Patient Outcomes of an International Telepediatric Cardiac Critical Care Program.

BACKGROUND: An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program. MATERIALS AND METHODS: A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS). RESULTS: Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min. CONCLUSIONS: An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.

International telemedicine in pediatric cardiac critical care: a multicenter experience.

OBJECTIVE: To describe our multicenter experience in telemedicine-assisted pediatric cardiac critical care (PCCC) with four hospitals in Latin America from July 2011 to June 2013. MATERIALS AND METHODS: This was a descriptive study based on telemedicine encounters related to quality of communication, assessed information, activities, and recommendations. Comparison among centers was performed. A postimplementation survey was conducted through a 5-point Likert scale questionnaire investigating acceptance among professionals involved with the telemedicine service through the assessment of general satisfaction, perception about the work system, usefulness, and impact on medical practice. RESULTS: One thousand forty consultations were conducted for 476 patients. Postoperatively, patients were distributed into Risk Adjustment Classification for Congenital Heart Surgery (RACHS-1) categories as follows: 2%, 26%, 36%, 26%, and 10% in categories 1, 2, 3, 4, and 6, respectively. A real-time intervention took place in 23% of encounters. Of the 2,173 recommendations given, 70 were related to extracorporeal membrane oxygenation management. There was a different RACHS-1 distribution and encounter characteristics among centers. From a total of 51 surveys sent, 27 responses were received, and among responders, overall satisfaction was very high (4.27 ± 0.18), as well as work system quality (4.4 ± 0.37). Telemedicine was considered useful in the cardiac intensive care unit (3.86 ± 0.60), for patient outcomes (3.8 ± 0.51), and for education (3.7 ± 0.71). There was a difference in overall satisfaction, perception about telemedicine usefulness in education, and impact on medical practice among centers. CONCLUSIONS: An international, multicenter telemedicine program in PCCC is technologically and logistically feasible. Prospective interventions in our international multicenter telemedicine program should consider differences in staff composition, perception of needs, and patient population among centers.

Películas infantiles como alternativa a la sedación en el estudio ecocardiográfico de pacientes pediátricos

Introducción. La realización del ecocardiograma se dificulta si el niño no coopera, por lo que es necesario sedarlo. Para evitar los posibles efectos adversos de la sedación se ha propuesto utilizar la proyección de películas infantiles durante el estudio. Material y métodos. Se formaron 2 grupos de pacientes no cooperadores entre 1 y 3 años de edad de manera aleatoria: uno sometido a sedación (13 niños) y otro al que se proyectó una película infantil (15 niños). En ambos grupos se evaluaron escalas semicuantitativas de cooperación, calidad de imagen y el tiempo de realización del estudio. Resultados. No se encontró diferencia estadísticamente significativa entre ambos grupos en cuanto a las escalas de cooperación y calidad de imagen, así como en el tiempo de realización del estudio. Conclusiones. Este método evita la exposición a los riesgos de la sedación, obteniendo cooperación e información similares, y pudiera disminuir los recursos necesarios para la realización del estudio.

Introduction. It is often difficult to perform echocardiograms in small children because of lack of cooperation, hence the need for sedation. In order to avoid the possible adverse effects of sedation, the projection of age-appropriate films during the study has been proposed as an alternative. Material and methods. Pediatric non-cooperative patients, ages between 1 and 3 years old with an indication for elective echocardiography were randomly assigned to either 1 of 2 groups: the first one (13 patients) with intranasal midazolam sedation (300 mg/kg), and the other group (15 patients) with video-projection of movies. Cooperation and image quality scores differences were evaluated (Mann-Whitney), as well as the mean study performance time between the 2 groups. Results. Cooperation and image quality scores were similar between the 2 groups. There was a trend toward a shorter mean study performance time in the video group, not reaching statistical significance. Conclusions. Projection of age-appropriate movies during echocardiographic studies in pediatric non-cooperative patients is a good alternative to sedation, avoiding related risks and resource expenditure with similar cooperation and echocardiographic information.

Terapia intensiva pediátrica: lujo o necesidad. Trece años de experiencia en el Hospital Central Militar / Intensive therapy in pediatrics: an actual necessity or a mare luxory modern convenience. Thirteen years of experience at the Militar Central Hospital

Se analizaron los datos de 2724 pacientes registrados en los archivos de la unidad de terapia intensiva pediátrica del Hospital Central Militar, desde su fundación, el 1 de septiembre de 1978 hasta el 31 de diciembre de 1990. Para su estudio se agruparon los datos en cuatro lapsos: de 1978 a 1981; de 1982 a 1985; de 1986 a 1989 y 1990. La mortalidad en los neonatos no ha variado en los lapsos estudiados (x=43.25 por ciento), pero el índice de gravedad evaluado por el número de procedimientos invasores ha aumentado significativamente del primero al último lapso. En niños mayores se observó una disminución significativa de la mortalidad, de 30.6 por ciento en el primer lapso a 17.4 por ciento en el último. La ventilación mecánica aumentó significativamente a través del tiempo hasta 81.6 por ciento disminuyendo asimismo la mortalidad a 45.9 por ciento en los neonatos sujetos al procedimiento; en los mayores la mortalidad también ha disminuido significativamente a 44.4 por ciento. Los pacientes contagiosos y reversos han aumentado de manera importante a través del tiempo. No es posible comparar nuestros resultados con los de otros autores debido a que nuestro estudio está basado en una clasificación por intervenciones, siendo sólo útil para comparar nuestro propio universo. Se propone utilizar escalas de criterios fisiológicos para poder hacer comparaciones con otras unidades de terapia intensiva pediátrica nacionales y extranjeras.

Diagnóstico de comunicación interventricular por resonancia magnética / Diagnosis by magnetic resonance imaging (MRI)

Las técnicas no invasivas han cobrado cada vez mayor importancia para la valoración pre y posoperatoria de las cardiopatías congénitas. La resonancia magnética ofrece un potencial enorme de aplicación para el estudio de las mismas, debido a su capacidad para el análisis anatómico y fisiológico del corazón. Se informa de un caso de comunicación interventricular en el cual la resonancia magnética fue útil para la evaluación preoperatoria, y se le propone como parte integral de la valoración de niños y adultos con cardiopatía congénita.