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Ambrose SE, Ongkasuwan J, Dedhia K, Diercks GR, Anne S, Shashidharan S, Raol N. Analysis of Vocal Fold Motion Impairment in Neonates Undergoing Congenital Heart Surgery. JAMA Otolaryngol Head Neck Surg 2019; 144:406-412. [PMID: 29543970 DOI: 10.1001/jamaoto.2017.3459] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Vocal fold motion impairment (VFMI) is a known risk factor following congenital heart surgery (CHS). The impact of this diagnosis on utilization and outcomes is unknown. Objective To evaluate the cost, postprocedure length of stay (PPLOS), and outcomes for neonates with VFMI after CHS. Design, Setting, and Participants A cross-sectional analysis of the 2012 Kids' Inpatient Database (KID) of neonates who underwent CHS was carried out. The KID is an administrative data set of patients, aged 20 years or younger, and contains data on more than 10 million hospitalizations from 44 states. The KID is limited to inpatient hospitalization and contains discharge summary level of data. Patients were limited to those who were born during the hospitalization and those who were aged 28 days or younger at the time of admission for CHS. A weighted total of 4139 neonates who underwent CHS were identified, of which 3725 survived. The proportion of neonates diagnosed with VFMI was 264 (6.92%) of 3725. Exposures Congenital heart surgery. Main Outcomes and Measures Cost of inpatient hospital stay, postprocedure length of stay, odds of pneumonia, gastrostomy tube placement, and tracheostomy tube placement. Risk-adjusted generalized linear models examined differences in cost and PPLOS between neonates who underwent CHS and were diagnosed with VFMI and those who were not. Risk-adjusted logistic regression compared the odds of selected outcomes (gastrostomy, tracheostomy, pneumonia). Models were weighted to provide national estimates. Results Of 3725 neonates (aged 0-28 days), 2203 (59.1%) were male and 1517 (40.7%) were female. Neonates diagnosed with VFMI had significantly higher total cost by $34 000 (95% CI, 2200-65 000) and PPLOS by 9.1 days (95% CI, 4.6-13.7) compared with those who did not. When PPLOS was included as a covariate in the model for cost, presence of VFMI was no longer significant. There were no differences in odds of pneumonia, gastrostomy, or tracheostomy. Conclusions and Relevance Vocal fold motion impairment after CHS was associated with significant increases in cost owing to increased PPLOS. These findings provide a foundation to further investigate standardized screening for VFMI following CHS; early identification and treatment may decrease cost and PPLOS.
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Affiliation(s)
- Stephanie E Ambrose
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Julina Ongkasuwan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College Of Medicine, Houston, Texas.,Department of Otolaryngology-Head and Neck Surgery, Texas Children's Hospital, Houston, Texas
| | - Kavita Dedhia
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Gillian R Diercks
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brookline, Massachusetts.,Massachusetts Eye and Ear Infirmary, Boston
| | - Samantha Anne
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Nikhila Raol
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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Rodney JP, Thompson JL, Anderson MP, Burkhart HM. Neonatal vocal fold motion impairment after complex aortic arch reconstruction: What should parents expect after diagnosis? Int J Pediatr Otorhinolaryngol 2019; 120:40-43. [PMID: 30753981 DOI: 10.1016/j.ijporl.2019.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To study the incidence, sequelae, follow up, and recovery rate of vocal fold motion impairment (VFMI) after complex aortic arch reconstruction in neonates. STUDY DESIGN Retrospective case control study. METHODS We retrospectively evaluated 105 neonates who underwent complex aortic arch reconstruction from 2014 to 2016. We compared patients that did have VFMI compared to a control group of patients with normal vocal fold movement. Descriptive statistics were computed for all demographic and clinical variables by treatment group. RESULTS 36% of patients were evaluated for VFMI (n = 38) by an otolaryngologist. The incidence of VFMI was 22% (n = 23). Females were more likely to have VFMI (p = 0.02). Aspiration was more common in patients with VFMI (p = 0.006). The difference in age, weight, incidence of pneumonia, nasogastric tube, gastrostomy, total length of stay, genetic anomaly, and reintubation was not significant between the VFMI group and control group (p > 0.05). Tracheostomy was not performed in any patients with unilateral paralysis. Only 61% of patients followed up in clinic (n = 14). 64% of patients showed improvement or resolution (n = 9). Average time to improvement was 4.8 months. Average time to complete resolution was 10.5 months. CONCLUSIONS VFMI after complex aortic arch reconstruction is relatively common. Despite increased aspiration in patients with VFMI, pneumonia did not occur at all in either group. Tracheostomy was not necessary in any patients with a unilateral paralysis. Most patients showed an improvement in the VFMI within 5 months of surgery. Our data support the need for otolaryngology follow-up after the diagnosis of VFMI.
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Affiliation(s)
- Jennifer P Rodney
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.
| | - Jess L Thompson
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Michael P Anderson
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States; College of Public Health, Biostatistics and Epidemiology, United States
| | - Harold M Burkhart
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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Kerris EJ, Patregnani JT, Sharron M, Sochet AA. Use of the pediatric intensive care unit for post-procedural monitoring in young children following microlaryngobronchoscopy: Impact on resource utilization and hospital cost. Int J Pediatr Otorhinolaryngol 2018; 115:1-5. [PMID: 30368366 DOI: 10.1016/j.ijporl.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/01/2018] [Accepted: 09/12/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the frequency of post-procedural complications, medical interventions, and hospital costs associated with microlaryngobronchoscopy (MLB) in children prophylactically admitted for pediatric intensive care unit (PICU) monitoring for age ≤ 2 years. METHODS We performed a single-center, retrospective, descriptive study within a 44-bed PICU in a stand-alone, tertiary, pediatric referral center. Inclusion criteria were age ≤2 years and pre-procedural selection of prophylactic PICU monitoring after MLB between January 2010 and December 2015. Children were excluded for existing tracheostomy, if undergoing concurrent non-otolaryngeal procedures, or if intubated at the time of PICU admission. Primary outcomes were the development of major and minor procedural complications and medical rescue interventions. Secondary outcomes were hospital cost and length of stay (LOS). RESULTS One hundred and eight subjects met inclusion criteria with a median age of 5.3 (IQR: 2.6-10.9) months. A majority (86%) underwent therapeutic instrumentation in addition to diagnostic MLB. There were no observed major complications or rescue interventions. Minor complications were noted within 5 h of monitoring and included isolated stridor (24%), desaturation <90% (10%), and nausea/emesis (8%). Minor interventions included supplemental oxygen via regular nasal cannula (39%), single-dose inhaled racemic epinephrine (19%), single-dose systemic corticosteroids (19%), or high flow nasal cannula (HFNC) therapy (4%). Save for two cases of HFNC, interventions were completed or discontinued within 5 h. Median PICU LOS was 1.1 days and median cost was $9650 (IQR: $8235- $14,861) per encounter. Estimated cost of same day observation in our post anesthesia care unit (PACU) following MLB without PICU admission is $1921 per encounter. CONCLUSIONS In children ≤ 2 years of age prophylactically admitted for PICU observation, we did not observe severe complications or major interventions after MLB. Minor interventions and complications were noted early during post-procedural monitoring. PICU monitoring was substantially more expensive than same-day PACU observation. Young age as the sole criteria for prophylactic PICU monitoring after diagnostic or therapeutic MLB may be unjustified when comparable, cost-conscious care can be achieved in a PACU setting. Prior to pre-procedural selection of PICU monitoring, we recommend a broad contextual risk assessment including a review of comorbidities, operative plan, and intended anesthetic exposure.
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Affiliation(s)
- Elizabeth J Kerris
- Pediatric Critical Care Medicine, Department of Medicine, Division of Critical Care Medicine, Children's National Health System, 111 Michigan Ave NW, Suite M4811, Washington, DC, 20010, USA.
| | - Jason T Patregnani
- Pediatric Cardiac Intensive Care Medicine, Department of Medicine Division of Cardiac Intensive Care Medicine, Children's National Health System, 111 Michigan Ave NW, Suite M4811, Washington, DC, 20010, USA.
| | - Matthew Sharron
- Pediatric Critical Care Medicine, Department of Medicine, Division of Critical Care Medicine, Children's National Health System, 111 Michigan Ave NW, Suite M4811, Washington, DC, 20010, USA.
| | - Anthony A Sochet
- Anesthesiology and Critical Care Medicine, Department of Medicine, Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, 501 6th Street South, OCC Suite 702, Room 709, St. Petersburg, FL, 33701, USA.
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Huff C, Mastropietro CW, Riley C, Byrnes J, Kwiatkowski DM, Ellis M, Schuette J, Justice L. Comprehensive Management Considerations of Select Noncardiac Organ Systems in the Cardiac Intensive Care Unit. World J Pediatr Congenit Heart Surg 2018; 9:685-695. [PMID: 30322370 DOI: 10.1177/2150135118779072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As the acuity and complexity of pediatric patients with congenital cardiac disease have increased, there are many noncardiac issues that may be present in these patients. These noncardiac problems may affect clinical outcomes in the cardiac intensive care unit and must be recognized and managed. The Pediatric Cardiac Intensive Care Society sought to provide an expert review of some of the most common challenges of the respiratory, gastrointestinal, hematological, renal, and endocrine systems in pediatric cardiac patients. This review provides a brief overview of literature available and common practices.
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Affiliation(s)
- Christin Huff
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher W Mastropietro
- 2 Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | - Jonathan Byrnes
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Misty Ellis
- 5 Department of Pediatric Critical Care, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | | | - Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Risk factors and outcomes of tracheostomy after prolonged mechanical ventilation in pediatric patients with heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chen T, Qiu L, Zhong L, Tao Q, Liu H, Chen L. Flexible bronchoscopy in pulmonary diseases in children with congenital cardiovascular abnormalities. Exp Ther Med 2018; 15:5481-5486. [PMID: 29904428 DOI: 10.3892/etm.2018.6113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/05/2018] [Indexed: 11/06/2022] Open
Abstract
There is a lack of data describing the role of flexible bronchoscopy (FB) in evaluating pulmonary diseases in children with congenital cardiovascular abnormalities in China. Determining whether those children suffer from respiratory complications may be useful for future preoperative planning and family counseling. The present study aimed to investigate the features and FB-associated findings with respect to pulmonary diseases in children with congenital cardiovascular abnormalities. The role of FB in guiding the treatment and safety of procedures was also evaluated. A cohort of 57 children with congenital cardiovascular abnormalities underwent FB for pulmonary diseases between November 2013 and June 2015. The demographics, bronchoscopy diagnoses, cellular analysis and microbiology of bronchoalveolar lavage fluid (BALF), and the clinically valuable contributions and side-effects of FB were analyzed retrospectively. The bronchoscopies were performed in patients with a median age of 4 months (range, 9 days-9 years) and 9 patients were intubated and mechanically ventilated. The most common types of congenital cardiovascular abnormalities were atrial septal defect, ventricular septal defect and patent ductus arteriosus. External compression of airways, tracheobronchomalacia, laryngomalacia, and airway narrowing were the most common airway abnormalities revealed by FB. BALF cellular analysis revealed an elevated total cell count and neutrophil percentage; 19.2% specimens harbored an etiological agent. FB findings contributed towards the clinical management of 26.3% patients. The complications of FB were mild and transient. In the present study, the majority of patients with cardiovascular abnormalities exhibited other airway disorders. The present findings suggest that FB was a useful and safe tool in the evaluation of this specific group of children.
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Affiliation(s)
- Ting Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China.,Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Li Qiu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China.,Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lin Zhong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Qingfen Tao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Hanmin Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China.,Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lina Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China.,Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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