1
|
Ortmann LA, Reeder RW, Raymond TT, Brunetti MA, Himebauch A, Bhakta R, Kempka J, di Bari S, Lasa JJ. Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records. Resuscitation 2023; 188:109855. [PMID: 37257678 PMCID: PMC10890910 DOI: 10.1016/j.resuscitation.2023.109855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children. METHODS This was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes). RESULTS A total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36-1.69), p = 0.53]. CONCLUSIONS Survivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.
Collapse
Affiliation(s)
- Laura A Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital, Dallas, TX, USA
| | - Marissa A Brunetti
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adam Himebauch
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rupal Bhakta
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica Kempka
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Shauna di Bari
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Critical Care, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
2
|
Payton KSE, Brunetti MA. Antibiotic Stewardship in Pediatrics. Adv Pediatr 2021; 68:37-53. [PMID: 34243858 DOI: 10.1016/j.yapd.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kurlen S E Payton
- Department of Pediatrics, Division of Neonatology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, NT Suite 4221, Los Angeles, CA 90048, USA.
| | - Marissa A Brunetti
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard Suite 8NE51, Philadelphia, PA 19104, USA
| |
Collapse
|
3
|
Brunetti MA, Gaynor JW, Retzloff LB, Lehrich JL, Banerjee M, Amula V, Bailly D, Klugman D, Koch J, Lasa J, Pasquali SK, Gaies M. Characteristics, Risk Factors, and Outcomes of Extracorporeal Membrane Oxygenation Use in Pediatric Cardiac ICUs: A Report From the Pediatric Cardiac Critical Care Consortium Registry. Pediatr Crit Care Med 2018; 19:544-552. [PMID: 29863638 PMCID: PMC6051408 DOI: 10.1097/pcc.0000000000001571] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiopulmonary failure in children with cardiac disease differs from the general pediatric critical care population, yet the epidemiology of extracorporeal membrane oxygenation support in cardiac ICUs has not been described. We aimed to characterize extracorporeal membrane oxygenation utilization and outcomes across surgical and medical patients in pediatric cardiac ICUs. DESIGN Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry to describe extracorporeal membrane oxygenation frequency and outcomes. Within strata of medical and surgical hospitalizations, we identified risk factors associated with extracorporeal membrane oxygenation use through multivariate logistic regression. SETTING Tertiary-care children's hospitals. PATIENTS Neonates through adults with cardiac disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 14,526 eligible hospitalizations from August 1, 2014, to June 30, 2016; 449 (3.1%) included at least one extracorporeal membrane oxygenation run. Extracorporeal membrane oxygenation was used in 329 surgical (3.5%) and 120 medical (2.4%) hospitalizations. Systemic circulatory failure and extracorporeal cardiopulmonary resuscitation were the most common extracorporeal membrane oxygenation indications. In the surgical group, risk factors associated with postoperative extracorporeal membrane oxygenation use included younger age, extracardiac anomalies, preoperative comorbidity, higher Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, bypass time, postoperative mechanical ventilation, and arrhythmias (all p < 0.05). Bleeding requiring reoperation (25%) was the most common extracorporeal membrane oxygenation complication in the surgical group. In the medical group, risk factors associated with extracorporeal membrane oxygenation use included acute heart failure and higher Vasoactive Inotropic Score at cardiac ICU admission (both p < 0.0001). Stroke (15%) and renal failure (15%) were the most common extracorporeal membrane oxygenation complications in the medical group. Hospital mortality was 49% in the surgical group and 63% in the medical group; mortality rates for hospitalizations including extracorporeal cardiopulmonary resuscitation were 50% and 83%, respectively. CONCLUSIONS This is the first multicenter study describing extracorporeal membrane oxygenation use and outcomes specific to the cardiac ICU and inclusive of surgical and medical cardiac disease. Mortality remains high, highlighting the importance of identifying levers to improve care. These data provide benchmarks for hospitals to assess their outcomes in extracorporeal membrane oxygenation patients and identify unique high-risk subgroups to target for quality initiatives.
Collapse
Affiliation(s)
- Marissa A Brunetti
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lauren B Retzloff
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Jessica L Lehrich
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health & Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Venugopal Amula
- Department of Pediatrics, Primary Children's Hospital & University of Utah School of Medicine, Salt Lake City, UT
| | - David Bailly
- Department of Pediatrics, Primary Children's Hospital & University of Utah School of Medicine, Salt Lake City, UT
| | - Darren Klugman
- Department of Pediatrics, Children's National Medical Center & George Washington University School of Medicine, Washington, DC
| | - Josh Koch
- Department of Pediatrics, Children's Medical Center & University of Texas Southwestern Medical Center, Dallas, TX
| | - Javier Lasa
- Department of Pediatrics, Texas Children's Hospital & Baylor College of Medicine, Houston, TX
| | - Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
4
|
Brunetti MA, Glatz AC, McCardle K, Mott AR, Ravishankar C, Gaynor JW. Unplanned Readmission to the Pediatric Cardiac Intensive Care Unit: Prevalence, Outcomes, and Risk Factors. World J Pediatr Congenit Heart Surg 2016; 6:597-603. [PMID: 26467874 DOI: 10.1177/2150135115594854] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Factors leading to cardiac intensive care unit (CICU) readmission and the impact on mortality have yet to be well delineated. We sought to define the prevalence and outcome for unscheduled CICU readmission. Secondary objectives were to identify indications and risk factors for unscheduled CICU readmission. METHODS Retrospective analysis of prospectively collected registry data at a tertiary care children's hospital. Pediatric and adult patients with congenital and acquired heart disease who survived to initial CICU discharge were included. Patients with unexpected return to the CICU for acute change in clinical status were defined as unscheduled readmissions. RESULTS Of the 645 discharges that met inclusion criteria, 37 resulted in unplanned readmission to the CICU. Patients requiring unscheduled readmission had higher mortality rates (16.2% vs 0.5%, P < .0001). Cardiac symptoms were the most common reason for readmission. On multivariate analysis, genetic anomaly (P = .001) and longer length of stay (LOS) during the index CICU admission (P = .01) were independently associated with readmission. For surgical patients, genetic anomaly (P = .001), single-ventricle anatomy (P = .05), and longer surgical support time (P < .001) were independently associated with readmission. CONCLUSION Unscheduled readmission to the CICU within the same hospitalization was uncommon but associated with a higher mortality rate. Genetic anomaly and longer initial LOS were important risk factors for the entire cohort. Single-ventricle anatomy and longer intraoperative course were risk factors for surgical readmissions.
Collapse
Affiliation(s)
- Marissa A Brunetti
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew C Glatz
- Division of Cardiology, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ken McCardle
- Clinical Data and Analytics, Mount Sinai Hospital, New York, NY, USA
| | - Antonio R Mott
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J William Gaynor
- Department of Cardiac Surgery, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Johnson JT, Sleeper LA, Chen S, Ohye RG, Gaies MG, Williams IA, Sachdeva R, Pruetz JD, Tatum GH, Thacker D, Brunetti MA, Frommelt MA, Jacobs JP, Kirsh JA, Lambert LM, Newburger JW, Pemberton VL, Zyblewski SC, Divanovic AA, Pinto NM. Associations Between Day of Admission and Day of Surgery on Outcome and Resource Utilization in Infants With Hypoplastic Left Heart Syndrome Who Underwent Stage I Palliation (from the Single Ventricle Reconstruction Trial). Am J Cardiol 2015; 116:1263-9. [PMID: 26303634 DOI: 10.1016/j.amjcard.2015.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 11/27/2022]
Abstract
Newborns with hypoplastic left heart syndrome and other single right ventricular variants require substantial health care resources. Weekend acute care has been associated with worse outcomes and increased resource use in other populations but has not been studied in patients with single ventricle. Subjects of the Single Ventricle Reconstruction trial were classified by whether they had a weekend admission and by day of the week of Norwood procedure. The primary outcome was hospital length of stay (LOS); secondary outcomes included transplant-free survival, intensive care unit (ICU) LOS, and days of mechanical ventilation. The Student's t test with log transformation and the Wilcoxon rank-sum test were used to analyze associations. Admission day was categorized for 533 of 549 subjects (13% weekend). The day of the Norwood was Thursday/Friday in 39%. There was no difference in median hospital LOS, transplant-free survival, ICU LOS, or days ventilated for weekend versus non-weekend admissions. Day of the Norwood procedure was not associated with a difference in hospital LOS, transplant-free survival, ICU LOS, or days ventilated. Prenatally diagnosed infants born on the weekend had lower mean birth weight, younger gestational age, and were more likely to be intubated but did not have a difference in measured outcomes. In conclusion, in this cohort of patients with single right ventricle, neither weekend admission nor end-of-the-week Norwood procedure was associated with increased use of hospital resources or poorer outcomes. We speculate that the complex postoperative course following the Norwood procedure outweighs any impact that day of admission or operation may have on these outcomes.
Collapse
Affiliation(s)
- Joyce T Johnson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Lynn A Sleeper
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Shan Chen
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Richard G Ohye
- University of Michigan Health System, Ann Arbor, Michigan
| | | | | | - Ritu Sachdeva
- Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Jay D Pruetz
- Children's Hospital Los Angeles, Los Angeles, California
| | - Gregory H Tatum
- Duke Children's Hospital and Health Center, Durham, North Carolina
| | - Deepika Thacker
- Nemours/Alfred L. DuPont Hospital for Children, Wilmington, Delaware
| | | | | | | | | | - Linda M Lambert
- University of Utah at Primary Children's Hospital, Salt Lake City, Utah
| | | | | | | | | | - Nelangi M Pinto
- University of Utah at Primary Children's Hospital, Salt Lake City, Utah
| |
Collapse
|
6
|
Brunetti MA, Ringel R, Owada C, Coulson J, Jennings JM, Hoyer MH, Everett AD. Percutaneous closure of patent ductus arteriosus: A multiinstitutional registry comparing multiple devices. Catheter Cardiovasc Interv 2010; 76:696-702. [DOI: 10.1002/ccd.22538] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
7
|
Ungar A, Morrione A, Rafanelli M, Ruffolo E, Brunetti MA, Chisciotti VM, Masotti G, Del Rosso A, Marchionni N. The management of syncope in older adults. Minerva Med 2009; 100:247-258. [PMID: 19749680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Syncope is a frequent symptom in older patients. The diagnostic and therapeutic management may be complex, particularly in older adults with syncope and comorbidities or cognitive impairment. Morbidity related to syncope is more common in older persons and ranges from loss of confidence, depressive illness and fear of falling, to fractures and consequent institutionalization. Moreover, advan-ced age is associated with short and long-term morbidity and mortality after syncope. A standardized approach may obtain a definite diagnosis in more than 90% of the older patients with syncope and may reduce diagnostic tools and hospitalizations. The initial evaluation, including anamnesis, medical examination, orthostatic hypotension test and electrocardiogram (ECG), may be more difficult in the elderly, specially for the limited value of medical history, particularly for the certain diagnosis of neuro-mediated syncope. For this reason neuroautonomic assessment is an essential step to confirm a suspect of neuromediated syncope. Orthostatic blood pressure measurement, head up tilt test, carotid sinus massage and insertable cardiac monitor are safe and useful investigations, particularly in older patients. The most common causes of syncope in the older adults are orthostatic hypotension, carotid sinus hypersensitivity, neuromediated syncope and cardiac arrhythmias. The diagnostic evaluation and the treatment of cardiac syncope are similar in older and young patients and for this reason will not be discussed. In older patients unexplained falls could be related to syncope, particularly in patients with retrograde amnesia. There are no consistent differences in the treatment of syncope between older and younger population, but a specific approach is necessary for orthostatic hypotension, drug therapy and pacemaker implantation.
Collapse
Affiliation(s)
- A Ungar
- Syncope Unit, Unit of Cardiology and Geriatric Medicine, Department of Critical Care Medicine and Surgery, University of Florence, Florence, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|