RESUMO
OBJECTIVES: Extracorporeal membrane oxygenation is often used in children with single-ventricle anomalies. We aimed to describe extracorporeal membrane oxygenation use in single-ventricle patients to test the hypothesis that despite increasing prevalence, mortality has not improved and overall burden measure by hospital charges and length of stay have increased. DESIGN: Retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed with sample weighting to generate national estimates. PATIENTS: Pediatric patients (age ≤ 20) with a diagnosis of single ventricle heart disease requiring extracorporeal membrane oxygenation support from 2000 to 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seven hundred one children (95% CI, 559-943) with single ventricle were supported with extracorporeal membrane oxygenation in the reporting period. Mortality was 57% and did not improve over time (2000 = 52%, 2003 = 63%, 2006 = 57%, and 2009 = 55%; p = 0.66). Single-ventricle patients who required extracorporeal membrane oxygenation were more likely to have had a cardiac procedure (90% vs 46%; p < 0.001), a diagnosis of arrhythmia (22% vs 13%; p < 0.001), cerebrovascular or neurologic insult (9% vs 1%; p < 0.001), heart failure (24% vs 12%; p < 0.001), acute renal failure (28% vs 3%; p < 0.001), or sepsis (28% vs 8%; p < 0.001). By multivariable analysis, acute renal failure was a risk factor for mortality (adjusted odds ratio, 3.12; 95% CI, 1.95-4.98; p < 0.001). The length of stay for single-ventricle patients with extracorporeal membrane oxygenation increased from 25.2 days in 2000 to 55.6 days in 2009 (p < 0.001). Total inflation-adjusted charges increased from $358,021 (95% CI, $278,658-439,765) in 2000 to $732,349 (95% CI, $671,781-792,917) in 2009 (p < 0.001). CONCLUSIONS: Extracorporeal membrane oxygenation support is uncommon with single-ventricle admissions occurring in 2.3% of all hospitalizations. Among those patients, the mortality rate was 57% with no change over time. Acute renal failure was an independent risk factor for mortality during hospitalization. In addition, length of stay for these patients increased and hospital charges doubled. Further studies are needed to determine suitability and cost-effectiveness of extracorporeal membrane oxygenation in single-ventricle patients.
Assuntos
Oxigenação por Membrana Extracorpórea/mortalidade , Cardiopatias Congênitas/terapia , Preços Hospitalares/tendências , Tempo de Internação/tendências , Adolescente , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/economia , Feminino , Ventrículos do Coração/anormalidades , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Tempo de Internação/economia , Masculino , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: The use of ventricular assist devices has increased dramatically in adult heart failure patients. However, the overall use, outcome, comorbidities, and resource utilization of ventricular assist devices in pediatric patients have not been well described. We sought to demonstrate that the use of ventricular assist devices in pediatric patients has increased over time and that mortality has decreased. DESIGN: A retrospective study of the Pediatric Health Information System database was performed for patients 20 years old or younger undergoing ventricular assist device placement from 2000 to 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred seventy-five pediatric patients were implanted with ventricular assist devices during the study period: 69 in 2000-2003 (era 1), 135 in 2004-2006 (era 2), and 271 in 2007-2010 (era 3). Median age at ventricular assist device implantation was 6.0 years (interquartile range, 0.5-13.8), and the proportion of children who were 1-12 years old increased from 29% in era 1 to 47% in era 3 (p = 0.002). The majority of patients had a diagnosis of cardiomyopathy; this increased from 52% in era 1 to 72% in era 3 (p = 0.003). Comorbidities included arrhythmias (48%), pulmonary hypertension (16%), acute renal failure (34%), cerebrovascular disease (28%), and sepsis/systemic inflammatory response syndrome (34%). Two hundred forty-seven patients (52%) underwent heart transplantation and 327 (69%) survived to hospital discharge. Hospital mortality decreased from 42% in era 1 to 25% in era 3 (p = 0.004). Median hospital length of stay increased (37 d [interquartile range, 12-64 d] in era 1 vs 69 d [interquartile range, 35-130] in era 3; p < 0.001) and median adjusted hospital charges increased ($630,630 [interquartile range, $227,052-$853,318] in era 1 vs $1,577,983 [interquartile range, $874,463-$2,280,435] in era 3; p < 0.001). Factors associated with increased mortality include age less than 1 year (odds ratio, 2.04; 95% CI, 1.01-3.83), acute renal failure (odds ratio, 2.1; 95% CI, 1.26-3.65), cerebrovascular disease (odds ratio, 2.1; 95% CI, 1.25-3.62), and extracorporeal membrane oxygenation (odds ratio, 3.16; 95% CI, 1.79-5.60). Ventricular assist device placement in era 3 (odds ratio, 0.3; 95% CI, 0.15-0.57) and a diagnosis of cardiomyopathy (odds ratio, 0.5; 95% CI, 0.32-0.84), were associated with decreased mortality. Large-volume centers had lower mortality (odds ratio, 0.55; 95% CI, 0.34-0.88), lower use of extracorporeal membrane oxygenation, and higher charges. CONCLUSIONS: The use of ventricular assist devices and survival after ventricular assist device placement in pediatric patients have increased over time, with a concomitant increase in resource utilization. Age under 1 year, certain noncardiac morbidities, and the use of extracorporeal membrane oxygenation are associated with worse outcomes. Lower mortality was seen at larger volume ventricular assist device centers.
Assuntos
Cardiomiopatias/terapia , Coração Auxiliar/estatística & dados numéricos , Preços Hospitalares/tendências , Mortalidade Hospitalar/tendências , Hospitais Pediátricos/estatística & dados numéricos , Injúria Renal Aguda/mortalidade , Adolescente , Fatores Etários , Cardiomiopatias/mortalidade , Transtornos Cerebrovasculares/mortalidade , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/mortalidade , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Transplante de Coração , Coração Auxiliar/efeitos adversos , Coração Auxiliar/tendências , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Lactente , Tempo de Internação/tendências , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto JovemRESUMO
To characterize the overall use, cost, and outcomes of extracorporeal membrane oxygenation (ECMO) as an adjunct to cardiopulmonary resuscitation (CPR) among hospitalized infants and children in the United States, retrospective analysis of the 2000, 2003, and 2006 Kids' Inpatient Database (KID) was performed. All CPR episodes were identified; E-CPR was defined as ECMO used on the same day as CPR. Channeling bias was decreased by developing propensity scores representing the likelihood of requiring E-CPR. Univariable, multivariable, and propensity-matched analyses were performed to characterize the influence of E-CPR on survival. There were 8.6 million pediatric hospitalizations and 9,000 CPR events identified in the database. ECMO was used in 82 (0.9 %) of the CPR events. Median hospital charges for E-CPR survivors were $310,824 [interquartile range (IQR) 263,344-477,239] compared with $147,817 (IQR 62,943-317,553) for propensity-matched conventional CPR (C-CPR) survivors. Median LOS for E-CPR survivors (31 days) was considerably greater than that of propensity-matched C-CPR survivors (18 days). Unadjusted E-CPR mortality was higher relative to C-CPR (65.9 vs. 50.9 %; OR 1.9, 95 % confidence interval 1.2-2.9). Neither multivariable analysis nor propensity-matched analysis identified a significant difference in survival between groups. E-CPR is infrequently used for pediatric in-hospital cardiac arrest. Median LOS and charges are considerably greater for E-CPR survivors with C-CPR survivors. In this retrospective administrative database analysis, E-CPR did not significantly influence survival. Further study is needed to improve outcomes and to identify patients most likely to benefit from this resource-intensive therapy.
Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca/terapia , Hospitais Pediátricos , Pacientes Internados , Intervalos de Confiança , Feminino , Seguimentos , Parada Cardíaca/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Triiodothyronine levels decrease in infants and children after cardiopulmonary bypass. We tested the primary hypothesis that triiodothyronine (T3) repletion is safe in this population and produces improvements in postoperative clinical outcome. METHODS AND RESULTS: The TRICC study was a prospective, multicenter, double-blind, randomized, placebo-controlled trial in children younger than 2 years old undergoing heart surgery with cardiopulmonary bypass. Enrollment was stratified by surgical diagnosis. Time to extubation (TTE) was the primary outcome. Patients received intravenous T3 as Triostat (n=98) or placebo (n=95), and data were analyzed using Cox proportional hazards. Overall, TTE was similar between groups. There were no differences in adverse event rates, including arrhythmia. Prespecified analyses showed a significant interaction between age and treatment (P=0.0012). For patients younger than 5 months, the hazard ratio (chance of extubation) for Triostat was 1.72. (P=0.0216). Placebo median TTE was 98 hours with 95% confidence interval (CI) of 71 to 142 compared to Triostat TTE at 55 hours with CI of 44 to 92. TTE shortening corresponded to a reduction in inotropic agent use and improvement in cardiac function. For children 5 months of age, or older, Triostat produced a significant delay in median TTE: 16 hours (CI, 7-22) for placebo and 20 hours (CI, 16-45) for Triostat and (hazard ratio, 0.60; P=0.0220). CONCLUSIONS: T3 supplementation is safe. Analyses using age stratification indicate that T3 supplementation provides clinical advantages in patients younger than 5 months and no benefit for those older than 5 months. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00027417.
Assuntos
Ponte Cardiopulmonar , Cardiopatias Congênitas/terapia , Tri-Iodotironina/administração & dosagem , Fatores Etários , Arritmias Cardíacas/induzido quimicamente , Pré-Escolar , Método Duplo-Cego , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Tempo , Tri-Iodotironina/efeitos adversosAssuntos
Cardiologia/educação , Cuidados Críticos , Bolsas de Estudo/normas , Pediatria/educação , Adolescente , Criança , Pré-Escolar , Competência Clínica , Educação Baseada em Competências/normas , Cuidados Críticos/métodos , Estado Terminal/terapia , Currículo/normas , Avaliação Educacional , Objetivos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/terapia , Cardiopatias/diagnóstico , Cardiopatias/terapia , Humanos , Lactente , Recém-Nascido , Comunicação Interdisciplinar , Segurança do Paciente , Melhoria de Qualidade , EnsinoRESUMO
BACKGROUND: Angiotensin-converting enzyme inhibitor therapy is often initiated in pediatric patients who have had cardiac surgery. Acute kidney injury can occur in patients secondary to angiotensin-converting enzyme inhibitor initiation. Risk factors for acute kidney injury after angiotensin-converting enzyme inhibitor initiation have yet to be defined in postoperative pediatric cardiac patients. OBJECTIVES: To identify the frequency of acute kidney injury in patients receiving angiotensin-converting enzyme inhibitor therapy in postoperative pediatric cardiac surgical patients and to identify risk factors for acute kidney injury in this patient population. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The pharmacy and surgery databases were used to identify all patients <18 yrs of age who received angiotensin-converting enzyme inhibitor therapy after cardiac surgery at our institution from January 2006 to December 2007. Patients who did not have a baseline serum creatinine and at least one serum creatinine obtained after angiotensin-converting enzyme inhibitor initiation were excluded. Data collection included demographic information and cardiac pathophysiology/surgery, diuretic and/or nephrotoxic medication use, and angiotensin-converting enzyme inhibitor characteristics and initiation date. Baseline, daily, and maximum serum creatinine values were collected. Acute kidney injury was defined as the maximum change in pediatric-modified RIFLE (Risk, Injury, Failure, Loss, End-stage) acute kidney injury criteria within 48 hrs of initiation or increase in dose of angiotensin-converting enzyme inhibitor. Descriptive statistics were used to characterize the patient population, and a multivariate logistic regression model was developed to identify independent predictors of angiotensin-converting enzyme inhibitor-associated acute kidney injury. The study included 415 patient admissions (386 patients), 57% (n = 239) being male and infants (31 days to 2 yrs) being the most common age group. A functional single ventricle was present in 46% of the patients. Enalapril was initiated in 60% (n = 250) and captopril in 40% (n = 165) of patient admissions. Acute kidney injury occurred in 21% (n = 88) of patients initiated on an angiotensin-converting enzyme inhibitor (pediatric-modified RIFLE categories: R = 15%, I = 3%, F = 4%). Logistic regression identified cyanosis, coadministration of furosemide, and baseline estimated creatinine clearance as independent risk factors for any degree of angiotensin-converting enzyme inhibitor-associated acute kidney injury (p < .05). The hospital lengths of stay of patients with angiotensin-converting enzyme inhibitor-associated acute kidney injury (median 12 days, range 4-298 days) were greater compared to those of patients without angiotensin-converting enzyme inhibitor-associated acute kidney injury (median 10 days, range 3-199 days, p < .05). CONCLUSIONS: Initiation of angiotensin-converting enzyme inhibitor after cardiac surgery in pediatric patients may result in acute kidney injury. The presence of cyanosis and coadministration of furosemide are independent risk factors for acute kidney injury in patients receiving angiotensin-converting enzyme inhibitor.
Assuntos
Injúria Renal Aguda/induzido quimicamente , Inibidores da Enzima Conversora de Angiotensina , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Torácicos , Adolescente , Criança , Pré-Escolar , Contraindicações , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Masculino , Estudos Retrospectivos , Fatores de Risco , TexasRESUMO
OBJECTIVE: To determine the efficacy and safety of labetalol for hypertensive crisis in children ≤ 24 months of age. DESIGN: Retrospective chart review. Statistical analysis utilized analysis of variance for continuous data, chi-square tests for nominal data, and linear regression. SETTING: A 737-bed pediatric teaching institution. PATIENTS: Twenty-seven patients ≤ 24 months of age were treated with 37 intravenous infusions of labetalol, nicardipine, or nitroprusside for hypertensive crisis or hypertensive urgency. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary end point consisted of time to 20% reduction in systolic blood pressure. Primary safety end points measured the prevalence of deleterious effects of labetalol. Continuous infusion of labetalol reduced mean systolic blood pressure by at least 20% in < 8 hrs. This effect was similar to nicardipine and nitroprusside infusions. The reported side effects were similar in each group. Patients receiving labetalol and presenting with ischemic or traumatic brain injury were likely to develop hypotension requiring infusion discontinuation. CONCLUSIONS: Continuous intravenous labetalol infusion is efficacious for treatment of hypertensive crisis in children ≤ 24 months of age. Aside from patients presenting with ischemic or traumatic brain injury, labetalol was safe to use in this population for hypertensive emergencies and had a satisfactory adverse effect profile. Labetalol may reach dose saturation at a much lower dose in young children in comparison to adults. Clinicians should use caution when initiating labetalol infusions in young patients with brain injury.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Labetalol/uso terapêutico , Análise de Variância , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/efeitos adversos , Distribuição de Qui-Quadrado , Feminino , Humanos , Lactente , Infusões Intravenosas , Labetalol/administração & dosagem , Labetalol/efeitos adversos , Modelos Lineares , Masculino , Nicardipino/uso terapêutico , Nitroprussiato/uso terapêutico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Pediatric patients with congenital heart disease can have physiologies that alter the pharmacokinetics of certain medications, such as aminoglycosides. Currently, no literature describes the appropriate dosing of aminoglycoside antibiotics for infants and children with congenital heart disease. Patients were identified through the pharmacy and laboratory computer systems. Patients were included in the study if they were younger than 18 years, received gentamicin on the acute-care (nonintensive care) cardiology floor at the authors' institution, had structural congenital heart disease, and had a peak and trough level obtained at about the third dose or later. Cohort achievement of therapeutic peak and trough concentrations based on standard dosing guidelines was evaluated. The inclusion criteria were met by 48 patients (31 boys). Eight patients (17%) had baseline cyanosis. Cardiac surgery was performed for 23 patients (48%) during the same admission at which aminoglycoside therapy was initiated. A total of 27 patients (56%) received at least one other nephrotoxic medication at the time of aminoglycoside therapy. Six patients had undetectable serum trough levels. A therapeutic peak concentration was not achieved by 16.7% of the cohort, and 7.1% of the cohort did not achieve a therapeutic trough concentration. Pediatric patients with congenital heart disease may require alterations in gentamicin dosing. Close pharmacokinetic monitoring of aminoglycoside therapy for these patients is warranted to ensure attainment of goal concentrations.
Assuntos
Antibacterianos/administração & dosagem , Gentamicinas/administração & dosagem , Cardiopatias Congênitas/complicações , Infecções/tratamento farmacológico , Adolescente , Antibacterianos/farmacocinética , Peso Corporal , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Gentamicinas/farmacocinética , Cardiopatias Congênitas/metabolismo , Humanos , Lactente , Recém-Nascido , Infecções/complicações , Infecções/metabolismo , Injeções Intravenosas , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To test the hypothesis that pediatric residents would have shorter time to attempted defibrillation using automated external defibrillators (AEDs) compared with manual defibrillators (MDs). STUDY DESIGN: A prospective, randomized, controlled trial of AEDs versus MDs was performed. Pediatric residents responded to a simulated in-hospital ventricular fibrillation cardiac arrest and were randomized to using either an AED or MD. The primary end point was time to attempted defibrillation. RESULTS: Sixty residents, 21 (35%) interns, were randomized to 2 groups (AED = 30, MD = 30). Residents randomized to the AED group had a significantly shorter time to attempted defibrillation [median, 60 seconds (interquartile range, 53 to 71 seconds)] compared with those randomized to the MD group [median, 103 seconds (interquartile range, 68 to 288 seconds)] (P < .001). All residents in the AED group attempted defibrillation at <5 minutes compared with 23 (77%) in the MD group (P = .01). CONCLUSIONS: AEDs improve the time to attempted defibrillation by pediatric residents in simulated cardiac arrests. Further studies are needed to help determine the role of AEDs in pediatric in-hospital cardiac arrests.
Assuntos
Desfibriladores , Cardioversão Elétrica/métodos , Parada Cardíaca/terapia , Desenho de Equipamento , Humanos , Internato e Residência , Manequins , Pediatria/educação , Estudos Prospectivos , Fatores de TempoRESUMO
OBJECTIVE: Published data describe the use of fenoldopam in adults for treatment of oliguria/anuria and for renal perfusion and protection, but pediatric data are scant. We assessed the effects of fenoldopam on urine output and potential deleterious changes in hemodynamics or serum creatinine in children. DESIGN: Retrospective analysis. SETTING: Academic institution. PATIENTS: : All patients
Assuntos
Estado Terminal , Agonistas de Dopamina/uso terapêutico , Fenoldopam/uso terapêutico , Adolescente , Adulto , Criança , Pré-Escolar , Creatinina/sangue , Diurese/efeitos dos fármacos , Agonistas de Dopamina/efeitos adversos , Feminino , Fenoldopam/efeitos adversos , Hemodinâmica/efeitos dos fármacos , Humanos , Lactente , Nefropatias/prevenção & controle , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVES: The purpose of this study was to determine the incidence of renal insufficiency in children hospitalized with acute decompensated heart failure and whether worsening renal function is associated with adverse cardiovascular outcome. DESIGN: Prospective observational cohort study. SETTING: Single-center children's hospital. PATIENTS: All pediatric patients from birth to age 21 yrs admitted to our institution with acute decompensated heart failure from October 2003 to October 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Acute decompensated heart failure was defined as new-onset or acute exacerbation of heart failure signs or symptoms requiring hospitalization and inpatient treatment. We required that heart failure be attributable to ventricular dysfunction only. Worsening renal function was defined as an increase in serum creatinine by > or = 0.3 mg/dL during hospitalization. Sixty-three patients (35 male, 28 female) comprised 73 patient hospitalizations. Median age at admission was 10 yrs (range 0.1-20.3 yrs). Median serum creatinine at admission was 0.6 mg/dL (range 0.2-3.5 mg/dL), and median creatinine clearance was 103 mL/min/1.73 m2 (range 22-431 mL/min/1.73 m2). Serum creatinine increased during 60 of 73 (82%) patient hospitalizations (median increase 0.2 mg/dL, range 0.1-2.7 mg/dL), and worsening renal function occurred in 35 of 73 (48%) patient hospitalizations. Clinical variables associated with worsening renal function included admission serum creatinine (p = .009) and blood urea nitrogen (p = .04) and, during hospitalization, continuous infusions of dopamine (p = .028) or nesiritide (p = .007). Worsening renal function was independently associated with the combined end point of in-hospital death or need for mechanical circulatory support (adjusted odds ratio 10.2; 95% confidence interval 1.7-61.2, p = .011). Worsening renal function was also associated with longer observed length of stay (33 +/- 30 days vs. 18 +/- 25 days, p < .03). CONCLUSIONS: These data suggest that an important cardiorenal interaction occurs in children hospitalized for acute decompensated heart failure. Renal function commonly worsens in such patients and is associated with prolonged hospitalization and in-hospital death or the need for mechanical circulatory assistance.
Assuntos
Insuficiência Cardíaca/fisiopatologia , Nefropatias/complicações , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Humanos , Incidência , Lactente , Recém-Nascido , Nefropatias/fisiopatologia , Nefropatias/terapia , Testes de Função Renal , Masculino , Síndrome , Resultado do TratamentoRESUMO
OBJECTIVE: We present a case of trauma-induced complete atrioventricular block (transient) after placement of a central venous catheter. DESIGN: Case report. SETTING: Neonatal intensive care unit in a tertiary care children's hospital. PATIENT: Review of the medical record and clinical course of a single premature infant. INTERVENTIONS: Removal of central venous catheter, monitoring of the cardiac output exam, and serial monitoring of the arrhythmia profile. MEASUREMENTS AND MAIN RESULTS: Trauma-induced complete atrioventricular block from placement of the central venous catheter resolved in 9 days, obviating the need for pacemaker placement. CONCLUSIONS: Complete atrioventricular block is an infrequent complication of central venous catheter placement and may require several days to resolve.
Assuntos
Cateterismo Venoso Central/efeitos adversos , Bloqueio Cardíaco/etiologia , Índice de Apgar , Eletrocardiografia , Seguimentos , Bloqueio Cardíaco/diagnóstico , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Fatores de TempoRESUMO
BACKGROUND: The treatment of children with cardiac disease is one of the most prevalent and costly pediatric inpatient conditions. The design of inpatient medical services for children admitted to and discharged from noncritical cardiology care units, however, is undefined. North American Pediatric Cardiology Programs were surveyed to define noncritical cardiac care unit models in current practice. METHOD: An online survey that explored institutional and functional domains for noncritical cardiac care unit was crafted. All questions were multi-choice with comment boxes for further explanation. The survey was distributed by email four times over a 5-month period. RESULTS: Most programs (n = 45, 60%) exist in free-standing children's hospitals. Most programs cohort cardiac patients on noncritical cardiac care units that are restricted to cardiac patients in 39 (54%) programs or restricted to cardiac and other subspecialty patients in 23 (32%) programs. The most common frontline providers are categorical pediatric residents (n = 58, 81%) and nurse practitioners (n = 48, 67%). However, nurse practitioners are autonomous providers in only 21 (29%) programs. Only 33% of programs use a postoperative fast-track protocol. When transitioning care to referring physicians, most programs (n = 53, 72%) use facsimile to deliver pertinent patient information. Twenty-two programs (31%) use email to transition care, and eighteen (25%) programs use verbal communication. CONCLUSION: Most programs exist in free-standing children's hospitals in which the noncritical cardiac care units are in some form restricted to cardiac patients. While nurse practitioners are used on most noncritical cardiac care units, they rarely function as autonomous providers. The majority of programs in this survey do not incorporate any postoperative fast-track protocols in their practice. Given the current era of focused handoffs within hospital systems, relatively few programs utilize verbal handoffs to the referring pediatric cardiologist/pediatrician.
Assuntos
Cardiologia/organização & administração , Atenção à Saúde/organização & administração , Cardiopatias/terapia , Hospitais Pediátricos , Pacientes Internados , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Canadá , Criança , Pré-Escolar , Humanos , Lactente , Estados UnidosRESUMO
OBJECTIVES: To document cerebral saturation in response to alterations in mechanical ventilation in infants with bidirectional superior cavopulmonary connection. DESIGN: Prospective study. SETTING: Pediatric cardiovascular intensive care unit. PATIENTS: Children with functional single ventricle who have undergone bidirectional superior cavopulmonary connection. INTERVENTIONS: We measured cerebral oxygenation using near-infrared spectroscopy in response to three ventilator interventions (change 50% from baseline): a) hyperventilation with increased tidal volume; b) hyperventilation with increased respiratory rate; and c) hypoventilation by decreased respiratory rate. Physiologic variables documented were cerebral oxygenation index (rSO2i), arterial pH, and PCO2. MEASUREMENTS AND MAIN RESULTS: Ten patients (eight males and two females) underwent placement of bidirectional superior cavopulmonary connection. There were no mortalities. The mean age was months 8.6 (+/-2.1) months. Hyperventilation (tidal volume increase) caused an increase in pH from 7.35 to 7.42 (p = .001), a decreased PCO2 from a baseline 45.9 to 33.9 mm Hg. (p = .002), a decrease in rSO2i from 64.4 to 52.0 (p < .001), and a decreased Po2 from 52.8 to 46.9 mm Hg (p = .008). Hyperventilation (respiratory rate increase) caused increased pH from 7.35 to 7.39 (p = .002), decreased PCO2 from a baseline 41 to 37 mm Hg. (p = .021), decreased rSO2i from 65.9 to 56.7 (p = .007), and decreased PO2 from 54.9 to 48.9 mm Hg (p = .006). Hypoventilation (respiratory rate decrease) did not change pH did not change from baseline 7.35. The PCO2 increased from 40.8 to 42, and the rSO2i increased from 64.0 to 68.6 (p = .004). CONCLUSIONS: Hyperventilation can potentially cause a decrease in cerebral oxygenation and should be avoided in children with bidirectional superior cavopulmonary connection. Normoventilation and mild respiratory acidosis, however, preserve cerebral oxygenation in these patients.
Assuntos
Circulação Cerebrovascular , Derivação Cardíaca Direita , Oxigênio/metabolismo , Cuidados Pós-Operatórios , Respiração Artificial/métodos , Feminino , Hemodinâmica , Humanos , Hiperventilação , Hipoventilação , Lactente , Modelos Lineares , Masculino , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho , Volume de Ventilação PulmonarRESUMO
Traumatic injury to the tricuspid valve can result from severe nonpenetrating chest wall trauma. We present the case of an initially asymptomatic 11-year-old girl who was kicked in the chest by a horse. The trauma resulted in avulsed papillary muscles, ruptured chordae, and right heart failure. She underwent early tricuspid valve reconstruction and annuloplasty. We advocate for routine use of echocardiography to assess for traumatic injury to intracardiac structures. In addition, we believe that early surgical intervention may prevent right-sided heart dysfunction, atrial arrhythmias, and the need for valve replacement.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Traumatismos Torácicos/complicações , Parede Torácica/lesões , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Ferimentos não Penetrantes/complicações , Criança , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Feminino , Humanos , Traumatismos Torácicos/diagnóstico por imagem , Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/etiologia , Ferimentos não Penetrantes/diagnóstico por imagemRESUMO
OBJECTIVE: To assess the hemodynamic effects and safety of hydrocortisone in neonates with low cardiac output syndrome requiring high levels of inotropic support and fluid resuscitation after cardiac surgery. DESIGN: Retrospective chart review. SETTING: Fifteen-bed pediatric cardiovascular intensive care unit. PATIENTS: Twelve neonates with low cardiac output syndrome after cardiac surgery to whom hydrocortisone was administered according to one of two dosing regimens (100 mg/[m.day] for 2 days, 50 mg/[m.day] for 2 days, and 25 mg/[m.day] for 1 day or 100 mg/[m.day] for 1 day, 50 mg/[m.day] for 2 days, and 25 mg/[m.day] for 2 days) were identified from the Department of Pharmacy database between September 2002 and January 2004. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mean and systolic blood pressure increased significantly 3 hrs after hydrocortisone treatment from the values preceding hydrocortisone administration. The mean blood pressure increased from 44.0+/-3.0 to 55.4+/-2.3 mm Hg (p=.01) and the systolic blood pressure increased from 64.2+/-4.7 to 78.3+/-3.4 mm Hg (p=.04). Comparable beneficial changes were also seen in the heart rate, which decreased from 168.3+/-4.6 to 148.3+/-5.6 beats/min (p=.004) after 24 hrs of hydrocortisone administration and remained at this level during the 72 hrs of follow-up. Significant weaning of epinephrine infusions was possible, from a mean dose of 0.16 to 0.06 microg/(kg.min) (p=.008), within 24 hrs after the initiation of steroid administration, and this reduction was not offset by increases in other inotropic agents. hydrocortisone administration caused nonsignificant increases in mean blood glucose concentration (from 116.2+/-20.6 to 156.0+/-25.6 mg/dL; p=.64), mean white blood cell count (from 16.6+/-1.6 to 18.9+/-2.6 x 10 U/L; p=.35), and sodium level (from 144.7+/-1.3 to 145.3+/-1.3 mmol/L; p=.51). Ten of the 12 patients (83.3%) survived. CONCLUSION: Most of the hemodynamically compromised neonates who were unresponsive to high doses of inotropic agents and fluid resuscitation after heart surgery responded to hydrocortisone with improvement of hemodynamic parameters and a decrease in inotropic requirements.
Assuntos
Anti-Inflamatórios/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Baixo Débito Cardíaco/tratamento farmacológico , Frequência Cardíaca/efeitos dos fármacos , Hidrocortisona/uso terapêutico , Anti-Inflamatórios/administração & dosagem , Baixo Débito Cardíaco/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiotônicos/uso terapêutico , Protocolos Clínicos , Feminino , Humanos , Hidrocortisona/administração & dosagem , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Factors leading to cardiac intensive care unit (CICU) readmission and the impact on mortality have yet to be well delineated. We sought to define the prevalence and outcome for unscheduled CICU readmission. Secondary objectives were to identify indications and risk factors for unscheduled CICU readmission. METHODS: Retrospective analysis of prospectively collected registry data at a tertiary care children's hospital. Pediatric and adult patients with congenital and acquired heart disease who survived to initial CICU discharge were included. Patients with unexpected return to the CICU for acute change in clinical status were defined as unscheduled readmissions. RESULTS: Of the 645 discharges that met inclusion criteria, 37 resulted in unplanned readmission to the CICU. Patients requiring unscheduled readmission had higher mortality rates (16.2% vs 0.5%, P < .0001). Cardiac symptoms were the most common reason for readmission. On multivariate analysis, genetic anomaly (P = .001) and longer length of stay (LOS) during the index CICU admission (P = .01) were independently associated with readmission. For surgical patients, genetic anomaly (P = .001), single-ventricle anatomy (P = .05), and longer surgical support time (P < .001) were independently associated with readmission. CONCLUSION: Unscheduled readmission to the CICU within the same hospitalization was uncommon but associated with a higher mortality rate. Genetic anomaly and longer initial LOS were important risk factors for the entire cohort. Single-ventricle anatomy and longer intraoperative course were risk factors for surgical readmissions.
Assuntos
Cardiopatias/terapia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Sistema de Registros , Criança , Pré-Escolar , Feminino , Cardiopatias/epidemiologia , Humanos , Lactente , Tempo de Internação/tendências , Masculino , Alta do Paciente/tendências , Prevalência , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The spectrum of sternal wound infections after cardiac surgery ranges from superficial infections to a deep sternal infection known as mediastinitis. Mediastinitis is a rare but clinically relevant source of postoperative morbidity and mortality in adult and pediatric patients after cardiac surgery. METHODS: We retrospectively identified all patients diagnosed with mediastinitis after cardiac surgery from January 1987 to December 2002 (17 patients/7,616 surgeries = 0.2%). Demographic data, cardiac diagnosis, cardiac surgery, hospital length of stay, associated medical diagnosis, and surgical treatment for mediastinitis were collected. RESULTS: Fifteen pediatric patients (age < 18 years) were diagnosed with mediastinitis (mean age at diagnosis 37.5 months, range 21 days to 17 years. The median postoperative day of diagnosis was 14 days (6 to 50 days). The most common organism was Staphylococcus species (n = 9). Six patients had an associated bacteremia. The median hospital length of stay for all patients was 42.5 days (range 16 to 163 days). The hospital mortality was 1 of 15 (6%). Each patient was treated with intravenous antibiotics; sternal debridement; and rectus abdominus flap reconstruction (n = 7), pectoralis muscle flap reconstruction (n = 3), omentum reconstruction (n = 1), or primary sternal closure (n = 4). Three patients have undergone redo-sternotomy with orthotopic heart transplantation, bidirectional cavopulmonary anastomosis, and replacement of a right ventricle to pulmonary artery homograft. CONCLUSIONS: Timely diagnosis, aggressive sternal debridement, and liberal use of rotational muscle flaps can potentially minimize the morbidity and mortality in pediatric postoperative cardiac patients. Subsequent redo-sternotomy has not been problematic.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Mediastinite/diagnóstico , Mediastinite/terapia , Adolescente , Antibacterianos , Procedimentos Cirúrgicos Cardíacos/métodos , Criança , Pré-Escolar , Estudos de Coortes , Terapia Combinada , Desbridamento/métodos , Quimioterapia Combinada/administração & dosagem , Feminino , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Recém-Nascido , Masculino , Mediastinite/etiologia , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Retalhos Cirúrgicos , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/terapia , Resultado do Tratamento , Cicatrização/fisiologiaRESUMO
BACKGROUND: A growing number of adults with functional single ventricles are presenting as candidates for first-time and redo-Fontan operations. This study describes the clinical presentation and early operative results of adults who have undergone Fontan modifications. METHODS: Between July 1995 and April 2003, 23 patients (>18 years old) had Fontan operations. We retrospectively reviewed their perioperative courses. RESULTS: Twenty-three Fontan operations (first-time [n = 8] and redo [n = 15]) were performed with no early or late deaths. No patient has required reoperation. One patient has been listed for orthotopic heart transplantation. The overall mean age is 23 years (18 to 41 years); mean follow-up, 30 months; median postoperative hospital stay, 8 days (4 to 34 days); and median duration of chest tube drainage, 4 days (2 to 12 days). The postoperative New York Heart Association (NYHA) functional class was improved in 22 of 23 patients. Eight first-time Fontan operations (7 of 8 nonfenestrated) were performed; lateral tunnel (n = 7) and extracardiac conduit (n = 1). Two patients had preoperative arrhythmias. New onset arrhythmias (ventricular tachycardia and sinus node dysfunction), requiring treatment, occurred in two patients. Fifteen redo-Fontan operations (all nonfenestrated) were performed; lateral tunnel (n = 5) and extracardiac conduit (n = 10). Fifteen patients had preoperative arrhythmias, thirteen of which had intraatrial reentry tachycardia (IART) and required antiarrhythmic medications. Concomitant intraoperative radiofrequency ablation (RFA) (n = 11) and cryoablation (n = 1) procedures were performed. In the immediate postoperative period, there was IART recurrence in five patients (post-RFA [n = 4] and postcryoablation [n = 1]). At latest follow-up, no patient is being treated with antiarrhythmic medications. Two patients had new onset atrial arrhythmias that required treatment. CONCLUSIONS: The Fontan operation can be performed in adults with minimal morbidity and improved NYHA functional class. New onset arrhythmias requiring treatment are sources of perioperative morbidity. Complete arrhythmia resolution of the preoperative arrhythmia may not be achieved in the immediate postoperative period in redo-Fontan patients. However, modification (intraoperative radiofrequency ablation-right atrial debulking) of the atrial tachycardia circuits in the redo-Fontan patients can result in complete resolution of preoperative atrial tachyarrhythmias at early follow-up.