Relationship between the HeartMate Risk Score category on admission and outcome in patients with acute heart failure referred to a cardiac intensive care unit.

The HeartMate Risk Score (HMRS), a simple clinical prediction rule based on the patients' age, albumin, creatinine, and the international normalized ratio of the prothrombin time (PT-INR), is correlated with mortality in the cohort of left ventricular assist device (LVAD) recipients. However, in an aging society, an LAVD is indicated for only a small proportion of patients with acute heart failure (AHF), and whether the HMRS has prognostic implications for unselected patients with AHF is unknown. This study aimed to assess the prognostic value of HMRS categories on admission in patients with AHF. We analyzed 339 hospitalized patients with AHF who had albumin, creatinine, and the PT-INR recorded on admission. The patients were categorized as follows: the High group (HMRS > 2.48, n = 131), Mid group (HMRS of 1.58-2.48, n = 97) group, and Low group (HMRS < 1.58, n = 111). The endpoints of this study were all-cause death and readmission for heart failure (HF). During a median follow-up of 247 days, 24 (18.3%) patients died in the High group, 7 (7.2%) died in the Mid group, and 8 (7.2%) died in the Low group. In a multivariable analysis adjusted for highly imbalanced baseline variables, a high HMRS was independently associated with survival, with a hazard ratio of 2.90 (95% confidence interval 1.42-5.96, P = 0.004). With regard to the composite endpoint of all-cause death and readmission for HF, the Mid group had a worse prognosis than the Low group, and the High group had the worst prognosis. A high HMRS on admission is associated with all-cause mortality and readmission for HF, and a mid-HMRS is associated with readmission for HF after AHF hospitalization. The HMRS may be a valid clinical tool to stratify the risk of adverse outcomes after hospitalization in unselected patients with AHF.

The Price We Pay for Progression in Shock Care: Economic Burden, Accessibility, and Adoption of Shock-Teams and Mechanical Circulatory Support Devices.

PURPOSE OF REVIEW: Cardiogenic shock (CS) is associated with high in-hospital and long-term mortality and morbidity that results in significant socio-economic impact. Due to the high costs associated with CS care, it is important to define the short- and long-term burden of this disease state on resources and review strategies to mitigate these. RECENT FINDINGS: In recent times, the focus on CS continues to be on improving short-term outcomes, but there has been increasing emphasis on the long-term morbidity. In this review we discuss the long-term outcomes of CS and the role of hospital-level and system-level disparities in perpetuating this. We discuss mitigation strategies including developing evidence-based protocols and systems of care, improvement in risk stratification and evaluation of futility of care, all of which address the economic burden of CS. CS continues to remain the pre-eminent challenge in acute cardiovascular care, and a combination of multi-pronged strategies are needed to improve outcomes in this population.

Obstructive Sleep Apnea and Short-Term Outcomes After Pediatric Cardiac Surgery.

Obstructive sleep apnea (OSA) has been associated with negative cardiovascular effects and negative outcomes following cardiovascular surgery in the adult population. Our objective was to evaluate if there is a similar association in children. Single center retrospective matched cohort study, we collected data on patients aged 1-18 who were admitted to the cardiac intensive care unit (CICU) between Jan 2012 and Dec 2021. We used a 3:1 propensity score matching for cases not diagnosed with OSA. Primary outcome was a composite variable: "adverse outcome," consisting of prolonged hospital and CICU stay, prolonged duration of mechanical ventilation, need for extracorporeal membrane oxygenation, and death. The study comprised 80 patients diagnosed with OSA and 240 patients without a diagnosis of OSA before cardiac surgery. The median age was 5.3 years (IQR 2.7-11.2). There were 184 (57.5%) males, and 102 (31.9%) had chromosomal and genetic abnormalities. There was a difference in "adverse outcome" between the OSA and non-OSA groups [34 (42.50%) vs 68 (28.33%), p = 0.027]. Moreover, bivariate analysis revealed that CICU length of stay, and chromosomal anomalies were statistically different between the groups. By logistic regression the composite variable "adverse outcome" remained associated to the OSA group (p = 0.009) with an adjusted odds ratio (OR) of 4.09 (1.83-9.18), p < 0.001. Children diagnosed with OSA had a higher risk of "adverse outcome" following cardiac surgery. The risk disappeared if the patient had Tonsillectomy and Adenoidectomy before cardiac surgery. Further studies should explore a proactive treatment for OSA in pediatric patients who need cardiac surgery.

A Pediatric Interprofessional Cardiac Intensive Care Unit Intervention: CICU Teams and Loved Ones Communicating (CICU TALC) is Feasible, Acceptable, and Improves Clinician Communication Behaviors in Family Meetings.

Parents of children in the pediatric cardiac intensive care unit (CICU) are often unprepared for family meetings (FM). Clinicians often do not follow best practices for communicating with families, adding to distress. An interprofessional team intervention for FM is feasible, acceptable, and positively impacts family preparation and conduct of FM in the CICU. We implemented a family- and team-support intervention for conducting FM and conducted a pretest-posttest study with parents of patients selected for a FM and clinicians. We measured feasibility, fidelity to intervention protocol, and parent acceptability via questionnaire and semi-structured interviews. Clinician behavior in meetings was assessed through semantic content analyses of meeting transcripts tracking elicitation of parental concerns, questions asked of parents, and responses to parental empathic opportunities. Logistic and ordinal logistic regression assessed intervention impact on clinician communication behaviors in meetings comparing pre- and post-intervention data. Sixty parents (95% of approached) were enrolled, with collection of 97% FM and 98% questionnaire data. We accomplished > 85% fidelity to intervention protocol. Most parents (80%) said the preparation worksheet had the right amount of information and felt positive about families receiving this worksheet. Clinicians were more likely to elicit parental concerns (adjusted odds ratio = 3.42; 95%CI [1.13, 11.0]) in post-intervention FM. There were no significant differences in remaining measures. Implementing an interprofessional team intervention to improve family preparation and conduct of FM is locally feasible, acceptable, and changes clinician behaviors. Future research should assess broader impact of training on clinicians, patients, and families.

Nutrition Provision in Children with Heart Disease on Extracorporeal Membrane Oxygenation (ECMO).

Nutrition provision for children with heart disease supported with extracorporeal membrane oxygenation (ECMO) involves nuanced decision making. We examined nutrition provision while on ECMO in the CICU and the relationship between energy and protein adequacy and end organ function as assessed by pediatric sequential organ failure assessment (pSOFA) scores in children with heart disease supported with ECMO. Children (≤ 21 years-old) with congenital or acquired heart disease who received ECMO in the cardiac intensive care unit were included. There were 259 ECMO runs in 252 patients over an 8-year study period (2013-2020). Median energy delivery and adequacy were 26.1 [8.4, 45.9] kcal/kg/day and 58.3 [19.8, 94.6]%, respectively. Median protein delivery and adequacy were 0.98 [0.36, 1.64] g/kg/day and 35.7 [13.4, 60.3]%, respectively. pSOFA increased by a median of four points during the ECMO run. Change in pSOFA score was not associated with energy or protein adequacy (p = 0.46 and p = 0.72, respectively). Higher energy and protein adequacy-from parenteral nutrition-correlated with increased hospital-acquired infections (HAIs, p = 0.031 and p = 0.003, respectively). Achieving nutritional adequacy was dependent on the use of parenteral nutrition. Similar clinical outcomes with regard to end organ function but with an increased incidence of HAIs suggests the need to explore the role of optimal enteral nutrition delivery on ECMO.

Unstable right ventricular hypertension in pulmonary atresia and intact ventricular septum: a case report.

Arterial oxygen saturation in single ventricle patients is dependent on systemic cardiac output. Here, we describe a case of a newborn with single ventricle physiology and an unusual mechanism to explain poor cardiac output and cyanosis. This case highlights the importance of identifying and considering ventricular morphology and ventricular-ventricular interactions to understand clinical challenges.

Approach to red blood cell transfusions in post-operative congenital heart disease surgery patients: when to stop?

BACKGROUND: The best transfusion approach for CHD surgery is controversial. Studies suggest two strategies: liberal (haemoglobin ≤ 9.5 g/dL) and restrictive (waiting for transfusion until haemoglobin ≤ 7.0 g/dL if the patient is stable). Here we compare liberal and restrictive transfusion in post-operative CHD patients in a cardiac intensive care unit. METHODS: Retrospective analysis was conducted on CHD patients who received liberal transfusion (2019-2021, n=53) and restrictive transfusion (2021-2022, n=43). RESULTS: The two groups were similar in terms of age, gender, Paediatric Risk of Mortality-3 score, Paediatric Logistic Organ Dysfunction-2 score, Risk Adjustment for Congenital Heart Surgery-1 score, cardiopulmonary bypass time, vasoactive inotropic score, total fluid balance, mechanical ventilation duration, length of cardiac intensive care unit stay, and mortality. The liberal transfusion group had a higher pre-operative haemoglobin level than the restrictive group (p < 0.05), with no differences in pre-operative anaemia. Regarding the minimum and maximum post-operative haemoglobin levels during a cardiac intensive care unit stay, the liberal group had higher haemoglobin levels in both cases (p<0.01 and p=0.019, respectively). The number of red blood cell transfusions received by the liberal group was higher than that of the restrictive group (p < 0.001). There were no differences between the two groups regarding lactate levels at the time of and after red blood cell transfusion. The incidence of bleeding, re-operation, acute kidney injury, dialysis, sepsis, and systemic inflammatory response syndrome was similar. CONCLUSIONS: Restrictive transfusion may be preferable over liberal transfusion. Achieving similar outcomes with restrictive transfusions may provide promising evidence for future studies.

Parental communication satisfaction with the clinical team in the paediatric cardiac ICU.

INTRODUCTION: Understanding parents' communication preferences and how parental and child characteristics impact satisfaction with communication is vital to mitigate communication challenges in the cardiac ICU. METHODS: This cross-sectional survey was conducted from January 2019 to March 2020 in a paediatric cardiac ICU with parents of patients admitted for at least two weeks. Family satisfaction with communication with the medical team was measured using the Communication Assessment Tool for Team settings. Clinical characteristics were collected via Epic, Pediatric Cardiac Critical Care Consortium local entry and Society for Thoracic Surgeons Congenital Heart Surgery Databases. Associations between communication score and parental mood, stress, perceptions of clinical care, and demographic characteristics along with patient demographic and clinical characteristics were examined. Multivariable ordinal models were conducted with characteristics significant in bivariate analysis. RESULTS: In total, 93 parents of 84 patients (86% of approached) completed surveys. Parents were 63% female and 70% White. Seventy per cent of patients were <6 months old at admission, 25% had an extracardiac abnormality, and 80% had a cardiac surgery this admission. Parents of children with higher pre-surgical risk of mortality scores (OR 2.875; 95%CI 1.076-7.678), presence of surgical complications (72 [63.0, 75.0] vs. 64 [95%CI 54.6, 73] (p = 0.0247)), and greater satisfaction with care in the ICU (r = 0.93922; p < 0.0001) had significantly higher communication scores. CONCLUSION: These findings can prepare providers for scenarios with higher risk for communication challenges and demonstrate the need for further investigation into interventions that reduce parental anxiety and improve communication for patients with unexpected clinical trajectories.

Out of hospital cardiac arrest - new insights and a call for a worldwide registry and guidelines.

INTRODUCTION: Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. METHOD: We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020-2023. RESULTS: A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1-2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. CONCLUSION: Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.

The impact of delirium on clinical and functional outcomes in hospitalized patients with acute coronary syndrome.

BACKGROUND: Delirium, which is prevalent in critical care settings, remains underexplored in acute coronary syndrome (ACS) patients in the cardiac intensive care unit (CICU). AIMS: To investigate the prevalence and clinical significance of delirium in patients with ACS admitted to the CICU. STUDY DESIGN: A prospective study (n = 106, mean age 74.2 ± 5.7 years) assessed delirium using the confusion assessment method-intensive care unit (CAM-ICU) tool in 21.7% of ACS patients during their CICU stay. Baseline characteristics, geriatric conditions and clinical procedures were compared between delirious and nondelirious patients. The outcomes included in-hospital mortality, 30-day and 6-month mortality, acute adverse events and length of CICU stay and hospital stay (LOS). RESULTS: Delirious patients who were older and had a higher incidence of coronary artery disease underwent more complex procedures (e.g., pacemaker placement). Multivariate analysis identified central venous catheter insertion, urinary catheterization and benzodiazepine use as independent predictors of delirium. Delirium was correlated with prolonged LOS (p < .001) and increased in-hospital, 30-day and 6-month mortality (p < .001). CONCLUSIONS: Delirium in ACS patients in the CICU extends hospitalization and increases in-hospital, 30-day and 6-month mortality. Early recognition and targeted interventions are crucial for mitigating adverse outcomes in this high-risk population. RELEVANCE TO CLINICAL PRACTICE: This study highlights the critical impact of delirium on outcomes in hospitalized patients with ACS in the CICU. Delirium, often overlooked in ACS management, significantly extends hospitalization and increases mortality rates. Nurses and physicians must be vigilant in identifying delirium early, particularly in older ACS patients or those with comorbidities. Recognizing independent predictors such as catheterization and benzodiazepine use allows for targeted interventions to reduce delirium incidence. Integrating routine delirium assessments and preventive strategies into ACS management protocols can improve outcomes, optimize resource utilization and enhance overall patient care in the CICU setting.

Planned Reoperation after Cardiac Surgery in the Cardiac Intensive Care Unit.

Background: Cardiac surgical re-exploration for bleeding is associated with increased morbidity and mortality. Whether to perform these procedures in the operating room (OR) or the Cardiac Intensive Care Unit (CICU) in uncertain. We sought to determine if the location of the reoperation would affect postoperative outcomes when a reoperation for bleeding is required following cardiac surgery. Methods: Patients who underwent planned cardiac re-explorations for bleeding at our center from January 2019 to December 2021 were retrospectively enrolled in this study. Patient outcomes were compared and analyzed. Results: Due to hemorrhagic shock, 72 patients underwent planned cardiac re-explorations, including 21 operated in the CICU and 51 in the OR. Within 12 h of the primary operation, 65 re-explorations (90.3%) were performed. The peak Vasoactive-Inotropic Score was 47.0 ± 27.4, systolic blood pressure was 89.4 ± 9.6 mmHg, central venous pressure was 12.1 ± 4.4 cmH 2 O, and the serum lactate was 5.5 ± 4.1 mmol/L prior to the reoperation. Multivariate logistic analysis showed that a reoperation performed in the CICU was not an independent risk factor for the occurrence of major complications. There was no significant difference in mortality between the two groups. Conclusions: Planned re-exploration for bleeding following open cardiac surgery in the CICU is feasible and safe.

Utility of nuclear cardiovascular imaging in the cardiac intensive care unit.

The contemporary Cardiac Intensive Care Unit (CICU) has evolved into a complex unit that admits a heterogeneous mix of patients with a wide range of acute cardiovascular diseases often complicated by multi-organ failure. Although electrocardiography (ECG) and echocardiography are well-established as first-line diagnostic modalities for assessing patients in the CICU, nuclear cardiology imaging has emerged as a useful adjunctive diagnostic modality. The versatility, safety and accuracy of nuclear imaging (e.g., perfusion, metabolism, inflammation) for the assessment of patient with coronary artery disease, ventricular arrhythmias, infiltrative cardiomyopathies, infective endocarditis and inflammatory aortopathies has been proven useful and now often incorporated into the best practices for the management of critically ill cardiac patients. Thus, clinicians must familiarize themselves with the value and current and future applications of nuclear imaging in the management of the cardiac patient in the CICU.

Does Compliance with Resuscitation Practice Guidelines Differ Between Pediatric Intensive Care Units and Cardiac Intensive Care Units?

Objective: Hospitalized children with cardiac disease have the highest rate of cardiac arrest compared to other disease types. Different intensive care unit (ICU) models exist, but it remains unknown whether resuscitation guideline adherence is different between cardiac ICUs (CICU) and general pediatric ICUs (PICU). We hypothesize there is no difference in resuscitation practices between unit types. Design: Retrospective observational study. Setting: The American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) registry. Patients: Children < 18 years old with medical or surgical cardiac disease who had cardiopulmonary arrest from 2014 to 2018. Intervention: None. Measurements and Main Results: Events were assessed for compliance with GWTG-R achievement measures of time to first chest compressions ≤ 1 min, time to intravenous/intraosseous epinephrine ≤ 5 min, time to first shock ≤ 2 min for ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), and confirmation of endotracheal tube placement. Additional practices were evaluated for consistency with Pediatric Advanced Life Support (PALS) recommendations. Eight hundred and eighty-six patients were evaluated, 687 (79%) in CICUs and 179 (21%) in PICUs. 484 (56%) had surgical cardiac disease. There were no differences in GWTG-R achievement measures or PALS recommendations between ICU types in univariable or multivariable models. Amiodarone, lidocaine, and nonstandard medication use did not differ by unit type. Extracorporeal cardiopulmonary resuscitation (ECPR) was more common in CICUs for both medical (16% vs 7%) and surgical (25% vs 2.5%) categories (P < .0001). Conclusions: Resuscitation compliance for patients with cardiac disease is similar between CICUs and PICUs. Patients were more likely to receive ECPR in CICUs. Additional study should evaluate how ICU type affects arrest outcomes in children with cardiac disease.

Nonagenarians admission and prognosis in a tertiary center intensive coronary care unit - a prospective study.

BACKGROUND: With increasing life expectancy, the prevalence of nonagenarians with cardiovascular disease is steadily growing. However, this population is underrepresented in randomized trials and thus poorly defined, with little quality evidence to support and guide optimal management. The aim of the present study was to evaluate the clinical management, therapeutic approach, and outcomes of nonagenarians admitted to a tertiary care center intensive coronary care unit (ICCU). METHODS: We prospectively collected all patients admitted to a tertiary care center ICCU between July 2019 - July 2022 and compared nonagenarians to all other patients. The primary outcome was in-hospital mortality. RESULTS: A total of 3807 patients were included in the study. Of them 178 (4.7%) were nonagenarians and 93 (52%) females. Each year the prevalence of nonagenarians has increased from 4.0% to 2019, to 4.2% in 2020, 4.6% in 2021 and 5.3% in 2022. Admission causes differed between groups, including a lower rate of acute coronary syndromes (27% vs. 48.6%, p < 0.001) and a higher rate of septic shock (4.5% vs. 1.2%, p < 0.001) in nonagenarians. Nonagenarians had more comorbidities, such as hypertension, renal failure, and atrial fibrillation (82% vs. 59.6%, 23% vs. 12.9%, 30.3% vs. 14.4% p < 0.001, respectively). Coronary intervention was the main treatment approach, although an invasive strategy was less frequent in nonagenarians in comparison to younger subjects. In-hospital mortality rate was 2-fold higher in the nonagenarians (5.6% vs. 2.5%, p = 0.025). CONCLUSION: With increasing life expectancy, the prevalence of nonagenarians in ICCU's is expected to increase. Although nonagenarian patients had more comorbidities and higher in-hospital mortality, they generally have good outcomes after admission to the ICCU. Hence, further studies to create evidence-based practices and to support and guide optimal management in these patients are warranted.

Dexmedetomidine as an anesthetic adjunct is associated with reduced complications and cardiac intensive care unit length of stay after heart valve surgery.

BACKGROUND: We sought to explore the relationship between dexmedetomidine as an anesthetic adjuvant in cardiac surgery and postoperative complications and length of stay (LOS) in the cardiac intensive care unit (CICU). METHODS: We conducted a retrospective study of patients aged 18 years and older who underwent heart valve surgery between October 2020 and June 2022. The primary endpoint of the study was major postoperative complications (cardiac arrest, atrial fibrillation, myocardial injury/infarction, heart failure) and the secondary endpoint was prolonged CICU LOS (defined as LOS > 90th percentile). Multivariate logistic regression analysis was performed for variables that were significant in the univariate analysis. RESULTS: A total of 856 patients entered our study. The 283 patients who experienced the primary and secondary endpoints were included in the adverse outcomes group, and the remaining 573 were included in the prognostic control group. Multivariate logistic regression analysis revealed that age > 60 years (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.23-2.31; p < 0.01), cardiopulmonary bypass (CPB) > 180 min (OR, 1.62; 95% CI, 1.03-2.55; p = 0.04) and postoperative mechanical ventilation time > 10 h (OR, 1.84; 95% CI, 1.35-2.52; p < 0.01) were independent risk factors for major postoperative complications; Age > 60 years (OR, 3.20; 95% CI, 1.65-6.20; p < 0.01), preoperative NYHA class 4 (OR, 4.03; 95% CI, 1.74-9.33; p < 0.01), diabetes mellitus (OR, 2.57; 95% CI, 1.22-5.41; p = 0.01), Intraoperative red blood cell (RBC) transfusion > 650 ml (OR, 2.04; 95% CI, 1.13-3.66; p = 0.02), Intraoperative bleeding > 1200 ml (OR, 2.69; 95% CI, 1.42-5.12; p < 0.01) were independent risk factors for prolonged CICU length of stay. Intraoperative use of dexmedetomidine as an anesthetic adjunct was a protective factor for major complications (odds ratio, 0.51; 95% confidence interval, 0.35-0.74; p < 0.01) and prolonged CICU stay. (odds ratio, 0.37; 95% confidence interval, 0.19-0.73; p < 0.01). CONCLUSIONS: In patients undergoing heart valve surgery, age, duration of cardiopulmonary bypass, and duration of mechanical ventilation are associated with major postoperative complication. Age, preoperative NYHA classification 4, diabetes mellitus, intraoperative bleeding, and RBC transfusion are associated with increased CICU length of stay. Intraoperative use of dexmedetomidine may improve such clinical outcomes.

Evaluation of the Performance of Vasoactive Ventilation Renal Score in Predicting the Duration of Mechanical Ventilation and Intensive Care Hospitalization After Pediatric Cardiac Surgery.

Various methods have been used to evaluate the predictivity of some markers during the recovery process after cardiac surgery in children. The aim herein was to evaluate the vasoactive ventilation renal (VVR) score in predicting the clinical outcomes of children who underwent congenital cardiac surgery within the early period in the pediatric intensive care unit (PICU). Patients who underwent congenital heart surgery (CHS) between November 2016 and March 2020 were enrolled and evaluated prospectively. The VVR score was calculated as follows: vasoactive inotrope score (VIS) + ventilation index + (change in serum creatinine level based on the baseline value × 10). The relationship between the duration of mechanical ventilation and the length of stay (LOS) in the PICU was evaluated via receiver operating characteristic (ROC) curve analysis and the cut-off values were calculated. At all of the time points identified in the study, the VVR score had a higher area under the ROC curve (AUC) when compared to the VIS and serum lactate levels, and the 48-h VVR score had the highest AUC (AUC 0.851, 95% confidence interval (CI) 0.761-0.942/LOS in the PICU; AUC 0.946, 95% CI 0.885-1.000/duration of mechanical ventilation). The 48-h VVR score for the LOS in the PICU was 6.7 (sensitivity 70%, specificity 92%) and that for the duration of mechanical ventilation was 9.1 (sensitivity 87%, specificity 97%). As a result, in our study, it was found that the VVR score is a new and effective predictor of the duration of mechanical ventilation and LOS in the PICU in postoperative CHS patients.

Parental holding of infants improves haemodynamics in the cardiac ICU.

We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.

Variation in hospital costs and resource utilisation after congenital heart surgery.

BACKGROUND: Children undergoing cardiac surgery have overall improving survival, though they consume substantial resources. Nationwide inpatient cost estimates and costs at longitudinal follow-up are lacking. METHODS: Retrospective cohort study of children <19 years of age admitted to Pediatric Health Information System administrative database with an International Classification of Diseases diagnosis code undergoing cardiac surgery. Patients were grouped into neonates (≤30 days of age), infants (31-365 days of age), and children (>1 year) at index procedure. Primary and secondary outcomes included hospital stay and hospital costs at index surgical admission and 1- and 5-year follow-up. RESULTS: Of the 99,670 cohort patients, neonates comprised 27% and had the highest total hospital costs, though daily hospital costs were lower. Mortality declined (5.6% in 2004 versus 2.5% in 2015, p < 0.0001) while inpatient costs rose (5% increase/year, p < 0.0001). Neonates had greater index diagnosis complexity, greater inpatient costs, required the greatest ICU resources, pharmacotherapy, and respiratory therapy. We found no relationship between hospital surgical volume, mortality, and hospital costs. Neonates had higher cumulative hospital costs at 1- and 5-year follow-up compared to infants and children. CONCLUSIONS: Inpatient hospital costs rose during the study period, driven primarily by longer stay. Neonates had greater complexity index diagnosis, required greater hospital resources, and have higher hospital costs at 1 and 5 years compared to older children. Surgical volume and in-hospital mortality were not associated with costs. Further analyses comprising merged clinical and administrative data are necessary to identify longer stay and cost drivers after paediatric cardiac surgery.

Implementation of the Cardiac Inpatient Neurodevelopmental Care Optimization (CINCO) programme: an interdisciplinary, generalisable approach to inpatient neurodevelopmental care.

BACKGROUND: Children with CHD are at risk for neurodevelopmental delays, and length of hospitalisation is a predictor of poorer long-term outcomes. Multiple aspects of hospitalisation impact neurodevelopment, including sleep interruptions, limited holding, and reduced developmental stimulation. We aimed to address modifiable factors by creating and implementing an interdisciplinary inpatient neurodevelopmental care programme in our Heart Institute. METHODS: In this quality improvement study, we developed an empirically supported approach to neurodevelopmental care across the continuum of hospitalisation for patients with CHD using three plan-do-study-act cycles. With input from multi-level stakeholders including parents/caregivers, we co-designed interventions that comprised the Cardiac Inpatient Neurodevelopmental Care Optimization (CINCO) programme. These included medical/nursing orders for developmental care practices, developmental kits for patients, bedside developmental plans, caregiver education and support, developmental care rounds, and a specialised volunteer programme. We obtained data from the electronic health record for patients aged 0-2 years admitted for at least 7 days to track implementation. RESULTS: There were 619 admissions in 18 months. Utilisation of CINCO interventions increased over time, particularly for the medical/nursing orders and caregiver handouts. The volunteer programme launch was delayed but grew rapidly and within six months, provided over 500 hours of developmental interaction with patients. CONCLUSIONS: We created and implemented a low-cost programme that systematised and expanded upon existing neurodevelopmental care practices in the cardiac inpatient units. Feasibility was demonstrated through increasing implementation rates over time. Key takeaways include the importance of multi-level stakeholder buy-in and embedding processes in existing clinical workflows.

Contemporary risk factors for a longer hospital stay following bidirectional cavopulmonary anastomosis.

BACKGROUND: Despite high survival after bidirectional cavopulmonary anastomosis, a considerable number of patients suffer significant post-operative morbidities related to prolonged length of stay. METHODS: A single-center retrospective cohort study of all consecutive patients undergoing a first-time bidirectional cavopulmonary anastomosis from 2006 to 2019. RESULTS: Prolonged length of stay was defined as hospital stay greater than the 75th percentile for our cohort. Of 195 patients who met inclusion criteria, the median post-operative length of stay was 8 days (interquartile range, 4-15 days). Prolonged length of stay was defined as greater than 15 days. In multivariate analysis, greater than mild systemic atrioventricular valve regurgitation (odds ratio 3.7, 95% CI 1.05-13.068, p = 0.04), longer length of stay after the initial palliative procedure (odds ratio 1.028, 95% CI 1.004-1.05, p = 0.02), and pre-operative higher superior vena cava oxygen saturation (odds ratio 0.922, 95% CI 0.85-0.99, p = 0.04) maintained statistical significance as independent risk and protective factors for prolonged length of stay. A one-level increase in the severity of pre-operative systemic atrioventricular valve regurgitation was associated with a multiplicative change in the odds ratio of prolonged length of stay of 5.45 (p = 0.005) independent of the severity of systemic ventricular dysfunction. CONCLUSION: Pre-operative characteristics with greater than mild systemic atrioventricular valve regurgitation, longer length of stay after the initial palliative procedure, and lower superior vena cava oxygen saturation were associated with prolonged length of stay after a first-time bidirectional cavopulmonary anastomosis.