheter examination prior to the Norwood procedure. He underwent bilateral pulmonary artery banding (PAB) on day 1 and was receiving dobutamine, milrinone, alprostadil, and dexmedetomidine in addition to air and nitrogen insufflation via HFNC, which was applied following extubation on day 3 and nitrogen therapy on day 6 owing to persistent pulmonary overcirculation symptoms (tachypnea and low arterial blood pressure) despite bilateral PAB. A catheter examination was performed on day 11 with careful monitoring of expired carbon dioxide and observation of chest wall motion. Adequate sedation was provided with supplemental midazolam and fentanyl along with HFNC without tracheal intubation.

Conclusions

The findings from this case suggest that HFNC is a safe and effective tool for oxygenation during cardiac catheter examination under sedation in neonates.

Bedside critical ultrasound as a key to the diagnosis of obstructive atelectasis complicated with acute cor pulmonale and differentiation from pulmonary embolism: A case report

Acute attack of dyspnea may be combined with acute cor pulmonale (ACP). Rapid and accurate identification of the etiology of ACP is the key to its diagnosis and treatment. Echocardiography is a better imaging tool in the assessment of right ventricular function. Under the guidance of the theory of cardiopulmonary interaction, ultrasonography can detect lung lesions, which causes ACP. We report the case of a 67-year-old man who received mechanical ventilation for acute respiratory failure. Right ventricular dysfunction was detected by echocardiography. Lung ultrasound showed a high risk of pulmonary embolism. However, obstructive atelectasis should not be ruled out after increasing back area ultrasonography. To avoid pitfalls, combined cardiac and lung ultrasound should be used carefully and strictly.

Anesthetic Considerations in Pediatric Patients With Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) in pediatrics is a significant cause for morbidity and mortality in children. Congenital heart disease and cardiomyopathy are the leading etiologies of ADHF. It is common for these children to undergo diagnostic, therapeutic, or surgical procedure under anesthesia, which may be associated with significant morbidity and mortality. The importance of preanesthetic multidisciplinary planning with all involved teams, including anesthesia, cardiology, intensive care, perfusion, and cardiac surgery, cannot be emphasized enough. In order to safely manage these patients, it is imperative for the anesthesiologist to understand the complex pathophysiological interactions between cardiopulmonary systems and anesthesia during these procedures. This review discusses the etiology, pathophysiology, clinical manifestations, and perioperative management of these patients.

Hospital outcomes for pediatric heart transplant recipients undergoing tracheostomy: A multi-institutional analysis

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.

The effect of positive end-expiratory pressure on cardiac output and oxygen delivery during cardiopulmonary resuscitation

Background

Positive end-expiratory pressure (PEEP) is used to optimize oxygenation by preventing alveolar collapse. However, PEEP can potentially decrease cardiac output through cardiopulmonary interactions. The effect of PEEP on cardiac output during cardiopulmonary resuscitation (CPR) is not known.

Methods

This was a preclinical randomized, controlled, animal study conducted in an animal research facility on 25 Landrace-Yorkshire pigs. After inducing cardiac arrest, CPR was performed with LUCAS 3. During CPR, pigs were ventilated at a PEEP of 0, 5, 10, 15, 20 cmH₂O (randomly determined via lottery) for 9 min. Cardiac output, obtained via ultrasound dilution, and PaO₂ were measured, and oxygen delivery calculated for each PEEP.

Results

A mixed-effects repeated-measures analysis of variance was used to compare the baseline value adjusted mean cardiac output, PaO₂, and oxygen delivery between PEEP groups. Least significant difference test was used to conduct pairwise comparisons between PEEP groups. To determine optimum PEEP, Gaussian mixture model was applied to the adjusted means of cardiac output and oxygen delivery. Increasing PEEP to 10 and higher resulted in significant declines in cardiac output. A PEEP of 15 and higher resulted in significant declines in oxygen delivery. As PEEP was increased from 0 to 20, PaO₂ increased significantly. Gaussian mixture model identified the 0–5 PEEP group as providing optimal cardiac output and oxygen delivery, with PEEP of 5 providing the highest oxygen delivery.

Conclusions

A PEEP of 0–5 resulted in the optimal oxygen delivery and cardiac output during CPR, with PEEP of 5 resulting in higher oxygen delivery, and a slightly lower, statistically insignificant cardiac output than PEEP of 0.

Relevance of Microvascular Flow Assessments in Critically Ill Neonates and Children: A Systematic Review

OBJECTIVES

Resolution of impaired microvascular flow may lag the normalization of macrocirculatory variables. The significance of microcirculatory dysfunction in critically ill children and neonates is unknown, but microcirculatory variables can be measured using Doppler or videomicroscopy imaging techniques. We outline the current understanding of the role of the microcirculation in critical illness, review methods for its assessment, and perform a systematic review of how it has been monitored in critically ill neonates and children.

DESIGN

Systematic review (PROSPERO CRD42019117993).

SETTING

Not applicable.

SUBJECTS

Not applicable.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We systematically searched MEDLINE, EMBASE, PubMed, and Web of Science. We included studies of critically ill patients 0 to 18 years old investigating microcirculatory blood flow. Two reviewers analyzed abstracts and articles. Results were qualitatively analyzed due to study heterogeneity. A total of 2,559 abstracts met search criteria, of which 94 underwent full-text review. Of those, 36 met inclusion criteria. Seven studies investigated microcirculatory changes in critically ill children. Twenty studies investigated the microcirculatory changes in neonates with variable diagnoses compared with a diverse set of clinical endpoints. Nine studies assessed the effects of age, sex, and birth weight on microvascular flow in neonates. Across all studies, microcirculatory dysfunction was associated with poor outcomes and may not correlate with observed macrovascular function.

CONCLUSIONS

Assessment of microvascular flow in critically ill children and neonates is possible, although significant challenges remain. In many such patients, microvascular blood flow is disrupted despite medical management targeting normalized macrovascular variables. Future studies are needed to define normal pediatric microvascular flow variables and to assess the impact of patient and treatment factors on its function.

Extracorporeal Membrane Oxygenation in Pediatric Pulmonary Hypertension

OBJECTIVE

To describe the epidemiology, critical care interventions, and mortality of children with pulmonary hypertension receiving extracorporeal membrane oxygenation.

DESIGN

Retrospective analysis of prospectively collected multicenter data.

SETTING

Data entered into the Extracorporeal Life Support Organization database between January 2007 and November 2018.

PATIENTS

Pediatric patients between 28 days and 18 years old with a diagnosis of pulmonary hypertension.

MEASUREMENTS AND MAIN RESULTS

Six hundred thirty-four extracorporeal membrane oxygenation runs were identified (605 patients). Extracorporeal membrane oxygenation support type was pulmonary (43.1%), cardiac (40.2%), and extracorporeal cardiopulmonary resuscitation (16.7%). The majority of cannulations were venoarterial (80.4%), and 30% had a pre-extracorporeal membrane oxygenation cardiac arrest. Mortality in patients with pulmonary hypertension was 51.3% compared with 44.8% (p = 0.001) in those without pulmonary hypertension. In univariate analyses, significant predictors of mortality included age less than 6 months and greater than 5 years; pre-extracorporeal membrane oxygenation cardiac arrest; pre-extracorporeal membrane oxygenation blood gas with pH less than 7.12, PaCO2 greater than 75, PaO2 less than 35, and arterial oxygen saturation less than 60%; extracorporeal membrane oxygenation duration greater than 280 hours; extracorporeal cardiopulmonary resuscitation; and extracorporeal membrane oxygenation complications including cardiopulmonary resuscitation, inotropic support, myocardial stun, tamponade, pulmonary hemorrhage, intracranial hemorrhage, seizures, other hemorrhage, disseminated intravascular coagulation, renal replacement therapy, mechanical/circuit problem, and metabolic acidosis. A co-diagnosis of pneumonia was associated with significantly lower odds of mortality (odds ratio, 0.5; 95% CI, 0.3-0.8). Prediction models were developed using three sets of variables: 1) pre-extracorporeal membrane oxygenation (age, absence of pneumonia, and pH < 7.12; area under the curve, 0.62); 2) extracorporeal membrane oxygenation related (extracorporeal cardiopulmonary resuscitation, any neurologic complication, pulmonary hemorrhage, renal replacement therapy, and metabolic acidosis; area under the curve, 0.72); and 3) all variables combined (area under the curve, 0.75) (p < 0.001).

CONCLUSIONS

Children with pulmonary hypertension who require extracorporeal membrane oxygenation support have a significantly greater odds of mortality compared with those without pulmonary hypertension. Risk factors for mortality include age, absence of pneumonia, pre-extracorporeal membrane oxygenation acidosis, extracorporeal cardiopulmonary resuscitation, pulmonary hemorrhage, neurologic complications, renal replacement therapy, and acidosis while on extracorporeal membrane oxygenation. Identification of those pulmonary hypertension patients requiring extracorporeal membrane oxygenation who are at even higher risk for mortality may inform clinical decision-making and improve prognostic awareness.

Hypoplastic left heart syndrome: from fetus to fontan

The care of children with hypoplastic left heart syndrome is constantly evolving. Prenatal diagnosis of hypoplastic left heart syndrome will aid in counselling of parents, and selected fetuses may be candidates for in utero intervention. Following birth, palliation can be undertaken through staged operations: Norwood (or hybrid) in the 1st week of life, superior cavopulmonary connection at 4-6 months of life, and finally total cavopulmonary connection (Fontan) at 2-4 years of age. Children with hypoplastic left heart syndrome are at risk of circulatory failure their entire life, and selected patients may undergo heart transplantation. In this review article, we summarise recent advances in the critical care management of patients with hypoplastic left heart syndrome as were discussed in a focused session at the 12th International Conference of the Paediatric Cardiac Intensive Care Society held on 9 December, 2016, in Miami Beach, Florida.

The Fontan Procedure for Single-Ventricle Physiology

The Fontan procedure is the final procedure in staged palliation for patients with functional single-ventricle physiology. The goal of the procedure is to separate systemic and pulmonary blood flow by directing systemic venous return through the Fontan connection to the pulmonary arteries and the lungs without ventricular contribution. Following the procedure, pulmonary blood flow is completely passive and dependent on pressure gradients, resulting in complex postoperative cardiopulmonary interactions. Understanding the physiology is essential to effectively manage these patients. Critical care nurses caring for patients after a Fontan procedure must understand preoperative data, risk factors, and unique postoperative physiology so they can anticipate specific postoperative problems, recognize trends in clinical status, and develop an appropriate plan of care. This paper reviews the first 2 stages of single-ventricle palliation, relevant modifications to the Fontan procedure, important preoperative cardiac catheterization data, common postoperative problems, and outcomes after the Fontan procedure.

Imaging sublingual microcirculatory perfusion in pediatric patients receiving procedural sedation with propofol: A pilot study

Objective

Procedural sedation with propofol is widely used in the pediatric population. A well‐known side effect of propofol is a decrease in peripheral vascular resistance resulting in hypotension, but little is known about the effects on microcirculation in humans. We aimed to evaluate the effects of propofol on the sublingual microcirculatory perfusion by continuous video imaging in pediatric patients undergoing procedural sedation.

Methods

Patients admitted to the Pediatric Intensive Care Unit for procedural sedation were recruited. Oral microcirculation was measured employing a continuous monitoring strategy with incident dark‐field illumination imaging. Measurements were obtained before and 3 minutes after propofol induction. Total and perfused vessel densities, proportion of perfused vessels, microvascular flow index, blood vessel diameter (Ø_bv), and systemic hemodynamics were analyzed.

Results

Continuous measurements were achieved in seven patients. Three minutes after propofol induction mean arterial pressure decreased (P = 0.028) and total and perfused vessel densities increased by 12% (P = 0.018) and 16% (P = 0.018), respectively. MFI was unaltered and mean Ø_bv increased but not significantly.

Conclusions

Propofol induction induces a reduction in mean arterial pressure and a rise in sublingual microvascular perfusion. The observed effects of propofol on the sublingual microcirculation may be due to a decrease in microvascular resistance.

Safety of tracheal intubation in the presence of cardiac disease in paediatric ICUs

IntroductionChildren with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.Materials and methodsWe sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.

RESULTS

A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.

CONCLUSIONS

The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.

Effect of Location on Tracheal Intubation Safety in Cardiac Disease-Are Cardiac ICUs Safer?

OBJECTIVES

Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease.

DESIGN

Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children).

SETTING

Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016.

PATIENTS

Children with medical or surgical cardiac disease who underwent intubation in an ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002).

CONCLUSIONS

In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Purpose

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.

Methods

The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.

Results

The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.

Conclusions

These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.

Complex effects of high-flow nasal cannula therapy on hemodynamics in the pediatric patient after cardiac surgery

Background

The high-flow nasal cannula (HFNC) system has been widely used for children in various clinical settings. However, the physiological and clinical impact of HFNC therapy on the pediatric patient with respiratory distress after cardiac surgery has not been thoroughly investigated.

Main body of the abstract

It seems logical to use HFNC as a primary therapy for post-extubation respiratory failure after congenital heart surgery, in which low cardiac output syndrome and upper airway obstruction are commonly encountered; the HFNC therapy alleviates the work of breathing and large negative swings of intrathoracic pressure, which in turn helps to decrease the systemic ventricular afterload. When applying HFNC to patients after congenital heart surgery, however, consideration must be given to its diverse effects on hemodynamics because of the complex respiratory and cardiac pathophysiology in these patients. The positive pressure generated by HFNC can exert different effects on pulmonary vascular resistance depending on the lung condition, while its impact on cardiac output may also differ depending on the cardiac physiology. The hemodynamic effects of HFNC may become even more complex in a patient with a single ventricle. To better assess its physiologic effects in patients after cardiac surgery, future studies could utilize various modalities including esophageal balloon catheters, electrical impedance tomography, and near-infrared spectroscopy. At the same time, studies should focus on specific types of cardiac pathophysiology or surgery when evaluating the effects of HFNC, since it may exert various effects, depending on the cardiac physiology or preoperative pulmonary hemodynamics. Lastly, the optimal flow rate at which the benefit of HFNC is maximized through favorable cardiopulmonary interactions should be determined in future studies.

Short conclusion

Further studies are needed to better understand the effect of HFNC in different cardiac and respiratory physiologies, given their complexity in pediatric patients after cardiac surgery.