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1.
J Extra Corpor Technol ; 55(2): 60-69, 2023 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-37378438

RESUMO

BACKGROUND: Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM® to reduce blood product utilization during and after neonatal and infant cardiac surgery. METHODS: We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. RESULTS: The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM® group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group. CONCLUSION: The utilization of ROTEM® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Recém-Nascido , Adulto , Humanos , Lactente , Procedimentos Cirúrgicos Cardíacos/métodos , Testes de Coagulação Sanguínea , Tromboelastografia/métodos , Estudos Retrospectivos , Algoritmos
2.
Pediatr Cardiol ; 42(7): 1526-1530, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33987706

RESUMO

Viral bronchiolitis is a relative contraindication to elective pediatric cardiac surgery. Nasopharyngeal swab utilizing polymerase chain reaction (PCR) screening for viruses known to cause bronchiolitis are commonly available. The objective of this study was to evaluate clinical outcomes in patients with nasopharyngeal viral PCR positive findings at the time of cardiac surgery. Retrospective review from January 2013 to May 2019 for patients with virus detected by PCR on nasopharyngeal swabs at the time of cardiac surgery. Single ventricle and two ventricle patients were compared to control group of age and procedure matched patients viral negative at the time of surgery. Outcome measures included OR extubation, reintubation, hospital length of stay, and mortality. For two ventricle patients (n = 81; control group = 165), there was no statistical difference in any outcome variable (OR extubation 74% vs 72%; p = 0.9; reintubation 9% vs 11% vs; p = 0.7; hospital length of stay 5 days (1-46) vs 4 days (2-131); p = 0.4; mortality 2 vs 1; p = 0.3). For single ventricle patients, there was no statistical difference in any outcome variable (OR extubation 81% vs 76%; p = 0.6; reintubation 14% vs 21% vs; p = 0.5; hospital length of stay 9.5 days (3-116) vs 15 days (2-241); p = 0.1; mortality 0 vs 3; (p = 0.6)). PCR is a sensitive test that fails to predict which patients will proceed to have a clinically significant infection. Viral bronchiolitis remains a relative risk factor for cardiac surgery; presence of detectable virus via nasopharyngeal swab with limited clinical symptoms may not be a contraindication to cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Extubação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Criança , Humanos , Intubação Intratraqueal , Reação em Cadeia da Polimerase , Estudos Retrospectivos
3.
Echocardiography ; 37(12): 2102-2106, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33169446

RESUMO

BACKGROUND: Yield of serial echocardiography in fetuses with atrioventricular septal defects (fAVSD) has not been well defined. The goal of this study was to document if any major changes occurred from initial fetal to initial postnatal echocardiogram in uncomplicated fAVSD. METHODS: fAVSD were excluded if initial fetal scan documented complex CHD or any concerns. Changes in ventricular function, valvular regurgitation, or diagnosis between first fetal and first postnatal echocardiogram were recorded. RESULTS: Fifty-seven fAVSD met criteria. Ninety-six fetal echocardiograms were done in 57 patients. Initial fetal scan was performed at 24.3 ± 3.7 weeks of estimated gestational age. All fAVSD had normal function, 38 had no atrioventricular valve regurgitation (AVVR), and 19 had mild AVVR. First postnatal echocardiogram was performed at 6.3 ± 15.3 days. Fifty-six patients had normal function, 1 patient had mild dysfunction, 16 patients had no AVVR, 36 had mild AVVR, and 5 had moderate AVVR. Three patients (5%) had an improvement in AVVR by one degree, 27 patients (47%) had no change in AVVR, 24 patients (42%) had an increase in AVVR by one degree, and 3 patients (5%) had an increase in AVVR by two degrees. There was no major missed anatomical diagnosis from first prenatal to first postnatal echocardiogram. CONCLUSION: In fAVSD that had no concerns on their initial fetal echocardiogram, the majority of patients had no major changes noted between their initial fetal echocardiogram and their first postnatal echocardiogram. Repeat fetal echocardiograms may not necessarily be needed in this cohort of patients.


Assuntos
Defeitos dos Septos Cardíacos , Ecocardiografia , Feminino , Feto , Defeitos dos Septos Cardíacos/diagnóstico por imagem , Valvas Cardíacas/diagnóstico por imagem , Humanos , Gravidez , Estudos Retrospectivos
4.
Artif Organs ; 41(1): 66-70, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27896819

RESUMO

Outcomes for extracorporeal membrane oxygenation (ECMO) have been described for patients with single ventricle physiology (SVP) undergoing cavopulmonary connection (Glenn procedure). An alternative surgical pathway for patients with SVP consists of an initial hybrid procedure followed by a comprehensive Stage II procedure. No data exist describing the outcomes of patients requiring ECMO after the comprehensive Stage II procedure. The goal of this study is to describe the outcomes for patients who required ECMO after the comprehensive Stage II procedure. Data from the Extracorporeal Life Support Organization (ELSO) registry from 2001 to 2015 for children undergoing the comprehensive Stage II procedure older than 3 months of age were retrospectively analyzed. Demographics and ECMO characteristics were recorded. A total of six children required ECMO support after the comprehensive Stage II procedure (2 males, 4 females). Four patients had the diagnosis of hypoplastic left heart syndrome and two patients had the diagnosis of an unbalanced atrioventricular septal defect. Bypass time was 242.8 ± 110.9 min and cross-clamp time was 91.2 ± 46.2 min for the surgical procedure. Weight was 5.8 ± 1.3 kg and age was 150.2 + 37.9 days at time of ECMO. ECMO duration was 276.0 ± 218.1 h. Complications during the ECMO run included hemorrhage in four patients (67%), renal dysfunction in two patients (33%), and neurologic injury in two patients (33%). Four patients (67%) were discharged alive after ECMO decannulation. Despite being a much more extensive surgical procedure, the morbidity and mortality after ECMO in patients undergoing the comprehensive Stage II procedure are similar to those in patients undergoing the Glenn procedure. If needed, ECMO support is reasonable for patients after the comprehensive Stage II procedure.


Assuntos
Oxigenação por Membrana Extracorpórea , Defeitos dos Septos Cardíacos/cirurgia , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Técnica de Fontan , Defeitos dos Septos Cardíacos/patologia , Ventrículos do Coração/patologia , Ventrículos do Coração/cirurgia , Hemorragia/etiologia , Humanos , Síndrome do Coração Esquerdo Hipoplásico/patologia , Lactente , Nefropatias/etiologia , Masculino , Estudos Retrospectivos , Resultado do Tratamento
5.
Paediatr Anaesth ; 25(5): 477-86, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25581204

RESUMO

BACKGROUND: The transfusion of blood products in the setting of uncontrolled bleeding is unquestionably lifesaving. However, in many instances, the decision to transfuse is based on physician gestalt rather than medical evidence. When indications for transfusion are unclear, the benefits of blood products must be balanced against their significant risks and associated costs. As our institution is a referral center for patients of Jehovah's Witness faith, this population has pushed our development of techniques to achieve the goal of bloodless surgery. Our practices in caring for this population have become our standard practice for managing all patients undergoing congenital cardiac surgery. OBJECTIVES: To evaluate our success in minimizing the use of blood products during pediatric cardiac surgery. METHODS: After IRB approval, we retrospectively reviewed all patients who underwent cardiac surgery utilizing cardiopulmonary bypass (CPB), for biventricular repair procedures. The study was conducted at a single institution (Nationwide Children's Hospital (NCH)) during the period: January 1, 2013 and December 31, 2013. RESULTS: A total of 209 patients were included. Overall, 81 patients (38.8%) and 81 of 136 (59.6%) weighing more than 6 kg received no blood products (bloodless) during their entire hospital stay. Bloodless surgery was most successful in patients weighing more than 18 kg, followed by patients weighing 6-18 kg. All 73 patients who weighed <6 kg received blood transfusion during their hospitalization. CONCLUSION: The techniques that we have developed to initially care for our Jehovah's Witness families may be applied to other pediatric and adult surgical procedures.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Cardiopatias Congênitas/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Testemunhas de Jeová , Tempo de Internação/estatística & dados numéricos , Masculino , Religião e Medicina , Estudos Retrospectivos , Adulto Jovem
6.
J Extra Corpor Technol ; 46(1): 45-52, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24783313

RESUMO

Whole blood from the heart-lung (bypass) machine may be processed through a cell salvaging device (i.e., cell saver [CS]) and subsequently administered to the patient during cardiac surgery. It was determined at our institution that CS volume was being discarded. A multidisciplinary team consisting of anesthesiologists, perfusionists, intensive care physicians, quality improvement (QI) professionals, and bedside nurses met to determine the challenges surrounding autologous blood delivery in its entirety. A review of cardiac surgery patients' charts (n = 21) was conducted for analysis of CS waste. After identification of practices that were leading to CS waste, interventions were designed and implemented. Fishbone diagram, key driver diagram, Plan-Do-Study-Act (PDSA) cycles, and data collection forms were used throughout this QI process to track and guide progress regarding CS waste. Of patients under 6 kg (n = 5), 80% had wasted CS blood before interventions, whereas those patients larger than 36 kg (n = 8) had 25% wasted CS before interventions. Seventy-five percent of patients under 6 kg who had wasted CS blood received packed red blood cell transfusions in the cardiothoracic intensive care unit within 24 hours of their operation. After data collection and didactic education sessions (PDSA Cycle I), CS blood volume waste was reduced to 5% in all patients. Identification and analysis of the root cause followed by implementation of education, training, and management of change (PDSA Cycle II) resulted in successful use of 100% of all CS blood volume.


Assuntos
Remoção de Componentes Sanguíneos/normas , Transfusão de Componentes Sanguíneos/normas , Transfusão de Sangue Autóloga/normas , Procedimentos Cirúrgicos Cardíacos/normas , Ponte Cardiopulmonar/normas , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Michigan , Reciclagem/normas , Manejo de Espécimes/normas
7.
JTCVS Open ; 13: 330-343, 2023 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-37063164

RESUMO

Objective: Pulmonary artery reconstruction during comprehensive stage 2 (CS2) procedure can be challenging. Since 2017, we have employed preemptive left pulmonary artery (LPA) stenting. We hypothesized that LPA stenting promotes adequate growth and without compromising Fontan candidacy. Herewith, we report our midterm results. Methods: From 2002 to 2020, 159 patients underwent CS2. Patients were divided as follows: no stent (n = 122; Group 1) and perioperative LPA stent (n = 37; Group 2). Group 2 was subdivided according to unplanned stent (n = 17; Group 2a) or preemptive stent (n = 20; Group 2b). Relevant perioperative data was reviewed. Nonparametric statistics were utilized. Results: Median age and weight at surgery and hospital length of stay after CS2 did not differ between groups. Median cardiopulmonary bypass and crossclamp times were significantly greater in Group 1 (265 vs 243 minutes [P = .021] and 46 vs 26 minutes [P = .008]). In-hospital mortality was similar between Groups 1 and 2 (9.0% vs 18.9%, respectively [P = .1348]). Group 2b demonstrated a superior survival compared to Group 2a (P = .0335) but not Group 1 (P > .9999). Preemptive stenting significantly increased median hilar LPA diameter at CS2 exit angiogram compared with no stenting (P < .0001). Groups 2a and 2b significantly increased the pre-Fontan diameter of the hilar LPA when compared with Group 1 (6.1 and 6.8 vs 5.7 mm, respectively [P < .0001]). A further 120 patients underwent Fontan operation (75%). Median follow-up for Groups 1 and 2 were 7.4 and 3.0 years, respectively. Conclusions: Perioperative LPA stenting during CS2 does not adversely affect pulmonary growth. Preemptive stenting seems advantageous for LPA growth in preparation for Fontan completion.

8.
Pediatr Qual Saf ; 8(3): e661, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38571741

RESUMO

Introduction: Patients following the Fontan procedure have a physiology that results in prolonged pleural effusion, often delaying hospital discharge. The hospital length of stay (LOS) of patients following the Fontan procedure at our institution was significantly longer than the Society of Thoracic Surgery benchmark. This quality improvement project aimed to decrease hospital LOS in patients following the Fontan procedure from a baseline of 23 days to 7 days by January 1, 2021, and sustain indefinitely. Methods: We implemented standardized postoperative clinical practice guidelines in April 2020. We designed guidelines using previously published protocols. Key features included an ambulatory PleurX drain (BD, Franklin Lakes, N.J.), diuresis with fluid restriction, and pulmonary vasodilation with supplemental oxygen and sildenafil. All patients were discharged from the hospital with a PleurX drain in place. We compared clinical outcome variables before and after guideline implementation. As a balancing measure, we tracked 30-day readmissions. Results: One hundred seven patients underwent the Fontan procedure before guideline implementation from January 2015 to January 2020, with an average hospital LOS of 23 days. Postguideline implementation, 35 patients underwent the Fontan procedure from April 2020 to July 2022, with an average hospital LOS of 8 days in 2020, which further improved to an average hospital LOS of 7 days. There was no change in 30-day readmission after guideline implementation (24% pre versus 23% post; P = 0.86). Conclusion: Implementing clinical practice guidelines for patients following the Fontan procedure led to an over 50% reduction in hospital LOS without increasing 30-day readmission.

9.
Pediatr Qual Saf ; 4(4): e188, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31572889

RESUMO

BACKGROUND: Healthcare-associated infections are a major focus for quality improvement in hospitals today. Surgical site infections (SSIs), a postoperative complication in cardiac surgery, are associated with increased morbidity, mortality, hospital length of stay, and financial burden. METHODS: A recent increase in cardiothoracic surgery SSIs (CT-SSIs) at our institution instigated a multidisciplinary team to explore infection prevention, bundle element compliance, and to identify interventions to reduce the CT-SSI rate. Key interventions included preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus with repeated intranasal applications of mupirocin, universal skin prep with chlorhexidine for all patients, and additional antibiotic dosing upon initiating cardiopulmonary bypass. RESULTS: In 2014, the CT-SSI rate at our institution was 1.9/100 cases, which increased during the "intervention period" to 3.6 infections/100 cases in 2015 (16 total infections). Postinterventions, the CT-SSI rate decreased to 0.3 infections/100 cases (2 total infections), which was significantly lower than our baseline before the spike in infection rate. CONCLUSIONS: A comprehensive interdisciplinary approach with multiple interventions was successful in significantly reducing the CT-SSI rate in cardiothoracic surgery at a tertiary care pediatric hospital.

10.
Ann Thorac Surg ; 105(5): 1455-1460, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29273201

RESUMO

BACKGROUND: The comprehensive stage 2 procedure (CS2) follows initial hybrid stage 1 palliation for patients with single-ventricle physiology. The goal of this study was to describe CS2 outcomes and differences between survivors of CS2 (s-CS2) and nonsurvivors (nons-CS2). METHOD: All patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database who underwent CS2 as index operation from 2010 to 2016 were included. Preoperative, operative, and postoperative data were analyzed, stratified by operative mortality (in-hospital or within 30 days of the operation), with univariate comparisons using χ2, Fisher exact, or Wilcoxon rank sum tests. RESULTS: Of 209 patients (49 centers) who met inclusion criteria, 141 patients had the diagnosis of hypoplastic left heart syndrome. Overall operative mortality was 12.4% (26 of 209). s-CS2 had a lower prevalence of preoperative extracorporeal membrane oxygenation use (0.0% vs 7.7%, p = 0.02) and less frequently underwent concomitant tricuspid valve procedures at the time of the operation (1.1% vs 11.5%, p = 0.01) than nons-CS2. Postoperatively, the prevalence of any of six The Society of Thoracic Surgeons Congenital Heart Surgery Database major complications was higher in nons-CS2 than in s-CS2 (53.9% vs 23.0%, p < 0.01), including a higher prevalence of renal failure (7.7% vs 0.6%, p = 0.04) and postoperative extracorporeal membrane oxygenation use (46.2% vs 2.7%, p < 0.01). There were no other preoperative, operative, or postoperative differences between the two groups. CONCLUSIONS: Operative mortality associated with the CS2 procedure is substantial, especially for patients receiving extracorporeal membrane oxygenation support after CS2. No obvious modifiable variables were noted between patients who died and those who survived.


Assuntos
Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/anormalidades , Cuidados Paliativos , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea , Feminino , Cardiopatias Congênitas/mortalidade , Mortalidade Hospitalar , Humanos , Lactente , Masculino , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
11.
Am J Crit Care ; 25(2): e30-7, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26932925

RESUMO

BACKGROUND: Postoperative cardiovascular surgical site infections are preventable events that may lead to increased morbidity, mortality, and health care costs. OBJECTIVE: To improve surgical wound surveillance and reduce the incidence of surgical site infections. METHODS: An institutional review of surgical site infections led to implementation of 8 surveillance and process measures: appropriate preparation the night before surgery and the day of surgery, use of appropriate preparation solution in the operating room, appropriate timing of preoperative antibiotic administration, placement of a photograph of the surgical site in the patient's chart at discharge, sending a photograph of the surgical site to the patient's primary care physician, 30-day follow-up of the surgical site by an advanced nurse practitioner, and placing a photograph of the surgical site obtained on postoperative day 30 in the patient's chart. RESULTS: Mean overall compliance with the 8 measures from March 2013 through February 2014 was 88%. Infections occurred in 10 of 417 total operative cases (2%) in 2012, in 8 of 437 total operative cases (2%) in 2013, and in 7 of 452 total operative cases (1.5%) in 2014. CONCLUSIONS: Institution of the surveillance process has resulted in improved identification of suspected surgical site infections via direct rather than indirect measures, accurate identification of all surgical site infections based on definitions of the National Healthcare Safety Network, collaboration with all persons involved, and enhanced communication with patients' family members and referring physicians.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Criança , Humanos
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