RESUMO
In the setting of physician shortages, nurse practitioner (NP) roles have evolved, with increasing independence across most healthcare settings. We sought to characterize referring clinician perceptions of NP-performed outpatient pediatric cardiology consultations. We electronically distributed to pediatric and family medicine physicians and NPs in Arkansas our 11-item survey assessing the acceptability of pediatric cardiology consultations being completed by an NP under varying circumstances. Circumstances included seven common referral indications, and the scale offered five answer choices ranging from "definitely unacceptable" to "definitely acceptable". A total of 292 of 1756 (16.6% response rate) referring clinicians responded to the survey. Overall, 57% of responses indicated that NP-completed pediatric cardiology evaluations were either definitely or probably unacceptable. Acceptability was varied by referral indication and referring clinician characteristics. Unacceptability of NP-completed pediatric cardiology evaluations was greatest among family medicine physicians (81%), pediatricians (66%), and clinicians working in solo or two-physician practices (77%) or community hospitals/clinics (71%). If NP evaluation of a murmur included required review with a cardiologist, the unacceptability rate dropped from 50 to 24% (p < 0.0001). Unacceptability was higher in physicians who do not work with NPs (69%) compared to those who do (60%) (pp < 0.0001). Many referring physicians were willing to send patients ≥ 100 miles to ensure evaluation by a pediatric cardiologist. Most referring physicians find pediatric cardiology evaluations performed by NPs to be unacceptable. Requisite review with a cardiologist improved acceptability of NP evaluations. Many referring physicians would send patients much farther to guarantee evaluation by a cardiologist.
Assuntos
Cardiologia , Profissionais de Enfermagem , Médicos , Criança , Humanos , Atenção à Saúde , Sopros CardíacosRESUMO
Ruptured diverticula and ventricular aneurysms are rare in the fetus, with a limited number of case reports published previously. Additional fetal complications secondary to these ventricular wall abnormalities can be seen. Interventional measures can be considered and attempted either in utero or postnatally to improve the chance of survival. We present a case of a ruptured diverticulum in a fetus and the clinical course.
Assuntos
Divertículo/diagnóstico , Doenças Fetais/diagnóstico , Ventrículos do Coração/anormalidades , Derrame Pericárdico/diagnóstico , Ultrassonografia Pré-Natal/métodos , Feminino , Feto/diagnóstico por imagem , Aneurisma Cardíaco/diagnóstico , Ventrículos do Coração/diagnóstico por imagem , Humanos , Recém-Nascido , Masculino , Derrame Pericárdico/cirurgia , Pericardiocentese/métodos , Gravidez , Cuidado Pré-Natal/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: Nitric oxide is utilized after pediatric cardiac surgery as an off-label medication without much evidence, is expensive, and varies among centers of varying surgical volume. The objective of our study was to describe the spectrum of nitric oxide utilization and to evaluate the effect of nitric oxide utilization on outcomes among patients cared for in centers of varying surgical volume using Pediatric Health Information system. METHODS: Patients aged ≤18 years undergoing heart surgery were included (2004-2015). Multivariable mixed-effects logistic regression models were fitted to evaluate association of center volume with odds of nitric oxide utilization among patients undergoing heart operations. Centers were classified into 3 volume categories based on tertiles of number of cardiopulmonary bypass cases performed (low volume: 34 792 patients, 21 centers; medium volume: 38 362 patients, 13 centers; high volume: 30 560 patients, 7 centers). RESULTS: A total of 103 714 patients from 41 hospitals were included. Of these, 15 708 (15.1%) patients received nitric oxide after cardiac surgery. Of the patients receiving nitric oxide, only 3936 (25.1%) patients were associated with a diagnosis of pulmonary hypertension. In adjusted models, low- and medium-volume centers were associated with higher nitric oxide utilization after heart operations as compared to high-volume centers (low vs high, odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.38-1.60; medium vs high, OR: 1.33, 95% CI: 1.26-1.41). Despite higher nitric oxide utilization, the mortality was worse among patients treated in low- and medium-volume centers, as compared to high-volume centers (low vs high, OR: 1.42, 95% CI: 1.26-1.60; medium vs high, OR: 1.14, 95% CI: 1.04-1.25). CONCLUSIONS: This study demonstrates variation in nitric oxide utilization after heart operations among centers of varying surgical volume. Further, it raises questions on the benefit of nitric oxide administration after pediatric cardiac surgery.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Óxido Nítrico/uso terapêutico , Uso Off-Label/estatística & dados numéricos , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Período Pós-Operatório , Resultado do Tratamento , Estados UnidosRESUMO
We report a case of subarachnoid haemorrhage resulting from a mycotic aortic aneurysm in a child with CHD. The patient previously underwent operations for CHD and had a subarachnoid haemorrhage of unknown cause before the scheduled re-operation. During the re-operation, a sealed rupture of an undiagnosed mycotic ascending aortic aneurysm was identified, and the causative organism was later identified as Streptococcus. A postoperative MRI indicated a partially thrombosed cerebral aneurysm. This case demonstrates that a mycotic aortic aneurysm can be a cause of intracranial haemorrhage in children.
Assuntos
Aneurisma Infectado/cirurgia , Aneurisma Aórtico/cirurgia , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/cirurgia , Aneurisma Infectado/complicações , Aneurisma Aórtico/complicações , Pré-Escolar , Endocardite Bacteriana/cirurgia , Cardiopatias Congênitas/cirurgia , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Infecções Estreptocócicas/complicações , Streptococcus/isolamento & purificação , Tomografia Computadorizada por Raios XRESUMO
Bleeding complications are a source of morbidity after Berlin EXCOR VAD implantation yet remain poorly characterized. We evaluated our experience to describe the bleeding complications among pediatric VAD recipients. We hypothesized that those with bleeding requiring exploration had abnormal coagulation profile compared with those without bleeding. The retrospective study included 43 consecutive patients with end-stage heart failure supported on pediatric mechanical cardiac support as a bridge to transplantation. Day-/event-based analysis on factors below associated with (i) bleeding and (ii) bleeding in next 48 h. Cases with bleeding were compared with day-matched patients without bleeding complications. Among 43 subjects bleeding occurred in 47% of cases, which necessitated exploration or chest tube placement. Twenty of 34 interventions for bleeding occurred in the first seven post-operative days. No differences in coagulation parameters or use of antiplatelet agents were noted among those who had bleeding vs. those who did not. Our results indicate that (i) re-bleeding requiring re-exploration was common, (ii) most of the bleeding occurred early post-implantation, (iii) there were no differences in coagulation parameters or the use of antiplatelet agents within 48 h of bleeding compared with those who did not bleed on each successive post-operative day.
Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Hemorragia Pós-Operatória/cirurgia , Adolescente , Transtornos da Coagulação Sanguínea/complicações , Estudos de Casos e Controles , Criança , Pré-Escolar , Humanos , Lactente , Hemorragia Pós-Operatória/etiologia , Reoperação , Estudos Retrospectivos , Fatores de Risco , EsternotomiaRESUMO
We evaluated whether near-infrared spectroscopy (NIRS) measurement from the flank correlates with renal vein saturation in children undergoing cardiac catheterization. Thirty-seven patients <18 years of age were studied. A NIRS sensor was placed on the flank, and venous oxygen saturations were measured from the renal vein and the inferior vena cava (IVC). There was a strong correlation between flank NIRS values (rSO(2)) and renal vein saturation (r = 0.821, p = 0.002) and IVC saturation (r = 0.638, p = 0.004) in children weighing ≤ 10 kg. In children weighing > 10 kg, there was no correlation between rSO(2) and renal vein saturation (r = 0.158, p = 0.57) or IVC saturation (r = -0.107, p = 0.67). Regional tissue oxygenation as measured by flank NIRS correlates well with both renal vein and IVC oxygen saturations in children weighing <10 kg undergoing cardiac catheterization, but not in larger children.
Assuntos
Cardiopatias/metabolismo , Rim/metabolismo , Consumo de Oxigênio , Oxigênio/metabolismo , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: Low-dose nonselective ß blockade is an effective treatment for problematic infantile hemangioma (PIH). Screening electrocardiograms (ECG) are performed prior to the initiation of propranolol to minimize the risk of exacerbating undiagnosed heart block. How ECG results affect subsequent propranolol usage and patient management remains unclear. We examined the value of ECG prior to propranolol therapy in a quaternary pediatric hospital. METHODS: A retrospective chart review was performed on all infants who received propranolol (2 mg/kg/day divided three times daily) to treat PIH at Arkansas Children's Hospital from Sept. 2008 to Sept. 2015. All available demographic, historical, and clinical data were obtained. ECGs and echocardiographic data were reviewed and summarized. A pediatric cardiologist read all ECGs. RESULTS: A total of 333 patients (75% female) received propranolol therapy. ECG information was available for 317 (95%). Abnormal findings were present on 44/317 (13.9%) of study ECGs. The most common abnormal finding was "voltage criteria for ventricular hypertrophy" (n = 35, 76.1%). Two patients had abnormal rhythms; one had first-degree atrioventricular (AV) block, and one had occasional premature atrial contractions. Of the 31 patients who underwent echocardiograms, 20 (35%) were abnormal. 2.9% of infants with PIH treated with propranolol required a follow-up with a cardiologist. No patient was precluded from taking propranolol due to the findings on screening ECG. CONCLUSIONS: Screening ECGs prior to propranolol therapy are abnormal in nearly 14% of patients with PIH but are unlikely to preclude therapy. In the absence of prior cardiac history, this cohort offers further evidence suggesting that screening ECGs may be of limited value in determining the safety of propranolol in otherwise healthy infants with PIH.
RESUMO
Pediatric cardiologists teach complicated concepts to a diverse group of learners that include medical students, nurses, residents, fellows, patients, and parents. Unfortunately, much of what is taught is not retained. In order to increase the likelihood of long-term retention, a cardiologist should teach with both meaning and sense. The authors provide a review of these concepts and give specific examples of how to teach in ways that both make sense and are meaningful to a cardiologist's leaners.
Assuntos
Cardiologia/educação , Competência Clínica , Currículo/normas , Internato e Residência , Pediatria/educação , Estudantes de Medicina , Ensino/normas , Criança , HumanosRESUMO
Congenital heart disease is a risk factor for the development of necrotizing enterocolitis, although the exact mechanism of development remains unclear. Herein, we report the case of an infant with pulmonary atresia, an intact ventricular septum, and multiple aortopulmonary collateral vessels. At 4 weeks of age, the infant developed necrotizing enterocolitis in association with significant mesenteric oxygen desaturation, as measured by means of near-infrared spectroscopy. With bowel rest and antibiotic therapy, the patient's mesenteric oxygen saturation and clinical status improved. This case highlights the importance of impaired mesenteric oxygen delivery consequential to congenital heart disease as a possible risk factor for necrotizing enterocolitis, and the use of near-infrared spectroscopy to measure tissue perfusion noninvasively in high-risk patients. To our knowledge, this is the 1st report of mesenteric oxyhemoglobin desaturation in association with necrotizing enterocolitis in a patient who also had congenital heart disease.
Assuntos
Enterocolite Necrosante/metabolismo , Intestino Delgado/irrigação sanguínea , Consumo de Oxigênio/fisiologia , Atresia Pulmonar/complicações , Circulação Esplâncnica/fisiologia , Antibacterianos/administração & dosagem , Gasometria , Progressão da Doença , Enterocolite Necrosante/tratamento farmacológico , Enterocolite Necrosante/etiologia , Seguimentos , Humanos , Recém-Nascido , Infusões Intravenosas , Masculino , Atresia Pulmonar/metabolismo , Espectroscopia de Luz Próxima ao InfravermelhoRESUMO
OBJECTIVES: To characterize cardiac arrest in children undergoing cardiac surgery using single-center data from the Society of Thoracic Surgeons and Pediatric Advanced Life Support Utstein-Style Guidelines. METHODS: Patients aged 18 years or less having a cardiac arrest for 1 minute or more during the same hospital stay as heart operation qualified for inclusion (2002-2014). Patients having a cardiac arrest both before or after heart operation were included. Heart operations were classified on the basis of the first cardiovascular operation of each hospital admission (the index operation). The primary outcome was survival to hospital discharge. RESULTS: A total of 3437 children undergoing at least 1 heart operation were included. Overall rate of cardiac arrest among these patients was 4.5% (n = 154) with survival to hospital discharge of 84 patients (66.6%). Presurgery cardiac arrest was noted among 28 patients, with survival of 21 patients (75%). Among the 126 patients with postsurgery cardiac arrest, survival was noted among 84 patients (66.6%). Regardless of surgical case complexity, the median days between heart operation and cardiac arrest, duration of cardiac arrest, and survival after cardiac arrest were similar. The independent risk factors associated with improved chances of survival included shorter duration of cardiac arrest (odds ratio, 1.12; 95% confidence interval, 1.05-1.20; P = .01) and use of defibrillator (odds ratio, 4.51; 95% confidence interval, 1.08-18.87; P = .03). CONCLUSIONS: This single-center study demonstrates that characterizing cardiac arrest in children undergoing cardiac surgery using definitions from 2 societies helps to increase data granularity and understand the relationship between cardiac arrest and heart operation in a better way.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Reanimação Cardiopulmonar/métodos , Parada Cardíaca/epidemiologia , Arkansas/epidemiologia , Feminino , Parada Cardíaca/terapia , Mortalidade Hospitalar/tendências , Humanos , Incidência , Lactente , Masculino , Razão de Chances , Alta do Paciente/tendências , Período Pré-Operatório , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
We describe the case of a 3-week-old infant who was diagnosed with pulmonary atresia, a ventricular septal defect, and discontinuous pulmonary arteries. The pulmonary artery anatomy was delineated by angiography: the right pulmonary artery arose from the proximal right coronary artery, and the left pulmonary artery arose from a left ductus arteriosus. This case illustrates the importance of careful delineation of the anatomy in complex pulmonary atresia before surgical intervention.
Assuntos
Anormalidades Múltiplas , Artéria Pulmonar/anormalidades , Atresia Pulmonar/etiologia , Atresia Pulmonar/cirurgia , Anormalidades Múltiplas/cirurgia , Procedimentos Cirúrgicos Cardíacos , Angiografia Coronária , Anomalias dos Vasos Coronários/cirurgia , Feminino , Comunicação Interventricular/epidemiologia , Humanos , Recém-Nascido , Artéria Pulmonar/cirurgiaRESUMO
BACKGROUND: Mitral valve replacement (MVR) in children has been associated with a high complication rate. We sought to assess predictors of outcomes in children undergoing MVR. METHODS: A retrospective review of clinical, surgical, and echocardiographic records of patients undergoing MVR was performed. Between 1982 and 2000, 53 children underwent 76 MVR procedures at a median age of 5 years (range, 1 day to 18 years) and weight of 17 kg (range, 3 to 121 kg). Eighteen patients (34%) had more than one MVR. Previous cardiac surgery had been performed in 39 (74%), with 27 (51%) undergoing previous mitral repair. Patients were followed for 9.2 +/- 4.8 (range, 2 to 20) years. RESULTS: There were 14 patient deaths, with 6 patients dying within 30 days, and five transplants (36%). Ten-year freedom from reoperation was 66%. Long-term survivors were older at initial repair (7.0 vs 2.5 years, p = 0.02), with a lower incidence of residual cardiac lesions (3% vs 37%, p < 0.001) and a lower incidence of surgical procedures at the time of MVR (31% vs 63%, p = 0.04). Survivors had better left ventricular function preoperatively (ejection fraction, 68% vs 54%; p = 0.001) and placement of a prosthetic valve within 1 z-score of the echocardiographically measured mitral valve annulus (p = 0.02). CONCLUSIONS: Adverse outcome after MVR is common, particularly in the young child undergoing palliative surgery or requiring additional surgical procedures. Preoperative assessment of mitral valve size and ventricular function is essential for risk stratification of these patients.
Assuntos
Doenças das Valvas Cardíacas/cirurgia , Valva Mitral/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , UltrassonografiaRESUMO
In Kawasaki disease, coronary aneurysms typically regress slowly, although some may develop stenosis 1-2 decades after the acute illness. This is the first case report describing rapid progression of coronary aneurysm to stenosis within 14 weeks.
Assuntos
Aneurisma Coronário/diagnóstico , Aneurisma Coronário/etiologia , Estenose Coronária/diagnóstico , Estenose Coronária/etiologia , Progressão da Doença , Síndrome de Linfonodos Mucocutâneos/complicações , Adenosina/uso terapêutico , Pré-Escolar , Aneurisma Coronário/tratamento farmacológico , Estenose Coronária/tratamento farmacológico , Ecocardiografia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Humanos , Masculino , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Vasodilatadores/uso terapêuticoRESUMO
Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart defect. It is typically diagnosed at a few months of age. The infant presents with cardiac failure secondary to left ventricular dysfunction from the coronary steal that develops as pulmonary vascular resistance (PVR) falls. With the diagnosis made, surgical repair is typically performed expeditiously in order to try and restore left ventricular perfusion and stop the ongoing coronary steal. We present an unusual case of a preterm infant undergoing a routine echocardiogram, who was incidentally found to have an ALCAPA. Management strategies between neonatology and cardiology may differ in this setting. In this case, elevated PVR helps to preserve myocardial perfusion prior to surgical repair. Therefore, common neonatal management strategies typically utilized for respiratory distress, elevated PVR, and cardiac dysfunction may have potential for detrimental effects on myocardial perfusion in this specific lesion. This case also emphasizes the importance of identifying the coronary origins as a routine part of a complete pediatric echocardiogram. It also presents a rarely encountered problem: when to repair an ALCAPA in an as yet asymptomatic patient. We believe this to be the youngest and smallest patient reported with the diagnosis and successful surgical correction of an ALCAPA.