An International Survey Comparing Different Physician Models for Health Care Delivery to Critically Ill Children With Heart Disease.

OBJECTIVES: To explore relationships between the training background of cardiac critical care attending physicians and self-reported perceived strengths and weaknesses in their ability to provide clinical care. DESIGN: Cross-sectional observational survey sent worldwide to ~550 practicing cardiac ICU attending physicians. SETTING: Hospitals providing cardiac critical care. SUBJECTS: Practicing cardiac critical care physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We received responses from 243 ICU attending physicians from 82 centers (14 countries). The primary training background of the respondents included critical care (62%), dual training in critical care and cardiology (16%), cardiology (14%), and other (8%). We received 49 responses from medical directors in nine countries, who reported that the predominant training background for attending physicians who provide cardiac intensive care at their institutions were critical care (58%), dual trained (18%), cardiology (12%), and other (11%). A greater proportion of physicians trained in either critical care or dual-training reported feeling confident managing multiple organ failure, neurologic conditions, brain death, cardiac arrest, and performing procedures like advanced airway placement and inserting chest- and abdominal-drains. In contrast, physicians with cardiology and dual-training reported feeling more confident managing intractable arrhythmias, understanding cardiopulmonary interactions, and interpreting echocardiogram, electrocardiogram, and cardiac catheterization. Overall, only 57% of the respondents felt comfortable based on their current training background to manage patients with complex cardiac issues without collaboration with other specialists. CONCLUSIONS: Our survey demonstrates that intensivists trained in critical care are more comfortable with critical care skills, cardiology-trained intensivists are more comfortable with cardiology skills, and dual-trained physicians are comfortable with both critical care skills and cardiology skills. These findings may help inform future efforts to optimize the educational curriculum and training pathways for future cardiac intensivists. These data may also be used to shape continuing medical education activities for cardiac intensivists who have already completed their training.

Spectrum of Off-Label Nitric Oxide Utilization After Pediatric Cardiac Surgery Among Centers of Varying Surgical Volume.

OBJECTIVE: Nitric oxide is utilized after pediatric cardiac surgery as an off-label medication without much evidence, is expensive, and varies among centers of varying surgical volume. The objective of our study was to describe the spectrum of nitric oxide utilization and to evaluate the effect of nitric oxide utilization on outcomes among patients cared for in centers of varying surgical volume using Pediatric Health Information system. METHODS: Patients aged ≤18 years undergoing heart surgery were included (2004-2015). Multivariable mixed-effects logistic regression models were fitted to evaluate association of center volume with odds of nitric oxide utilization among patients undergoing heart operations. Centers were classified into 3 volume categories based on tertiles of number of cardiopulmonary bypass cases performed (low volume: 34 792 patients, 21 centers; medium volume: 38 362 patients, 13 centers; high volume: 30 560 patients, 7 centers). RESULTS: A total of 103 714 patients from 41 hospitals were included. Of these, 15 708 (15.1%) patients received nitric oxide after cardiac surgery. Of the patients receiving nitric oxide, only 3936 (25.1%) patients were associated with a diagnosis of pulmonary hypertension. In adjusted models, low- and medium-volume centers were associated with higher nitric oxide utilization after heart operations as compared to high-volume centers (low vs high, odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.38-1.60; medium vs high, OR: 1.33, 95% CI: 1.26-1.41). Despite higher nitric oxide utilization, the mortality was worse among patients treated in low- and medium-volume centers, as compared to high-volume centers (low vs high, OR: 1.42, 95% CI: 1.26-1.60; medium vs high, OR: 1.14, 95% CI: 1.04-1.25). CONCLUSIONS: This study demonstrates variation in nitric oxide utilization after heart operations among centers of varying surgical volume. Further, it raises questions on the benefit of nitric oxide administration after pediatric cardiac surgery.

Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest.

OBJECTIVES: To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data. DESIGN: Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest. SETTING: American Heart Association's Get With the Guidelines-Resuscitation Registry. PATIENTS: Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006-2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013-2015: 13.8%), compared with previous years (2006-2009: 16.0%). CONCLUSIONS: Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care.

Cardiopulmonary Resuscitation in the Pediatric Cardiac Catheterization Laboratory: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry.

OBJECTIVES: Hospitalized children with underlying heart disease are at high risk for cardiac arrest, particularly when they undergo invasive catheterization procedures for diagnostic and therapeutic interventions. Outcomes for children experiencing cardiac arrest in the cardiac catheterization laboratory remain under-reported with few studies reporting survival beyond the catheterization laboratory. We aim to describe survival outcomes after cardiac arrest in the cardiac catheterization laboratory while identifying risk factors associated with hospital mortality after these events. DESIGN: Retrospective observational study of data from a multicenter cardiac arrest registry from November 2005 to November 2016. Cardiac arrest in the cardiac catheterization laboratory was defined as the need for chest compressions greater than or equal to 1 minute in the cardiac catheterization laboratory. Primary outcome was survival to discharge. Variables analyzed using generalized estimating equations for association with survival included age, illness category (surgical cardiac, medical cardiac), preexisting conditions, pharmacologic interventions, and event duration. SETTING: American Heart Association's Get With the Guidelines-Resuscitation registry of in-hospital cardiac arrest. PATIENTS: Consecutive patients less than 18 years old experiencing an index (i.e., first) cardiac arrest event reported to the Get With the Guidelines-Resuscitation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 203 patients met definition of index cardiac arrest in the cardiac catheterization laboratory composed primarily of surgical and medical cardiac patients (54% and 41%, respectively). Children less than 1 year old comprised the majority of patients, 58% (117/203). Overall survival to hospital discharge was 69% (141/203). No differences in survival were observed between surgical and medical cardiac patients (p = 0.15). The majority of deaths (69%, 43/62) occurred in patients less than 1 year old. Bradycardia (with pulse) followed by pulseless electrical activity/asystole were the most common first documented rhythms observed (50% and 27%, respectively). Preexisting metabolic/electrolyte abnormalities (p = 0.02), need for vasoactive infusions (p = 0.03) prior to arrest, and use of calcium products (p = 0.005) were found to be significantly associated with lower rates of survival to discharge on multivariable regression. CONCLUSIONS: The majority of children experiencing cardiac arrest in the cardiac catheterization laboratory in this large multicenter registry analysis survived to hospital discharge, with no observable difference in outcomes between surgical and medical cardiac patients. Future investigations that focus on stratifying medical complexity in addition to procedural characteristics at the time of catheterization are needed to better identify risks for mortality after cardiac arrest in the cardiac catheterization laboratory.

Magnitude and Pace of Improvement in Performance of Hospitals Treating Mechanically Ventilated Children in the United States: Analysis From Two National Databases.

OBJECTIVES: To use two national databases to quantify the pace and magnitude of improvement in hospital performance (as measured by mortality) across hospitals caring for critically ill children in the United States. DESIGN: We used empirical Bayes shrinkage estimators to obtain shrinkage estimators of observed/expected mortality ratios for each hospital assuming a Gamma Poisson posterior distribution. Revised mortality rates for each hospital were obtained from the shrunken incidence ratios. SETTING: Pediatric Health Information System participating hospital and Kids' Inpatient Database participating hospital. PATIENTS: Patients less than or equal to 18 years old who received invasive mechanical ventilation during their hospital stay at a Pediatric Health Information System participating hospital (2005-2015) or a Kids' Inpatient Database participating hospital (1997-2012) were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 486,838 patients from 48 Pediatric Health Information System hospitals and 798,840 patients from 947 Kids' Inpatient Database hospitals were included. For the Pediatric Health Information System hospitals, the median shrunken adjusted mortality decreased from 11.66% in 2005 to 7.11% in 2015; for the Kids' Inpatient Database hospitals, it decreased from 5.79% in 1997 to 3.86% in 2012. By 2015, more than 95% of the Pediatric Health Information System hospitals performed better than or as well as the best 25% of the hospitals in 2005. By 2012, 33.7% of Kids' Inpatient Database hospitals performed better than or as well as the best 25% of the hospitals in 1997. CONCLUSIONS: This study provides insight into the magnitude of improvement in patient mortality in hospitals caring for critically ill children in the United States. This study quantifies hospital performance in pediatric critical care over time, and it provides benchmarks against which individual hospitals can assess their own performance. In future pediatric epidemiologic studies, we should identify outcomes other than mortality to quantify improvement in hospital performance.

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients.

OBJECTIVES: To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness. DESIGN: Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach. SETTING: Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database. PATIENTS: Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90. CONCLUSIONS: This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Relationship of Hospital Costs With Mortality in Pediatric Critical Care: A Multi-Institutional Analysis.

OBJECTIVE: With increasing emphasis on high "value" care, we designed this study to evaluate the relationship between hospital costs and patient outcomes in pediatric critical care. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information Systems. Multivariable mixed effects logistic regression models were fitted to evaluate association of hospital cost tertiles with odds of mortality after adjusting for patient and center characteristics. SETTING: Forty-seven children's hospitals across the United States. PATIENTS: Patients 18 years old or younger admitted to a PICU at a Pediatric Health Information Systems participating hospital were included (2004-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 917,663 patients from 47 hospitals were included. Median cost per patient was $42,181 in the low-cost hospitals (341,689 patients, 16 hospitals), $56,806 in the middle-cost hospitals (310,293 patients, 16 hospitals), and $82,588 in the high-cost hospitals (265,681 patients, 15 hospitals). In unadjusted analysis, patients cared for in the high-cost tertile hospitals were younger in age, associated with more comorbidities, had higher resource utilization (including extracorporeal membrane oxygenation and nitric oxide), had higher prevalence of cardiac arrest, and were associated with worse outcomes (including mortality). In adjusted analysis, high-cost tertile hospitals were not associated with improved mortality, when compared with low- and medium-cost tertile hospitals (low cost vs high cost: odds ratio, 0.99; 95% CI, 0.79-1.25 and middle cost vs high cost: odds ratio, 1.10; 95% CI, 0.86-1.41). When stratified by diagnoses category, we noted similar trends among cardiac and noncardiac patients. CONCLUSIONS: This large observational study did not demonstrate any relationship between hospital costs and patient outcomes in children with critical illness. Further efforts are needed to evaluate quality-cost relationship and high value care in critically ill children across centers of varying volume by linking data from clinical and administrative databases.

Impact of 24/7 In-Hospital Intensivist Coverage on Outcomes in Pediatric Intensive Care. A Multicenter Study.

RATIONALE: The around-the-clock presence of an in-house attending critical care physician (24/7 coverage) is purported to be associated with improved outcomes among high-risk children with critical illness. OBJECTIVES: To evaluate the association of 24/7 in-house coverage with outcomes in children with critical illness. METHODS: Patients younger than 18 years of age in the Virtual Pediatric Systems Database (2009-2014) were included. The main analysis was performed using generalized linear mixed effects multivariable regression models. In addition, multiple sensitivity analyses were performed to test the robustness of our findings. MEASUREMENTS AND MAIN RESULTS: A total of 455,607 patients from 125 hospitals were included (24/7 group: 266,319 patients; no 24/7 group: 189,288 patients). After adjusting for patient and center characteristics, the 24/7 group was associated with lower mortality in the intensive care unit (ICU) (24/7 vs. no 24/7; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33-0.80; P = 0.002), a lower incidence of cardiac arrest (OR, 0.73; 95% CI, 0.54-0.99; P = 0.04), lower mortality after cardiac arrest (OR, 0.56; 95% CI, 0.340-0.93; P = 0.02), a shorter ICU stay (mean difference, -0.51 d; 95% CI, -0.93 to -0.09), and shorter duration of mechanical ventilation (mean difference, -0.68 d; 95% CI, -1.23 to -0.14). CONCLUSIONS: In this large observational study, we demonstrated that pediatric critical care provided in the ICUs staffed with a 24/7 intensivist presence is associated with improved overall patient survival and survival after cardiac arrest compared with patients treated in ICUs staffed with discretionary attending coverage. However, results from a few sensitivity analyses leave some ambiguity in these results.

Effect of Inhaled Nitric Oxide on Outcomes in Children With Acute Lung Injury: Propensity Matched Analysis From a Linked Database.

OBJECTIVES: To evaluate the effect of inhaled nitric oxide on outcomes in children with acute lung injury. DESIGN: Retrospective study with a secondary data analysis of linked data from two national databases. Propensity score matching was performed to adjust for potential confounding variables between patients who received at least 24 hours of inhaled nitric oxide (inhaled nitric oxide group) and those who did not receive inhaled nitric oxide (no inhaled nitric oxide group). SETTING: Linked data from Virtual Pediatric Systems (LLC) database and Pediatric Health Information System. PATIENTS: Patients less than 18 years old receiving mechanical ventilation for acute lung injury at nine participating hospitals were included (2009-2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 20,106 patients from nine hospitals were included. Of these, 859 patients (4.3%) received inhaled nitric oxide for at least 24 hours during their hospital stay. Prior to matching, patients in the inhaled nitric oxide group were younger, with more comorbidities, greater severity of illness scores, higher prevalence of cardiopulmonary resuscitation, and greater resource utilization. Before matching, unadjusted outcomes, including mortality, were worse in the inhaled nitric oxide group (inhaled nitric oxide vs no inhaled nitric oxide; 25.7% vs 7.9%; p < 0.001; standardized mortality ratio, 2.6 [2.3-3.1] vs 1.1 [1.0-1.2]; p < 0.001). Propensity score matching of 521 patient pairs revealed no difference in mortality in the two groups (22.3% vs 20.2%; p = 0.40; standardized mortality ratio, 2.5 [2.1-3.0] vs 2.3 [1.9-2.8]; p = 0.53). However, the other outcomes such as ventilation free days (10.1 vs 13.6 d; p < 0.001), duration of mechanical ventilation (13.8 vs 10.1 d; p < 0.001), duration of ICU and hospital stay (15.5 vs 12.2 d; p < 0.001 and 28.0 vs 24.1 d; p < 0.001), and hospital costs ($150,569 vs $102,823; p < 0.001) were significantly worse in the inhaled nitric oxide group. CONCLUSIONS: This large observational study demonstrated that inhaled nitric oxide administration in children with acute lung injury was not associated with improved mortality. Rather, it was associated with increased hospital utilization and hospital costs.

Association of Freestanding Children's Hospitals With Outcomes in Children With Critical Illness.

OBJECTIVES: Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness. DESIGN: Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score. SETTING: Retrospective study from an existing national database, Virtual PICU Systems (LLC) database. PATIENTS: Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p < 0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p < 0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p < 0.001; reintubation: 3.4% vs 3.8%, p < 0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001). CONCLUSIONS: In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.

Temporal Trends of Respiratory Syncytial Virus-Associated Hospital and ICU Admissions Across the United States.

OBJECTIVES: To describe the regionality and seasonality of respiratory syncytial virus-associated hospital and ICU admissions for 10 consecutive years using a national database. DESIGN: Post hoc analysis of data from an existing national database, Pediatric Health Information System. We modeled the adjusted odds of hospital and ICU admissions for varied seasons (fall, winter, spring, and summer) and regions (Northeast, South, Midwest, and West) using a mixed-effects logistic regression model after adjusting for several patient and center characteristics. SETTING: Forty-two children's hospitals across the Unites States. PATIENTS: Patients 1 day through 24 months old with inpatient admission (ward and/or ICU) for respiratory syncytial virus- associated infection at a Pediatric Health Information System-participating hospital were included (2004-2013). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1,937,994 inpatient admissions during the study period, 146,357 children were admitted for respiratory syncytial virus-associated acute respiratory illness. Of these inpatient admissions, 32,470 children(22%) were admitted to ICU during their hospital stay. Overall adjusted odds of respiratory syncytial virus-associated hospital and ICU admissions in recent years (2010-2013) were higher than previous years (2004-2006 and 2007-2009). In recent years, respiratory syncytial virus-associated hospital and ICU admissions have increased in winter and spring seasons. Regionally in recent years, the overall adjusted odds of both respiratory syncytial virus-associated hospital and ICU admissions have increased in the South and West regions. CONCLUSIONS: Wide variations in regional and seasonal patterns in hospital and ICU admissions were noted in children with respiratory syncytial virus-associated acute respiratory illness across the United States. Results from our study help us better understand the seasonality and regionality of respiratory syncytial virus infection in the United States with the goal to decrease the financial impact on our already stressed healthcare system by being better prepared for respiratory syncytial virus season.

Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival?

OBJECTIVE: To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004-2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes. SETTING: Forty-two children's hospitals across the United States. PATIENTS: Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074-48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased. CONCLUSIONS: This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory.

Outcomes Following Single and Recurrent In-Hospital Cardiac Arrests in Children With Heart Disease: A Report From American Heart Association's Get With the Guidelines Registry-Resuscitation.

OBJECTIVES: Little is known regarding patient characteristics and outcomes associated with cardiac arrest in hospitalized children with underlying heart disease. We described clinical characteristics and in-hospital outcomes in cardiac patients with both single and recurrent cardiac arrests. DESIGN: Retrospective analysis evaluating characteristics and outcomes in single versus recurrent arrest groups in unadjusted and adjusted analyses. SETTING: American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2010). PATIENTS: Children younger than 18 years, identified with medical or surgical cardiac disease and one or more in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: One thousand eight hundred and eighty-nine patients with 2,387 cardiac arrests from 157 centers met inclusion criteria: 1,546 (82%) with a single arrest and 343 (18%) with a recurrent arrest. More than two thirds of recurrent cardiac arrests occurred in ICUs, and those with recurrent arrest had a higher prevalence of baseline comorbidities (e.g., more likely to be mechanically ventilated and receiving vasoactive infusions). Overall survival to hospital discharge was 51%, and was lower in the recurrent versus single arrest group (41% vs 53%; p < 0.001). In analysis adjusted for baseline comorbidities, there was no longer a statistically significant association between recurrent arrest and survival (odds ratio, 0.74; 95% CI, 0.33-1.63; p = 0.45). In stratified analysis, the relationship between recurrent arrest and lower survival was more prominent in the surgical-cardiac (odds ratio, 0.39; 95% CI, 0.14-1.11; p = 0.09) versus medical-cardiac (odds ratio, 0.96; 95% CI, 0.28-3.30; p = 0.95) group. CONCLUSIONS: In this large multicenter study, half of pediatric cardiac patients who suffered a cardiac arrest survived to hospital discharge. Lower survival in the group with recurrent arrest may be explained in part by the higher prevalence of baseline comorbidities in these patients, and surgical cardiac patients appeared to be at greatest risk. Further study is necessary to develop strategies to reduce subsequent mortality in these high-risk patients.

Association of house staff training with mortality in children with critical illness.

AIM: To evaluate the association of house staff training with mortality in children with critical illness. METHODS: Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009-2013) were included. The study population was divided in two study groups: hospitals with residency programme only and hospitals with both residency and fellowship programme. Control group constituted hospitals with no residency or fellowship programme. The primary study outcome was mortality before intensive care unit (ICU) discharge. Multivariable logistic regression models were fitted to evaluate association of training programmes with ICU mortality. RESULTS: A total of 336 335 patients from 108 centres were included. Case-mix of patients among the hospitals with training programmes was complex; patients cared for in the hospitals with training programmes had greater severity of illness, had higher resource utilisation and had higher overall admission risk of death compared to patients cared for in the control hospitals. Despite caring for more complex and sicker patients, the hospitals with training programmes were associated with lower odds of ICU mortality. CONCLUSION: Our study establishes that ICU care provided in hospitals with training programmes is associated with improved adjusted survival rates among the Virtual PICU database hospitals in the United States.

Impact of varied center volume categories on volume-outcome relationship in children receiving ECMO for heart operations.

To study the volume-outcome relationship among children receiving extracorporeal membrane oxygenation (ECMO), different studies from different databases use different volume categories. The objective of this study was to evaluate if different center volume categories impact the volume-outcome relationship among children receiving ECMO for heart operations. We performed a post hoc analysis of data from an existing national database, the Pediatric Health Information System. Centers were classified into five different volume categories using different cut-offs and different variables. Mortality rates were compared between the varied volume categories using a mixed effects logistic regression model after adjusting for patient- and center-level risk factors. Data collection included demographic information, baseline characteristics, pre-ECMO risk factors, operation details, patient diagnoses, and center data. In unadjusted analysis, there was a significant relationship between center volume and mortality, with low-and medium-volume centers associated with higher mortality rates compared to high-volume centers in all volume categories, except the hierarchical clustering volume category. In contrast, there was no significant association between center-volume and mortality among all volume categories in adjusted analysis. We concluded that high-volume centers were not associated with improved outcomes for the majority of the categorization schemes despite using different cut-offs and different variables for volume categorization.

Impact of Timing of ECMO Initiation on Outcomes After Pediatric Heart Surgery: A Multi-Institutional Analysis.

Little is known about the relationship of timing of extracorporeal membrane oxygenation (ECMO) initiation on patient outcomes after pediatric heart surgery. We hypothesized that increasing timing of ECMO initiation after heart surgery will be associated with worsening study outcomes. Patients aged ≤18 years receiving ECMO after pediatric cardiac surgery at a Pediatric Health Information System-participating hospital (2004-2013) were included. Outcomes evaluated included in-hospital mortality, composite poor outcome, prolonged length of ECMO, prolonged length of mechanical ventilation, prolonged length of ICU stay, and prolonged length of hospital stay. Multivariable logistic regression models were fitted to study the probability of study outcomes as a function of timing from cardiac surgery to ECMO initiation. A total of 2908 patients from 42 hospitals qualified for inclusion. The median timing of ECMO initiation after cardiac surgery was 0 days (IQR 0-1 day; range 0-294 days). After adjusting for patient and center characteristics, increasing duration of time from surgery to ECMO initiation was not associated with higher mortality or worsening composite poor outcome. However, increasing duration of time from surgery to ECMO initiation was associated with prolonged length of ECMO, prolonged length of ventilation, prolonged length of ICU stay, and prolonged length of hospital stay. Although this relationship was statistically significant, the odds for prolonged length of ECMO, prolonged length of ventilation, prolonged length of ICU stay, and prolonged length of hospital stay increased by only 1-3 % for every 1-day increase in ECMO that may be clinically insignificant. We did not demonstrate any relationship between timing of ECMO initiation and mortality among the patients of varying age groups, and patients undergoing cardiac surgery of varying complexity. We concluded that increasing duration of time from surgery to ECMO initiation is not associated with worsening mortality. Our results suggest that ECMO is initiated at the appropriate time when dictated by clinical situation among patients of all age groups, and among patients undergoing heart operations of varying complexity.

Longitudinal renal function in pediatric heart transplant recipients: 20-years experience.

This study was initiated to assess the temporal trends of renal function, and define risk factors associated with worsening renal function in pediatric heart transplant recipients in the immediate post-operative period. We performed a single-center retrospective study in children ≤18 yr receiving OHT (1993-2012). The AKIN's validated, three-tiered AKI staging system was used to categorize the degree of WRF. One hundred sixty-four patients qualified for inclusion. Forty-seven patients (28%) were classified as having WRF after OHT. Nineteen patients (11%) required dialysis after heart transplantation. There was a sustained and steady improvement in renal function in children following heart transplantation in all age groups, irrespective of underlying disease process. The significant factors associated with risk of WRF included body surface area (OR: 1.89 for 0.5 unit increase, 95% CI: 1.29-2.76, p = 0.001) and use of ECMO prior to and/or after heart transplantation (OR: 3.50, 95% CI: 1.51-8.13, p = 0.004). Use of VAD prior to heart transplantation was not associated with WRF (OR: 0.50, 95% CI: 0.17-1.51, p = 0.22). On the basis of these data, we demonstrate that worsening renal function improves early after orthotopic heart transplantation.

Outcomes associated with the use of renal replacement therapy in children receiving extracorporeal membrane oxygenation after heart surgery: a multi-institutional analysis.

BACKGROUND: The primary objective of this investigation was to study the association between renal replacement therapy (RRT) and outcomes in children receiving extracorporeal membrane oxygenation (ECMO). METHODS: Patients aged ≤18 years receiving ECMO before or after a pediatric heart operation at a Pediatric Health Information System (PHIS)-participating hospital (2004-2013) were included. The associations between RRT and study outcomes were computed using multivariate logistic regression analysis. RESULTS: A total of 3,502 patients from 43 hospitals qualified for inclusion. Of these, 484 (14 %) patients received RRT at some point during their hospital stay. After adjusting for patient and center characteristics, the odds of mortality were significantly higher in the RRT group (OR: 1.86, 95 % CI: 1.46- 2.37, p < 0.0001). However, there were considerable reductions in adjusted odds of mortality, compared to unadjusted odds of mortality. In adjusted models, length of ECMO was longer by 0.81 days (95 % CI: 0.13- 1.49, p = 0.02) in patients receiving RRT. CONCLUSIONS: We demonstrated worsening outcomes in children receiving ECMO with RRT compared to children receiving ECMO without RRT. Although the results could reflect confounding by severity of illness, they provide a rationale for prospective testing of use of RRT in critically ill children receiving ECMO with heart surgery.

Association Between Extracorporeal Membrane Oxygenation Center Volume and Mortality Among Children With Heart Disease: Propensity and Risk Modeling.

OBJECTIVES: To evaluate the relationship between extracorporeal membrane oxygenation center volume and mortality in children undergoing heart operations using propensity score matching in a multiinstitutional cohort. DESIGN: Post hoc analysis of data from an existing national database, Pediatric Health Information System. Propensity score matching was performed to 1-1-1 match patients in low-volume (0-30 cases per year), medium-volume (31-50 cases per year), and high-volume (> 50 cases per year) categories. We tested the sensitivity of our findings by repeating the primary analyses using traditional statistical techniques (traditional regression-based methods and covariate adjustment using propensity score). SETTING: Forty-two children's hospitals across the Unites States. PATIENTS: Patients 18 years old or younger receiving extracorporeal membrane oxygenation before or after pediatric heart operation at a Pediatric Health Information System participating hospital (2004-2013) were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 3,502 from 42 hospitals qualified for inclusion. Using propensity score matching, 1,962 patients were matched 1-1-1 to compare the three volume categories (654 patients in each category). Overall mortality was 1,493 patients (43%). Before matching and adjustment, low- and medium-volume centers were associated with higher mortality (low versus high volume: unadjusted odds ratio, 1.99; 95% CI, 1.68-2.36; p < 0.001). After matching, there was no significant association between center volume and mortality in unadjusted and adjusted analyses (low versus high volume: unadjusted odds ratio, 1.06; 95% CI, 0.85-1.32; p = 0.62 and adjusted odds ratio, 0.97; 95% CI, 0.63-1.50; p = 0.90). This relationship remained similar for analyses using traditional statistical techniques (regression adjustment, low versus high volume: adjusted odds ratio, 1.23; 95% CI, 0.80-1.89; p = 0.35 and covariate adjustment using propensity score, low versus high volume: adjusted odds ratio, 1.16; 95% CI, 0.77-1.74; p = 0.49). CONCLUSIONS: We demonstrated no relationship between extracorporeal membrane oxygenation center volume and mortality. Further analyses are needed to evaluate this relationship.

Relationship between renal function and extracorporeal membrane oxygenation use: a single-center experience.

The effects of extracorporeal membrane oxygenation (ECMO) support on renal function in children with critical illness are unknown. The objective of this study was to investigate the impact of ECMO on renal function among children in different age groups. We performed a single-center retrospective observational study in critically ill children ≤ 18 years supported on ECMO for refractory cardiac or pulmonary failure (2006-2012). The patient population was divided into four age groups for the purpose of comparisons. The Acute Kidney Injury Network's (AKIN's) validated, three-tiered staging system for acute kidney injury was used to categorize the degree of worsening renal function. Data on patient demographics, baseline characteristics, renal function parameters, dialysis, ultrafiltration, duration of mechanical cardiac support, and mortality were collected. Comparisons of baseline characteristics, duration of mechanical cardiac support, and renal function were made between the four age groups. During the study period, 311 patients qualified for inclusion, of whom 289 patients (94%) received venoarterial (VA) ECMO, 12 (4%) received venovenous (VV) ECMO, and 8 (3%) received both VV and VA ECMO. A total of 109 patients (36%) received ultrafiltration on ECMO, 58 (19%) received hemodialysis, and 51 (16%) received peritoneal dialysis. There was a steady and sustained improvement in renal function in all age groups during the ECMO run, with the maximum and longest-sustained improvement occurring in the oldest age group. Proportions of patients in different AKIN stages remained similar in the first 7 days after ECMO initiation. We demonstrate that renal dysfunction improves early after ECMO support. Irrespective of the underlying disease process or patient age, renal function improves in children with pulmonary or cardiac failure who are placed on ECMO.