Using Quality Improvement to Optimize Blood Product Utilization in a Pediatric Cardiac Catheterization Laboratory.

Packed red blood cells (PRBC) are frequently ordered for cardiac catheterization procedures, which increases resource utilization and patient charges. We applied the Plan-Do-Study-Act (PDSA) principle in order to optimize the ordering of PRBC for pediatric cardiac procedures and reducing charges. Our primary aim was to increase adherence to ordering guidelines to greater than 97%, with a global aim to reduce resource utilization. The existing PRBC ordering guidelines were revised and procedure reports were updated to include administration of PRBC. The rate of pre-procedure PRBC orders, adherence to the new protocol guidelines, presence of documentation and rate of blood transfusion within 24 h post-procedure, frequency of emergency release blood during a procedure were monitored. During our study period, there was an increased adherence from 86 to 100% adherence following implementation of the updated guidelines. With improved adherence, we decreased PRBC ordering and hospital charges to the patient in low-risk cardiac catheterization procedures, without an increase in blood transfusions.

Efficacy of a Longitudinal Project-Based Quality Improvement Curriculum in Pediatric Cardiology Fellowship.

Quality improvement knowledge is a requirement of fellowship training. Our goal was to evaluate the efficacy of a 3-year quality improvement and patient safety (QI/PS) curriculum that gives fellows both didactic knowledge and first-hand experience with improvement science, and meets Clinical Learning Environment Review (CLER) requirements. Knowledge assessment is obtained through pre- and post-surveys. A secondary measure of success is academic products resulting from fellows' QI/PS work, and future participation in QI/PS efforts. Since 2019, 51 pre-tests and 36 post-tests were completed, showing improvement across all competencies. Fellows have produced one published manuscript, two poster presentations, and two oral presentations describing their improvement work. Additionally, mentoring faculty members have gone on to lead other QI work throughout the division. This longitudinal QI/PS curriculum provides both knowledge and experience in QI/PS work. It also creates opportunities for academic publications and presentations, builds faculty expertise, and most importantly, works to improve multiple aspects of patient care. This curriculum can serve as a model for other cardiology fellowships working to meet CLER requirements.

Longitudinal Assessment of Cardiac Function Following Multisystem Inflammatory Syndrome in Children Associated with COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 is commonly associated with cardiac involvement. Studies found myocardial dysfunction, as measured by decreased ejection fraction and abnormal strain, to be common early in illness. However, there is limited data on longitudinal cardiac outcomes. We aim to describe the evolution of cardiac findings in pediatric MIS-C from acute illness through at least 2-month follow-up. A retrospective single-center review of 36 patients admitted with MIS-C from April 2020 through September 2021 was performed. Echocardiographic data including cardiac function and global longitudinal strain (GLS) were analyzed at initial presentation, discharge, 2-4-week follow-up, and at least 2-month follow-up. Patients with mild and severe disease, normal and abnormal left ventricular ejection fraction (LVEF), and normal and abnormal GLS at presentation were compared. On presentation, 42% of patients with MIS-C had decreased LVEF < 55%. In patients in whom GLS was obtained (N = 18), 44% were abnormal (GLS < |- 18|%). Of patients with normal LVEF, 22% had abnormal GLS. There were no significant differences in troponin or brain natriuretic peptide between those with normal and abnormal LVEF. In most MIS-C patients with initial LVEF < 55% (90%), LVEF normalized upon discharge. At 2-month follow-up, all patients had normal LVEF with 21% having persistently abnormal GLS. Myocardial systolic dysfunction and abnormal deformation were common findings in MIS-C at presentation. While EF often normalized by 2 months, persistently abnormal GLS was more common, suggesting ongoing subclinical dysfunction. Our study offers an optimistic outlook for recovery in patients with MIS-C and carditis, however ongoing investigation for longitudinal effects is warranted.

Standardizing Discharge Furosemide Duration Following Congenital Heart Surgery.

Background: Pediatric cardiothoracic surgery has evolved over the last several decades with shorter bypass times and less need for hypothermic arrest. Diuretics have been commonly used in the post-operative period with no guidelines on duration following cardiopulmonary bypass. As a result, we conducted a single-center quality improvement project to reduce overuse of diuretics in post-operative patients without causing an increase in complications. We devised an early diuretic wean protocol that was implemented upon patient discharge. Methods: All patients who underwent uncomplicated congenital heart surgery after November 2018 were considered for the protocol. We defined an early diuretic wean protocol with a total duration of ten days of single diuretic therapy following hospital discharge. Patients were evaluated in clinic two weeks following discharge, after completion of diuretic therapy, to assess for clinical symptoms and development of effusions. Results: Retrospective pre-protocol data found the average duration a patient was on diuretics was 32 days following hospital discharge from uncomplicated congenital heart surgery. Following implementation of the protocol, there was a decrease in the total duration to 14 days, demonstrating a 56% decrease. With this practice change, there was no notable increase in adverse events. Conclusions: With implementation of the protocol, practice variability was minimized and the average post-operative diuretic duration was decreased without an increase in pleural and/or pericardial effusions or readmissiosn rates. Future directions and ongoing changes include expanding to a multicenter quality improvement collaborative focusing on decreasing the average duration of furosemide to less than five days after hospital discharge.

Multidrug-resistant organisms: A significant cause of severe sepsis in pediatric intestinal and multi-visceral transplantation.

Severe sepsis in immunocompromised children is associated with increased mortality. This paper describes the epidemiology landscape, clinical acuity, and outcomes for severe sepsis in pediatric intestinal (ITx) and multi-visceral (MVTx) transplant recipients requiring admission to the pediatric intensive care unit (PICU). Severe sepsis episodes were retrospectively reviewed in 51 ITx and MVTx patients receiving organs between 2009 and 2015. Twenty-nine (56.8%) patients had at least one sepsis episode (total of 63 episodes) through December 2016. Bacterial etiologies accounted for 66.7% of all episodes (n = 42), occurring a median of 122.5 days following transplant (IQR 59-211.8 days). Multidrug-resistant organisms (MDROs) accounted for 73.8% of bacterial infections; extended spectrum beta-lactamase producers, vancomycin-resistant enterococcus, and highly-resistant Pseudomonas aeruginosa were the most commonly identified. Increased mechanical ventilation and vasoactive requirements were noted in MDRO episodes (OR 3.03, 95% CI 1.09-8.46 and OR 3.07, 95% CI 1.09-8.61, respectively; p < .05) compared to non-MDRO episodes. PICU length of stay was significantly increased for MDRO episodes (7 vs. 3 days, p = .02). Graft loss was 24.1% (n = 7) and mortality was 24.1% (n = 7) in patients who experienced severe sepsis. Further attention is needed for MDRO risk mitigation and modification of sepsis treatment guidelines to ensure MDRO coverage for this population.

Micturition syncope with asystole in a paediatric patient.

Syncope occurs frequently in children, and the differential includes situational syncope, specifically micturition syncope. We report the youngest child to our knowledge to have micturition syncope associated with a prolonged asystolic pause. He underwent a neurological and cardiovascular evaluation without additional findings. Behavioural modifications were instituted with no recurrent syncope.

Prophylactic pacemaker placement at first signs of conduction disease in Kearns-Sayre syndrome.

Cardiac conduction disease affects patients with Kearns-Sayre syndrome. We report a young asymptomatic patient with Kearns-Sayre syndrome with abnormal conduction on electrocardiogram and Holter monitor, although not advanced atrioventricular block. She underwent prophylactic pacemaker placement, and rapidly developed complete atrioventricular block, which resulted in 100% ventricular pacing. It may be reasonable to consider prophylactic pacemaker implantation in patients with Kearns-Sayre syndrome with evidence of cardiac conduction disease even without overt atrioventricular block given its unpredictable progression to complete atrioventricular block.

Comparing imaging modalities for screening aortic complications in patients with bicuspid aortic valve.

OBJECTIVE: Bicuspid aortic valve (BAV) is associated with aortic root and ascending aorta aneurysm and increased risk for aortic dissection. Guidelines recommend transthoracic echocardiography (TTE) for primary aortic evaluation, although cardiac magnetic resonance (CMR) may be superior at detecting abnormalities. This study compares TTE and CMR imaging for aortic evaluation in patients with BAV. DESIGN: Data from all patients ≥13 years of age with BAV who underwent CMR between 2003 and 2009 at our institution were reviewed, including demographics, blood pressure (BP), and TTE findings prior to CMR. TTE and CMR aortic maximum diameter (MaxD) measurements were compared using paired t-tests. Based on CMR findings, TTE sensitivity was evaluated for aortic dilation (sinuses of Valsalva [SV] ≥ 3.5 cm, ascending aorta [AscAo] ≥ 3.8 cm), and aneurysm defined as MaxD cross-sectional area/height ≥ 10. Linear regression was used to identify risk factors associated with MaxD. RESULTS: There were 106 patients with mean age at CMR 34 ± 13 years. Mean CMR MaxD was 37 ± 7 mm. TTE and CMR MaxD mean difference (-1.6 mm) was statistically significantly (P =.002), particularly when TTE AscAo was not measured (-2.0 mm, P =.007). TTE sensitivity was 75% (SV) and 47% (AscAo) for dilation, and 100% (SV) and 83% (AscAo) for aneurysm. Bivariate correlation showed significant positive association between MaxD and diastolic BP and weight (P <.05). With multivariate regression, MaxD was significantly smaller in patients with coarctation of the aorta (P <.001). CONCLUSION: TTE missed aortic dilation and aneurysm, particularly when AscAo evaluation was incomplete. Therefore, CMR is a valuable adjunctive imaging modality in aortic screening of patients with BAV.

Usefulness of screening cardiovascular magnetic resonance imaging to detect aortic abnormalities after repair of coarctation of the aorta.

Guidelines recommend screening cardiovascular magnetic resonance (Sc-CMR) imaging for all patients after coarctation of the aorta repair, although there are limited data verifying its clinical utility. Therefore, we sought to assess the value of Sc-CMR in detecting aortic complications and at-risk abnormalities after coarctation of the aorta repair and to identify significant risk factors. We reviewed 76 patients (mean age 31 ± 10 years), including 40 with symptomatically indicated CMR (Sx-CMR) and 36 with Sc-CMR studies. CMR angiograms were evaluated for aortic abnormalities. Recoarctation was defined as residual narrowing/descending aorta at the diaphragm ≤0.5 (at risk ≤0.75), ascending aorta aneurysm as maximum ascending cross-sectional area/height ≥10 (at risk ≥5), and descending aorta aneurysm as maximum descending diameter/descending aorta at the diaphragm ≥1.5 (at risk ≥1.25). Aortic complications or abnormalities were found in 45 patients (59%). No patient met criteria for recoarctation (at risk 10 Sx-CMR vs 5 Sc-CMR). Significant risk factors included heart failure symptoms and female gender (p <0.05). One patient (Sc-CMR) had ascending aneurysm (at risk 17 Sx-CMR vs 8 Sc-CMR). Time from repair was a significant predictor (p <0.05). There were 10 patients (6 Sx-CMR vs 4 Sc-CMR) with descending aneurysm (at risk 8 Sx-CMR vs 7 Sc-CMR). Cardiovascular symptoms, hypertension, and echocardiogram were not predictive. In conclusion, >50% of patients undergoing Sc-CMR had aortic abnormalities, which was not significantly different from those undergoing Sx-CMR. In particular, Sc-CMR identified descending aorta aneurysms that were not predicted by clinical parameters or echocardiogram.

Safe utilization of hyperglycemia management in the ICU.

Critically ill patients admitted to intensive care units (ICUs) often present with multiple medical or surgical problems requiring a high level of care. In addition to a patient's underlying illness, a number of known risk factors can predispose patients to episodes of hyperglycemia as well as hypoglycemia. The concept of glycemic control and its implication on morbidity and mortality has been well-described, along with the potential risks. Conflicting study results have complicated implementing universal methods for optimal glycemic control in the ICUs. There are many factors to consider when implementing intensive glycemic control, including reliability of point-of-care testing for glucose measurement, healthcare resources, types of protocols and appropriate target ranges. It is important that clinicians fully understand the risks and benefits of glucose management in the ICU setting to safely administer this potentially beneficial therapy.