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Staehler H, Schaeffer T, Ruf B, Heinisch PP, Di Padua C, Burri M, Piber N, Hager A, Ewert P, Hörer J, Ono M. Impact of calorie intake and weight gain after Norwood procedure on the outcome of stage II palliation. Cardiol Young 2024; 34:876-883. [PMID: 37927221 DOI: 10.1017/s1047951123003736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND This study aimed to assess the impact of caloric intake and weight-for-age-Z-score after the Norwood procedure on the outcome of bidirectional cavopulmonary shunt. METHODS A total of 153 neonates who underwent the Norwood procedure between 2012 and 2020 were surveyed. Postoperative daily caloric intake and weight-for-age-Z-score up to five months were calculated, and their impact on outcome after bidirectional cavopulmonary shunt was analysed. RESULTS Median age and weight at the Norwood procedure were 9 days and 3.2 kg, respectively. Modified Blalock-Taussig shunt was used in 95 patients and right ventricle to pulmonary artery conduit in 58. Postoperatively, total caloric intake gradually increased, whereas weight-for-age-Z-score constantly decreased. Early and inter-stage mortality before stage II correlated with low caloric intake. Older age (p = 0.023) at Norwood, lower weight (p < 0.001) at Norwood, and longer intubation (p = 0.004) were correlated with low weight-for-age-Z-score (< -3.0) at 2 months of age. Patients with weight-for-age-Z-score < -3.0 at 2 months of age had lower survival after stage II compared to those with weight-for-age-Z-score of -3.0 or more (85.3 versus 92.9% at 3 years after stage II, p = 0.017). There was no difference between inter-stage weight gain and survival after bidirectional cavopulmonary shunt between the shunt types. CONCLUSION Weight-for-age-Z-score decreased continuously throughout the first 5 months after the Norwood procedure. Age and weight at Norwood and intubation time were associated with weight gain. Inter-stage low weight gain (Z-score < -3) was a risk for survival after stage II.
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Affiliation(s)
- Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Bettina Ruf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Chiara Di Padua
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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2
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Ganta S, Haley J, El-Said H, Lane B, Haldeman S, Karamlou T, Moore J, Rao R, Nigro JJ. Stage 1 and 2 Palliation: Comparing Ductal Stenting and Aorto-Pulmonary Shunts in Single Ventricles with Duct-Dependent Pulmonary Blood Flow. Pediatr Cardiol 2024; 45:471-482. [PMID: 38265483 PMCID: PMC10891206 DOI: 10.1007/s00246-023-03386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
Patent ductus arteriosus stenting (PDAS) for ductal-dependent pulmonary blood flow (DDPBF) provides a new paradigm for managing neonates with single ventricles (SV). Currently, sparse data exist regarding outcomes for subsequent palliation. We describe our experience with inter-stage care and stage 2 (S2P) conversion with PDAS in comparison to a prior era of patients who received surgical aorto-pulmonary shunts (APS). Retrospective review of 18 consecutive DDPBF SV patients treated with PDAS between 2016 and 2021 was done and compared with 9 who underwent APS from 2010 to 2016. Patient outcomes and pulmonary artery (PA) growth were analyzed. S2P was completed in all 18 with PDAS with no cardiac arrests and one post-S2P mortality. In the 9 APS patients, there was one cardiac arrest requiring ECMO and one mortality inter-stage. Off cardiopulmonary bypass strategy was utilized in 10/18 in the PDAS and 1/9 in the APS group (p = 0.005) at S2P. Shorter ventilation time, earlier PO feeding, and shorter hospital stay were noted in the PDAS group (p = 0.01, p = 0.006, p = 0.03) (S2P). Median Nakata index increase inter-stage was not significant between the PDAS and APS at 94.1 mm2/m2 versus 71.7 mm2/m2 (p = 0.94). Median change in pulmonary artery symmetry (PAS) was - 0.02 and - 0.24, respectively, which was statistically significant (p = 0.008). Neurodevelopmental outcomes were better in the PDAS group compared to the APS group (p = 0.02). PDAS provides excellent PA growth, inter-stage survival, progression along multistage single-ventricle palliation, and potentially improved neurodevelopmental outcomes. Most patients can be transitioned through 2 stages of palliation without CPB.
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Affiliation(s)
- Srujan Ganta
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA.
| | - Jessica Haley
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Howaida El-Said
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Brian Lane
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Shylah Haldeman
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Moore
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Rohit Rao
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - John J Nigro
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA
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Fisenne DT, Burns J, Dhar A. Feeding Difficulties Following Vascular Ring Repair: A Contemporary Narrative Review. Cureus 2022; 14:e24623. [PMID: 35651405 PMCID: PMC9138490 DOI: 10.7759/cureus.24623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/30/2022] [Indexed: 11/24/2022] Open
Abstract
Vascular rings are congenital abnormalities of the aortic arch vascular system that compress the trachea and esophagus. A review of long-term outcomes suggests that chronic feeding difficulties can persist following surgical repair of vascular rings. Previous reports of postoperative vascular ring division outcomes indicate that chronic esophageal symptoms may persist following repair, though most available data focuses on persistent respiratory symptoms. It is therefore the aim of this article to summarize and organize recent evidence reporting the frequency, presentation, and management of feeding difficulties following vascular ring repair in pediatric patients. Pathophysiologic mechanisms for postoperative esophageal symptoms may include residual compression from an unresected diverticulum of Kommerell or delayed repair leading to chronic esophageal dysmotility despite correction of esophageal compression. Guidance on the management of feeding difficulties following vascular ring repair is limited. The authors describe success in one case with nasogastric tube feeding and interdisciplinary evaluation. Consensus regarding the management of feeding difficulty following vascular ring repair is needed.
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Liu JF, Xie WP, Lei YQ, Cao H, Yu XR, Chen Q. Effects of different feeding intervals on the feeding outcomes of infants who underwent surgical repair of ventricular septal defects. J Card Surg 2021; 36:4134-4138. [PMID: 34423474 DOI: 10.1111/jocs.15933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/19/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the present study is to explore the effect of different feeding intervals on the feeding outcomes of infants who underwent ventricular septal defect (VSD) closure. METHODS This study is a prospective, randomized controlled trial conducted by a provincial hospital in China. According to different feeding intervals, 78 eligible participants were randomly divided into Group A (2-h interval, n = 39) and Group B (3-h interval, n = 39). The basic clinical data, total feeding time, incidence of feeding intolerance, and nurse job satisfaction scores of the two groups were collected. RESULTS The total feeding time in Group A was significantly longer than that in Group B (142.5 ± 15.4 vs. 132.0 ± 16.1 min/d, p = .020). The nurse job satisfaction scores in Group A were significantly lower than those in Group B (101.7 ± 9.8 vs. 108.8 ± 10.1, p = .005). There were no significant differences in the duration of mechanical ventilation (3.7 ± 1.1 vs. 3.9 ± 1.0 d, p = .272), length of ICU stay (4.5 ± 1.1 d vs. 4.7 ± 0.9 d, p = .451), or length of hospital stay (13.2 ± 1.4 vs. 13.3 ± 1.0 d, p = .642) between the two groups. Although the incidence of feeding intolerance in Group A was slightly lower than that in Group B, the difference was not statistically significant. CONCLUSION Feeding at an interval of 2 or 3 h has no significant effect on the feeding outcomes of infants, and feeding at intervals of 3 h can reduce nurses' workload and improve nursing job satisfaction.
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Affiliation(s)
- Jian-Feng Liu
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Peng Xie
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yu-Qing Lei
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Xian-Rong Yu
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
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5
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Variables Prevalent Among Early Unplanned Readmissions in Infants Following Congenital Heart Surgery. Pediatr Cardiol 2021; 42:1449-1456. [PMID: 33974090 DOI: 10.1007/s00246-021-02631-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
Medically complex children including infants undergoing cardiac surgery are at increased risk for hospital readmissions. Investigation of this population may reveal opportunities to optimize systems and coordination of care. A retrospective study of all infants undergoing cardiac surgery from 2015 through 2016 at a large tertiary institution who were readmitted within 1 year of discharge from cardiac surgical hospitalization was performed. Data specific to patient characteristics, surgical hospitalization, and readmission hospitalization are described. Unplanned readmissions within 1 year of hospital discharge were analyzed with Cox proportional hazard regression to identify factors associated with increased hazard for earlier unplanned readmission. Comparable to previous reports, 12% (78/658) of all surgical hospitalizations were associated with unplanned readmission within 30 days. Infectious etiology, followed by cardiac and gastrointestinal problems, was the most common reasons for unplanned 30-day readmission. Unplanned readmissions within 2 weeks of discharge were multifactorial and less commonly related to cardiac or surgical care. Primary nasogastric tube feeding at the time of discharge was the only significant risk factor for earlier unplanned readmission (p = 0.032) on multivariable analysis. Increased care coordination with particular attention to feeding and comorbidity management may be future targets to effectively mitigate readmissions and improve quality of care in this population.
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Kurtz JD, Chowdhury SM, Woodard FK, Strelow JR, Zyblewski SC. Factors Associated with Delayed Transition to Oral Feeding in Infants with Single Ventricle Physiology. J Pediatr 2019; 211:134-138. [PMID: 30952511 PMCID: PMC7161424 DOI: 10.1016/j.jpeds.2019.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the duration of time to achieve exclusive oral feeding in infants with single ventricle physiology and to identify risk factors associated with prolonged gastrostomy tube dependence. STUDY DESIGN Single center, retrospective study of infants with single ventricle physiology. The primary outcome was duration of time required to achieve oral feeding. Transition periods were defined as exclusive oral feeding by Glenn palliation (early), by 1 year of age (mid), or after 1 year of age (late). RESULTS Seventy-eight infants were analyzed; 46 (59%) were discharged to home with a gastrostomy tube after the initial hospitalization. Overall, 39 infants (50%) achieved early transition, 14 (18%) mid, and 18 (23%) late. The group who achieved early transition had a higher percentage of preoperative oral feeding (P < .01), greater weight-for-age z score at initial discharge (P = .03), shorter initial intensive care unit duration (P < .01), shorter initial hospital length of stay (P < .01), and greater weight-for-age z score at Glenn admission (P = .02). No preoperative oral feeding (OR = 0.12, P = .02) and greater number of cardiac medications at initial discharge (OR = 3.8, P = .03) were associated with failure to achieve early transition. No preoperative oral feeding (OR = 0.09, P = .01) and longer initial intensive care unit duration (OR = 1.1, P = .03) were associated with failure to achieve mid transition. CONCLUSION Preoperative oral feeding may potentially be a modifiable factor to help improve early transition to oral feeding.
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7
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Ehrmann DE, Mulvahill M, Harendt S, Church J, Stimmler A, Vichayavilas P, Batz S, Rodgers J, DiMaria M, Jaggers J, Barrett C, Kaufman J. Toward standardization of care: The feeding readiness assessment after congenital cardiac surgery. CONGENIT HEART DIS 2017; 13:31-37. [PMID: 29148256 DOI: 10.1111/chd.12550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/21/2017] [Accepted: 10/28/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Feeding practices after neonatal and congenital heart surgery are complicated and variable, which may be associated with prolonged hospitalization length of stay (LOS). Systematic assessment of feeding skills after cardiac surgery may earlier identify those likely to have protracted feeding difficulties, which may promote standardization of care. METHODS Neonates and infants ≤3 months old admitted for their first cardiac surgery were retrospectively identified during a 1-year period at a single center. A systematic feeding readiness assessment (FRA) was utilized to score infant feeding skills. FRA scores were assigned immediately prior to surgery and 1, 2, and 3 weeks after surgery. FRA scores were analyzed individually and in combination as predictors of gastrostomy tube (GT) placement prior to hospital discharge by logistic regression. RESULTS Eighty-six patients met inclusion criteria and 69 patients had complete data to be included in the final model. The mean age of admit was five days and 51% were male. Forty-six percent had single ventricle physiology. Twenty-nine (42%) underwent GT placement. The model containing both immediate presurgical and 1-week postoperative FRA scores was of highest utility in predicting discharge with GT (intercept odds = 10.9, P = .0002; sensitivity 69%, specificity 93%, AUC 0.913). The false positive rate was 7.5%. CONCLUSIONS In this analysis, systematic and standardized measurements of feeding readiness employed immediately before and one week after congenital cardiac surgery predicted need for GT placement prior to hospital discharge. The FRA score may be used to risk stratify patients based on likelihood of prolonged feeding difficulties, which may further improve standardization of care.
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Affiliation(s)
- Daniel E Ehrmann
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matthew Mulvahill
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Shaunda Harendt
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Audiology, Speech Pathology, & Learning Services, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jessica Church
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amy Stimmler
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Piyagarnt Vichayavilas
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Sanja Batz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Occupational Therapy, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jennifer Rodgers
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Occupational Therapy, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michael DiMaria
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - James Jaggers
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Cindy Barrett
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jon Kaufman
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
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8
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Noncompliance to a Postoperative Algorithm Using Feeding Readiness Assessments Prolonged Length of Stay at a Pediatric Heart Institute. Pediatr Qual Saf 2017; 2:e042. [PMID: 30229178 PMCID: PMC6132464 DOI: 10.1097/pq9.0000000000000042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/16/2017] [Indexed: 01/25/2023] Open
Abstract
Introduction: Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS. Methods: We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a “sentinel” FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm. Results: Sixty-nine patients were included. Forty-nine complied with the algorithm (71%), and 45 received GT (65.2%). Noncompliers had significantly longer LOS (34 versus 25 days; P = 0.01). Among GT recipients, noncompliers waited 6 additional days for a GT compared with compliers (P ≤ 0.001). Subjective decisions to extend oral feeding trials or await results of a swallow study were associated with algorithm noncompliance. Conclusions: This audit of compliance to a feeding algorithm after pediatric cardiac surgery highlighted variability of practice, including relying on subjective appraisals of feeding skills over objective FRAs. This variability was associated with increased LOS and can be hypothesis-generating for future quality improvement efforts.
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9
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Simsic JM, Carpenito KR, Kirchner K, Peters S, Miller-Tate H, Joy B, Galantowicz M. Reducing variation in feeding newborns with congenital heart disease. CONGENIT HEART DIS 2016; 12:275-281. [PMID: 27865060 DOI: 10.1111/chd.12435] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/22/2016] [Accepted: 10/03/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Enteral feeding is associated with decreased infection rates, decreased mechanical ventilation, decreased hospital length of stay, and improved wound healing. Enteral feeding difficulties are common in congenital heart disease. Our objective was to develop experience-based newborn feeding guidelines for the initiation and advancement of enteral feeding in the cardiothoracic intensive care unit. DESIGN This is a retrospective analysis of a quality improvement project. SETTING This quality improvement project was performed in a cardiothoracic intensive care unit. PATIENTS Newborns admitted to the cardiothoracic intensive care unit for cardiac surgery from January 2011 to May 2015 were retrospectively reviewed. INTERVENTION Newborn feeding guidelines for the initiation and advancement of enteral feeding were implemented in January 2012. OUTCOME MEASURES Guideline compliance and clinical variables before and after guideline implementation were reviewed. RESULTS Compliance with the guidelines increased from 83% in 2012 to 100% in the first two quarters of 2015. Preguidelines (January 2011-December 2011): 45 newborns underwent cardiac surgery; 8 deaths prior to discharge; 1 patient discharged from NICU, therefore, N = 36. Postguidelines (January 2012-May 2015): 131 newborns with 12 deaths, 12 admitted from home, 8 in the NICU, 3 on the floor preop, and 3 back transferred, therefore, N = 93. No difference in feeding preop (post 75% vs pre 69%; P = .5) or full po feeds at discharge (post 78% vs pre 89%; P = .2). Mesenteric ischemia was not statistically different postguidelines (post 6% vs pre 14%; P = .14). Length of hospital stay decreased postguidelines (post 27 + 17 d vs pre 34 + 42 d; P < .001). CONCLUSIONS Implementation of experience-based newborn feeding guidelines for initiation and advancement of enteral feeding in the cardiothoracic intensive care unit was successful in reducing practice variation supported by increasing guideline compliance. Percentage of patient's full oral feeding at discharge did not change. Length of hospital stay was reduced although cannot be fully attributed to feeding guideline implementation.
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Affiliation(s)
- Janet M Simsic
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | | | - Kristin Kirchner
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Stephanie Peters
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Holly Miller-Tate
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Brian Joy
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Mark Galantowicz
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, 43205, USA
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10
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Improving Outcomes for Infants with Single Ventricle Physiology through Standardized Feeding during the Interstage. Nurs Res Pract 2016; 2016:9505629. [PMID: 27313883 PMCID: PMC4893427 DOI: 10.1155/2016/9505629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/04/2016] [Accepted: 04/14/2016] [Indexed: 01/25/2023] Open
Abstract
Congenital heart disease is identified as the most common birth defect with single ventricle physiology carrying the highest mortality. Staged surgical palliation is required for treatment, with mortality historically as high as 22% in the four- to six-month period from the first- to second-stage surgical palliation, known as the interstage. A standardized postoperative feeding approach was implemented through an evidence-based protocol, parent engagement, and interprofessional team rounds. Five infants with single ventricle physiology preprotocol were compared with five infants who received the standardized feeding approach. Mann-Whitney U tests were conducted to evaluate the hypotheses that infants in the intervention condition would consume more calories and have a positive change in weight-to-age z-score (WAZ) and shorter length of stay (LOS) following the first and second surgeries compared to infants in the control condition. After the protocol, the change in WAZ during the interstage increased by virtually one standard deviation from 0.05 to 0.91. Median LOS dropped 32% after the first surgery and 43% after the second surgery. Since first- and second-stage palliative surgeries occur within the same year of life, this represents savings of $500,000 to $800,000 per year in a 10-infant model. The standardized feeding approach improved growth in single ventricle infants while concurrently lowering hospital costs.
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11
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Jenkins E. Feeding Protocols for Neonates With Hypoplastic Left Heart Syndrome. AACN Adv Crit Care 2015. [DOI: 10.4037/nci.0000000000000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Optimizing nutrition in neonates with hypoplastic left heart syndrome is essential, given the high rate of growth failure in this population. Infants with hypoplastic left heart syndrome are predisposed to nutritional deficiency as a result of their increased metabolic demand; however, early enteral feeding also increases the risk of serious gastrointestinal morbidity and mortality caused by poor intestinal perfusion. Consequently, providers have difficulty deciding when and how to safely feed these patients. A review of the literature found that implementation of a structured enteral feeding protocol may decrease the risk of gastrointestinal complications while also minimizing dependence on parenteral nutrition and decreasing length of hospital stay. As these studies were limited, further research is warranted to establish a best practice feeding protocol to decrease risk and optimize nutrition in this fragile population.
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Affiliation(s)
- Erin Jenkins
- Erin Jenkins is Pediatric Acute Care Nurse Practitioner, 250 Hartford St, #4, San Francisco, CA 94114
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12
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Kaufman J, Vichayavilas P, Rannie M, Peyton C, Carpenter E, Hull D, Alpern J, Barrett C, da Cruz EM, Roosevelt G. Improved nutrition delivery and nutrition status in critically ill children with heart disease. Pediatrics 2015; 135:e717-25. [PMID: 25687139 DOI: 10.1542/peds.2014-1835] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This initiative sought to improve nutrition delivery in critically ill children with heart disease admitted to the cardiac ICU (CICU) and neonates undergoing stage 1 palliation (S1P) for single-ventricle physiology through interdisciplinary team interventions. Specific goals were increased caloric and protein delivery for all patients and a more nourished state for infants with single ventricles at the time of discharge. METHODS We developed a nutrition flow sheet in the electronic health record to track whether daily nutrition goals were met. Interventions included nurses reporting daily whether caloric and protein goals were met, mandatory involvement of feeding specialists, and introduction of an enteral nutrition guideline. For infants undergoing S1P, weight-for-age z score (as an indicator for assessing malnutrition) was calculated at admission and discharge. RESULTS The percentage of patient days per month when daily caloric goals were met increased from 50.1% to 60.7%, and protein goals met increased from 51.6% to 72.7%. Hospital length of stay, need for ventilation, and mortality did not differ. Patients undergoing S1P demonstrated a statistically significant improvement in weight-for-age z score compared with the preintervention group (P = .003). Thirteen S1P patients were discharged undernourished in the preintervention group; 5 were severely undernourished. In the intervention group, 4 patients were discharged undernourished, and none were severely undernourished. CONCLUSIONS This initiative resulted in improved nutrition delivery for a heterogeneous population of cardiac patients in the CICU as well as significant improvements in weight gain and nourishment status at discharge in infants undergoing S1P.
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Affiliation(s)
- Jon Kaufman
- The Heart Institute at Children's Hospital Colorado, Department of Pediatrics,
| | - Piyagarnt Vichayavilas
- The Heart Institute at Children's Hospital Colorado, Clinical Nutrition at Children's Hospital Colorado, and
| | - Michael Rannie
- Clinical Informatics at Children's Hospital Colorado, Aurora, Colorado
| | - Christine Peyton
- The Heart Institute at Children's Hospital Colorado, School of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
| | - Esther Carpenter
- The Heart Institute at Children's Hospital Colorado, School of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
| | - Danielle Hull
- Clinical Nutrition at Children's Hospital Colorado, and
| | - Jennifer Alpern
- The Heart Institute at Children's Hospital Colorado, School of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
| | - Cindy Barrett
- The Heart Institute at Children's Hospital Colorado, Department of Pediatrics
| | - Eduardo M da Cruz
- The Heart Institute at Children's Hospital Colorado, Department of Pediatrics
| | - Genie Roosevelt
- Department of Emergency Medicine, Denver Health Hospital Authority, Denver, Colorado
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Twite MD, Ing RJ. Anesthetic Considerations in Infants With Hypoplastic Left Heart Syndrome. Semin Cardiothorac Vasc Anesth 2013; 17:137-45. [DOI: 10.1177/1089253213476958] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypoplasia of the left ventricle is a congenital cardiac lesion that is almost universally fatal if left untreated. Six decades of improved diagnostic modalities, greater understanding of single ventricle physiology, and earlier surgical and palliative options have given many of these patients an opportunity of surviving well into adulthood. This review will summarize these advances and focus on the anesthetic implications of this challenging disease from diagnosis to beyond the first palliative surgery.
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Affiliation(s)
- Mark D. Twite
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Anschutz Medical Campus, Denver, CO, USA
| | - Richard J. Ing
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Anschutz Medical Campus, Denver, CO, USA
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