RESUMO
BACKGROUND: Postoperative care delivered in the pediatric cardiac intensive care unit (CICU) relies on providers' understanding of patients' congenital heart defects (CHDs) and procedure performed. Novel, bedside use of virtual, three-dimensional (3D) heart models creates access to patients' CHD to improve understanding. This study evaluates the impact of patient-specific virtual 3D heart models on CICU provider attitudes and care delivery. METHODS: Virtual 3D heart models were created from standard preoperative cardiac imaging of ten patients with CHD undergoing repair and displayed on a bedside tablet in the CICU. Providers completed a Likert questionnaire evaluating the models' value in understanding anatomy and improving care delivery. Responses were compared using two-tailed t test and Mann-Whitney U test and were also compared to previously collected CICU provider responses regarding use of printed 3D heart models. RESULTS: Fifty-three clinicians (19 physicians, 34 nurses/trainees) participated; 49 (92%) of 53 and 44 (83%) of 53 reported at least moderate to high satisfaction with the virtual 3D heart's ability to enhance understanding of anatomy and surgical repair, respectively. Seventy-one percent of participants felt strongly that virtual 3D models improved their ability to manage postoperative problems. The majority of both groups (63% physicians, 53% nurses) felt that virtual 3D heart models improved CICU handoffs. Virtual 3D heart models were as effective as printed models in improving understanding and care delivery, with a noted provider preference for printed 3D heart models. CONCLUSIONS: Virtual 3D heart models depicting patient-specific CHDs are perceived to improve understanding and postoperative care delivery in the CICU.
Assuntos
Cuidados Críticos/normas , Cardiopatias Congênitas/cirurgia , Coração/anatomia & histologia , Modelos Anatômicos , Cuidados Pós-Operatórios/normas , Autoeficácia , Atitude do Pessoal de Saúde , Competência Clínica , Humanos , Imageamento Tridimensional , Unidades de Terapia Intensiva/normas , Enfermeiras e Enfermeiros/psicologia , Médicos/psicologia , Estudos Prospectivos , Melhoria de Qualidade , Inquéritos e QuestionáriosRESUMO
BACKGROUND: We analyzed the UNOS database to better define the risk of transmission of central nervous system (CNS) tumors from donors to adult recipients of thoracic organs. METHODS: Data were procured from the Standard Transplant Analysis and Research dataset files. Donors with CNS tumors were identified, and recipients from these donors comprised the study group (Group I). The remaining recipients of organs from donors who did not have CNS tumors formed the control group (Group II). Incidence of recipient CNS tumors, donor-related malignancies, and overall survival were calculated and compared in addition to multivariable logistic regression. RESULTS: A cohort of 58 314 adult thoracic organ recipients were included, of which 337 received organs from donors who had documented CNS tumors (Group I). None of these recipients developed CNS tumors at a median follow-up of 72 months (IR: 30-130 months). Although overall mortality in terms of the percentage was higher in Group I than Group II (163/320=51% vs 22 123/52 691=42%), Kaplan-Meier curves indicate no significant difference in the time to death between the two groups (P=.92). CONCLUSIONS: There is little risk of transmission of the common nonaggressive CNS tumors to recipients of thoracic organs.
Assuntos
Neoplasias do Sistema Nervoso Central/etiologia , Bases de Dados Factuais , Transplante de Coração/efeitos adversos , Transplante de Pulmão/efeitos adversos , Complicações Pós-Operatórias , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Adulto , Aloenxertos , Neoplasias do Sistema Nervoso Central/epidemiologia , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Prognóstico , Sistema de Registros , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Acquired von Willebrand syndrome (AvWS) in the setting of congenital heart disease is an under-recognized cause of bleeding in the pediatric cardiac critical care unit. METHODS: Fourteen patients diagnosed with AvWS admitted to the cardiac intensive care unit at the Children's National Health System between December 2009 and September 2015 were identified with subsequent chart review and case analysis. RESULTS: Of the 14 patients included in this study, 4 patients were on ventricular-assist devices, 6 patients were on extracorporeal membrane oxygenation, and 4 were patients with congenital heart disease not receiving any mechanical circulatory support. All patients identified manifested persistent severe bleeding, despite appropriate management of anticoagulation and blood product administration based on the established protocols. Detailed hemostatic testing including quantitative von Willebrand factor (vWF) multimer analysis revealed decreased high-molecular-weight multimers (HMWMs) and absent ultra-HMWM, consistent with AvWS in all patients. Eight patients received treatment with vWF concentrate, one patient with desmopressin, and five recovered without specific treatment. Bleeding ceased in all but one patient. CONCLUSIONS: Acquired von Willebrand syndrome is an uncommon but important cause of bleeding in pediatric patients with cardiac disease. A high index of clinical suspicion with knowledge of the characteristic clinical scenario in addition to low levels of vWF multimers is required to manage and diagnose AvWS. Although the optimal management of AvWS in this patient population is unclear, vWF concentrates are available and appear to be efficacious for controlling life-threatening bleeding.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiopatias Congênitas/cirurgia , Unidades de Terapia Intensiva , Hemorragia Pós-Operatória/etiologia , Doenças de von Willebrand/complicações , Adolescente , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/complicações , Coração Auxiliar/efeitos adversos , Humanos , Lactente , Recém-Nascido , Masculino , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/diagnóstico , Doenças de von Willebrand/sangue , Doenças de von Willebrand/diagnóstico , Fator de von Willebrand/metabolismoRESUMO
BACKGROUND: High-fidelity simulation using patient-specific three-dimensional (3D) models may be effective in facilitating pediatric cardiac intensive care unit (PCICU) provider training for clinical management of congenital cardiac surgery patients. METHODS: The 3D-printed heart models were rendered from preoperative cross-sectional cardiac imaging for 10 patients undergoing congenital cardiac surgery. Immediately following surgical repair, a congenital cardiac surgeon and an intensive care physician conducted a simulation training session regarding postoperative care utilizing the patient-specific 3D model for the PCICU team. After the simulation, Likert-type 0 to 10 scale questionnaire assessed participant perception of impact of the training session. RESULTS: Seventy clinicians participated in training sessions, including 22 physicians, 38 nurses, and 10 ancillary care providers. Average response to whether 3D models were more helpful than standard hand off was 8.4 of 10. Questions regarding enhancement of understanding and clinical ability received average responses of 9.0 or greater, and 90% of participants scored 8 of 10 or higher. Nurses scored significantly higher than other clinicians on self-reported familiarity with the surgery (7.1 vs. 5.8; P = .04), clinical management ability (8.6 vs. 7.7; P = .02), and ability enhancement (9.5 vs. 8.7; P = .02). Compared to physicians, nurses and ancillary providers were more likely to consider 3D models more helpful than standard hand off (8.7 vs. 7.7; P = .05). Higher case complexity predicted greater enhancement of understanding of surgery (P = .04). CONCLUSION: The 3D heart models can be used to enhance congenital cardiac critical care via simulation training of multidisciplinary intensive care teams. Benefit may be dependent on provider type and case complexity.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Cuidados Críticos , Cardiopatias Congênitas/cirurgia , Transferência da Responsabilidade pelo Paciente , Pediatria/educação , Cuidados Pós-Operatórios , Impressão Tridimensional , Treinamento por Simulação , Enfermagem de Cuidados Críticos/educação , Estudos Transversais , Cardiopatias Congênitas/patologia , Humanos , Unidades de Terapia Intensiva Pediátrica , Enfermagem Pediátrica/educação , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Injury to the recurrent laryngeal nerve can lead to significant morbidity during congenital cardiac surgery. The objective is to expand on the limited understanding of the severity and recovery of this iatrogenic condition. DESIGN: A six-year retrospective review of all congenital heart operations at a single institution from January 1, 2008 to December 31, 2013 was performed. All patients with documented vocal cord paralysis on laryngoscopic examination comprised the study cohort. Evaluation of time to vocal cord recovery and need for further surgical intervention was the primary focus. RESULTS: The incidence of post-operative vocal cord paralysis was 1.1% (32 out of 3036 patients; 95% confidence interval: 0.7-1.5%). The majority were left-sided injuries (71%). Overall rate of recovery was 61% with a median time of 10 months in those who recovered, and a total follow up of 46 months. Due to feeding complications, 45% of patients required gastrostomy tube after the injury, and these patients were found to have longer duration of post-operative days of intubation (median 10 vs. 5 days, p = 0.03), ICU length of stay (50 vs. 8 days, p = 0.002), and hospital length of stay (92 vs. 41 days, p = 0.01). No pre-operative variables were identified as predictive of recovery or need for gastrostomy placement. CONCLUSION: Recurrent laryngeal nerve injury is a serious complication of congenital heart surgery that impacts post-operative morbidity, in some cases leading to a need for further intervention, in particular, gastrostomy tube placement. A prospective, multi-center study is needed to fully evaluate factors that influence severity and time to recovery.
RESUMO
BACKGROUND: Shunt or conduit thrombosis in a single ventricle circuit is a life-threatening complication that requires prompt treatment to rapidly restore shunt/conduit patency. Transcatheter interventions represent an attractive alternative to systemic thrombolysis or open surgical procedures. We report our center's experience with catheter-based approaches in patients with palliated single ventricle who present with shunt/conduit thrombosis. METHODS: A retrospective review was performed of all patients with palliated single ventricle physiology who were diagnosed over a 5-year period with shunt/conduit thrombosis and received catheter-based interventions. Patients were followed up to hospital discharge. RESULTS: Thirteen patients were identified that were diagnosed with thrombosis of a modified Blalock-Taussig shunt (five patients), bidirectional cavopulmonary shunt (one patient), and total cavopulmonary pathway (seven patients). Shunt/conduit thrombosis occurred both early and late after palliation surgery. Catheter-based interventions included balloon angioplasty (one patient), stent implantation (12 patients), and mechanical thrombectomy (one patient). Thrombophilia was identified in seven patients. Technical and clinical success with restoration of normal shunt flow and improvement in clinical status was achieved in 12 patients. Reversible procedure-related complications occurred in three patients with no significant sequelae. CONCLUSIONS: Our experience suggests that percutaneous catheter-based interventions are safe and effective in managing shunt/conduit thrombosis in infants and children with palliated single ventricle circulation.
Assuntos
Angioplastia Coronária com Balão , Procedimento de Blalock-Taussig/efeitos adversos , Cateterismo Cardíaco , Derivação Cardíaca Direita/efeitos adversos , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Trombectomia , Trombose/terapia , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/instrumentação , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Feminino , Cardiopatias Congênitas/diagnóstico , Ventrículos do Coração/anormalidades , Humanos , Masculino , Cuidados Paliativos , Estudos Retrospectivos , Stents , Trombectomia/efeitos adversos , Trombose/diagnóstico , Trombose/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Gastrostomy tube (G-tube) placement during three-stage surgical palliation of single-ventricle cardiac physiology has been shown to improve weight gain in this population of infants who often suffer from inadequate feeding. The optimal timing of this intervention is unclear and requires further investigation. DESIGN: A retrospective review of all patients who underwent G-tube placement at any stage of surgical palliation of single-ventricle physiology from January 2005 to December 2012 was performed at a single congenital cardiac surgery center. Analysis of weight gain and survival was undertaken by comparing patients who received the G-tube either less than or greater than 90 days after the first surgical stage. RESULTS: Fifty-four patients were identified that met the criteria, 26 (48%) of which received the G-tube within 90 days of stage 1, while 28 (52%) patients received the tube at greater than 90 days. Percentage of weight gain at time of discharge from stage 1 was significantly higher for group B (A: median 9.9%, interquartile range [IQR] 4.9-29.8; B: median 29.0%, IQR 16.0-44.3; P = .05). However, total hospital length of stay was decreased for the patients who received G-tubes earlier (A: median 60 days, IQR 35-100; B: median 83, IQR 48-184) as was intensive care unit length of stay (A: median 27 days, IQR 13-69; B: median 48, IQR 16-119) by nearly half, although not statistically significant (P = .47). Survival to time of discharge from stage 1 surgery was not significantly different between earlier tube placements vs. later (92% vs. 100%, respectively; P = .14). Multivariable analysis found inclusion of fundoplication to predict weight gain (P = .006) at time of first discharge. CONCLUSION: Earlier placement of G-tube may increase the rate of recovery from stage 1 of multistage palliative cardiac surgery for single-ventricle physiology. Fundoplication may improve perioperative weight gain when indicated.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Nutrição Enteral/instrumentação , Gastrostomia/instrumentação , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Cuidados Paliativos , Tempo para o Tratamento , Fatores Etários , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Nutrição Enteral/efeitos adversos , Nutrição Enteral/mortalidade , Feminino , Fundoplicatura , Gastrostomia/efeitos adversos , Gastrostomia/mortalidade , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/mortalidade , Ventrículos do Coração/anormalidades , Mortalidade Hospitalar , Humanos , Lactente , Mortalidade Infantil , Fenômenos Fisiológicos da Nutrição do Lactente , Tempo de Internação , Modelos Lineares , Masculino , Análise Multivariada , Estado Nutricional , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Aumento de PesoRESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a life-saving measure for pediatric patients with cardiopulmonary failure. The option of cannulating neck vessels versus those of the groin exists for patients over 15 kg; however, each carries the risk for complications. We present a single-center experience comparing the risks and benefits of these alternate peripheral ECMO cannulation sites. METHODS: All pediatric patients supported by venoarterial (VA) ECMO via peripheral cannulation from January 2006 to May 2013 were retrospectively reviewed, excluding those weighing less than 15 kg. We compared complications of neck versus groin cannulation sites, including neurologic dysfunction, limb ischemia, and in-hospital mortality. Univariate analysis and multivariable logistic regression were performed to identify factors for complications including mortality. RESULTS: Thirty-six patients (median age 10.8 years, interquartile range: 6.0-15.8) were cannulated for VA ECMO. Forty-four percent were cannulated via neck vessels and 47% were cannulated via groin. Nine percent were cannulated at both sites. Overall survival was 72% at decannulation and 67% at hospital discharge. No statistically significant survival difference between groin and neck cannulation subgroups was found. Rate of neurologic injury was higher in neck (25%) versus groin (12%) cannulation, but this was not statistically significant (p = 0.52). Extremity ischemia occurred in five patients having groin cannulation (29%, p = 0.04). CONCLUSIONS: Neck cannulation is a valuable alternative to groin vessels in patients above 15 kg. Risk of limb ischemia with groin cannulation is significant, and must be considered when choosing the cannulation site for ECMO support.
Assuntos
Peso Corporal , Cateterismo Periférico/métodos , Oxigenação por Membrana Extracorpórea/métodos , Adolescente , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/mortalidade , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Virilha/irrigação sanguínea , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pescoço/irrigação sanguínea , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Medição de RiscoRESUMO
Menetrier`s disease is a rare form of acquired gastropathy that presents mostly during adulthood, but is extremely rare in children. It is a clinicopathological diagnosis that typically presents with abdominal pain, vomiting, and edema secondary to hypoalbuminemia. Endoscopy usually shows giant gastric mucosal folds, and gastric biopsy shows foveolar hyperplasia and decreased oxyntic glands. Here, we describe a 5-year-old boy from Saudi Arabia with typical presentation of Menetrier`s disease and serological evidence of acute cytomegalovirus infection.