Transcatheter Palliation With Pulmonary Artery Flow Restrictors in Neonates With Congenital Heart Disease: Feasibility, Outcomes, and Comparison With a Historical Hybrid Stage 1 Cohort.

BACKGROUND: Neonates with complex congenital heart disease and pulmonary overcirculation have been historically treated surgically. However, subcohorts may benefit from less invasive procedures. Data on transcatheter palliation are limited. METHODS: We present our experience with pulmonary flow restrictors (PFRs) for palliation of neonates with congenital heart disease, including procedural feasibility, technical details, and outcomes. We then compared our subcohort of high-risk single ventricle neonates palliated with PFRs with a similar historical cohort who underwent a hybrid Stage 1. Cox regression was used to evaluate the association between palliation strategy and 6-month mortality. RESULTS: From 2021 to 2023, 17 patients (median age, 4 days; interquartile range [IQR], 2-8; median weight, 2.5 kilograms [IQR, 2.1-3.3]) underwent a PFR procedure; 15 (88%) had single ventricle physiology; 15 (88%) were high-risk surgical candidates. All procedures were technically successful. At a median follow-up of 6.2 months (IQR, 4.0-10.8), 13 patients (76%) were successfully bridged to surgery (median time since PFR procedure, 2.6 months [IQR, 1.1-4.4]; median weight, 4.9 kilograms [IQR, 3.4-5.8]). Pulmonary arteries grew adequately for age, and devices were easily removed without complications. The all-cause mortality rate before target surgery was 24% (n=4). Compared with the historical hybrid stage 1 cohort (n=23), after adjustment for main confounding (age, weight, intact/severely restrictive atrial septum or left ventricle to coronary fistulae), the PFR procedure was associated with a significantly lower all-cause 6-month mortality risk (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.82]). CONCLUSIONS: Transcatheter palliation with PFR is feasible, safe, and represents an effective strategy for bridging high-risk neonates with congenital heart disease to surgical palliation, complete repair, or transplant while allowing for clinical stabilization and somatic growth.

Reduction of infant mortality from congenital heart defects in a middle-income country: Costa Rican experience.

BACKGROUND: We aimed to analyze recent infant and neonatal mortality from congenital heart defects (CHD) in Costa Rica, a middle-income country where CHD mortality was above expectations. METHODS: A descriptive analysis of infant and neonatal mortality rates from CHD (IMR-CHD and NMR-CHD) during 2000-2019 was performed, according to province, sex, specific CHD, and sub-period, using data from the National Institute of Statistics and Censuses. We used joinpoint regression to identify any calendar-year where a significant change in trend occurred; the average annual percent change (AAPC) was determined. Using Poisson regression, marginal means and mortality ratios (MR) for IMR-CHD and NMR-CHD by sub-period (2000-2006-referent-, 2007-2013, 2014-2019) were estimated and compared using Wald's chi-square tests (α ≤ .05). RESULTS: During 2000-2019, CHD accounted for 12% of overall infant mortality. IMR-CHD and NMR-CHD decreased linearly over the study period (AAPC = -3.4; p < .01). IMR-CHD decreased by 41%, from 13.6 per 10,000 in 2000-2006 (13.4% of infant mortality) to 8.1 per 10,000 in 2014-2019 (10% of infant mortality) (MR = 0.59; 95% confidence intervals [CI] = 0.52-0.68). NMR-CHD decreased by 38%, from 7.9 per 10,000 in 2000-2006 (11.1% of neonatal mortality) to 4.9 per 10,000 in 2014-2019 (7.9% of infant mortality) (MR = 0.59; 95% CI = 0.52-0.68). Male presented significantly higher NMR-CHD. The main causes of mortality (2014-2019) were total anomalous pulmonary venous connections, hypoplastic left heart syndrome, and double inlet ventricle. CONCLUSIONS: IMR-CHD, NMR-CHD, and their proportional contribution to mortality by all causes and by birth defects decreased significantly, demonstrating that all improvements implemented in the last decades have yielded favorable results.

Factors Associated With Initiation of Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Population: An International Survey.

Although extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly utilized in the pediatric critical care environment, our understanding regarding pediatric candidacy for ECPR remains unknown. Our objective is to explore current practice and indications for pediatric ECPR. Scenario-based, self-administered, online survey, evaluating clinical determinants that may impact pediatric ECPR initiation with respect to four scenarios: postoperative cardiac surgery, cardiac failure secondary to myocarditis, septic shock, and chronic respiratory failure in a former preterm child. Responders are pediatric critical care physicians from four societies. 249 physicians, mostly from North America, answered the survey. In cardiac scenarios, 40% of the responders would initiate ECPR, irrespective of CPR duration, compared with less than 20% in noncardiac scenarios. Nearly 33% of responders would consider ECPR if CPR duration was less than 60 minutes in noncardiac scenarios. Factors strongly decreasing the likelihood to initiate ECPR were out-of-hospital unwitnessed cardiac arrest and blood pH <6.60. Additional factors reducing this likelihood were multiple organ failure, pre-existing neurologic delay, >10 doses of adrenaline, poor CPR quality, and lactate >18 mmol/l. Pediatric intensive care unit location for cardiac arrest, good CPR quality, 24/7 in-house extracorporeal membrane oxygenation (ECMO) team moderately increase the likelihood of initiating ECPR. This international survey of pediatric ECPR initiation practices reveals significant differences regarding ECPR candidacy based on patient category, location of arrest, duration of CPR, witness status, and last blood pH. Further research identifying prognostic factors measurable before ECMO initiation should help define the optimal ECPR initiation strategy.

International Survey on the Use of Arginine Vasopressin in the Postoperative Management of Single Ventricle Patients.

Management of patients with single ventricle physiology after surgical palliation is challenging. Arginine vasopressin has gained popularity in recent years as a non-catecholamine vasoactive medication due to its unique properties. However, data regarding its use in the pediatric population is limited. Therefore, we designed a survey to explore whether and how clinicians use this medication in intensive care units for the postoperative management of single ventricle patients. This international survey aimed to assess usage, practices, and concepts related to arginine vasopressin in pediatric intensive care units worldwide. Directors of pediatric intensive care units who are members of the following international professional societies: European Society of Pediatric Neonatal Intensive Care, Association for European Pediatric and Congenital Cardiology, and Pediatric Cardiac Intensive Care Society were invited to participate in this survey. Of the 62 intensive care unit directors who responded, nearly half use arginine vasopressin in the postoperative management of neonatal single ventricle patients, and 90% also use the drug in subsequent surgical palliation. The primary indications are vasoplegia, hemodynamic instability, and refractory shock, although it is still considered a second-line medication. Conceptual benefits include improved hemodynamics and end-organ perfusion and decreased incidence of low cardiac output syndrome. Those practitioners who do not use arginine vasopressin cite lack of availability, fear of potential adverse effects, unclear indication for use, and lack of evidence suggesting improved outcomes. Both users and non-users described increased myocardial afterload and extreme vasoconstriction as potential disadvantages of the medication. Despite the lack of conclusive data demonstrating enhanced clinical outcomes, our study found arginine vasopressin is used widely in the care of infants and children with single ventricle physiology after the first stage and subsequent palliative surgeries. While many intensive care units use this medication, few had protocols, offering an area for further growth and development.

Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC).

BACKGROUND: Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. METHODS: Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature-a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. RESULTS: Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached "strong agreement," 20 "weak agreement," and 2 had "no agreement." Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. CONCLUSIONS: These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.

The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation.

Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.

Antiplatelet Effect of Ketorolac in Children After Congenital Cardiac Surgery.

BACKGROUND: Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via the arachidonic acid (AA) pathway. The degree of platelet inhibitory effect after cardiac surgery is not well characterized. Thromboelastography with platelet mapping (TEG-PM) is emerging as a frequently used test to evaluate platelet inhibition via the AA pathway. METHODS: Post hoc analysis of a data set collected in a prospective observational cohort study evaluating platelet inhibition in children after congenital heart surgery with cardiopulmonary bypass (CPB). Categorization into two groups: (1) received ketorolac and (2) did not receive ketorolac for analgesia after surgery. The TEG-PM was evaluated at two time points (prior to surgery and 12-48 hours after CPB). RESULTS: Fifty-three children were studied; mean age was 6.6 (range: 0.07-16.7) years and 45% (n = 24) were female. Participants were distributed into two groups by ketorolac use, 41 within the ketorolac group and 12 in the no ketorolac group. All 41 participants who received ketorolac had platelet inhibition and 11 (91.7%) of 12 participants who did not receive ketorolac had normal platelet function after surgery ( P < .0001). There was no difference in patient characteristics or clinical data between the two groups. CONCLUSIONS: Ketorolac use in a cohort of children after congenital cardiac surgery was associated with platelet inhibition via the AA pathway when evaluated by TEG-PM.

Morphine Pharmacokinetics in Children With Down Syndrome Following Cardiac Surgery.

OBJECTIVES: To assess if morphine pharmacokinetics are different in children with Down syndrome when compared with children without Down syndrome. DESIGN: Prospective single-center study including subjects with Down syndrome undergoing cardiac surgery (neonate to 18 yr old) matched by age and cardiac lesion with non-Down syndrome controls. Subjects were placed on a postoperative morphine infusion that was adjusted as clinically necessary, and blood was sampled to measure morphine and its metabolites concentrations. Morphine bolus dosing was used as needed, and total dose was tracked. Infusions were continued for 24 hours or until patients were extubated, whichever came first. Postinfusion, blood samples were continued for 24 hours for further evaluation of kinetics. If patients continued to require opioid, a nonmorphine alternative was used. Morphine concentrations were determined using a unique validated liquid chromatography tandem-mass spectrometry assay using dried blood spotting as opposed to large whole blood samples. Morphine concentration versus time data was modeled using population pharmacokinetics. SETTING: A 16-bed cardiac ICU at an university-affiliated hospital. PATIENTS: Forty-two patients (20 Down syndrome, 22 controls) were enrolled. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The pharmacokinetics of morphine in pediatric patients with and without Down syndrome following cardiac surgery were analyzed. No significant difference was found in the patient characteristics or variables assessed including morphine total dose or time on infusion. Time mechanically ventilated was longer in children with Down syndrome, and regarding morphine pharmacokinetics, the covariates analyzed were age, weight, presence of Down syndrome, and gender. Only age was found to be significant. CONCLUSIONS: This study did not detect a significant difference in morphine pharmacokinetics between Down syndrome and non-Down syndrome children with congenital heart disease.

Clinical Associations of Early Dysnatremias in Critically Ill Neonates and Infants Undergoing Cardiac Surgery.

Dysnatremias (DN) are common electrolyte disturbances in cardiac critical illness and are known risk factors for adverse outcomes in certain populations. Little information exists on DN in children with cardiac disease admitted to the cardiac intensive care unit (CICU) after undergoing cardiac surgery, either corrective or palliative. The aim was to determine the incidence and adverse outcomes associated with DN in neonates and infants undergoing cardiac surgery. Retrospective cohort and single center study performed at Children's Hospital Colorado from May 2013 to May 2014, in children under 1 year old admitted to the CICU after undergoing surgery for congenital or acquired cardiac disease. 183 subjects were analyzed. EXCLUSIONS: subjects that demonstrated DN before surgery. Serum sodium levels were recorded for the first 72 h post-operatively. DN was present in 54% of the subjects (98/183): hypernatremia in 60 (33%), hyponatremia in 38 (21%). Multivariate analysis revealed that mild hypernatremia (146-150 mmol/dl) and moderate hypernatremia (151-155 mmol/dl) were associated with longer hospital length of stay (LOS, p < 0.05) and ventilation times (p < 0.05). No association was shown between mild/moderate hyponatremia (125-134 mmol/dl) with either outcome. Hours to DN were significantly lower in hypernatremic (median = 5.8 h) than hyponatremic (median = 43.8 h) patients (p < 0.001). Children younger than 30 days presented DN at an earlier stage than those 31 days-1 year old (median +2.2 vs. 17.3 h). No associations present between DN and the class of diuretic (loop vs. thiazide) administered, or the route of administration (intravenous bolus vs. constant infusion). Total median sodium bicarbonate administration was associated with hypernatremia, as was exposure to vasopressin within the first 72 h post-operatively. Dysnatremias are common in the early post-operative period in neonates and infants undergoing cardiac surgery. Mild to moderate hypernatremia, but not hyponatremia, is associated with longer LOS and longer ventilation time in infants undergoing cardiovascular surgery. Hypernatremia is also associated with younger infants, a higher surgical complexity, administration of bicarbonate and exposure to vasopressin. Diuretic type or interval timing of intravenous delivery did not demonstrate any effect. Prospective studies are needed in this population, in order to determine how DN, particularly hypernatremia, contributes to adverse outcomes, whether this association is independent of illness severity, and what may be safe treatments and interventions for these disorders.

A Decline in Intraoperative Renal Near-Infrared Spectroscopy Is Associated With Adverse Outcomes in Children Following Cardiac Surgery.

OBJECTIVES: Renal near-infrared spectroscopy is known to be predictive of acute kidney injury in children following cardiac surgery using a series of complex equations and area under the curve. This study was performed to determine if a greater than or equal to 20% reduction in renal near-infrared spectroscopy for 20 consecutive minutes intraoperatively or within the first 24 postoperative hours is associated with 1) acute kidney injury, 2) increased acute kidney injury biomarkers, or 3) other adverse clinical outcomes in children following cardiac surgery. DESIGN: Prospective single center observational study. SETTING: Pediatric cardiac ICU. PATIENTS: Children less than or equal to age 4 years who underwent cardiac surgery with the use of cardiopulmonary bypass during the study period (June 2011-July 2012). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A reduction in near-infrared spectroscopy was not associated with acute kidney injury. Nine of 12 patients (75%) with a reduction in renal near-infrared spectroscopy did not develop acute kidney injury. The remaining three patients had mild acute kidney injury (pediatric Risk, Injury, Failure, Loss, End stage-Risk). A reduction in renal near-infrared spectroscopy was associated with the following adverse clinical outcomes: 1) a longer duration of mechanical ventilation (p = 0.05), 2) longer intensive care length of stay (p = 0.05), and 3) longer hospital length of stay (p < 0.01). A decline in renal near-infrared spectroscopy in combination with an increase in serum interleukin-6 and serum interleukin-8 was associated with a longer intensive care length of stay, and the addition of urine interleukin-18 to this was associated with a longer hospital length of stay. CONCLUSIONS: In this cohort, the rate of acute kidney injury was much lower than anticipated thereby limiting the evaluation of a reduction in renal near-infrared spectroscopy as a predictor of acute kidney injury. A greater than or equal to 20% reduction in renal near-infrared spectroscopy was significantly associated with adverse outcomes in children following cardiac surgery. The addition of specific biomarkers to the model was predictive of worse outcomes in these patients. Thus, real-time evaluation of renal near-infrared spectroscopy using the specific levels of change of a 20% reduction for 20 minutes may be useful in predicting prolonged mechanical ventilation and other adverse outcomes in children undergoing cardiac surgery.

Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future.

BACKGROUND: The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes. METHODS: The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership. RESULTS: Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges. CONCLUSIONS: Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.

Improved nutrition delivery and nutrition status in critically ill children with heart disease.

BACKGROUND: This initiative sought to improve nutrition delivery in critically ill children with heart disease admitted to the cardiac ICU (CICU) and neonates undergoing stage 1 palliation (S1P) for single-ventricle physiology through interdisciplinary team interventions. Specific goals were increased caloric and protein delivery for all patients and a more nourished state for infants with single ventricles at the time of discharge. METHODS: We developed a nutrition flow sheet in the electronic health record to track whether daily nutrition goals were met. Interventions included nurses reporting daily whether caloric and protein goals were met, mandatory involvement of feeding specialists, and introduction of an enteral nutrition guideline. For infants undergoing S1P, weight-for-age z score (as an indicator for assessing malnutrition) was calculated at admission and discharge. RESULTS: The percentage of patient days per month when daily caloric goals were met increased from 50.1% to 60.7%, and protein goals met increased from 51.6% to 72.7%. Hospital length of stay, need for ventilation, and mortality did not differ. Patients undergoing S1P demonstrated a statistically significant improvement in weight-for-age z score compared with the preintervention group (P = .003). Thirteen S1P patients were discharged undernourished in the preintervention group; 5 were severely undernourished. In the intervention group, 4 patients were discharged undernourished, and none were severely undernourished. CONCLUSIONS: This initiative resulted in improved nutrition delivery for a heterogeneous population of cardiac patients in the CICU as well as significant improvements in weight gain and nourishment status at discharge in infants undergoing S1P.

Prenatal diagnosis and successful outcome in neonate of aorto-left ventricle tunnel.

Aorto-left ventricular tunnel (ALVT) is an abnormal congenital communication between the ascending aorta and the left ventricle. Prenatal diagnosis is rare and can be misinterpreted as aortic insufficiency on fetal echocardiogram. We present a case of ALVT diagnosed in a fetus who underwent successful early neonatal surgical repair.

Tachyarrhythmias after the Norwood procedure: relationship and effect of vasoactive agents.

Tachyarrhythmias are common after the Norwood stage I palliation. The effects of vasoactive medications on the development of post-operative tachyarrhythmias have not been studied. The primary objective was to identify associations between postoperative tachyarrhythmias and vasoactive medication usage after Norwood stage 1 palliation. Secondary objectives included evaluation for morbidities of tachyarrhythmias and for associations with anatomical or surgical variables. Retrospective chart review was performed on all patients who underwent the Norwood stage 1 palliation at Children's Hospital Colorado between January 2008 and June 2012. Primary outcomes were development of postoperative tachyarrhythmias and the effects of vasoactive medications. Dopamine, epinephrine, milrinone, and vasopressin duration, cumulative dose, highest dose, and dose at onset of tachyarrhythmia were identified. The effects of surgical variables and anatomy were also studied. Sixty-six patients underwent the Norwood procedure, and 33 (50 %) of these patients had postoperative tachyarrhythmias. Patients with tachyarrhythmias had longer ICU stays (p = 0.02) and hospital stays (p < 0.01), but no change in mortality (p = 1.0). Multivariate Cox regression analysis showed that the right ventricle to pulmonary artery shunt (p < 0.01), longer duration of epinephrine treatment (p = 0.02), and higher milrinone dose (p = 0.002) were associated with tachyarrhythmias. Postoperative tachyarrhythmias are common after the Norwood procedure and are associated with longer ICU and hospital stays. High doses of milrinone, longer duration of epinephrine treatment, and the right ventricle to pulmonary artery shunt were associated with for the development of tachyarrhythmias. Further studies are required to determine the effects of anatomy on post-operative tachyarrhythmias.

Tricuspid atresia associated with truncus arteriosus versus aortopulmonary window: combining fetal and postnatal echocardiography to make the diagnosis.

The coincident occurrence of tricuspid atresia and aortopulmonary window (APW) is exceedingly rare, with one previous case reported in the literature. We present a patient with tricuspid atresia, pulmonary atresia, and APW. Postnatal echocardiograms demonstrated no visible pulmonary valve, and additional defects including a bicuspid aortic valve, right aortic arch and anomalous coronary arteries raised suspicion for tricuspid atresia with persistent truncus arteriosus. However, fetal echocardiography and direct visualization of the anatomy confirmed the alternate diagnosis. The patient underwent successful palliation consisting of APW repair, atrial septectomy and a 3.5 mm modified Blalock-Taussig shunt, followed by a bidirectional cavopulmonary connection.

A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.

BACKGROUND: Handoff protocols from the cardiovascular operating room (CVOR) to the cardiac intensive care unit (CICU) can improve patient outcomes and delivery of care beyond the immediate postoperative period. In a prospective quality improvement study, a structured CVOR-to-CICU handoff protocol was implemented at a university-affiliated children's hospital. As a parallel project, an initiative to reduce unplanned extubations in the CICU was implemented. METHODS: In a 41-month period, 1,507 neonates, infants, children, and adults were admitted to the CICU from the CVOR after undergoing a surgical procedure. The study was divided into a 17-month prehandoff-protocol period (January 2009-May 2010) and a 24-month posthandoff-protocol period (June 2010-May 2012). The handoff protocol was intended to streamline the handoff process from the CVOR and throughout the transition to the CICU. The specifics of the handoff, as outlined in a bedside laminated flowchart, included patient transport from the CVOR, the cardiovascular surgeon's report, the anesthesiologist's report, and the patient status summary and care plan. RESULTS: After introduction of the handoff protocol, there was a statistically significant and sustained reduction in the mean rate of unplanned extubations from 0.62 to 0.24 per 100 ventilator-days (p = .03). There was a statistically significant reduction in median ventilator time per patient--from 17 hours (interquartile range [IQR]: 5.3 to 57.7) to 12.8 hours (IQR: 4.8 to 31.8); p = .02). The mean rate of unplanned extubations was 0.26 in 2011 and 0.30 in 2012. CONCLUSIONS: Implementation of a handoff protocol from the CVOR to the CICU was associated with sustained decrease in unplanned extubations and in mean ventilator times.

Perioperative management of shock in two fontan patients with plastic bronchitis.

Plastic bronchitis is potentially a life-threatening complication of long-standing surgically palliated single ventricle congenital heart disease. Patients can present with hypoxia requiring urgent bronchoscopy for removal of bronchial casts. Perioperative care for these patients is challenging and anesthesia is associated with significant cardiac risk. As more surgically corrected single ventricle patients survive to adulthood, these patients are expected to present more frequently. This report details the perioperative management of 2 Fontan patients with hypoxia and significant plastic bronchitis disease burden.

Extended survival and re-hospitalisation among paediatric patients requiring extracorporeal membrane oxygenation for primary cardiac dysfunction.

BACKGROUND: Although survival to hospital discharge among children requiring extracorporeal membrane oxygenation support for medical and surgical cardio-circulatory failure has been reported in international registries, extended survival and re-hospitalisation rates have not been well described in the literature. MATERIAL AND METHODS: This is a single-institution, retrospective review of all paediatric patients receiving extracorporeal membrane oxygenation for primary cardiac dysfunction over a 5-year period. RESULTS: A total of 74 extracorporeal membrane oxygenation runs in 68 patients were identified, with a median follow-up of 5.4 years from hospital discharge. Overall, 66% of patients were decannulated alive and 25 patients (37%) survived to discharge. There were three late deaths at 5 months, 20 months, and 6.8 years from discharge. Of the hospital survivors, 88% required re-hospitalisation, with 63% of re-admissions for cardiac indications. The median number of hospitalisations per patient per year was 0.62, with the first re-admission occurring at a mean time of 9 months after discharge from the index hospitalisation. In all, 38% of patients required further cardiac surgery. CONCLUSIONS: Extended survival rates for paediatric hospital survivors of cardiac extracorporeal membrane oxygenation support for medical and post-surgical indications are encouraging. However, re-hospitalisation within the first year following hospital discharge is common, and many patients require further cardiac surgery. Although re-admission hospital mortality is low, longer-term follow-up of quality-of-life indicators is required

An interdisciplinary initiative to reduce unplanned extubations in pediatric critical care units.

OBJECTIVE: Unplanned extubations in pediatric critical care units can result in increased mortality, morbidity, and length of stay. We sought to reduce the incidence of these events by reliably measuring occurrences and instituting a series of coordinated interdisciplinary interventions. METHODS: This was an internal review board-approved quality improvement project. Data were prospectively collected from the electronic medical record, and analyzed over 24 months (January 1, 2009-December 2010), and divided into 3 periods: baseline (9 months), intervention with multiple rapid improvement cycles (8 months), and postintervention (7 months). Interventions included standardization of endotracheal tube taping practices upon admission, improved patient handoffs, systematic review of unplanned events, reexamination of sedation practices, and promotion of transparency of performance measures. RESULTS: The PICU experienced 21 events in the 9 months before the initiative, 13 events over the 8-month intervention period, and 5 events in the 7-month postintervention period. The cardiac intensive care unit (CICU) experienced 11, 4, and 0 events, respectively. Mean event rates per 100 patient days for each interval were 0.80, 0.50, and 0.29 for the PICU and 0.74, 0.44, and 0 for the CICU. Monthly event rates for the CICU were significantly different by using the Kruskal-Wallis test (P < .05) but not for the PICU (P = .36) CONCLUSIONS: Through accurate tracking, multiple practice changes, and promoting transparency of efforts and data, an interdisciplinary team reduced the number of unplanned extubations in both ICUs. This reduction has been sustained throughout the postintervention monitoring period.