Advances in Extracorporeal Support Technologies in Critically Ill Children.

The field of pediatric heart failure is evolving, and the patient population is growing as survival after complex congenital heart surgeries is improving. Mechanical circulatory support and extracorporeal respiratory support in critically ill children has progressed to a mainstay rescue modality in pediatric intensive care medicine. The need for mechanical circulatory support is growing, since the number of organ donors does not meet the necessity. This article aims to review the current state of available mechanical circulatory and respiratory support systems in acute care pediatrics, with an emphasis on the literature discussing the challenges associated with these complex support modalities.

Contemporary Use of Ultrasonography in Acute Care Pediatrics.

Use of ultrasonography by clinicians at the point of care has expanded widely and rapidly. Pediatric acute care providers now leverage this valuable tool to guide procedures, diagnose pathophysiologic processes, and inform time-sensitive decisions in sick and unstable children. However, the deployment of any new technology must be packaged with training, protocols, and safeguards to optimize safety for patients, providers, and institutions. As ultrasonography is increasingly incorporated into residency, fellowship, and even medical student curricula, it is important that educators and trainees are aware of the diversity of its clinical applications. This article aims to review the current state of point-of-care ultrasonography in acute care pediatrics, with an emphasis on the literature supporting the use of this important clinical tool.

Hospital-Acquired Infection in Pediatric Subjects With Congenital Heart Disease Postcardiotomy Supported on Extracorporeal Membrane Oxygenation.

OBJECTIVE: To determine prevalence of and risk factors for infection in pediatric subjects with congenital heart disease status postcardiotomy supported on extracorporeal membrane oxygenation, as well as outcomes of these subjects. DESIGN: Retrospective cohort from the Extracorporeal Life Support Organization. SETTING: U.S. and international medical centers providing care to children with congenital heart disease status postcardiotomy. PATIENTS: Critically ill pediatric subjects less than 8 years old admitted to medical centers between January 1, 2013, and December 31, 2015, who underwent cardiac surgery for congenital heart disease and required extracorporeal membrane oxygenation support within the first 14 postoperative days. Subjects were excluded if they underwent orthotopic heart transplantation, required preoperative extracorporeal membrane oxygenation, and had more than one postoperative extracorporeal membrane oxygenation run. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 1,314 extracorporeal membrane oxygenation subject encounters in the Extracorporeal Life Support Organization registry met inclusion criteria. Neonates comprised 53% (n = 696) of the cohort, whereas infants made up 33% (n = 435). Of the 994 subjects with Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categorizable surgery, 33% (n = 325) were in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 23% (n = 231) in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 5. While on extracorporeal membrane oxygenation, 229 subjects (17%) acquired one or more extracorporeal membrane oxygenation-related infections, which represents an occurrence rate of 67 infections per 1,000 extracorporeal membrane oxygenation days. Gram-negative (62%) and Gram-positive (42%) infections occurred most commonly. Forty percent had positive blood cultures. Infants and children were at higher infection risk compared with neonatal subjects; subjects undergoing less complex surgery had higher infection rates. Unadjusted survival to hospital discharge was lower in infected subjects compared with noninfected subjects (43% vs 51%; p = 0.01). After adjusting for confounders via propensity matching, we identified no significant mortality difference between infected and noninfected subjects. CONCLUSIONS: Neonatal and pediatric subjects in this study have a high rate of acquired infection. Infants and children were at higher infection risk compared with neonatal subjects. There was not, however, a significant association between extracorporeal membrane oxygenation-related infection and survival to hospital discharge after propensity matching.

Reducing Ischemic Injury From Indwelling Peripheral Arterial Catheters in a Pediatric Cardiac ICU: A Quality Improvement Initiative.

OBJECTIVES: To reduce the number of ischemic arterial catheter injuries in children with congenital or acquired heart disease. DESIGN: This is a quality improvement study with pre- and postintervention groups. SETTING: University-affiliated pediatric cardiac center in a quaternary care freestanding children's hospital. PATIENTS: All patients with an indwelling peripheral arterial catheter placed in the Children's Hospital of Philadelphia Cardiac Center associated with an admission to the Cardiac Intensive Cardiac Unit from January 2015 to July 2017 are included. Patients with umbilical arterial catheters were excluded from the cohort. The rate of arterial catheter injury is reported per 1,000 catheter days. The rate of "concerning" arterial catheter assessments is reported as a percentage of catheters per month. INTERVENTION: Initial intervention replaced intermittent manual arterial catheter flushing with a continuous arterial catheter infusion system during the delivery of anesthesia. The second intervention implemented a daily arterial catheter safety assessment during cardiac ICU rounds with documentation of the assessment in the cardiac ICU daily attending progress note. MEASUREMENTS AND MAIN RESULTS: Our project included 1,945 arterial catheters encompassing 7,197 catheter days. During the preintervention period, on average, 3.1 patients per month experienced an arterial catheter-related injury compared with 1.9 patients per month following intervention, a reduction of 38.7% (3.1 vs 1.9; p = 0.01). The rate of injury per 1,000 arterial catheter days was reduced from 16.7 pre intervention to 7.52 post intervention, a 55% overall reduction (16.7 vs 7.52; p = 0.0001). The rate of concerning arterial catheter nursing assessment based on our definition was reduced by 18.0% following our intervention cycles (25.5% vs 20.9%; p = 0.001) CONCLUSIONS:: Implementation of a quality improvement initiative and changing local practices reduced arterial catheter-associated harm in children with congenital and acquired heart disease requiring care in a cardiac ICU.

Postoperative management of heart failure in pediatric patients.

Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25-65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.

Transesophageal echocardiography in patients with cryptogenic cerebral ischemia.

BACKGROUND: In about one third of all patients with cerebral ischemia, no definite cause can be identified (cryptogenic stroke). In many patients with initially suspected cryptogenic stroke, however, a cardiogenic etiology can eventually be determined. Hence, the aim of this study was to describe the prevalence of abnormal echocardiographic findings in a large number of these patients. METHOD: Patients with cryptogenic cerebral ischemia (ischemic stroke, IS, and transient ischemic attack, TIA) were included. The initial work-up included a neurological examination, EEG, cCT, cMRT, 12-lead ECG, Holter-ECG, Doppler ultrasound of the extracranial arteries, and transthoracic echocardiography. A multiplane transeophageal echocardiography (TEE, including i.v. contrast medium application [Echovist], Valsalva maneuver) was performed in all patients RESULTS: 702 consecutive patients (380 male, 383 IS, 319 TIA, age 18-90 years) were included. In 52.6% of all patients, TEE examination revealed relevant findings. Overall, the most common findings in all patients were: patent foramen ovale (21.7%), previously undiagnosed valvular disease (15.8%), aortic plaques, aortic valve sclerosis, atrial septal aneurysms, regional myocardial dyskinesia, dilated left atrium and atrial septal defects. Older patients (> 55 years, n = 291) and patients with IS had more relevant echocardiographic findings than younger patients or patients with TIA, respectively (p = 0.002, p = 0.003). The prevalence rates of PFO or ASD were higher in younger patients (PFO: 26.8% vs. 18.0%, p = 0.005, ASD: 9.6% vs. 4.9%, p = 0.014). CONCLUSION: A TEE examination in cryptogenic stroke reveals contributing cardiogenic factors in about half of all patients. Younger patients had a higher prevalence of PFO, whereas older patients had more frequently atherosclerotic findings. Therefore, TEE examinations seem indicated in all patients with cryptogenic stroke - irrespective of age - because of specific therapeutic consequences.