Pediatric Cardiac Patients Research Articles

Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients.

Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery. Observational cohort study. PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals. Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution. None. Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days. Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.

A Novel Situational Awareness Scoring System in Pediatric Cardiac Intensive Care Unit Patients

AbstractThe aim of this study was to describe a novel Situational Awareness Scoring System (SASS)'s performance in discriminating between patients who had cardiac arrest (CA) and those who did not, in a pediatric cardiac intensive care unit (PCICU). Retrospective, observational-cohort study in a quaternary-care PCICU. Patients who had CA in the PCICU between January 2014 and December 2018, and patients admitted to the PCICU in 2018 who did not have CA were included. Patients with do not resuscitate or do not intubate orders, extracorporeal membrane oxygenation, ventricular assist device, and PCICU stay &lt; 2 hours were excluded. SASS score statistics were calculated within 2, 4-, 6-, and 8-hour time intervals counting backward from the time of CA, or end of PCICU stay in patients who did not have CA. Cross-validated discrete time logistic regression models were used to calculate area under the receiver operating characteristic (AUC) curves. Odds ratios (ORs) for CA were calculated per unit increase of the SASS score. Twenty-eight CA events were analyzed in 462 PCICU admissions from 267 patients. Maximum SASS score within 4-hour time interval before CA achieved the highest AUC of 0.91 (95% confidence interval [CI]: 0.86–0.96) compared with maximum SASS score within 2-, 6-, and 8-hour time intervals before CA of 0.88 (0.79–96), 0.90 (0.85–0.95), and 0.89 (0.83–0.95), respectively. A cutoff value of 60 for maximum SASS score within 4-hour time interval before CA resulted in 82.1 and 83.2% of sensitivity and specificity, respectively. OR for CA was 1.32 (95% CI: 1.26–1.39) for every 10 units increase in the maximum SASS score within each 4-hour time interval before CA. The maximum SASS score within various time intervals before CA achieved promising performance in discriminating patients regarding occurrence of CA.

Development of a Model for the Pediatric Survival After Veno-Arterial Extracorporeal Membrane Oxygenation Score: The Pedi-SAVE Score.

Pediatric cardiac extracorporeal membrane oxygenation (ECMO) patients have high mortality rates. The purpose of our study was to develop and validate the Pediatric Survival After Veno-arterial ECMO (Pedi-SAVE) score for predicting survival at hospital discharge after pediatric cardiac veno-arterial (VA) ECMO. We used data for pediatric cardiac VA-ECMO patients from the Extracorporeal Life Support Organization registry (1/1/2001-12/31/2015). Development and validation cohorts were created using 2:1 random sampling. Predictors of survival to develop pre- and postcannulation models were selected using multivariable logistic regression and random forest models. ß-coefficients were standardized to create the Pedi-SAVE score. Of 10,091 pediatric cardiac VA-ECMO patients, 4,996 (50%) survived to hospital discharge. Pre- and postcannulation Pedi-SAVE scores predicted that the lowest risk patients have a 65% and 74% chance of survival at hospital discharge, respectively, compared to 33% and 22% in the highest risk patients. In the validation cohort, pre- and postcannulation Pedi-SAVE scores had c-statistics of 0.64 and 0.71, respectively. Precannulation factors associated with survival included: nonsingle ventricle congenital heart disease, older age, white race, lower STAT mortality category, higher pH, not requiring acid-buffer administration, <2 cardiac procedures, and indication for VA-ECMO other than failure to wean from cardiopulmonary bypass. Postcannulation, additional factors associated with survival included: lower ECMO pump flows at 24 hours and lack of complications. The Pedi-SAVE score is a novel validated tool to predict survival at hospital discharge for pediatric cardiac VA-ECMO patients, and is an important advancement in risk adjustment and benchmarking for this population.

Complications associated with peripherally inserted central catheters in paediatric cardiac patients.

To characterise the use of peripherally inserted central catheters in paediatric cardiac patients and to identify risk factors associated with their complications. Observational retrospective cohort study in paediatric cardiac patients who underwent peripherally inserted central catheter placement in a tertiary children's hospital from January 2000 to June 2018. 1822 cardiac patients underwent 2952 peripherally inserted central catheter placements in the study period. Median age was 29 days, with survival to hospital discharge of 96.4%. Successful placement achieved 94.5% of attempts, with a median line duration of 12 days. Factors associated with successful placement were the use of general anaesthesia (odds ratio 7.52, p < 0.001) and year of placement (odds ratio 1.08, p < 0.001). The incidence of complications was 28.6%, with thrombosis/occlusion being the most frequent (33%). Thrombosis/occlusion were associated with two and three lumens (odds ratio 1.96, p < 0.001 and 4.63, p = 0.037, respectively). Lines placed by interventional radiology had decreased infiltration (odds ratio 0.20, p = 0.002) and lower migration/malposition (odds ratio 0.36, p < 0.001). The use of maintenance intravenous fluids (odds ratio 3.98, p = 0.008) and peripheral tip position (odds ratio 3.82, p = 0.001) were associated with increased infiltration. The probability of infection decreased over time (odds ratio 0.79, p < 0.001). Peripherally inserted central catheters in paediatric cardiac patients have complication rates similar to other paediatric populations. A prospective assessment of the factors associated with their complications in this patient population may be beneficial in improving outcomes.

Central Venous Catheter Tip Malposition After Internal Jugular Vein Cannulation in Pediatric Patients With Congenital Heart Disease

The primary objective of the study was to identify the incidence of catheter tip malposition as determined by postoperative radiography after central venous cannulation by right and left internal jugular venous routes in pediatric cardiac surgical patients. The secondary objective was to determine the relative risk of malposition between the 2 approaches into specific major thoracic veins other than the right superior vena cava. A prospective observational study. A tertiary cardiac care center. Pediatric patients undergoing cardiac surgery INTERVENTIONS: Internal jugular vein cannulation with ultrasound guidance. Two hundred pediatric patients undergoing cardiac surgeries for cardiac anomalies with Risk Adjustment in Congenital Heart Surgery scores of 1- to-6 were included in the study. After anesthetic induction, 50% of the patients were cannulated via the right internal jugular vein (RIJV group, n=100), and the other 50% via the left internal jugular vein (LIJV group, n=100). The position of the catheter tip was ascertained by a plain chest x-ray. The central venous catheter tip was deemed to be malpositioned if the tip was in the ipsilateral or contralateral subclavian vein or in the contralateral internal jugular vein. In the RIJV group, 4% of the patients had the central venous catheter tip in a malposition (4/100). In the LIJV group, 6 of the 100 patients had a left superior vena cava and were excluded. In the rest of the LIJV group, the central venous catheter tip was in a malposition in 22.3% of patients (21/94, relative risk: 6.90, p < 0.001). Malposition into the right subclavian vein was more frequent with the left internal jugular vein access (11/94, 11.7%) compared with the right internal jugular vein access (relative risk: 13.12, p=0.015). The incidence of a malposition of a central venous catheter tip after either right or left internal jugular vein approach was ascertained. The relative risk of a malposition occurring with the left internal jugular approach was higher, and the most common site of malposition was in the right subclavian vein.

Reducing Opioid-Induced Constipation Post-Cardiac Surgery: An Improvement Project in a Pediatric Cardiac Intensive Care Unit.

Pain management with opioids and underutilization of prophylaxis for constipation can prolong a patient's hospital length of stay and impede pain management efforts. In pediatric postoperative cardiac patients, opioid therapy is a common approach to pain management but often places them at greater risk for constipation due to anatomy and age. A retrospective review of 50 patients' medical records for baseline data was conducted, and a survey evaluated providers' current knowledge and practice. The intervention was an electronic order set that provided decision support. Additionally, prophylactic measures were supported by a validated assessment tool that created a common language to report constipation risk. Although not statistically significant, postintervention data demonstrated a 21.5% decrease in postoperative constipation and a 57% increase in ordered bowel regimens. More focus is needed toward prophylactic bowel regimens to reduce the risk in this already high-risk population.

Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis.

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.

Trends in bacteriological spectrum and antibiotic susceptibility on blood culture in pediatric cardiac patients at a tertiary childcare health facility.

Objectives:To report trends in bacteriological spectrum and antibiotic susceptibility on blood culture in admitted pediatric cardiac patients at a Tertiary Childcare Health Facility.Methods:This cross-sectional observational study was conducted at the Department of Pediatric Cardiology, The Children’s Hospital and Institute of Child Health, Multan from January 2018 to December 2020. We included admitted children of both genders aged one day to 12 years and whose blood sample was sent for blood culture analysis. Gram staining was used to identify isolated organisms. Distribution of types of strains, bacterial isolates and antimicrobial sensitivity/resistance were recorded.Results:During the study period, a total of 772 blood samples were sent for blood culture analysis, out of which, 154 (19.9%) turned out to be positive. Mean age was noted to be 1.12±2.3 years. Gram negative rods were the most frequently noted strains found among 69 (44.8%) cases. A total of 131 strains were found to have bacterial isolates. Salmonella typhi was the commonest bacterial agent noted in 30 (19.4%) cases while Coagulase Negative Staphylococcus in 18 (11.7%) and acinetobacter baumannii in 16 (10.4%).Conclusion:Blood culture positivity rate was found to be 19.9%. Gram negative rods were the most frequently noted strains. Salmonella typhi, Coagulase Negative Staphylococcus and Acinetobacter baumannii were found to be the commonest bacterial isolates responsible. Routinely used antibiotics like Ciprofloxacin, Cefotaxime, Ceftizadime and Ampicillin were found to have high rates of resistance against most commonly found bacterial isolates.

Free-running cardiac and respiratory motion-resolved 5D whole-heart coronary cardiovascular magnetic resonance angiography in pediatric cardiac patients using ferumoxytol

BackgroundCoronary cardiovascular magnetic resonance angiography (CCMRA) of congenital heart disease (CHD) in pediatric patients requires accurate planning, adequate sequence parameter adjustments, lengthy scanning sessions, and significant involvement from highly trained personnel. Anesthesia and intubation are commonplace to minimize movements and control respiration in younger subjects. To address the above concerns and provide a single-click imaging solution, we applied our free-running framework for fully self-gated (SG) free-breathing 5D whole-heart CCMRA to CHD patients after ferumoxytol injection. We tested the hypothesis that spatial and motion resolution suffice to visualize coronary artery ostia in a cohort of CHD subjects, both for intubated and free-breathing acquisitions.MethodsIn 18 pediatric CHD patients, non-electrocardiogram (ECG) triggered 5D free-running gradient echo CCMRA with whole-heart 1 mm3 isotropic spatial resolution was performed in seven minutes on a 1.5T CMR scanner. Eleven patients were anesthetized and intubated, while seven were breathing freely without anesthesia. All patients were slowly injected with ferumoxytol (4 mg/kg) over 15 minutes. Cardiac and respiratory motion-resolved 5D images were reconstructed with a fully SG approach. To evaluate the performance of motion resolution, visibility of coronary artery origins was assessed. Intubated and free-breathing patient sub-groups were compared for image quality using coronary artery length and conspicuity as well as lung-liver interface sharpness.ResultsData collection using the free-running framework was successful in all patients in less than 8 min; scan planning was very simple without the need for parameter adjustments, while no ECG lead placement and triggering was required. From the resulting SG 5D motion-resolved reconstructed images, coronary artery origins could be retrospectively extracted in 90% of the cases. These general findings applied to both intubated and free-breathing pediatric patients (no difference in terms of lung-liver interface sharpness), while image quality and coronary conspicuity between both cohorts was very similar.ConclusionsA simple-to-use push-button framework for 5D whole-heart CCMRA was successfully employed in pediatric CHD patients with ferumoxytol injection. This approach, working without any external gating and for a wide range of heart rates and body sizes provided excellent definition of cardiac anatomy for both intubated and free-breathing patients.

Critical Care Nutrition Support following Cardiac Surgery in the Pediatric and Adult Population—A Review Article

AbstractCardiac surgical patients in the intensive care unit certainly develop complex nutritional issues. Nutrition support is indicated in these subsets of patients and the same may be customized depending on individual patient characteristics. This review article that aims to examine the American Society for Parenteral and Enteral Nutrition guidelines for the use of parenteral and enteral nutrition in pediatric and adult cardiac surgical patients in cardiac critical care/intensive care unit evaluates the evidence related to the use of nutritional screening and nutritional assessment. The goal of this review is to enrich the discussion contained in the clinical guidelines and simplify the guideline statements to provide a platform for cardiac care providers to implement into their daily practice related to nutrition support in postoperative cardiac surgery patients.

Outcome of Ventilator-Associated Pneumonia in Children Post Cardiac Surgery: A Prospective Observational Study

Abstract Background Ventilator-associated pneumonia (VAP) is a serious complication in post congenital cardiac repair in children leading to high morbidity and mortality. We conducted this study with an aim to determine incidence, risk factors, and mortality of VAP in pediatric cardiac surgical patients. Methodology This prospective observational study included 371 children aged less than 12 years who underwent elective cardiac surgery for congenital heart disease from March 2020 to September 2021. Patients were categorized into two groups: those with VAP and without VAP. Results Out of 371 patients, 67 patients (18%) developed VAP. The VAP incidence density was 36.3 episodes per 1,000 mechanical ventilation days. Age less than 1 year (p &lt;0.001), prolonged preoperative hospital stay (odds ratio: 2.25; 95% CI:1.11–4.52; p = 0.007), and higher RACHS1 (risk adjustment in congenital heart surgery) category, prolonged invasive mechanical ventilation (p &lt;0.001), delayed sternal closure, tracheostomy, reintubation, use of uncuffed ET tube, and peritoneal dialysis were associated with higher incidence of VAP. Total 86 tracheal samples were taken. Most frequently isolated microorganisms were Acinetobacter baumannii (43%) and Klebsiella pneumoniae (23%). Antibiotic resistance was alarming as Acinetobacter and Klebsiella species were highly resistant to commonly used broad spectrum antibiotics like cephalosporins, aminoglycosides, and carbapenems. Conclusion VAP incidence in our study was 18% and VAP incidence density was 36.3 per 1,000 mechanical ventilation days. Patients with VAP had higher mortality (32%) as compared with patients without VAP (12%).

Assessment of stress response attenuation with caudal morphine using a surrogate marker during pediatric cardiac surgery.

Background:Measurement of biomarkers representing sympathetic tone and the surgical stress response are helpful for objective comparison of anesthetic protocols.Aims:The primary aim was to compare changes in chromogranin A levels following pump pediatric cardiac surgery between children who received bolus caudal morphine and those who received a conventional intravenous narcotic-based anesthesia regime. The secondary objectives were to compare hemodynamic responses to skin incision and the magnitude of the rise in blood sugar values between the groups.Settings and Design:A prospective observational study at a tertiary cardiac center.Measurements and Methods:Sixty pediatric cardiac surgical patients were randomized to Group I [n = 30] to receive intravenous narcotic-based anesthesia and Group II [n = 30] to receive single-shot caudal morphine. Baseline and postoperative chromogranin A levels, the hemodynamic response to skin incision, changes in blood sugar levels, and the total intravenous narcotic dose administered were recorded for each participant.Statistical Analysis:Pearson's Chi-squared test was used for comparison of categorized variables, and Mann–Whitney test was used for the analysis of continuous data.Results:Changes in chromogranin A levels and blood sugar levels were comparable in both groups. Group II received a lower narcotic dosage (P ≤ 0.001), and the response to skin incision as reflected by systolic pressure rise was less (P = 0.006).Conclusions:Surgical stress response attenuation was similar to caudal morphine as compared with intravenous narcotic-based anesthesia techniques as reflected by a similar increase in chromogranin A levels.

Case Report: Traumatic Stress and Developmental Regression: An Unintended Consequence of Complex Cardiac Care

This brief case report outlines a novel approach to supporting the development of a pediatric complex cardiac care patient. Patient X is a 19-month old patient who spent 5.5 months in hospital and underwent multiple surgeries including heart transplantation. This case report explores the impacts of his condition and care on his development and family functioning within the framework of an integrated care model. This case report is uniquely complimented by outpatient neurodevelopmental follow up, dyadic trauma-informed intervention and use of telemedicine allowing for a deeper understanding of the family adaptation that provide novel insight into long-term trajectory beyond discharge. Throughout care Patient X met criteria for both a traumatic stress disorder and global developmental delay. This case study highlights the threat complex care poses to neurodevelopment, pediatric mental health and family dynamics as well as opportunities for intervention.

Preoperative Iron Supplementation in Pediatric Cardiac Surgical Patients: A Preliminary Single-Center Experience

To assess preoperative hemoglobin and perioperative red blood cell transfusion in children undergoing cardiac surgery after the implementation of a preoperative patient blood management (PBM) clinic with oral iron supplementation. A retrospective analysis. A single tertiary hospital. Patients who underwent cardiac surgery with cardiopulmonary bypass at the Hospital for Sick Children (Toronto, Canada) during a 12-month period before and following the implementation of a preoperative PBM clinic. Patients younger than 3 months of age, or who were admitted to the cardiac intensive care unit preoperatively, were excluded because they were not systematically assessed by the PBM clinic. None. A total of 296 patients were included in the authors' analysis. After adjustment for confounding factors (age at surgery, preoperative oxygen saturation, type of congenital heart disease, surgery type), they found that preoperative hemoglobin levels were significantly higher in children treated with iron supplementation (n=201) compared to historic controls (n=95) (13.9 [12.8-15.1] g/dL v 12.9 [11.7-15.0] g/dL, adjusted p=0.001). The exposure rate to red blood cell transfusion (50% v 61%, adjusted p=0.930) was not significantly different between groups. However, the volumes of allogeneic red blood cells (1.4 (0.0-14.0) mL/kg v 12.5 (0.0-23.0) mL/kg, adjusted p=0.004) and autologous blood (11.0 (6.8-17.0) v 17.0 (11.0-31.0), adjusted p < 0.001) transfused were significantly reduced in children treated with iron supplementation. Preoperative iron supplementation led to an increase in preoperative hemoglobin levels. The exact prevalence of iron deficiency and the effect of iron supplementation on perioperative allogeneic blood transfusion and long-term outcomes should be studied in a prospective randomized study.

A National Study of Healthcare Service Patterns at the End of Life Among Children With Cardiac Disease.

Heart diseases are one of the leading causes of health-related deaths among children. Concurrent hospice care offers hospice and nonhospice healthcare services simultaneously, but the use of these services by children with cardiac disease has been rarely investigated. The aims of this study were to identify patterns of nonhospice healthcare services used in concurrent hospice care and describe the profile of children with cardiac disease in these clusters. This study was a retrospective cohort analysis of Medicaid claims data collected between 2011 and 2013 from 1635 pediatric cardiac patients. The analysis included descriptive statistics and latent class analysis. Children in the sample used more than 314 000 nonhospice healthcare services. The most common services were inpatient hospital procedures, durable medical equipment, and home health. Latent class analysis clustered children into "moderate intensity" (60.0%) and "high intensity" classes (40.0%). Children in "moderate intensity" had dysrhythmias (31.7%), comorbidities (85.0%), mental/behavioral health conditions (55%), and technology dependence (71%). They commonly resided in urban areas (60.1%) in the Northeast (44.4%). The health profile of children in the "high intensity" class included dysrhythmias (39.4%), comorbidities (97.6%), mental/behavioral health conditions (71.5%), and technology dependence (85.8%). These children resided in rural communities (50.7%) in the South (53.1%). Two patterns of use of nonhospice healthcare services were identified in this study. This information may be used by nurses and other healthcare professionals working in concurrent hospice care to assess the healthcare service needs of children with cardiac conditions at the end of life.

Point-of-Care Ultrasound-Guided Protocol to Confirm Central Venous Catheter Placement in Pediatric Patients Undergoing Cardiothoracic Surgery: A Prospective Feasibility Study.

Background: Central venous catheters (CVC) are commonly required for pediatric congenital cardiac surgeries. The current standard for verification of CVC positioning following perioperative insertion is postsurgical radiography. However, incorrect positioning may induce serious complications, including pleural and pericardial effusion, arrhythmias, valvular damage, or incorrect drug release, and point of care diagnostic may prevent these serious consequences. Furthermore, pediatric patients with congenital heart disease receive various radiological procedures. Although relatively low, radiation exposure accumulates over the lifetime, potentially reaching high carcinogenic values in pediatric patients with chronic disease, and therefore needs to be limited. We hypothesized that correct CVC positioning in pediatric patients can be performed quickly and safely by point-of-care ultrasound diagnostic. Methods: We evaluated a point-of-care ultrasound protocol, consistent with the combination of parasternal craniocaudal, parasternal transversal, suprasternal notch, and subcostal probe positions, to verify tip positioning in any of the evaluated views at initial CVC placement in pediatric patients undergoing cardiothoracic surgery for congenital heart disease. Results: Using the combination of the four views, the CVC tip could be identified and positioned in 25 of 27 examinations (92.6%). Correct positioning was confirmed via chest X-ray after the surgery in all cases. Conclusions: In pediatric cardiac patients, point-of-care ultrasound diagnostic may be effective to confirm CVC positioning following initial placement and to reduce radiation exposure.

83 The predictive role of neutrophil-to-lymphocyte ratio in post-operative cardiopulmonary bypass surgery

Abstract Aims Postoperative arrhythmias (POA) are a common complication after cardiac surgical repairs for congenital heart disease (CHD), representing a substantial source of morbidity, mortality, and prolonged total in-hospital stay, with an incidence of 7.5–48% in postoperative pediatric cardiac patients. The etiology is multifactorial, and it has been related to the direct surgical manipulation of the cardiac conduction system, to the local tissue inflammation in the myocardium adjacent to the conduction system and to the arrhythmogenic effects of cardiopulmonary bypass (CPB), inotropes, and electrolyte disturbances. Recently, the prognostic role of neutrophil-to-lymphocyte ratio (NLR), a novel inflammation marker, has been evaluated in pediatric patients after CPB surgery. To evaluate the predictive role of NLR in POA in a population of pediatric CHD patients after CPB. Methods and results We retrospectively collected perioperative clinical and laboratory data of 146 patients (age 8.27 ± 10.79 years; male gender: 60.8%) consecutively admitted to the cardiac surgery intensive care unit (ICU) of our institute after elective cardiac surgery with CPB in 2018. We grouped and analyzed our population over NLR tertiles evaluated at 24 h from CPB and types of POA: supraventricular (SVT) and junctional (JET). The prognostic value of NLR and its association with POA was analyzed. Diagnoses of 146 patients included atrial septal defect (n = 36), ventricular septal defect (n = 20), pulmonary atresia/stenosis (n = 10), tetralogy of Fallot (n = 20), endocardial cushion defect (n = 8), left ventricular outflow tract obstruction (n = 14), anomalous origin of coronary artery (n = 6), complex CHD (n = 13), interrupted/hypoplastic aortic arch (n = 12), anomalous pulmonary venous return (n = 3). The mean CPB time was 121.6 ± 84.6 min. The median ICU hospitalization was 48 h [Q1, Q3: 24, 96]. Twelve patients experienced POA: 6 SVT and 6 JET. The frequency of POA incremented over NLR-tertiles (P-Trend 0.017), while SVT onset was associated with higher values of NLR and C-reactive protein (P = 0.034 and P = 0.011, respectively). Patients in the second and third tertiles of NLR had a prolonged hospitalization (log-rank, P = 0.029), especially when associated with POA (log-rank, P = 0.012). At the multivariable analysis, higher age and NLR values were independently associated with SVT [OR per year 1.22; 95% CI (1.02, 1.25), P = 0.043 and OR per point 1.91; 95% CI (1.29, 2.82), P = 0.012, respectively], but not with JET. Conclusions 24-h post-CPB NLR can predict postoperative SVT in a population of pediatric CHD patients. Our data suggest that the NLR could be a useful, easy-to-obtain marker for postoperative outcome in pediatric patients who had undergone elective CPB.

Abstract 13712: Clinical Predictive Tool for Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation Therapy and Ultrafiltration

Introduction: Fluid overload is common among pediatric cardiac patients receiving ECMO. It is often treated with in-line ultrafiltration (UF) with some patients progressing to continuous renal replacement therapy (CRRT). We assessed whether requiring CRRT was associated with increased morbidity and mortality compared to UF alone. Additionally, we evaluated characteristics associated with the progression from UF to CRRT to create a clinical decision support tool to help identify patients likely to require CRRT. Hypothesis: Pediatric cardiac patients on ECMO who require CRRT have increased morbidity and mortality compared to UF alone and can be identified at the time UF is initiated. Methods: Retrospective chart review of patients age ≤18 years treated with ECMO from 1/14-12/19 at a single quaternary care cardiac ICU. Bivariate comparisons using Chi-square or Fisher’s Exact and Mann-Whitney U tests were used as appropriate. ROC curve was used to create a tool predictive of the need for CRRT at the time of initiation of UF. Results: Of 131 ECMO patients, 45 (32%) underwent UF and 13 (10%) UF then CRRT. Patients who required CRRT had a higher creatinine and BUN at time of UF initiation (p=0.04 and p=&lt;0.01), longer time on ECMO (p=&lt;0.01), a lower rate of renal recovery (p=0.02), and higher mortality (p=0.01). Using ROC analysis, presence of ≤3 of 7 variables (BUN &gt;20 and GFR &lt;60 at UF initiation, low MAP and RPP 12 hours before initiation of UF, total fluid overload &gt; 10%, daily fluid balance &gt; 50mL/kg in the 24 hours prior to UF initiation, and urine output &lt;1ml/kg/hr in the day prior to UF initiation) had a positive predictive value of 87.5% and negative predictive value of 50.0% for the use of UF alone (AUC 0.801; p=0.002). Conclusions: Pediatric cardiac patients treated with ECMO and UF who require CRRT demonstrate increased morbidity and mortality compared to UF alone. A novel clinical tool may assist in stratifying patients at UF initiation.

Abstract 9588: Higher Survival With the Use of Extracorporeal Cardiopulmonary Resuscitation Compared With Conventional Cardiopulmonary Resuscitation in Children Undergoing Cardiac Surgery: Analysis of the Get With the Guidelines Registry©

Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been increasingly utilized during in-hospital arrest in postoperative pediatric cardiac surgical patients. Despite this and the significant associated mortality, few pediatric multicenter analyses have evaluated if E-CPR increases survival for in-hospital cardiac arrest compared with conventional cardiopulmonary resuscitation (C-CPR). Methods: Children &lt;18 years in the Get with the Guidelines-Resuscitation Registry© suffering in-hospital cardiac arrest following cardiac surgery who received ≥10 minutes of CPR between January 2008 and December 2020 were included. We compared patient factors, pre-arrest comorbid conditions, and survival to hospital discharge for E-CPR and C-CPR groups. Results: Among 1219 patients from 56 institutions, 483 patients (39.6%) received E-CPR. Nearly 75% (910/1219) of patients were &lt;1 year of age with 39% (477/1219) under 1 month. Older patients were more likely to receive E-CPR (p=0.004). E-CPR utilization increased over the study period (p&lt;0.001). Non-Hispanic White patients accounted for almost half of the population (575/1219) and were also more likely to receive E-CPR (p=0.044) compared to other races/ethnicities. Patients with cyanotic cardiac malformations (p=0.005), congestive heart failure prior to admission (p=0.007), and hypotension prior to arrest (p=0.014) were also more likely to receive E-CPR. Unadjusted survival of the index CPR event (98% vs. 63%, p&lt;0.001) and to hospital discharge (47% vs 39%, p=0.007) were both higher in the E-CPR compared to C-CPR group. Conclusions: In a large, multicenter study of pediatric cardiac surgical patients suffering in-hospital arrest, we found that E-CPR is commonly used and had significantly higher survival to hospital discharge compared with C-CPR. E-CPR is an important rescue strategy for children with heart disease and centers performing cardiac surgery should develop E-CPR programs.

Abstract 14159: Characteristics and Outcomes in COVID-19 Pediatric In-Hospital Cardiac Arrest Patients

Introduction: Survival of adult patients with COVID-19 who had an in-hospital cardiac arrest (IHCA) are poor. Characteristics and outcomes for pediatric IHCA patients with COVID-19 are unknown. Hypothesis: We hypothesized that pediatric COVID-19 patients would have worse survival outcomes when compared to non-COVID patients. Methods: A multicenter, multinational cohort of pediatric IHCA in the pediRES-Q collaborative were reviewed (March 1, 2020 - April 1, 2021). We characterized patients with COVID-19 compared to patients without COVID-19 and investigated whether COVID-19 was associated with survival outcomes using multivariate logistic regression with mixed effects. Results: We identified 362 pediatric IHCAs of which 14 were COVID-19 positive. For non-COVID-19 vs COVID-19 patients respectively, median [Q1; Q3] age was 1.0 [0.3; 7.1] vs. 7.1 [1.5; 14.0] years and 42% vs. 43% were female. Immediate cause of arrest was hypotension: 8% vs. 43%, respiratory decompensation: 19% vs. 21%, and hypoxia 22% vs. 36% for non-COVID-19 vs. COVID-19 patients. For non-COVID-19 vs COVID-19 patients, total CPR duration was 10 [4; 33] min vs 19 [5; 33] min (for non-return of spontaneous circulation (ROSC) cases only: 35 [20; 55] min vs 34 [24; 34] min). For non-COVID-19 vs COVID-19 patients, ROSC was 79% vs. 57%, aOR: 0.48 (95% CI: 0.24-0.98), survival to hospital discharge was 45% vs. 29%, aOR: 0.63 (95% CI: 0.25-1.57) and survival with favorable neurological outcome was 39% vs. 21%, aOR: 0.51 (95% CI: 0.16-1.65). Conclusions: In a pediatric resuscitation quality improvement collaborative, pediatric IHCA patients with COVID-19 were older when compared to non-COVID-19 patients. Median CPR duration was &gt;30 minutes for COVID-19 non-survivors, COVID-19 patients had lower chance of ROSC when compared to non-COVID-19 patients but considerably better survival outcomes than those reported for adults.