Characteristics and Outcomes of Adults With Congenital Heart Disease in the Cardiac Intensive Care Unit.

Background: Little is known regarding the characteristics, treatment patterns, and outcomes in patients with adult congenital heart disease (ACHD) admitted to cardiac intensive care units (CICUs). Objectives: The authors sought to better define the contemporary epidemiology, treatment patterns, and outcomes of ACHD admissions in the CICU. Methods: The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Participating centers contributed prospective data from consecutive admissions during 2-month annual snapshots from 2017 to 2022. We analyzed characteristics and outcomes of admissions with ACHD compared with those without ACHD. Multivariable logistic regression was used to assess mortality in ACHD vs non-ACHD admissions. Results: Of 23,299 CICU admissions across 42 sites, there were 441 (1.9%) ACHD admissions. Shunt lesions were most common (46.1%), followed by right-sided lesions (29.5%) and complex lesions (28.7%). ACHD admissions were younger (median age 46 vs 67 years) than non-ACHD admissions. ACHD admissions were more commonly for heart failure (21.3% vs 15.7%, P < 0.001), general medical problems (15.6% vs 6.0%, P < 0.001), and atrial arrhythmias (8.6% vs 4.9%, P < 0.001). ACHD admissions had a higher median presenting Sequential Organ Failure Assessment score (5.0 vs 3.0, P < 0.001). Total hospital stay was longer for ACHD admissions (8.2 vs 5.9 days, P < 0.01), though in-hospital mortality was not different (12.7% vs 13.6%; age- and sex-adjusted OR: 1.19 [95% CI: 0.89-1.59], P = 0.239). Conclusions: This study illustrates the unique aspects of the ACHD CICU admission. Further investigation into the best approach to manage specific ACHD-related CICU admissions, such as cardiogenic shock and acute respiratory failure, is warranted.

Acute Heart Valve Emergencies.

Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.

A Pulse Check on Leadership and Teamwork: An Evaluation of the First 5 Minutes of Emergency Department Resuscitation During Pediatric Cardiopulmonary Arrests.

OBJECTIVES: Effective leadership and teamwork are imperative during pediatric cardiopulmonary resuscitations (CPR). The initial phase of pediatric CPR, termed the "first 5 minutes," has significant care delivery gaps in both leadership and team performance. The aim of the study was to describe the performance data of emergency department (ED) teams who performed CPR in a pediatric ED. METHODS: We conducted a retrospective video review of resuscitations involving pediatric patients younger than 21 years who presented in cardiac arrest to a tertiary pediatric ED. Descriptive statistics were used for data analysis. RESULTS: Twenty events met study inclusion criteria. Prearrival task completion included the following: estimated weight (90%), airway set-up (85%), epinephrine dose prepared (84%), defibrillator ready (75%), and intraosseous kit ready (50%). Median prearrival notification time was 5 minutes 34 seconds (interquartile range = 4:44-7:13) with no significant relationship between prearrival time and task completion. Within the first 5 minutes, the team leader provided a care summary in 84%, prioritized tasks in 95%, and assigned roles for airway management (90%), intravenous/intravenous access (63%), and CPR/pulse check (63%). Most critical tasks were completed within 1 minute; however, only 25% had defibrillator pads placed within the 5-minute window. CONCLUSIONS: Our study of leadership and teamwork during the first 5 minutes of pediatric CPR care noted wide variation in team performance. Opportunities for improvements in CPR readiness can be incorporated into education and quality programs to drive improvements in the care of future pediatric patients experiencing cardiac arrest.

Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality.

OBJECTIVE: Minimizing pauses in chest compressions during cardiopulmonary resuscitation (CPR) is recommended by the American Heart Association (AHA) and is associated with improved patient outcomes. We studied the quality of pediatric CPR performed in a tertiary pediatric emergency department (ED) with a focus on pauses in chest compressions. METHODS: We conducted an observational study of CPR quality in two pediatric EDs using video review during pediatric cardiac arrest. Events were reviewed for AHA guideline adherence. Parameters of CPR performance were described according to individual compressor segment. Pauses in compressions were analyzed for duration and pause activities. RESULTS: From a 30-month period, 81 cardiac arrests were analyzed, including 1003 individual compressor segments and 900 pauses. Median chest compression fraction was 91%, with a median pause duration of 4 s (IQR 2, 10); 22% of pauses were prolonged (>10 s). Pulse checks occurred in 23% of pauses; 62% were prolonged. Checking a single pulse site (p < 0.001) and having fingers ready pre-pause (p = 0. 001) were associated with significantly shorter pause duration. Pause duration was correlated with the number of pause tasks (r = 0.559, p < 0.001). "Coordinated pauses" (pulse check, rhythm check and compressor change) were rare (6%) and long in duration (19 s; IQR 11, 30). CONCLUSIONS: Prolonged pauses in chest compressions occurred frequently during CPR and were associated with pulse checks and multiple simultaneous tasks. Checking a single pulse site with fingers ready on the pulse site pre-pause could decrease pause duration and improve CPR quality.

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations.

BACKGROUND: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration. OBJECTIVE: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations. METHODS/DESIGN: We conducted a retrospective review of video recordings of pediatric patients who required critical care ("resuscitation") in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained. RESULTS: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR. CONCLUSION: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.