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OBJECTIVES: We describe the process by which a PICU and a PICU care team were incorporated into a hospital-wide ICU care model during the coronavirus disease 2019 pandemic. DESIGN: A descriptive, retrospective report from a single-center PICU. SETTING: Twenty-three bed, quaternary PICU, within an 862-bed hospital. PATIENTS: Critically ill adults, with coronavirus disease 2019-related disease. INTERVENTIONS: ICU care provided by pediatric intensivists with training and support from medical intensivists. MEASUREMENTS AND MAIN RESULTS: Within the context of the institution's comprehensive effort to centralize and systematize care for adults with severe coronavirus disease 2019 disease, the PICU was transitioned to an adult coronavirus disease 2019 critical care unit. Nurses and physicians underwent just-in-time training over 3 days and 2 weeks, respectively. Medical ICU physicians and nurses provided oversight for care and designated hospital-based teams were available for procedures and common adult emergencies. Over a 7-week period, the PICU cared for 60 adults with coronavirus disease 2019-related critical illness. Fifty-three required intubation and mechanical ventilation for a median of 18 days. Eighteen required renal replacement therapy and 17 died. CONCLUSIONS: During the current and potentially in future pandemics, where critical care resources are limited, pediatric intensivists and staff can be readily utilized to meaningfully contribute to the care of critically ill adults.
Assuntos
COVID-19 , Cuidados Críticos , Unidades de Terapia Intensiva Pediátrica , Admissão e Escalonamento de Pessoal , Adulto , Criança , Humanos , Pandemias , Estudos Retrospectivos , SARS-CoV-2RESUMO
OBJECTIVES: To describe the unique perspective of pediatric intensivists caring for critically ill adults during the coronavirus disease 2019 pandemic. DESIGN: Observational study. SETTING: Academic medical center in New York City. PATIENTS: Coronavirus disease 2019 positive adults requiring admission to an ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In late March 2020, New York Presbyterian Hospital centralized all of its inpatient pediatric units (n = 4) from across the network to a single center, in order to create space to accommodate the increasing number of critically ill adults with coronavirus disease 2019. Within 1 week, the PICU at New York Presbyterian Hospital-Weill Cornell Medicine transferred or discharged all inpatients, underwent a transformation of the physical space, and began admitting adults of all ages with coronavirus disease 2019 related acute respiratory failure. The New York Presbyterian Hospital-Weill Cornell Medicine PICU physician group continued to lead this unit. PICU nurses, respiratory therapists, social workers, and child life specialists joined their PICU physician colleagues to care for these critically ill adults. CONCLUSIONS: In the coronavirus disease 2019 pandemic, PICU physicians are well poised to care for adult patients in a surge capacity, and bring a unique perspective to the experience.
Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Cuidados Críticos/organização & administração , Estado Terminal/terapia , Unidades de Terapia Intensiva Pediátrica/organização & administração , Pneumonia Viral/terapia , Centros de Atenção Terciária/organização & administração , Adulto , COVID-19 , Infecções por Coronavirus/epidemiologia , Estado Terminal/epidemiologia , Feminino , Humanos , Masculino , Cidade de Nova Iorque , Pandemias , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Índice de Gravidade de DoençaRESUMO
Epstein-Barr virus (EBV) viremia (EV) in pediatric solid organ transplant (SOT) recipients is a significant risk factor for posttransplant lymphoproliferative disease (PTLD) but not all patients with EV develop PTLD. We identify predictive factors for PTLD in patients with EV. We conducted a retrospective chart review of all pediatric SOT recipients (0 to 21 y) at a single institution between 2001 and 2009. A total of 350 pediatric patients received a SOT and 90 (25.7%) developed EV. Of EV patients, 28 (31%) developed PTLD. The median age at transplant was 11.5 months in the PTLD group and 21.5 months in the EV-only group (P=0.003). Twenty-three (37%) EV-only patients had immunosuppression increased before EV, compared with 28 (100%) of PTLD patients (P<0.001). The median peak EBV level was 3212 EBV copies/10 lymphocytes for EV-only and 8392.5 EBV copies/10 lymphocytes for PTLD (P=0.005). All patients who developed PTLD had ≥1 clinical symptoms. Younger age at transplant, increased immunosuppression before EV, higher peak EBV level, and presence of clinical symptoms have predictive value in the development of PTLD in SOT patients with EV.
Assuntos
Infecções por Vírus Epstein-Barr/complicações , Transtornos Linfoproliferativos/diagnóstico , Transtornos Linfoproliferativos/virologia , Transplante de Órgãos/efeitos adversos , Viremia/complicações , Adolescente , Fatores Etários , Criança , Pré-Escolar , Infecções por Vírus Epstein-Barr/imunologia , Feminino , Rejeição de Enxerto/tratamento farmacológico , Rejeição de Enxerto/imunologia , Humanos , Imunossupressores/efeitos adversos , Lactente , Recém-Nascido , Transtornos Linfoproliferativos/imunologia , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Viremia/imunologia , Adulto JovemRESUMO
A 3-year-old girl with Alport syndrome presented with decompensated heart failure from hypertension-induced cardiomyopathy 6 months following renal biopsy. Selective renal angiography revealed a large left renal arteriovenous fistula (AVF) with poor perfusion to the left renal parenchyma. The AVF was treated by transcatheter embolization using an Amplatzer vascular plug. Her blood pressure normalized after embolization, and her cardiac function normalized over the following 4 months.
Assuntos
Fístula Arteriovenosa/terapia , Malformações Arteriovenosas/terapia , Embolização Terapêutica/instrumentação , Hipertensão/patologia , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/patologia , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/patologia , Biópsia/instrumentação , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/patologia , Cardiomiopatia Dilatada/terapia , Cardiotônicos/uso terapêutico , Pré-Escolar , Ecocardiografia , Feminino , Humanos , Rim/diagnóstico por imagem , Rim/patologia , Rim/cirurgia , Nefropatias/diagnóstico por imagem , Nefropatias/patologia , Nefropatias/terapia , Milrinona/uso terapêutico , Radiografia , Resultado do TratamentoRESUMO
OBJECTIVES: To determine if a relationship exists between regional oxyhemoglobin saturation (rSO(2)) measured at various body locations by near-infrared spectroscopy (NIRS) and blood lactate level in children after cardiac surgery. DESIGN: A prospective, observational study. SETTING: A pediatric cardiac intensive care unit in a university hospital. PARTICIPANTS: Twenty-three children undergoing repair of congenital heart disease. Patients with single-ventricle physiology and/or residual intracardiac shunts were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cerebral, splanchnic, renal, and muscle rSO(2) values were recorded every 30 seconds via NIRS for 24 hours postoperatively. Blood lactate levels measured minimally at 0, 2, 4, 6 and 24 hours postoperatively were correlated with rSO(2) values derived by averaging all values recorded during the 60 minutes preceding the blood draw. Twenty-three patients were enrolled with 163 lactate measurements and more than 39,000 rSO(2) observations analyzed. Cerebral rSO(2) had the strongest inverse correlation with lactate level followed by splanchnic, renal, and muscle rSO(2) (r = -0.74, p < 0.0001, r = -0.61, p < 0.0001, r = -0.57, p < 0.0001, and r = -0.48, p < 0.0001, respectively). The correlation improved by averaging the cerebral and renal rSO(2) values (r = -0.82, p < 0.0001). Furthermore, an averaged cerebral and renal rSO(2) value
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ácido Láctico/sangue , Complicações Pós-Operatórias/sangue , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos ProspectivosRESUMO
We report a five-yr-old child, presenting three yr after heart transplant with acalculous cholecystitis. Histology revealed EBV negative T-cell PTLD. The disease involved the gallbladder, liver, lungs, and mesenteric lymph nodes. He was treated with chemotherapy, went into remission, but relapsed after 11 months and died.
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Colecistite Acalculosa/diagnóstico , Colecistite Acalculosa/imunologia , Transtornos Linfoproliferativos/diagnóstico , Transtornos Linfoproliferativos/imunologia , Linfócitos T/imunologia , Cardiomiopatia Dilatada/terapia , Criança , Diagnóstico Diferencial , Evolução Fatal , Vesícula Biliar/patologia , Transplante de Coração/efeitos adversos , Humanos , Masculino , Indução de Remissão , Resultado do TratamentoRESUMO
Systematic collection and electronic storage of data can assist in improving quality and efficiency of patient care and can provide a data set to interrogate for subsequent performance improvement and clinical research purposes. In this article, an electronic perioperative pediatric cardiac surgery database to be used by a multidisciplinary care team was designed, developed, and implemented. Technical goals for the design included low cost, rapid development and implementation, adequate security, and potential for internal and external distribution. Implementation of the described database has proved to be invaluable for quality assurance and statistical analysis of data relevant to patient care. From the overall positive experience, it was concluded that the electronic data management does not always need major cost investment.
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Anestesia/estatística & dados numéricos , Anestesiologia/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Bases de Dados Factuais , Pediatria/estatística & dados numéricos , Criança , Sistemas de Gerenciamento de Base de Dados , Humanos , Sistemas Computadorizados de Registros Médicos , Alta do PacienteRESUMO
In focal brain lesions, alterations in blood flow and cerebral metabolism can be detected in brain areas remote from the primary injury. The cellular consequences of this phenomenon, originally termed diaschisis, are not fully understood. Here, we report that in two distinct models of forebrain injury, neuronal death in the cerebellum, a site distant to the primary injury, results as consequence of neuronal loss in the forebrain. Fourteen-day-old rats were subjected to unilateral forebrain injury, achieved by either hypoxia-ischemia (right carotid artery ligation and hypoxia) or direct needle injury to brain tissue. At defined times after injury, the presence of apoptosis was investigated by cell morphology, in situ end labeling, electron microscopy and poly-ADP-ribose polymerase (PARP) cleavage. Injury to the rat forebrain following hypoxia-ischemia increased apoptosis in the internal granular and Purkinje cell layers of the cerebellum, a site distant to that of the primary injury. The number of apoptotic cells in the cerebellum was significantly related to cell death in the hippocampus. Similarly, direct needle injury to the forebrain resulted in extensive apoptotic cell death in the cerebellum. These results emphasize the intimate relationship between defined neuronal populations in relatively distant brain areas and suggest a cellular basis for diaschisis.
Assuntos
Apoptose/fisiologia , Cerebelo/crescimento & desenvolvimento , Cerebelo/patologia , Prosencéfalo/crescimento & desenvolvimento , Prosencéfalo/lesões , Animais , Western Blotting , Hipóxia-Isquemia Encefálica/patologia , Hibridização In Situ , Microscopia Eletrônica de Transmissão , Neurônios/ultraestrutura , Poli(ADP-Ribose) Polimerases/metabolismo , Ratos , Ratos WistarRESUMO
BACKGROUND: Primary repair of tetralogy of Fallot (TOF) has low surgical mortality, but some patients still experience significant postoperative morbidity. AIM: To review our institutional experience with primary TOF repair, and identify predictors of intensive care unit (ICU) morbidity. SETTINGS AND DESIGN: Medium-sized pediatric cardiology program. Retrospective study. SUBJECTS AND METHODS: We retrospectively reviewed all the patients with TOF and pulmonic stenosis who underwent primary repair in infancy at our institution from January 2001 to December 2012. Preoperative, operative, and postoperative demographic and morphologic data were analyzed. ICU morbidity was defined as prolonged ICU stay (≥7 days), and/or prolonged duration of mechanical ventilation (≥48 h). STATISTICAL ANALYSIS USED: Multiple logistic regression analysis. RESULTS: Ninety-seven patients underwent primary surgical repair during the study period. The median age was 4.9 months (1-9 months) and the median weight was 5.3 kg (3.1-9.8 kg). There was no early surgical mortality. Incidence of junctional ectopic tachycardia (JET) and persistent complete heart block was 2 and 1%, respectively. The median length of ICU stay was 6 days (2-21 days) and median duration of mechanical ventilation was 19 h (0-136 h). By multiple regression analysis, age and weight were independent predictors of length of ICU stay, while surgical era was an independent predictor of duration of mechanical ventilation. CONCLUSION: Primary TOF repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery remain significant predictors of morbidity.
RESUMO
BACKGROUND: Our objectives were to review our institutional early and midterm experience with primary tetralogy of Fallot (TOF) repair, and identify predictors of intensive care unit (ICU) morbidity. METHODS: We analyzed perioperative and midterm follow-up data for all cases of primary TOF repair from 2001 to 2012. The primary endpoint was early mortality and morbidity, and the secondary endpoint was survival and functional status at follow-up. RESULTS: Ninety-seven patients underwent primary repair. The median age was 4.9 months (range, 1 to 9 months), and the median weight was 5.3 kg (range, 3.1 to 9.8 kg). There was no early surgical mortality. The incidence of junctional ectopic tachycardia and persistent complete heart block was 2% and 1%, respectively. The median length of ICU stay was 6 days (range, 2 to 21 days), and the median duration of mechanical ventilation was 19 hours (range, 0 to 136 hours). By multiple regression analysis, age and weight were independent predictors of the length of ICU stay, while the surgical era was an independent predictor of the duration of mechanical ventilation. At the 8-year follow-up, freedom from death and re-intervention was 97% and 90%, respectively. CONCLUSION: Primary TOF repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery remain significant predictors of morbidity.
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BACKGROUND: Primary repair of tetralogy of Fallot has low surgical mortality, but some patients still experience significant postoperative morbidity. Our objectives were to review our institutional experience with primary tetralogy of Fallot repair, and identify predictors of intensive care unit morbidity. METHODS: We reviewed all patients with tetralogy of Fallot who underwent primary repair in infancy from 2001 to 2012. Preoperative, operative, and postoperative demographic and morphologic data were analyzed. Intensive care unit morbidity was defined as prolonged intensive care unit stay (≥ 7 days) and/or prolonged duration of mechanical ventilation (≥ 48 h). RESULTS: 97 patients who underwent primary surgical repair during the study period were included in the study. The median age was 4.9 months (range 1-9 months) and the median weight was 5.3 kg (range 3.1-9.8 kg). There was no early surgical mortality. The incidence of junctional ectopic tachycardia and persistent complete heart block was 2% and 1%, respectively. The median intensive care unit stay was 6 days (range 2-21 days) and the median duration of mechanical ventilation was 19 h (range 0-136 h). Age and weight were independent predictors of intensive care unit stay, while surgical era predicted the duration of mechanical ventilation. CONCLUSION: Primary tetralogy of Fallot repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery were significant predictors of morbidity.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Unidades de Terapia Intensiva Pediátrica , Complicações Pós-Operatórias/terapia , Tetralogia de Fallot/cirurgia , Fatores Etários , Peso Corporal , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Humanos , Incidência , Lactente , Tempo de Internação , Masculino , Cidade de Nova Iorque , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Tetralogia de Fallot/mortalidade , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Thromboembolic events while receiving ventricular assist device (VAD) support remain a significant cause of morbidity and mortality despite standard anti-coagulation and anti-platelet therapies. The use of bivalirudin and epoprostenol infusions as an alternate anti-thrombotic (AT) regimen in pediatric VAD patients was reviewed. METHODS: This was a retrospective record review of 6 pediatric patients (aged ≤17 years) at 2 institutions treated with bivalirudin and epoprostenol infusions while being supported with the Berlin Heart EXCOR (Berlin Heart GmbH, Berlin, Germany) VAD. RESULTS: Six patients (age, 0.8-14 years; weight, 6.7-29.7 kg) were treated. Diagnoses included cardiomyopathy in 2 and congenital heart disease in 4. VAD support was left VAD in 2 and bi-VAD in 4, with duration of support of 21 to 155 days. Three patients required extracorporeal membrane oxygenation before VAD support. Bivalirudin/epoprostenol was used after recurrent thromboses on conventional medication in 3 patients, heparin-induced thrombocytopenia in 2, and in 1 patient considered high risk with a prosthetic mitral valve. The bivalirudin dose was titrated to partial thromboplastin time (PTT) of 1.5- to 2-times baseline (0.1-0.8 mg/kg/hour); the epoprostenol dose was 2 to 10 ng/kg/min. Additional anti-platelet agents included acetylsalicylic acid, dipyridamole, and clopidogrel in 5 patients each. No bleeding complications occurred. One patient sustained a cerebrovascular infarct on therapy, with subsequent complete recovery. No other complications occurred. Five patients underwent successful transplantation, and 1 patient died of multisystem organ failure. CONCLUSIONS: This report provides data on estimated safety and efficacy of bivalirudin and epoprostenol as an AT strategy in pediatric patients on extended VAD support. The short drug half-life and predictable AT response facilitated conversion to standard AT regimens at the time of transplantation (heparin-induced thrombocytopenia-negative patients). These agents should be considered for management of pediatric VAD patients when standard regimens fail.
Assuntos
Cardiomiopatias/terapia , Fibrinolíticos/uso terapêutico , Cardiopatias Congênitas/terapia , Coração Auxiliar , Tromboembolia/prevenção & controle , Adolescente , Criança , Pré-Escolar , Gerenciamento Clínico , Relação Dose-Resposta a Droga , Epoprostenol/efeitos adversos , Epoprostenol/uso terapêutico , Fibrinolíticos/efeitos adversos , Coração Auxiliar/classificação , Hirudinas/efeitos adversos , Humanos , Lactente , Fragmentos de Peptídeos/efeitos adversos , Fragmentos de Peptídeos/uso terapêutico , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Early extubation in the operating room after surgery for congenital heart disease has been described; however, postoperative mechanical ventilation in the intensive care unit remains common practice in many institutions. The goal of this study was to identify perioperative factors associated with not proceeding with planned operating room extubation. METHODS: We performed a retrospective chart review of 224 patients (aged 1 month to 18 years, median 20 months) undergoing surgery for congenital heart defects requiring cardiopulmonary bypass. Patients mechanically ventilated preoperatively were excluded. A stepwise logistic regression model was used to test for the independent influence of various perioperative factors on extubation in the operating room. RESULTS: Overall, 79% of patients were extubated in the operating room. Younger age and longer cardiopulmonary bypass time were the strongest predictors for not extubating. Each step down to a younger age group (<2, 2-4, 4-6, 6-12, >12 months) reduced the chance of extubation in the operating room by 56%. Cardiopulmonary bypass time for more than 150 minutes was associated with an 11.8-fold increased risk of not being extubated. Male gender and high inotrope requirement after cardiopulmonary bypass were also significantly associated with fewer children being extubated. CONCLUSION: Extubation in the operating room after surgery for congenital heart disease was successful in the majority of patients. The strongest independent risk factors for failure of this strategy included younger age and longer cardiopulmonary bypass time.
Assuntos
Cardiopatias Congênitas/cirurgia , Cuidados Pós-Operatórios/métodos , Respiração Artificial , Desmame do Respirador/métodos , Adolescente , Ponte Cardiopulmonar , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal , Masculino , Análise de Regressão , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de RiscoRESUMO
We describe a fast track anesthesia technique that facilitates congenital heart surgery via right axillary thoracotomy in children. Continuous positive airway pressure on the dependent lung, before and during cardiopulmonary bypass, approximates the heart towards the chest wall incision, and significantly improves the surgeon's access to the heart.