The Inadequate Oxygen Delivery Index and Low Cardiac Output Syndrome Score As Predictors of Adverse Events Associated With Low Cardiac Output Syndrome Early After Cardiac Bypass.

OBJECTIVES: To evaluate the effectiveness of two scoring systems, the inadequate oxygen delivery index, a risk analytics algorithm (Etiometry, Boston, MA) and the Low Cardiac Output Syndrome Score, in predicting adverse events recognized as indicative of low cardiac output syndrome within 72 hours of surgery. DESIGN: A retrospective observational pair-matched study. SETTING: Tertiary pediatric cardiac ICU. PATIENTS: Children undergoing cardiac bypass for congenital heart defects. Cases experienced an adverse event linked to low cardiac output syndrome in the 72 hours following surgery (extracorporeal membrane oxygenation, renal replacement therapy, cardiopulmonary resuscitation, and necrotizing enterocolitis) and were matched with a control patient on criteria of procedure, diagnosis, and age who experienced no such event. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of a total 536 bypass operations in the study period, 38 patients experienced one of the defined events. Twenty-eight cases were included in the study after removing patients who suffered an event after 72 hours or who had insufficient data. Clinical and laboratory data were collected to derive scores for the first 12 hours after surgery. The inadequate oxygen delivery index was calculated by Etiometry using vital signs and laboratory data. A modified Low Cardiac Output Syndrome Score was calculated from clinical and therapeutic markers. The mean inadequate oxygen delivery and modified Low Cardiac Output Syndrome Score were compared within each matched pair using the Wilcoxon signed-rank test. Inadequate oxygen delivery correctly differentiated adverse events in 13 of 28 matched pairs, with no evidence of inadequate oxygen delivery being higher in cases (p = 0.71). Modified Low Cardiac Output Syndrome Score correctly differentiated adverse events in 23 of 28 matched pairs, with strong evidence of a raised score in low cardiac output syndrome cases (p < 0.01). CONCLUSIONS: Although inadequate oxygen delivery is an Food and Drug Administration approved indicator of risk for low mixed venous oxygen saturation, early postoperative average values were not linked with medium-term adverse events. The indicators included in the modified Low Cardiac Output Syndrome Score had a much stronger association with the specified adverse events.

Global perspective on training and staffing for paediatric cardiac critical care.

This manuscript provides a global perspective on physician and nursing education and training in paediatric cardiac critical care, including available resources and delivery of care models with representatives from several regions of the world including Africa, Israel, Asia, Australasia, Europe, South America, and the United States of America.

Regionalization in neonatal congenital heart surgery: the impact of distance on outcome after discharge.

Studies have shown improved perioperative outcomes after neonatal heart surgery at centers with greater surgical volumes. The impact of increasing distance from such centers on outcome after discharge has not yet been reported. Chart review and cross-sectional survey were performed on children discharged or transferred after undergoing neonatal congenital heart surgery as neonates (<30 days of age) from January 2005 to June 2006. The association of distance from center with mortality and adverse events was analyzed by univariate and multivariate regression and stratified by the Risk Adjustment for Congenital Heart Surgery-1 for complexity. Among 217 patients, those living further from the surgical center were smaller and older at surgery and more likely to be RACHS-1 class 6. Overall mortality was 8% (16 of 202) and was not associated with distance. Surveys were completed by 109 (54%) families with mean follow-up of 24 (± 3) months. Unplanned admissions after discharge and unplanned interventions occurred in 45% and 40% of patients, respectively. After adjusting for case complexity, living 90-300 min away from the surgical center was associated with fewer unplanned admissions compared with those living <90 min away. After neonatal cardiac surgery, adverse events were common. Distance from the surgical center was not associated with mortality, but it was associated with morbidity in a nonlinear fashion. This relation, its mediators, and its possible impact on mortality and later outcomes warrant further study to aid in planning appropriate patient follow-up.

Morbidity and mortality after surgery for congenital cardiac disease in the infant born with low weight.

OBJECTIVE: Low weight at birth is a risk factor for increased mortality in infants undergoing surgery for congenitally malformed hearts. There has been a trend towards performing surgery in patients early, and for amenable lesions, in a single stage rather than following initial palliative procedures. Our goal was to report on the current incidences of morbidities and mortality in infants born with low weight and undergoing surgery for congenital cardiac disease. METHODS: We made a retrospective review of the data from patients meeting our criterions for entry from July, 2000, through July, 2004. The criterions for inclusion were weight at birth less than or equal to 2500 grams, and congenital cardiac malformations requiring surgery during the initial hospitalization. A criterion for exclusion was isolated persistent patency of the arterial duct. We assessed preoperative, intraoperative, and postoperative variables. RESULTS: We found a total of 105 patients meeting the criterions for inclusion. The median weight at birth was 2130 grams, and median gestational age was 36 weeks. The most common morbidity identified was infections of the blood stream. Infections, and chronic lung disease, were associated with increased length of stay. Survival overall was 76%. Patients with hypoplastic left heart syndrome, or a variant thereof, had the lowest survival, of 62%. The needs for cardiopulmonary resuscitation, or extracorporeal membrane oxygenation, post-operatively were the only factors identified as independent risk factors for mortality. CONCLUSION: Patients undergoing surgery during infancy for congenital cardiac disease who are born with low weight have a higher mortality and morbidity than those born with normal weight.

Critical heart disease in the neonate: presentation and outcome at a tertiary care center.

OBJECTIVE: To define the modes of presentation, incidence of major organ dysfunction, predictors of hospital mortality, and adverse outcomes in neonates with critical heart disease admitted to a tertiary care center. DESIGN: Retrospective chart review. SETTING: A tertiary care pediatric cardiac intensive care unit and neonatal intensive care unit. PATIENTS: The medical records for all neonates (< or = 30 days of age) with heart disease admitted to the cardiac intensive care unit or neonatal intensive care unit between October 1, 2002, and September 30, 2003, were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 190 neonates met inclusion criteria during this 1-yr period, of which 146 (77%) had at least one surgical procedure. Single ventricle heart disease was present in 42%. The most common mode of presentation was following a prenatal diagnosis (53%), followed by diagnosis in the newborn nursery (38%) and diagnosis after newborn hospital discharge (8%). The most common presenting findings in the newborn nursery were isolated murmur (38%) or cyanosis (32%), while circulatory collapse (38%) was the most common presentation after discharge. For the entire study cohort, 13% had a known genetic syndrome, 23% had a major noncardiac congenital anomaly, and 16% weighed < 2.5 kg. The hospital mortality for the entire cohort was 7.4%. Risk factors associated with an increased risk of hospital mortality included younger age at admission, higher number of cardiopulmonary bypass runs, and need for postoperative cardiopulmonary resuscitation. Total hospital length of stay was > 1 month in 17% of neonates. CONCLUSIONS: In patients with complex congenital heart disease, including nearly half with single ventricle heart disease, neonatal hospital mortality was 7%. These patients have a high frequency of multiple congenital anomalies, genetic syndromes, low birth weight, and prolonged length of stay.

Risk factors for mediastinitis following median sternotomy in children.

BACKGROUND: Mediastinitis is a devastating complication of pediatric cardiothoracic surgery. However, risk factors for the development of mediastinitis are poorly characterized. The objective of this study was to identify risk factors for mediastinitis in a cohort of children undergoing cardiothoracic surgery at a tertiary care children's hospital. METHODS: This case-control study included patients who underwent median sternotomy between January 1, 1995 and December 31, 2003. Univariate analyses, logistic regression, and multinomial regression were performed to determine the association between potential risk factors and the development of mediastinitis. RESULTS: Forty-three patients with mediastinitis and 184 patients without mediastinitis were included. One hundred and twelve (49%) patients were female. The median patient age was 128 days (interquartile range: 7 days-2.0 years). A known or possible genetic syndrome was present in 53 (24%) patients. The following factors were associated with the development of mediastinitis: presence of a known or possible genetic syndrome (adjusted odds ratio, OR: 4.5; 95% confidence interval, CI: 1.8-11.4); American Society of Anesthesiologists score >3 (adjusted OR: 3.4; 95% CI: 1.1-10.3); and presence of intracardiac pacing wires for >3 days (adjusted OR: 15.8; 95% CI: 2.0-127.2). CONCLUSIONS: The presence of a known or possible genetic syndrome, American Society of Anesthesiologists score >3, and the presence of intracardiac pacing wires for >3 days were each associated with the development of mediastinitis in children after median sternotomy.

Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients.

BACKGROUND: Catheter-associated bloodstream infections (CABSI) are among the most common and serious adverse events experienced by critically ill children. Randomized trials have demonstrated that the use of central venous catheters (CVC) coated with antiseptic solutions reduces rates of CABSI in adult patients; however, their efficacy in children has not been evaluated. OBJECTIVE: To compare the incidence of CABSI, rate of complications, and microbiology of infection in critically ill children treated with antibiotic-coated or noncoated CVC (NC-CVC). METHODS: A prospective observational trial was conducted in the pediatric intensive care unit (PICU) during a 13-month period. A minocycline-rifampin-coated CVC (MR-CVC) or NC-CVC was placed by PICU physicians who nonpreferentially selected CVC type. RESULTS: We studied the outcomes associated with the first CVC placed in 225 patients, including 69 MR-CVC and 156 NC-CVC. Patients who received MR-CVC, as compared with NC-CVC, were similar in gender, age, and severity of illness at time of PICU admission. The incidence density of CABSI did not vary by catheter type [MR-CVC: 7.53 per 1000 catheter-days (95% confidence interval 2.05-19.17); NC-CVC: 8.64 CABSI per 1000 catheter-days (95% confidence interval 3.74-16.96)]. However, the median time to infection in children with MR-CVC was 3-fold longer than in children with NC-CVC [18 versus 5 days (P = 0.053)]. No difference was seen in the incidence of complications, including thrombosis and catheter site reaction, between MR- and NC-CVC. No significant difference was observed in the types of organisms recovered from patients with MR- and NC-CVC. CONCLUSIONS: The use of MR-CVC significantly delayed the onset of CABSI in PICU patients. Larger, randomized trials are needed to better define potential differences in the incidence of CABSI, rate of complications, and microbiology of infection among pediatric patients treated with antiseptic-coated CVC and NC-CVC.

Cause and prevention of central nervous system injury in neonates undergoing cardiac surgery.

Neurologic morbidity has been identified as increasingly problematic in neonates with congenital heart disease as surgical mortality rates have improved. The presence of "congenital brain disease" in patients with congenital heart disease represents a challenge in improving long-term neurologic outcomes. Mechanisms of central nervous system injury in infants undergoing cardiac surgery include hypoxia-ischemia, emboli, reactive oxygen species, and inflammatory microvasculopathy. Preoperatively, the primary focus is on preventing hypoxic-ischemic injury and thromboembolic insults. Modifiable intraoperative factors associated with central nervous system injury include, but are not limited to, pH management, hematocrit during cardiopulmonary bypass, regional cerebral perfusion, and the use of deep hypothermic circulatory arrest. Postoperatively, secondary neurologic injury may be related to post-cardiopulmonary bypass alterations in cerebral autoregulation and additional hypoxic-ischemic insult, seizures, or other issues associated with prolonged intensive care unit stay. In addition to prenatal and modifiable perioperative factors, genetic and environmental factors are known to be important. Unfortunately, modifiable perioperative factors may explain less of the variability in long-term outcomes than do patient-specific factors.

Brain tissue oxygen monitoring in pediatric patients with severe traumatic brain injury.

OBJECT: Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring are fundamental to the management of severe traumatic brain injury (TBI). In adults, brain tissue oxygen monitoring (specifically PO2) and treatment have been shown to be safe additions to conventional neurocritical care and are associated with improved outcome. Brain tissue oxygen monitoring, however, has not been described in pediatric patients with TBI. In this report, the authors present preliminary experience with the use of ICP and PO2 monitoring in this population. METHODS: Pediatric patients (age <18 years) with severe TBI (Glasgow Coma Scale score <8) admitted to a Level 1 trauma center who underwent ICP and PO2 monitoring were evaluated. Therapy was directed at maintaining ICP below 20 mm Hg and age-appropriate CPP (> or =40 mm Hg). Data obtained in six patients (two girls and four boys ranging in age from 6-16 years) were analyzed. Brain tissue oxygen levels were significantly higher (p < 0.01) at an ICP of less than 20 mm Hg (PO2 29.29 +/- 7.17 mm Hg) than at an ICP of greater than or equal to 20 mm Hg (PO2 22.83 +/- 13.85 mm Hg). Significant differences (p < 0.01) were also measured when CPP was less than 40 mm Hg (PO2 2.53 +/- 7.98 mm Hg) and greater than or equal to 40 mm Hg (PO2 28.97 +/- 7.85 mm Hg). CONCLUSIONS: Brain tissue oxygen monitoring may be a safe and useful addition to ICP monitoring in the treatment of pediatric patients with severe TBI.

Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic left heart syndrome.

OBJECTIVE: Although extracorporeal membrane oxygenation (ECMO) is an acceptable strategy for children with refractory cardiac dysfunction after cardiac surgery, its role after stage I reconstruction for hypoplastic left heart syndrome and its variants is controversial. Our objective is to describe the outcome of "nonelective" ECMO after stage I reconstruction. DESIGN: Retrospective case series. SETTING: Pediatric cardiac intensive care unit. PATIENTS: Infants placed on ECMO after stage I reconstruction from January 1998 to May 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 382 infants who underwent stage I reconstruction during the study period, 36 (9.4%) required ECMO in the postoperative period. There were 22 infants with hypoplastic left heart syndrome. Indications for ECMO included inability to separate from cardiopulmonary bypass in 14 and cardiac arrest in 22. Fourteen infants (38.8%) survived to hospital discharge. Nonsurvivors had longer cardiopulmonary bypass time (150.1 +/- 70.0 mins vs. 103.9 +/- 30.0 mins, p =. 01). 9/14 infants (64%) supported with ECMO> than 24 hrs after stage I reconstruction survived while only 5/22 infants (22%) requiring ECMO< 24 hrs of stage I reconstruction survived (p =. 02). Of note, all five infants diagnosed with an acute shunt thrombosis were early survivors. Mean duration of ECMO was 50.1 +/- 12.5 hrs for survivors and 125.2 +/- 25.0 for nonsurvivors (p =. 01). 7/14 early survivors are alive at a median follow-up of 20 months (2-78 months). CONCLUSIONS: In our experience, ECMO after stage I reconstruction can be life saving in about a third of infants with otherwise fatal conditions. It is particularly useful in potentially reversible conditions such as acute shunt thrombosis and transient depression of ventricular function.

Review of bispectral index monitoring in the emergency department and pediatric intensive care unit.

OBJECTIVES: Sedation is a key component in the management of pediatric patients both in the pediatric emergency department (PED) and pediatric intensive care unit (PICU) for the treatment of pain and anxiety. Bispectral (BIS) index monitoring has been developed to help clinicians assess degree of hypnosis with anesthesia and may be useful in these environments. METHODS: Literature searches were conducted through MEDLINE for case series/reports, retrospective studies, and randomized trials that evaluate the validity and applications of BIS monitoring in the PED and PICU. RESULTS: Most of the studies are case series or retrospective studies in children. There are several prospective studies assessing validation of the monitor in children. Only a few studies have been performed that assess the influence of monitoring on outcomes in these environments. CONCLUSIONS: Bispectral values correlate fairly well with commonly used clinical sedation scores, but more variability in the scores has been observed at lighter levels of sedation. More studies are needed to assess the value of titrating sedation in the PED and PICU within specific BIS parameters to reduce morbidity and costs associated with over-sedation.