1
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Werho DK, Fisk A, Yeh J, Rooney S, Wilkes R, Shin AY, Zhang W, Banerjee M, Gaies M. Measuring Critical Care Unit Performance Using a Postoperative Mechanical Ventilation Quality Metric. Ann Thorac Surg 2024; 117:440-447. [PMID: 36470563 DOI: 10.1016/j.athoracsur.2022.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/12/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Safely minimizing postoperative mechanical ventilation duration after congenital heart surgery could be a cardiac intensive care unit (CICU) quality measure. We aimed to measure CICU performance using duration of postoperative mechanical ventilation and identify organizational factors associated with this metric. METHODS Observational analysis of 16,848 surgical hospitalizations of patients invasively ventilated on admission from the operating room from 26 Pediatric Cardiac Critical Care Consortium CICUs. We fitted a multivariable model to predict duration of postoperative mechanical ventilation adjusting for pre- and postoperative factors to measure CICU performance accounting for postoperative illness severity. We used our model to calculate observed-to-expected (adjusted) ventilation duration ratios for each CICU, describe variation across CICUs, and characterize outliers based on bias-corrected bootstrap 95% CIs. We explored associations between organizational characteristics and patient-level adjusted ventilation duration by adding these as independent variables to the model. RESULTS We observed wide variation across CICUs in adjusted ventilation duration ratios, ranging from 0.7 to 1.7. Nine of 26 CICUs had statistically better than expected ventilation duration, while 10 were significantly worse than expected. Organizational characteristics associated with shorter adjusted ventilation duration included mixed (60%-90%) staffing by critical care or anesthesia-trained attendings, lower average attending-to-patient ratio, average CICU daily occupancy 80% to 90%, and greater nurse staffing ratios and experience. CONCLUSIONS CICU performance in postoperative duration of mechanical ventilation varies widely across Pediatric Cardiac Critical Care Consortium centers. Several potentially modifiable organizational factors are associated with this metric. Taken together, these findings could spur efforts to improve ventilation duration at outlier hospitals.
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Affiliation(s)
- David K Werho
- Division of Pediatric Cardiology, Department of Pediatrics, Rady Children's Hospital, UC San Diego, San Diego, California.
| | - Anna Fisk
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, Massachusetts
| | - Justin Yeh
- Division of Pediatric Cardiac Intensive Care Medicine, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sydney Rooney
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ryan Wilkes
- Division of Pediatric Cardiology, Department of Pediatrics, Levine Children's Hospital, Charlotte, North Carolina
| | - Andrew Y Shin
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
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2
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Kumar SR, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Husain SA, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for centers performing pediatric heart surgery in the United States. J Thorac Cardiovasc Surg 2023; 166:1782-1820. [PMID: 37777958 DOI: 10.1016/j.jtcvs.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minn
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | | | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Md
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, Calif
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, Mo
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Va
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, Calif
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tenn
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
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3
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Lasa JJ, Guffey D, Bhalala U, Thiagarajan RR. Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database. Pediatr Crit Care Med 2023; 24:910-918. [PMID: 37458512 DOI: 10.1097/pcc.0000000000003321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population. DESIGN Retrospective analysis of the Virtual Pediatric System database (VPS, LLC, Los Angeles, CA). SETTING PICUs categorized as either cardiac-only versus mixed ICU cohort type. PATIENTS Consecutive cardiac patients less than 18 years old experiencing cardiac arrest in the ICU and resuscitated using E-CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Event and time-stamp filtering identified E-CPR events. Patient, hospital, and event-related variables were aggregated for independent and multivariable mixed effects logistic regression to assess the association between ICU cohort type and survival. Among ICU admissions in the VPS database, 2010-2018, the prevalence of E-CPR was 0.07%. A total of 671 E-CPR events (650 patients) comprised the final cohort; congenital heart disease (84%) was the most common diagnosis versus acquired heart diseases. The majority of E-CPR events occurred in mixed ICUs (67%, n = 449) and in ICUs with greater than 20 licensed bed capacity (65%, n = 436). Survival to hospital discharge was 51% for the overall cohort. Independent logistic regression failed to reveal any association between survival to hospital discharge and ICU type (ICU type: cardiac ICU, odds ratio [OR], 1.01; 95% CI, 0.71-1.44; p = 0.95). However, multivariable logistic regression revealed an association between cardiac surgical patients and greater odds for survival (OR, 2.03; 95% CI, 1.40-2.95; p < 0.001). Also, there was an association between ICUs with capacity greater than 20 (vs not) and lower survival odds (OR, 0.65; 95% CI, 0.43-0.96). CONCLUSIONS The overall prevalence of E-CPR among critically ill children with cardiac disease observed in the VPS database is low. We failed to identify an association between ICU cohort type and survival. Further investigation into organizational factors is warranted.
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Affiliation(s)
- Javier J Lasa
- Division of Cardiology, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX
- Division of Critical Care, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX
| | - Utpal Bhalala
- Division of Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, TX
| | - Ravi R Thiagarajan
- Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA
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4
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Kumar SR, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Husain SA, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. Ann Thorac Surg 2023; 116:871-907. [PMID: 37777933 DOI: 10.1016/j.athoracsur.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, Texas
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, Virginia
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Geogria
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, California
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, North Carolina
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, Missouri
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Virginia
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, California
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tennessee
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
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5
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Sperotto F, Gearhart A, Hoskote A, Alexander PMA, Barreto JA, Habet V, Valencia E, Thiagarajan RR. Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review. Eur J Pediatr 2023; 182:4289-4308. [PMID: 37336847 PMCID: PMC10909121 DOI: 10.1007/s00431-023-05055-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Victoria Habet
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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6
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Ram Kumar S, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Adil Husain S, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. World J Pediatr Congenit Heart Surg 2023; 14:642-679. [PMID: 37737602 DOI: 10.1177/21501351231190353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, TX, USA
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, VA, USA
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Vanderbilt, TN, USA
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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7
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Perry T, Raymond TT, Fishbein J, Gaies MG, Sweberg T. Does Compliance with Resuscitation Practice Guidelines Differ Between Pediatric Intensive Care Units and Cardiac Intensive Care Units? J Intensive Care Med 2023:8850666231162568. [PMID: 36938706 DOI: 10.1177/08850666231162568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Objective: Hospitalized children with cardiac disease have the highest rate of cardiac arrest compared to other disease types. Different intensive care unit (ICU) models exist, but it remains unknown whether resuscitation guideline adherence is different between cardiac ICUs (CICU) and general pediatric ICUs (PICU). We hypothesize there is no difference in resuscitation practices between unit types. Design: Retrospective observational study. Setting: The American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) registry. Patients: Children < 18 years old with medical or surgical cardiac disease who had cardiopulmonary arrest from 2014 to 2018. Intervention: None. Measurements and Main Results: Events were assessed for compliance with GWTG-R achievement measures of time to first chest compressions ≤ 1 min, time to intravenous/intraosseous epinephrine ≤ 5 min, time to first shock ≤ 2 min for ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), and confirmation of endotracheal tube placement. Additional practices were evaluated for consistency with Pediatric Advanced Life Support (PALS) recommendations. Eight hundred and eighty-six patients were evaluated, 687 (79%) in CICUs and 179 (21%) in PICUs. 484 (56%) had surgical cardiac disease. There were no differences in GWTG-R achievement measures or PALS recommendations between ICU types in univariable or multivariable models. Amiodarone, lidocaine, and nonstandard medication use did not differ by unit type. Extracorporeal cardiopulmonary resuscitation (ECPR) was more common in CICUs for both medical (16% vs 7%) and surgical (25% vs 2.5%) categories (P < .0001). Conclusions: Resuscitation compliance for patients with cardiac disease is similar between CICUs and PICUs. Patients were more likely to receive ECPR in CICUs. Additional study should evaluate how ICU type affects arrest outcomes in children with cardiac disease.
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Affiliation(s)
- Tanya Perry
- The Heart Institute, 2518Cincinnati Children's Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tia T Raymond
- Division of Cardiac Critical Care, Department of Pediatrics, 203414Medical City Children's Hospital, Dallas, TX, USA
| | - Joanna Fishbein
- Biostatistics Unit, The Feinstein Institutes for Medical Research - Northwell Health, New York, USA
| | - Michael G Gaies
- The Heart Institute, 2518Cincinnati Children's Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Todd Sweberg
- Pediatric Critical Care Medicine, 554322Cohen Children's Medical Center of New York - Northwell Health, New York, USA
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8
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Genna C, Thekkan KR, Raymakers-Janssen PAMA, Gawronski O. Is nurse staffing associated with critical deterioration events on acute and critical care pediatric wards? A literature review. Eur J Pediatr 2023; 182:1755-1770. [PMID: 36763191 DOI: 10.1007/s00431-022-04803-2] [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: 12/05/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023]
Abstract
UNLABELLED Pediatric and neonatal patients admitted to acute and critical care wards may experience critical deterioration events that may lead to unexpected deaths if unrecognized and untreated promptly. Adequate levels and skill-mix of nurse staffing are essential for the quality of patient monitoring and response to deteriorating patients. Insufficient staffing may have an impact on the occurrence of missed care and consequently on critical deterioration events, increasing the risk of mortality and failure-to-rescue. To review the literature to explore the association between nurse staffing levels or skill-mix and pediatric and neonatal critical deterioration events, such as mortality, pediatric intensive care unit (PICU)/neonatal intensive care unit (NICU) unplanned admissions, cardiac arrests, and failure-to-rescue. A structured narrative literature review was performed. Pubmed, Cinhal, and Web of Science were searched from January 2010 to September 2022. Four independent reviewers conducted the study screening and data extraction. The quality of the studies included was evaluated using the Joanna Briggs Institute critical appraisal tools. Out of a total of 2319 studies, 15 met the inclusion criteria. A total of seven studies were performed in PICU, six in NICU, and two in general pediatric wards. Nurse staffing measures and outcomes definitions used were heterogeneous. Most studies suggested nursing skill-mix, increased working experience, or higher nursing degrees were associated with increased survival in PICU. Decreased nursing staffing levels were associated with increased mortality in NICU and mechanically ventilated patients in PICU. CONCLUSION Evidence on the association of nurse staffing and critical deterioration events in PICU and NICU is limited, while there is no evidence reported for pediatric wards. Future research is needed to determine adequate levels of nurse/patient ratios and proportion of registered nurses in the skill-mix for pediatric acute and critical care nursing to improve outcomes on in-patient wards. WHAT IS KNOWN • Adult nursing skill-mix, staffing ratios, and level of education are associated with patient mortality and failure to rescue. • In children, nurse staffing levels are associated with clinical outcomes. WHAT IS NEW • Evidence on the association of nurse staffing levels or skill-mix with pediatric or neonatal mortality is limited. • There is some evidence regarding the association of nursing work experience, certification, higher level degree with in-hospital survival in PICU.
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Affiliation(s)
- Catia Genna
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Kiara Ros Thekkan
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paulien A M A Raymakers-Janssen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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9
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Pollak U, Zemmour H, Shaked E, Magenheim J, Fridlich O, Korach A, Serraf AE, Mishaly D, Glaser B, Shemer R, Dor Y. Novel cfDNA Methylation Biomarkers Reveal Delayed Cardiac Cell Death after Open-heart Surgery. J Cardiovasc Transl Res 2023; 16:199-208. [PMID: 35978264 DOI: 10.1007/s12265-022-10295-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
The use of cardiopulmonary bypass (CPB) is thought to cause delayed cardiac damage. DNA methylation-based liquid biopsies are novel biomarkers for monitoring acute cardiac cell death. We assessed cell-free DNA molecules as markers for cardiac damage after open-heart surgery. Novel cardiomyocyte-specific DNA methylation markers were applied to measure cardiac cfDNA in the plasma of 42 infants who underwent open-heart surgery. Cardiac cfDNA was elevated following surgery, reflecting direct surgery-related tissue damage, and declined thereafter in most patients. The concentration of cardiac cfDNA post-surgery correlated with the duration of CPB and aortic cross clamping. Strikingly, cardiac cfDNA at 6 h predicted duration of mechanical ventilation and maximal vasoactive-inotropic score better than did maximal troponin levels. Cardiac cfDNA reveals heart damage associated with CPB, and can be used to monitor cardiac cell death, to predict clinical outcome of surgery and to assess performance of cardioprotective interventions.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hai Zemmour
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Elior Shaked
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Judith Magenheim
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Ori Fridlich
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Amit Korach
- Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Thoracic Surgery, Hadassah University Medical Center, Jerusalem, Israel
| | - Alain E Serraf
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Benjamin Glaser
- Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel.,Endocrinology and Metabolism Service, Hadassah University Medical Center, Jerusalem, Israel
| | - Ruth Shemer
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel.
| | - Yuval Dor
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel.
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10
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Sperotto F, Daverio M, Amigoni A, Gregori D, Dorste A, Allan C, Thiagarajan RR. Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2256178. [PMID: 36763356 PMCID: PMC9918886 DOI: 10.1001/jamanetworkopen.2022.56178] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
IMPORTANCE Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population. OBJECTIVE To investigate incidence, trends, and factors associated with IHCA and mortality in children with cardiac disease in the ICU. DATA SOURCES A systematic review was conducted using PubMed, Web of Science, EMBASE, and CINAHL, from inception to September 2021. STUDY SELECTION Observational studies on IHCA in pediatric ICU patients with cardiac disease were selected (age cutoffs in studies varied from age ≤18 y to age ≤21 y). DATA EXTRACTION AND SYNTHESIS Quality of studies was assessed using the National Institutes of Health Quality Assessment Tools. Data on incidence, mortality, and factors associated with IHCA or mortality were extracted by 2 independent observers. Random-effects meta-analysis was used to compute pooled proportions and pooled ORs. Metaregression, adjusted for type of study and diagnostic category, was used to evaluate trends in incidence and mortality. MAIN OUTCOMES AND MEASURES Primary outcomes were incidence of IHCA and in-hospital mortality. Secondary outcomes were proportions of patients who underwent extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) and those who did not achieve return of spontaneous circulation (ROSC). RESULTS Of the 2574 studies identified, 25 were included in the systematic review (131 724 patients) and 18 in the meta-analysis. Five percent (95% CI, 4%-6%) of children with cardiac disease in the ICU experienced IHCA. The pooled in-hospital mortality among children who experienced IHCA was 51% (95% CI, 42%-59%). Thirty-nine percent (95% CI, 29%-51%) did not achieve ROSC; in centers with ECMO, 22% (95% CI, 14%-33%) underwent ECPR, whereas 22% (95% CI, 12%-38%) were unable to be resuscitated. Both incidence of IHCA and associated in-hospital mortality decreased significantly in the last 20 years (both P for trend < .001), whereas the proportion of patients not achieving ROSC did not significantly change (P for trend = .90). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, prearrest mechanical ventilation or ECMO, and higher surgical complexity were associated with increased incidence of IHCA and mortality odds. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found that 5% of children with cardiac disease in the ICU experienced IHCA. Decreasing trends in IHCA incidence and mortality suggest that education on preventive interventions, use of ECMO, and post-arrest care may have been effective; however, there remains a crucial need for developing resuscitation strategies specific to children with cardiac disease.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Laboratories of Epidemiological Methods and Biostatistics, Department of Environmental Medicine and Public Health, University of Padova, Italy
| | - Anna Dorste
- Boston Children’s Hospital Library, Boston Children’s Hospital, Boston, Massachusetts
| | - Catherine Allan
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi R. Thiagarajan
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Riley CM, Murphy LD, Mastropietro CW. Cardiac Arrest in Children Following Cardiac Surgery: A Scoping Review of Contributing Factors. World J Pediatr Congenit Heart Surg 2022; 13:475-481. [PMID: 35757944 DOI: 10.1177/21501351221100791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nearly half of children experiencing cardiac arrest following cardiac surgery do not survive hospital discharge and patients who survive often experience significant neurological impairment. Additionally, increased resource utilization following cardiac arrest translates into adverse logistical and financial consequences. Although some studies have identified patient characteristics that increase the risk of cardiac arrest after pediatric cardiac surgery, modifiable risk factors, which could provide a foundation for effective prevention strategies, have been elusive. This scoping review explores the current knowledge surrounding risk factors associated with cardiac arrest in children following cardiac surgery and provides recommendations for future research.
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Affiliation(s)
| | - Lee D Murphy
- Indiana University School of Medicine, Riley 548952Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Indiana University School of Medicine, Riley 548952Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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12
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Lasa JJ, Banerjee M, Zhang W, Bailly DK, Sasaki J, Bertrandt R, Raymond TT, Olive MK, Smith A, Alten J, Gaies M. Critical Care Unit Organizational and Personnel Factors Impact Cardiac Arrest Prevention and Rescue in the Pediatric Cardiac Population. Pediatr Crit Care Med 2022; 23:255-267. [PMID: 35020714 DOI: 10.1097/pcc.0000000000002892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patient-level factors related to cardiac arrest in the pediatric cardiac population are well understood but may be unmodifiable. The impact of cardiac ICU organizational and personnel factors on cardiac arrest rates and outcomes remains unknown. We sought to better understand the association between these potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue. DESIGN Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry. SETTING Pediatric cardiac ICUs. PATIENTS All cardiac ICU admissions were evaluated for cardiac arrest and survival outcomes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Successful prevention was defined as the proportion of admissions with no cardiac arrest (inverse of cardiac arrest incidence). Rescue was the proportion of patients surviving to cardiac ICU discharge after cardiac arrest. Cardiac ICU organizational and personnel factors were captured via site questionnaires. The associations between organizational and personnel factors and prevention/rescue were analyzed using Fine-Gray and multinomial regression, respectively, accounting for clustering within hospitals. We analyzed 54,521 cardiac ICU admissions (29 hospitals) with 1,398 cardiac arrest events (2.5%) between August 1, 2014, and March 5, 2019. For both surgical and medical admissions, lower average daily cardiac ICU occupancy was associated with better cardiac arrest prevention. Better rescue for medical admissions was observed for higher registered nursing hours per patient day and lower proportions of "part time" cardiac ICU physician staff (< 6 service weeks/yr). Increased registered nurse experience was associated with better rescue for surgical admissions. Increased proportion of critical care certified nurses, full-time intensivists with critical care fellowship training, dedicated respiratory therapists, quality/safety resources, and annual cardiac ICU admission volume were not associated with improved prevention or rescue. CONCLUSIONS Our multi-institutional analysis identified cardiac ICU bed occupancy, registered nurse experience, and physician staffing as potentially important factors associated with cardiac arrest prevention and rescue. Recognizing the limitations of measuring these variables cross-sectionally, additional studies are needed to further investigate these organizational and personnel factors, their interrelationships, and how hospitals can modify structure to improve cardiac arrest outcomes.
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Affiliation(s)
- Javier J Lasa
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Wenying Zhang
- PC 4 Data Coordinating Center, Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor, MI
| | - David K Bailly
- Primary Children's, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Jun Sasaki
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL
| | - Rebecca Bertrandt
- Division of Pediatric Critical Care, Children's Wisconsin, Milwaukee, WI
| | - Tia T Raymond
- Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX
| | - Mary K Olive
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Andrew Smith
- Monroe Carell Jr Children's Hospital at Vanderbilt, Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jeffrey Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael Gaies
- Monroe Carell Jr Children's Hospital at Vanderbilt, Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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13
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Yu P, Esangbedo I, Zhang X, Hanna R, Niles DE, Nadkarni V, Raymond T. Paediatric In-hospital cardiopulmonary resuscitation quality and outcomes in children with CHD during nights and weekends. Cardiol Young 2022; 33:1-10. [PMID: 35057875 DOI: 10.1017/s1047951122000099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Survival after paediatric in-hospital cardiac arrest is worse on nights and weekends without demonstration of disparity in cardiopulmonary resuscitation quality. It is unknown whether these findings differ in children with CHD. This study aimed to determine whether cardiopulmonary resuscitation quality might explain the hypothesised worse outcomes of children with CHD during nights and weekends. METHODS In-hospital cardiac arrest data collected by the Pediatric Resuscitation Quality Collaborative for children with CHD. Chest compression quality metrics and survival outcomes were compared between events that occurred during day versus night, and during weekday versus weekend using multivariable logistic regression. RESULTS We evaluated 3614 sixty-second epochs of chest compression data from 132 subjects between 2015 and 2020. There was no difference in chest compression quality metrics during day versus night or weekday versus weekend. Weekday versus weekend was associated with improved survival to hospital discharge (adjusted odds ratio 4.56 [1.29,16.11]; p = 0.02] and survival to hospital discharge with favourable neurological outcomes (adjusted odds ratio 6.35 [1.36,29.6]; p = 0.02), but no difference with rate of return of spontaneous circulation or return of circulation. There was no difference in outcomes for day versus night. CONCLUSION For children with CHD and in-hospital cardiac arrest, there was no difference in chest compression quality metrics by time of day or day of week. Although there was no difference in outcomes for events during days versus nights, there was improved survival to hospital discharge and survival to hospital discharge with favourable neurological outcome for events occurring on weekdays compared to weekends.
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Affiliation(s)
- Priscilla Yu
- University of Texas Southwestern Medical Center, Department of Pediatrics, Division of Critical Care Medicine, Dallas, TX, USA
| | - Ivie Esangbedo
- University of Washington, Department of Pediatrics, Division of Critical Care, Section of Cardiac Critical Care, Seattle, Washington, USA
| | - Xuemei Zhang
- The Children's Hospital of Philadelphia, Department of Biomedical and Health Informatics, Philadelphia, PA, USA
| | - Richard Hanna
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care, Philadelphia, PA, USA
| | - Dana E Niles
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care, Philadelphia, PA, USA
| | - Vinay Nadkarni
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Tia Raymond
- Medical City Dallas Hospital, Department of Pediatrics, Cardiac Intensive Care, Dallas, TX, USA
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14
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Klinische Notfallausbildung in der Pädiatrie. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01250-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Zusammenfassung
Hintergrund und Fragestellung
Die klinische Notfallausbildung von WeiterbildungsassistentInnen (WBA) ist uneinheitlich. Pädiatrische Reanimationen sind seltener erforderlich als Reanimationen erwachsener Patienten; erstversorgende Teams treffen ad hoc zusammen und stehen initial oft unter der Leitung junger ÄrztInnen. Die Teamzusammenarbeit ist von besonderer Bedeutung für das Überleben und Outcome der PatientInnen.
Ziel der Arbeit
Die subjektive Sicherheit im Notfallmanagement der WBA in sächsischen Kinderkliniken sollte ermittelt werden.
Material und Methoden
Hierzu wurde ein Erhebungsbogen für eine webbasierte Umfrage entwickelt, die folgende Aspekte umfasste: Berufserfahrung, innerhäusliche Ausbildung, Erfahrung und gefühlte Sicherheit im Management von Notfallsituationen.
Ergebnisse
Von geschätzten 230 Pädiatrie-WBA in Sachsen antworteten 66 (ca. 29 %). Es fühlten sich 14 % der WBA gut (3 % sehr gut) für Notfallsituationen ausgebildet, wobei 11 % auch eine (sehr) gute Sicherheit in der Teamleitung von Notfällen angaben. Demgegenüber hatten 42 % bereits eine oder mehrere Reanimationen als TeamleiterInnen erlebt. Von den befragten WBA gaben 42 % an, in den letzten 12 Monaten kein Simulationstraining absolviert zu haben; die Mehrzahl der WBA wünscht sich jedoch mehr Training.
Schlussfolgerung
Die Ergebnisse zeigen, dass sich viele WBA in sächsischen Kinderkliniken im Notfallmanagement unzureichend ausgebildet fühlen. Es besteht eine deutliche Diskrepanz zwischen den tatsächlichen Anforderungen und der innerklinischen Ausbildung.
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15
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Ravishankar C, Naim MY. Prediction of Cardiac Arrest: A Dream or Reality? J Am Coll Cardiol 2021; 77:3193-3194. [PMID: 34167644 DOI: 10.1016/j.jacc.2021.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Chitra Ravishankar
- Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Maryam Y Naim
- Department of Anesthesia and Critical Care Medicine, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Reducing Cardiac Arrests in the PICU: Initiative to Improve Time to Administration of Prearrest Bolus Epinephrine in Patients With Cardiac Disease. Crit Care Med 2021; 48:e542-e549. [PMID: 32304416 DOI: 10.1097/ccm.0000000000004349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of a quality-improvement initiative in reducing cardiac arrests in infants and children in the cardiac ICU. DESIGN Prospective observational before-after cohort study. SETTING Single pediatric cardiac ICU in the United Kingdom. PATIENTS All patients less than 18 years old admitted to the ICU. INTERVENTION Initial interdisciplinary training in cardiac arrest prevention followed by clinical practice change whereby patients with high-risk myocardium were identified on daily rounds. High-risk patients had bolus epinephrine preordered and prepared for immediate administration in the event of acute hypotension. MEASUREMENTS AND MAIN RESULTS Interrupted time series analysis was used to compare the cardiac arrest rate in the 18 months before and 4.5 years after implementation. Mean monthly cardiac arrest rate was 17.2 per 1,000 patient days before and 7.6 per 1,000 patient days after the initiative (56% decrease). Patient characteristics and ICU interventions were similar in the control and intervention periods. In the time series analysis, monthly cardiac arrest rate in the ICU decreased by 12.4 per 1,000 patient days (95% CI, -1.5 to -23.3; p = 0.03) immediately following the intervention, followed by a nonsignificant downward trend of 0.36 per 1,000 patient days per month (95% CI, -1.3 to 0.6; p = 0.44). Bolus epinephrine was administered during 110 hypotension events in 77 patients (eight administrations per 1,000 ICU days); responder rate was 77%. There were no significant changes in ICU and hospital mortality. CONCLUSIONS Implementation of the initiative led to a significant, sustained reduction in ICU cardiac arrest rate.
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Mustafa K, Buckley H, Feltbower R, Kumar R, Scholefield BR. Epidemiology of Cardiopulmonary Resuscitation in Critically Ill Children Admitted to Pediatric Intensive Care Units Across England: A Multicenter Retrospective Cohort Study. J Am Heart Assoc 2021; 10:e018177. [PMID: 33899512 PMCID: PMC8200770 DOI: 10.1161/jaha.120.018177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Cardiopulmonary arrests are a major contributor to mortality and morbidity in pediatric intensive care units (PICUs). Understanding the epidemiology and risk factors for CPR may inform national quality improvement initiatives. Methods and Results A retrospective cohort analysis using prospectively collected data from the Paediatric Intensive Care Audit Network database. The Paediatric Intensive Care Audit Network contains data on all PICU admissions in the United Kingdom. We identified children who received cardiopulmonary resuscitation (CPR) in 23 PICUs in England (2013-2017). Incidence rates of CPR and associated factors were analyzed. Logistic regression was used to estimate the size and precision of associations. Cumulative incidence of CPR was 2.2% for 68 114 admissions over 5 years with an incidence rate of 4.9 episodes/1000 bed days. Cardiovascular diagnosis (odds ratio [OR], 2.30; 95% CI, 2.02-2.61), age <1 year (OR, 1.84; 95% CI, 1.65-2.04), the Paediatric Index of Mortality 2 score on admission (OR, 1.045; 95% CI, 1.042-1.047) and longer length of stay (OR, 1.013; 95% CI, 1.012-1.014) were associated with increased odds of receiving CPR. We also found a higher risk of CPR associated with a history of preadmission cardiac arrest (OR, 20.69; [95% CI, 18.16-23.58) and for children with a cardiac condition admitted to a noncardiac PICU (OR, 2.75; 95% CI, 1.91-3.98). Children from Black (OR, 1.68; 95% CI, 1.36-2.07) and Asian (OR, 1.49; 95% CI, 1.28-1.74) racial/ethnic backgrounds were at higher risk of receiving CPR in PICU than White children. Conclusions Data from this first multicenter study from England provides a foundation for further research and evidence for benchmarking and quality improvement for prevention of cardiac arrests in PICU.
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Affiliation(s)
- Khurram Mustafa
- Paediatric Intensive Care Leeds Children's Hospital United Kingdom
| | | | | | - Ramesh Kumar
- Paediatric Intensive Care Leeds Children's Hospital United Kingdom
| | - Barnaby R Scholefield
- Birmingham Acute Care Research Group Institute of Inflammation and AgeingUniversity of Birmingham United Kingdom.,Paediatric Intensive Care Birmingham Women and Children's Hospital NHS Foundation Trust United Kingdom
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18
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Carroll K, Frey-Moylan G. Nursing Perspectives and Knowledge With an Acuity Adaptable Model. Nurs Sci Q 2020; 33:128-131. [PMID: 32180512 DOI: 10.1177/0894318419901283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An acuity adaptable pediatric cardiac care model provides healthcare centered on the practice of having the child remain in the same unit and receive care from the same clinical team from admission to discharge. This means the child is managed as they progress from an acute, intermediate, intensive care, and sometimes even long-term status within the same room. This article highlights the relationship-based care nursing model, a patient-centered care model, and the importance of nursing disciplinary knowledge from the Roy adaptation model and its impact on the healthcare this population receives within a unique environment.
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Affiliation(s)
- Karen Carroll
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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19
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Extubation Failure and Major Adverse Events Secondary to Extubation Failure Following Neonatal Cardiac Surgery. Pediatr Crit Care Med 2020; 21:e1119-e1125. [PMID: 32804741 DOI: 10.1097/pcc.0000000000002470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the prevalence and consequences of major adverse events secondary to extubation failure after neonatal cardiac surgery. DESIGN A single-center cohort study. SETTING A medical-surgical, 30-bed PICU in Victoria, Australia. PATIENTS One thousand one hundred eighty-eight neonates less than or equal to 28 days old who underwent cardiac surgery from January 2007 to December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extubation failure was defined as unplanned reintubation within 72 hours after a planned extubation. Major adverse event was defined as one or more of cardiac arrest, emergency chest reopening, extracorporeal membrane oxygenation, or death within 72 hours after extubation. One hundred fifteen of 1,188 (9.7%) neonates had extubation failure. Hospital mortality was 17.4% and 2.0% in neonates with and without extubation failure. Major adverse event occurred in 12 of 115 reintubated neonates (10.4%). major adverse event included cardiac arrest (n = 10), chest reopening (n = 8), extracorporeal membrane oxygenation (n = 5), and death (n = 0). Cardiovascular compromise accounted for major adverse event in eight: ventricular dysfunction (n = 3), pulmonary overcirculation (n = 2), coronary ischemia (n = 2), cardiac tamponade (n = 1). In a multivariable logistic regression, factors associated with major adverse event were high complexity in cardiac surgery (odds ratio 5.9; 95% CI: 1.1-32.2) and airway anomaly (odds ratio 6.0; 95% CI: 1.1-32.6). Hospital morality was 25% and 17% in reintubated neonates with and without major adverse event. CONCLUSIONS Around 10% of reintubated neonates suffered major adverse event within 72 hours of extubation. Neonates suffering major adverse event had high mortality. Major adverse event should be monitored and reported in future studies of extubation failure. Along with tracking of extubation failure rates, major adverse event secondary to extubation failure may also serve as a key performance indicator for ICUs and registries.
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De Jesus-Brugman N, Hobson MJ, Herrmann JL, Friedman ML, Cordes T, Mastropietro CW. Improved outcomes in neonates who require venoarterial extracorporeal membrane oxygenation after the Norwood procedure. Int J Artif Organs 2019; 43:180-188. [PMID: 31623516 DOI: 10.1177/0391398819882020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation after the Norwood procedure has historically been associated with poor outcomes, with reported hospital survival rates of 13%-48%. We hypothesized that contemporary outcomes in this population have improved. We aimed to compare clinical outcomes of contemporary cohorts of patients with functional single ventricle physiology who did and did not receive extracorporeal membrane oxygenation after the Norwood procedure. METHODS Single-center retrospective cohort study of patients with single ventricle anatomy who underwent the Norwood procedure between 2009 and 2017 was performed. Kaplan-Meier survival curves were constructed, and Cox proportional hazard regression analyses were performed to compare transplant-free survival in patients who did and did not receive venoarterial extracorporeal membrane oxygenation. RESULTS In total, 85 patients met inclusion criteria. Venoarterial extracorporeal membrane oxygenation was utilized in 25 patients (29%). A total of 18 patients (72%) who received venoarterial extracorporeal membrane oxygenation survived to hospital discharge, compared to 54 patients (92%) who did not receive venoarterial extracorporeal membrane oxygenation (p = 0.013). Post-discharge transplant-free survival was not significantly different between patients who did and did not receive venoarterial extracorporeal membrane oxygenation (log-rank p value = 0.28). Cox proportional hazard regression analysis revealed that the occurrence of cardiac arrest requiring cardiopulmonary resuscitation (hazard ratio = 4.5; 95% confidence interval = 2.0-10.1) during the perioperative period was independently associated with death or transplantation, whereas venoarterial extracorporeal membrane oxygenation was not an independent risk factor for death or transplantation (hazard ratio = 2.0; 95% confidence interval = 0.8-4.9). CONCLUSION In our cohort of children who received venoarterial extracorporeal membrane oxygenation after the Norwood procedure, hospital survival was improved compared to historical data. In addition, venoarterial extracorporeal membrane oxygenation utilization was not independently associated with worse outcomes.
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Affiliation(s)
- Nicole De Jesus-Brugman
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Michael Joe Hobson
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Department of Surgery, Division of Vascular and Cardiothoracic Surgery, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Matthew L Friedman
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Timothy Cordes
- Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Ferentzi H, Pfitzer C, Rosenthal LM, Berger F, Schmitt KRL, Kramer P. Developmental Outcome in Infants with Cardiovascular Disease After Cardiopulmonary Resuscitation: A Pilot Study. J Clin Psychol Med Settings 2019; 26:575-583. [PMID: 30850900 DOI: 10.1007/s10880-019-09613-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Unfavorable neurological outcome in children after cardiopulmonary resuscitation in infancy is frequent. However, few studies have investigated the development of these patients using comprehensive developmental tests and the feasibility of the Bayley Scales of Infant Development, 3rd Edition (BSID-III) has not been reported for this population. In this cross-sectional pilot study, we assessed the cognitive, language, and motor development in infants after cardiopulmonary resuscitation of ≥ 5 min with the BSID-III at the age of 12 or 24 months, depending on recruitment age. For analysis, 11 patients with in-hospital (n = 8) and out-of-hospital (n = 3) cardiac arrest were included. BSID-III results could not be quantified in three patients because of visual/hearing and/or motor impairment. In patients with quantifiable scores, 50.0% scored average in composite BSID-III scores, while the other 50.0% showed developmental delays, scoring distinctly below average. We conclude that the BSID-III is feasible for developmental assessment in the majority of the study population, but the use of instruments suitable for hearing/visually impaired and/or severely disabled infants is crucial to avoid biased results. Accurate characterization of developmental deficits is important to facilitate early identification and therapy of deficits.
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Affiliation(s)
- Hannah Ferentzi
- Department of Congenital Heart Disease - Paediatric Cardiology, German Heart Centre Berlin, Augustenburger Platz, 13353, Berlin, Germany
| | - Constanze Pfitzer
- Department of Congenital Heart Disease - Paediatric Cardiology, German Heart Centre Berlin, Augustenburger Platz, 13353, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.
| | - Lisa-Maria Rosenthal
- Department of Congenital Heart Disease - Paediatric Cardiology, German Heart Centre Berlin, Augustenburger Platz, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease - Paediatric Cardiology, German Heart Centre Berlin, Augustenburger Platz, 13353, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Paediatric Cardiology, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Katharina R L Schmitt
- Department of Congenital Heart Disease - Paediatric Cardiology, German Heart Centre Berlin, Augustenburger Platz, 13353, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease - Paediatric Cardiology, German Heart Centre Berlin, Augustenburger Platz, 13353, Berlin, Germany
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Changing Risk of In-Hospital Cardiac Arrest in Children Following Cardiac Surgery in Victoria, Australia, 2007-2016. Heart Lung Circ 2018; 28:1904-1912. [PMID: 30591395 DOI: 10.1016/j.hlc.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/18/2018] [Accepted: 11/02/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Reported incidence of in hospital cardiac arrest (IHCA) after paediatric cardiac surgery varies between 3-4% in high income countries and this risk may have changed over time. We sought to examine this trend in detail. METHODS A retrospective observational study of 3,781 children who underwent 4,938 cardiac surgeries between 1 January 2007 and 31 December 2016 in a tertiary children's hospital. IHCA was defined as cessation of cardiac mechanical activity requiring cardiac massage for ≥1minute. Surgical complexity was categorised using risk adjusted congenital heart surgery (RACHS-1) category. Poisson regression was used to analyse trends for every two-year period. RESULTS There were a total of 211 (4.3%) IHCA events after surgery. These patients were younger, more likely to have had a premature birth, have a chromosomal or genetic syndrome association and have a high surgical complexity. Overall, there was a 52% reduction in IHCA rate over 10 years: reducing from 5.4 /100 surgeries in 2007-08 to 2.6/100 surgeries in 2015-16 (p-trend=<0.001). The reduction was mainly seen in low-to-moderate risk categories (RACHS-1 categories 1-4) and not in high risk categories (RACHS-1 category 5-6). Children in high risk categories were 13.6 times more likely to experience an IHCA (compared to low risk categories). Overall hospital mortality for children suffering IHCA decreased from 42.5/100 patients in 2007-08 to 11.1/100 patients in 2015-16 (p-trend=0.037). CONCLUSIONS The IHCA rate following cardiac surgery has more than halved over the last decade; children who experience IHCA also have lower mortality than in previous years. High risk procedures still have a substantial rate of IHCA and efforts are needed to minimise the burden further in this population.
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Delaney M, Roberts J, Mazor R, Townsend-McCall D, Saifee NH, Pagano MB, Matthews DC, Stone K. Bleeding emergencies in neonatal and paediatric patients: improving the quality of care using simulation. Transfus Med 2018; 28:405-412. [PMID: 30325081 DOI: 10.1111/tme.12562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/06/2018] [Accepted: 09/10/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Using a multidisciplinary approach and simulation, a massive transfusion process (MTP) was developed to care for patients in need of emergency transfusion. It was then assessed for effectiveness. BACKGROUND After a series of sentinel emergency bleeding events, a reliable process for hospital staff to deliver appropriate blood products and obtain relevant laboratory tests to guide therapy for patients with emergency bleeding was needed. METHODS To determine the feasibility of the new MTP, multidisciplinary teams participated in simulation events. Each simulation event helped refine the MTP. A special laboratory testing panel was devised. To judge the effectiveness and timeliness of the MTP, process measures and patient survival was retrospectively evaluated during the time period before and after MTP implementation. RESULTS A new emergency bleeding panel of laboratory tests significantly decreased the turn-around time for fibrinogen, haematocrit, International normalised ratio (INR) and platelet count. The speed of commencing the first red blood cells transfusion was also improved (2:00 h vs 0:20 min, P = 0·001). Of 78 patients, there was no change in survival before (n = 31, 48·4%) and after (n = 47, 42·6%; P = 0·6478) MTP implementation. However, there was significant improvement in survival associated with MTP events on the weekdays. CONCLUSIONS A reliable emergency transfusion process consists of an automatic chain of events that keeps decision-making to a minimum and leads to the fast procurement of blood products and salient test results. This work shows that a multidisciplinary iterative process using simulation increases the efficiency of clinical care delivery for bleeding paediatric and neonatal patients.
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Affiliation(s)
- M Delaney
- Laboratory Division, Seattle Children's Hospital, Seattle, Washington, USA.,Bloodworks NW, Seattle, Washington, USA.,Children's National Medical Center, Washington DC, USA
| | - J Roberts
- Critical Care, Department of Paediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - R Mazor
- Critical Care, Department of Paediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - D Townsend-McCall
- Laboratory Division, Seattle Children's Hospital, Seattle, Washington, USA
| | - N H Saifee
- Laboratory Division, Seattle Children's Hospital, Seattle, Washington, USA.,Bloodworks NW, Seattle, Washington, USA
| | - M B Pagano
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - D C Matthews
- Center for Cancer and Blood Disorders, Seattle Children's Hospital, Seattle, Washington, USA
| | - K Stone
- Division of Emergency Medicine, Department of Paediatrics, Seattle Children's Hospital, Seattle, Washington, USA
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Abstract
OBJECTIVES In-hospital cardiac arrest occurs in 2.6-6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about cardiac arrest in pediatric cardiac ICUs; therefore, we aimed to describe cardiac arrest epidemiology in a contemporary multicenter cardiac ICU cohort. DESIGN Retrospective analysis within the Pediatric Cardiac Critical Care Consortium clinical registry. SETTING Cardiac ICUs within 23 North American hospitals. PATIENTS All cardiac medical and surgical patients admitted from August 2014 to July 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 15,908 cardiac ICU encounters (6,498 medical, 9,410 surgical). 3.1% had cardiac arrest; rate was 4.8 cardiac arrest per 1,000 cardiac ICU days. Medical encounters had 50% higher rate of cardiac arrest compared with surgical encounters. Observed (unadjusted) cardiac ICU cardiac arrest prevalence varied from 1% to 5.5% among the 23 centers; cardiac arrest per 1,000 cardiac ICU days varied from 1.1 to 10.4. Over half cardiac arrest occur within 48 hours of admission. On multivariable analysis, prematurity, neonatal age, any Society of Thoracic Surgeons preoperative risk factor, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 4, 5 had strongest association with surgical encounter cardiac arrest. In medical encounters, independent cardiac arrest risk factors were acute heart failure, prematurity, lactic acidosis greater than 3 mmol/dL, and invasive ventilation 1 hour after admission. Median cardiopulmonary resuscitation duration was 10 minutes, return of spontaneous circulation occurred in 64.5%, extracorporeal cardiopulmonary resuscitation in 27.2%. Unadjusted survival was 53.2% in encounters with cardiac arrest versus 98.2% without. Medical encounters had lower survival after cardiac arrest (37.7%) versus surgical encounters (62.5%); Norwood patients had less than half the survival after cardiac arrest (35.6%) compared with all others. Unadjusted survival after cardiac arrest varied greatly among 23 centers. CONCLUSIONS We provide contemporary epidemiologic and outcome data for cardiac arrest occurring in the cardiac ICU from a multicenter clinical registry. As detailed above, we highlight high-risk patient cohorts and periods of time that may serve as targets for research and quality improvement initiatives aimed at cardiac arrest prevention.
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Cardiac Arrest in Pediatric Cardiac ICUs: What Are the Differences? Pediatr Crit Care Med 2017; 18:989-990. [PMID: 28976463 DOI: 10.1097/pcc.0000000000001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lauridsen KG, Schmidt AS, Caap P, Aagaard R, Løfgren B. Clinical experience and skills of physicians in hospital cardiac arrest teams in Denmark: a nationwide study. Open Access Emerg Med 2017; 9:37-41. [PMID: 28331374 PMCID: PMC5349502 DOI: 10.2147/oaem.s124149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The quality of in-hospital resuscitation is poor and may be affected by the clinical experience and cardiopulmonary resuscitation (CPR) training. This study aimed to investigate the clinical experience, self-perceived skills, CPR training and knowledge of the guidelines on when to abandon resuscitation among physicians of cardiac arrest teams. Methods We performed a nationwide cross-sectional study in Denmark. Telephone interviews were conducted with physicians in the cardiac arrest teams in public somatic hospitals using a structured questionnaire. Results In total, 93 physicians (53% male) from 45 hospitals participated in the study. Median age was 34 (interquartile range: 30–39) years. Respondents were medical students working as locum physicians (5%), physicians in training (79%) and consultants (16%), and the median postgraduate clinical experience was 48 (19–87) months. Most respondents (92%) felt confident in treating a cardiac arrest, while fewer respondents felt confident in performing intubation (41%) and focused cardiac ultrasound (39%) during cardiac arrest. Median time since last CPR training was 4 (2–10) months, and 48% had attended a European Resuscitation Council (ERC) Advanced Life Support course. The majority (84%) felt confident in terminating resuscitation; however, only 9% were able to state the ERC guidelines on when to abandon resuscitation. Conclusion Physicians of Danish cardiac arrest teams are often inexperienced and do not feel competent performing important clinical skills during resuscitation. Less than half have attended an ERC Advanced Life Support course, and only very few physicians know the ERC guidelines on when to abandon resuscitation.
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Affiliation(s)
- Kasper G Lauridsen
- Department of Internal Medicine; Clinical Research Unit, Regional Hospital of Randers, Randers; Research Center for Emergency Medicine, Aarhus University Hospital
| | - Anders S Schmidt
- Department of Internal Medicine; Clinical Research Unit, Regional Hospital of Randers, Randers; Research Center for Emergency Medicine, Aarhus University Hospital
| | - Philip Caap
- Research Center for Emergency Medicine, Aarhus University Hospital; Institute of Clinical Medicine, Aarhus University, Aarhus
| | - Rasmus Aagaard
- Clinical Research Unit, Regional Hospital of Randers, Randers; Research Center for Emergency Medicine, Aarhus University Hospital; Department of Anesthesiology, Randers Regional Hospital, Denmark
| | - Bo Løfgren
- Department of Internal Medicine; Research Center for Emergency Medicine, Aarhus University Hospital; Institute of Clinical Medicine, Aarhus University, Aarhus
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Burke CR, Chan T, Brogan TV, McMullan DM. Pediatric extracorporeal cardiopulmonary resuscitation during nights and weekends. Resuscitation 2017; 114:47-52. [PMID: 28263789 DOI: 10.1016/j.resuscitation.2017.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 02/26/2017] [Accepted: 03/01/2017] [Indexed: 11/18/2022]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) is a lifesaving rescue therapy for patients with refractory cardiac arrest. Previous studies suggest that maintaining a 24/7 in-house surgical team may reduce ECPR initiation time and improve survival in adult patients. However, an association between cardiac arrest occurring during off-hours and ECPR outcome has not been established in children. METHODS This is a single institution, retrospective review of all pediatric patients who received ECPR from December 2008 to August 2015. RESULTS During the study period, ECPR was performed 54 times in 53 patients (20 weekday, 34 night/weekend). Interval from ECPR activation to initiation of extracorporeal life support was significantly longer during night/weekends (49min night/weekend vs. 33min weekday, p<0.001) as was the interval from ECPR activation to incision for cannulation (26min night/weekend vs. 14min Weekday, p<0.001). Rate of central nervous system (CNS) injury was higher in the night/weekend group (43% night/weekend vs. 15% weekday, p=0.04), with associated 75% mortality prior to hospital discharge. Time of arrest did not impact survival to hospital discharge (44% night/weekend vs. 55% weekday, p=0.57), one-year survival (33% night/weekend vs. 44% weekday, p=0.44), or neurologic outcome (Pediatric Cerebral Performance Score at 1-year post-ECPR, 1.45 weekday vs. 1.50 night/weekend, p=0.82). CONCLUSIONS Cardiac arrest occurring at night or during weekend hours is associated with a longer ECPR initiation time and higher rates of CNS injury. However, prolonged pre-ECPR support associated with off-hours cardiac arrest does not appear to impact survival or functional outcome in pediatric patients.
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Affiliation(s)
- Christopher R Burke
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - Titus Chan
- Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Thomas V Brogan
- Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - D Michael McMullan
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, United States.
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Caring for the Acutely, Severely Ill Child-A Multifaceted Situation with Paradoxical Elements: Swedish Healthcare Professionals' Experiences. J Pediatr Nurs 2016; 31:e293-300. [PMID: 27237793 DOI: 10.1016/j.pedn.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/02/2016] [Accepted: 05/06/2016] [Indexed: 11/21/2022]
Abstract
UNLABELLED The aim of this study was to describe healthcare professionals' experience of caring for acutely, severely ill children in hospital in Sweden. DESIGN AND METHODS Five focus group interviews were conducted with nurses, nurse assistants and physicians comprising a total of 20 participants. Data were analyzed using qualitative content analysis. RESULTS An overall theme emerged that describes healthcare professionals' experiences as: "being in a multifaceted area of tension with paradoxical elements". The theme is based on three categories: proficiency of the individuals and the team is the fundamental base; interactions are crucial in an area of tension; and wellbeing of the individual is a balance of contradictory emotions. With maintained focus on the ill child, proficiency is the fundamental base, interactions are crucial, and moreover contradictory emotions are described. CONCLUSIONS The interplay based on proficiency may influence the assessments and treatments of acutely, severely ill children. PRACTICE IMPLICATIONS Recognizing the multifaceted area of tension with paradoxical elements, practical teamwork exercises, a structured approach, and assessment tools could be a possible way to develop interprofessional team collaboration to improve the care of acutely, severely ill children in order to increase patient safety.
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Abstract
OBJECTIVES The objectives of this review are to discuss the scope of neurologic injuries in newborns with congenital heart disease, the mechanisms of injury, including prenatal, pre-, intra-, and postoperative factors, neurodevelopmental outcomes, and therapeutic strategies for the timely intervention and prevention of neurologic injury. DATA SOURCE MEDLINE and PubMed. CONCLUSION At the current time, important research is underway to 1) better understand the developing brain in the fetus with complex congenital heart disease, 2) to identify modifiable risk factors in the operating room and ICU to maximize long-term neurodevelopmental outcomes, and 3) develop strategies to improve family psychosocial health, childhood development, and health-related quality of life following hospital discharge. Crucial in this effort is the identification of an early postoperative surrogate variable with good predictive validity for long-term outcomes. If an appropriate surrogate variable for long-term outcomes can be identified, and measured relatively early after surgical intervention for complex congenital heart disease, reliable clinical trials can be undertaken to improve upon current outcomes.
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da Cruz EM, Tabbutt S, Eisenhaur MC, Jacobs JP, Graham EM, Smith LC, Simsic J, Laussen PC. Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future. World J Pediatr Congenit Heart Surg 2016; 6:556-64. [PMID: 26467870 DOI: 10.1177/2150135115596440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes. METHODS The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership. RESULTS Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges. CONCLUSIONS Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.
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Affiliation(s)
- Eduardo M da Cruz
- Children's Hospital Colorado Heart Institute, University of Colorado Denver, School of Medicine, Aurora, CO, USA
| | - Sarah Tabbutt
- University of California San Francisco Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA, USA
| | | | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute, Johns Hopkins University, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Eric M Graham
- The Children's Heart Program of South Carolina, Medical University of South Carolina, Charleston, SC, USA
| | - Liz C Smith
- Great Ormond Street Hospital for Sick Children, London, United Kingdom
| | - Janet Simsic
- The Heart Center at Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Peter C Laussen
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Hickey PA, Pasquali SK, Gaynor JW, He X, Hill KD, Connor JA, Gauvreau K, Jacobs ML, Jacobs JP, Hirsch-Romano JC. Critical Care Nursing's Impact on Pediatric Patient Outcomes. Ann Thorac Surg 2016; 102:1375-80. [PMID: 27173065 DOI: 10.1016/j.athoracsur.2016.03.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/11/2016] [Accepted: 03/02/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Previous studies have demonstrated the effect of adult nursing skill mix, staffing ratios, and level of education on patient deaths, complication rates, and failure to rescue (FTR). To date, only one known study had examined the effect of nursing experience and education on postoperative pediatric cardiac operations. METHODS Nursing survey data were linked to The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database for patients undergoing cardiac operations (2010 to 2011). Logistic regression models were used to estimate associations of nursing education and years of clinical experience with in-hospital mortality rates, complication rates, and FTR. Generalized estimating equations and robust standard error estimates were used to account for within-center correlation of outcomes. RESULTS Among 15,463 patients (29 hospitals), the in-hospital mortality rate was 2.8%, postoperative complications occurred in 42.4%, and the FTR rate was 6.4%. After covariate adjustment, pediatric critical care units with a higher proportion of nurses with a Bachelor of Science degree or higher had lower odds of complication (odds ratio for 10% increase, 0.85; 95% confidence interval, 0.76 to 0.96; p = 0.009). Units with a higher proportion of nurses with more than 2 years of experience had lower mortality rates (odds ratio for 10% increase, 0.92; 95% confidence interval, 0.85 to 0.99; p = 0.025). CONCLUSIONS This is the first study to demonstrate that higher levels of nursing education and experience are significantly associated with fewer complications after pediatric cardiac operations and aligns with our previous findings on their association with reduced deaths. These results provide data for pediatric hospital leaders and reinforce the importance of organization-wide mentoring strategies for new nurses and retention strategies for experienced nurses.
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Affiliation(s)
- Patricia A Hickey
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, Massachusetts.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Xia He
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin D Hill
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jean A Connor
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Johns Hopkins Children's Heart Surgery, All Children's Hospital, St. Petersburg, Florida
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Reuter-Rice K, Madden MA, Gutknecht S, Foerster A. Acute Care Pediatric Nurse Practitioner: The 2014 Practice Analysis. J Pediatr Health Care 2016; 30:241-51. [PMID: 26878813 DOI: 10.1016/j.pedhc.2016.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/16/2016] [Accepted: 01/18/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Practice research serves as the certification framework for validating advanced practice roles and updating national qualifying examinations. This national study describes the current practice of the acute care pediatric nurse practitioner (AC PNP) to inform an update of the Certified Pediatric Nurse Practitioner-Acute Care (CPNP-AC) examination content outline. METHOD A descriptive analysis was performed of the responses of 319 pediatric nurse practitioners, practicing in an acute care role, who completed a practice survey in 2014. RESULTS Respondents were primarily White women with a mean age of 40 years; 75% had been formally educated as AC PNPs, compared with 48% in 2009. Regional practice was most heavily concentrated in the Southeast (28%) and Midwest (27%). Most respondents (81%) practiced in urban areas. Respondents reported spending 75% of practice time in inpatient settings. The most frequently cited areas of practice were critical care (36%), followed by emergency department (9%) and subspecialty practices. DISCUSSION This third analysis of AC PNP practice 10 years after initiation of the CPNP-AC certification examination demonstrates changes in clinical practice and educational preparation.
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Impact of System Factors and Modifiable ICU Interventions on the Outcome of Cardio-pulmonary Resuscitation in PICU. Indian Pediatr 2016; 52:485-8. [PMID: 26121723 DOI: 10.1007/s13312-015-0661-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the impact of system factors and modifiable interventions on outcome of cardiac arrest in a pediatric intensive care unit. DESIGN Retrospective medical record review. SETTING Pediatric intensive care unit of a hospital in China. PARTICIPANTS Children (age<14 yrs) who had cardiac arrest within our PICU over a period of two years. RESULTS Sixty-one of the 94 cardiac arrest events were successfully resuscitated. There was no significant association between personal and unit factors with immediate outcomes in our unit. The rate of unsuccessful resuscitation in sedated patients and those without sedation was 26% and 50%, respectively. Unsuccessful resuscitation occurred in 19% of patients who were on positive pressure ventilation as compared with 74% for those without positive pressure ventilation. Arrests which had resuscitation attempts that lasted more than 30 min had 135-fold higher odds of unsuccessful outcome. 78% of patients who received base supplement at the time of arrest had unsuccessful resuscitation compared with 21% for those without base supplement. CONCLUSION Our data shows no impact of system factors on the outcome of cardio-pulmonary resuscitation in our PICU. Pre-arrest sedation in pediatric critical ill patients might be beneficial to the outcome of cardiac arrests.
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Lasa JJ, Rogers RS, Localio R, Shults J, Raymond T, Gaies M, Thiagarajan R, Laussen PC, Kilbaugh T, Berg RA, Nadkarni V, Topjian A. Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During Pediatric In-Hospital Cardiopulmonary Arrest Is Associated With Improved Survival to Discharge: A Report from the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry. Circulation 2016; 133:165-76. [PMID: 26635402 PMCID: PMC4814337 DOI: 10.1161/circulationaha.115.016082] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although extracorporeal cardiopulmonary resuscitation (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR and continued C-CPR has been reported. METHODS AND RESULTS Consecutive patients <18 years old with CPR events ≥10 minutes in duration reported to the Get With the Guidelines-Resuscitation registry between January 2000 and December 2011 were identified. Hospitals were grouped by teaching status and location. Primary outcome was survival to discharge. Regression modeling was performed, conditioning on hospital groups. A secondary analysis was performed with the use of propensity score matching. Of 3756 evaluable patients, 591 (16%) received E-CPR and 3165 (84%) received C-CPR only. Survival to hospital discharge and survival with favorable neurological outcome (Pediatric Cerebral Performance Category score of 1-3 or unchanged from admission) were greater for E-CPR (40% [237 of 591] and 27% [133 of 496]) versus C-CPR patients (27% [862 of 3165] and 18% [512 of 2840]). Odds ratios (ORs) for survival to hospital discharge and survival with favorable neurological outcome were greater for E-CPR versus C-CPR. After adjustment for covariates, patients receiving E-CPR had higher odds of survival to discharge (OR, 2.80; 95% confidence interval, 2.13-3.69; P<0.001) and survival with favorable neurological outcome (OR, 2.64; 95% confidence interval, 1.91-3.64; P<0.001) than patients who received C-CPR. This association persisted when analyzed by propensity score-matched cohorts (OR, 1.70; 95% confidence interval, 1.33-2.18; P<0.001; and OR, 1.78; 95% confidence interval, 1.31-2.41; P<0.001, respectively]. CONCLUSION For children with in-hospital CPR of ≥10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurological outcome compared with C-CPR.
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Affiliation(s)
- Javier J Lasa
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.).
| | - Rachel S Rogers
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Russell Localio
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Justine Shults
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Tia Raymond
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Michael Gaies
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Ravi Thiagarajan
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Peter C Laussen
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Todd Kilbaugh
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Robert A Berg
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Vinay Nadkarni
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Alexis Topjian
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
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Abstract
OBJECTIVE To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. DESIGN One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. SETTING Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. PARTICIPANTS Pediatric critical care nurses and nurse scientists attending the open consensus meeting. INTERVENTIONS Systematic review, gap analysis, and interactive multivoting. MEASUREMENTS AND MAIN RESULTS The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children. CONCLUSIONS The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.
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Labenne M, Paut O. Arrêt cardiaque chez l’enfant : définition, épidémiologie, prise en charge et pronostic. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jeurea.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McCrory MC, Gower EW, Simpson SL, Nakagawa TA, Mou SS, Morris PE. Off-hours admission to pediatric intensive care and mortality. Pediatrics 2014; 134:e1345-53. [PMID: 25287463 PMCID: PMC9923532 DOI: 10.1542/peds.2014-1071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Critically ill patients are admitted to the pediatric ICU at all times, while staffing and other factors may vary by day of the week or time of day. The purpose of this study was to evaluate whether admission during off-hours is independently associated with mortality in PICUs. METHODS A retrospective cohort study of admissions of patients <18 years of age to PICUs was performed using the Virtual PICU Systems (VPS, LLC) database. "Off-hours" was defined as nighttime (7:00 pm to 6:59 am) or weekend (Saturday or Sunday any time). Mixed-effects multivariable regression was performed by using Pediatric Index of Mortality 2 (PIM2) to adjust for severity of illness. Primary outcome was death in the pediatric ICU. RESULTS Data from 234,192 admissions to 99 PICUs from January 2009 to September 2012 were included. When compared with regular weekday admissions, off-hours admissions were less likely to be elective, had a higher risk for mortality by PIM2, and had a higher observed ICU mortality (off-hours 2.7% vs weekdays 2.2%; P < .001). Multivariable regression revealed that, after adjustment for other significant factors, off-hours admission was associated with lower odds of mortality (odds ratio, 0.91; 95% confidence interval, 0.85-0.97; P = .004). Post hoc multivariable analysis revealed that admission during the morning period 6:00 am to 10:59 am was independently associated with death (odds ratio, 1.27; 95% confidence interval, 1.16-1.39; P < .0001). CONCLUSIONS Off-hours admission does not independently increase odds of death in the PICU. Admission from 6:00 am to 10:59 am is associated with increased risk for death and warrants further investigation in the PICU population.
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Affiliation(s)
- Michael C. McCrory
- Departments of Anesthesiology, Section on Pediatric Critical Care Medicine, ,Address correspondence to Michael C. McCrory, MD, MS, Department of Anesthesiology, Section on Pediatric Critical Care Medicine, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1009. E-mail:
| | | | - Sean L. Simpson
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas A. Nakagawa
- Departments of Anesthesiology, Section on Pediatric Critical Care Medicine
| | - Steven S. Mou
- Departments of Anesthesiology, Section on Pediatric Critical Care Medicine
| | - Peter E. Morris
- Internal Medicine, Section on Pulmonary and Critical Care Medicine, and
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del Castillo J, López-Herce J, Cañadas S, Matamoros M, Rodríguez-Núnez A, Rodríguez-Calvo A, Carrillo A. Cardiac arrest and resuscitation in the pediatric intensive care unit: A prospective multicenter multinational study. Resuscitation 2014; 85:1380-6. [DOI: 10.1016/j.resuscitation.2014.06.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 05/13/2014] [Accepted: 06/20/2014] [Indexed: 11/25/2022]
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Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries. Pediatr Crit Care Med 2014; 15:529-37. [PMID: 24777300 PMCID: PMC4159673 DOI: 10.1097/pcc.0000000000000153] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To empirically derive the optimal measure of pharmacologic cardiovascular support in infants undergoing cardiac surgery with bypass and to assess the association between this score and clinical outcomes in a multi-institutional cohort. DESIGN Prospective, multi-institutional cohort study. SETTING Cardiac ICUs at four academic children's hospitals participating in the Pediatric Cardiac Critical Care Consortium during the study period. PATIENTS Children younger than 1 year at the time of surgery treated postoperatively in the cardiac ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three hundred ninety-one infants undergoing surgery with bypass were enrolled consecutively from November 2011 to April 2012. Hourly doses of all vasoactive agents were recorded for the first 48 hours after cardiac ICU admission. Multiple derivations of an inotropic score were tested, and maximum vasoactive-inotropic score in the first 24 hours was further analyzed for association with clinical outcomes. The primary composite "poor outcome" variable included at least one of mortality, mechanical circulatory support, cardiac arrest, renal replacement therapy, or neurologic injury. High vasoactive-inotropic score was empirically defined as more than or equal to 20. Multivariable logistic regression was performed controlling for center and patient characteristics. Patients with high vasoactive-inotropic score had significantly greater odds of a poor outcome (odds ratio, 6.5; 95% CI, 2.9-14.6), mortality (odds ratio, 13.2; 95% CI, 3.7-47.6), and prolonged time to first extubation and cardiac ICU length of stay compared with patients with low vasoactive-inotropic score. Stratified analyses by age (neonate vs infant) and surgical complexity (low vs high) showed similar associations with increased morbidity and mortality for patients with high vasoactive-inotropic score. CONCLUSIONS Maximum vasoactive-inotropic score calculated in the first 24 hours after cardiac ICU admission was strongly and significantly associated with morbidity and mortality in this multi-institutional cohort of infants undergoing cardiac surgery. Maximum vasoactive-inotropic score more than or equal to 20 predicts an increased likelihood of a poor composite clinical outcome. The findings were consistent in stratified analyses by age and surgical complexity.
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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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Who is minding the store: intensive care unit personnel and its effect on cardiac arrest outcome. Pediatr Crit Care Med 2012; 13:604-5. [PMID: 22955464 DOI: 10.1097/pcc.0b013e318241711e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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