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Mai DH, Sutherland S, Blinder J, Hollander SA. A novel acute kidney injury scoring system for renal and clinical outcomes in pediatric heart transplant patients. Pediatr Transplant 2023; 27:e14565. [PMID: 37409513 DOI: 10.1111/petr.14565] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND The development of acute kidney injury (AKI) has been associated with worse outcomes in children after heart transplantation. Our study compares the application of a cumulative six-point Kidney Diseases Improving Global Outcomes (KDIGO) AKI scoring system, utilizing both creatinine and urine output criteria that we term as the AKI-6 criteria, to traditional AKI staging as a predictor for clinical and renal outcomes in the pediatric heart transplant recipients. METHODS We conducted a retrospective single-center chart review on 155 pediatric patients who underwent heart transplantation from May 2014 to December 2021. The primary independent variable was the presence of severe AKI. Severe AKI by KDIGO was defined as Stage ≥2, whereas severe AKI by AKI-6 was defined as cumulative scores ≥4 or Stage 3 AKI based on either KDIGO criterion alone. Primary outcomes included actuarial survival and renal dysfunction by 1-year post-transplant, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2 . RESULTS In total, 140 (90%) patients developed AKI; 98 (63%) patients developed severe AKI by KDIGO, and 60 (39%) by AKI-6. Severe AKI by AKI-6 was associated with worse actuarial survival following heart transplantation compared with KDIGO (p = 0.01). Of the 143 patients with 1-year creatinine data, 6 (11%) patients out of 54 with severe AKI by AKI-6 had evidence of renal dysfunction (p = 0.01), compared with 6 (7%) patients out of 88 by KDIGO (p = 0.3). CONCLUSIONS AKI-6 scoring provides greater prognostic utility for actuarial survival and renal dysfunction by 1-year post-heart transplantation in pediatric patients than traditional KDIGO staging.
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Affiliation(s)
- Daniel H Mai
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott Sutherland
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Joshua Blinder
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Stanford University School of Medicine, Palo Alto, California, USA
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Vazquez-Fuster JI, Rivera G, Vicenty-Rivera SI, Merced F. Myxedema Coma and the Heart: Would You Miss the Signs? Cureus 2023; 15:e45164. [PMID: 37842478 PMCID: PMC10575566 DOI: 10.7759/cureus.45164] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Myxedema Coma (MC) is a life-threatening medical emergency that occurs as a severe complication of untreated or poorly managed hypothyroidism. Prompt diagnosis is crucial as the condition can rapidly deteriorate and lead to life-threatening complications. Timely treatment of myxedema coma with intravenous levothyroxine is the cornerstone of treatment, along with glucocorticoids to support adrenal function. This condition is associated with cardiovascular manifestations that contribute to its high mortality rate. The heart in hypothyroidism typically shows reversible dysfunction that can be corrected with hormonal supplementation, and in some cases, requires inotropic and aminergic support. This case involves a patient who was admitted to the intensive care unit with suspected MC, and necessitated life-saving hormonal and cardiovascular support to manage the condition.
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Affiliation(s)
| | - Giovanni Rivera
- Internal Medicine, Veteran Affairs Caribbean Healthcare System, San Juan, PRI
| | | | - Francisco Merced
- Cardiology, Veteran Affairs Caribbean Healthcare System, San Juan, PRI
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Milligan C, Mills KI, Ge S, Michalowski A, Braudis N, Mansfield L, Nathan M, Sleeper LA, Teele SA. Cardiovascular intensive care unit variables inform need for feeding tube utilization in infants with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2023; 165:1248-1256. [PMID: 35691711 DOI: 10.1016/j.jtcvs.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/24/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Feeding strategies in infants with hypoplastic left heart syndrome (HLHS) following stage 1 palliation (S1P) include feeding tube utilization (FTU). Timely identification of infants who will fail oral feeding could mitigate morbidity in this vulnerable population. We aimed to develop a novel clinical risk prediction score for FTU. METHODS This was a retrospective study of infants with HLHS admitted to the Boston Children's Hospital cardiovascular intensive care unit for S1P from 2009 to 2019. Infants discharged with feeding tubes were compared with those on full oral feeds. Variables from early (birth to surgery), mid (postsurgery to cardiovascular intensive care unit transfer), and late (inpatient transfer to discharge) hospitalization were analyzed in univariate and multivariable models. RESULTS Of 180 infants, 66 (36.7%) discharged with a feeding tube. In univariate analyses, presence of a genetic disorder (early variable, odds ratio, 3.25; P = .014) and nearly all mid and late variables were associated with FTU. In the mid multivariable model, abnormal head imaging, ventilation duration, and vocal cord dysfunction were independent predictors of FTU (c-statistic 0.87). Addition of late variables minimally improved the model (c-statistic 0.91). A risk score (the HV2 score) for FTU was developed based on the mid multivariable model with high specificity (93%). CONCLUSIONS Abnormal head imaging, duration of ventilation, and presence of vocal cord dysfunction were associated with FTU in infants with HLHS following S1P. The predictive HV2 risk score supports routine perioperative head imaging and vocal cord evaluation. Future application of the HV2 score may improve nutritional morbidity and hospital length of stay in this population.
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Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
| | - Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Shirley Ge
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Anna Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Nancy Braudis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Laura Mansfield
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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Bouchlarhem A, Bazid Z, Ismaili N, Noha EO. Usefulness of the Quick-Sepsis Organ Failure Assessment Score in Cardiovascular Intensive Care Unit to Predict Prognosis in Acute Coronary Syndrome. Clin Appl Thromb Hemost 2023; 29:10760296231218705. [PMID: 38083859 PMCID: PMC10718056 DOI: 10.1177/10760296231218705] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Triage of patients with acute coronary syndrome (ACS) at high risk of in-hospital complications is essential. In this study, we evaluated the quick sepsis organ failure assessment (qSOFA) score as a tool for predicting the prognosis of 964 patients admitted to the cardiovascular intensive care unit (CICU) with ACS over a 4-year period. In total, out of 964 patients included, with a percentage of 4.6% for 30-day mortality. The risk of 30-day mortality was independently associated with qSOFA ≥ 2 at admission (hazard ratio = 2.76, 95% CI 1.32-5.74, p = 0.007). For MACEs, qSOFA ≥ 2 at admission was a predictive factor with (odds ratio = 2.42, 95% CI 1.37-4.36, p = .002). A qSOFA ≥ 2 on admission had an AUC of 0.729 (95% CI [0.694, 0.762]), with a good specificity of 91.6%. For 30-day mortality, an AUC of 0.759 (95%CI [0.726, 0.792]) for cardiogenic shock with specificity of 92.5%. For MACEs, an AUC of 0.702 (95% CI [0.64, 0.700] with a specificity of 95%. Concerning the different scores tested, we found no significant difference between the Zwolle score and the qSOFA score for predicting prognosis, whereas the CADILLAC score was better than qSOFA for predicting 30-day mortality (AUC = 0.829 and De long test = 0.03). However, there was no difference between qSOFA and CADILLAC scores for predicting cardiogenic shock (De Long test at 0.08). This is the first study to evaluate qSOFA as a predictive score for 30-day mortality and MACEs, and the results are very encouraging, particularly for cardiogenic shock.
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Affiliation(s)
- Amine Bouchlarhem
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
- Department of Cardiology, Mohammed VI University Hospital Mohammed I University, Oujda, Morocco
| | - Zakaria Bazid
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
- Department of Cardiology, Mohammed VI University Hospital Mohammed I University, Oujda, Morocco
| | - Nabila Ismaili
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
- Department of Cardiology, Mohammed VI University Hospital Mohammed I University, Oujda, Morocco
| | - El Ouafi Noha
- Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, Morocco
- Department of Cardiology, Mohammed VI University Hospital Mohammed I University, Oujda, Morocco
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Sawyer KE, Carpenter AT, Coleman RD, Tume SC, Crawford CA, Casas JA. Provider Perceptions for Withdrawing Life Sustaining Therapies at a Large Pediatric Hospital. J Pain Symptom Manage 2022; 64:e115-e121. [PMID: 35613688 DOI: 10.1016/j.jpainsymman.2022.05.009] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/15/2022] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT More than 74% of pediatric deaths occur in an intensive care unit (ICU), with 40% occurring after withdrawal of life-sustaining therapies (WOLST). No needs assessment has described provider needs or suggestions for improving the WOLST process in pediatrics. OBJECTIVES This study aims to describe interdisciplinary provider self-reported confidence, needs, and suggestions for improving the WOLST process. METHODS A convergent parallel mixed-methods design was used. An online survey was distributed to providers involved in WOLSTs in a quaternary children's hospital between January and December 2018. The survey assessed providers' self-reported confidence in their role, in providing guidance to families about the WOLST, experiences with the WOLST process, areas for improvement, and symptom management. Kruskal-Wallis testing was used for quantitative data analysis with P values <0.05 considered significant. Analysis was performed with SPSS v27. Qualitative data were thematically analyzed using Atlas.ti.8 and NVivo. RESULTS A total of 297 surveys were received (48% survey completion) that consisted of multiple choice, Likert-type, and yes/no questions with options for open-ended responses. Mean provider self-rated confidence was high and varied significantly between disciplines. Qualitative analysis identified four areas for refining communication: 1) between the primary team and family, 2) within the primary team, 3) between the primary team and consulting providers, and 4) logistical challenges. CONCLUSIONS While participants' self-rated confidence was high, it varied between disciplines. Participants identified opportunities for improved communication and planning before a WOLST. Future work includes development and implementation of a best practice guideline to address gaps and standardize care delivery.
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Affiliation(s)
- Kimberly E Sawyer
- St. Jude Children's Research Hospital (K.E.S.), Memphis, Tennessee, USA
| | | | - Ryan D Coleman
- Baylor College of Medicine (R.D.C., S.C.T., J.A.C.), Houston, Texas, USA
| | - Sebastian C Tume
- Baylor College of Medicine (R.D.C., S.C.T., J.A.C.), Houston, Texas, USA
| | | | - Jessica A Casas
- Baylor College of Medicine (R.D.C., S.C.T., J.A.C.), Houston, Texas, USA.
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Loughran J, Puthawala T, Sutton BS, Brown LE, Pronovost PJ, DeFilippis AP. The Cardiovascular Intensive Care Unit-An Evolving Model for Health Care Delivery. J Intensive Care Med 2016; 32:116-123. [PMID: 26768424 DOI: 10.1177/0885066615624664] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 11/16/2022]
Abstract
Prior to the advent of the coronary care unit (CCU), patients having an acute myocardial infarction (AMI) were managed on the general medicine wards with reported mortality rates of greater than 30%. The first CCUs are believed to be responsible for reducing mortality attributed to AMI by as much as 40%. This drastic improvement can be attributed to both advances in medical technology and in the process of health care delivery. Evolving considerably since the 1960s, the CCU is now more appropriately labeled as a cardiac intensive care unit (CICU) and represents a comprehensive system designed for the care of patients with an array of advanced cardiovascular disease, an entity that reaches far beyond its early association with AMI. Grouping of patients by diagnosis to a common physical space, dedicated teams of health care providers, as well as the development and implementation of evidence-based treatment algorithms have resulted in the delivery of safer, more efficient care, and most importantly better patient outcomes. The CICU serves as a platform for an integrated, team-based patient care delivery system that addresses a broad spectrum of patient needs. Lessons learned from this model can be broadly applied to address the urgent need to improve outcomes and efficiency in a variety of health care settings.
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Affiliation(s)
- John Loughran
- 1 Division of Cardiovascular Medicine, University of Louisville, Jewish Hospital/Kentucky One Health, Louisville, KY, USA
| | - Tauqir Puthawala
- 2 Division of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brad S Sutton
- 1 Division of Cardiovascular Medicine, University of Louisville, Jewish Hospital/Kentucky One Health, Louisville, KY, USA
| | - Lorrel E Brown
- 1 Division of Cardiovascular Medicine, University of Louisville, Jewish Hospital/Kentucky One Health, Louisville, KY, USA
| | - Peter J Pronovost
- 3 Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,4 Department of Health Policy & Management, The Bloomberg School of Public Health, Baltimore, MD, USA.,5 School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew P DeFilippis
- 1 Division of Cardiovascular Medicine, University of Louisville, Jewish Hospital/Kentucky One Health, Louisville, KY, USA
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