A multidimensional family-integrated comfort care model improves outcomes in children undergoing cardiac catheterization for congenital heart disease: A randomized controlled trial.

No specific regimen has been universally accepted as ideal for sedation during cardiac catheterization in infants and children. We evaluated a combination of ketamine and dexmedetomidine for sedation during cardiac catheterization in children with congenital heart disease. The study design included a retrospective analysis of data sheets and hospital records. The protocol for sedation was standardized and data collected prospectively for an ongoing quality assurance project. Heart rate, blood pressure, and oxygen saturation were recorded every 1 minute for the first 5 minutes and then at 5-minute intervals. The efficacy of sedation was judged by the need for supplemental ketamine doses. The study cohort included 16 infants and children undergoing either diagnostic or therapeutic cardiac catheterization. Sedation was initiated with a bolus dose of ketamine (2 mg/kg) and dexmedetomidine (1 microg/kg) administered over 3 minutes followed by a continuous infusion of dexmedetomidine (2 microg/kg per hour for the initial 30 minutes followed by 1 microg/kg per hour for the duration of the case). Supplemental analgesia/sedation was provided by ketamine (1 mg/kg) as needed. The baseline heart rate was 103 +/- 21 beats/minute. After the bolus dose of ketamine and dexmedetomidine, the heart rate increased by 7 +/- 5 beats/minute. The greatest increase was 15 beats/minute. The low heart rate after the bolus dose of ketamine/dexmedetomidine or during the subsequent dexmedetomidine infusion was 91 +/- 20 beats/minute (P < 0.001 compared with baseline) and the high heart rate was 110 +/- 25 beats/minute (P < 0.01 compared with baseline). In two patients, the dexmedetomidine infusion was decreased from 2 to 1 microg/kg per hour at 12 to 15 minutes instead of 30 minutes as a result of a decreased heart rate. No clinically significant changes in blood pressure or respiratory rate were noted. Two patients developed upper airway obstruction, which responded to repositioning of the airway. No apnea was noted. During the procedure, the PaCO2 varied from 37.5 to 48 mm Hg and was > or =45 mm Hg in seven patients. No patient responded to local infiltration of the groin and placement of the arterial and venous cannulae. Three patients required a supplemental dose of ketamine (1 mg/kg) during the procedure. In two of these patients, this was required before changing the cannulae. Our preliminary data suggest that a combination of ketamine and dexmedetomidine provides effective sedation for cardiac catheterization in infants and children without significant effects on cardiovascular or ventilatory function.

In pediatric catheterization, the palpation and landmark (PL) technique is widely used for femoral arterial and venous (FAV) cannulation. Over the past decade, the ultrasound-guided (US) technique has replaced the PL technique. This study aimed to assess the clinical impact of application of the US technique on the success rate and completion time of FAV cannulation during cardiac catheterization in children. This is a retrospective observational study of consecutive pediatric patients who underwent cardiac catheterization in a tertiary care children's hospital from April 2016 to March 2022. The association between FAV cannulation success rate and the US technique was analyzed using multiple logistic regression analysis by adjusting for potential confounders, including patient and operator characteristics and procedural details. A total of 749 patients (PL, 378; US, 371) were analyzed. The odds ratio (OR) of the US technique success rate for FAV cannulation was 2.03, 95% confidence interval (CI), 1.10-3.73; p=0.02. The OR of the cannulation success rate of children aged <1 year was 0.16 (95% CI, 0.03-0.97; p=0.046). The US-guided technique was associated with an increased success rate of FAV cannulation, compared with the PL technique. Moreover, age < 1 year was an independent factor associated with a lower success rate of FAV cannulation. The US-guided technique might be an effective procedure in FAV cannulation during cardiac catheterization in children.

Incidence of thrombotic and bleeding complications during cardiac catheterization in children: comparison of high‐dose vs. low‐dose heparin protocols

Objectives:Direct measurement of skin dose of radiation for children using optically stimulated luminescence (OSL) technology using nanoDot® (Landauer, Glenwood, IL, USA).Background:Radiation dose is estimated as cumulative air kerma (AK) and dosearea product based on standards established for adult size patients. Body size of pediatric patients who undergo cardiac catheterization for congenital heart disease vary widely from newborn to adolescence. Direct, skindose measurement applying OSL technology may eliminate errors in the estimate.Materials and Methods:The nanoDot® (1 cm × 1 cm × flat plastic cassette) is applied to patient's skin using adhesive tape during cardiac catheterization and radiation skin doses were read within 24 hrs. nanoDot® values were compared to the currently available cumulative AK values estimated and displayed on fluoroscopy monitor.Results:A total of 12 children were studied, aged 4 months to 18 years (median 1.1 years) and weight range 5.3–86 kg (median 8.4 kg). nanoDot® readings ranged from 2.58 mGy to 424.8 mGy (median 84.1 mGy). Cumulative AK ranged from 16.2 mGy to 571.2 mGy (median 171.1 mGy). Linear correlation was noted between nanoDot® values and AK values (R2 = 0.88, R = 0.94). nanoDot® readings were approximately 65% of the estimated cumulative AK estimated using the International Electrotechnical Commission standards.Conclusions:Application of OSL technology using nanoDot® provides an alternative to directly measure fluoroscopic skin dose in children during cardiac catheterization. Our data show that the actual skin dose for children is approximately one-third lower than the AK estimated using international standards for adult size patients.

No specific regimen has been universally accepted as ideal for procedural sedation during cardiac catheterization in infants and children. In this paper, we retrospectively describe our preliminary experience with a continuous infusion of dexmedetomidine and propofol for sedation during cardiac catheterization in children with congenital heart disease. The short-half life of these two drugs creates a potential for easier titration, quicker recovery and less prolonged sedation-related adverse effects. This combination was not only able to limit the dose of either drugs, but was also very stable from cardio-respiratory standpoint. There were no adverse effects noted in our two patients. This initial experience showed that the combination of propofol and dexmedetomidine as a continuous infusion may be a suitable alternative for sedation in spontaneously breathing children undergoing cardiac catheterization.

Introduction: Children with congenital and acquired heart disease are at high risk for stroke. One-quarter of acute ischemic strokes (AIS) in children with cardiac disease occur in the peri-procedural period. Children with AIS can be treated successfully with hyperacute therapies. However, this requires timely identification of stroke, which has historically proved challenging in children. By developing and implementing a standardized screening assessment, we aim to decrease the time to detection of strokes occurring after cardiac catheterization in children. Methods: We retrospectively reviewed the medical records of children who had a stroke after cardiac catheterization at a tertiary children’s hospital between December 2006 and July 2016. We then developed a standardized screening stroke assessment. This was incorporated into the electronic medical record, and cardiology bedside nurses were trained in its use. The performance of the screen was analyzed retrospectively for children with a known stroke after cardiac catheterization. Results: Twenty children had a clinically-apparent stroke after cardiac catheterization prior to implementation of our screen. The time from the end of catheterization to the first documented assessment of neurologic function in any domain ranged from 22 minutes to 3.3 days (median 126 minutes). Given this variability, we developed a screening assessment that is brief, feasible, and within the scope of practice of cardiology bedside nurses. This was introduced to all nurses involved in the acute assessment of children after cardiac catheterization and is now performed on all children after catheterization. Retrospective application of the screen to the 20 children with a post-catheterization stroke would have resulted in detection of 18 (90%) of these strokes. Conclusion: Stroke after cardiac catheterization in children is rare; however, it is accompanied by a high rate of morbidity and mortality. The diagnosis of stroke after cardiac catheterization is often delayed. Development of screening methods to rapidly identify stroke in this population is feasible and has the potential to decrease the time to detection of stroke, thereby expanding access to hyperacute therapies.

Stroke After Cardiac Catheterization in Children

A technique for the management of cardiac catheterization in children is described which combines axillary plexus block with basal sedation. The technique offers a quiet still arm with pronounced vasodilatation, permitting the use of larger catheters than usual, making sampling easier, and giving undamped pressure records. These factors, together with the absence of venospasm, make catheterization of an arm vein in young chīldren a feasible proposition; in addition arterial sampling via the brachial artery may be performed without further inconvenience to the child.

Background: Diagnostic cardiac catheterisation is an important tool to define the detailed anatomy in children with Fallot's tetralogy pre-operatively. With advance in technology most of this information can be gained by cardiac echocardiogram or further non-invasive imaging like CT scan or MRI. A recent telephone survey across the cardiac units in the UK showed that majority centers now use cardiac catheterisations as a secondary investigation. Diagnostic cardiac catheterisation still remains extremely important in selected cases. Aims and Objectives: To find out the risk of significant complications during or within 12 hours of routine diagnostic catheterisation in cases of Fallot's Tetralogy. Design and Methods: A retrospective observational study and cases were identified from the database. Data was collected from 72 Fallot's cases undergoing diagnostic cardiac catheterisation at Leeds General infirmary between January 2004 and September 2009. Results: 17 out of the 72 (23%) cases had significant complication as a result of diagnostic cardiac catheterisation. Common complications included hypercyanotic spells in 10 cases (14%) and heart block in 4 (5%) cases. Other complications included ventricular ectopics (1 case), cold leg requiring heparin (1 case) and significant bradycardia (1 case) requiring external cardiac message. Conclusion: Diagnostic cardiac catheterisation in small infants and children with Tetralogy of Fallot's carries a high risk of complications even in expert hands. In our series 23% had significant complications. Whenever possible detailed anatomy should be defined by other non-invasive modalities like echocardiogram, MRI scan etc and cases for diagnostic cardiac catheterisation should be chosen judiciously.

Tokel K, Gümüş A, Ayabakan C, Varan B, Erdoğan İ. Complications of cardiac catheterization in children with congenital heart disease. Turk J Pediatr 2018; 60: 675-683. Catheterization procedures for congenital heart disease include a broad range of procedures with a large spectrum of potential adverse outcomes. We aimed to determine the incidence of various complications during pediatric cardiac catheterizations and to designate the relative risk factors for such complications. All pediatric patients undergoing cardiac catheterizations between January 2005-December 2010 were included. Data are collected prospectively by filling out computerized catheterization reports. Patient records were scanned for potential risk factors retrospectively. Groups were divided based on cardiac diagnosis; type of procedure. Adverse events were categorized into major or minor events. A total of 2662 cardiac catheterizations were performed during this period. The mean age of patients was 53.2±64.3 months. Diagnostic catheterizations were done for 1797 (67.5%) patients, and interventional procedures were done in 865 (32.5%) cases. Adverse events were observed in 688 patients (26%) during 941 procedures. Minor and major events were seen in 21.4% and 7.1% of the procedures respectively. Most frequent major complications were anesthesia related (6%), most frequent minor complications were vascular complications (45.2%). Complications were more frequent in younger patients (p=0.0001), during interventional procedures (p=0.0001). Thirteen patients died after a cardiac catheterization; they were younger and had longer procedures compared to those who survived (p=0.0001). Vascular complications were frequent among younger patients, with prolonged procedure time and vessel access (p < 0.0001). Cyanotic patients had more complications (p < 0.05; OR for major and minor complications: 3.5 and 2 respectively). Minor complications were 2.7 times more likely in ventricular outflow obstructions (p < 0.05). The complication rates of cardiac catheterization in children are low, but not negligible. Defining risk factors will help anticipate adverse events, which will guide in preparation for rescue procedures and improvement of patient safety systems in catheterization laboratories.

Objective To explore the efficiency of professional transport team on transporting emergency patients within the hospital. Methods 98 critical patients who were admitted to the emergency department of Beijing Tongren hospital with an urgent need of transportation were recruited into the study from June 2015 to June 2016. According to the random number table, the participants were divided into the intervention group (n=49) and the control group (n=49). The control group received the conventional transport method while the intervention group was transported by a professional transport team. Comparing the satisfaction of nurses and patients, and the incidence of adverse events. Results The intervention group had less adverse events and higher satisfaction compared with the control group (12.18% vs. 4.08% for adverse events incidence; 95.91% vs. 77.54% for nurses' satisfaction; 91.83% vs. 73.56% for patients' satisfaction; P<0.05) . Conclusions The professional transportation should be further developed in clinical practice since it can significantly reduce the incidence of adverse events and improve the satisfaction of patients and nurses. Key words: First aid; Professional transport team; Transport

Introduction: Stroke is an uncommon yet serious complication associated with cardiac catheterization in children with congenital heart disease. Our objective was to estimate the frequency and predictors of arterial ischemic stroke (AIS) in this specific setting. Methods: We performed a case-control study of children with congenital heart disease, who developed stroke in relation to cardiac catheterization performed at the Hospital for Sick Children between 1 January, 1992 and 1 January, 2014. Cases had new AIS (either symptomatic or silent) within 72 hours of cardiac catheterization and controls had cardiac catheterization but no new stroke within this time window. We estimated the frequency of AIS in children who underwent cardiac catheterization in this study period. Predictors of stroke that were tested include age, nature of intra-cardiac shunt, pre-procedural peripheral capillary oxygen saturation (SpO 2 ), type of catheterization (diagnostic versus interventional), duration of procedure, right versus left heart protocol, procedural anticoagulation and major/minor complications. Pediatric Stroke Outcome Measure was used to assess the neurological outcome of cases. Results: Twenty eight children (mean age1.66years; 64% males) developed stroke among 19414 children who underwent cardiac catheterization during the study period. The frequency of cardiac catheterization related-stroke in children is 1.44/1000 cardiac catheterizations. Univariate analysis revealed that younger age (OR 1.22; 95% CI (1.02,1.45); p=0.030), low SpO 2 pre-catheterization (OR 1.08; 95% CI (1.03,1.12); p=0.004), lack of procedural anticoagulation with heparin (OR 3.57; 95% CI (1.04,11.76); p=0.044), and minor complications during catheterization (OR 7.15; 95% CI (1.51,33.79); p=0.013) were associated with stroke. Low SpO 2 pre-catheterization and lack of procedural anticoagulation remained significant in multivariate analysis. Conclusion: The frequency of stroke after cardiac catheterization in children with congenital heart disease is 1.44/1000 cardiac catheterizations. Low SpO 2 pre-catheterization and lack of procedural anticoagulation appear to be associated with a higher risk of stroke.

The application of traditional Chinese medicine nursing combined with the health education standard path in acute myeloid leukaemia

Objective To investigate the effect of health education on anxiety, depression and maternal and fetal outcomes in women pregnant with twins. Methods 86 women pregnant with twins were divided into a study group and a control group by random number table, 43 cases for each group. Both groups were given routine physical examination and nursing care; in addition, the study group were given comprehensive health education guidance. The scores of Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) and maternal and child outcomes were compared between the 2 groups before and after the intervention. Results Before the intervention, the scores of SAS and SDS were (62.49±10.28) and (53.37±9.26) in the study group and were (63.02±10.31) and (54.11±9.88) in the control group, respectively. After the intervention, the scores of SAS and SDS were (47.49±8.07) and (44.47±10.15) in the study group and were (33.63±7.45) and (37.26±8.33) in the control group, respectively, which significantly lower than those before the intervention in both groups (allP<0.05). After the intervention, the scores SAS and SDS were lower in the study group than in the control group, with statistical differences (bothP<0.05). Conclusion Health education can improve the anxiety and depression of women pregnant with twins and improve the maternal and child outcomes, so it is worth being generalized. Key words: Health education; Pregnant with twins; Anxiety; Depression; Maternal and child outcomes

Effect of center catheterization volume on risk of catastrophic adverse event after cardiac catheterization in children