Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes.

OBJECTIVES: The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU). DESIGN: Registry data (August 2014 to October 2020). SETTING: Forty-five Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS: Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains. CONCLUSIONS: UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.

HeartWatch: Implementing a Pediatric Heart Center Program to Prevent Cardiac Arrests Outside the ICU.

Pediatric patients with cardiovascular disease are at increased risk of cardiopulmonary arrest. Despite utilization of Cardiac Pediatric Early Warning Scores to identify patients at risk of decompensation, our institution had a twofold increase in cardiac arrests (CAs) in the acute care cardiology unit (ACCU) over 2 years. Through a quality improvement initiative, we developed a watcher program, HeartWatch, to reduce the CA arrest rate in the ACCU by 50% over the first year of implementation. Methods: HeartWatch aims to identify patients not adequately captured by Cardiac Pediatric Early Warning Scores who are at high risk for sudden decompensation. Inclusion criteria were developed and evaluated during pilot and implemented phases (April 2020-April 2021) and then monitored in a sustained phase through June 2022. Our primary outcome was the reduction in the out-of-ICU CA rate. Results: During the 13 months, we enrolled 169 patients, and the CA rate decreased from 0.7 to 0.33 per 1,000 patient days, a 53% reduction. The CA rate further decreased to 0.28 events per 1,000 patient days, a 60% reduction, by June 2022. The most common indications for HeartWatch inclusion were high-risk single-ventricle patients (31%) and patients with diminished ventricular function (20%). Conclusions: Implementation of HeartWatch was associated with a meaningful reduction in CA in the ACCU. Creating shared mental models for high-risk patients is essential for patient safety. Future work will optimize local processes that focus on the sustainability of our gains. We will also evaluate opportunities to adapt and implement a similar framework in other institutions to assess reproducibility.

Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations.

Cerebrovascular pressure autoregulation promotes stable cerebral blood flow (CBF) across a range of arterial blood pressures. Cerebral autoregulation (CA) is a developmental process that reaches maturity around term gestation and can be monitored prenatally with both Doppler ultrasound and magnetic resonance imaging (MRI) techniques. Postnatally, there are key advantages and limitations to assessing CA with Doppler ultrasound, MRI, and near-infrared spectroscopy. Here we review these CBF monitoring techniques as well as their application to both fetal and neonatal populations at risk of perturbations in CBF. Specifically, we discuss CBF monitoring in fetuses with intrauterine growth restriction, anemia, congenital heart disease, neonates born preterm and those with hypoxic-ischemic encephalopathy. We conclude the review with insights into the future directions in this field with an emphasis on collaborative science and precision medicine approaches.

Evaluating the Use of Octreotide for Acquired Chylothorax in Pediatric Critically Ill Patients Following Cardiac Surgery.

OBJECTIVES: To evaluate the impact of octreotide on time to resolution of chylothorax compared with conventional therapy. Secondary outcomes include the following: time to reduction of chest tube output by 20%, additional surgeries for chylothorax, hospital length of stay, in-hospital mortality, and adverse drug reactions. METHODS: We retrospectively evaluated the efficacy of octreotide vs conventional therapy for treatment postoperative chylothorax in pediatric patients in the cardiac ICU following surgery for congenital heart disease between October 2008 and June 2017. RESULTS: Final analysis included 32 patients with chylothorax who met inclusion criteria. Patients who received octreotide had a longer duration of chest tube drainage than those who received conventional therapy (24 vs 9 days, p < 0.001). Resolution of chylothorax was achieved in 13 of 16 (81.3%) octreotide patients and 16 of 16 (100%) conventional patients (p = 0.178). There was a comparable time to reduction by 20% in drainage (6 vs 8 days, p = 0.337). There was no significant correlation between time after starting conventional management and reduction chylous output in either the octreotide or conventional therapy group (p = 0.809, p = 0.107, respectively). However, there was a significant and moderate correlation between octreotide and reduction in a chylous output following initiation of octreotide (R 2 = 0.464, p = 0.021). CONCLUSIONS: Octreotide is potentially a safe and effective therapy for treatment in pediatric patients with refractory chylothorax following surgery for congenital heart disease.

Feeding and nutritional challenges in infants with single ventricle physiology.

PURPOSE OF REVIEW: Adequate enteral nutrition and growth are vital to recovery and survival of infants following palliation for univentricular hearts. This group of patients experiences frequent feeding complications that may impede adequate delivery of enteral nutrition. This review presents the most recent data related to feeding practices, growth patterns and outcomes. It also explores management strategies for delivering enteral nutrition safely and effectively to this high-risk group of infants. RECENT FINDINGS: Infants following palliation for single ventricle physiology have persistent growth failure until at least 14 months of life. Greater daily caloric intake attenuates this growth failure. Persistent growth failure is associated with increased mortality following cardiac surgery. Management of enteral nutrition varies widely both pre and postoperatively. Data suggest that standardizing feeding practices improves delivery of enteral nutrition and decreases feeding complications. Evidence-based international feeding guidelines do not exist. SUMMARY: Delivery of adequate nutrition in infants with single ventricle physiology is essential to improve outcomes but is often difficult to achieve. Evidence-based feeding guideline development is crucial to improve outcomes in this group of patients.