Opioid Utilization after Cardiac Surgery in the Pediatric Medicaid-Insured Population.

OBJECTIVE: To determine the variation of outpatient opioid prescribing across the US in postoperative pediatric cardiac patients. STUDY DESIGN: Retrospective, cross-sectional study using a concatenated database of Medicaid claims between from 2016 through 2018 of children 0-17 years, discharged after cardiac surgery and receiving an opioid prescription within 30 days. Filled prescriptions were identified and converted to morphine milligram equivalents (MME). Use, duration, and dose were analyzed by sex, race, ethnicity, residence urbanicity, and region. RESULTS: Among 17 186 Medicaid-enrolled children after cardiac surgery, 2129 received opioids within 30 days of discharge. Females received lower doses than males (coefficient -0.17, P = .022). Hispanic individuals were less likely to receive opioids (coefficient 0.53, P < .05, 95% CI: 0.38-0.71) and for shorter periods (coefficient 0.83, P < .001). Midwest (MW) (OR 0.61, 95% P-values < 0.05, 95% CI: 0.46-0.80) and Northeast (NE) (OR 0.43, 95% P-values < 0.05, 95% CI: 0.30-0.61) regions were less likely to receive opioids but used higher doses compared with the Southeast (SE) (MW coefficient 0.41, Southwest (SW) coefficient 0.18, NE coefficient 0.32, West (W) coefficient 0.19, P < .05). CONCLUSIONS: There were significant variations in opioid prescribing after cardiac surgery by race, ethnicity, sex, and region. National guidelines for outpatient use of opioids in children after cardiac surgery may help limit practice variation and reduce potential harms in outpatient opioid usage.

A comparison of high-flow nasal cannula versus non-invasive positive pressure ventilation for respiratory support in infants following cardiac surgery.

BACKGROUND: Following cardiac surgery, infants often remain endotracheally intubated upon arrival to the cardiac ICU. High-flow nasal cannula and non-invasive positive pressure ventilation are used to support patients following extubation. There are limited data on the superiority of either mode to prevent extubation failure. METHODS: We conducted a single-centre retrospective study for infants (<1 year) and/or <10 kg who underwent cardiac surgery between 3/2019-3/2020. Data included patient and clinical characteristics and operative variables. The study aimed to compare high-flow nasal cannula versus non-invasive positive pressure ventilation following extubation and their association with extubation failure. Secondarily, we examined risk factors associated with extubation failure. RESULTS: There were 424 patients who met inclusion criteria, 320 (75%) were extubated to high-flow nasal cannula, 104 (25%) to non-invasive positive pressure ventilation, and 64 patients (15%) failed extubation. The high-flow nasal cannula group had lower rates of extubation failure (11%, versus 29%, p = 0.001). Infants failing extubation were younger and had higher STAT score (p < 0.05). Compared to high-flow nasal cannula, non-invasive positive pressure ventilation patients were at 3.30 times higher odds of failing extubation after adjusting for patient factors (p < 0.0001). CONCLUSIONS: Extubation failure after cardiac surgery occurs in smaller, younger infants, and those with higher risk surgical procedures. Patients extubated to non-invasive positive pressure ventilation had 3.30 higher odds to fail extubation than patients extubated to high-flow nasal cannula. The optimal mode of respiratory support in this patient population is unknown.

Incidence and recovery of post-surgical heart block in children following cardiac surgery.

BACKGROUND: A subset of patients who develop post-surgical heart block have recovery of atrioventricular node function. Factors predicting recovery are not understood. We investigated our centre's incidence of post-surgical heart block and examine factors associated with recovery of atrioventricular node function. METHODS: We conducted a single-centre retrospective study of patients 0 - 21 years who underwent cardiac surgery between January 2010 and December 2019 and experienced post-operative heart block. Data including patient and clinical characteristics and operative variables were collected and analysed. RESULTS: Of 6333 surgical hospitalisations, 128 (2%) patients developed post-operative heart block. Of the 128 patients, 90 (70%) had return of atrioventricular node function, and 38 (30%) had pacemaker placement. Of the 38 patients who underwent pacemaker placement, 6 (15.8%) had recovery of atrioventricular node function noted on long-term follow-up. Median time from onset of heart block to late atrioventricular node recovery was 13 days (Interquartile range: 5 - 117). Patients with single-ventricle physiology (p = 0.04), greater weight (p = 0.03), and shorter cardiopulmonary bypass time (p = 0.015) were more likely to have recovery. The use of post-operative steroids was similar between all groups (p = 0.445). Infectious or wound complications were similar between pacemaker groups (p = 1). CONCLUSIONS: Two per cent of patients who underwent congenital cardiac surgery developed post-operative heart block, and 0.6% underwent pacemaker placement. Early recovery of atrioventricular node was associated with greater weight at the time of surgery, single-ventricle physiology, and shorter cardiopulmonary bypass time. Late recovery of atrioventricular node conduction following pacemaker placement occurred in 15.8% of patients.

Milrinone for treatment of elevated lactate in the pre-operative newborn with hypoplastic left heart syndrome.

BACKGROUND: There is a paucity of information reported regarding the use of milrinone in patients with hypoplastic left heart syndrome prior to the Norwood procedure. At our institution, milrinone is initiated in the pre-operative setting when over-circulation and elevated serum lactate levels develop. We aimed to review the responses associated with the administration of milrinone in the pre-operative hypoplastic left heart syndrome patient. Second, we compared patients who received high- versus low-dose milrinone prior to Norwood procedure. METHODS: Single-centre retrospective study of patients diagnosed with hypoplastic left heart syndrome between January 2000 and December 2019 who underwent Norwood procedure. Patient characteristics and outcomes were compared. RESULTS: During the study period, 375 patients were identified; 79 (21%) received milrinone prior to the Norwood procedure with median lactate 2.55 mmol/l, and SpO2 93%. Patients who received milrinone were older at the time of Norwood procedure (6 vs. 5 days) and were more likely to be intubated and sedated. In a subset analysis stratifying patients to low- versus high-dose milrinone, median lactate decreased from time of initiation (2.39 vs 2.75 to 1.6 vs 1.8 mmol/l) at 12 hours post-initiation, respectively. Repeated measures analysis showed a significant decrease in lactate levels by 4 hours following initiation of milrinone, that persisted over time, with no significant difference in mean arterial pressure. CONCLUSIONS: The use of milrinone in the pre-operative over-circulated hypoplastic left heart syndrome patient is well tolerated, is associated with decreased lactate levels, and was not associated with significant hypotension or worsening of excess pulmonary blood flow.

Utilisation of RAM cannula for non-invasive respiratory support for infants in the cardiac ICU.

BACKGROUND: Children with CHD carry an additional burden of pulmonary insufficiency, often necessitating prolonged ventilatory support, especially in the peri-operative phase. There has been an increase in the utilisation of non-invasive ventilatory support for these children. The objective of this study was to evaluate the utilisation, safety, and outcomes of RAM cannula as a tool for escalation and de-escalation of respiratory support in paediatric cardiac patients less than one year of age. METHODS: A single-centre retrospective cohort study of patients supported with RAM cannula. RESULTS: A total of 275 instances of RAM use were included in the study, 81.1% being post-operative. Patients were stratified into escalation and de-escalation cohorts based on the indication of non-invasive ventilation. The success rate of using RAM cannula was 69.5% overall, 66.1% in the escalation group, and 72.8% in the de-escalation group. At baseline, age at cardiac ICU admission >30 days, FiO2 ≤ 40%, PaCO2 ≤ 50 mmHg; and after 12 hours of non-invasive ventilation support respiratory rate ≤ 60/min, PaO2 ≥ 50 mmHg, PaCO2 ≤ 50 mmHg; and absence of worsening on follow-up chest X-ray predicted the success with a sensitivity of 95% in the logistic regression model. Successful support was associated with a significantly shorter unit stay. CONCLUSIONS: RAM cannula can be safely used to provide non-invasive support to infants in the cardiac ICU for escalation and de-escalation of respiratory support. Factors associated with success can be used to make decisions about candidacy and appropriate timing of non-invasive ventilation use to maximise effectiveness.

Clinical and Hematological Outcomes of Aminocaproic Acid Use During Pediatric Cardiac ECMO.

Bleeding and thrombosis-related complications are common in pediatric cardiac patients supported by extracorporeal membrane oxygenation (ECMO) and are associated with morbidity and mortality. The purpose of this study was to evaluate the utility of aminocaproic acid (ACA), an antifibrinolytic agent, as it pertains to bleeding in pediatric cardiac patients on ECMO. This included a retrospective cohort study of pediatric cardiac patients receiving ACA while supported on ECMO between 2013 and 2017. For each patient, data were collected in three time intervals: the 24 hours before ACA initiation, and then 0-24 and 24-48 hours following ACA initiation. For each time frame, bleeding, component transfusion, and laboratory data were collected and analyzed. A total of 62 patients were included, representing 42% of our cardiac ECMO patients during the time period. ACA was initiated at 16.3 ± 8.7 hours following initiation of ECMO. The mean bleeding rate before ACA was 10.57 mL/kg/h, which reduced to 7.8 mL/kg/h in the 24-hour period after initiation of ACA and a further decrease to 3.65 mL/kg/h during the 24- to 48-hour time period following ACA initiation. ACA administration was associated with reduction in bleeding (p < .001) and packed red blood cell transfusions (p = .02), administration of fresh frozen plasma (p < .001), platelets (p = .017), cryoprecipitate (p = .05), factor VII (p = .002), and Cell Saver (p = .005). Hemoglobin and platelet count were stable, whereas prothrombin time (PT), partial thromboplastin time, and international normalized ratio (INR) showed significant reduction over the time course. ACA administration was not associated with specific adverse effects. A clinically significant reduction in bleeding amount, red blood cell transfusions, and other hematologic interventions occurred following ACA administration for pediatric patients on ECMO. Wider consideration for ACA use as a part of a multipronged strategy to manage bleeding during ECMO should be considered.

Using pulse oximetry waveforms to detect coarctation of the aorta.

BACKGROUND: Coarctation of the aorta is a common form of critical congenital heart disease that remains challenging to diagnose prior to clinical deterioration. Despite current screening methods, infants with coarctation may present with life-threatening cardiogenic shock requiring urgent hospitalization and intervention. We sought to improve critical congenital heart disease screening by using a novel pulse oximetry waveform analysis, specifically focused on detection of coarctation of the aorta. METHODS AND RESULTS: Over a 2-year period, we obtained pulse oximetry waveform data on 18 neonates with coarctation of the aorta and 18 age-matched controls hospitalized in the cardiac intensive care unit at Children's Healthcare of Atlanta. Patients with coarctation were receiving prostaglandin E1 and had a patent ductus arteriosus. By analyzing discrete features in the waveforms, we identified statistically significant differences in the maximum rate of fall between patients with and without coarctation. This was accentuated when comparing the difference between the upper and lower extremities, with the lower extremities having a shallow slope angle when a coarctation was present (p-value 0.001). Postoperatively, there were still differences in the maximum rate of fall between the repaired coarctation patients and controls; however, these differences normalized when compared with the same individual's upper vs. lower extremities. Coarctation patients compared to themselves (preoperatively and postoperatively), demonstrated waveform differences between upper and lower extremities that were significantly reduced after successful surgery (p-value 0.028). This screening algorithm had an accuracy of detection of 72% with 0.61 sensitivity and 0.94 specificity. CONCLUSIONS: We were able to identify specific features in pulse oximetry waveforms that were able to accurately identify patients with coarctation and further demonstrated that these changes normalized after surgical repair. Pulse oximetry screening for congenital heart disease in neonates may thus be improved by including waveform analysis, aiming to identify coarctation of the aorta prior to critical illness. Further large-scale testing is required to validate this screening model among patients in a newborn nursery setting who are low risk for having coarctation.

Aortic and Mitral Valve Disease and Left Ventricular Dysfunction in Children.

OBJECTIVES: In this review, we will discuss aortic stenosis, aortic regurgitation, mitral regurgitation, and mitral stenosis. We will review the etiology, anatomy, pathophysiology, presentation, and treatment of aortic and mitral valve disease. Age and lesion specific treatments are outlined based on the severity of valve disease with an aim at long-term preservation of left ventricular function. DATA SOURCE: MEDLINE and PubMed. CONCLUSIONS: Mitral and aortic valve disease leads to unique hemodynamic burdens that can impact left ventricular function, quality of life, and longevity. The primary challenge in the management of mitral and aortic valve disease is to apply appropriate medical management and identify that point in time at which the surgery is necessary. Although guidelines have been established for the management of aortic and mitral valve disease in adults, the challenges of early presentation, maintenance of growth potential, and apparent increased tolerance of hemodynamic burden in children makes decision making challenging.

Novel tubing connectors reduce ECMO circuit thrombosis.

BACKGROUND: Thrombosis within extracorporeal membrane oxygenation (ECMO) circuits is a common complication that dominates clinical management of patients receiving mechanical circulatory support. Prior studies have identified that over 80% of circuit thrombosis can be attributed to tubing-connector junctions. METHODS: A novel connector was designed that reduces local regions of flow stagnation at the tubing-connector junction to eliminate a primary source of ECMO circuit thrombi. To compare clotting between the novel connectors and the traditional connectors, both in vitro loops and an in vivo caprine model of long-term (48 h) ECMO were used to generate tubing-connector junction clots. RESULTS: In vitro, the traditional connectors uniformly (9/9) formed large thrombi, while novel connectors formed a small thrombus in only one of nine (p < 0.0001). In the long-term goat ECMO circuits, the traditional connectors exhibited more thrombi (p < 0.04), and these thrombi were more likely to protrude into the lumen of the tubing (p < 0.001). CONCLUSION: Both in vitro and in vivo validation experiments successfully recreated circuit thrombosis and demonstrate that the adoption of novel connectors can reduce the burden of circuit thrombosis.

Hemodynamic effects of implanting a unidirectional valve in the inferior vena cava of the Fontan circulation pathway: an in vitro investigation.

The Fontan surgical procedure used for treating patients with single ventricle congenital heart disorders results in a total cavopulmonary connection (TCPC) of the vena cavae to the pulmonary arteries (PAs). Sluggish TCPC flow and elevated hepatic venous pressures are commonly observed in this altered physiology, which in turn can lead to long-term complications including liver congestion and cirrhosis. The hypothesis of this study is that placement of a unidirectional valve within the inferior vena cava (IVC) will improve hemodynamics of the Fontan circulation by preventing retrograde flow and lowering hepatic venous pressure. An in vitro experimental setup consisting of an idealized TCPC model with flexible walls was used for investigation, and a bovine venous valve was inserted in the IVC below the TCPC. Pressure fluctuations were introduced in the flow through the model to simulate venous pulsatility. Hemodynamics of baseline and valve-implanted conditions were compared across total caval flows ranging from 1.0 to 2.5 l/min with varying caval flow distributions. The results indicated that valve closure occurred for 15-20% of the total cycle, with consequent reduction in the upstream hepatic venous pressure by 5 to 10 mmHg. Energy loss (EL) through the TCPC was lowered with valve implantation to 20-50% of baseline, occurring across all flow conditions considered with mean caval and PA pressures greater than 10 mmHg. The results of this in vitro modeling suggest that IVC valve placement has the potential to improve hemodynamics in the Fontan circulation by decreasing hepatic venous hypertension and EL.

Safe and effective use of a glycemic control protocol for neonates in a cardiac ICU.

OBJECTIVE: To investigate the safety and efficacy of a hyperglycemia protocol in neonates with critical cardiac illness. Neonates are often regarded as high risk for hypoglycemia while receiving continuous insulin infusions and thus have been excluded from some clinical trials. DESIGN: A retrospective review. SETTING: A pediatric cardiac ICU in a tertiary academic center. INTERVENTIONS: Neonates with critical cardiac illness who developed hyperglycemia were placed on an insulin-hyperglycemia protocol at the attending physician's discretion. Insulin infusions were titrated based on frequent blood glucose monitoring. MEASUREMENTS: Critical illness hyperglycemia was defined as a blood glucose less than 140 mg/dL. Hypoglycemia was defined as moderate (≤ 60 mg/dL) or severe (≤ 40 mg/dL). Initiating blood glucose, lowest blood glucose during insulin infusion, doses of insulin, duration of insulin, and time to blood glucose greater than 140 mg/dL were evaluated. MAIN RESULTS: A total of 44 patients were placed on the protocol between January 2009 and October 2011. The majority of insulin infusions were initiated in the early postoperative period (33 of 44, 75%). Moderate hypoglycemia occurred in two patients (4.5%), with blood glucose levels of 49 and 53 mg/dL. No episodes of severe hypoglycemia occurred. A total of 345 discrete blood glucose levels were analyzed; two of these being greater than 60 mg/dL (0.58%). Mean blood glucose prior to starting insulin was 252 ± 45 mg/dL and time until euglycemia was 6.1 ± 3.9 hours. The mean duration of insulin infusion was 24.6 ± 38.7 hours, mean peak dose was 0.10 ± 0.05 units/kg/hour, and mean insulin dose was 0.06 ± 0.02 units/kg/hour. For postoperative patients, mean time after bypass until onset of hyperglycemia was 2.2 ± 2.6 hours. CONCLUSIONS: A glycemic control protocol can safely and effectively be applied to neonates with critical cardiac disease. Neonates with critical cardiac illness should be included in clinical trials evaluating the benefits of glycemic control.

Impact of Antegrade Pulmonary Blood Flow as Patients Progress Through Single-Ventricle Palliations.

BACKGROUND: The impact of antegrade pulmonary blood flow (APBF) during single-ventricle (SV) palliation continues to be debated. We sought to assess its impact on the hemodynamic profile and the short- and long-term outcomes of patients progressing through stages of SV palliation. METHODS: A retrospective single-center study was conducted of SV patients who underwent surgery between January 2010 and December 2020. Patients with APBF were matched to those with no APBF by a propensity score based on body surface area, sex, and type of systemic ventricle. Analysis was performed using appropriate statistics with a significance level of P = .05. RESULTS: Sixty-three patients with APBF were matched with 95 patients with no APBF. At the pre-stage 2 catheterization, APBF patients had a larger left pulmonary artery diameter (z score, 0.1 vs -0.8; P < .042). Patients with APBF had shorter cardiopulmonary bypass time (57.0 vs 79.0 minutes), shorter duration of mechanical ventilation (14.1 vs 17.4 hours), and shorter hospital length of stay (5.0 vs 7.0 days) at stage 2 palliation (P < .05). In the multivariable Cox regression analysis, patients with hypoplastic pulmonary arteries (z scores < -2; adjusted hazard ratio, 9.17) and patients with chromosomal abnormalities/genetic syndrome (adjusted hazard ratio, 4.03) were at increased risk for poor outcomes (P < .05). During the follow-up period, there was no significant difference in risk of the composite poor outcome and long-term survival between groups. CONCLUSIONS: SV patients with APBF had shorter cardiopulmonary bypass time, duration of mechanical ventilation, and hospital length of stay after stage 2 palliation. Patients with hypoplastic pulmonary arteries or chromosomal abnormalities/genetic syndromes had increased risk for poor outcomes. Maintaining APBF has better short-term outcomes, but there are no long-term hemodynamic or survival benefits.

External airway splint placement for severe pediatric tracheobronchomalacia.

OBJECTIVE: To present external airway splinting with bioabsorbable airway supportive devices (ASD) for severe, life-threatening cases of pediatric tracheomalacia (TM) or tracheobronchomalacia (TBM). METHODS: A retrospective cohort was performed for 5 pediatric patients with severe TM or TBM who underwent ASD placement. Devices were designed and 3D-printed from a bioabsorbable material, polycaprolactone (PCL). Pre-operative planning included 3-dimensional airway modeling of tracheal collapse and tracheal suture placement using nonlinear finite element (FE) methods. Pre-operative modeling revealed that triads along the ASD open edges and center were the most effective suture locations for optimizing airway patency. Pediatric cardiothoracic surgery and otolaryngology applied the ASDs by suspending the trachea to the ASD with synchronous bronchoscopy. Respiratory needs were trended for all cases. Data from pediatric patients with tracheostomy and diagnosis of TM or TBM, but without ASD, were included for discussion. RESULTS: Five patients (2 Females, 3 Males, ages 2-9 months at time of ASD) were included. Three patients were unable to wean from respiratory support after vascular ring division; all three weaned to room air post-ASD. Two patients received tracheostomies prior to ASD placement, but continued to experience apparent life-threatening events (ALTE) and required ventilation with supraphysiologic ventilator settings. One patient weaned respiratory support successfully after ASD placement. The last patient died post-ASD due to significant respiratory co-morbidity. CONCLUSION: ASD can significantly benefit patients with severe, unrelenting tracheomalacia or tracheobronchomalacia. Proper multidisciplinary case deliberation and selection are key to success with ASD. Pre-operative airway modeling allows proper suture placement to optimally address the underlying airway collapse.

Risk Factors for Extubation Failure After Pediatric Cardiac Surgery and Impact on Outcomes: A Multicenter Analysis.

IMPORTANCE: Extubation failure (EF) after pediatric cardiac surgery is associated with increased morbidity and mortality. OBJECTIVES: We sought to describe the risk factors associated with early (< 48 hr) and late (48 hr ≤ 168 hr) EF after pediatric cardiac surgery and the clinical implications of these two types of EF. DESIGN SETTING AND PARTICIPANTS: Retrospective cohort study using prospectively collected clinical data for the Pediatric Cardiac Critical Care Consortium (PC4) Registry. Pediatric patients undergoing Society of Thoracic Surgeons benchmark operation or heart transplant between 2013 and 2018 available in the PC4 Registry were included. MAIN OUTCOMES AND MEASURES: We analyzed demographics and risk factors associated with EFs (primary outcome) including by type of surgery. We identified potentially modifiable risk factors. Clinical outcomes of mortality and length of stay (LOS) were reported. RESULTS: Overall 18,278 extubations were analyzed. Unplanned extubations were excluded from the analysis. The rate of early EF was 5.2% (948) and late EF was 2.5% (461). Cardiopulmonary bypass time, ventilator duration, airway anomaly, genetic abnormalities, pleural effusion, and diaphragm paralysis contributed to both early and late EF. Extubation during day remote from shift change and nasotracheal route of initial intubation was associated with decreased risk of early EF. Extubation in the operating room was associated with an increased risk of early EF but with decreased risk of late EF. Across all operations except arterial switch, EF portrayed an increased burden of LOS and mortality. CONCLUSION AND RELEVANCE: Both early and late EF are associated with significant increase in LOS and mortality. Study provides potential benchmarking data by type of surgery. Modifiable risk factors such as route of intubation, time of extubation as well as treatment of potential contributors such as diaphragm paralysis or pleural effusion can serve as focus areas for reducing EFs.

Short-term outcomes in premature neonates adhering to the philosophy of supportive care allowing for weight gain and organ maturation prior to cardiac surgery.

BACKGROUND: Prematurity is a recognized risk factor for morbidity and mortality following cardiac surgery. The purpose of this study was to examine short-term outcomes following cardiac surgery in premature neonates adhering to our institutional philosophy of supportive care allowing for weight gain and organ maturation. METHODS: Retrospective review of all neonates undergoing cardiac surgery from January 2002 to May 2008. A total of 810 neonates (<30 days of age) were identified. Prematurity defined as less than 36 weeks of gestation. Neonates undergoing ductus arteriosus ligation alone were excluded. In all, 63 neonates comprised the premature group. Term group comprised 244 randomly selected term neonates in a 1:4 ratio. Outcome variables were compared between the 2 groups. RESULTS: Median gestation 34 weeks, range 24 to 35 weeks. Defects: 2 ventricle, normal arch (41% premature vs 44% term; P = .7), 2 ventricle, abnormal arch (24% vs 22%; P = .8), single ventricle, normal arch (21% vs 15%; P = .2), single ventricle, abnormal arch (14% vs 19%; P = .4). Premature neonates were older and smaller at surgery. Cardiopulmonary bypass procedures were performed less frequently in premature neonates (49% vs 69%; P = .004). Length of mechanical ventilation at our institution (6 days [0.5-54) vs 4 days [0.5-49); P = .06); postoperative hospital stay at our institution (17 days [1-161) vs 15 days [0-153); P = .06); and mortality (16% vs 11%; P = .2) was not different between the 2 groups. CONCLUSION: Early outcome seems independent of weight, prematurity, cardiopulmonary bypass, and type of first intervention. Importantly, there was no statistical difference in mortality between the 2 groups, regardless of how they were treated. Further long-term follow-up is needed in this patient population.

B-type natriuretic peptide in the recognition of critical congenital heart disease in the newborn infant.

OBJECTIVE: Infants with congenital heart disease having obstruction to the left ventricular outflow and ductal-dependent systemic circulation can present critically ill with shock. Prompt disease recognition and initiation of prostaglandins are necessary to prevent excess morbidity and mortality. We assessed a large cohort of newborn infants with ductal-dependent systemic circulation to determine if B-type natriuretic peptide (BNP) is consistently elevated at presentation, potentially aiding in diagnosis and treatment. METHODS: The clinical records of infants with left-sided obstructive lesions admitted from January 2005 to June 2009 were reviewed. Infants were divided into 2 groups: group 1 was diagnosed with cardiogenic/circulatory shock at presentation, and group 2 consisted of infants with ductal-dependent systemic circulation without evidence of shock. B-type natriuretic peptide levels and other variables between the groups were compared. RESULTS: All patients with critical congenital heart disease presenting with shock had elevated BNP levels, ranging from 553 to greater than 5000 pg/mL. Infants in group 1 (shock, n = 36) had significantly higher median BNP levels of 4100 pg/mL at presentation compared with group 2 patients (no shock, n = 86), who had a median BNP of 656 pg/mL (range, 30-3930 pg/mL; P < 0.001). Every 100 U of increase in BNP at presentation increased the likelihood of shock (odds ratio, 100; P < 0.001). CONCLUSIONS: B-type natriuretic peptide is markedly elevated in neonates presenting in shock secondary to left-sided obstructive heart disease and is an important diagnostic tool to aid in the rapid identification and treatment of these patients.

Domain Adaptation Using Convolutional Autoencoder and Gradient Boosting for Adverse Events Prediction in the Intensive Care Unit.

More than 5 million patients have admitted annually to intensive care units (ICUs) in the United States. The leading causes of mortality are cardiovascular failures, multi-organ failures, and sepsis. Data-driven techniques have been used in the analysis of patient data to predict adverse events, such as ICU mortality and ICU readmission. These models often make use of temporal or static features from a single ICU database to make predictions on subsequent adverse events. To explore the potential of domain adaptation, we propose a method of data analysis using gradient boosting and convolutional autoencoder (CAE) to predict significant adverse events in the ICU, such as ICU mortality and ICU readmission. We demonstrate our results from a retrospective data analysis using patient records from a publicly available database called Multi-parameter Intelligent Monitoring in Intensive Care-II (MIMIC-II) and a local database from Children's Healthcare of Atlanta (CHOA). We demonstrate that after adopting novel data imputation on patient ICU data, gradient boosting is effective in both the mortality prediction task and the ICU readmission prediction task. In addition, we use gradient boosting to identify top-ranking temporal and non-temporal features in both prediction tasks. We discuss the relationship between these features and the specific prediction task. Lastly, we indicate that CAE might not be effective in feature extraction on one dataset, but domain adaptation with CAE feature extraction across two datasets shows promising results.

Measures of anticoagulation and coagulopathy in pediatric cardiac extracorporeal membrane oxygenation patients.

INTRODUCTION: Pediatric cardiac Extracorporeal Membrane Oxygenation (ECMO) is effective, however, bleeding and clotting issues continue to cause significant morbidity and mortality. The objective of this study was to assess the correlation between measures of anticoagulation, the heparin dose in pediatric cardiac ECMO patients as well as to assess covert coagulopathy as measured by thromboelastography (TEG). METHODS: Retrospective study of cardiac ECMO patients in a large, academic referral center using anticoagulation data during the ECMO support. RESULTS: Five hundred and eighty-four sets of anticoagulation tests and 343 TEG from 100 patients with median age of 26 days were reviewed. ECMO was post-surgical for congenital heart disease in 94% with resuscitation (ECPR) in 38% of the cases. Mean duration of support was 6.3 days. Overall survival to discharge was 35%. There was low but statistically significant correlation between individual anticoagulation measures and low correlation between Anti-Xa levels and heparin dose. There was no correlation between PTT and heparin dose. 343 TEG with Heparinase were reviewed to assess covert coagulopathy which was present in 25% of these. The coagulopathy noted was pro-hemorrhagic in almost all of the cases with high values of reaction time and kinetics and low values for angle and maximum amplitude. CONCLUSION: Coagulation monitoring on ECMO may benefit from addition of Heparinase TEG to diagnose covert coagulopathy which can contribute to significant hemorrhagic complications. There is a need for a prospective, thromboelastography guided intervention trial to reduce coagulopathy related morbidity and mortality in ECMO.

Clinical grade manufacture of 3D printed patient specific biodegradable devices for pediatric airway support.

Implantable patient-specific devices are the next frontier of personalized medicine, positioned to improve the quality of care across multiple clinical disciplines. Translation of patient-specific devices requires time- and cost-effective processes to design, verify and validate in adherence to FDA guidance for medical device manufacture. In this study, we present a generalized strategy for selective laser sintering (SLS) of patient-specific medical devices following the prescribed guidance for additive manufacturing of medical devices issued by the FDA in 2018. We contextualize this process for manufacturing an Airway Support Device, a life-saving tracheal and bronchial implant restoring airway patency for pediatric patients diagnosed with tracheobronchomalacia and exhibiting partial or complete airway collapse. The process covers image-based modeling, design inputs, design verification, material inputs and verification, device verification, and device validation, including clinical results. We demonstrate how design and material assessment lead to verified Airway Support Devices that achieve desired airway patency and reduction in required Positive End-Expiratory Pressure (PEEP) after patient implantation. We propose this process as a template for general quality control of patient-specific, 3D printed implants.

Utility of bedside angiography in the evaluation of vascular obstruction in the pediatric intensive care patient.

OBJECTIVE: To review our experience with bedside angiography in order to demonstrate the utility of this technique for evaluation of blood vessels in the critically ill patient. DESIGN: Retrospective review. SETTING: Pediatric cardiac intensive care unit at a children's hospital. PATIENTS: Five patients aged 5 days to 17 yrs in the cardiac intensive care unit at our institution received bedside angiography. Indications for bedside angiography included abnormal radiographic appearance of central catheter location or clinical suspicion of vascular obstruction. Institutional review board approval for this retrospective review was obtained, and the waiver of consent was approved by the institutional review board. INTERVENTIONS: For angiographic evaluation of blood vessels, a radiographic plate was placed behind the area of blood vessels to be evaluated. Approximately 1 mL/kg of iohexol contrast was injected rapidly by hand into the blood vessel in question. Just at completion of the contrast injection, a radiograph was taken by portable radiograph equipment. MAIN RESULTS: A total of five patients with potential blood vessel compromise were evaluated by bedside angiography. All angiograms clearly demonstrated the vascular anatomy and catheter location, in addition to identifying areas of obstruction and collateral flow. There were no cases of renal compromise due to contrast use and no blood vessel compromise from contrast injection. CONCLUSIONS: Bedside angiography is a rapid, safe, and useful tool for the evaluation of complex vascular anatomy in critically ill patients. In cases where vascular ultrasound is unable to provide detailed anatomy or identify collateral flow, this technique may be useful in providing safe and accurate assessment of blood vessels associated with vascular access devices.