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Crawford R, Akmyradov C, Dachepally R, Prodhan P. Hospital Outcomes Among Children With Congenital Heart Disease and Adenovirus Pneumonia. Pediatr Infect Dis J 2024:00006454-990000000-00816. [PMID: 38564736 DOI: 10.1097/inf.0000000000004341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/04/2024]
Abstract
BACKGROUND The aim of the study is to evaluate the mortality risk factors and hospitalization outcomes of adenovirus pneumonia in pediatric patients with congenital heart disease. METHODS In this retrospective multicenter cohort study utilizing the Pediatric Health Information System database, we analyzed congenital heart disease patients with adenovirus pneumonia from January 2004 to September 2018, categorizing them into shunts, obstructive lesions, cyanotic lesions and mixing lesions. Multivariate logistic regression analysis was employed to identify mortality risk factors with 2 distinct models to mitigate collinearity issues and the Mann-Whitney U test was used to compare the hospital length of stay between survivors and nonsurvivors across these variables. RESULTS Among 381 patients with a mean age of 3.2 years (range: 0-4 years), we observed an overall mortality rate of 12.1%, with the highest mortality of 15.1% noted in patients with shunts. Model 1 identified independent factors associated with increased mortality, including age 0-30 days (OR: 8.13, 95% CI: 2.57-25.67, P < 0.005), sepsis/shock (OR: 3.34, 95% CI: 1.42-7.83, P = 0.006), acute kidney failure (OR: 4.25, 95% CI: 2.05-13.43, P = 0.0005), shunts (OR: 2.95, 95% CI: 1.14-7.67, P = 0.03) and cardiac catheterization (OR: 6.04, 95% CI: 1.46-24.94, P = 0.01), and Model 2, extracorporeal membrane oxygenation (OR: 3.26, 95% CI: 1.35-7.87, P = 0.008). Nonsurvivors had a median hospital stay of 47 days compared to 15 days for survivors. CONCLUSION The study revealed a 12.1% mortality rate in adenoviral pneumonia among children with congenital heart disease, attributed to risk factors such as neonates, sepsis, acute kidney failure, shunts, cardiac catheterization, extracorporeal membrane oxygenation use and a 3-fold longer hospital stay for nonsurvivors compared to survivors.
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Affiliation(s)
- Richard Crawford
- From the Department of Cardiology, University of Oklahoma, Oklahoma
| | | | - Rashmitha Dachepally
- Department of Cardiology and Pediatric Intensive Care, University of Arkansas for Medical Sciences, Arkansas
- Department of Pediatric Critical Care, University of Nebraska Medical Center
| | - Parthak Prodhan
- Department of Cardiology and Pediatric Intensive Care, University of Arkansas for Medical Sciences, Arkansas
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Young HL, Brown CC, Crawford B, Blaszak RT, Prodhan P. Streptococcus pneumoniae associated hemolytic uremic syndrome in children. Front Pediatr 2023; 11:1268971. [PMID: 38027264 PMCID: PMC10665843 DOI: 10.3389/fped.2023.1268971] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Previous small-scale, single-center investigations of Streptococcus pneumoniae associated hemolytic uremic syndrome (SpHUS) have shown increased disease severity among SpHUS relative to non-SpHUS patients. Our study compares the impact of S. pneumoniae on patient outcomes between SpHUS cases and non-SpHUS controls using the national, multicenter retrospective Pediatric Health Information Systems (PHIS) Database. Methods Children <18 years of age with a diagnosis of HUS were included. Univariate analyses and multivariable linear and logistic regressions were utilized to assess the impact of S. pneumoniae on mortality, length of stay (LOS), intensive care unit admission (ICU), and mechanical ventilation use. Models were adjusted for demographic and clinical characteristics, including cardiac, neurologic, pulmonary, gastrointestinal, immunologic and renal clinical complications. Results Of 3,952 index HUS hospitalizations, 231 (5.8%) were due to SpHUS. SpHUS patients had worse outcomes, including longer hospital stays, increased rate of ICU admission, and increased use of mechanical ventilation (p < 0.001 for all). There was a strong positive relationship between clinical complications and adverse outcomes. After adjusting for covariates, SpHUS was associated with an increase in hospital LOS by 3.47 days (p = 0.009) and overall ICU-LOS by 4.21 days (p < 0.001). SpHUS was also associated with increased likelihood of mechanical ventilation (OR: 3.08; p < 0.001), with no increase in ICU admission (p = 0.070) and in-hospital mortality (p = 0.3874). Discussion Our study highlights that SpHUS patients are at increased risk of multiple adverse outcomes likely due to the summative impact of pneumococcal infection and HUS as well as more frequent clinical complications.
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Affiliation(s)
- Heather L. Young
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Clare C. Brown
- Health Policy and Management Department, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Brendan Crawford
- Division of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Richard T. Blaszak
- Division of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Parthak Prodhan
- Division of Cardiology/Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Asfari A, Jacobs JP, Byrnes JW, Borasino S, Prodhan P, Zaccagni H, Dabal RJ, Sorabella RA, Hammel JM, Smith-Parrish M, Zhang W, Banerjee M, Schumacher KR, Tabbutt S. Norwood Operation: Immediate vs Delayed Sternal Closure. Ann Thorac Surg 2023; 115:649-654. [PMID: 35863395 DOI: 10.1016/j.athoracsur.2022.06.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 03/03/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications. METHODS This retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure). RESULTS The incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%). CONCLUSIONS For important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.
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Affiliation(s)
- Ahmed Asfari
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Jeffrey P Jacobs
- Department of Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Jonathan W Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Santiago Borasino
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Parthak Prodhan
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Hayden Zaccagni
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert J Dabal
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert A Sorabella
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Hammel
- Department of Cardiovascular Surgery, University of Nebraska, Omaha, Nebraska
| | - Melissa Smith-Parrish
- Divisions of Pediatric Critical Care Medicine and Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine and Monroe Carrell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, Michigan
| | - Sarah Tabbutt
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco Benioff Children's Hospitals, San Francisco, California
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Crawford R, Dachepally R, Akmyradov C, Prodhan P. Mortality among children with congenital heart disease and adenovirus pneumonia. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00362-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Dachepally R, Allen B, Almasri M, Akmyradov C, Qasim A, Seib PM, Prodhan P. Factors associated with prolonged length of stay after balloon aortic valvuloplasty for congenital aortic stenosis. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00361-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Dachepally R, Prodhan P, Bhakta RT, Eble BK, Cunningham TW, Seib PM, Garcia X, Moss MM, Gatlin SW, Kane J. Sustained reduction in cardiac arrest events in a cardiac intensive care unit: a single center quality improvement experience. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Liboiron M, Malone MP, Brown CC, Prodhan P. Extracorporeal Membrane Oxygenation and Hemolytic Uremic Syndrome in Children: Outcome Review of a Multicenter National Database. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0042-1758478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AbstractHemolytic uremic syndrome (HUS) is a triad of hemolytic anemia, thrombocytopenia, and acute renal failure. In critically ill children with HUS, extrarenal manifestations may require intensive care unit admission and extracorporeal membrane oxygenation (ECMO) support. Outcomes specific to HUS and ECMO in children have not been well investigated. The primary aim of this project was to query a multicenter database to identify risk factors associated with mortality in HUS patients supported on ECMO. A secondary aim was to identify factors associated with ECMO utilization in children with HUS. Utilizing the Pediatric Health Information System database (January 2004 and September 2018), this retrospective, multicenter cohort study identified the index HUS hospitalization among children aged 0 to 18 years. Univariate analysis was used to compare demographics, clinical characteristics, and procedures to identify risk factors associated with adverse outcomes. Among 4,144 subjects, 37 were supported on ECMO. Survival for those on ECMO support was 54%. Among nonsurvivors, 59% of deaths occurred within 14 days of hospitalization. The mean hospital LOS was 15.9 days in nonsurvivors versus 53.9 days for survivors (p < 0.001). When comparing subjects supported on ECMO to those who were not, patients with ECMO support had statistically longer hospital LOS and higher rates of extrarenal involvement (p < 0.001). This study found a mortality rate of 46% among HUS patients requiring ECMO. The investigated clinical risk factors were not associated with mortality among the ECMO population. The study identifies risk factors associated with ECMO utilization in children with HUS.
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Affiliation(s)
- Mireille Liboiron
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Matthew P. Malone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Clare C. Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Parthak Prodhan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Arthur L, Prodhan P, Blaszak R, Crawford B, Brown CC, Arthur J. Evaluation of lung ultrasound to detect volume overload in children undergoing dialysis. Pediatr Nephrol 2022:10.1007/s00467-022-05723-x. [PMID: 36434355 PMCID: PMC9702747 DOI: 10.1007/s00467-022-05723-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 08/13/2022] [Accepted: 08/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lung ultrasound is a well-established technique to assess extravascular lung water, a proxy for volume status, in the adult population. Despite its utility, the data are limited supporting the use of ultrasound to evaluate fluid volume status among pediatric patients. Our study uses a simplified ultrasound protocol to evaluate changes in extravascular lung water, represented by b-lines, among pediatric patients undergoing hemodialysis. METHODS This prospective single-center study included children from birth to 18 years of age. The number of b-lines per ml/kg of fluid removed was compared prior to, at the midpoint, and following termination of dialysis. An 8-zone protocol was utilized, and b-lines were correlated to hemoconcentration measured by the CRIT-LINE® hematocrit. RESULTS Six patients with a total of 26 hemodialysis sessions were included in this study. The b-line measurements post-dialysis were 2.27 (p < 0.001; 94%CI -3.31, -1.22) lower relative to pre-dialysis. The number of b-lines was reduced by 1.69 (p < 0.001; -2.58, -0.80) between pre-dialysis and at the midpoint of dialysis and by 0.58 (p = 0.001; -0.90, -0.24) between the midpoint of dialysis and post-dialysis. A 1 mL/kg fluid loss correlated to a decrease in the original b-lines by 0.079. An inverse relationship (r = -0.54; 95% CI: -0.72, -0.34; p < 0.001) was noted between the b-lines and the patients' hematocrit levels. CONCLUSIONS A simplified 8-zone ultrasound protocol can assess fluid volume change in real time and correlates with hematocrit levels obtained throughout dialysis. This provides a valuable method for monitoring fluid status in volume overloaded patient populations. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Lindsay Arthur
- Section of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA.
| | - Parthak Prodhan
- Section of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205 USA ,Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Richard Blaszak
- Section of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Brendan Crawford
- Section of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Clare C. Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Jason Arthur
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA ,Section of Pediatric Emergency Medicine, Pharmacology, & Toxicology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR USA
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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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Prodhan P, Steiner M, Greiten LE. Systemic-to-Pulmonary Artery Shunt Thromboprophylaxis: Searching for the Holy Grail. Pediatr Crit Care Med 2022; 23:757-759. [PMID: 36053038 DOI: 10.1097/pcc.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/26/2022]
Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Marie Steiner
- Pediatric Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lawrence E Greiten
- Pediatric Critical Care/Pediatric Hematology-Oncology, University of Minnesota, Minneapolis, MN
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Dalabih AR, Prodhan P, Harris ZL, Bone MF. Employment Opportunities for Pediatric Critical Care Fellowship Trained Physicians in the United States. J Pediatr Intensive Care 2022; 11:105-108. [DOI: 10.1055/s-0040-1716908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022] Open
Abstract
AbstractPediatric Critical Care Medicine (PCCM) training programs and trained fellows in the United State increased steadily without a corresponding increase in population growth. PCCM trainees worry about limited employment prospects. This study aimed to quantify the demand for PCCM trained physicians in the United States by prospectively tracking full-time employment opportunities over 12 months. The number of advertised opportunities identified was low compared with number of fellows likely to be seeking jobs during same time period. If market demand remains stable, there is risk of excess supply if number of newly fellowship-trained PCCM physicians continues to rise.
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Affiliation(s)
- Abdallah R. Dalabih
- Division of Pediatric Critical Care Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Parthak Prodhan
- Division of Pediatric Critical Care Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Zena L. Harris
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Meredith F. Bone
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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12
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Schoeneberg L, Prodhan P, Spray B, Akmyradov C, Zakaria D. Risk Factors for Increased Post-operative Length of Stay in Children with Coarctation of Aorta. Pediatr Cardiol 2021; 42:1567-1574. [PMID: 34052859 DOI: 10.1007/s00246-021-02641-x] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
Coarctation of the aorta is a relatively common congenital heart disease occurring in 0.4-0.6 per 1000 live births with a low mortality rate. This is a retrospective study, with data abstracted from the Pediatric Health Information System database (PHIS). The study sample included pediatric patients less than or equal to 3 months of age discharged from a PHIS participating hospital between January 1, 2004 and December 31, 2018 who underwent surgical repair of isolated COA. The primary outcome for the study was post-operative hospital length of stay (PH-LOS), and the secondary outcome was in-hospital mortality. Patient demographics, comorbidities, procedures, and outcomes were assessed for statistical differences between eras. A total of 5354 patients were included in the study. The study highlights an increasing trend in PH-LOS and NICU hospital length of stay (NICU-LOS) across the investigated eras. Prematurity (before 37 weeks gestation) was an independent risk factor associated with both longer post-operative length of the stay and higher mortality. In addition, congenital anomalies, respiratory and abdominal surgeries have a significant impact on the post-operative hospital stay. In conclusion, this study is the largest published systematic assessment of PH-LOS in patients with isolated COA repair during infancy to date and identifies independent risk factors of increased PH-LOS.
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Affiliation(s)
- Laura Schoeneberg
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA
| | - Parthak Prodhan
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA
| | - Beverly Spray
- Arkansas Children's Research Institute (Biostatistics), Little Rock, USA
| | - Chary Akmyradov
- Arkansas Children's Research Institute (Biostatistics), Little Rock, USA
| | - Dala Zakaria
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA.
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13
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Sanders E, Brown CC, Blaszak RT, Crawford B, Prodhan P. Cardiac Manifestation among Children with Hemolytic Uremic Syndrome. J Pediatr 2021; 235:144-148.e4. [PMID: 33819463 PMCID: PMC8316308 DOI: 10.1016/j.jpeds.2021.03.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 06/29/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The primary objectives of the study were to describe the association between cardiac manifestations and in-hospital mortality among children with hemolytic uremic syndrome. STUDY DESIGN Using the Pediatric Health Information System database, this retrospective, multicenter, cohort study identified the first hemolytic uremic syndrome-related inpatient visit among children ≤18 years (years 2004-2018). The frequency of selected cardiac manifestations and mortality rates were calculated. Multivariate analysis identified the association of specific cardiac manifestations and the risk of in-hospital mortality. RESULTS Among 3915 patients in the analysis, 238 (6.1%) had cardiac manifestations. A majority of patients (82.8%; n = 197) had 1 cardiac condition and 17.2% (n = 41) had ≥2 cardiac conditions. The most common cardiac conditions was pericardial disease (n = 102), followed by congestive heart failure (n = 46) and cardiomyopathy/myocarditis (n = 34). The percent mortality for patients with 0, 1, or ≥2 cardiac conditions was 2.1%, 17.3%, and 19.5%, respectively. Patients with any cardiac condition had an increased odds of mortality (OR, 9.74; P = .0001). In additional models, the presence of ≥2 cardiac conditions (OR, 9.90; P < .001), cardiac arrest (OR, 38.25; P < .001), or extracorporeal membrane oxygenation deployment (OR, 11.61; P < .001) were associated with increased risk of in-hospital mortality. CONCLUSIONS This study identified differences in in-hospital mortality based on the type of cardiac manifestations, with increased risk observed for patients with multiple cardiac involvement, cardiac arrest, and extracorporeal membrane oxygenation deployments.
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Affiliation(s)
- Emily Sanders
- Pediatrics, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Clare C. Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Richard T Blaszak
- Nephrology; Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Brendan Crawford
- Nephrology; Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
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14
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Ahmed A, Prodhan P, Spray BJ, Bolin EH. Impact of Perioperative Tachydysrhythmias on Mortality and Length of Stay in Complete Repair of Tetralogy of Fallot: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System. Cardiology 2021; 146:368-374. [PMID: 33735878 DOI: 10.1159/000512777] [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] [Received: 05/12/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Tachydysrhythmias (TDS) frequently occur after complete repair of tetralogy of Fallot (TOF). However, not much is known about the effect of TDS on morbidity and mortality after TOF repair. We sought to assess the associations between TDS and mortality and morbidity after repair of TOF using a multicentre database. MATERIALS AND METHODS We identified all children aged 0-5 years in the Pediatric Health Information System who underwent TOF repair between 2004 and 2015. Codes for TDS were used to identify cases. Outcome variables were inpatient mortality and total length of stay (LOS). Univariate and multiple logistic and linear regression analyses were used to identify the effects of multiple risk factors, including TDS, on mortality and LOS. RESULTS A total of 7,749 patients met inclusion criteria, of which 1,493 (19%) had codes for TDS. There was no association between TDS and inpatient mortality. However, TDS were associated with 1.1 days longer LOS and accounted for 2% of the variation observed in LOS. CONCLUSION After complete repair of TOF, TDS were not associated with mortality and appeared to have only a modest effect on LOS.
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Affiliation(s)
- Aziez Ahmed
- Children's Heart Center, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, Connecticut, USA,
| | - Parthak Prodhan
- Department of Pediatrics, Section of Pediatric Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
| | - Beverly J Spray
- Biostatistics Core, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
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15
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Brown CC, Garcia X, Bhakta RT, Sanders E, Prodhan P. Severe Acute Neurologic Involvement in Children With Hemolytic-Uremic Syndrome. Pediatrics 2021; 147:peds.2020-013631. [PMID: 33579812 PMCID: PMC7919116 DOI: 10.1542/peds.2020-013631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Acute severe neurologic involvement is the most threatening complication in children with hemolytic-uremic syndrome (HUS). Our primary study objectives were to describe the association between acute neurologic manifestations (ANMs) and in-hospital mortality among children with HUS. METHODS Using the Pediatric Health Information System database, in this retrospective multicenter cohort study, we identified the first HUS-related inpatient visit among children ≤18 years (years 2004-2018). Frequency of selected ANMs and combinations of ANMs, as well as the rate of mortality, was calculated. Multivariate logistic regression was used to identify the association of ANMs and the risk of in-hospital mortality. RESULTS Among 3915 patients included in the analysis, an ANM was noted in 10.4% (n = 409) patients. Encephalopathy was the most common ANM (n = 245). Mortality was significantly higher among patients with an ANM compared with patients without an ANM (13.9% vs 1.8%; P < .001). Individuals with any ANM had increased odds of mortality (odds ratio [OR]: 2.25; 95% confidence interval [CI]: 1.29-3.93; P = .004), with greater risk (OR: 2.60; 95% CI: 1.34-5.06; P = .005) among patients with ≥2 manifestations. Brain hemorrhage (OR: 3.09; 95% CI: 1.40-6.82; P = .005), brain infarction (OR: 2.64; 95% CI: 1.10-6.34; P = .03), anoxic brain injury (OR: 3.92; 95% CI: 1.49-10.31; P = .006), and brain edema (OR: 4.81; 95% CI: 1.82-12.71; P = .002) were independently associated with mortality. CONCLUSIONS In this study, the largest systematic assessment of ANMs among children with HUS to date, we identify differences in in-hospital mortality based on the type of ANM, with increased risk observed for patients with multiple ANMs.
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Affiliation(s)
- Clare C. Brown
- Health Policy and Management Department, Fay W. Boozman College of Public Health and
| | - Xiomara Garcia
- Pediatric Cardiology, and Pediatric Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Rupal T. Bhakta
- Pediatric Cardiology, and Pediatric Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, Arkansas
| | | | - Parthak Prodhan
- Pediatric Cardiology, and Pediatric Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
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16
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Abstract
Infection by SARS-CoV-2 has led to disease referred to as coronavirus disease 2019 which, in children has been described as of multisystem inflammatory syndrome in children. Our experience demonstrates 2 distinct presentations of this syndrome which have different clinical courses and may have differing long-term outcomes.
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Affiliation(s)
- Richard L Crawford
- From the Department of Pediatrics, Section of Cardiology, University of Arkansas for Medical Sciences Little Rock, Arkansas
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17
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Liboiron M, Malone M, Prodhan P. 1146: ECMO and Hemolytic Uremic Syndrome in Children: Outcome Review of a Multicenter Database. Crit Care Med 2021. [DOI: 10.1097/01.ccm.0000730472.93685.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Ranabothu S, Brown CC, Blaszak R, Millner R, Moore KR, Prodhan P. Utilization Pattern for Eculizumab Among Children With Hemolytic Uremic Syndrome. Front Pediatr 2021; 9:733042. [PMID: 34676187 PMCID: PMC8523981 DOI: 10.3389/fped.2021.733042] [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: 06/29/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Hemolytic uremic syndrome (HUS) is a complex disease with multi-organ involvement. Eculizumab therapy is recommended for treatment of complement mediated hemolytic uremic syndrome (cHUS). However, there are few studies evaluating eculizumab therapy among children with HUS. The primary objectives of the study were to describe and identify factors associated with eculizumab therapy in children with HUS. Design/Methods: This large, retrospective, multi-center, cohort study used the Pediatric Health Information System (PHIS) database to identify the index HUS-related hospitalization among patients ≤18 years of age from September 23, 2011 (Food and Drug Administration approval date of eculizumab) through December 31, 2018. Multivariate analysis was used to identify independent factors associated with eculizumab therapy during or after the index hospitalization. Results: Among 1,885 children included in the study, eculizumab therapy was noted in 167 children with a median age of 3.99 years (SD ± 4.7 years). Eculizumab therapy was administered early (within the first 7 days of hospitalization) among 65% of children who received the drug. Mortality during the index hospitalization among children with eculizumab therapy was 4.2 vs. 3.0% without eculizumab therapy (p = 0.309). Clinical factors independently associated with eculizumab therapy were encephalopathy [odds ratio (OR) = 3.09; p ≤ 0.001], seizure disorder (OR = 2.37; p = 0.006), and cardiac involvement (OR = 6.36, p < 0.001). Conclusion(s): Only 8.9% of children received eculizumab therapy. Children who presented with neurological and cardiac involvement with severe disease were more likely to receive eculizumab therapy, and children who received therapy received it early during their index hospitalization. Further prospective studies are suggested to confirm these findings.
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Affiliation(s)
- Saritha Ranabothu
- Department of Pediatrics, Pediatric Nephrology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Clare C Brown
- Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Richard Blaszak
- Department of Pediatrics, Pediatric Nephrology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Rachel Millner
- Department of Pediatrics, Pediatric Nephrology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Kristen Rice Moore
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Parthak Prodhan
- Pediatrics, Pediatric Cardiology/Pediatric Critical Care, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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19
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Garcia X, Frazier E, Kane J, Jones A, Brown C, Bryant T, Prodhan P. Pediatric Cardiac Critical Care Transport and Palliative Care: A Case Series. Am J Hosp Palliat Care 2020; 38:94-97. [PMID: 32462881 DOI: 10.1177/1049909120928280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 11/17/2022] Open
Abstract
OBJECTIVE To present our center's experience with terminal extubation in 3 palliative critical care home transports from the Pediatric Cardiac Intensive Unit. DESIGN All cases were identified from our Cardiovascular intensive care unit ( CVICU). Patients were terminally ill children with no other surgical or medical option who were transported home between 2014 and 2018, for terminal extubation and end-of-life care according to their families' wishes. INTERVENTIONS The patients were 7, 9 months, and 19 years; and they had very complex and chronic conditions. The families were approached by the CVICU staff during multidisciplinary meetings, where goals of care were established. Parental expectations were clarified, and palliative care team was involved, as well as home hospice was arranged pre transfer. The transfer process was discussed and all the needs were established. All patients had unstable medical conditions, with needs for transport for withdrawal of life support and death at home. Each case needed a highly trained team to support life while in transport. The need of these patients required coordination with home palliative care services, as well as community resources due to difficulty to get in their homes. CONCLUSIONS Transportation of pediatric cardiac critical care patients for terminal extubation at home is a relatively infrequent practice. It is a feasible alternative for families seeking out of the hospital end-of-life care for their critically ill and technology dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports.
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Affiliation(s)
- Xiomara Garcia
- Pediatric Cardiology, Pediatric Critical Care, 3342University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Elizabeth Frazier
- Pediatric Cardiology, Pediatric Critical Care, 3342University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Janie Kane
- Pediatric Cardiology, Pediatric Critical Care, 3342University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Amber Jones
- Pediatric Cardiology, Pediatric Critical Care, 3342University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Carrie Brown
- Palliative Care, Department of Pediatrics, University of Arkansas for Medical Sciences, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Tonja Bryant
- Pediatric Cardiology, Pediatric Critical Care, 3342University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Parthak Prodhan
- Pediatric Cardiology, Pediatric Critical Care, 3342University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
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20
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Purifoy ET, Spray BJ, Riley JS, Prodhan P, Bolin EH. Effect of Trisomy 21 on Postoperative Length of Stay and Non-cardiac Surgery After Complete Repair of Tetralogy of Fallot. Pediatr Cardiol 2019; 40:1627-1632. [PMID: 31494702 DOI: 10.1007/s00246-019-02196-y] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
Trisomy 21 (T21) is the most common chromosomal abnormality, and is frequently associated with congenital heart disease. Results of previous studies evaluating the effect of T21 on postoperative outcomes and complications following heart surgery have been mixed. Our goal was to determine if T21 is associated with higher frequency of adverse postoperative outcomes following repair of tetralogy of Fallot (TOF). A query of the Pediatric Health Information System was performed for patients who underwent complete repair of TOF from 2004 to 2015. Patients with a genetic syndrome other than T21 and tracheostomy and/or gastrostomy prior to heart surgery were excluded. Two groups were created on the basis of whether patients received a diagnostic code for T21. The adverse outcomes of interest were postoperative mortality, postoperative length of stay (LOS), postoperative gastrostomy, and postoperative tracheostomy. Univariate and Kaplan-Meier analysis were performed to evaluate outcomes. There were a total of 4790 patients; 430 (9%) patients had T21, and 4360 (91%) patients without a genetic diagnosis. There was no significant difference in mortality before discharge between those with and without T21 (2.3% vs 1.4%; p = 0.155). Patients with T21 had longer postoperative LOS (mean of 19.8 days vs 12.4 days; p < 0.001), and higher rates of postoperative gastrostomy (13.3% vs 5.3%; p < 0.02). There was no significant difference between groups for rates of postoperative tracheostomy (1.9% vs 1.2%; p = 0.276). Kaplan-Meier analysis confirmed that patients with T21 had longer postoperative LOS and greater incidence of gastrostomy.
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Affiliation(s)
- Eric T Purifoy
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA.
| | - Beverly J Spray
- Biostatistics Core, Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202-3591, USA
| | - Joe S Riley
- Biostatistics Core, Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202-3591, USA
| | - Parthak Prodhan
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA
| | - Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA
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21
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Ahmed A, Prodhan P, Spray BJ, Bolin E. JUNCTIONAL ECTOPIC TACHYCARDIA INCREASES HOSPITAL LENGTH OF STAY IN PRIMARY REPAIR OF TETRALOGY OF FALLOT: A PHIS DATABASE STUDY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31243-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Asfari A, Dent JA, Corken A, Herington D, Kaliki V, Sra N, Hefley G, Pasala S, Prodhan P, Ware J. Platelet Glycoprotein VI Haplotypes and the Presentation of Paediatric Sepsis. Thromb Haemost 2018; 119:431-438. [PMID: 30597490 DOI: 10.1055/s-0038-1676794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Sepsis triggers a complex series of pathophysiologic events involving inflammatory responses and coagulation abnormalities. While circulating blood platelets are well-characterized for their contributions to coagulation, increasingly platelet-dependent effects on inflammation are being recognized. Here, we focus on the platelet membrane receptor, glycoprotein VI (GPVI), and its role in platelet microparticle (pMP) release. The GPVI receptor is a platelet-specific collagen membrane receptor that, upon ligand binding, facilitates the release of pMPs. As membrane-bound platelet fragments of less than 1 μm, pMPs are known to have both pro-inflammatory and pro-coagulant properties. Thus, pMPs are potentially impacting sepsis at multiple stages of the inflammatory response. Studies are presented documenting the impact of the most common GPVI haplotypes, GPVIa and GPVIb, on pMP levels and release in healthy individuals (n = 49). The GPVIa haplotype corresponds to an approximately twofold increase in circulating pMPs as a percentage of total microparticles in healthy individuals along with a heightened in vitro release of pMPs. Additionally, patients admitted to a paediatric intensive care unit (ICU) (n = 73) with an initial diagnosis of sepsis were recruited and their GPVI haplotypes determined. Septic patients of the GPVIa haplotype (n = 59) were statistically more likely to present with a diagnosis of severe sepsis or septic shock, as compared with GPVIb individuals (n = 14). Independent disease classification via PELOD-2 and Pediatric Risk of Mortality III scores confirmed individuals with the GPVIa haplotype were more likely to have significant organ failure. Thus, GPVI haplotypes influence pMP levels in the circulation and are predictive of sepsis severity when presenting to the ICU.
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Affiliation(s)
- Ahmed Asfari
- Section of Cardiac Critical Care Medicine, Department of Pediatric Cardiology, University of Alabama at Birmingham College of Medicine, Birmingham, Alabama, United States.,Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Judith A Dent
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Adam Corken
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Danielle Herington
- Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States.,Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
| | - Vamsikrishna Kaliki
- Pediatric Emergency Medicine, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - Natasha Sra
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Glenda Hefley
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Sanjiv Pasala
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Parthak Prodhan
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Jerry Ware
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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23
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Prodhan P, Tang X, Gossett J, Beam B, Simsic J, Ghanayem N, ElHassan NO. Gastrostomy tube placement among infants with hypoplastic left heart syndrome undergoing stage 1 palliation. CONGENIT HEART DIS 2018; 13:519-527. [PMID: 29756326 DOI: 10.1111/chd.12610] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/23/2018] [Accepted: 03/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Different feeding strategies have been suggested to improve growth and survival of infants with hypoplastic left heart syndrome following stage 1 palliation. The study objective was to assess hospital mortality following stage 1 palliation among infants with hypoplastic left heart syndrome who had two feeding modalities, gastrostomy tube vs no gastrostomy tube. DESIGN Retrospective study design. SETTING Multicenter pediatric heath information system database. PATIENT About 4287 patients with hypoplastic left heart syndrome who underwent stage 1 Norwood procedure from 2004 through 2013. Infants who had gastrostomy tube with or without fundoplication procedure were identified and their clinical characteristics were compared. INTERVENTION None. OUTCOMES MEASURES The primary outcome was discharge hospital mortality following stage 1 palliation. RESULTS About 1214 patients who underwent stage 1 palliation had gastrostomy tube placement prior to hospital discharge. About 881 only had this procedure, while 333 patients also underwent fundoplication. Infants who had a gastrostomy tube placement vs no gastrostomy procedure had longer hospital stay, but significantly lower hospital mortality (5% vs 19%, P < .001). Hospital mortality was lower in infants who had only gastrostomy vs gastrostomy with fundoplication procedure (4% vs 8%, P = .004). In the multivariable analysis, gastrostomy procedure was associated with a higher likelihood of survival to hospital discharge (HR: 0.06, CI [0.04, 0.1]), whereas additional fundoplication procedure increased the risk of mortality (HR: 2.77, CI [1.52, 5.04]). CONCLUSIONS The gastrostomy procedure did not place infants with hypoplastic left heart syndrome at higher risk of mortality. These infants should be considered for gastrostomy tube placement if they had persistent difficulty in oral feeding following stage 1 palliation.
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Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Xinyu Tang
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Jeffrey Gossett
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Brandon Beam
- Bioinformatics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Janet Simsic
- Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nancy Ghanayem
- Cardiac Critical Care, Department of Pediatrics, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nahed O ElHassan
- Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
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24
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Cranmer JM, Scurlock AM, Hale RB, Ward WL, Prodhan P, Weber JL, Casey PH, Jacobs RF. An Adaptable Pediatrics Faculty Mentoring Model. Pediatrics 2018; 141:peds.2017-3202. [PMID: 29669752 DOI: 10.1542/peds.2017-3202] [Citation(s) in RCA: 8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 11/24/2022] Open
Abstract
An effective faculty mentoring program (FMP) is 1 approach that academic departments can use to promote professional fulfillment, faculty retention, and mitigate the risks of faculty burnout. Mentoring has both direct benefits for junior faculty mentees as they navigate the academic promotion process with their mentors, in addition to broader departmental and institutional benefits, with regard to recruitment, retention, and academic productivity. We describe a successful FMP model that has been adapted for use in 6 other pediatrics departments, summarizing the key personnel, mentoring process, and program evaluation methods. Important lessons learned and a generalizable mentoring "model" are provided. Program evaluation indicates a positive effect for the FMP on enhanced faculty self-efficacy, job satisfaction, and career development. The importance of communication, oversight, feedback, accountability, and valuing all faculty members is emphasized. Strategies to promote faculty engagement and the critical role of departmental leadership in prioritizing mentorship are discussed. The success of academic medical departments is inextricably linked to its commitment to the career development of individual faculty members at all levels and in all academic pathways. With our findings, we support the positive impact of a formal FMP in promoting enhanced self-efficacy and career satisfaction, which directly benefits the department and institution through enhanced productivity, retention, successful promotion, and overall professional fulfillment.
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Affiliation(s)
- Joan M Cranmer
- Departments of Pediatrics, .,Pharmacology and Toxicology, and
| | | | | | | | | | | | - Patrick H Casey
- Departments of Pediatrics.,Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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25
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Zakaria D, Tang X, Bhakta R, ElHassan NO, Prodhan P. Chromosomal Abnormalities Affect the Surgical Outcome in Infants with Hypoplastic Left Heart Syndrome: A Large Cohort Analysis. Pediatr Cardiol 2018; 39:11-18. [PMID: 28921168 DOI: 10.1007/s00246-017-1717-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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] [Received: 06/02/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Abstract
Patients with hypoplastic left heart syndrome (HLHS) can have associated genetic abnormalities. This study evaluated the incidence of genetic abnormalities among infants with HLHS and the short-term outcomes of this population during the first hospitalization. This is a retrospective analysis of the multi-center Pediatric Heath Information System database of infants with HLHS who underwent Stage I Norwood, Hybrid, or heart transplant during their first hospitalization from 2004 through 2013. We compared clinical data between infants with and without genetic abnormality, among the three most common chromosomal abnormalities, and between survivors and non-survivors. Multivariable analysis was completed to evaluate predictors of mortality among patients with genetic abnormalities. A total of 5721 infants with HLHS were identified; 282 (5%) had associated genetic abnormalities. The three most common chromosomal abnormalities were Turner (25%), DiGeorge (22%), and Downs (12.7%) syndromes. Over the study period, the number of patients with genetic abnormalities undergoing cardiac operations increased without any significant increases in mortality. Infants with genetic abnormalities compared to those without abnormalities had longer hospital length of stay and higher morbidity and mortality. Variables associated with mortality were lower gestational age, longer duration of vasopressor therapy, need for dialysis, and cardiopulmonary resuscitation; and complicated clinical course as suggested by necrotizing enterocolitis, septicemia. Presence of any genetic abnormality in infants with HLHS undergoing cardiac surgery is associated with increased mortality and morbidity. Timely genetic testing, appropriate family counseling, and thorough preoperative case selection are suggested for these patients for any operative intervention.
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Affiliation(s)
- Dala Zakaria
- Pediatric Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Xinyu Tang
- Biostatistics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rupal Bhakta
- Pediatric Critical Care Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nahed O ElHassan
- Neonatology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Parthak Prodhan
- Pediatric Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Asfari A, Ahmed M, Edwards L, Irby K, Agarwal A, Pasala S, Prodhan P, Frazier B, Sanders R. Survival from Septic Shock Secondary to Disseminated Group A Streptococcal Infection after Central Extracorporeal Membrane Oxygenation. JCS 2017. [DOI: 10.1055/s-0037-1607312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective The objective of this study was to describe a case of severe life-threatening acute respiratory distress syndrome (ARDS) and septic shock in a child who responded to a prolonged extracorporeal membrane oxygenation (ECMO) support course utilizing different cannulation techniques depending on the physiological derangement until he recovered.
Design This is a case report.
Setting This study was done at the medical–surgical pediatric intensive care unit in an academic freestanding children's hospital.
Patient A previously healthy 4-year-old boy was presented with respiratory distress and fever. He was diagnosed with respiratory syncytial viral upper respiratory tract infection and group A β-hemolytic Streptococcus septic shock.
Interventions The patient was referred to peripheral ECMO for hemodynamic, ventilatory, and oxygenation support; conversion to central ECMO to augment blood flow; and transition to extracorporeal carbon dioxide removal before successful wean off extracorporeal support.
Measurements and Main Results Patient experienced severe pediatric ARDS and septic shock that were refractory to maximal medical therapy. Patient was able to be decannulated after 75 days of extracorporeal support. He was weaned completely off of mechanical ventilation and oxygen after 6 months. The only neurological deficit he exhibited was poor fine motor skills of his hands for which he continued to receive physical therapy.
Conclusion Central ECMO may benefit children with pediatric ARDS and septic shock who require higher flows than what can be provided from peripheral ECMO. Extracorporeal membrane carbon dioxide removal may be an effective option in children who do not respond to mechanical ventilation alone.
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Affiliation(s)
- A. Asfari
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - M. Ahmed
- Section of Critical Care, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, United States
| | - L. Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - K. Irby
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - A. Agarwal
- Section of Pulmonology, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - S. Pasala
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - P. Prodhan
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
- Section of Cardiology, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - B. Frazier
- Department of Extracorporeal Membrane Oxygenation, Arkansas Children's Hospital, Little Rock, Arkansas, United States
| | - R. Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Tadphale SD, Tang X, ElHassan NO, Beam B, Prodhan P. Cavopulmonary Anastomosis During Same Hospitalization as Stage 1 Norwood/Hybrid Palliative Surgery. Ann Thorac Surg 2017; 103:1285-1291. [PMID: 28274521 DOI: 10.1016/j.athoracsur.2017.01.013] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/27/2016] [Accepted: 01/03/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Limited literature has examined characteristics of infants with hypoplastic left heart syndrome (HLHS) who remain hospitalized during the interstage period. We described their epidemiologic characteristics, in-hospital outcomes, and identified risk factors that predict the need for superior cavopulmonary anastomosis (SCPA) during the same hospitalization. METHODS This retrospective multicenter database analysis included infants with HLHS who underwent stage 1 palliation from 2004 through 2013. RESULTS Among 5374 infants with HLHS, 314 (5.8%) underwent SCPA during the same hospitalization as stage 1 palliation. They had a higher incidence of baseline comorbidities, complications, and interventions than infants who were discharged. Despite an overall increase in need for SCPA in the same hospitalization across different eras, there was no significant statistical difference in mortality in the two groups in the same era. Septicemia, necrotizing enterocolitis, modified Blalock-Taussig shunt, cardiac catheterization, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, gastrostomy tube, and antiarrhythmic agents were independently associated with increased odds of undergoing SCPA during the same hospitalization. Patients undergoing right ventricle to pulmonary artery shunt were less likely to remain hospitalized until stage 2 palliation. Nonsurvivors in the SCPA group had greater need for interventions and worse intensive care unit outcomes. CONCLUSIONS Infants with HLHS who remain hospitalized after stage 1 until their stage 2 palliation differ significantly from infants who were discharged. Several clinical characteristics, comorbidities, and need for interventions are associated with the likelihood for undergoing stage 2 palliation during the same hospitalization. Timely identification and intervention of adjustable causes of heart failure may improve outcomes.
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Affiliation(s)
- Sachin D Tadphale
- Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee; Pediatric Critical Care, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee.
| | - Xinyu Tang
- Department of Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Nahed O ElHassan
- Department of Neonatology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Brandon Beam
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Parthak Prodhan
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Department of Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
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Lorusso R, Gelsomino S, Parise O, Mendiratta P, Prodhan P, Rycus P, MacLaren G, Brogan TV, Chen YS, Maessen J, Hou X, Thiagarajan RR. Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Trends in Application and Outcome From the Extracorporeal Life Support Organization (ELSO) Registry. Ann Thorac Surg 2017; 104:62-69. [PMID: 28131429 DOI: 10.1016/j.athoracsur.2016.10.023] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 09/06/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (RCS) is increasingly used in adult patients, but age represents a controversial factor in this setting. METHODS Data from the Extracorporeal Life Support Organization registry was analyzed to assess in-hospital survival of elderly patients (≥70 years of age) undergoing VA-ECMO for RCS from 1992 to 2015. In-hospital survival and complications for elderly patients were compared with data in younger adults (≥18 to <70 years of age) supported with VA-ECMO during the same time period for similar indications. RESULTS The mean age of the patient cohort (n = 5,408) was 53.0 ± 15.7 years (range, 18 to 91 years). The elderly group included 735 patients (13.6%), with a mean age of 75.2 ± 4.4 years. In the elderly group, pre-ECMO cardiac procedures were performed in 134 cases (18.9%), and 2.2% received VA-ECMO for postcardiotomy support compared with 0.7% in the younger cohort. The mean duration of VA-ECMO in the elderly group was 101 ± 91 h compared with 138 ± 146 h in the younger group (p < 0.001). Overall, survival to hospital discharge for the entire adult cohort was 41.4% (2,240 of 5,408), with 30.5% (224 of 735) in the elderly patient group and 43.1% (2,016 of 4,673) in the younger patient group (p < 0.001). Elderly patients had a higher rate of multiorgan failure. At multivariable analysis age represented an independent negative predictor of in-hospital survival. CONCLUSIONS Based on the acceptable survival to hospital discharge in our study, older age alone should not represent an absolute contraindication when considering VA-ECMO support for RCS.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Unit, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Sandro Gelsomino
- Cardio-Thoracic Surgery Unit, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Orlando Parise
- Cardio-Thoracic Surgery Unit, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Priya Mendiratta
- Division of Geriatrics, University of Arkansas, Little Rock, Arkansas
| | - Parthak Prodhan
- Division of Cardiology, University of Arkansas, Little Rock, Arkansas
| | - Peter Rycus
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University, Singapore
| | - Thomas V Brogan
- Department of Pediatrics, Division of Critical Care, Seattle Children's Hospital, Seattle, Washington
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Ped Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jos Maessen
- Cardio-Thoracic Surgery Unit, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Xiaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
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Zakaria D, Frazier E, Imamura M, Garcia X, Pye S, Knecht KR, Prodhan P, Gossett JR, Swearingen CJ, Morrow WR. Improved Survival While Waiting and Risk Factors for Death in Pediatric Patients Listed for Cardiac Transplantation. Pediatr Cardiol 2017; 38:77-85. [PMID: 27803956 DOI: 10.1007/s00246-016-1486-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Received: 05/24/2016] [Accepted: 10/18/2016] [Indexed: 11/29/2022]
Abstract
Our aim is to determine (a) the effect of changes in pre-transplant management and era of listing on survival of children listed for HTx and (b) risk factors for death while waiting. This retrospective study included all children listed between 1/1993 and 12/2009 at our center. Survival was determined using survival analysis and competing outcomes modeling. There were 254 listed patients of whom 144 (57%) had congenital heart disease, 208 (82%) were status 1, 52 used ECMO (20%), and 28 used ventricular assist device support (VAD) (11%) beginning in 2005. Overall mortality while waiting was 17% at 6 months, and 69% underwent transplant. Seven of 95 patients (7%) died waiting after 2004 compared to 36 of 159 (23%) before. ECMO and earlier year of listing were significant risk factors (p < 0.001) for wait-list mortality, whereas mortality was significantly lower (p = 0.002) after availability of VADs. Race, gender, blood type, and congenital diagnosis were not significant risk factors for death. Survival in pediatric patients listed for HTx has improved significantly in the current era at our institution. The availability of pediatric VADs has had a significant impact on survival while waiting in children listed for transplantation.
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Affiliation(s)
- Dala Zakaria
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA.
| | - Elizabeth Frazier
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA
| | - Michiaki Imamura
- Division of Pediatric Cardiothoracic Surgery, Arkansas Children's Hospital, University of Arkansas for the Medical Science, Little Rock, AR, USA
| | - Xiomara Garcia
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA
| | - Sherry Pye
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA
| | - Kenneth R Knecht
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA
| | - Parthak Prodhan
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA
| | - Jeffrey R Gossett
- Division of Pediatric Cardiology, College of Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, USA
| | - Christopher J Swearingen
- Biostatistics Program, Arkansas Children's Hospital, University of Arkansas for the Medical Science, Little Rock, AR, USA
| | - W Robert Morrow
- Division of Pediatric Cardiology, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Garcia X, Pye S, Tang X, Gossett J, Prodhan P, Bhutta A. Catheter-Associated Blood Stream Infections in Intracardiac Lines. J Pediatr Intensive Care 2016; 6:159-164. [PMID: 31073442 DOI: 10.1055/s-0036-1596064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022] Open
Abstract
Purpose Right atrial (RA) or intracardiac lines are commonly used for hemodynamic monitoring in children undergoing cardiac surgery. In some institutions, these lines are used as the preferred long-term access line due to concerns for catheter-associated blood stream infections (CABSI) and catheter-related venous thrombosis with central lines in other locations. However, the rates and risk factors for CABSI and other complications are not known for RA lines. We undertook this study to estimate CABSI rates for RA lines in comparison with central catheters of various types and locations and to evaluate the incidence of other complications associated with the use of RA lines. Methods After approval from the Institutional Review Board, a retrospective review of all patients undergoing cardiac surgery at Arkansas Children's Hospital between the dates of January 1, 2006 and December 31, 2011 was performed. Demographic data, clinical features, and outcomes were summarized on a per-patient level. Type, location of placement, and duration of all centrally placed catheters as well as associated complications were recorded. Central venous lines (CVL) used in our unit include peripherally inserted central catheters (PICC) lines, and antibiotic and heparin coated double or triple lumen lines placed in internal jugular (IJ), femoral (Fem), or RA positions. The data were analyzed using statistical software STATA/MP. Results A total of 2,736 central lines were used in 1,537 patients. Data on line duration, alteplase use, and percentage of lines developing CABSI are described in the study. Disease severity as assessed by risk-adjusted classification for congenital heart surgery (RACHS) score ( p < 0.046), year of placement ( p < 0.001), and line type adjusted for thrombolytic (alteplase) use are significantly associated with risk of any CABSI. Overall, IJ and RA lines had least risk of CABSI while PICC lines had the highest CABSI rates. RA lines are also associated with other medically significant complications. Conclusion The CABSI rates associated with RA lines are lower than those seen with PICC lines. However, RA line use is associated with other, potentially significant complications. RA lines may be used cautiously as long-term access lines in cardiac patients in whom it is important to preserve venous patency for future interventions.
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Affiliation(s)
- Xiomara Garcia
- Pediatric Critical Care Medicine and Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Sherry Pye
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Xinyu Tang
- Pediatrics-Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, United States
| | - Jeffrey Gossett
- Pediatrics-Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, United States
| | - Parthak Prodhan
- Pediatric Critical Care Medicine and Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Adnan Bhutta
- Pediatric Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Tadphale S, Tang X, El-Hassan N, Beam B, Prodhan P. 189: INFANTS NEEDING SUPERIOR CAVOPULMONARY ANASTOMOSIS DURING SAME HOSPITALIZATION AS STAGE I PALLIATION. Crit Care Med 2016. [DOI: 10.1097/01.ccm.0000508870.06947.fa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Prodhan P, Agarwal A, ElHassan NO, Bolin EH, Beam B, Garcia X, Gaies M, Tang X. Tracheostomy Among Infants With Hypoplastic Left Heart Syndrome Undergoing Cardiac Operations: A Multicenter Analysis. Ann Thorac Surg 2016; 103:1308-1314. [PMID: 27865477 DOI: 10.1016/j.athoracsur.2016.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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] [Received: 03/01/2016] [Revised: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Less than 2.7% of infants undergoing congenital heart disease operations have difficulty weaning from invasive mechanical ventilation. In such instances, clinicians may choose to perform tracheostomy. Limited literature has examined tracheostomy placement specifically in infants with hypoplastic left heart syndrome (HLHS). This study evaluated the risk factors for tracheostomy placement in infants with HLHS and examined the outcomes of these infants before their first hospital discharge. METHODS This retrospective analysis of the Pediatric Heath Information System data set included infants with HLHS who underwent stage 1 Norwood operation, a hybrid procedure, or heart transplant from 2004 through 2013. RESULTS We identified 5721 infants with HLHS, and 126 underwent tracheostomy placement. Infants in the tracheostomy group had more morbidities and a higher mortality rate across the study period. Diagnosis of chromosomal abnormalities, anomalies of the trachea and esophagus, larynx, diaphragm and nervous system, bilateral vocal cord paralysis, and necrotizing enterocolitis, and procedures including extracorporeal membrane oxygenation support, cardiac catheterization, and gastrostomy tube were independently associated with tracheostomy placement in the study population. Despite an overall increase in rates of tracheostomy performed in infants with HLHS during the study period, the mortality rate did not improve among tracheostomy patients. CONCLUSIONS Several risk factors were identified in infants with HLHS in whom a tracheostomy was placed during their first hospitalization. Despite an overall increase in rates of tracheostomies during the study period, the mortality rate did not improve among these patients. Appropriate family counseling and thorough preoperative case selection is suggested when discussing possible tracheostomy placement in infants with HLHS.
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Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas.
| | - Amit Agarwal
- Pulmonary Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Nahed O ElHassan
- Neonatology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Elijah H Bolin
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Brandon Beam
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Xiomara Garcia
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Michael Gaies
- Pediatric Cardiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Xinyu Tang
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
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Abstract
Acute hypoxemic respiratory failure (AHRF) is one of the hallmarks of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), which are caused by an inflammatory process initiated by any of a number of potential systemic and/or pulmonary insults that result in heterogeneous disruption of the capillary-pithelial interface. In these critically sick patients, optimizing the management of oxygenation is crucial. Physicians managing pediatric patients with ALI or ARDS are faced with a complex array of options influencing oxygenation. Certain treatment strategies can influence clinical outcomes, such as a lung protective ventilation strategy that specifies a low tidal volume (6 mL/kg) and a plateau pressure limit (30 cm H2O). Other strategies such as different levels of positive end expiratory pressure, altered inspiration to expiration time ratios, recruitment maneuvers, prone positioning, and extraneous gases or drugs may also affect clinical outcomes. This article reviews state-of-the-art strategies on the management of oxygenation in acute hypoxemic respiratory failure in children.
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Affiliation(s)
- Parthak Prodhan
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Boston, Massachusetts 02114, USA
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Byrnes JW, Bhutta AT, Rettiganti MR, Gomez A, Garcia X, Dyamenahalli U, Johnson C, Jaquiss RD, Imamura M, Prodhan P. Steroid Therapy Attenuates Acute Phase Reactant Response Among Children on Ventricular Assist Device Support. Ann Thorac Surg 2015; 99:1392-8. [DOI: 10.1016/j.athoracsur.2014.11.046] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 11/07/2014] [Accepted: 11/18/2014] [Indexed: 11/28/2022]
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Prodhan P, Gossett JM, Rycus PT, Gupta P. Extracorporeal membrane oxygenation in children with heart disease and del22q11 syndrome: a review of the Extracorporeal Life Support Organization Registry. Perfusion 2015; 30:660-5. [PMID: 25795680 DOI: 10.1177/0267659115578945] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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
The study objective was to evaluate outcomes among children with del22q11 (DiGeorge) syndrome supported on ECMO for heart disease. The ELSO registry database was queried to include all children <18 years undergoing heart surgery for either common atrio-ventricular canal, tetralogy of Fallot, truncus arteriosus or transposition of the great vessels and interrupted aortic arch and requiring ECMO, from 1998-2011. The outcomes evaluated included mortality, ECMO duration and length of hospital stay in patients with del22q11 syndrome and with no del22q11 syndrome. Eighty-eight ECMO runs occurred in children with del22q11 syndrome while 2694 ECMO runs occurred in children without del22q11 syndrome. For patients with heart defects receiving ECMO, del22q11 syndrome did not confer a significant mortality risk or an increased risk of infectious complications before or while on ECMO support. Neither the duration of ECMO nor mechanical ventilation prior to ECMO deployment were prolonged in patients with del22q11 syndrome compared to the controls.
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Affiliation(s)
- P Prodhan
- Division of Pediatric Cardiology, University of Arkansas Medical Sciences, Little Rock, Arkansas, USA Division of Critical Care, University of Arkansas Medical Sciences, Little Rock, Arkansas, USA
| | - J M Gossett
- Division of Biostatistics, Department of Pediatrics, University of Arkansas Medical Sciences, Little Rock, Arkansas, USA
| | - P T Rycus
- Extracorporeal Life Support Organization, University of Michigan, Ann Arbor, Michigan, USA
| | - P Gupta
- Division of Pediatric Cardiology, University of Arkansas Medical Sciences, Little Rock, Arkansas, USA Division of Critical Care, University of Arkansas Medical Sciences, Little Rock, Arkansas, USA
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Prodhan P, Kalikivenkata G, Tang X, Thomas K, Byrnes J, Imamura M, Jaquiss RDB, Garcia X, Frazier EA, Bhutta AT, Dyamenahalli U. Risk factors for prolonged mechanical ventilation for children on ventricular assist device support. Ann Thorac Surg 2015; 99:1713-8. [PMID: 25754963 DOI: 10.1016/j.athoracsur.2014.12.068] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 12/03/2014] [Accepted: 12/16/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with end-stage heart failure possess many attributes that place them at risk for prolonged mechanical ventilation (MV). However, there are only limited data on MV support among children after ventricular assist device (VAD) implantation. We report the duration of MV after VAD placement, indications for respiratory support in the postimplantation period, and associated patient factors. METHODS This single-center retrospective study included 43 consecutive children (aged <18 years) with end-stage heart failure who were supported with a VAD as a bridge to transplantation from January 2005 to December 2011. Multivariable analysis was performed using the multiple Poisson regression model for the duration of MV. RESULTS Overall, 33% (n = 14) remained on MV until heart transplant or death. Of those requiring pre-VAD extracorporeal membrane oxygenation (ECMO) support, 63% (n = 12 of 19) remained on MV until heart transplant or death compared with 8% (n = 2 of 24) among those not on ECMO before VAD (p < 0.001). Patients with moderate or severe mitral regurgitation while on VAD support had 1.7-times more MV days compared with those with none or trivial on-VAD mitral regurgitation. In addition, previous support on ECMO, those with moderate or severe tricuspid regurgitation, and those with only left VAD implants had an increased risk of prolonged MV. CONCLUSIONS Our results suggest that VAD recipients previously supported on ECMO, those with moderate or severe mitral regurgitation, moderate or severe tricuspid regurgitation, and those with only left VAD implants had an increased risk of prolonged MV. Future studies in larger cohorts are necessary to confirm the findings from this single-institutional experience.
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Affiliation(s)
- Parthak Prodhan
- Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas; Division of Pediatric Cardiology, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas.
| | - Giridhar Kalikivenkata
- Division of Pediatric Cardiology, Department of Pediatrics, University of Florida Hospitals, Gainesville, Florida
| | - Xinyu Tang
- Division of Biostatistics, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas
| | - Kassandra Thomas
- Division of Pediatric Cardiology, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas
| | - Jonathan Byrnes
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Childrens Hospital, Cincinnati, Ohio
| | - Michiaki Imamura
- Division of Cardiovascular Surgery, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas
| | - Robert D B Jaquiss
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Duke Medical Center, Durham, North Carolina
| | - Xiomara Garcia
- Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas; Division of Pediatric Cardiology, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas
| | - Elizabeth A Frazier
- Division of Pediatric Cardiology, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas
| | - Adnan T Bhutta
- Division of Pediatric Critical Care, Department of Pediatrics, University of Maryland, Baltimore, Maryland
| | - Umesh Dyamenahalli
- Division of Pediatric Cardiology, Department of Pediatrics, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, Arkansas; Division of Pediatric Cardiology, Department of Pediatrics, University of Chicago, Chicago, Illinois
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Arthur C, Tang X, Romero JR, Gossett JG, Harik N, Prodhan P. Stenotrophomonas maltophilia infection among young children in a cardiac intensive care unit: a single institution experience. Pediatr Cardiol 2015; 36:509-15. [PMID: 25293429 DOI: 10.1007/s00246-014-1041-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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] [Received: 06/30/2014] [Accepted: 09/27/2014] [Indexed: 01/18/2023]
Abstract
Stenotrophomonas maltophilia can present as bacteremia, respiratory tract infection, urinary tract infection, soft tissue and wound infections, bone and joint infections, meningitis, and endocarditis especially in immunosuppressed patients and those with underlying medical conditions. The incidence and impact of S. maltophilia in young children with heart disease are poorly defined. A single center retrospective observational study was conducted in infants <180 days of age with positive S. maltophilia cultures over a period of 5 years. The overall incidence for S. maltophilia infection was 0.8 % (n = 32/3656). Among 32 identified infants, there were 47 episodes of S. maltophilia infection 66 % of infants had prior exposure to broad spectrum antibiotics. 97 % of positive isolates were susceptible to trimethoprim/sulfamethoxazole and 91 % to levofloxacin as well as ticarcillin/clavulanate. Ventilator-free days and absolute lymphocyte count prior to acquiring infection were significantly lower in non-survivors than in survivors. 100 % of survivors had clearance of positive cultures compared to 50 % in non-survivors (p < 0.05). The crude all-cause mortality rate was 37.5 %. All non-survivors had increased length of ICU stay and duration of mechanical ventilation and had delayed clearance of infection and required longer duration of treatment.
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Affiliation(s)
- Ciji Arthur
- Department of Pediatric Cardiology, Infectious Diseases, Critical Care, Biostatistics, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, 72205, USA,
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Byrnes JW, Frazier E, Tang X, Eble B, McKamie A, Gomez A, Imamura M, Prodhan P. Hemorrhage requiring surgical intervention among children on pulsatile ventricular assist device support. Pediatr Transplant 2014; 18:385-92. [PMID: 24802345 DOI: 10.1111/petr.12266] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 02/28/2014] [Indexed: 11/29/2022]
Abstract
Bleeding complications are a source of morbidity after Berlin EXCOR VAD implantation yet remain poorly characterized. We evaluated our experience to describe the bleeding complications among pediatric VAD recipients. We hypothesized that those with bleeding requiring exploration had abnormal coagulation profile compared with those without bleeding. The retrospective study included 43 consecutive patients with end-stage heart failure supported on pediatric mechanical cardiac support as a bridge to transplantation. Day-/event-based analysis on factors below associated with (i) bleeding and (ii) bleeding in next 48 h. Cases with bleeding were compared with day-matched patients without bleeding complications. Among 43 subjects bleeding occurred in 47% of cases, which necessitated exploration or chest tube placement. Twenty of 34 interventions for bleeding occurred in the first seven post-operative days. No differences in coagulation parameters or use of antiplatelet agents were noted among those who had bleeding vs. those who did not. Our results indicate that (i) re-bleeding requiring re-exploration was common, (ii) most of the bleeding occurred early post-implantation, (iii) there were no differences in coagulation parameters or the use of antiplatelet agents within 48 h of bleeding compared with those who did not bleed on each successive post-operative day.
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Affiliation(s)
- Jonathan W Byrnes
- Department of Pediatrics, University of Arkansas Medical Sciences, Arkansas Children Hospital, Little Rock, AR, USA
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Byrnes JW, Prodhan P, Williams BA, Schmitz ML, Moss MM, Dyamenahalli U, McKamie W, Morrow WR, Imamura M, Bhutta AT. Incremental Reduction in the Incidence of Stroke in Children Supported With the Berlin EXCOR Ventricular Assist Device. Ann Thorac Surg 2013; 96:1727-33. [DOI: 10.1016/j.athoracsur.2013.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 05/23/2013] [Accepted: 06/03/2013] [Indexed: 11/30/2022]
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Prodhan P, Bhutta AT, Gossett JM, Dodgen AL, Seib PM, Imamura M, Gupta P. Comparative effects of ventricular assist device and extracorporeal membrane oxygenation on renal function in pediatric heart failure. Ann Thorac Surg 2013; 96:1428-1434. [PMID: 23987896 DOI: 10.1016/j.athoracsur.2013.05.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [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] [Received: 03/11/2013] [Revised: 05/16/2013] [Accepted: 05/24/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Effects of mechanical cardiac support on renal function in children with end-stage heart failure are unknown. The objective of this study was to investigate the impact of ventricular assist device (VAD) and extracorporeal membrane oxygenation (ECMO) on renal function in children. METHODS We performed a single center retrospective observational study in children with end-stage heart failure supported on pediatric mechanical cardiac support. The patient population was divided into three groups: the VAD group included patients receiving ventricular assist device support; the ECMO group included patients receiving extracorporeal membrane oxygenation membrane support for more than 14 days; and the ECMO+VAD group included patients receiving ECMO followed by VAD support. Comparison of baseline characteristics, duration of mechanical cardiac support, and renal function was made between the three groups. RESULTS During the study period, there were 23 patients in the VAD group, 16 patients in the ECMO+VAD group, and 37 patients in the ECMO group. The patients in the ECMO group were significantly younger and smaller than the patients in the VAD and ECMO+VAD groups. There was a steady improvement in eGFR in the VAD group and the ECMO+VAD group until day 7 after which there was a decline in renal function. In the ECMO group, the improvement in eGFR continued until day 28 after which there was a steady decline in eGFR. Improvement in eGFR in the VAD group and the ECMO+VAD group was much higher than in the ECMO group in the first 7 days. CONCLUSIONS On the basis of these data, we demonstrate that renal dysfunction improves early after mechanical cardiac support.
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Affiliation(s)
- Parthak Prodhan
- Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Adnan T Bhutta
- Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey M Gossett
- Section of Biostatistics, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Andrew L Dodgen
- Section of Medical Education, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Paul M Seib
- Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michiaki Imamura
- Department of Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Punkaj Gupta
- Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Steiner MB, Tang X, Gossett JM, Malik S, Prodhan P. Timing of complete repair of non-ductal-dependent tetralogy of Fallot and short-term postoperative outcomes, a multicenter analysis. J Thorac Cardiovasc Surg 2013; 147:1299-305. [PMID: 23879934 DOI: 10.1016/j.jtcvs.2013.06.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [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] [Received: 12/20/2012] [Revised: 04/30/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE There is cross-center variability with regard to timing repair of non-ductal-dependent tetralogy of Fallot (TOF). We hypothesized that earlier repair in the neonatal period is associated with increased mortality and morbidity. METHODS This was a retrospective analysis of the Pediatric Health Information System of tetralogy of Fallot patients undergoing complete repair from 2004 through 2010 between the ages of 1 day to younger than 19 years. Patients with pulmonary valve atresia, those who received prostaglandin during hospital admission, and those who underwent prior shunt palliation were excluded. RESULTS A total of 4698 patients met our inclusion criteria, of whom 202 were younger than 30 days old (group A), 861 were 31 to 90 days old (group B), 1796 were 91 to 180 days old (group C), and 1839 were older than 180 days (group D). In-hospital mortality, intensive care unit length of stay, and total hospital length of stay were significantly higher in group A. Patients in group A had a significantly increased postoperative requirement for mechanical ventilation, intravenous blood pressure support, medical diuresis, extracorporeal membrane oxygenation, gastrostomy tube insertion, heart catheterization, and surgical revision. Significant institutional variability was noted for timing of TOF complete repair, with one third of the centers performing 75% of the repairs at younger than 30 days old. The institutional approach to timing TOF complete repair showed no relation to surgical volume. CONCLUSIONS Across all centers analyzed, primary neonatal elective TOF repair (<30 days of age) is associated with significantly higher postoperative in-hospital morbidity and mortality, although a few centers have shown an ability to use this strategy with excellent survivability.
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Affiliation(s)
- Matthew B Steiner
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark.
| | - Xinyu Tang
- Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark
| | - Jeffrey M Gossett
- Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark
| | - Sadia Malik
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark
| | - Parthak Prodhan
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark; Division of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark
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Dyamenahalli U, Morris M, Rycus P, Bhutta AT, Tweddell JS, Prodhan P. Short-Term Outcome of Neonates With Congenital Heart Disease and Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2013; 95:1373-6. [DOI: 10.1016/j.athoracsur.2013.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 11/22/2012] [Accepted: 01/03/2013] [Indexed: 01/12/2023]
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Gupta P, Kuperstock JE, Hashmi S, Arnolde V, Gossett JM, Prodhan P, Venkataraman S, Roth SJ. Efficacy and predictors of success of noninvasive ventilation for prevention of extubation failure in critically ill children with heart disease. Pediatr Cardiol 2013. [PMID: 23196891 DOI: 10.1007/s00246-012-0590-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [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: 11/28/2022]
Abstract
The study aimed primarily to evaluate the efficacy of noninvasive ventilation (NIV) and to identify possible predictors for success of NIV therapy in preventing extubation failure in critically ill children with heart disease. The secondary objectives of this study were to assess the efficacy of prophylactic NIV therapy initiated immediately after tracheal extubation and to determine the characteristics, outcomes, and complications associated with NIV therapy in pediatric cardiac patients. A retrospective review examined the medical records of all children between the ages 1 day and 18 years who sustained acute respiratory failure (ARF) that required NIV in the cardiovascular intensive care unit (CVICU) at Lucile Packard Children's Hospital between January 2008 and June 2010. Patients were assigned to a prophylactic group if NIV was started directly after extubation and to a nonprophylactic group if NIV was started after signs and symptoms of ARF developed. Patients were designated as responders if they received NIV and did not require reintubation during their CVICU stay and nonresponders if they failed NIV and reintubation was performed. The data collected included demographic data, preexisting conditions, pre-event characteristics, event characteristics, and outcome data. The outcome data evaluated included success or failure of NIV, duration of NIV, CVICU length of stay (LOS), hospital LOS, and hospital mortality. The two complications of NIV assessed in the study included nasal bridge or forehead skin necrosis and pneumothorax. The 221 eligible events during the study period involved 172 responders (77.8 %) and 49 nonresponders (22.2 %). A total of 201 events experienced by the study cohort received continuous positive airway pressure (CPAP), with 156 responders (78 %), whereas 20 events received bilevel positive airway pressure (BiPAP), with 16 responders (80 %). In the study, 58 events (26.3 %) were assigned to the prophylactic group and 163 events (73.7 %) to the nonprophylactic group. Compared with the nonprophylactic group, the prophylactic group experienced significantly shorter CVICU LOS (median, 49 vs 88 days; p = 0.03) and hospital LOS (median, 60 vs 103 days; p = 0.05). The CVICU LOS and hospital LOS did not differ significantly between the responders (p = 0.56) and nonresponders (p = 0.88). Significant variables identifying a responder included a lower risk-adjusted classification for congenital heart surgery (RACHS-1) score (1-3), a good left ventricular ejection fraction, a normal respiratory rate (RR), normal or appropriate oxygen saturation, prophylactic or therapeutic glucocorticoid therapy within 24 h of NIV initiation, presence of atelectasis, fewer than two organ system dysfunctions, fewer days of intubation before extubation, no clinical or microbiologic evidence of sepsis, and no history of reactive airway disease. As a well-tolerated therapy, NIV can be safely and successfully applied in critically ill children with cardiac disease to prevent extubation failure. The independent predictors of NIV success include lower RACHS-1 classification, presence of atelectasis, steroid therapy received within 24 h after NIV, and normal heart rate and oxygen saturations demonstrated within 24 h after initiation of NIV.
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Affiliation(s)
- Punkaj Gupta
- Section of Pediatric Cardiology and Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR 72202-3591, USA.
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Gautam NK, Schmitz ML, Harrison D, Zabala LM, Killebrew P, Belcher RH, Prodhan P, McKamie W, Norvell DC. Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass. Paediatr Anaesth 2013; 23:233-41. [PMID: 23279140 DOI: 10.1111/pan.12109] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [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: 11/28/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG). BACKGROUND Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients. METHODS A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV. RESULTS Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs. 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups. CONCLUSION Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.
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Affiliation(s)
- Nischal K Gautam
- Division of Pediatric Anesthesiology and Pain Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA.
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Abstract
Despite the absence of clinical safety data, heated, humidified high-flow nasal cannula (HHFNC) therapy is increasingly being used as an alternative to positive-pressure ventilation in pediatrics. This use of HHFNC is "off label" because the US Food and Drug Administration's approval for these devices was only for air humidification and not as a modality to provide positive distending pressure. For the first time we describe 3 cases who developed serious air leaks related to HHFNC therapy. The first child was a previously healthy 2-month-old male infant with respiratory syncytial virus bronchiolitis who developed a right pneumothorax on day 5 of his illness at 8 liters per minute (lpm). He subsequently required intubation and ventilation for 14 days. The second case involved an otherwise healthy 16-year-old boy with cerebral palsy who developed pneumomediastinum and died of its complications. He was receiving 20 lpm HHFNC therapy when he developed pneumomediastinum. The third case involved a 22-month-old, previously healthy boy who developed subdural hematoma secondary to abuse. He developed a right pneumothorax while receiving HHFNC at a flow of 6 lpm, requiring chest tube placement. These cases emphasize the need for extreme caution while using HHFNC for the off-label indication of providing positive distending pressure in children, especially at flows higher than the patient's minute ventilation. A more detailed study to specifically look at the serious adverse events related to HHFNC is urgently needed.
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Affiliation(s)
- Satyanarayan Hegde
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA.
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Irby K, Swearingen C, Byrnes J, Bryant J, Prodhan P, Fiser R. 280. Crit Care Med 2012. [DOI: 10.1097/01.ccm.0000424498.71413.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mendiratta P, Tilford JM, Prodhan P, Curseen K, Azhar G, Wei JY. Trends in percutaneous endoscopic gastrostomy placement in the elderly from 1993 to 2003. Am J Alzheimers Dis Other Demen 2012; 27:609-13. [PMID: 23038714 PMCID: PMC4011175 DOI: 10.1177/1533317512460563] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate national trends in percutaneous endoscopic gastrostomy (PEG) tube placement for hospitalized elderly patients from 1993 to 2003. METHODS Retrospective analysis of patients ≥ 65 years of age with PEG tube placement from 1993 to 2003 from the Nationwide Inpatient Sample (NIS) database was utilized to calculate PEG placement rates per 1000 people. RESULTS Placement of PEG tube increased by 38% in elderly patients during the study period, from 2.71 procedures during hospitalization per 1000 people to 3.75 procedures during hospitalization per 1,000 people. Placement of PEG tube in patients with Alzheimer's dementia doubled (5%-10%) over the study period. CONCLUSION Over a 10-year period, PEG tube use in hospitalized elderly patients increased significantly. More importantly, approximately 1 in 10 PEG tube placements occurred in patients with dementia.
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Affiliation(s)
- P. Mendiratta
- Donald W Reynolds Institute on Aging and Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, and Geriatric Research Education and Clinical Center (GRECC), Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, AR, USA
| | - J. M. Tilford
- Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - P. Prodhan
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - K. Curseen
- Donald W Reynolds Institute on Aging and Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, and Geriatric Research Education and Clinical Center (GRECC), Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, AR, USA
| | - G. Azhar
- Donald W Reynolds Institute on Aging and Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, and Geriatric Research Education and Clinical Center (GRECC), Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, AR, USA
| | - Jeanne Y. Wei
- Donald W Reynolds Institute on Aging and Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences, and Geriatric Research Education and Clinical Center (GRECC), Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, AR, USA
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Gupta P, McDonald R, Gossett JM, Butt W, Shinkawa T, Imamura M, Bhutta AT, Prodhan P. A Single-Center Experience of Extubation Failure in Infants Undergoing the Norwood Operation. Ann Thorac Surg 2012; 94:1262-8. [DOI: 10.1016/j.athoracsur.2012.05.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 05/08/2012] [Accepted: 05/11/2012] [Indexed: 10/28/2022]
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Mian A, Becton D, Saylors R, James L, Tang X, Bhutta A, Prodhan P. Biomarkers for risk stratification of febrile neutropenia among children with malignancy: a pilot study. Pediatr Blood Cancer 2012; 59:238-45. [PMID: 22535591 DOI: 10.1002/pbc.24158] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [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] [Received: 06/02/2011] [Accepted: 03/09/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients receiving myelosuppressive chemotherapy remain at increased risk for developing febrile neutropenia (FN). For this heterogeneous population, a biomarker based risk stratification of FN patients may be a useful clinical tool. We hypothesized that serum biomarkers during initial presentation of an FN event could be predictive of subsequent clinical outcome. PROCEDURE Eighty-nine FN events from 36 non-consecutive subjects were analyzed. "High-risk" FN criteria included prolonged hospitalization (≥ 7 days), admission to pediatric intensive care unit (PICU) or a microbiology confirmed bacteremia. Patients with "low risk" FN had none of the above. Biomarkers measured during the first 2 days of FN hospitalization were analyzed and correlated with respective clinical outcome. RESULTS Of the 89 FN events, 44 (49%) fulfilled pre-defined high-risk criteria and 45 (51%) were low-risk. Procalcitonin level (>0.11 ng/ml) was found to be associated with the high-risk FN outcome with sensitivity of 97%. With an increase in log scale by 1, the odds of being high-risk FN increased twofold. Hs-CRP >100 mg/L had sensitivity of 88% in predicting high-risk FN. The odds of a high-risk FN event increased by approximately 1.8-fold with an increase in the log scale of hs-CRP by 1 (10-fold). In univariate analysis, IL-6, IL-8, and IL-10 were statistically significant and associated with high-risk FN. However, no statistically significant difference was found for IL-1α, sIL-2Ra, IL-3, or TNF-α. CONCLUSIONS Biomarkers with appropriate critical threshold values may be a useful clinical tool for appropriate risk stratification of children with FN.
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Affiliation(s)
- Amir Mian
- Department of Pediatric Hematology-Oncology, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas 72205, USA.
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