Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway.

OBJECTIVES: Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization. DESIGN: A quality improvement study using a prospective cohort design with historical controls. SETTING: Four hundred seven-bed free standing quaternary care academic children's hospital. PATIENTS: All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022. INTERVENTIONS: Unit-specific standard approaches to iNO initiation and weaning. MEASUREMENTS AND MAIN RESULTS: Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (-24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings. CONCLUSIONS: Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.

Building a Culture of Wellness When Systems Do Not Allow for Collaborative Care.

INTRODUCTION: Health care is fragmented and frustrating to patients and physicians. The consequences include patient and physician dissatisfaction. METHODS: The author's perspective is informed by his research, innovation, and leadership to optimize the experience of care for physicians and patients. RESULTS: Understanding and prioritizing the touchpoints between patients and physicians is essential to designing health care delivery that is compassionate to patients and is fulfilling and sustainable for physicians. CONCLUSIONS: Hospital administrative leaders and physicians must reject the culture of a dichotomy in purpose, and partner to create systems that make the right thing to do, the easy thing to do. LEVELS OF EVIDENCE: Level V-expert opinion.

An Elevated Low Cardiac Output Syndrome Score Is Associated With Morbidity in Infants After Congenital Heart Surgery.

OBJECTIVES: To evaluate an empirically derived Low Cardiac Output Syndrome Score as a clinical assessment tool for the presence and severity of Low Cardiac Output Syndrome and to examine its association with clinical outcomes in infants who underwent surgical repair or palliation of congenital heart defects. DESIGN: Prospective observational cohort study. SETTING: Cardiac ICU at Seattle Children's Hospital. PATIENTS: Infants undergoing surgical repair or palliation of congenital heart defects. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical and laboratory data were recorded hourly for the first 24 hours after surgery. A Low Cardiac Output Syndrome Score was calculated by assigning one point for each of the following: tachycardia, oliguria, toe temperature less than 30°C, need for volume administration in excess of 30 mL/kg/d, decreased near infrared spectrometry measurements, hyperlactatemia, and need for vasoactive/inotropes in excess of milrinone at 0.5 µg/kg/min. A cumulative Low Cardiac Output Syndrome Score was determined by summation of Low Cardiac Output Syndrome Score on arrival to cardiac ICU, and 8, 12, and 24 hours postoperatively. Scores were analyzed for association with composite morbidity (prolonged mechanical ventilation, new infection, cardiopulmonary arrest, neurologic event, renal dysfunction, necrotizing enterocolitis, and extracorporeal life support) and resource utilization. Fifty-four patients were included. Overall composite morbidity was 33.3%. Median peak Low Cardiac Output Syndrome Score and cumulative Low Cardiac Output Syndrome Score were higher in patients with composite morbidity (3 [2-5] vs 2 [1-3]; p = 0.003 and 8 [5-10] vs 2.5 [1-5]; p < 0.001)]. Area under the receiver operating characteristic curve for cumulative Low Cardiac Output Syndrome Score versus composite morbidity was 0.83, optimal cutoff of greater than 6. Patients with cumulative Low Cardiac Output Syndrome Score greater than or equal to 7 had higher morbidity, longer duration of mechanical ventilation, cardiac ICU, and hospital length of stay (all p ≤ 0.001). After adjusting for other relevant variables, peak Low Cardiac Output Syndrome Score and cumulative Low Cardiac Output Syndrome Score were independently associated with composite morbidity (odds ratio, 2.57; 95% CI, 1.12-5.9 and odds ratio, 1.35; 95% CI, 1.09-1.67, respectively). CONCLUSION: Higher peak Low Cardiac Output Syndrome Score and cumulative Low Cardiac Output Syndrome Score were associated with increased morbidity and resource utilization among infants following surgery for congenital heart defects and might be a useful tools in future cardiac intensive care research. Independent validation is required.

Critical Heart Failure and Shock.

OBJECTIVES: The objectives of this review are to discuss the clinical assessment, pathophysiology, and management of shock, with an emphasis on circulatory physiology, cardiopulmonary interactions, and pharmacologic strategies to optimize systemic oxygen delivery. These principles will then be applied to the clinical syndromes of heart failure and cardiogenic shock that are seen in children. DATA SOURCE: MEDLINE, PubMed. CONCLUSION: An understanding of essential circulatory physiology and the pathophysiology of shock are necessary for managing patients at risk for or in a state of shock. A timely and accurate assessment of cardiac function, cardiac output, and tissue oxygenation and the means by which to enhance the relationship between oxygen delivery and consumption are essential in order to optimize outcomes.

Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda.

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

Pathophysiology of right ventricular failure in pulmonary hypertension.

This review focuses on right ventricular anatomy and function and the significance of ventricular interdependence in the response of the right ventricle to an increase in afterload. This is followed by a discussion of the pathophysiology of right ventricular failure in pulmonary arterial hypertension as well as in other clinical syndromes of pulmonary hypertension. Pulmonary hypertension is common in critically ill children and is associated with several conditions. Regardless of the etiology, an increase in right ventricular afterload leads to a number of compensatory changes in cardiovascular physiology. These changes are not altogether intuitive and require an understanding of right ventricular physiology and ventricular interdependence to optimize the care of these patients.

CONNECT Workshops to Enhance Physician and Patient Experience: Interviews Reveal the Physician Perspective.

INTRODUCTION: Physicians' relationships with patients are a critical determinant of job satisfaction, and patients who experience compassionate care have better outcomes. The CONNECT workshop at Seattle Children's teaches communication strategies to optimize both patient and physician experience. This article describes participants' experiences during the workshops and the impact on their subsequent behaviors and satisfaction. METHODS: Thirteen semistructured interviews were conducted with physicians, representing 11 specialties. Researchers used a series of immersion-crystallization cycles through which they iteratively immersed themselves in the data by reviewing all transcripts and coming up with key themes. According to thematic findings, they adjusted the interview guides, adding or deleting probes. After crystallizing an initial list of key themes, they created a codebook, coded using qualitative analysis software and met after coding each transcript to discuss their codes, add, and change codes, and recode when necessary. RESULTS: Researchers identified 2 thematic responses concerning workshop experience. Physicians valued colleague interaction (Theme A) and appreciated the nonprescriptive curriculum (Theme B). Likewise, 3 themes reflecting workshop impact also emerged. Physicians reported the workshop encouraged presence and self-awareness during patient encounters (Theme C). They learned to address patient-driven concerns (Theme D), and learned empathetic strategies to connect more deeply with patients (Theme E). CONCLUSION: This study offers perspectives from a diverse group of physicians concerning their experience with the communication workshop, including the opportunity for physicians to focus on self-discovery, authenticity, connect on a deeper level with colleagues, and adopt key strategies to enhance interactions with patients.

An investigation of Aspergillus cardiac surgical site infections in 3 pediatric patients.

BACKGROUND: Within a 3-month period, 3 pediatric patients at our hospital developed Aspergillus surgical site infections after undergoing cardiac surgery. METHODS: A multidisciplinary team conducted an epidemiologic review of the 3 patients and their infections, operative and postoperative patient care delivery, and routine maintenance of hospital equipment and air-filtration systems and investigated potential environmental exposures within the hospital that may have contributed to the development of these infections. RESULTS: Review of the patients and their infections, operative and postoperative patient care delivery, and routine maintenance did not reveal a source for infection. Inspection of operating room (OR) facilities identified several areas in need of repair. Of the 58 samples of air and equipment exhaust in the ORs and patient care areas, 11 revealed 2 to 4 colony-forming units of various Aspergillus species per cubic meter of air, and the remaining 47 samples were negative for Aspergillus. Eighty-three samples of surfaces and equipment water reservoirs were obtained from the OR and patient care areas. One culture of a soiled liquid nitrogen tank housed between the 2 cardiac ORs revealed 13 colony-forming units of Aspergillus. CONCLUSION: No definitive source was identified, although a soiled liquid nitrogen tank contaminated with Aspergillus and kept near the OR was found and could have been a possible source.

Noninvasive positive-pressure ventilation in children with lower airway obstruction.

STUDY OBJECTIVES: Mechanical ventilation of patients with severe lower airway obstruction presents significant risks; therefore, avoiding the intubation in these patients has been a principal goal of clinical management. Noninvasive positive-pressure ventilation has been shown to be effective in treating adults with chronic obstructive pulmonary disease, but its use has not been studied prospectively in children with acute obstructive lower airways disease. The objective of this study was to determine whether noninvasive mask ventilation improved respiratory function in children with asthma and other obstructive lower airways diseases. STUDY DESIGN: A prospective, randomized, crossover study. PATIENTS: A total of 20 children admitted to the pediatric intensive care unit with acute lower airway obstruction. METHODS: Children were randomized to receive either 2 hrs of noninvasive ventilation followed by crossover to 2 hrs of standard therapy or 2 hrs of standard therapy followed by 2 hrs of noninvasive ventilation. RESULTS: Using a Clinical Asthma Score, we found that noninvasive ventilation decreased signs of work of breathing such as respiratory rate, accessory muscle use, and dyspnea as compared with standard therapy. There was no serious morbidity associated with noninvasive ventilation. CONCLUSIONS: We conclude that noninvasive ventilation can be an effective treatment for children with acute lower airway obstruction.

Examining palliative care team involvement in automatic consultations for children on extracorporeal life support in the pediatric intensive care unit.

BACKGROUND: Extracorporeal life support (ECLS) is an advanced form of life-sustaining therapy that creates stressful dilemmas for families. In May 2009, Seattle Children's Hospital (SCH) implemented a policy to involve the Pediatric Advanced Care Team (PACT) in all ECLS cases through automatic referral. OBJECTIVE: Our aim was to describe PACT involvement in the context of automatic consultations for ECLS patients and their family members. METHODS: We retrospectively examined chart notes for 59 consecutive cases and used content analysis to identify themes and patterns. RESULTS: The degree of PACT involvement was related to three domains: prognostic uncertainty, medical complexity, and need for coordination of care with other services. Low PACT involvement was associated with cases with little prognostic uncertainty, little medical complexity, and minimal need for coordination of care. Medium PACT involvement was associated with two categories of cases: 1) those with a degree of medical complexity but little prognostic uncertainty; and 2) those that had a degree of prognostic uncertainty but little medical complexity. High PACT involvement had the greatest medical complexity and prognostic uncertainty, and also had those cases with a high need for coordination of care. CONCLUSIONS: We describe a framework for understanding the potential involvement of palliative care among patients receiving ECLS that explains how PACT organizes its efforts toward patients and families with the highest degree of need. Future studies should examine whether this approach is associated with improved patient and family outcomes.