Pediatric cardiac intensive care: current state of the art and beyond the millennium

Advanced fellowship training for cardiology fellows in acute care cardiology

Hospitalised children have become more medically complex and increasingly require specialised teams and units properly equipped to care for them. Within paediatric cardiology, this trend, which is well demonstrated by the expansion of cardiology-specific ICUs, has more recently led to the development of acute care cardiology units to deliver team-based and condition-focused inpatient care. These care teams are now led by paediatric cardiologists with particular investment in the acute care cardiology environment. Herein, we describe the foundation and development of an Acute Care Cardiology Advanced Training Fellowship to meet the clinical, scholarly, and leadership training needs of this emerging care environment.

Developmental Care for Hospitalized Infants With Complex Congenital Heart Disease: A Science Advisory From the American Heart Association

Developmental disorders, disabilities, and delays are a common outcome for individuals with complex congenital heart disease, yet targeting early factors influencing these conditions after birth and during the neonatal hospitalization for cardiac surgery remains a critical need. The purpose of this science advisory is to (1) describe the burden of developmental disorders, disabilities, and delays for infants with complex congenital heart disease, (2) define the potential health and neurodevelopmental benefits of developmental care for infants with complex congenital heart disease, and (3) identify critical gaps in research aimed at evaluating developmental care interventions to improve neurodevelopmental outcomes in complex congenital heart disease. This call to action targets research scientists, clinicians, policymakers, government agencies, advocacy groups, and health care organization leadership to support funding and hospital-based infrastructure for developmental care in the complex congenital heart disease population. Prioritization of research on and implementation of developmental care interventions in this population should be a major focus in the next decade.

TIVA versus Inhalational Agents for Pediatric Cardiac Intensive Care

The field of pediatric intensive care has come a long way, especially with the recognition that adequate sedation and analgesia form an imperative cornerstone of patient management. With various drugs available for the same, the debate continues as to which is the better: total intravenous anesthesia (TIVA) or inhalational agents. While each have their own advantages and disadvantages, in the present era of balance toward the IV agents, we should not forget the edge our volatile agents (VAs) might have in special scenarios. And ultimately as anesthesiologists, let us not forget that be it knob and dial, or syringe and plunger, our aim is to put pain to sleep and awaken a new faith to breathe.

Pediatric Cardiac Intensive Care Distribution, Service Delivery, and Staffing in the United States in 2018

OBJECTIVES

To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States.

DESIGN

Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders.

SETTING

Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease.

PARTICIPANTS

Cardiac ICU or mixed ICU physician medical directors or designees.

MEASUREMENTS AND MAIN RESULTS

One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001).

CONCLUSIONS

Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.

An International Survey Comparing Different Physician Models for Health Care Delivery to Critically Ill Children With Heart Disease

OBJECTIVES

To explore relationships between the training background of cardiac critical care attending physicians and self-reported perceived strengths and weaknesses in their ability to provide clinical care.

DESIGN

Cross-sectional observational survey sent worldwide to ~550 practicing cardiac ICU attending physicians.

SETTING

Hospitals providing cardiac critical care.

SUBJECTS

Practicing cardiac critical care physicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We received responses from 243 ICU attending physicians from 82 centers (14 countries). The primary training background of the respondents included critical care (62%), dual training in critical care and cardiology (16%), cardiology (14%), and other (8%). We received 49 responses from medical directors in nine countries, who reported that the predominant training background for attending physicians who provide cardiac intensive care at their institutions were critical care (58%), dual trained (18%), cardiology (12%), and other (11%). A greater proportion of physicians trained in either critical care or dual-training reported feeling confident managing multiple organ failure, neurologic conditions, brain death, cardiac arrest, and performing procedures like advanced airway placement and inserting chest- and abdominal-drains. In contrast, physicians with cardiology and dual-training reported feeling more confident managing intractable arrhythmias, understanding cardiopulmonary interactions, and interpreting echocardiogram, electrocardiogram, and cardiac catheterization. Overall, only 57% of the respondents felt comfortable based on their current training background to manage patients with complex cardiac issues without collaboration with other specialists.

CONCLUSIONS

Our survey demonstrates that intensivists trained in critical care are more comfortable with critical care skills, cardiology-trained intensivists are more comfortable with cardiology skills, and dual-trained physicians are comfortable with both critical care skills and cardiology skills. These findings may help inform future efforts to optimize the educational curriculum and training pathways for future cardiac intensivists. These data may also be used to shape continuing medical education activities for cardiac intensivists who have already completed their training.

Quality Improvement in Congenital Heart Surgery

Congenital heart disease is a major public health concern in the United States. Outcomes of surgery for children with congenital heart disease have dramatically improved over the last several decades with current aggregate operative mortality rates approximating 3%, inclusive of all ages and defects. However, there remains significant variability among institutions, especially for higher-risk and more complex patients. As health care moves toward the quadruple aim of improving patient experience, improving the health of populations, lowering costs, and increasing satisfaction among providers, congenital heart surgery programs must evolve to meet the growing scrutiny, demands, and expectations of numerous stakeholders. Improved outcomes and reduced interinstitutional variability are achieved through prioritization of quality assurance and improvement.

Establishing a High-Quality Congenital Cardiac Surgery Program in a Developing Country: Lessons Learned

Background: Developing countries are profoundly affected by the burden of congenital heart disease (CHD) because of limited resources, poverty, cost, and inefficient governance. The outcome of pediatric cardiac surgery in developing countries is suboptimal, and the availability of sustainable programs is minimal. Aim: This study describes the establishment of a high quality in-situ pediatric cardiac surgery program in Lebanon, a limited resource country. Methods: We enrolled all patients operated for CHD at the Children's Heart Center at the American University of Beirut between January 2014 and December 2018. Financial information was obtained. We established a partnership between the state, private University hospital, and philanthropic organizations to support the program. Results: In 5 years, 856 consecutive patients underwent 993 surgical procedures. Neonates and infants constituted 22.5 and 22.6% of our cohort, respectively. Most patients (82.6%) underwent one cardiac procedure. Our results were similar to those of the Society of Thoracic Surgeons (STS) harvest and to the expected mortalities in RACHS-1 scores with an overall mortality of 2.8%. The government (Public) covered 43% of the hospital bill, the Philanthropic organizations covered 30%, and the Private hospital provided a 25% discount. The parents' out-of-pocket contribution included another 2%. The average cost per patient, including neonates, was $19,800. Conclusion: High standard pediatric cardiac surgery programs can be achieved in limited-resource countries, with outcome measures comparable to developed countries. We established a viable financial model through a tripartite partnership between Public, Private, and Philanthropy (3P system) to provide high caliber care to children with CHD.

Impact of intensive care unit attending physician training background on outcomes in children undergoing heart operations

Background:

The existing training pathways to become a pediatric cardiac intensivist are very variable with physicians coming from varied training backgrounds of pediatric critical care, pediatric cardiology, neonatology, or pediatric anesthesia.

Aim:

To evaluate the impact of cardiac Intensive Care Unit (ICU) attending physician training background on outcomes in children undergoing heart operations.

Setting and Design:

Patients in the age group from 1 day to 18 years undergoing heart operation at a Pediatric Health Information System database participating hospital were included (2010–2015).

Patients and Methods:

Based on the training background of majority of attending physicians in an ICU, the participating ICUs were divided into three groups: critical care medicine (CCM), cardiology, and indeterminate.

Statistical Analysis:

Multivariable logistic regression models were fitted to evaluate the association of ICU physician training background with study outcomes.

Results:

A total of 54,935 patients from 42 ICUs were included. Of these, 31,815 patients (58%) were treated in the CCM group (26 ICUs), 19,340 patients (35%) were treated in the cardiology group (12 ICUs), and 3780 patients (7%) were treated in the indeterminate group (4 ICUs). In adjusted models, no specific group based on ICU attending physician training background was associated with lower mortality (CCM vs. cardiology, odds ratio: 0.75, 95% confidence interval: 0.48–1.18), or lower incidence of cardiac arrest, or prolonged hospital length of stay, or prolonged mechanical ventilation.

Conclusions:

This large observational study did not demonstrate any impact of ICU attending training background on outcomes in children undergoing heart operations.

Perceptions of Bedside Cardiac Critical Care Registered Nurses on 24 Hour Attending Intensivist Coverage

OBJECTIVE

To elicit the perceptions of bedside critical care nurses toward continual in-house attending coverage and its effect on patient safety, communication, and nursing education.

DESIGN

A 5-point Likert-type questionnaire was designed to evaluate the perception of bedside nurses in the pediatric cardiac intensive care unit (PCICU) toward the presence of a 24 hour in-house attending physician.

SETTING

Single tertiary referral PCICU in Washington, DC SUBJECTS: The 46 PCICU nurses who participated in the study were separated into two groups based on exposure to the recent implementation of continual in-house attending coverage at our institution. Group one consisted of 14 nurses with only exposure to the new 24/7 in-house coverage while group two encompassed 32 nurses who had experienced both the new and old system (off-site on-demand attending physician).

MEASUREMENTS AND MAIN RESULTS

Surveys demonstrated that both groups found that the new system has a positive impact on nursing education (median score of 5) as well as a positive impact on the communication between multidisciplinary teams and between care team and families (median score of 5). Nurses who experienced only the new system scored one point lower (median score of 4) regarding the effect of this staffing model on patient outcomes than nurses who had experienced both systems (median score of 5, P = .016). Between 83% and 98% of all 46 nurses who participated indicated they agree or strongly agree with each of the questions regarding the benefit of 24 hour in-house attending coverage.

CONCLUSION

Our study suggests that regardless of differences in experience, pediatric cardiac nurses believe the presence of an on-site intensivist to be beneficial to both nursing and patients.

Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: a single center experience in a developing economy

Background:

The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world.

Objective:

We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution.

Methods:

The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection.

Results:

The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance.

Conclusions:

The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.

An impact evaluation of a newly developed pediatric cardiac intensive care unit

PURPOSE

The highly complex pediatric patients with congenital heart disease require interprofessional teamwork and collaboration to ensure high-quality outcomes with low mortality and morbidity (Congenit Heart Dis. 2013;8:3-19). The purpose of this study was to conduct an impact evaluation for a newly formed pediatric cardiac intensive care unit (PCICU) and to answer: Is there a difference between the pediatric intensive care unit and the PCICU on clinical outcome measures of pediatric cardiac postoperative patients and nursing resources?

DESIGN

A retrospective pretest/posttest design was used with the independent variables being type of intensive care unit. The confounding variables included demographic data, clinical outcome data, registered nurse (RN) staffing data, and RN turnover data.

SETTING

The setting was a large, level I pediatric medical and surgical intensive care unit (ICU) located at a children's hospital within an academic medical center.

SAMPLE

The population was pediatric cardiac postoperative patients. Patients excluded were those older than 18 years or cases without a Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality Category score of 1 through 5.

METHODS

Owen's impact evaluation method and descriptive statistical measures, t test and Pearson χ test, were used for analysis.

RESULTS

Demographic data were comparable between the pediatric intensive care unit (n = 296) and PCICU (n = 333). No statistical differences were found in several of the clinical outcome measures. Statistically significant differences were found in surgeon (P = .00) and RN nursing hours per patient day for all cardiac patients (P = .01). The PCICU time frame had a higher RN turnover rate.

CONCLUSIONS

The majority of quality measures were not statistically different between the 2 ICUs. Even though statistical significance was not reached, the clinical impact of the PCICU's reduction in patient infections, mortality, and ICU length of stay was noted.

IMPLICATIONS

This evaluation has provided organizational leaders the quality indicators and costs that have been impacted with the addition of interprofessional teamwork and coordination of care through the development of a PCICU.

Template of patient-specific summaries facilitates education and outcomes in paediatric cardiac surgery units

OBJECTIVES

Few educational opportunities exist in paediatric cardiac critical care units (PCCUs). We introduced a new educational activity in the PCCU in the form of of patient-specific summaries (TPSS). Our objective was to study the role of TPSS in the provision of a positive learning experience to the multidisciplinary clinical team of PCCUs and in improving patient-related clinical outcomes in the PCCU.

METHODS

Prospective educational intervention with simultaneous clinical assessment was undertaken in PCCU in an academic children's hospital. TPSS was developed utilizing the case presentation format for upcoming week's surgical cases and delivered once every week to each PCCU clinical team member. Role of TPSS to provide clinical education was assessed using five-point Likert-style scale responses in an anonymous survey 1 year after TPSS provision. Paediatric cardiac surgery patients admitted to the PCCU were evaluated for postoperative outcomes for TPSS provision period of 1 year and compared with a preintervention period of 1 year.

RESULTS

TPSS was delivered to 259 clinical team members including faculty, fellows, residents, nurse practitioners, nurses, respiratory therapists and others from the Divisions of Anesthesia, Cardiology, Cardio-Thoracic Surgery, Critical Care, and Pediatrics working in the PCCU. Two hundred and twenty-four (86%) members responded to the survey and assessed the role of TPSS in providing clinical education to be excellent based on mean Likert-style scores of 4.32 ± 0.71 in survey responses. Seven hundred patients were studied for the two time periods and there were no differences in patient demographics, complexity of cardiac defect and surgical details. The length of mechanical ventilation for the TPSS period (57.08 ± 141.44 h) was significantly less when compared with preintervention period (117.39 ± 433.81 h) (P < 0.001) with no differences in length of PCICU stay, hospital stay and mortality for the two time periods.

CONCLUSIONS

Provision of TPSS in a paediatric cardiac surgery unit is perceived to be beneficial in providing clinical education to multidisciplinary clinical teams and may be associated with improved clinical outcome.

Variation in models of care delivery for children undergoing congenital heart surgery in the United States

Limited data are available regarding contemporary models of care delivery for patients undergoing congenital heart surgery. The purpose of this survey was to evaluate current US practice patterns in this patient population. Cross-sectional evaluation of US centers caring for patients undergoing congenital heart surgery was performed using an Internet-based survey. Data regarding postoperative care were collected and described overall and were compared in centers with a pediatric intensive care unit (PICU) versus dedicated pediatric cardiac intensive care unit (CICU). A total of 94 (77%) of the estimated 122 US centers performing congenital heart surgery participated in the survey. The majority (79%) of centers were affiliated with a university. Approximately half were located in a free-standing children's hospital and half in a children's hospital in a hospital. Fifty-five percent provided care in a PICU versus a CICU. A combination of cardiologists and/or critical care physicians made up the largest proportion of physicians primarily responsible for postoperative care. Trainee involvement most often included critical care fellows (53%), pediatric residents (53%), and cardiology fellows (47%). Many centers (76%) also used physician extenders. In centers with a CICU, there was greater involvement of cardiologists and physicians with dual training (cardiology and critical care), fellows versus residents, and physician extenders. Results of this survey demonstrate variation in current models of care delivery used in patients undergoing congenital heart surgery in the United States. Further study is necessary to evaluate the implications of this variability on quality of care and patient outcomes.

Establishing a pediatric cardiac intensive care unit - Special considerations in a limited resources environment

Pediatric cardiac intensive care has evolved as a distinct discipline in well-established pediatric cardiac programs in developed nations. With increasing demand for pediatric heart surgery in emerging economies, a number of new programs are being established. The development of robust pediatric cardiac intensive care units (PCICU) is critical to the success of these programs. Because of substantial resource limitations existing models of PCICU care cannot be applied in their existing forms and structure. A number of challenges need to be addressed to deliver pediatric cardiac intensive care in the developing world. Limitations in infrastructure, human, and material resources call for a number of innovations and adaptations. Additionally, a variety of strategies are required to minimize costs of care to the individual patient. This review provides a framework for the establishment of a new PCICU program in face of resource limitations typically encountered in the developing world and emerging economies.

Care models and associated outcomes in congenital heart surgery

OBJECTIVE

Recently, there has been a shift toward care of children undergoing heart surgery in dedicated pediatric cardiac intensive care units (CICU). The impact of this trend on patient outcomes is unclear. We evaluated postoperative outcomes associated with a CICU versus other ICU models.

PATIENTS AND METHODS

Society of Thoracic Surgeons Congenital Heart Surgery Database participants (2007-2009) who completed an ICU survey were included. In multivariable analysis, we evaluated outcomes associated with a CICU versus other ICUs, adjusting for center volume, patient factors, and Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery surgical risk category.

RESULTS

A total of 20 922 patients (47 centers; 25 with a CICU) were included. Overall unadjusted mortality was 3.8%, median length of stay was 6 days (interquartile range: 4-13), and 21% had 1 or more complications. In multivariable analysis, there was no difference in mortality comparing CICUs versus other ICUs (odds ratio: 0.88 [95% confidence interval: 0.65-1.19]). In stratified analysis, CICUs were associated with lower mortality only among those in Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category 3 (odds ratio: 0.47 [95% confidence interval: 0.25-0.86]), primarily related to atrioventricular canal repair and arterial switch operation. There was no difference in length of stay or complications overall or in stratified analysis.

CONCLUSIONS

We were not able to detect a difference in postoperative morbidity or mortality associated with the presence of a dedicated CICU for children undergoing heart surgery. There may be a survival benefit in certain subgroups .

Brain tumor resection in children: neurointensive care unit course and resource utilization

OBJECTIVE

To describe the pediatric intensive care unit (PICU) course and resource utilization for children with brain tumor resection and to identify factors predicting prolonged (>1 day) PICU length of stay. After craniotomy for brain tumor resection, children recover in the PICU. A few require critical care interventions and a >24-hr length of stay.

DESIGN

We reviewed all brain tumor resection patients admitted to the PICU over 2 yrs. Preoperative, intraoperative, and postoperative variables and tumor characteristics were examined. The extracted variables were compared between two groups with a length of stay in the PICU of >1 or <1 day.

SETTING

Pediatric intensive care unit in a tertiary academic children's medical center.

PATIENTS

A total of 105 patients post brain tumor resection were admitted to the PICU over the study period and analyzed.

INTERVENTIONS

Record review.

MEASUREMENTS AND MAIN RESULTS

Thirty-two (31%) of 105 patients remained in the PICU for >1 day. The mean age of patients in the >1 day group was 5.0 ± 0.81 yrs and 8.78 ± 0.65 yrs in the <1 day group (p < .05). The estimated blood loss was 20 ± 2.37 mL/kg in the >1 day and 9 ± 0.92 mL/kg in the <1 day group (p < .05). Fifteen (14.3%) patients were mechanically ventilated on arrival in the PICU; these patients more often had a length of stay of >1 day (p < .05). The number of unexpected intensive care unit interventions were 0.7 per patient, were more common in the >1 day group, and included treatment of sodium abnormalities, new neurologic deficits, paresis, or seizures (p < .05). In a logistic regression model, estimated blood loss and intubation on arrival predicted longer lengths of stay in the PICU (odds ratio, 1.1; 95% confidence interval, 1.05-1.18; and odds ratio, 33; 95% confidence interval, 2.57-333, respectively), with a receiver operating characteristic curve of 0.86 and 95% confidence interval, 0.78-0.94.

CONCLUSIONS

Large intraoperative estimated blood loss and intubation on arrival may be predictive of PICU lengths of stay of >1 day for children who have had a craniotomy for brain tumor resection. Intensive care unit interventions are more common in these children.

Pediatric critical care--a new frontier

Pediatric intensive care is now a subspecialty of pediatric medicine. Different pathologic and physiologic processes occur in pediatric patients who require intensive care. Thus, the faculty and staffing requirement differ in many aspects from those of adult intensive care units (ICUs). In Taiwan, pediatric intensive care is relatively less developed than adult care. However, thanks to the implementation of national health insurance and increasing emphasis of children's health, the scope and quality of pediatric intensive care has widened and rapidly improved. Research has shown that full time in-ICU staffing and patient care will result in improved outcomes for critically ill pediatric patients. In this article, we review the literature and recent advances in pediatric intensive care; we also outline the challenges arising. Special emphasis was made to the clinical context of Taiwan.

[Care of the critically ill child with heart disease in Spain]

INTRODUCTION

The objective of the present study is to present the organization of the resources of paediatric cardiac critical care in Spain.

PATIENTS AND METHODS

Data were collected through questionnaires sent by e-mail to Spanish PICUs.

RESULTS

22 PICUs were enrolled. The median number of beds were 9.5 (4-18 beds). Total cardiac admissions represented a 20 % of total PICUs admissions per year, firstly for congenital heart defects, and secondly for respiratory problems. Cardiac surgical activities were carried out in 16 centres, centralized in PICU in 10 cases. Mechanical support of the myocardium was performed in 7 PICUs. A total of 10 participating PICUs considered echocardiograph training necessary and also an increase in the amount of activity for better results.

CONCLUSIONS

Paediatric cardiac critical care involves a significant use of resources, including PICUs with no surgical activity. This study is useful for detecting common problems and for improving clinical care.

A history of pediatric critical care medicine

Critical care medicine developed out of other subspecialties' need to provide care for their most critically ill patients. Advanced technologies, the understanding of the pathophysiology of critical illness, and the development of the multidisciplinary team have made this care possible. Pediatric critical care medicine emerged in the 1960s and has expanded dramatically since then. The field has made major advances in the areas of lung injury, sepsis, traumatic brain injury, and postoperative care. We review here the evolution of modern pediatric critical care medicine from its roots in general pediatric and cardiac surgery, adult respiratory care medicine, neonatology, and pediatric anesthesiology to its current state as a unique discipline.

Pediatric cardiac intensivists: are enough being trained?

OBJECTIVE

To determine both the number of cardiac intensivists being trained by member institutions of the Pediatric Cardiac Intensive Care Society and the perceived need for these professionals.

DESIGN

Web-based survey of pediatric cardiac intensive care unit program directors.

RESULTS

A total of 54 directors completed the survey (41% response rate). Twelve pediatric cardiac critical care fellowship positions are offered each year among the responding Pediatric Cardiac Intensive Care Society institutions in the United States and Canada-only six of the 12 positions were filled in the academic year 2002-2003. Cardiac intensivist recruitment was ongoing at 25 of the programs surveyed (46%). An additional 45 cardiac intensivists will be sought during the next 1-3 yrs and 36 during the subsequent 3- to 5-yr period.

CONCLUSIONS

There is a discrepancy between the current and growing need for trained pediatric cardiac intensivists and the graduation rate of these professionals from teaching programs.

Increased airway mucins after cardiopulmonary bypass associated with postoperative respiratory complications in children

OBJECTIVE

Airway mucins may play an important role in the mechanism of respiratory complications after cardiopulmonary bypass in infants and children. Our aim was to measure airway mucin levels before and after cardiopulmonary bypass and to determine whether changes in mucin levels were associated with the development of respiratory complications.

METHODS

Airway glycoprotein and mucins (MUC5AC, MUC5B, and MUC2) in serial small-volume airway lavage samples from 39 young children who underwent cardiac operations with cardiopulmonary bypass were measured by slot-blot assay with specific antimucin peptide antibodies. The relationship between mucin changes and post-cardiopulmonary bypass respiratory complications was investigated. Airway lavage samples were also collected from 11 children before and after operation without cardiopulmonary bypass, and changes in mucin levels were compared with those in subjects who underwent cardiopulmonary bypass. Airway lavage sample DNA was also measured to investigate the relationship between mucin changes and lung injury.

RESULTS

Glycoprotein, MUC5AC, and MUC5B levels were significantly increased after cardiopulmonary bypass (P <.001) whereas MUC2 level was not. Children with respiratory complications showed significantly higher glycoprotein and MUC5AC levels than did children without respiratory complications before and after cardiopulmonary bypass (P <.05). Increase of total mucin (MUC5AC, MUC5B, and MUC2) during cardiopulmonary bypass showed positive correlation with DNA increase during cardiopulmonary bypass (r = 0.73), PaCO(2) (r = 0.62) and alveolar-arterial oxygen difference (r = 0.55) immediately after cardiopulmonary bypass. Increase of total mucin was associated with postoperative respiratory complications and their severity. There were no significant changes detected in airway mucin during operations without cardiopulmonary bypass.

CONCLUSIONS

Airway mucins were increased during cardiopulmonary bypass, and this increase was associated with markers of lung injury after cardiopulmonary bypass and with the development of postoperative respiratory complications.

How to start and sustain a successful pediatric cardiac intensive care program: A combined clinical and administrative strategy

OBJECTIVE: To delineate key clinical and administrative factors in starting a pediatric cardiac intensive care program and to introduce a scorecard concept to measure excellence in such a new program. Methods: Review of current clinical research data in pediatric cardiac intensive care and administrative business concepts for their application to the pediatric cardiac intensive care program. RESULTS: Although clinical concepts in cardiac intensive care are useful as basic philosophical strategies at the bedside, administrative principles are essential in operational strategies vital to the success of such a program. Using both clinical and business administrative concepts, a balanced strategy can be formulated. CONCLUSIONS: Starting a pediatric cardiac intensive care program is a difficult endeavor. A combined clinical and administrative approach is needed in starting and sustaining excellence in a pediatric cardiac intensive care program. Monitoring excellence in such a program warrants application of a scorecard system.