Neonatal Congenital Heart Disease Surgical Readiness and Timing

Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis

BACKGROUND

Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited.

OBJECTIVES

To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates.

DESIGN

We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol.

INTERVENTIONS

Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm.

MEASUREMENTS AND MAIN RESULTS

Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation.

CONCLUSIONS

If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.

Pediatric Cardiology Condolence Letter Writing: Does a Fellowship Curriculum Impact Practice?

CONTEXT

Condolence letter (CL) writing after the death of a child is an important opportunity for humanism. Pediatric cardiology fellowship training now recognizes the importance of palliative care, but rarely includes CL education, despite its fragile patient population.

OBJECTIVES

To address this professionalism gap, a formal CL writing curriculum was created and implemented in a pediatric cardiology fellowship. This study investigated the impact of the curriculum on pediatric cardiology CL writing, and broader CL practices and beliefs.

METHODS

Pediatric cardiology fellows at a high volume urban academic program from 2000 to 2022 were divided into two cohorts (exposure to CL curriculum [2014-2022] vs. no exposure [2000-2013]) and responded by anonymous electronic multiple choice and open ended survey to assess the CL curriculum and describe current CL practices and beliefs. Impact of curriculum elements was determined by ordinal ranking. A 5-point Likert scale was used to report physician behaviors. Chi-square tests of independence were utilized for group comparisons.

RESULTS

The overall survey response rate was 59% (63/107). Cardiologists who participated in the curriculum (64%, 35/55) were more likely to report writing CLs (80% vs. 40%; P < 0.01). Impactful curriculum elements included the opportunity for all fellows to contribute to a CL (78%) and identifying a primary fellow to write the CL (66%). A majority (>75%) of curriculum participants agreed that formal teaching increased their frequency, ability, and comfort in writing CLs.

CONCLUSION

Development of condolence expression educational programs in pediatric cardiology training should be expanded.

Isolated aortic arch anomalies are associated with defect severity and outcome in patients with congenital diaphragmatic hernia

PURPOSE

Congenital diaphragmatic hernia (CDH) patients often have suspected isolated aortic arch anomalies (IAAA) on imaging. The purpose of this work was to describe the incidence and outcomes of CDH + IAAA patients.

METHODS

Cardiovascular data were collected for infants from the CDH Study Group born between 2007 and 2019. IAAA were defined as coarctation of aorta, hypoplastic aortic arch, interrupted aortic arch, and aortic aneurysmal disease on early, postnatal echocardiography. Patients with major cardiac malformations and/or chromosomal abnormalities were excluded. Primary outcomes included the rate of aortic intervention, rates of extracorporeal life support (ECLS) utilization, and mortality.

RESULTS

Of 6357 CDH infants, 432 (7%) were diagnosed with a thoracic aortic anomaly. Of these, 165 were diagnosed with IAAA, most commonly coarctation of the aorta (n = 106; 64%) or hypoplastic aortic arch (n = 58; 35%). CDH + IAAA patients had lower birthweights (3 kg vs. 2.9 kg) and Apgar scores (7 vs. 6) than patients without IAAA (both χ² p < 0.001). CDH + IAAA were less likely to undergo diaphragm repair (72 vs. 87%, p < 0.001), and overall mortality was higher for CDH + IAAA infants (58 vs. 24%, p < 0.001). When controlling for defect size, birth weight, and Apgar, IAAA were significantly associated with mortality (OR 3.3, 95% CI 2.2-5.0; p < 0.01) but not associated with ECLS (OR 0.98, 95% CI 0.65-1.50; p = 0.90). Only 17% (n = 28) of CDH + IAAA patients underwent aortic intervention.

CONCLUSIONS

IAAA in CDH are associated with increased mortality. This often simply reflects severity of the defect and thoracic anatomic derangement, as opposed to unique aortic pathology, given few CDH + IAAA patients undergo aortic intervention.