Berlin Heart EXCOR Paediatric Ventricular Assist Device: Does Weight Matter?

BACKGROUND: Berlin Heart EXCOR (BH) ventricular assist devices provide mechanical long-term circulatory support in children with end-stage heart failure, as a bridge to transplantation or to recovery. Most studies are from large-volume paediatric cardiac centres. AIM: The aim of this study was to analyse the experiences of three French centres and to compare these with available published data. METHOD: We performed a retrospective observational study of three paediatric cardiac intensive care units. All children supported with BH devices were included. Morbidity and mortality data were collected and risk factors analysed. RESULTS: Fifty-four (54) patients (54% male) were included. Survival rate was 73% while on a BH device. Median age at BH device implantation was 17 months (range 2-180 months). The predominant indication was dilated cardiomyopathy (61%). Bi-ventricular assist device was used in 25 (46%) cases. The total length of long-term circulatory support was 3,373 days, with a mean length per patient of 62.5 days (range 5-267 days). Thirty-two (32) patients were transplanted (59%) and seven (13%) were successfully weaned. Type and length of support did not influence morbidity. Main complications were renal dysfunction (57%), bleeding (41%), and infection (39%). In multivariate analysis, a weight <5 kg was significantly associated with higher mortality. CONCLUSIONS: The weight seems to be the most important risk factor of mortality in this precarious condition.

Extracorporeal life support for refractory out-of-hospital cardiac arrest: Should we still fight for? A single-centre, 5-year experience.

BACKGROUND: Cardiopulmonary resuscitation displays low survival rate after out-of-hospital cardiac arrest (OHCA). Extracorporeal life support (ECLS) could be suggested as a rescue therapeutic option in refractory OHCA. The aim of this report is to analyze our experience of ECLS implantation for refractory OHCA. METHODS: We performed a retrospective observational analysis of our prospectively collected database. Patients were divided into a shockable rhythm (SH-R) and a non-shockable rhythm (NSH-R) group according to cardiac rhythm at ECLS implantation. The primary endpoint was survival to hospital discharge with good neurological recovery. RESULTS: From January 2010 to December 2014 we used ECLS in 68 patients (SH-R, n=19, 27.9% vs. NSH-R, n=49, 72.1%) for refractory OHCA. The clinical profile before ECLS implantation was comparable between the groups. Eight (11.7%) patients were successfully weaned from ECLS (SH-R=31.5% vs. NSH-R=4.0%, p=0.01) after a mean period of support of 2.1 days (SH-R=4.1 days vs. NSH-R=1.4 days, p=0.01). Six (8.8%) patients survived to discharge (SH-R=31.5% vs. NSH-R=0%, p=0.00). In the SH-R group 50% of the survivors were discharged without neurological complications. CONCLUSIONS: ECLS for refractory OHCA should be limited in consideration of its poor, especially neurological, outcome. Non-shockable rhythms could be considered as a formal contraindication allowing a concentration of our efforts on the shockable rhythms, where the chances of success are substantial.

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

OBJECTIVE: Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. DESIGN: We performed a multicenter longitudinal study using routinely collected hospital data. SETTING: Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. PATIENTS: A total of 5,718 inpatient stays were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3-9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3-3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0-15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3-7.9]) were also associated with increased mortality. CONCLUSIONS: This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers' resources to patients' needs.

[Streamlining of medical orders in an intensive care unit]. / Rationalisation des prescriptions en réanimation.

OBJECTIVES: To We assessed whether intensivists ICU physician acceptance of a system designed to would accept to optimise e their orders for ings of biological samplesings, X-rays and target drugs, and to assess the consequences of this rationalization for on patient's outcome. STUDY DESIGN: Monocentric evaluation of medical economic procedure. The medical ordering process started to be assessed in our ICU in late 2006, METHODS: Mat meetings of consultants, registrars and residents, held started on Dec. 21, 2006 with 2-3 2 or 3 times a year sessions a year in order to evaluate the process of medical ordering. The p Physicians and pharmacists provided ordering data at each meeting Orderings of routine samplesings, bedside X-rays and unjustified expansive costly drugs were was discouraged, while targeted sampling ings and lung chest ultrasonography were encouraged. New residents were systematically taught about informed of the this programme. Meanwhile m Monthly morbidity-mortality meetings were pursued in order to assess the consequences impact of this politicspolicy. RESULTS: While Although ICU total ICU activity increased by 3.4%, and potentially evitable avoidable deaths decreased fell by 34%, % and annual expenses decreased dropped by approximatively about 777 750 000 euros from 2006 to 2008. This cost saving was due to decreased orderings fewer orders in for biological samples y by (-30%), bedside X-rays by (-10%), computed tomographic scans computed tomography by (-16%) and target drugs? by (-35%). However, an increased ordering in use of 4 target drugs was increased observed in between 2008 as compared with 2007 and 2008. CONCLUSION: Multidisciplinary optimisation of medical ordering can thus be efficient effective in an in ICU, although. However a profit-sharing with ordering physicians would be necessary to might help to prolong the system.

Anesthesia management in a child with PHACE syndrome and agenesis of bilateral internal carotid arteries.

This is the first case report of successful anesthesia management in a high-risk neurological procedure in a patient with PHACE syndrome. PHACE syndrome is rare but an important clinical entity. Anesthesiologists should be aware of the neurological, otolaryngogical, and vascular risk associated with this syndrome.

Time course and prognostic value of plasma B-type natriuretic peptide concentration in neonates undergoing the arterial switch operation.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) can predict postoperative complications after cardiac surgery in adults. Our aim was to investigate BNP kinetics and prognostic value in neonates undergoing the arterial switch operation (ASO) for transposition of the great arteries (TGA). METHODS: We measured BNP concentrations in 30 neonates before, immediately after, and 6, 12, 24, and 48 h after ASO for TGA. Complicated postoperative evolution was defined as patients requiring mechanical ventilation or presenting low cardiac output syndrome for more than 72 h. We studied the ability of postoperative BNP concentrations to predict complicated evolution. RESULTS: Intubation duration, inotropic support duration, and intensive care unit stay were 68 (48-121) h, 78 (69-141) h, and 96 (76-149) h respectively. Patients with complicated evolution had higher 6 and 12-h BNP concentrations than patients with simple evolution (459 (210-897) vs 137 (67-248) ng/L and 547 (193-868) vs 185 (79-354) ng/L respectively; P < 0.05) and had longer intubation, inotropic support, and intensive care unit stay (96 (70-190) vs 50 (48-66) h, 100 (83-190) vs 70 (59-72) h, and 120 (90-240) vs 84 (72-96) h, P < 0.05). A 6-h BNP concentration >160 ng/L was able to predict complicated evolution with a sensitivity of 93% and a specificity of 67%. CONCLUSION: In neonates, BNP concentrations can predict adverse outcome in the postoperative period after ASO for TGA. This marker has potential clinical applications.

Antibiotic prophylaxis with cefazolin and gentamicin in cardiac surgery for children less than ten kilograms.

OBJECTIVE: Antibiotic prophylaxis is recommended in pediatric cardiac surgery, but no data concerning the current antibiotic regimen were available. DESIGN: Prospective study from April to June 2000. SETTING: University hospital operating room and postoperative intensive care unit. PARTICIPANTS: Nineteen consecutive infants less than 10 kg with normal renal function undergoing cardiac surgery with cardiopulmonary bypass longer than 30 minutes. INTERVENTIONS: Intravenous administration of cefazolin, 40 mg/kg, and gentamicin, 5 mg/kg, at induction of anesthesia; followed by cefazolin, 35 mg/kg every 8 hours, and gentamicin, 2 mg/kg every 12 hours, over 48 hours. MEASUREMENTS AND MAIN RESULTS: Levels of serum antibiotics were measured: cefazolin (microbiologic) and gentamicin (fluorescence immunoassay) with 8 intraoperative and 5 postoperative samplings. Intraoperatively, cefazolin levels decreased from 166 +/- 44 (mean +/- standard deviation) down to 54 +/- 16 microg/mL and gentamicin from 20.8 +/- 9.5 down to 5.9 +/- 1.5 microg/mL. The postoperative trough levels were 12 +/- 7, 15 +/- 10, and 19 +/- 22 microg/mL for cefazolin and 1.1 +/- 0.5, 0.8 +/- 0.4, and 0.8 +/- 0.9 microg/mL for gentamicin. CONCLUSIONS: Antibiotic serum levels are consistent with satisfactory efficacy, but intraoperative gentamicin peak levels appeared too high.