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Hasson DC, Alten JA, Bertrandt RA, Zang H, Selewski DT, Reichle G, Bailly DK, Krawczeski CD, Winlaw DS, Goldstein SL, Gist KM. Persistent acute kidney injury and fluid accumulation with outcomes after the Norwood procedure: report from NEPHRON. Pediatr Nephrol 2024; 39:1627-1637. [PMID: 38057432 DOI: 10.1007/s00467-023-06235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CS-AKI) is common, but its impact on clinical outcomes is variable. Parsing AKI into sub-phenotype(s) and integrating pathologic positive cumulative fluid balance (CFB) may better inform prognosis. We sought to determine whether durational sub-phenotyping of CS-AKI with CFB strengthens association with outcomes among neonates undergoing the Norwood procedure. METHODS Multicenter, retrospective cohort study from the Neonatal and Pediatric Heart and Renal Outcomes Network. Transient CS-AKI: present only on post-operative day (POD) 1 and/or 2; persistent CS-AKI: continued after POD 2. CFB was evaluated per day and peak CFB during the first 7 postoperative days. Primary and secondary outcomes were mortality, respiratory support-free and hospital-free days (at 28, 60 days, respectively). The primary predictor was persistent CS-AKI, defined by modified neonatal Kidney Disease: Improving Global Outcomes criteria. RESULTS CS-AKI occurred in 59% (205/347) neonates: 36.6% (127/347) transient and 22.5% (78/347) persistent; CFB > 10% occurred in 18.7% (65/347). Patients with either persistent CS-AKI or peak CFB > 10% had higher mortality. Combined persistent CS-AKI with peak CFB > 10% (n = 21) associated with increased mortality (aOR: 7.8, 95% CI: 1.4, 45.5; p = 0.02), decreased respiratory support-free (predicted mean 12 vs. 19; p < 0.001) and hospital-free days (17 vs. 29; p = 0.048) compared to those with neither. CONCLUSIONS The combination of persistent CS-AKI and peak CFB > 10% after the Norwood procedure is associated with mortality and hospital resource utilization. Prospective studies targeting intra- and postoperative CS-AKI risk factors and reducing CFB have the potential to improve outcomes.
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Affiliation(s)
- Denise C Hasson
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
- Hassenfeld Children's Hospital, Division of Pediatric Critical Care, NYU Langone, New York, NY, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
| | - Rebecca A Bertrandt
- Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Huaiyu Zang
- Department of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Garrett Reichle
- Department of Pediatrics, Primary Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - David S Winlaw
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
- Lurie Children's Hospital, Department of Pediatric Surgery, Northwestern University School of Medicine, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA.
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Salem AM, Smith T, Wilkes J, Bailly DK, Heyrend C, Profsky M, Yellepeddi VK, Gopalakrishnan M. Pharmacokinetic Modeling Using Real-World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement-Clinical Outcomes Relationship. J Clin Pharmacol 2024; 64:30-44. [PMID: 37565528 DOI: 10.1002/jcph.2333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO), but evidence is lacking on the ideal dosing. We aimed to (1) develop a population pharmacokinetic (PK) model for UFH, measured through anti-factor Xa assay; (2) optimize UFH starting infusions and dose titrations through simulations; and (3) explore UFH exposure-clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A 1-compartment PK model with time-varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first-order rate constant to reach steady-state CL were 0.57 L/(h·10 kg) and 0.02/h. Comparable to non-ECMO patients, the typical steady-state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 and 20 IU/h/kg for patients aged younger than 6 years and 6 years or older, respectively, achieved the therapeutic target in 56.6% of all patients, whereas only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in more than 90% of patients while less than 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti-factor Xa target rapidly and safely.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Trey Smith
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Analytics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caroline Heyrend
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Michael Profsky
- Mechanical Circulatory Support, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Venkata K Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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3
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Ware AL, Reiter L, Winder M, Kelly D, Marietta J, Ohsiek S, Ou Z, Presson A, Bailly DK. The final hospital need in children discharged from a cardiology acute care unit: a single-centre survey study. Cardiol Young 2023; 33:1967-1974. [PMID: 36440531 DOI: 10.1017/s1047951122003596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Children with heart disease may require inpatient care for many reasons, but ultimately have a final reason for hospitalisation prior to discharge. Factors influencing length of stay in paediatric cardiac acute care units have been described but the last reason for hospitalisation has not been studied. Our aim was to describe Final Hospital Need as a novel measure, determine Final Hospital Need in our patients, and describe factors associated with this Need. METHODS Single-centre survey design. Discharging providers selected a Final Hospital Need from the following categories: cardiovascular, respiratory, feeding/fluid, haematology/ID, pain/sedation, systems issues, and other/wound issues. Univariable and multivariable analyses were performed separately for outcomes "cardiovascular" and "feeding/fluid." MEASUREMENTS AND RESULTS Survey response rate was 99% (624 encounters). The most frequent Final Hospital Needs were cardiovascular (36%), feeding/fluid (24%) and systems issues (13%). Probability of Final Hospital Need "cardiovascular" decreased as length of stay increased. Multivariate analysis showed Final Hospital Need "cardiovascular" was negatively associated with aortic arch repair, Norwood procedure, and Final ICU Need "respiratory" and "other." Final Hospital Need "feeding/fluid" was negatively associated with left-sided valve procedure, but positively associated with final ICU need "respiratory," and tube feeding at discharge. CONCLUSIONS Final Hospital Need is a novel measure that can be predicted by clinical factors including age, Final ICU Need, and type of surgery. Final Hospital Need may be utilised to track changes in clinical care over time and as a target for improvement work.
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Affiliation(s)
- Adam L Ware
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Lauren Reiter
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Melissa Winder
- Heart Center, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Dallin Kelly
- Undergraduate Studies, Brigham Young University, Provo, UT, USA
| | | | - Sonja Ohsiek
- Heart Center, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Zhining Ou
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Angela Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - David K Bailly
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT, USA
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Fogg KL, Trauth A, Horsley M, Vichayavilas P, Winder M, Bailly DK, Gordon EE. Nutritional management of postoperative chylothorax in children with CHD. Cardiol Young 2023; 33:1663-1671. [PMID: 36177859 DOI: 10.1017/s1047951122003109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Chylothorax after congenital cardiac surgery is associated with increased risk of malnutrition. Nutritional management following chylothorax diagnosis varies across sites and patient populations, and a standardised approach has not been disseminated. The aim of this review article is to provide contemporary recommendations related to nutritional management of chylothorax to minimise risk of malnutrition. METHODS The management guidelines were developed by consensus across four dietitians, one nurse practitioner, and two physicians with a cumulative 52 years of experience caring for children with CHD. A PubMed database search for relevant literature included the terms chylothorax, paediatric, postoperative, CHD, chylothorax management, growth failure, and malnutrition. RESULTS Fat-modified diets and nil per os therapies for all paediatric patients (<18 years of age) following cardiac surgery are highlighted in this review. Specific emphasis on strategies for treatment, duration of therapies, optimisation of nutrition including nutrition-focused lab monitoring, and supplementation strategies are provided. CONCLUSIONS Our deliverable is a clinically useful guide for the nutritional management of chylothorax following paediatric cardiac surgery.
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Affiliation(s)
- Kristi L Fogg
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Amiee Trauth
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Melissa Winder
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Erin E Gordon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX, USA
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5
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Brandewie KL, Selewski DT, Bailly DK, Bhat PN, Diddle JW, Ghbeis M, Krawczeski CD, Mah KE, Neumayr TM, Raymond TT, Reichle G, Zang H, Alten JA. Early postoperative weight-based fluid overload is associated with worse outcomes after neonatal cardiac surgery. Pediatr Nephrol 2023; 38:3129-3137. [PMID: 36973562 DOI: 10.1007/s00467-023-05929-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/06/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES Evaluate the association of postoperative day (POD) 2 weight-based fluid balance (FB-W) > 10% with outcomes after neonatal cardiac surgery. METHODS Retrospective cohort study of 22 hospitals in the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) registry from September 2015 to January 2018. Of 2240 eligible patients, 997 neonates (cardiopulmonary bypass (CPB) n = 658, non-CPB n = 339) were weighed on POD2 and included. RESULTS Forty-five percent (n = 444) of patients had FB-W > 10%. Patients with POD2 FB-W > 10% had higher acuity of illness and worse outcomes. Hospital mortality was 2.8% (n = 28) and not independently associated with POD2 FB-W > 10% (OR 1.04; 95% CI 0.29-3.68). POD2 FB-W > 10% was associated with all utilization outcomes, including duration of mechanical ventilation (multiplicative rate of 1.19; 95% CI 1.04-1.36), respiratory support (1.28; 95% CI 1.07-1.54), inotropic support (1.38; 95% CI 1.10-1.73), and postoperative hospital length of stay (LOS 1.15; 95% CI 1.03-1.27). In secondary analyses, POD2 FB-W as a continuous variable demonstrated association with prolonged durations of mechanical ventilation (OR 1.04; 95% CI 1.02-1.06], respiratory support (1.03; 95% CI 1.01-1.05), inotropic support (1.03; 95% CI 1.00-1.05), and postoperative hospital LOS (1.02; 95% CI 1.00-1.04). POD2 intake-output based fluid balance (FB-IO) was not associated with any outcome. CONCLUSIONS POD2 weight-based fluid balance > 10% occurs frequently after neonatal cardiac surgery and is associated with longer cardiorespiratory support and postoperative hospital LOS. However, POD2 FB-IO was not associated with clinical outcomes. Mitigating early postoperative fluid accumulation may improve outcomes but requires safely weighing neonates in the early postoperative period. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Katie L Brandewie
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Priya N Bhat
- Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - John W Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Muhammad Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine D Krawczeski
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Tia T Raymond
- Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, TX, USA
| | - Garrett Reichle
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Huaiyu Zang
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
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6
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Winder MM, Schwartz S, Buckley JR, Fogg KL, Matiasek M, Lyman A, Tortorich A, Holmes K, Frank DU, Nasworthy M, Vichayavilas PE, Bertrandt RA, Kasmai C, Kuester JC, Raymond TT, Greiten LE, Reeder RW, Bailly DK. Optimal Fat-modified Diet Duration for the Treatment of Postoperative Chylothorax in Children. Ann Thorac Surg 2023:S0003-4975(23)00581-7. [PMID: 37308065 DOI: 10.1016/j.athoracsur.2023.05.021] [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: 02/27/2023] [Revised: 04/12/2023] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Dietary modification is the mainstay of treatment for postoperative chylothorax in children. However, optimal fat-modified diet (FMD) duration to prevent recurrence is unknown. Our aim was to determine the association between FMD duration and chylothorax recurrence. METHODS Retrospective cohort study conducted across six pediatric cardiac intensive care units within the United States. Patients <18 years who developed chylothorax within 30 days following cardiac surgery between January 2020 and April 2022 were included. Patients with a Fontan palliation or who died or were lost to follow-up or within 30 days of resuming a regular diet were excluded. FMD duration was defined as the first day of a FMD when chest tube output was <10 mL/kg/day without increasing until the resumption of a regular diet. Patients were classified into three groups (< 3 weeks, 3-5 weeks, >5 weeks) based on FMD duration. RESULTS 105 patients were included; <3 weeks (n=61) 3-5 weeks (n=18), and >5 weeks (n=26). Demographic, surgical, and hospitalization characteristics were not different across groups. In the >5 weeks group, chest tube duration was longer compared to the <3 weeks and 3-5 weeks groups (median: 17.5 days (IQR: 9, 31) vs 10 and 10.5 days; p=0.04). There was no recurrence of chylothorax within 30 days once chylothorax was resolving regardless of FMD duration. CONCLUSIONS FMD duration was not associated with recurrence of chylothorax, suggesting FMD duration can safely be shortened to at least < 3 weeks from time of resolving chylothorax.
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Affiliation(s)
- Melissa M Winder
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah.
| | - Stephanie Schwartz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of North Carolina
| | - Jason R Buckley
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina
| | | | - Megan Matiasek
- Department of Pediatrics, Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Alissa Lyman
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Science University
| | - Alisa Tortorich
- Department of Pediatrics, Division of Pediatric Gastroenterology, Oregon Health and Science University
| | - Kathy Holmes
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health and Science University
| | - Deborah U Frank
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Virginia
| | - Mandy Nasworthy
- Department of Pediatrics, Division of Pediatric Cardiology, University of Virginia
| | | | - Rebecca A Bertrandt
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin/Children's Wisconsin
| | - Cam Kasmai
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin/Children's Wisconsin
| | - Jill C Kuester
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin/Children's Wisconsin
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital
| | - Lawrence E Greiten
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Arkansas Children's Hospital
| | - Ron W Reeder
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Utah
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Utah
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Miya TR, Furlong-Dillard JM, Sizemore JM, Meert KL, Dalton HJ, Reeder RW, Bailly DK. Association Between Mortality and Ventilator Parameters in Children With Respiratory Failure on ECMO. Respir Care 2023; 68:592-601. [PMID: 36787913 PMCID: PMC10171354 DOI: 10.4187/respcare.10107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND In refractory respiratory failure, extracorporeal membrane oxygenation (ECMO) is a rescue therapy to prevent ventilator-induced lung injury. Optimal ventilator parameters during ECMO remain unknown. Our objective was to describe the association between mortality and ventilator parameters during ECMO for neonatal and pediatric respiratory failure. METHODS We performed a secondary analysis of the Bleeding and Thrombosis on ECMO dataset. Ventilator parameters included breathing frequency, tidal volume, peak inspiratory pressure, PEEP, dynamic driving pressure, pressure support, mean airway pressure, and FIO2 . Parameters were evaluated before cannulation, on the calendar day of ECMO initiation (ECMO day 1), and the day before ECMO separation. RESULTS Of 237 included subjects analyzed, 64% were neonates, of whom 36% had a congenital diaphragmatic hernia. Of all the subjects, 67% were supported on venoarterial ECMO. Overall in-hospital mortality was 35% (n = 83). The median (interquartile range) PEEP on ECMO day 1 was 8 (5.0-10.0) cm H2O for neonates and 10 (8.0-10.0) cm H2O for pediatric subjects. By multivariable analysis, higher PEEP on ECMO day 1 in neonates was associated with lower odds of in-hospital mortality (odds ratio 0.77, 95% CI 0.62-0.92; P = .01), with a further amplified effect in neonates with congenital diaphragmatic hernia (odds ratio 0.59, 95% CI 0.41-0.86; P = .005). No ventilator type or parameter was associated with mortality in pediatric subjects. CONCLUSIONS Avoiding low PEEP on ECMO day 1 for neonates on ECMO may be beneficial, particularly those with a congenital diaphragmatic hernia. No additional ventilator parameters were associated with mortality in either neonatal or pediatric subjects. PEEP is a modifiable parameter that may improve neonatal survival during ECMO and requires further investigation.
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Affiliation(s)
- Tadashi R Miya
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah.
| | - Jamie M Furlong-Dillard
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Johnna M Sizemore
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Heidi J Dalton
- Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - David K Bailly
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Neumayr TM, Alten JA, Bailly DK, Bhat PN, Brandewie KL, Diddle JW, Ghbeis M, Krawczeski CD, Mah KE, Raymond TT, Reichle G, Zang H, Selewski DT. Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods. Pediatr Nephrol 2023; 38:1355-1364. [PMID: 36066771 DOI: 10.1007/s00467-022-05697-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 05/31/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population. METHODS Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database. RESULTS Forty-five percent (n = 998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53-0.98), cardiopulmonary bypass (0.59; 0.42-0.83), delayed sternal closure (0.27; 0.19-0.38), prophylactic peritoneal dialysis use (0.58; 0.34-0.99), and mechanical ventilation on POD 2 (0.23; 0.16-0.33). Correlation between FB-IO and FB-W was weak for every POD 1-6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12-0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6-13.4%) with wide 95% limits of agreement (- 15.4-40.4%). CONCLUSIONS Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Jeffrey A Alten
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Priya N Bhat
- Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Katie L Brandewie
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Muhammad Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine D Krawczeski
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tia T Raymond
- Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, TX, USA
| | | | - Huaiyu Zang
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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9
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Bailly DK, Reeder RW, Muszynski JA, Meert KL, Ankola AA, Alexander PM, Pollack MM, Moler FW, Berg RA, Carcillo J, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Dalton H, Zuppa AF. Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis. Perfusion 2023; 38:363-372. [PMID: 35220828 DOI: 10.1177/02676591211056562] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, 14434University of Utah, Salt Lake, UT, USA
| | - Jennifer A Muszynski
- Division of Critical Care, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Center for Clinical and Translational Research, 2650The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen L Meert
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Cardiology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Peta Ma Alexander
- Department of Pediatrics, 14434Harvard Medical School, Boston, MA, USA
| | - Murray M Pollack
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Frank W Moler
- Department of Pediatrics and Communicable Diseases, 1259University of Michigan, Ann Arbor, MI, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Critical Care Medicine, 6619Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Berger
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Michael J Bell
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - J M Dean
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Carol Nicholson
- Trauma and Critical Illness Branch, 35040National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA.,35040National Institutes of Health, Bethesda, MD, USA
| | - Pamela Garcia-Filion
- Department of Biomedical Informatics, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David Wessel
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Sabrina Heidemann
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Allan Doctor
- Department of Pediatrics and Center for Blood Oxygen Transport and Hemostasis, 12264University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Rick Harrison
- Department of Pediatrics, 21785Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Heidi Dalton
- Department of Pediatrics and Heart and Vascular Institute, 3313Inova Fairfax Hospital, Fall Church, VA, USA
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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10
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Moza R, Winder M, Adamson GT, Ou Z, Presson AP, Vijayarajah S, Goldstein SA, Bailly DK. Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax. Pediatr Cardiol 2023:10.1007/s00246-022-03034-4. [PMID: 36754886 DOI: 10.1007/s00246-022-03034-4] [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] [Received: 04/09/2022] [Accepted: 10/14/2022] [Indexed: 02/10/2023]
Abstract
Earlier diagnosis of chylothorax following pediatric cardiac surgery is associated with decreased duration of chylothorax. Pleural fluid testing is used to diagnosis chylothorax which may delay detection in patients who are not enterally fed at time of chylothorax onset. Our aim was to develop and externally validate a prediction model to detect chylothorax earlier than pleural fluid testing in pediatric patients following cardiac surgery. A multivariable logistic regression model was developed to detect chylothorax using a stepwise approach. The model was developed using data from patients < 18 years following cardiac surgery from Primary Children's Hospital, a tertiary-care academic center, between 2017 and 2020. External validation used a contemporary cohort (n = 171) from Lucille Packard Children's Hospital. A total of 763 encounters (735 patients) were analyzed, of which 72 had chylothorax. The final variables selected were chest tube output (CTO) the day after sternal closure (dichotomized at 15.6 mL/kg/day, and as a continuous variable) and delayed sternal closure. The highest odds of chylothorax were associated with CTO on post-sternal closure day 1 > 15.6 mL/kg/day (odds ratio 11.3, 95% CI 6,3, 21.3). The c-statistic for the internal and external validation datasets using the dichotomized CTO variable were 0.78 (95% CI 0.73, 0.82) and 0.84 (95% CI, 0.78, 0.9) and performance improved when using CTO as a continuous variable (OR 0.84, CI: 95% CI 0.80, 0.87). Using the models described, chylothorax after pediatric cardiac surgery may be detected earlier and without reliance on enteral feeds.
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Affiliation(s)
- Rohin Moza
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Melissa Winder
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Gregory T Adamson
- Department of Pediatric Cardiology, Stanford University/Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA, 94304, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Senthuran Vijayarajah
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, 1200 Everett Dr, Oklahoma City, OK, 73104, USA
| | - Stephanie A Goldstein
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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11
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Glenn ET, Harman JR, Marietta J, Lake J, Bailly DK, Ou Z, Griffiths ER, Ware AL. Impact of a Surgical Wound Infection Prevention Bundle in Pediatric Cardiothoracic Surgery. Ann Thorac Surg 2023; 115:126-134. [PMID: 36126719 DOI: 10.1016/j.athoracsur.2022.08.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/16/2022] [Revised: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this project was to decrease the incidence of surgical wound infection (SWI) to <1.5% in our pediatric cardiothoracic surgery patients using a prevention bundle and quality improvement process. METHODS An SWI prevention bundle addressing preoperative, intraoperative, and postoperative risks was implemented. The primary outcome was SWI based on Society of Thoracic Surgeons criteria (superficial, deep, or mediastinitis). Novel aspects of the bundle included standardization of surgical closure and wound coverage for 14 days with a negative pressure dressing or a silicone dressing. Data were collected from January 2017 to November 2021; bundle intervention began in December 2019. SWIs were tracked using a g-chart. Preintervention and postintervention cohorts were compared by standard descriptive statistics. There were no changes in SWI tracking methods during the study. RESULTS During the study, 1159 individuals underwent 1768 surgical interventions. Preintervention (n = 931) and postintervention (n = 837) groups were clinically similar, with fewer neonatal surgeries in the postintervention group. SWI decreased in all patients (preintervention period: 1 SWI per 22 surgeries; postintervention period: 1 SWI per 62.6 surgeries) and in neonates (preintervention period: 1 SWI per 12 surgeries; postintervention period: 1 SWI per 26.7 surgeries). Special cause variation was achieved in the entire cohort by March 2021 and in neonates by April 2021. Decreases in SWI occurred in superficial and deep wounds but not in mediastinitis. Annual rate of total SWIs decreased from 2.83% in 2019 to 1.15% in 2021. Intensive care unit and hospital length of stay did not change. CONCLUSIONS We demonstrated a reduction in SWI rates after implementing an SWI prevention bundle including standardized surgical closure and prolonged wound protection.
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Affiliation(s)
- Emilee T Glenn
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah.
| | - Jeremy R Harman
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Jennifer Marietta
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Jason Lake
- Division of Pediatric Infectious Disease, University of Utah, Salt Lake City, Utah
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Eric R Griffiths
- Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Adam L Ware
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah
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12
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Bailly DK, Alten JA, Gist KM, Mah KE, Kwiatkowski DM, Valentine KM, Diddle JW, Tadphale S, Clarke S, Selewski DT, Banerjee M, Reichle G, Lin P, Gaies M, Blinder JJ. Fluid Accumulation After Neonatal Congenital Cardiac Operation: Clinical Implications and Outcomes. Ann Thorac Surg 2022; 114:2288-2294. [PMID: 35245511 PMCID: PMC9433462 DOI: 10.1016/j.athoracsur.2021.12.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study was conducted to determine the association between fluid balance metrics and mortality and other postoperative outcomes after neonatal cardiac operation in a contemporary multicenter cohort. METHODS This was an observational cohort study across 22 hospitals in neonates (≤30 days) undergoing cardiac operation. We explored overall percentage fluid overload, postoperative day 1 percentage fluid overload, peak percentage fluid overload, and time to first negative daily fluid balance. The primary outcome was in-hospital mortality. Secondary outcomes included postoperative duration of mechanical ventilation and intensive care unit (ICU) and hospital length of stay. Multivariable logistic or negative binomial regression was used to determine independent associations between fluid overload variables and each outcome. RESULTS The cohort included 2223 patients. In-hospital mortality was 3.9% (n = 87). Overall median peak percentage fluid overload was 4.9% (interquartile range, 0.4%-10.5%). Peak percentage fluid overload and postoperative day 1 percentage fluid overload were not associated with primary or secondary outcomes. Hospital resource utilization increased on each successive day of not achieving a first negative daily fluid balance and was characterized by longer duration of mechanical ventilation (incidence rate ratio, 1.11; 95% CI, 1.08-1.14), ICU length of stay (incidence rate ratio, 1.08; 95% CI, 1.03-1.12), and hospital length of stay (incidence rate ratio, 1.09; 95% CI, 1.05-1.13). CONCLUSIONS Time to first negative daily fluid balance, but not percentage fluid overload, is associated with improved postoperative outcomes in neonates after cardiac operation. Specific treatments to achieve an early negative fluid balance may decrease postoperative care durations.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah.
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katja M Gist
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David M Kwiatkowski
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Kevin M Valentine
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Sachin Tadphale
- Department of Pediatrics, University of Tennessee College of Medicine, Le Bonheur Children's Hospital, Memphis Tennessee
| | - Shanelle Clarke
- Department of Pediatrics, Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - David T Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Garrett Reichle
- Pediatric Cardiac Critical Care Consortium, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Paul Lin
- Pediatric Cardiac Critical Care Consortium, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Michael Gaies
- Pediatric Cardiac Critical Care Consortium, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joshua J Blinder
- Division of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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13
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Bushnell J, Connelly C, Algaze CA, Bailly DK, Koth A, Mafla M, Presnell L, Shin AY, McCammond AN. Team Communication and Expectations Following Pediatric Cardiac Surgery: A Multi-Disciplinary Survey. Pediatr Cardiol 2022; 44:908-914. [PMID: 36436004 DOI: 10.1007/s00246-022-03059-9] [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: 04/12/2022] [Accepted: 11/16/2022] [Indexed: 11/28/2022]
Abstract
Patients and families desire an accurate understanding of the expected recovery following congenital cardiac surgery. Variation in knowledge and expectations within the care team may be under-recognized and impact communication and care delivery. Our objective was to assess knowledge of common postoperative milestones and perceived efficacy of communication with patients and families and within the care team. An 18-question survey measuring knowledge of expected milestones for recovery after four index operations and team communication in the postoperative period was distributed electronically to multidisciplinary care team members at 16 academic pediatric heart centers. Answers were compared to local median data for each respondent's heart center to assess accuracy and stratified by heart center role and years of experience. We obtained 874 responses with broad representation of disciplines. More than half of all respondent predictions (55.3%) did not match their local median data. Percent matching did not vary by care team role but improved with increasing experience (35.8% < 2 years vs. 46.4% > 10 years, p = 0.2133). Of all respondents, 62.7% expressed confidence discussing the anticipated postoperative course, 78.6% denoted confidence discussing postoperative complications, and 55.3% conveyed that not all members of their care team share a common expectation for typical postoperative recovery. Most respondents (94.6%) stated that increased knowledge of local data would positively impact communication. Confidence in communication exceeded accuracy in predicting the timing of postoperative milestones. Important variation in knowledge and expectations for postoperative recovery in pediatric cardiac surgery exists and may impact communication and clinical effectiveness.
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Affiliation(s)
- Julie Bushnell
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Chloe Connelly
- University of Cincinnati School of Medicine, Cincinnati Children's Hospital and James M. Anderson Center for Health Systems Excellence, Cincinnati, OH, USA
| | - Claudia A Algaze
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David K Bailly
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew Koth
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Monica Mafla
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Laura Presnell
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Andrew Y Shin
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amy N McCammond
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA.
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14
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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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15
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Lasa JJ, Banerjee M, Zhang W, Bailly DK, Sasaki J, Bertrandt R, Raymond TT, Olive MK, Smith A, Alten J, Gaies M. Critical Care Unit Organizational and Personnel Factors Impact Cardiac Arrest Prevention and Rescue in the Pediatric Cardiac Population. Pediatr Crit Care Med 2022; 23:255-267. [PMID: 35020714 DOI: 10.1097/pcc.0000000000002892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patient-level factors related to cardiac arrest in the pediatric cardiac population are well understood but may be unmodifiable. The impact of cardiac ICU organizational and personnel factors on cardiac arrest rates and outcomes remains unknown. We sought to better understand the association between these potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue. DESIGN Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry. SETTING Pediatric cardiac ICUs. PATIENTS All cardiac ICU admissions were evaluated for cardiac arrest and survival outcomes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Successful prevention was defined as the proportion of admissions with no cardiac arrest (inverse of cardiac arrest incidence). Rescue was the proportion of patients surviving to cardiac ICU discharge after cardiac arrest. Cardiac ICU organizational and personnel factors were captured via site questionnaires. The associations between organizational and personnel factors and prevention/rescue were analyzed using Fine-Gray and multinomial regression, respectively, accounting for clustering within hospitals. We analyzed 54,521 cardiac ICU admissions (29 hospitals) with 1,398 cardiac arrest events (2.5%) between August 1, 2014, and March 5, 2019. For both surgical and medical admissions, lower average daily cardiac ICU occupancy was associated with better cardiac arrest prevention. Better rescue for medical admissions was observed for higher registered nursing hours per patient day and lower proportions of "part time" cardiac ICU physician staff (< 6 service weeks/yr). Increased registered nurse experience was associated with better rescue for surgical admissions. Increased proportion of critical care certified nurses, full-time intensivists with critical care fellowship training, dedicated respiratory therapists, quality/safety resources, and annual cardiac ICU admission volume were not associated with improved prevention or rescue. CONCLUSIONS Our multi-institutional analysis identified cardiac ICU bed occupancy, registered nurse experience, and physician staffing as potentially important factors associated with cardiac arrest prevention and rescue. Recognizing the limitations of measuring these variables cross-sectionally, additional studies are needed to further investigate these organizational and personnel factors, their interrelationships, and how hospitals can modify structure to improve cardiac arrest outcomes.
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Affiliation(s)
- Javier J Lasa
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Wenying Zhang
- PC 4 Data Coordinating Center, Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor, MI
| | - David K Bailly
- Primary Children's, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Jun Sasaki
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL
| | - Rebecca Bertrandt
- Division of Pediatric Critical Care, Children's Wisconsin, Milwaukee, WI
| | - Tia T Raymond
- Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX
| | - Mary K Olive
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Andrew Smith
- Monroe Carell Jr Children's Hospital at Vanderbilt, Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jeffrey Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael Gaies
- Monroe Carell Jr Children's Hospital at Vanderbilt, Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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Ankola AA, Bailly DK, Reeder RW, Cashen K, Dalton HJ, Dolgner SJ, Federman M, Ghassemzadeh R, Himebauch AS, Kamerkar A, Koch J, Kohne J, Lewen M, Srivastava N, Willett R, Alexander PMA. Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis. Front Cardiovasc Med 2022; 8:812881. [PMID: 35097029 PMCID: PMC8792849 DOI: 10.3389/fcvm.2021.812881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac patients. We aimed to identify anticoagulation practices, cardiac diagnoses, and surgical variables associated with bleeding during pediatric cardiac ECMO by combining two established databases, the Collaborative Pediatric Critical Care Research Network (CPCCRN) Bleeding and Thrombosis in ECMO (BATE) and the Extracorporeal Life Support Organization (ELSO) Registry. Methods: All children (<19 years) with a primary cardiac diagnosis managed on ECMO included in BATE from six centers were analyzed. ELSO Registry criteria for bleeding events included pulmonary or intracranial bleeding, or red blood cell transfusion >80 ml/kg on any ECMO day. Bleeding odds were assessed on ECMO Day 1 and from ECMO Day 2 onwards with multivariable logistic regression. Results: There were 187 children with 114 (61%) bleeding events in the study cohort. Biventricular congenital heart disease (94/187, 50%) and cardiac medical diagnoses (75/187, 40%) were most common, and 48 (26%) patients were cannulated directly from cardiopulmonary bypass (CPB). Bleeding events were not associated with achieving pre-specified therapeutic ranges of activated clotting time (ACT) or platelet levels. In multivariable analysis, elevated INR and fibrinogen were associated with bleeding events (OR 1.1, CI 1.0–1.3, p = 0.02; OR 0.77, CI 0.6–0.9, p = 0.004). Bleeding events were also associated with clinical site (OR 4.8, CI 2.0–11.1, p < 0.001) and central cannulation (OR 1.75, CI 1.0–3.1, p = 0.05) but not with cardiac diagnosis, surgical complexity, or cannulation from CPB. Bleeding odds on ECMO day 1 were increased in patients with central cannulation (OR 2.82, 95% CI 1.15–7.08, p = 0.023) and those cannulated directly from CPB (OR 3.32, 95% CI 1.02–11.61, p = 0.047). Conclusions: Bleeding events in children with cardiac diagnoses supported on ECMO were associated with central cannulation strategy and coagulopathy, but were not modulated by achieving pre-specified therapeutic ranges of monitoring assays.
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Affiliation(s)
- Ashish A. Ankola
- Department of Pediatrics, Divisions of Critical Care and Cardiology, Baylor College of Medicine, Houston, TX, United States
- *Correspondence: Ashish A. Ankola
| | - David K. Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, United States
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Katherine Cashen
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States
| | - Heidi J. Dalton
- Department of Pediatrics and Heart and Vascular Institute, Inova Fairfax Hospital, Fall Church, VA, United States
| | - Stephen J. Dolgner
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, United States
| | - Rod Ghassemzadeh
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Adam S. Himebauch
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Asavari Kamerkar
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Josh Koch
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Joseph Kohne
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
| | - Margaret Lewen
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, United States
| | - Renee Willett
- Department of Pediatrics, Children's National Hospital, Washington, DC, United States
| | - Peta M. A. Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics and Harvard Medical School, Boston, MA, United States
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17
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Winder MM, Vijayarajah S, Reeder RW, Glenn ET, Moza R, Eckhauser AW, Bailly DK. Successfully Reducing Fat-modified Diet Duration for Treating Postoperative Chylothorax in Children. Ann Thorac Surg 2021; 114:2363-2371. [PMID: 34801476 DOI: 10.1016/j.athoracsur.2021.10.028] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medical management, primarily a fat-modified diet (FMD), is the mainstay of treatment for the majority of patients with chylothorax. Duration of FMD is traditionally reported as 6 weeks, but no studies demonstrate the shortest effective duration that prevents recurrence of chylothorax. Our aim was to decrease FMD duration to 2 weeks in children with postoperative chylothorax without a significant increase in recurrence. METHODS Our single-center study included pediatric (<18 years of age) patients that developed chylothorax within 30 days of cardiac surgery. Patients with cavopulmonary anastomoses were excluded. The pre-intervention cohort was 19 patients diagnosed between 2/2014-6/2015, and the post-intervention cohort was 98 patients from 7/2015-12/2019. FMD duration was decreased from 6 weeks to 4 weeks in May 2016, and to 2 weeks in June 2018. Recurrence was defined as a return of a chylous effusion requiring chest tube placement or hospital readmission within 30 days of resuming a regular diet. RESULTS The median duration of FMD decreased from 42 days (interquartile range: 30,43) in the pre-intervention cohort to 26 days (interquartile range: 14,29) post-intervention, with no recurrence of chylothorax in any group. Compliance to the FMD duration instruction in the 6-week, 4-week, and 2-week groups was 100%, 84% and 67% respectively. Compared to the first 6 months, compliance to the 2-week FMD instruction during the final 12 months increased from 40% (6/15) to 79% (26/33). CONCLUSIONS At our center, FMD duration decreased from 6 weeks to 2 weeks without any recurrence of chylothorax.
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Affiliation(s)
- Melissa M Winder
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT; Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, UT.
| | - Senthuran Vijayarajah
- Department of Pediatrics, Division of Pediatric Critical Care, University of Oklahoma, Oklahoma City, OK
| | - Ron W Reeder
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
| | - Emilee T Glenn
- Department of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, UT
| | - Rohin Moza
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
| | - Aaron W Eckhauser
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
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18
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Workman JK, Bailly DK, Reeder RW, Dalton HJ, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Dean JM, Meert KL. Risk Factors for Mortality in Refractory Pediatric Septic Shock Supported with Extracorporeal Life Support. ASAIO J 2021; 66:1152-1160. [PMID: 33136603 PMCID: PMC7773130 DOI: 10.1097/mat.0000000000001147] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Risk factors for mortality in children with refractory pediatric septic shock who are supported with extracorporeal life support (ECLS) are largely unknown. Therefore, we performed univariable and multivariable analyses to determine risk factors for mortality among children (<19 years) who underwent an ECLS run between January 2012 and September 2014 at eight tertiary pediatric hospitals, and who had septic shock based on 2005 International Consensus Criteria. Of the 514 children treated with ECLS during the study period, 70 were identified with septic shock. The mortality rate was similar between those with (54.3%) and without septic shock (43.7%). Among those with septic shock, significant risk factors for mortality included cardiac failure or extracorporeal cardiopulmonary resuscitation (ECPR) as indication for ECLS cannulation compared with respiratory failure (P = 0.003), having a new neurologic event following cannulation (P = 0.032), acquiring a new infection following cannulation (P = 0.005), inability to normalize pH in the 48 hours following ECLS cannulation (P = 0.010), and requiring higher daily volume of platelet transfusions (P = 0.005). These findings can be used to help guide clinical decision making for children with septic shock that is refractory to medical management.
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Affiliation(s)
- Jennifer K. Workman
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - David K. Bailly
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Ron W. Reeder
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Heidi J. Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, Virginia
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P. Shanley
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher J. L. Newth
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rick Harrison
- Department of Pediatrics, University of Califronia, Mattel Children’s Hospital, Los Angeles, California
| | - J. Michael Dean
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Kathleen L. Meert
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan/Wayne State University, Detroit, Michigan
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19
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Bailly DK, Furlong-Dillard JM, Winder M, Lavering M, Barbaro RP, Meert KL, Bratton SL, Dalton H, Reeder RW. External validation of the Pediatric Extracorporeal Membrane Oxygenation Prediction model for risk adjusting mortality. Perfusion 2020; 36:407-414. [PMID: 32862782 PMCID: PMC7956121 DOI: 10.1177/0267659120952979] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The Pediatric Extracorporeal Membrane Oxygenation Prediction (PEP) model was created to provide risk stratification for all pediatric patients requiring extracorporeal life support (ECLS). Our purpose was to externally validate the model using contemporaneous cases submitted to the Extracorporeal Life Support Organization (ELSO) registry. METHODS This multicenter, retrospective analysis included pediatric patients (<19 years) during their initial ECLS run for all indications between January 2012 and September 2014. Median values from the BATE dataset for activated partial thromboplastin time and internationalized normalized ratio were used as surrogates as these were missing in the ELSO group. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC), and goodness-of-fit was evaluated using the Hosmer-Lemeshow test. RESULTS A total of 4,342 patients in the ELSO registry were compared to 514 subjects from the bleeding and thrombosis on extracorporeal membrane oxygenation (BATE) dataset used to develop the PEP model. Overall mortality was similar (42% ELSO vs. 45% BATE). The c-statistic after external validation decreased from 0.75 to 0.64 and model calibration decreases most in the highest risk deciles. CONCLUSION Discrimination of the PEP model remains modest after external validation using the largest pediatric ECLS cohort. While the model overestimates mortality for the highest risk patients, it remains the only prediction model applicable to both neonates and pediatric patients who require ECLS for any indication and thus maintains potential for application in research and quality benchmarking.
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Affiliation(s)
- David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jamie M Furlong-Dillard
- Department of Pediatric Critical Care, Norton Children's Hospital/University of Louisville, Louisville, KY, USA
| | - Melissa Winder
- Department of Pediatric Critical Care, Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Ryan P Barbaro
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Susan L Bratton
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Heidi Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Fall Church, VA, USA
| | - Ron W Reeder
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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20
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Bailly DK, Reeder RW, Winder M, Barbaro RP, Pollack MM, Moler FW, Meert KL, Berg RA, Carcillo J, Zuppa AF, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Bratton SL, Dalton H. Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality. Pediatr Crit Care Med 2019; 20:426-434. [PMID: 30664590 PMCID: PMC6502677 DOI: 10.1097/pcc.0000000000001882] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation initiation for children which is important for determining center-specific risk-adjusted outcomes. DESIGN Multivariable logistic regression using a large national cohort of pediatric extracorporeal membrane oxygenation patients. SETTING The ICUs of the eight tertiary care children's hospitals of the Collaborative Pediatric Critical Care Research Network. PATIENTS Five-hundred fourteen children (< 19 yr old), enrolled with an initial extracorporeal membrane oxygenation run for any indication between January 2012 and September 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 514 first extracorporeal membrane oxygenation runs were analyzed with an overall mortality of 45% (n = 232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric Extracorporeal Membrane Oxygenation Prediction model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for extracorporeal membrane oxygenation (extracorporeal cardiopulmonary resuscitation, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (odds ratio, 5.26; CI, 1.90-14.57) followed by extracorporeal cardiopulmonary resuscitation (odds ratio, 4.36; CI, 2.23-8.51). The C-statistic was 0.75 (95% CI, 0.70-0.80). CONCLUSIONS The Pediatric Extracorporeal Membrane Oxygenation Prediction model represents a model for predicting in-hospital mortality among children receiving extracorporeal membrane oxygenation support for any indication. Consequently, it holds promise as the first comprehensive pediatric extracorporeal membrane oxygenation risk stratification model which is important for benchmarking extracorporeal membrane oxygenation outcomes across many centers.
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Affiliation(s)
- David K. Bailly
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Ron W. Reeder
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Melissa Winder
- Department of Pediatric Critical Care, Primary
Children’s Hospital, Salt Lake City, UT
| | - Ryan P. Barbaro
- Department of Pediatrics and Communicable Diseases,
University of Michigan, Ann Arbor, MI
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National
Medical Center, Washington, DC
| | - Frank W. Moler
- Department of Pediatrics and Communicable Diseases,
University of Michigan, Ann Arbor, MI
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of
Michigan, Detroit, MI
| | - Robert A. Berg
- Department of Anesthesia and Critical Care,
Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s
Hospital of Pittsburgh, Pittsburgh, PA
| | - Athena F. Zuppa
- Department of Anesthesia and Critical Care,
Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine,
Children’s Hospital Los Angeles, Los Angeles, CA
| | - John Berger
- Department of Pediatrics, Children’s National
Medical Center, Washington, DC
| | - Michael J. Bell
- Department of Critical Care Medicine, Children’s
Hospital of Pittsburgh, Pittsburgh, PA
| | - J. Michael Dean
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Carol Nicholson
- Trauma and Critical Illness Branch, National Institute of
Child Health and Human Development NICHD, National Institutes of Health, Bethesda,
MD
| | | | - David Wessel
- Department of Pediatrics, Children’s National
Medical Center, Washington, DC
| | - Sabrina Heidemann
- Department of Pediatrics, Children’s Hospital of
Michigan, Detroit, MI
| | - Allan Doctor
- Departments of Pediatrics and Biochemistry, Washington
University, St. Louis, MO
| | - Rick Harrison
- Department of Pediatrics, Mattel Children’s
Hospital UCLA, Los Angeles, CA
| | - Susan L. Bratton
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Heidi Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Fall
Church, VA
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21
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Bailly DK, Reeder RW, Zabrocki LA, Hubbard AM, Wilkes J, Bratton SL, Thiagarajan RR. Development and Validation of a Score to Predict Mortality in Children Undergoing Extracorporeal Membrane Oxygenation for Respiratory Failure: Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction Score. Crit Care Med 2017; 45:e58-e66. [PMID: 27548818 DOI: 10.1097/ccm.0000000000002019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Our objective was to develop and validate a prognostic score for predicting mortality at the time of extracorporeal membrane oxygenation initiation for children with respiratory failure. Preextracorporeal membrane oxygenation mortality prediction is important for determining center-specific risk-adjusted outcomes and counseling families. DESIGN Multivariable logistic regression of a large international cohort of pediatric extracorporeal membrane oxygenation patients. SETTING Multi-institutional data. PATIENTS Prognostic score development: A total of 4,352 children more than 7 days to less than 18 years old, with an initial extracorporeal membrane oxygenation run for respiratory failure reported to the Extracorporeal Life Support Organization's data registry during 2001-2013 were used for derivation (70%) and validation (30%). Bidirectional stepwise logistic regression was used to identify factors associated with mortality. Retained variables were assigned a score based on the odds of mortality with higher scores indicating greater mortality. External validation was accomplished using 2,007 patients from the Pediatric Health Information System dataset. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction score included mode of extracorporeal membrane oxygenation; preextracorporeal membrane oxygenation mechanical ventilation more than 14 days; preextracorporeal membrane oxygenation severity of hypoxia; primary pulmonary diagnostic categories including, asthma, aspiration, respiratory syncytial virus, sepsis-induced respiratory failure, pertussis, and "other"; and preextracorporeal membrane oxygenation comorbid conditions of cardiac arrest, cancer, renal and liver dysfunction. The area under the receiver operating characteristic curve for internal and external validation datasets were 0.69 (95% CI, 0.67-0.71) and 0.66 (95% CI, 0.63-0.69). CONCLUSIONS Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction is a validated tool for predicting in-hospital mortality among children with respiratory failure receiving extracorporeal membrane oxygenation support.
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Affiliation(s)
- David K Bailly
- 1Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT. 2Division of Pediatric Critical Care, Department of Pediatrics, Naval Medical Center San Diego, San Diego, CA. 3Department of Cardiology, Boston Children's Hospital, Boston, MA. 4Department of Pediatrics, Harvard Medical School, Boston, MA
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22
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Truong DT, Johnson JT, Bailly DK, Clawson JR, Sheng X, Burch PT, Witte MK, LuAnn Minich L. Platelet Inhibition in Shunted Infants on Aspirin at Short and Midterm Follow-Up. Pediatr Cardiol 2017; 38:401-409. [PMID: 28039526 DOI: 10.1007/s00246-016-1529-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 05/27/2016] [Accepted: 11/11/2016] [Indexed: 02/04/2023]
Abstract
There are few data to guide aspirin therapy to prevent shunt thrombosis in infants. We aimed to determine if aspirin administered at conventional dosing in shunted infants resulted in ≥50% arachidonic acid (AA) inhibition in short and midterm follow-up using thromboelastography with platelet mapping (TEG-PM) and to describe bleeding and thrombotic events during follow-up. We performed a prospective observational study of infants on aspirin following Norwood procedure, aortopulmonary shunt alone, or cavopulmonary shunt surgery. We obtained TEG-PM preoperatively, after the third dose of aspirin, at the first postoperative clinic visit, and 2-8 months after surgery. The primary outcome was the proportion of subjects with ≥50% AA inhibition on aspirin. All bleeding and thrombotic events were collected. Of 24 infants analyzed, 13% had ≥50% AA inhibition at all designated time points after aspirin initiation; 38% had ≥50% AA inhibition after the third aspirin dose of aspirin, 60% at the first postoperative clinic visit, and 26% 2-8 months after surgery. Bleeding events occurred in eight subjects, and two had a thrombotic event. Bleeding events were associated with greater AA inhibition just prior to starting aspirin (p = 0.02) and after the third dose of aspirin (p = 0.04), and greater ADP inhibition before surgery (p = 0.03). The majority of infants failed to consistently have ≥50% AA inhibition when checked longitudinally postoperatively. Preoperative TEG-PM may be useful in identifying infants at higher risk of bleeding events on aspirin in the early postoperative period. Further research is needed to guide antiplatelet therapy in this population.
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Affiliation(s)
- Dongngan T Truong
- Division of Cardiology, Department of Pediatrics, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| | - Joyce T Johnson
- Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - David K Bailly
- Division of Critical Care, Department of Pediatrics, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Jason R Clawson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Xiaoming Sheng
- Department of Pediatrics, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Phillip T Burch
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Madolin K Witte
- Division of Critical Care, Department of Pediatrics, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - L LuAnn Minich
- Division of Cardiology, Department of Pediatrics, Primary Children's Hospital and University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
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23
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Zubair MM, Bailly DK, Lantz G, Sunstrom RE, Saharan S, Boshkov LK, Sochacki P, Roger Hohimer A, Lasarev MR, Langley SM. Preoperative platelet dysfunction predicts blood product transfusion in children undergoing cardiac surgery. Interact Cardiovasc Thorac Surg 2014; 20:24-30. [PMID: 25281704 DOI: 10.1093/icvts/ivu315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Excessive bleeding can be a problem during or after cardiac surgery. While cardiopulmonary bypass-associated platelet dysfunction is an important inducer of coagulopathy, preoperative platelet dysfunction can also contribute to this bleeding. We investigated the relationship between preoperative platelet dysfunction and transfusion of blood products given to children undergoing cardiac surgery. METHODS The platelet function analyser test measures platelet function in vitro by aspirating blood through a small standard hole (creating high shear) in a collagen membrane infused with a platelet agonist. The time taken to form a platelet plug is known as closure time and prolonged closure time (CT) indicates platelet dysfunction. Three hundred and thirty-eight children who had undergone surgery with cardiopulmonary bypass between 2008 and 2012 were included. The volume of red blood cells and fresh-frozen plasma transfused was recorded. The relationship between closure time and transfusion requirements was analysed using linear and logistic regression. RESULTS Patients with prolonged closure time had greater odds of getting red blood cells and fresh-frozen plasma transfusions compared with patients with normal closure time (P <0.01). On univariate analysis, age, weight, haematocrit, cardiopulmonary bypass time, Risk Adjustment for Congenital Heart Surgery score and closure time were associated with increased odds of red blood cells and fresh-frozen plasma transfusion in the operation theatre (P <0.05). However, when logistic multivariable regression analysis was applied, only age, cardiopulmonary bypass time and closure time remained as significant predictive factors for transfusion. CONCLUSIONS In children who have undergone cardiac surgery, when age and cardiopulmonary bypass time are accounted for, a prolonged preoperative closure time is significantly associated with increased odds of red blood cells and fresh-frozen plasma transfusion in the operation theatre. This may have implications for planning and utilization of blood products.
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Affiliation(s)
- M Mujeeb Zubair
- Division of Pediatric Cardiac Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - David K Bailly
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Gurion Lantz
- Division of Pediatric Cardiac Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Rachel E Sunstrom
- Division of Pediatric Cardiac Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Sunil Saharan
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Lynn K Boshkov
- Division of Hematology, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Paul Sochacki
- Division of Hematology, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - A Roger Hohimer
- Perinatal Division, Department of Obstetrics, Oregon Health & Science University, Portland, OR, USA
| | - Michael R Lasarev
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Stephen M Langley
- Division of Pediatric Cardiac Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
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Bailly DK, Boshkov LK, Zubair MM, Rogers VJC, Lantz G, Armsby L, Hohimer AR, Martchenke J, Sochacki P, Langley SM. Congenital cardiac lesions involving systolic flow abnormalities are associated with platelet dysfunction in children. Ann Thorac Surg 2014; 98:1419-24. [PMID: 25130078 DOI: 10.1016/j.athoracsur.2014.05.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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] [Received: 02/19/2014] [Revised: 05/02/2014] [Accepted: 05/12/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Shear stress-induced platelet dysfunction (PD) is prevalent among adults with aortic stenosis. Our aim was to determine whether abnormal platelet function was associated with specific congenital cardiac lesions in children. METHODS The charts of 407 children who had undergone cardiopulmonary bypass and had preoperative platelet function analysis were evaluated. Patients were assigned to 1 of 11 different lesion categories. Platelet dysfunction (PD) was defined as prolonged closure time (CT) as measured with a platelet function analyzer. Odds ratio (OR) estimates for prolonged CT were calculated for each lesion category. Mean CTs were compared with Tukey-Kramer separated means testing. Analysis of variance modeling was used to determine association between hematocrit value and CT. RESULTS CT in patients with ventricular septal defects (VSD) and right ventricular outflow tract obstruction (RVOTO) lesions was prolonged. OR analysis found that patients with VSDs (OR, 2.46) or RVOTO (OR, 2.88) had at least a 95% probability of an abnormal CT. In contrast, patients with atrial septal defect (ASD), bidirectional Glenn procedure (BDG), and pulmonary insufficiency (PI) had a reduced probability of a prolonged CT (p < 0.05). A similar pattern was seen in parametric analysis comparing mean CTs across lesion categories. A lower preoperative hematocrit value was associated with prolonged CTs across all lesion types (p < 0.05). CONCLUSIONS PD was common in children with congenital cardiac lesions involving systolic flow abnormalities and was uncommon among children with lesions having diastolic abnormalities. Lower preoperative hematocrit values were associated with prolonged CTs, suggesting subclinical bleeding secondary to excessive platelet shearing.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Lynn K Boshkov
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon; Department of Pathology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - M Mujeeb Zubair
- Department of Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Vanessa J C Rogers
- Department of Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Gurion Lantz
- Department of Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Laurie Armsby
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - A Roger Hohimer
- Department of Obstetrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Julie Martchenke
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Paul Sochacki
- Department of Pathology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Stephen M Langley
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon; Department of Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon.
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