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Peng DM, Kwiatkowski DM, Lasa JJ, Zhang W, Banerjee M, Mikesell K, Joong A, Dykes JC, Tume SC, Niebler RA, Teele SA, Klugman D, Gaies MG, Schumacher KR. Contemporary Care and Outcomes of Critically-ill Children With Clinically Diagnosed Myocarditis. J Card Fail 2024; 30:350-358. [PMID: 37150502 DOI: 10.1016/j.cardfail.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE To describe contemporary management and outcomes in children with myocarditis who are admitted to a cardiac intensive care unit (CICU) and to identify the characteristics associated with mortality. METHODS All patients in the Pediatric Cardiac Critical Care Consortium (PC4) registry between August 2014 and June 2021 who were diagnosed with myocarditis were included. Univariable analyses and multivariable logistic regression evaluated the factors associated with in-hospital mortality. RESULTS There were 847 CICU admissions for myocarditis in 51 centers. The median age was 12 years (IQR 2.7-16). In-hospital mortality occurred in 53 patients (6.3%), and 60 (7.1%) had cardiac arrest during admission. Mechanical ventilation was required in 339 patients (40%), and mechanical circulatory support (MCS) in 177 (21%); extracorporeal membrane oxygenation (ECMO)-only in 142 (16.7%), ECMO-to-ventricular assist device (VAD) in 20 (2.4%), extracorporeal cardiac resuscitation in 43 (5%), and VAD-only in 15 (1.8%) patients. MCS was associated with in-hospital mortality; 20.3% receiving MCS died compared to 2.5% without MCS (P < 0.001). Mortality rates were similar in ECMO-only, ECMO-to-VAD and VAD-only groups. The median time from CICU admission to ECMO was 2.0 hours (IQR 0-9.4) and to VAD, it was 9.9 days (IQR 6.3-16.8). Time to MCS was not associated with mortality. In multivariable modeling of patients' characteristics, smaller body surface area (BSA) and low eGFR were independently associated with mortality, and after including critical therapies, mechanical ventilation and ECMO were independent predictors of mortality. CONCLUSION This contemporary cohort of children admitted to CICUs with myocarditis commonly received high-resource therapies; however, most patients survived to hospital discharge and rarely received VAD. Smaller patient size, acute kidney injury and receipt of mechanical ventilation or ECMO were independently associated with mortality.
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Affiliation(s)
- David M Peng
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI.
| | | | - Javier J Lasa
- Texas Children's Hospital, 6621 Fannin Street, Houston, TX
| | - Wendy Zhang
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
| | - Mousumi Banerjee
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
| | - Katherine Mikesell
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
| | - Anna Joong
- Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL
| | - John C Dykes
- Lucile Packard Children's Hospital Stanford, 725 Welch Road, Palo Alto, CA
| | | | - Robert A Niebler
- Children's Hospital Wisconsin, 8915 West Connell Court, Milwaukee, WI
| | - Sarah A Teele
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA
| | - Darren Klugman
- The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD
| | - Michael G Gaies
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH
| | - Kurt R Schumacher
- University of Michigan, CS Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI
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2
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Perry T, Klugman D, Schumacher K, Banerjee M, Zhang W, Bertrandt R, Wolovits JS, Murphy LD, Misfeldt AM, Alten J, Cooper DS. Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes. Pediatr Crit Care Med 2023; 24:551-562. [PMID: 37070818 DOI: 10.1097/pcc.0000000000003235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU). DESIGN Registry data (August 2014 to October 2020). SETTING Forty-five Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains. CONCLUSIONS UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.
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Affiliation(s)
- Tanya Perry
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Darren Klugman
- Department of Pediatrics, John's Hopkins Children's Hospital Medical Center, Baltimore, MD
| | - Kurt Schumacher
- Congenital Heart Center, University of Michigan, Ann Arbor, MI
| | | | - Wenying Zhang
- Congenital Heart Center, University of Michigan, Ann Arbor, MI
| | - Rebecca Bertrandt
- Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Joshua S Wolovits
- Department of Pediatrics, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX
| | - Lee D Murphy
- Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Andrew M Misfeldt
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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3
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Gaies M, Olive MK, Owens GE, Charpie JR, Zhang W, Pasquali SK, Klugman D, Costello JM, Schwartz SM, Banerjee M. Methods to Enhance Causal Inference for Assessing Impact of Clinical Informatics Platform Implementation. Circ Cardiovasc Qual Outcomes 2023; 16:e009277. [PMID: 36727516 DOI: 10.1161/circoutcomes.122.009277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hospitals are increasingly likely to implement clinical informatics tools to improve quality of care, necessitating rigorous approaches to evaluate effectiveness. We leveraged a multi-institutional data repository and applied causal inference methods to assess implementation of a commercial data visualization software in our pediatric cardiac intensive care unit. METHODS Natural experiment in the University of Michigan (UM) Cardiac Intensive Care Unit pre and postimplementation of data visualization software analyzed within the Pediatric Cardiac Critical Care Consortium clinical registry; we identified N=21 control hospitals that contributed contemporaneous registry data during the study period. We used the platform during multiple daily rounds to visualize clinical data trends. We evaluated outcomes-case-mix adjusted postoperative mortality, cardiac arrest and unplanned readmission rates, and postoperative length of stay-most likely impacted by this change. There were no quality improvement initiatives focused specifically on these outcomes nor any organizational changes at UM in either era. We performed a difference-in-differences analysis to compare changes in UM outcomes to those at control hospitals across the pre versus postimplementation eras. RESULTS We compared 1436 pre versus 779 postimplementation admissions at UM to 19 854 (pre) versus 14 160 (post) at controls. Admission characteristics were similar between eras. Postimplementation at UM we observed relative reductions in cardiac arrests among medical admissions, unplanned readmissions, and postoperative length of stay by -14%, -41%, and -18%, respectively. The difference-in-differences estimate for each outcome was statistically significant (P<0.05), suggesting the difference in outcomes at UM pre versus postimplementation is statistically significantly different from control hospitals during the same time. CONCLUSIONS Clinical registries provide opportunities to thoroughly evaluate implementation of new informatics tools at single institutions. Borrowing strength from multi-institutional data and drawing ideas from causal inference, our analysis solidified greater belief in the effectiveness of this software across our institution.
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Affiliation(s)
- Michael Gaies
- Heart Institute, Cincinnati Children's Hospital Medical Center, OH (M.G.)
| | - Mary K Olive
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - Gabe E Owens
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - Wenying Zhang
- Michigan Congenital Heart Outcomes Research and Discovery Unit, PC4 Data Coordinating Center, University of Michigan, Ann Arbor, MI (W.Z.)
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - Darren Klugman
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (D.K.)
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC (J.M.C.)
| | - Steven M Schwartz
- Department of Paediatrics, Temerty Faculty of Medicine, The University of Toronto, ON (S.M.S.)
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI (M.B.)
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4
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Alten J, Cooper DS, Klugman D, Raymond TT, Wooton S, Garza J, Clarke-Myers K, Anderson J, Pasquali SK, Absi M, Affolter JT, Bailly DK, Bertrandt RA, Borasino S, Dewan M, Domnina Y, Lane J, McCammond AN, Mueller DM, Olive MK, Ortmann L, Prodhan P, Sasaki J, Scahill C, Schroeder LW, Werho DK, Zaccagni H, Zhang W, Banerjee M, Gaies M. Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration. JAMA Pediatr 2022; 176:1027-1036. [PMID: 35788631 PMCID: PMC9257678 DOI: 10.1001/jamapediatrics.2022.2238] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
Abstract
Importance Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear. Objective To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate. Design, Setting, and Participants Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020. Interventions CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients. Main Outcomes and Measures Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions). Results The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention. Conclusions and Relevance Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.
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Affiliation(s)
- Jeffrey Alten
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - David S. Cooper
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Darren Klugman
- Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC
- Division of Anesthesia, Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Tia Tortoriello Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children’s Hospital, Dallas, Texas
| | - Sharyl Wooton
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Janie Garza
- Department of Pediatrics, Cardiac Critical Care, Medical City Children’s Hospital, Dallas, Texas
| | - Katherine Clarke-Myers
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | - Mohammed Absi
- Department of Pediatrics, Heart Institute, University of Tennessee, Le Bonheur Children’s Hospital, Memphis
| | - Jeremy T. Affolter
- Department of Pediatrics, Critical Care Medicine, University of Missouri, Children’s Mercy Hospital, Kansas City
- Department of Pediatrics, University of Texas at Austin-Dell Medical School, Dell Children’s Medical Center of Central Texas, Austin
| | - David K. Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Rebecca A. Bertrandt
- Department of Pediatric Critical Care, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee
| | - Santiago Borasino
- Department of Pediatrics, University of Alabama at Birmingham, Cardiac Critical Care, Birmingham
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati School of Medicine, Division of Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Yuliya Domnina
- Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC
- Department of Pediatrics and Critical Care Medicine, Cardiac Intensive Care Unit, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Lane
- Division of Cardiovascular Intensive Care, Phoenix Children’s Hospital, Phoenix Arizona
| | - Amy N. McCammond
- Department of Pediatrics, Pediatric Cardiac Intensive Care, University of California San Francisco, Benioff Children’s Hospital, San Francisco
| | - Dana M. Mueller
- Department of Pediatrics, Division of Critical Care, University of Washington, Seattle Children’s Hospital, Seattle
- Division of Cardiology, Department of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego
| | - Mary K. Olive
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | - Laura Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha
| | - Parthak Prodhan
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock
| | - Jun Sasaki
- Division of Cardiac Critical Care Medicine, Nicklaus Children’s Hospital, Miami, Florida
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Carly Scahill
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, Aurora
| | - Luke W. Schroeder
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - David K. Werho
- Division of Cardiology, Department of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego
| | - Hayden Zaccagni
- Department of Pediatrics, University of Alabama at Birmingham, Cardiac Critical Care, Birmingham
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Mousumi Banerjee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Michael Gaies
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
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5
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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6
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Sethi N, Klugman D, Said M, Hom L, Bowers S, Berger JT, Wernovsky G, Donofrio MT. Standardized delivery room management for neonates with a prenatal diagnosis of congenital heart disease: A model for improving interdisciplinary delivery room care. J Neonatal Perinatal Med 2021; 14:317-329. [PMID: 33361613 DOI: 10.3233/npm-200626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Precise characterization of cardiac anatomy and physiology through fetal echocardiography can predict early postnatal clinical course. Some neonates with prenatally defined critical congenital heart disease have anticipated precipitous compromise during perinatal transition for which specialized, diagnosis-specific delivery room care can be arranged to expeditiously stabilize cardiopulmonary hemodynamics. In this article, we describe our institutional approach to the delivery room care of neonates with prenatally diagnosed congenital heart disease, emphasizing our diagnosis-specific care pathways for newborns with critical disease.
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Affiliation(s)
- N Sethi
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - D Klugman
- Division of Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - M Said
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - L Hom
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - S Bowers
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - J T Berger
- Division of Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - G Wernovsky
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
- Division of Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - M T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
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7
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Klugman D, Melton K, Maynord PO, Dawson A, Madhavan G, Montgomery VL, Nock M, Lee A, Lyren A. Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children. JAMA Pediatr 2020; 174:e200268. [PMID: 32282029 PMCID: PMC7154960 DOI: 10.1001/jamapediatrics.2020.0268] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events. OBJECTIVE To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events. DESIGN, SETTING, AND PARTICIPANTS This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study. INTERVENTIONS Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses. MAIN OUTCOMES AND MEASURES The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level. RESULTS Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days. CONCLUSIONS AND RELEVANCE This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.
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Affiliation(s)
- Darren Klugman
- Divisions of Cardiac Critical Care Medicine and Cardiology, Children’s National Hospital, The George Washington University School of Medicine, Washington, DC
| | - Kristin Melton
- Division of Neonatology, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patrick O’Neal Maynord
- Pediatric Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Aaron Dawson
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Gowri Madhavan
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Vicki Lee Montgomery
- Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Mary Nock
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anthony Lee
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Anne Lyren
- Departments of Pediatrics and Bioethics, UH Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
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8
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Abstract
Despite numerous advances in medical and surgical management, congenital heart disease (CHD) remains the number one cause of death in the first year of life from congenital malformations. The current strategies used to approach improving outcomes in CHD are varied. This article will discuss the recent impact of pulse oximetry screening for critical CHD, describe the contributions of advanced cardiac imaging in the neonate with CHD, and highlight the growing importance of quality improvement and safety programs in the cardiac intensive care unit.
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Affiliation(s)
- Gerard R Martin
- Division of Cardiology, Children's National Heart Institute, George Washington University School of Medicine, Washington, District of Columbia
| | - Russell R Cross
- Division of Cardiology, Children's National Heart Institute, George Washington University School of Medicine, Washington, District of Columbia
| | - Lisa A Hom
- Division of Cardiology, Children's National Heart Institute, George Washington University School of Medicine, Washington, District of Columbia
| | - Darren Klugman
- Division of Cardiology, Children's National Heart Institute, George Washington University School of Medicine, Washington, District of Columbia.,Division of Cardiac Critical Care Medicine, Children's National Heart Institute, George Washington University School of Medicine, Washington, District of Columbia
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9
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Galiote JP, Ridoré M, Carman J, Zell L, Brant K, Gayle C, Short BL, Klugman D, Soghier L. Reduction in Unintended Extubations in a Level IV Neonatal Intensive Care Unit. Pediatrics 2019; 143:peds.2018-0897. [PMID: 31028159 DOI: 10.1542/peds.2018-0897] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Unintended extubations (UEs) lead to significant morbidity in neonates. A quality improvement project was initiated in response to high rates in our level IV NICU. We targeted creating and sustaining UE rates below the published standard of 1 per 100 ventilator days. METHODS This project spanned 4 time periods: baseline, epoch 1 (December 2010-May 2012), sustain, and epoch 2 (May 2015-December 2017) by using standard quality improvement methodology. Epoch 1 interventions included real-time analysis of UE events, standardization of taping, patient positioning and movement, accurate event reporting, and change in nomenclature. Epoch 2 interventions included reduction in daily chest radiographs (CXRs) and development of a high-risk tool. Patient and event characteristics were statistically compared across time points. RESULTS Of the 612 UE events recorded over 10 years, 249 UEs occurred from May 2011 to 2017 involving 184 unique patients. UE rates decreased by 43% (from 1.75 to 0.99 per 100 ventilator days; epoch 1) and were sustained until a notable spike. Epoch 2 interventions led to a further 31% rate reduction. Single CXR use decreased by half. Median corrected gestational age at the time of an event was 35 weeks (interquartile range: 29-41). Seventy percent of infants experiencing an UE required reintubation, 29% had a previous event, and 9% had a code event. CONCLUSIONS A decrease in UE below benchmarks can be achieved and sustained by standardization and mitigation interventions. This decline was also accompanied by a reduction in use of CXRs without increasing UE events.
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Affiliation(s)
- John P Galiote
- Departments of Neonatology.,Virginia Hospital Center, Arlington, Virginia; and.,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Jessica Carman
- Neonatal Intensive Care Unit, Children's National Health System, Washington, District of Columbia
| | - Lisa Zell
- Neonatal Intensive Care Unit, Children's National Health System, Washington, District of Columbia
| | | | | | - Billie L Short
- Departments of Neonatology.,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Darren Klugman
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,Pediatric Critical Care Medicine and Pediatric Cardiology, and
| | - Lamia Soghier
- Departments of Neonatology, .,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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10
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Gaies M, Olive MK, Owens G, Charpie J, Zhang W, Pasquali S, Klugman D, Costello J, Hammel J, Gaynor JW, Banerjee M, Schwartz S. PEDIATRIC CARDIAC CRITICAL CARE OUTCOMES IMPROVE FOLLOWING IMPLEMENTATION OF A COMMERCIAL DATA AGGREGATION AND VISUALIZATION SOFTWARE PLATFORM. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31170-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Patregnani J, Klugman D, Zurakowski D, Sinha P, Freishtat R, Berger J, Diab Y. High on Aspirin Platelet Reactivity in Pediatric Patients Undergoing the Fontan Procedure. Circulation 2018; 134:1303-1305. [PMID: 27777299 DOI: 10.1161/circulationaha.116.023457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jason Patregnani
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.).
| | - Darren Klugman
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.)
| | - David Zurakowski
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.)
| | - Pranava Sinha
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.)
| | - Robert Freishtat
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.)
| | - John Berger
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.)
| | - Yaser Diab
- From Department of Critical Care (J.P., D.K., R.F., J.B.), Department of Cardiovascular Surgery (P.S., Y.D.), and Department of Hematology/Oncology (P.S., Y.D.), Children's National Health System, Washington, DC; and Department of Surgery and Anesthesia, Children's Hospital of Boston, MA (D.Z.)
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12
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Patregnani JT, Sochet AA, Zurakowski D, Klugman D, Diab Y, Berger JT, Sinha P. Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts. World J Pediatr Congenit Heart Surg 2018; 9:276-282. [PMID: 29692234 DOI: 10.1177/2150135118755985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis. METHODS Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors. RESULTS Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038). CONCLUSION Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.
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Affiliation(s)
- Jason T Patregnani
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Anthony A Sochet
- 2 Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, St Petersburg, FL, USA
| | - David Zurakowski
- 3 Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,4 Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Klugman
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Yaser Diab
- 5 Division of Hematology/Oncology, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - John T Berger
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Pranava Sinha
- 6 Division of Cardiovascular Surgery, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
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13
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Brunetti MA, Gaynor JW, Retzloff LB, Lehrich JL, Banerjee M, Amula V, Bailly D, Klugman D, Koch J, Lasa J, Pasquali SK, Gaies M. Characteristics, Risk Factors, and Outcomes of Extracorporeal Membrane Oxygenation Use in Pediatric Cardiac ICUs: A Report From the Pediatric Cardiac Critical Care Consortium Registry. Pediatr Crit Care Med 2018; 19:544-552. [PMID: 29863638 PMCID: PMC6051408 DOI: 10.1097/pcc.0000000000001571] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiopulmonary failure in children with cardiac disease differs from the general pediatric critical care population, yet the epidemiology of extracorporeal membrane oxygenation support in cardiac ICUs has not been described. We aimed to characterize extracorporeal membrane oxygenation utilization and outcomes across surgical and medical patients in pediatric cardiac ICUs. DESIGN Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry to describe extracorporeal membrane oxygenation frequency and outcomes. Within strata of medical and surgical hospitalizations, we identified risk factors associated with extracorporeal membrane oxygenation use through multivariate logistic regression. SETTING Tertiary-care children's hospitals. PATIENTS Neonates through adults with cardiac disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 14,526 eligible hospitalizations from August 1, 2014, to June 30, 2016; 449 (3.1%) included at least one extracorporeal membrane oxygenation run. Extracorporeal membrane oxygenation was used in 329 surgical (3.5%) and 120 medical (2.4%) hospitalizations. Systemic circulatory failure and extracorporeal cardiopulmonary resuscitation were the most common extracorporeal membrane oxygenation indications. In the surgical group, risk factors associated with postoperative extracorporeal membrane oxygenation use included younger age, extracardiac anomalies, preoperative comorbidity, higher Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, bypass time, postoperative mechanical ventilation, and arrhythmias (all p < 0.05). Bleeding requiring reoperation (25%) was the most common extracorporeal membrane oxygenation complication in the surgical group. In the medical group, risk factors associated with extracorporeal membrane oxygenation use included acute heart failure and higher Vasoactive Inotropic Score at cardiac ICU admission (both p < 0.0001). Stroke (15%) and renal failure (15%) were the most common extracorporeal membrane oxygenation complications in the medical group. Hospital mortality was 49% in the surgical group and 63% in the medical group; mortality rates for hospitalizations including extracorporeal cardiopulmonary resuscitation were 50% and 83%, respectively. CONCLUSIONS This is the first multicenter study describing extracorporeal membrane oxygenation use and outcomes specific to the cardiac ICU and inclusive of surgical and medical cardiac disease. Mortality remains high, highlighting the importance of identifying levers to improve care. These data provide benchmarks for hospitals to assess their outcomes in extracorporeal membrane oxygenation patients and identify unique high-risk subgroups to target for quality initiatives.
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Affiliation(s)
- Marissa A Brunetti
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lauren B Retzloff
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Jessica L Lehrich
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health & Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Venugopal Amula
- Department of Pediatrics, Primary Children's Hospital & University of Utah School of Medicine, Salt Lake City, UT
| | - David Bailly
- Department of Pediatrics, Primary Children's Hospital & University of Utah School of Medicine, Salt Lake City, UT
| | - Darren Klugman
- Department of Pediatrics, Children's National Medical Center & George Washington University School of Medicine, Washington, DC
| | - Josh Koch
- Department of Pediatrics, Children's Medical Center & University of Texas Southwestern Medical Center, Dallas, TX
| | - Javier Lasa
- Department of Pediatrics, Texas Children's Hospital & Baylor College of Medicine, Houston, TX
| | - Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
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14
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Sochet AA, Cartron AM, Nyhan A, Spaeder MC, Song X, Brown AT, Klugman D. Surgical Site Infection After Pediatric Cardiothoracic Surgery. World J Pediatr Congenit Heart Surg 2017; 8:7-12. [PMID: 28033082 DOI: 10.1177/2150135116674467] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Surgical site infection (SSI) occurs in 0.25% to 6% of children after cardiothoracic surgery (CTS). There are no published data regarding the financial impact of SSI after pediatric CTS. We sought to determine the attributable hospital cost and length of stay associated with SSI in children after CTS. METHODS We performed a retrospective, matched cohort study in a 26-bed cardiac intensive care unit (CICU) from January 2010 through December 2013. Cases with SSI were identified retrospectively and individually matched to controls 2:1 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, and primary cardiac diagnosis and procedure. RESULTS Of the 981 cases performed during the study period, 12 with SSI were identified. There were no differences in demographics, clinical characteristics, or intraoperative data. Median total hospital costs were higher in participants with SSI as compared to controls (US$219,573 vs US$82,623, P < .01). Children with SSI had longer median CICU length of stay (9 vs 3 days, P < .01), hospital length of stay (18 vs 8.5 days, P < .01), and duration of mechanical ventilation (2 vs 1 day, P < .01) and vasoactive administration (4.5 vs 1 day, P < .01). CONCLUSIONS Children with SSI after CTS have an associated increase in hospital costs of US$136,950/case and hospital length of stay of 9.5 days/case. The economic burden posed by SSI stress the importance of infection control surveillance, exhaustive preventative measures, and identification of modifiable risk factors.
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Affiliation(s)
- Anthony A Sochet
- 1 Division of Critical Care Medicine, Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA.,2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Alexander M Cartron
- 3 Division of Critical Care Medicine, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Aoibhinn Nyhan
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Michael C Spaeder
- 4 Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Xiaoyan Song
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,5 Division of Infectious Disease, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Anna T Brown
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,6 Division of Anesthesiology, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Darren Klugman
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,7 Division of Cardiology, Department of Pediatrics, Children's National Health System, Washington, DC, USA
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15
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Buckley JR, Graham EM, Gaies M, Alten JA, Cooper DS, Costello JM, Domnina Y, Klugman D, Pasquali SK, Donohue JE, Zhang W, Scheurer MA. Clinical epidemiology and centre variation in chylothorax rates after cardiac surgery in children: a report from the Pediatric Cardiac Critical Care Consortium. Cardiol Young 2017; 27:1-8. [PMID: 28552079 DOI: 10.1017/s104795111700097x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Introduction Chylothorax after paediatric cardiac surgery incurs significant morbidity; however, a detailed understanding that does not rely on single-centre or administrative data is lacking. We described the present clinical epidemiology of postoperative chylothorax and evaluated variation in rates among centres with a multicentre cohort of patients treated in cardiac ICU. METHODS This was a retrospective cohort study using prospectively collected clinical data from the Pediatric Cardiac Critical Care Consortium registry. All postoperative paediatric cardiac surgical patients admitted from October, 2013 to September, 2015 were included. Risk factors for chylothorax and association with outcomes were evaluated using multivariable logistic or linear regression models, as appropriate, accounting for within-centre clustering using generalised estimating equations. RESULTS A total of 4864 surgical hospitalisations from 15 centres were included. Chylothorax occurred in 3.8% (n=185) of hospitalisations. Case-mix-adjusted chylothorax rates varied from 1.5 to 7.6% and were not associated with centre volume. Independent risk factors for chylothorax included age <1 year, non-Caucasian race, single-ventricle physiology, extracardiac anomalies, longer cardiopulmonary bypass time, and thrombosis associated with an upper-extremity central venous line (all p<0.05). Chylothorax was associated with significantly longer duration of postoperative mechanical ventilation, cardiac ICU and hospital length of stay, and higher in-hospital mortality (all p<0.001). CONCLUSIONS Chylothorax after cardiac surgery in children is associated with significant morbidity and mortality. A five-fold variation in chylothorax rates was observed across centres. Future investigations should identify centres most adept at preventing and managing chylothorax and disseminate best practices.
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Affiliation(s)
- Jason R Buckley
- 1Department of Pediatrics,Division of Pediatric Cardiology,Medical University of South Carolina,Charleston,South Carolina,United States of America
| | - Eric M Graham
- 1Department of Pediatrics,Division of Pediatric Cardiology,Medical University of South Carolina,Charleston,South Carolina,United States of America
| | - Michael Gaies
- 2Department of Pediatrics and Communicable Diseases,Division of Cardiology,C.S. Mott Children's Hospital,University of Michigan Medical School,Ann Arbor,Michigan,United States of America
| | - Jeffrey A Alten
- 3Department of Pediatrics,Division of Pediatric Cardiology,University of Alabama at Birmingham,Birmingham,Alabama,United States of America
| | - David S Cooper
- 4The Heart Institute,Cincinnati Children's Hospital Medical Center,Cincinnati,Ohio,United States of America
| | - John M Costello
- 5Department of Pediatrics,Division of Cardiology,Ann & Robert H. Lurie Children's Hospital of Chicago,Northwestern University Feinberg School of Medicine,Chicago,Illinois,United States of America
| | - Yuliya Domnina
- 6Department of Critical Care Medicine,Division of Cardiac Intensive Care,Children's Hospital of Pittsburgh,University of Pittsburgh Medical Center,Pittsburgh,Pennsylvania,United States of America
| | - Darren Klugman
- 7Department of Critical Care Medicine and Cardiology,Children's National Medical Center,Washington,District of Columbia,United States of America
| | - Sara K Pasquali
- 2Department of Pediatrics and Communicable Diseases,Division of Cardiology,C.S. Mott Children's Hospital,University of Michigan Medical School,Ann Arbor,Michigan,United States of America
| | - Janet E Donohue
- 8Michigan Congenital Heart Outcomes Research and Discovery Unit,University of Michigan Congenital Heart Center,Ann Arbor,Michigan,United States of America
| | - Wenying Zhang
- 8Michigan Congenital Heart Outcomes Research and Discovery Unit,University of Michigan Congenital Heart Center,Ann Arbor,Michigan,United States of America
| | - Mark A Scheurer
- 1Department of Pediatrics,Division of Pediatric Cardiology,Medical University of South Carolina,Charleston,South Carolina,United States of America
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16
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El-Sayed Ahmed MM, Kurkluoglu M, Hynes CF, Klugman D, Puscasiu E, Nath DS. Intracardiac Fungal Mass in a Term Neonate. Methodist Debakey Cardiovasc J 2017; 12:225-226. [PMID: 28289498 DOI: 10.14797/mdcj-12-4-225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Systemic fungal infections pose insidious challenges in neonatal intensive care settings. We present the case of a 9-day-old male term neonate admitted for polymicrobial sepsis and hepatic dysfunction who later developed candidemia superinfection. Despite broad antifungal therapy, the fungemia was complicated by progressive growth of a fungus ball in the right ventricular outflow tract that threatened cardiac function. Surgical excision of the mass was undertaken by right atriotomy and histologic examination confirmed Candida albicans.
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Affiliation(s)
- Magdy M El-Sayed Ahmed
- Children's National Health System, Washington, DC; Zagazig University Faculty of Medicine, Zigzag, Egypt
| | | | | | | | | | - Dilip S Nath
- Children's National Health System, Washington, DC
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17
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McBride ME, Floh A, Krishnamurthy G, Checchia P, Klugman D. Advancing Cardiac Critical Care: A Call for Training, Collaboration, and Family Engagement. World J Pediatr Congenit Heart Surg 2016; 7:135-8. [PMID: 26957394 DOI: 10.1177/2150135115623962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The evolution and development of pediatric cardiac critical care as a distinct subspecialty have occurred rapidly over the past 20 years. As the field has grown, models for education, training, and care delivery have changed as well. This review will highlight the current state of education, training, and parental involvement in care delivery for pediatric cardiac critical care as initially.
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Affiliation(s)
- Mary E McBride
- Division of Cardiology & Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL,USA
| | - Alejandro Floh
- Department of Pediatrics, Hospital for Sick Kids, Toronto, ON, Canada Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Ganga Krishnamurthy
- Division of Neonatology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Paul Checchia
- Section of Critical Care Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Darren Klugman
- Divisions of Critical Care Medicine & Cardiology, Children's National Health System, The George Washington University School of Medicine, Washington, DC, USA
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18
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Anand V, Kwiatkowski DM, Ghanayem NS, Axelrod DM, DiNardo J, Klugman D, Krishnamurthy G, Siehr S, Stromberg D, Yates AR, Roth SJ, Cooper DS. Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society. World J Pediatr Congenit Heart Surg 2016; 7:81-8. [PMID: 26714998 DOI: 10.1177/2150135115614576] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.
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Affiliation(s)
- Vijay Anand
- Department of Critical Care, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - David M Kwiatkowski
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Nancy S Ghanayem
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - David M Axelrod
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - James DiNardo
- Department of Anesthesia, Boston Children's Hospital, Boston, MA, USA
| | - Darren Klugman
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Stephanie Siehr
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Daniel Stromberg
- Department of Pediatrics and Critical Care Medicine, Medical City Children's Hospital, Dallas, TX, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Stephen J Roth
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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19
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Buckley J, Graham E, Gaies M, Alten JA, Cooper D, Costello J, Domnina Y, Donahue J, Klugman D, Pasquali S, Zhang W, Scheurer M. CLINICAL EPIDEMIOLOGY OF CHYLOTHORAX AFTER CARDIAC SURGERY IN CHILDREN: A REPORT FROM THE PEDIATRIC CARDIAC CRITICAL CARE CONSORTIUM. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)30914-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Hickok RL, Spaeder MC, Berger JT, Schuette JJ, Klugman D. Postoperative Abdominal NIRS Values Predict Low Cardiac Output Syndrome in Neonates. World J Pediatr Congenit Heart Surg 2016; 7:180-4. [DOI: 10.1177/2150135115618939] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: The development of low cardiac output syndrome (LCOS) after cardiopulmonary bypass (CPB) occurs in up to 25% of neonates and is associated with increased morbidity. Invasive cardiac output monitors such as pulmonary artery catheters have limited availability and are costly. Near-infrared spectroscopy (NIRS) is a noninvasive tool for monitoring regional oxygenation in neonates in the cardiac intensive care unit (CICU). We hypothesize that anterior abdominal NIRS may aid in the early identification of LCOS after cardiac surgery. Methods: Prospective observational study from October 2013 to October 2014 of all neonates with congenital heart disease admitted to the CICU following CPB. Abdominal NIRS values were continuously recorded upon CICU admission and for the subsequent 24-hour period. The primary outcome was the development of LCOS. Low cardiac output syndrome was defined as the presence of metabolic lactic acidosis (pH < 7.3 and lactate > 4) or addition of a new vasoactive agent or a vasoactive inotropic score > 15. Autoregressive time series models were constructed for each patient based on the continuously recorded NIRS values, and patients were stratified by development of LCOS. Results: Twenty-seven neonates met inclusion criteria, of whom 11 developed LCOS. Neonates who developed LCOS had lower constant NIRS values (49% vs 66%, P < .001). Constant NIRS values less than 58% best predicted development of LCOS with a sensitivity of 100% and specificity of 69%. Conclusion: Lower constant anterior abdominal NIRS values in the early postoperative period may allow early identification of neonates at risk for LCOS.
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Affiliation(s)
- Rhiannon L. Hickok
- Division of Critical Care Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Michael C. Spaeder
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
| | - John T. Berger
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
- Division of Cardiology, Children's National Health System, Washington, DC, USA
| | | | - Darren Klugman
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
- Division of Cardiology, Children's National Health System, Washington, DC, USA
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Patregnani JT, Spaeder MC, Lemon V, Diab Y, Klugman D, Stockwell DC. Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection. Jt Comm J Qual Patient Saf 2015; 41:108-14. [PMID: 25977126 DOI: 10.1016/s1553-7250(15)41015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The safety profile of anticoagulants, which are being used with increasing frequency in pediatric populations, is not well studied. Automatic triggers built into electronic health record systems (EHR) have been shown to be an effective way to monitor for and identify medication errors. Anticoagulant-associated adverse events were examined through the use of an anticoagulant trigger panel. METHODS In a retrospective, five-year (September 2007-September 2012) observational study, four automated triggers were used to detect anticoagulant-related adverse events: activated partial thromboplastin time (aPTT) > 100 seconds in patients on an unfractionated heparin (UFH) infusion, International Normalized Ratio (INR) > 4, anti-factor Xa (anti-FXa) >1.5U/mL for patients on enoxaparin, and the documented use of protamine. RESULTS For the 1,664 triggers evaluated, 12 were associated with the aPTT trigger, only 1 of which was preventable. Receiver operator characteristic curve analysis indicated that increasing the aPTT trigger > 140 seconds would optimize sensitivity and specificity. The INR trigger identified four outpatients with adverse events. No adverse events were associated with the anti-FXa trigger. The protamine trigger identified 12 adverse events and was associated with more severe events. Minimal overlap was found with protamine and aPTT triggers. CONCLUSION Laboratory- and medication-based triggers can be effective monitoring tools for anticoagulants. For patients receiving a UFH infusion, an aPTT cutoff value of > 140 seconds is more precise. We also found that protamine use as a trigger adds value to a trigger-based anticoagulant monitoring system. Continued improvement in the logic algorithms associated with the EHR-based trigger tool will allow expanded use of this tool in a clinical manner.
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Affiliation(s)
- Jason T Patregnani
- Department of Pediatric Critical Care, Children's National Health System, Washington, DC, USA
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Shankar V, Costello JP, Peer SM, Klugman D, Nath DS. Ethical dilemma: offering short-term extracorporeal membrane oxygenation support for terminally ill children who are not candidates for long-term mechanical circulatory support or heart transplantation. World J Pediatr Congenit Heart Surg 2015; 5:311-4. [PMID: 24668981 DOI: 10.1177/2150135113509820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in terminally ill pediatric patients who are not candidates for long-term mechanical circulatory support or heart transplantation requires careful deliberation. We present the case of a 16-year-old female with a relapse of acute lymphoid leukemia and acute-on-chronic cardiomyopathy who received short-term ECMO therapy. In addition, we highlight several ethical considerations that were crucial to this patient's family-centered care and demonstrate that this therapy can be accomplished in a manner that respects patient autonomy and family wishes.
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Affiliation(s)
- Venkat Shankar
- Department of Critical Care Medicine, Children's National Medical Center, Washington, DC, USA
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Gutierrez S, Shaw S, Huseni S, Sachdeva S, Costello JP, Basu S, Nath DS, Klugman D. Extracorporeal life support for a 5-week-old infant with idiopathic pulmonary hemosiderosis. Eur J Pediatr 2014; 173:1573-6. [PMID: 23942745 DOI: 10.1007/s00431-013-2130-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 07/30/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Idiopathic pulmonary hemosiderosis is a rare disease defined by the triad of iron deficiency anemia, hemoptysis, and diffuse pulmonary infiltrates on chest radiograph. Idiopathic pulmonary hemosiderosis is known to cause dyspnea and, in some cases, acute onset of massive pulmonary hemorrhage which is traditionally treated with conventional mechanical ventilation or high-frequency oscillation in conjunction with immunosuppressive therapy. In this case report, we describe a 5-week-old infant presenting with hemoptysis, massive pulmonary hemorrhage, and significant hypercapnic respiratory failure. The patient failed conventional ventilation but responded well to extracorporeal life support that was initiated early in his course. Idiopathic pulmonary hemosiderosis was suspected in light of his response to high-dose steroids and was confirmed by subsequent lung biopsies. CONCLUSION Patients with severe pulmonary hemorrhage secondary to idiopathic pulmonary hemosiderosis can be safely supported with extracorporeal life support when conventional therapies have been exhausted.
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Affiliation(s)
- Sherrill Gutierrez
- Division of Critical Care Medicine , Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC, 20010, USA
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Abstract
BACKGROUND The frequency of off-label drug use and its association with morbidity and mortality in the cardiac intensive care unit (CICU) has not been previously studied. METHODS Patients less than 18 years of age admitted to the CICU from June to August 2008 were retrospectively identified. Patient demographics were collected for 30 days or until CICU discharge. Off-label drug use was defined as the prescription of a medication that lacked a labeled indication based on patient's age as reported in the Micromedex drug database and electronic Physician's Desk Reference. RESULTS Eighty-two patients were admitted to the CICU during the study period. In all, 40 (46%) patients were male; the median age was 10.6 months. Common diagnoses were left-to-right shunt lesions (20.7%) and single-ventricle lesions (20.7%), with an overall mortality of 2.4%. Of all drugs prescribed, 36% were off-label. In all, 94% of the patients received ≥1 drug off-label. The median number of drugs prescribed off-label was four. Patients receiving more than four off-label medications were younger, had longer CICU lengths of stay (median 9.5 vs 2 days, P < .001), and increased ventilator days (median two vs one day, P < .001). CONCLUSIONS Off-label drug use in the CICU is common. Frequency of use is likely higher in patients with a higher severity of illness. Further safety, efficacy, and pharmaceutical trials are warranted to optimize the use of these drugs to improve outcomes.
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Affiliation(s)
- Lily A Maltz
- Department of Cardiology, Children's National Medical Center, Washington, DC, USA
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Costello JP, Emerson DA, Shu MK, Peer SM, Zurakowski D, Reilly BK, Klugman D, Jonas RA, Nath DS. Outcomes of tracheostomy following congenital heart surgery: a contemporary experience. CONGENIT HEART DIS 2014; 10:E25-9. [PMID: 24898170 DOI: 10.1111/chd.12192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2014] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Following congenital heart surgery, pediatric patients may experience persistent respiratory failure that requires tracheostomy placement. Currently, definitive knowledge of the optimal timing for tracheostomy placement in this patient population is lacking. METHODS An 8-year retrospective review of 17 pediatric patients who underwent congenital heart surgery and subsequently required tracheostomy placement was performed. Patients were evaluated with regard to the timing of tracheostomy and mortality. RESULTS The overall study mortality was 24%. The median duration of intubation prior to tracheostomy was 60 days (interquartile range: 19-90 days); there was no difference in the average time between intubation and tracheostomy for survivors compared with nonsurvivors (51 vs. 73 days, P = .37). No difference was observed in the overall duration of positive pressure ventilation when tracheostomy was performed within 30 days of intubation compared with greater than 30 days following intubation (481 vs. 451 days, P = .88). Overall, 18% of patients were successfully weaned from the ventilator after a median duration of positive pressure ventilation of 212 days. CONCLUSION The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population.
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Affiliation(s)
- John P Costello
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, USA; The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
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Klugman D, Berger JT, Spaeder MC, Wright A, Pastor W, Stockwell DC. Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates. Intensive Care Med 2013; 39:1333-4. [DOI: 10.1007/s00134-013-2932-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2013] [Indexed: 11/29/2022]
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Ghelani SJ, Spaeder MC, Pastor W, Spurney CF, Klugman D. Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011. Circ Cardiovasc Qual Outcomes 2012; 5:622-7. [PMID: 22828827 DOI: 10.1161/circoutcomes.112.965749] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is a lack of clear diagnostic and management guidelines for acute myocarditis in the pediatric population. We used a multi-institutional database to characterize demographics, practice variability, and outcomes in this population. METHODS AND RESULTS Patients with acute myocarditis (n=514) were identified from April 2006 to March 2011 using the Pediatric Health Information System database, and regional variations in management and outcomes were analyzed. Ninety-seven patients (18.9%) received extracorporeal membrane oxygenation, 22 (4.3%) received ventricular assist device, 21 (4.1%) received heart transplantation, and 37 (7.2%) died. Of the 104 patients who received extracorporeal membrane oxygenation or ventricular assist device, 17 (16.3%) had heart transplantation, 25 (24%) died, and 62 (59.6%) showed recovery of myocardial function. There was a decrease in the use of endomyocardial biopsy (P=0.03) and an increase in the use of magnetic resonance imaging (P<0.01) over the study period. Although the use of medications and procedures varied between different regions, the occurrence of death or heart transplantation showed no significant regional associations. The use of extracorporeal membrane oxygenation (odds ratio, 5.8; 95% confidence interval, 2.9-11.4; P<0.01), ventricular assist device (odds ratio, 8.2; 95% confidence interval, 2.7-24.9; P<0.01), and vasoactive medications (odds ratio, 5.7; 95% confidence interval, 1.2-26.1; P=0.03) was independently associated with death/transplantation. CONCLUSIONS There is significant temporal and regional variation in the diagnostic modalities and management used for pediatric myocarditis, which continues to have high morbidity and mortality. Extracorporeal membrane oxygenation, ventricular assist device, and vasoactive medications are independently associated with increased mortality/transplantation.
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Affiliation(s)
- Sunil J Ghelani
- Division of Cardiology, Division of Critical Care Medicine, and Clinical Data Operations, Children's National Medical Center, Washington, DC 20010, USA
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Abstract
OBJECTIVE To determine how the anti-inflammatory properties of aprotinin impact on postoperative complications in children undergoing the Fontan procedure. METHODS We included all patients between 14 months and 18 years (n=56) undergoing a Fontan operation at our institution between January 2005 and June 2009. The study group (n=29) included patients from January 2005 through December 2007 all of whom received aprotinin. The control group (n=27) included all patients from January 2008 through June 2009 who did not receive aprotinin. We reviewed all medical records and collected preoperative, intraoperative and postoperative data. Duration and volume of chest tube drainage were the primary outcome measures. RESULTS Of the 20% of patients who had postoperative arrhythmias, multivariate logistic regression analysis demonstrated only aprotinin was associated with significantly decreased postoperative arrhythmias (P=0.01). Renal function and fenestration or Fontan thrombosis did not differ significantly; there was no statistically significant difference in volume or duration of chest tube drainage. Median duration of chest tube drainage was 7 days in the aprotinin group and 8 days for patients who did not receive aprotinin (P=0.36). CONCLUSION The anti-inflammatory properties of aprotinin may be protective against postoperative arrhythmias. Aprotinin does not confer increased risks of prolonged chest tube drainage, renal dysfunction or thrombosis in patients undergoing the Fontan procedure.
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Affiliation(s)
- D Klugman
- Department of Critical Care Medicine and Cardiology, Children's National Heart Institute, Children's National Medical Center, The George Washington University School of Medicine, Washington, DC 20010, USA.
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Hussain SZ, Bashir RM, Kerzner B, Klugman D, Mohan P, Bader AA. Application of a self-expandable metal stent (SEMS) in a child with complete malignant large bowel obstruction. Dig Dis Sci 2004; 49:1145-8. [PMID: 15387336 DOI: 10.1023/b:ddas.0000037802.52686.4a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Sunny Z Hussain
- Department of Gastroenterology, National Children's Medical Center, Washington, DC 20010, USA
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Affiliation(s)
- S T Melman
- MCP Hahnemann University, Philadelphia, PA, USA
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Abstract
The masseter muscle is functionally heterogeneous with a complex architecture consisting of multiple tendons and a multipennate arrangement of muscle fibers. In this study, the anatomical partitioning of the rabbit masseter is described on the basis of the tendons of origin and insertion, general partition orientation relative to the zygomatic arch, motor endplate descriptions, and primary nerve branches that innervate these partitions. This work refines previous descriptions of the rabbit masseter and describes 13 anatomical partitions, each with a unique tendinous attachment. In addition, 14 naturally occurring primary nerve branches were identified and found to innervate different regions of the muscle. After correlating the anatomical partitions and the associated neural innervation pattern, it was determined that simple branch order will not adequately define all the neuromuscular compartments in the rabbit masseter.
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Affiliation(s)
- C G Widmer
- Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida, Gainesville 32610-0416, USA.
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