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Influenza is associated with adverse outcomes in children, although modification by additional medical conditions is not well-documented. We aimed to compare outcomes in children with versus without congenital heart defects (CHDs) who were hospitalized for influenza. We retrospectively evaluated patients 1-18y hospitalized for influenza in the Pediatric Health Information (PHIS) database from 2004 to 2019. Outcomes were compared by CHD presence and then by CHD severity (minor biventricular, major biventricular, and single ventricle disease) using log-binomial regression adjusted for propensity scores accounting for age at admission, sex, and history of asthma. Outcomes included inpatient mortality, intensive care unit (ICU) admission, mechanical ventilation, and length of stay (LOS) > 12 days. To evaluate for effect modification by genetic diagnoses, analyses were repeated stratified by CHD and genetic diagnosis. Among 55,161 children hospitalized for influenza, 2369 (4.3%) had CHDs, including 963 with minor biventricular, 938 with major biventricular, and 468 with single ventricle CHDs. Adjusting for propensity scores, children with CHDs had higher mortality (4.1% versus 0.9%) compared to those without CHDs (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.9-3.4). Children with CHDs were at higher risk of mechanical ventilation (RR 1.6, 95% CI 1.6-1.7), ICU admission (RR 1.9, 95% CI 1.8-2.1), and LOS > 12 days (RR 2.2, 95% CI 2.0-2.3). Compared to those with neither CHD nor genetic condition, children with both had significantly higher risk of all outcomes, with the largest difference for LOS > 12 days (RR 2.3, 95% CI 2.0-2.7). Children with CHDs hospitalized for influenza are particularly susceptible to adverse outcomes compared to those without CHDs. Future studies are needed to corroborate findings in light of influenza vaccination.
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BACKGROUND: We describe outcomes and management strategies for single-ventricle and bilaterally discontinuous pulmonary arteries (PAs) originating from bilateral ductus arteriosus. METHODS: We reviewed 22 patients with aforementioned anatomy and PA centralization from 1995 to 2023, excluding those with biventricular repair. RESULTS: Median age at centralization was 9 days (minimum-maximum, 0 days-2 years). Centralization was performed with systemic-to-pulmonary shunt (n =20 [91%]; 2 after bilateral ductal stents) or bidirectional cavopulmonary connection (n = 2 [9%]) using pericardial roll (n = 14 [64%]), patch-augmented direct anastomosis (n = 7 [32%]), and interposition graft (n = 1 [5%]) techniques. Concurrent total anomalous pulmonary venous connection (TAPVC, n = 11 [50%]) was associated with significantly inferior survival (P = .01). Five patients (23%) died at a median of 59 days (minimum-maximum, 6-257 days) after centralization, all with noncardiac TAPVC. At the latest follow-up for 17 survivors (median, 13.5 years; minimum-maximum, 0.5-25.1 years after centralization), 12 completed Fontan, 4 completed second-stage palliation, and 1 received a transplant before second-stage palliation. PA reintervention was required in 14 patients (64%), including 3 with reoperations independent of staged palliation. Echocardiography from baseline to before the second stage demonstrated branch PA growth with significantly increased diameters (left, P = .0006; right, P = .0002); z-scores significantly increased for right (P = .004) but not left (P = .11). CONCLUSIONS: Successful single-ventricle palliation is possible, although high risk, for patients with bilateral discontinuous ductal PAs. Early postcentralization mortality remains substantial, particularly with associated noncardiac TAPVC. Many require reintervention to maintain PA growth, typically concurrently with staged palliation.
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In 2019, an interprofessional team at Texas Children's Hospital designed and instituted developmental care rounds to better coordinate developmentally appropriate care within the cardiac intensive care unit. During the first 2 years, we conducted 230 developmental care rounds on 169 patients; for these rounds, family participation was greater than 85%. Since their inception, these rounds have undergone several modifications, including changes to the patient selection criteria and team role delegation. Importantly, the structure of these rounds has evolved to prominently integrate family members' perspectives and experiences. Lessons learned through developmental care rounds have formed a foundation for implementing other developmentally appropriate practices and initiatives throughout the hospital's Heart Center.
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Rondas de Enseñanza , Niño , Humanos , Unidades de Cuidados Intensivos , Relaciones Profesional-Familia , Familia , Hospitales Pediátricos , Grupo de Atención al PacienteRESUMEN
INTRODUCTION: Transporting critically ill patients to diagnostic imaging for needed studies can be challenging and even prohibitive. A portable computerized tomography (CT) scanner allows the patient to remain in the intensive care unit, but presents new positioning and team challenges. Before activation of a portable CT scanner in our pediatric intensive care unit and through the use of iterative simulation-based Plan-Do-Study-Act (PDSA) cycles in the clinical environment, a multidisciplinary team of bedside caregivers determined optimal patient positioning, equipment needs, and specific staffing and choreography to develop detailed portable CT guidelines. METHOD: Our team engaged stakeholders from radiology, critical care, respiratory therapy, environmental services, facilities operations, and the CT vendor to develop scenarios. Simulations included infant and pediatric patients who required critical invasive monitoring and treatment devices, such as ventilators, and high-risk intracardiac and intravascular lines. Scenario objectives centered on the safe positioning, transfer, and scanning of the patient. Trained simulation specialists from the hospital's simulation center facilitated simulation sessions. RESULTS: Simulation-based PDSA testing identified 31 latent safety threats, including the need for a custom bed adapter due to pediatric patients' variable size. We paused portable CT activation pending the custom adapter's availability and remediation of other latent safety threats. Additional simulation-based PDSA cycles further refined the process once the custom adapter was available. CONCLUSIONS: Simulation identified unanticipated latent safety threats before the implementation of a portable CT scanner.
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OBJECTIVE: Neurodevelopmental impairment is common after surgery for congenital heart disease (CHD) in infancy. While neurodevelopmental follow-up of high-risk patients has increased, the referral patterns for ancillary services following initial evaluation have not been reported. The aim of this study is to describe the rates and patterns of referral at the initial visit to our outcomes clinic of patients who underwent surgery for CHD during infancy. OUTCOMES MEASURES: The Cardiac Developmental Outcomes Program clinic at Texas Children's Hospital provides routine longitudinal follow-up with developmental pediatricians and child psychologists for children who required surgery for CHD within the first 3 months of life. Demographic, diagnostic, and clinical data, including prior receipt of intervention and referral patterns at initial presentation, were abstracted from our database. RESULTS: Between April 2013 and May 2017, 244 infants under 12 months of age presented for initial evaluation at a mean age of 7 ± 1.3 months. At presentation, 31% (76/244) were referred for either therapeutic intervention (early intervention or private therapies), ancillary medical services, or both. Referral rates for low-risk (STAT 1-3) and high-risk (STAT 4-5) infants were similar (28 vs. 33%, P = .48). Referrals were more common in: Hispanic white infants (P = .012), infants with non-cardiac congenital anomalies (P = .001), history of gastrostomy tube placement (P < .001), and infants with prior therapy (P = .043). Infants of non-English speaking parents were three times more likely to be referred (95% CI = 1.5, 6.4; P = .002). CONCLUSIONS: At the time of presentation, nearly 1 in 3 infants required referral. Referral patterns did not vary by traditional risk stratification. Sociodemographic factors and co-morbid medical conditions increased the likelihood of referral. This supports the need for routine follow-up for all post-surgical infants regardless of level of surgical complexity. Further research into the completion of referrals and long-term referral patterns is needed.
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Desarrollo Infantil , Discapacidades del Desarrollo/etiología , Sistemas de Información en Salud/estadística & datos numéricos , Cardiopatías Congénitas/complicaciones , Derivación y Consulta/estadística & datos numéricos , Medición de Riesgo/métodos , Procedimientos Quirúrgicos Cardíacos , Preescolar , Discapacidades del Desarrollo/epidemiología , Discapacidades del Desarrollo/psicología , Femenino , Estudios de Seguimiento , Cardiopatías Congénitas/cirugía , Humanos , Incidencia , Lactante , Masculino , Estudios Retrospectivos , Factores de Riesgo , Texas/epidemiologíaRESUMEN
Introduction Maternal obesity is associated with an increased risk for adverse perinatal outcomes. Obesity is also associated with a chronic inflammatory state and metabolic derangements that affect the newborn. The additional use of cardiopulmonary bypass during the neonatal period could impact the systemic inflammatory response in the immediate postoperative period that manifests as cardiac depression and multi-organ dysfunction. This study aimed to determine the association of maternal obesity and excessive weight gain during pregnancy with the immediate postoperative morbidity of neonatal patients undergoing cardiopulmonary bypass. METHODS: A retrospective review of neonates who underwent cardiopulmonary bypass within the first 30 days of life at our institution between 2011 and 2013 was conducted. Postoperative variables investigated included the duration of length of mechanical ventilation, length of stay in the ICU, peak vasoactive inotrope scores, and peak lactate level. Maternal obesity was defined as 1st trimester body mass index ⩾30 kg/m2. Excessive weight gain was defined as ⩾12 kg gained during pregnancy. In order to determine the association between maternal obesity or excessive weight gain and postoperative variables, we used multiple linear regression, adjusting for birth weight and risk adjustment for congenital heart surgery score. RESULTS: Records from 58 mother-baby dyads were examined. After controlling for birth weight and risk adjustment for congenital heart surgery score, there were no significant associations between maternal obesity and excessive weight gain during pregnancy versus all postoperative outcomes measured. CONCLUSION: Despite the known negative impact of maternal obesity on perinatal outcomes, we were unable to find associations between maternal obesity and excessive weight gain during pregnancy versus postoperative outcomes.
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Puente Cardiopulmonar/efectos adversos , Cardiopatías Congénitas/cirugía , Obesidad , Complicaciones Posoperatorias , Aumento de Peso , Adulto , Índice de Masa Corporal , Femenino , Humanos , Recién Nacido , Modelos Lineales , Masculino , Embarazo , Complicaciones del Embarazo , Efectos Tardíos de la Exposición Prenatal , Estudios Retrospectivos , Ajuste de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Palivizumab is the standard immunoprophylaxis against serious disease due to respiratory syncytial virus infection. Current evidence-based prophylaxis guidelines may not address certain children with CHD within specific high-risk groups or clinical/management settings. METHODS: An international steering committee of clinicians with expertise in paediatric heart disease identified key questions concerning palivizumab administration; in collaboration with an additional international expert faculty, evidence-based recommendations were formulated using a quasi-Delphi consensus methodology. RESULTS: Palivizumab prophylaxis was recommended for children with the following conditions: <2 years with unoperated haemodynamically significant CHD, who are cyanotic, who have pulmonary hypertension, or symptomatic airway abnormalities; <1 year with cardiomyopathies requiring treatment; in the 1st year of life with surgically operated CHD with haemodynamically significant residual problems or aged 1-2 years up to 6 months postoperatively; and on heart transplant waiting lists or in their 1st year after heart transplant. Unanimous consensus was not reached for use of immunoprophylaxis in children with asymptomatic CHD and other co-morbid factors such as arrhythmias, Down syndrome, or immunodeficiency, or during a nosocomial outbreak. Challenges to effective immunoprophylaxis included the following: multidisciplinary variations in identifying candidates with CHD and prophylaxis compliance; limited awareness of severe disease risks/burden; and limited knowledge of respiratory syncytial virus seasonal patterns in subtropical/tropical regions. CONCLUSION: Evidence-based immunoprophylaxis recommendations were formulated for subgroups of children with CHD, but more data are needed to guide use in tropical/subtropical countries and in children with certain co-morbidities.
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Consenso , Cardiopatías Congénitas/complicaciones , Palivizumab/administración & dosificación , Infecciones por Virus Sincitial Respiratorio/complicaciones , Infecciones por Virus Sincitial Respiratorio/virología , Antivirales/administración & dosificación , Preescolar , ADN Viral/genética , Relación Dosis-Respuesta a Droga , Femenino , Cardiopatías Congénitas/terapia , Humanos , Inmunización/métodos , Lactante , Masculino , Infecciones por Virus Sincitial Respiratorio/terapia , Virus Sincitiales Respiratorios/genéticaRESUMEN
BACKGROUND: Sequential nephron blockade using intravenous chlorothiazide is often used to enhance urine output in patients with inadequate response to loop diuretics. A few data exist to support this practice in critically ill infants. METHODS: We included 100 consecutive patients <1 year of age who were administered intravenous chlorothiazide while receiving furosemide therapy in the cardiac ICU in our study. The primary end point was change in urine output 24 hours after chlorothiazide administration, and patients were considered to be responders if an increase in urine output of 0.5 ml/kg/hour was documented. Data on demographic, clinical, fluid intake/output, and furosemide and chlorothiazide dosing were collected. Multivariable regression analyses were performed to determine variables significant for increase in urine output after chlorothiazide administration. RESULTS: The study population was 48% male, with a mean weight of 4.9±1.8 kg, and 69% had undergone previous cardiovascular surgery. Intravenous chlorothiazide was initiated at 89 days (interquartile range 20-127 days) of life at a dose of 4.6±2.7 mg/kg/day (maximum 12 mg/kg/day). Baseline estimated creatinine clearance was 83±42 ml/minute/1.73 m2. Furosemide dose before chlorothiazide administration was 2.8±1.4 mg/kg/day and 3.3±1.5 mg/kg/day after administration. A total of 43% of patients were categorised as responders, and increase in furosemide dose was the only variable significant for increase in urine output on multivariable analysis (p<0.05). No graphical trends were noted for change in urine output and dose of chlorothiazide. CONCLUSIONS: Sequential nephron blockade with intravenous chlorothiazide was not consistently associated with improved urine output in critically ill infants.
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Clorotiazida/administración & dosificación , Cuidados Críticos/métodos , Enfermedad Crítica/terapia , Diuresis/efectos de los fármacos , Nefronas/efectos de los fármacos , Diuréticos/administración & dosificación , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Furosemida/administración & dosificación , Humanos , Lactante , Recién Nacido , Inyecciones Intravenosas , Masculino , Estudios RetrospectivosRESUMEN
Data regarding availability of prostaglandin E1 (PGE) and its impact on the stabilization, transport, critical care course, and surgical outcome of infants with ductal-dependent congenital heart disease in the current pediatric healthcare environment are unknown. We sought to determine the proportion of hospitals in Texas that stock PGE and to investigate associations between PGE availability and clinical outcomes. All birth institutions listed with the Texas Department of Health and Human Services were contacted to determine PGE availability as of 2011. Outcomes of all infants admitted to our institution from 2007 to 2012 who received PGE for ductal-dependent lesions were evaluated. PGE was stocked in 50 % (n = 139) of hospitals that performed deliveries in Texas in 2011 representing 79.1 % (303, 481) of births. Hospitals that did not stock PGE had less annual births and were located a further distance from a center that provided pediatric cardiac surgical services. Patients born at a hospital that did not stock PGE had significantly greater serum lactate and creatinine (p = 0.002) and serum lactate on admission (p < 0.001). The PGE availability was not associated with hospital length of stay, postoperative length of stay, or mortality. When stratifying in TGA and HLHS subgroups, lack of PGE availability remained associated with higher creatinine, higher lactate, lower glucose, and lower pH. PGE is not universally available in all healthcare institutions providing obstetrical services. Lack of availability of PGE at an outlying hospital was associated with increased morbidity, but was not associated with mortality or length of stay.
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Alprostadil/provisión & distribución , Equipos y Suministros de Hospitales/estadística & datos numéricos , Cardiopatías Congénitas/mortalidad , Tiempo de Internación/estadística & datos numéricos , Vasodilatadores/provisión & distribución , Centros de Asistencia al Embarazo y al Parto/estadística & datos numéricos , Cuidados Críticos , Femenino , Cardiopatías Congénitas/tratamiento farmacológico , Cardiopatías Congénitas/cirugía , Humanos , Recién Nacido , Modelos Lineales , Masculino , Morbilidad , Análisis Multivariante , TexasRESUMEN
One of the basic tenets of cardiac critical care is to ensure adequate tissue oxygenation. As with other critical illness such as trauma and acute myocardial infarction studies have demonstrated that making the right diagnosis at the right time improves outcomes. The same is true for the management of patients at risk for or in a state of shock. In order to optimize outcomes an accurate and timely assessment of cardiac function, cardiac output and tissue oxygenation must be made. This review discusses the limitations of the standard assessment of cardiovascular function, and adjunctive monitoring modalities that may be used to enhance the accuracy and timely implementation of therapeutic strategies to improve tissue oxygenation.
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Insuficiencia Cardíaca/fisiopatología , Gasto Cardíaco , Niño , Humanos , Monitoreo Fisiológico , Oximetría , Espectroscopía Infrarroja CortaRESUMEN
Hemodynamic monitoring is central to the management of critically ill patients in the cardiac intensive care unit (CICU). The goals of hemodynamic monitoring are to anticipate threats and complications before they arise, to gauge the effectiveness of interventions, and to avoid progression to a decompensated shock state. Although there are numerous modalities of hemodynamic monitoring in the CICU, discordance exists between assessments based on physical exam and standard hemodynamic parameters and those based on measurements of cardiac output. This article will review both the standard and advanced hemodynamic monitoring strategies employed in the CICU.
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Unidades de Cuidados Coronarios , Cuidados Críticos/métodos , Cardiopatías/diagnóstico , Hemodinámica , Monitoreo Fisiológico/métodos , Cateterismo de Swan-Ganz , Cardiopatías/fisiopatología , Cardiopatías/terapia , Humanos , Oximetría , Valor Predictivo de las Pruebas , Pronóstico , Espectroscopía Infrarroja CortaRESUMEN
Within the first 24h of hormonally stimulated adipocyte differentiation, murine 3T3-L1 preadipocytes undergo a mitotic expansion phase prior to terminal differentiation. During this time, the cell cycle regulatory proteins, p130 and p107 undergo dramatic differential expression and the transient increase in expression of p107 appears to be required for terminal differentiation. Recently, human adipose-derived human stem cells (hASC) of mesenchymal origin have been used as a model of human adipocyte differentiation and we sought to determine if differentiating hASC undergo clonal expansion and if the regulated expression of p130/p107 was similar to that observed during 3T3-L1 adipogenesis. Results indicate that differentiating hASC, unlike 3T3-L1 cells do not undergo clonal expansion and p130 expression gradually diminishes across differentiation. However, p107 expression is transiently increased during hASC differentiation in a manner analogous to 3T3-L1 cells suggesting a similar role for p107 in terminal differentiation in human adipocytes.