Hypothermia after extracorporeal cardiopulmonary resuscitation not associated with improved neurologic complications or survival in children: An analysis of the ELSO registry.

AIM: To analyze the association between hypothermia and neurologic complications among children who were treated with extracorporeal cardiopulmonary resuscitation (ECPR) using the Extracorporeal Life Support Organization (ELSO) international registry. METHODS: We conducted a retrospective, multicenter, database study utilizing ELSO data for ECPR encounters from January 1, 2011, through December 31, 2019. Exclusion criteria included multiple ECMO runs and lack of variable data. The primary exposure was hypothermia under 34 °C for greater than 24 hours. The primary outcome, determined a priori, was a composite of neurologic complications defined by ELSO registry including brain death, seizures, infarction, hemorrhage, diffuse ischemia. Secondary outcomes were mortality on ECMO and mortality prior to hospital discharge. Multivariable logistic regression determined the odds of neurologic complications, mortality on ECMO or prior to hospital discharge associated with hypothermia after adjustment for available pertinent covariables. RESULTS: Of the 2,289 ECPR encounters, no difference in odds of neurologic complications were found between the hypothermia and non-hypothermia groups (AOR 1.10, 95% CI 0.80-1.51). However, hypothermia exposure was associated with decreased odds of mortality on ECMO (AOR 0.76, 95% CI 0.59-0.97), but no difference in mortality prior to hospital discharge (AOR 0.96, 95% CI 0.76-1.21) CONCLUSION: Analysis of a large, multicenter, international dataset demonstrates that hypothermia for greater than 24 hours among children who undergo ECPR is not associated with decreased neurologic complications or mortality benefit at time of hospital discharge.

Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD.

OBJECTIVE: A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap. METHODS: Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. "Consensus" was defined as ≥ 80% of responses as "agree" or "strongly agree" to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not. RESULTS: The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for "low" and "high" volume patients, and timing and duration of fat-modified diet. All recommendations achieved "consensus" (agreement >80%) by the workgroup (range 81-100%). Ex vivo simulations demonstrated good understanding by developers (range 94-100%) and non-developers (73%-100%). CONCLUSIONS: The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.

Use of ECMO for Cardiogenic Shock in Pediatric Population.

In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical and surgical heart disease. Indications, contraindications, and outcomes of VA ECMO in the pediatric population are discussed.VA ECMO provides biventricular and respiratory support and can be deployed in rapid fashion to rescue patient with failing physiology. There have been advances in conduct and technologic aspects of VA ECMO, but survival outcomes have not improved. Stringent selection and optimal timing of deployment are critical to improve mortality and morbidity of the patients supported with VA ECMO.

CPR during COVID-19: Use of Expert-driven Rapid Cycle Deliberate Practice to Implement PALS Guidelines.

The American Heart Association (AHA) and other national institutions have endorsed modifications to resuscitation guidelines given the risk of healthcare workers' (HCWs) exposure to COVID-19. Institutional implementation of the COVID-19-focused guidelines requires both proof of feasibility and education of HCW. Pediatric critical care medical directors at The University of Texas Southwestern/Children's Health System of Texas (UTSW/CHST) created a guideline for the resuscitation of COVID-19 patients. The simulation team used in situ simulation to demonstrate guideline feasibility and to create educational materials. METHODS: A UTSW/CHST guideline incorporated COVID-19-focused AHA and other national organizational recommendations to fit the institutional needs. A high-fidelity in situ simulation helped test the feasibility and optimize the UTSW/CHST guideline. We developed a novel form of rapid cycle deliberate practice (RCDP), expert-driven RCDP, in which all simulation participants are experts, to debrief the simulation. RESULTS: In situ simulation with expert-driven RCDP demonstrated guideline feasibility in the resuscitation of a COVID-19 patient while balancing the protection of HCW. Expert-driven RCDP allowed for real-time alterations to the guideline during the simulation event. Video recording and dissemination of the simulation allowed for the education of over 300 staff on the new recommendations. CONCLUSIONS: High-fidelity in situ simulation with expert-driven RCDP created a rapid consensus among expert critical care providers to develop the UTSW/CHST guideline and quickly adopt the new AHA recommendations. This debriefing method helped minimize the risk of HCW exposure by minimizing the number of required participants and time for simulation. We recommend using this distinctive, expert-driven RCDP debriefing method for expeditious testing of COVID-19-focused processes at other institutions.Video Abstract available at: [link forthcoming].

Early Fluid Accumulation and Intensive Care Unit Mortality in Children Receiving Extracorporeal Membrane Oxygenation.

Purpose of this study was to evaluate the impact of early fluid accumulation and renal dysfunction on mortality in children receiving extracorporeal membrane oxygenation (ECMO). Retrospective cohort study of neonatal and pediatric patients who received ECMO between January 2010 and December 2012 in a tertiary level multidisciplinary pediatric intensive care unit (ICU). Ninety-six patients were included, and forty-six (48%) of them received continuous renal replacement therapy (CRRT) during ECMO. Overall mortality was 38.5%. Proportion of patients with acute kidney injury (AKI) at ICU admission was 33% and increased to 47% at ECMO initiation. High-risk diagnoses, extracorporeal cardiopulmonary resuscitation (ECPR), and venoarterial (VA)-ECMO were more common among nonsurvivors. Nonsurvivors had significantly higher proportion of AKI at ICU admission (OR: 2.59, p = 0.04) and fluid accumulation on ECMO day 1 (9% vs. 1%, p = 0.05) compared with survivors. Multivariable logistic regression analysis (adjusted for a propensity score based on nonrenal factors associated with increased mortality) demonstrated that fluid accumulation on ECMO day 1 is significantly associated with increased ICU mortality (OR: 1.07, p = 0.04). Fluid accumulation within the first 24 hours after ECMO cannulation is significantly associated with increased ICU mortality in neonatal and pediatric patients. Prospective studies evaluating the impact of conservative fluid management and CRRT during the initial phase of ECMO may help further define this relationship.

An International Survey Comparing Different Physician Models for Health Care Delivery to Critically Ill Children With Heart Disease.

OBJECTIVES: To explore relationships between the training background of cardiac critical care attending physicians and self-reported perceived strengths and weaknesses in their ability to provide clinical care. DESIGN: Cross-sectional observational survey sent worldwide to ~550 practicing cardiac ICU attending physicians. SETTING: Hospitals providing cardiac critical care. SUBJECTS: Practicing cardiac critical care physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We received responses from 243 ICU attending physicians from 82 centers (14 countries). The primary training background of the respondents included critical care (62%), dual training in critical care and cardiology (16%), cardiology (14%), and other (8%). We received 49 responses from medical directors in nine countries, who reported that the predominant training background for attending physicians who provide cardiac intensive care at their institutions were critical care (58%), dual trained (18%), cardiology (12%), and other (11%). A greater proportion of physicians trained in either critical care or dual-training reported feeling confident managing multiple organ failure, neurologic conditions, brain death, cardiac arrest, and performing procedures like advanced airway placement and inserting chest- and abdominal-drains. In contrast, physicians with cardiology and dual-training reported feeling more confident managing intractable arrhythmias, understanding cardiopulmonary interactions, and interpreting echocardiogram, electrocardiogram, and cardiac catheterization. Overall, only 57% of the respondents felt comfortable based on their current training background to manage patients with complex cardiac issues without collaboration with other specialists. CONCLUSIONS: Our survey demonstrates that intensivists trained in critical care are more comfortable with critical care skills, cardiology-trained intensivists are more comfortable with cardiology skills, and dual-trained physicians are comfortable with both critical care skills and cardiology skills. These findings may help inform future efforts to optimize the educational curriculum and training pathways for future cardiac intensivists. These data may also be used to shape continuing medical education activities for cardiac intensivists who have already completed their training.

Impact of intensive care unit attending physician training background on outcomes in children undergoing heart operations.

BACKGROUND: The existing training pathways to become a pediatric cardiac intensivist are very variable with physicians coming from varied training backgrounds of pediatric critical care, pediatric cardiology, neonatology, or pediatric anesthesia. AIM: To evaluate the impact of cardiac Intensive Care Unit (ICU) attending physician training background on outcomes in children undergoing heart operations. SETTING AND DESIGN: Patients in the age group from 1 day to 18 years undergoing heart operation at a Pediatric Health Information System database participating hospital were included (2010-2015). PATIENTS AND METHODS: Based on the training background of majority of attending physicians in an ICU, the participating ICUs were divided into three groups: critical care medicine (CCM), cardiology, and indeterminate. STATISTICAL ANALYSIS: Multivariable logistic regression models were fitted to evaluate the association of ICU physician training background with study outcomes. RESULTS: A total of 54,935 patients from 42 ICUs were included. Of these, 31,815 patients (58%) were treated in the CCM group (26 ICUs), 19,340 patients (35%) were treated in the cardiology group (12 ICUs), and 3780 patients (7%) were treated in the indeterminate group (4 ICUs). In adjusted models, no specific group based on ICU attending physician training background was associated with lower mortality (CCM vs. cardiology, odds ratio: 0.75, 95% confidence interval: 0.48-1.18), or lower incidence of cardiac arrest, or prolonged hospital length of stay, or prolonged mechanical ventilation. CONCLUSIONS: This large observational study did not demonstrate any impact of ICU attending training background on outcomes in children undergoing heart operations.

Early fluid accumulation in children with shock and ICU mortality: a matched case-control study.

PURPOSE: The purpose of this study was to evaluate the association between early fluid accumulation and mortality in children with shock states. METHODS: We retrospectively reviewed children admitted in shock states to the pediatric intensive care unit (ICU) at a tertiary level children's hospital over a 7-month period. The study was designed as a matched case-control study. Children with early fluid overload, defined as fluid accumulation of ≥10% of admission body weight during the initial 3 days, were designated as the cases. They were compared with matched controls without early fluid accumulation. Cases and controls were matched for age, severity of illness at ICU admission and need for organ support. They were compared with respect to all-cause ICU mortality and other secondary outcomes. RESULTS: A total of 114 children (age range 0-17.4 years; N = 42 cases and 72 matched controls) met the study criteria. Mortality rate was 13% (15/114) in this cohort. Multivariable logistic regression analysis identified the presence of early fluid overload [adjusted odds ratio (OR) 9.17, 95% confidence interval (CI) 2.22-55.57], its severity (adjusted OR 1.11, 95% CI 1.05-1.19) and its duration (adjusted OR 1.61, 95% CI 1.21-2.28) as independent predictors of mortality. Cases had higher mortality than the controls (26 vs. 6 %; p 0.003), and this difference remained significant in the matched analysis (37 vs. 3%; p 0.002). CONCLUSION: The presence, severity and duration of early fluid are associated with increased ICU mortality in children admitted to the pediatric ICU in shock states.