Efficacy of Distraction for Reducing Pain and Distress Associated With Venipuncture in the Pediatric Posttransplant Population: A Randomized Controlled Trial.

OBJECTIVE: Distraction can reduce pain and distress associated with painful procedures but has never been studied in children with solid organ transplants. We aimed to determine whether there is a difference in pain and distress associated with venipuncture in pediatric posttransplant patients who receive distraction compared with those who do not. METHODS: Randomized controlled trial of children aged 4 to 17 years with solid organ transplants undergoing venipuncture in the outpatient setting. Patients were randomized to receive distraction or no distraction. The primary outcome was the Faces Pain Scale-Revised. Secondary outcomes were the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale. Exploratory outcomes included the number of venipuncture attempts, time to successful venipuncture, and satisfaction of phlebotomists and parents. RESULTS: Median age of the 40 children enrolled was 11.5 years. Type of transplants included the heart (67.5%), kidney (22.5%), liver (7.5%), and more than 1 organ (2.5%). There was no difference between the Faces Pain Scale-Revised scores in distraction and no distraction groups (1.4; 95% confidence interval, 0.9-1.9; and 1.3, 95% confidence interval, 0.5-2.1, respectively). There was also no difference in the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale scores, number of venipuncture attempts, or time to successful venipuncture. Phlebotomists were more satisfied with the venipuncture when distraction was implemented. CONCLUSIONS: In children with solid organ transplants, there was no difference in pain and distress associated with venipuncture between those who did and did not receive distraction. There was also no difference in other procedure-related outcomes except for greater phlebotomist satisfaction when distraction was implemented.

Anodal stimulation in pediatric patients with permanent epicardial ventricular pacemakers.

OBJECTIVES: We aimed to measure the frequency and factors associated with anodal stimulation in a pediatric population with epicardial pacing leads. BACKGROUND: In bipolar pacemakers, capture of the myocardium typically occurs at the cathode. However, AS with capture at the anode has been described. This has not been described in epicardial pacemakers. METHODS: Retrospective data were collected from patients ≤ 21 years of age with permanent bipolar epicardial ventricular pacemakers from 1/2017 to 1/2018. AS was defined as a clear change on surface ECG in at least one of the 12 leads assessed by two blinded pediatric electrophysiologists. RESULTS: Twenty-four bipolar leads in 23 patients were included in the study. One patient had both biventricular leads tested. Median age was 7.1 years (IQR 5.0-10.9), weight was 20.9 kg (IQR 16.5-33.5), and 65% were male. Testing was performed at a median of 2.8 years (IQR 1.6-6.1) after implant. Congenital heart disease was present in 57%. Complete heart block was the pacemaker indication in 78%. AS was identified in 16/24 (67%) of leads tested. Identification of AS was associated with presence of congenital heart disease (p = 0.004) and 3DD between electrodes (p = 0.04). CONCLUSIONS: AS is common in pediatric patients and was associated with a history of congenital heart disease and greater estimated 3DD between electrodes. The prevalent nature of AS may allow clinicians to utilize existing pacemakers as multisite pacing systems.

Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression.

BACKGROUND: Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aimed to assess whether balloon atrioseptostomy (BAS) is a safe and efficient strategy. METHODS: All patients who underwent percutaneous static BAS under VA-ECMO at four tertiary institutions were retrospectively reviewed. RESULTS: From 2000 to 2014, BAS was performed in 64 patients (32 adults and 32 children). Indications for ECMO support included acute myocarditis (31.3%) and non-myocarditis cardiac disease, mostly end-stage dilated cardiomyopathy (32.8%). BAS was required because of pulmonary oedema/haemorrhage and left ventricular (LV) distension. The mean balloon diameter was 21.8 ± 8.4mm. Adequate LA decompression was achieved in all patients. Mean LA pressure fell from 24.2 ± 6.9 mmHg to 7.8 ± 2.6 mmHg ( p < 0.001). The left-to-right atrial pressure gradient fell from 17.2 ± 7.1 mmHg to 0.09 ± 0.5 mmHg ( p < 0.001). Echocardiography showed an unrestrictive left-to-right atrial shunting in all patients. Improvement of day 1 chest X-ray was observed in 76.6% of patients, clinical status in 98.4% of patients and pulmonary haemorrhage in 14 out of 14 patients. Complications occurred in 9.4% of patients, representing pericardial effusion, fast atrial fibrillation, ventricular fibrillation requiring defibrillation, transient complete heart block and femoral venous dissection requiring covered stent placement. In the 37 (57.8%) patients who were successfully decannulated, the median ECMO duration was 9 (range: 4-24) days. After a median follow-up of 12.3 (range: 0.1-142) months, 35.9% patients died, 17.2% received a LV assist device as a bridge to transplantation, 31.2% were transplanted and 56.2% were home discharged and alive. CONCLUSIONS: Percutaneous BAS may be a safe and efficient strategy for discharging the LA in both adults and children supported by VA-ECMO.

Cardiac Catheterization in Pediatric Patients Supported by Extracorporeal Membrane Oxygenation: A 15-Year Experience.

Cardiac catheterization is commonly performed in patients being supported by extracorporeal membrane oxygenation (ECMO). We aimed to evaluate the safety, benefit, and outcomes of catheterization in pediatric patients supported by ECMO. Retrospective review of cardiac catheterizations performed in patients ≤18 years of age while on ECMO at a large tertiary care center between January 2000 and May 2015. A total of 55 catheterizations were performed on 51 patients during 53 unique ECMO courses. Indications for ECMO include ventricular dysfunction (22), cardiac arrest (20), inability to wean from cardiopulmonary bypass (7), and persistent cyanosis (4). Catheterizations included purely diagnostic studies (11), atrial septostomies (34), stenting of vessels or surgical shunts (6), adjustment of a stent (1), coil embolization (1), and endomyocardial biopsy (1). Septostomy was elective in 58.8% of cases (20) and emergent in 41.2% (14). Forty-six catheterizations had either surgical or catheter intervention during the same or subsequent study (83.6%). High severity complications occurred in three patients (5.6%), including one death due to hemothorax after pulmonary artery stent placement. There were no complications during patient transport. In total, 38 out of 53 (71.7%) ECMO courses resulted in decannulation, 29 (54.7%) patients survived to discharge from the hospital, and 25 (47.2%) were alive at follow-up. Cardiac catheterization can be safely performed on patients supported by ECMO. Cardiac catheterization is a critical tool in the early recognition, diagnosis, and direct treatment of hemodynamic/anatomic abnormalities in patients supported by ECMO.