Pediatric Cardiac Surgical Patients Research Articles

Fast-track paediatric and adult congenital cardiac surgery

Background: Aim of the study was to evaluate the benefits and predictors of success of fast-track and ultra-fast track paediatric and congenital cardiac surgery. Methods: Retrospective observational study of paediatric and adult congenital cardiac surgical patients presented for surgery in period between October 2023 and April 2024 at Queen Alia heart institute (QAHI). Patients’ demographic, clinical and perioperative date were collected and analysed. Patients were divided into groups according to their extubation time: UFTE (Ultra-fast track extubation group, FTE (Fast-track extubation) group, CE (Conventional extubation) group and DE (Delayed extubation) group. All groups were compared in reference to their age, weight, CPB time, AXC time, length of ICU stay and hospitalisation time. Statistical analysis was done to determine the benefits of early extubation after paediatric and congenital cardiac surgery. Predictors of early and DE were studied. Results: Data of 73 paediatric and adult congenital cardiac surgical patients was reviewed and analysed. Patients were 37 males and 36 females. Average age of patients was 11.1 years (ranged from 5 days to 57 years). Average weight of patients was 29.3 kg (ranged from 2.4 to 109 kg) and average height was 104.8 cm. Average time of tracheal extubation was 13.1 hours (ranged from 0 to 168 hours). UFTE was accomplished in 11 patients (15.1%). FTE was done in 19 patients (26%). CE (between was 6 and 24 hours) was carried out in 38 patients (52.1%) and DE (after more than 24 hours) was noted in 5 patients (6.8%). The average ICU stay was 3 days (ranged from 1 to 15 days). Patients from the UFTE group had the shortest average ICU stay of 1.2 days, while patients from the FTE group had an average ICU stay of 1.9 days. Patients from the CE and the DE groups had an average ICU stay of 4 days and 9.4 days, respectively. Length of hospitalisation was shortest in the UFTE group with an average of 6 days. The hospitalisation time doubled in the DE group to 12 days. The shorter the CPB and AXC times the more likely patients were to have UFTE and FTE. Neonates were less likely to have UFTE and FTE. Conclusions: UFTE and FTE were associated with shorter ICU stay and hospitalisation time. Predictors of UFTE and FTE were simple cardiac procedures, shorter CPB and AXC durations. Neonatal age and low body weight paediatric cardiac surgical patients were predictors for conventional or DE.

Cardiac resternotomy after cardiac surgery in kids: CRACK the chest.

Emergent resuscitation of postoperative paediatric cardiac surgical patients requires specialised skills and multidisciplinary teamwork. Bedside resternotomy is a rare but life-saving procedure and few studies focus on ways to prepare providers and improve performance. We created a multidisciplinary educational intervention that addressed teamwork and technical skills. We aimed to evaluate the efficiency of the intervention to decrease time to perform critical tasks and improve caregiver comfort. A simulation-based, in situ resternotomy educational intervention was implemented. Pre-intervention data were collected. Educational aids were used weekly during day and night nursing huddles over a three-month period. All ICU charge nurses had separate educational sessions with study personnel and were required to demonstrate competency in all the critical tasks. Post-intervention simulations were performed after intervention and at 6 months and post-intervention surveys were performed. A total of 186 providers participated in the intervention. There was a decrease in time to obtain defibrillator, setup resternotomy equipment and internal defibrillator paddles and deliver sedation and fluid (all p < 0.05). Time to escort family from the room and obtain blood was significantly decreased after intervention (p < 0.05). There was no difference in time to first dose of epinephrine, defibrillator pads on the patient, or time to call the cardiovascular surgeon or blood bank. Providers reported increased comfort in identifying equipment needed for resternotomy (p < 0.01) and setting up the internal defibrillator paddles (p < 0.01). Implementation of a novel educational intervention increased provider comfort and decreased time to perform critical tasks in an emergent resternotomy scenario.

Noninvasive Cardiac Output Monitoring by Electrical Cardiometry with Transthoracic Echocardiography in Postoperative Paediatric Cardiac Surgical Patients: Comment.

Noninvasive Cardiac Output Monitoring by Electrical Cardiometry with Transthoracic Echocardiography in Postoperative Paediatric Cardiac Surgical Patients: Comment.

Association of Vasoactive-Inotropic Score with Postoperative Outcomes in Children with Congenital Heart Diseases Undergoing Cardiac Surgery

Objectives: This cross-sectional study aimed to evaluate the association between the vasoactive-inotropic score (VIS) and post-operative morbidity and mortality in pediatric patients undergoing cardiac surgery for congenital heart diseases (CHDs). Methodology: A cross-sectional study was conducted at the Pediatric Cardiac Intensive Care Unit (PCICU) of the National Institute of Cardiovascular Diseases, Karachi, Pakistan, between October 2021 and March 2022. A total of 101 children up to 18 years of age admitted to the PCICU were included in the analysis. Demographic characteristics and peri-operative variables were recorded, and VIS scores were collected to assess their association with post-surgery outcomes. A score of ≥15 was considered high, while a score &lt;15 was considered low. Results: Among the 101 children included in the study, 49 (48.5%) were male and 52 (51.5%) were female, with a mean age of 7.45±2.81 years. Fifteen (14.9%) patients had a high VIS score during their ICU stay, while 86 patients had a low VIS score. Low cardiac output was the most common post-operative morbidity observed in 9 (8.9%) children, followed by hepatic dysfunction and acute kidney injury, each reported in 8 (7.9%) children. Significant associations were found between high VIS and hepatic dysfunction (p&lt;0.001), acute kidney injury (p&lt;0.001), low cardiac output (p&lt;0.001), neurological dysfunction (p=0.016), and mortality (p&lt;0.001). Conclusion: High VIS scores were significantly associated with poor short-term morbidity and mortality in children undergoing corrective surgery for CHDs. The VIS system can aid in predicting disease progression, severity, and outcomes in pediatric cardiac surgical patients.

Predictors and Associations of Prolonged Tracheostomy in Pediatric Cardiac Surgical Patients

Objectives: To describe the predictors and associations of prolonged tracheostomy duration in pediatric cardiac surgical patients. Method: Prospective study. All pediatric patients below 10 years of age who underwent tracheostomy after cardiac surgery from January 2019 to December 2019, were subdivided into short and long groups according to the tracheostomy duration during the intrahospital stay if more than 21 days. Different variables were compared. Results:1084 pediatric patients who underwent cardiac surgery during study period, 41 (3.7%) received tracheostomy. LT group was associated with univentricular repair (p=0.03) and sepsis (p=0.04), longer days of ventilation (p=0.0005), higher number of extubation trials (p=0.02), higher accidental tracheostomy tube dislodgement (p=0.048), ventilator-associated pneumonia (p=0.013), more days of feed interruption (p=0.0089), higher days of hospital stay (p=0.0001) and intensive care unit stay (p=0.0001). ST was associated with significantly higher anticipated longer duration of ventilation and earlier liberation from the ventilator as an indication for tracheostomy than LT (p=0.02). Conclusions: Univentricular repair, sepsis, longer mechanical ventilation, longer duration of intensive care unit and hospital stay, a higher number of extubation trials, higher number of accidental tracheostomy tube dislodgement, ventilator-associated pneumonia, higher days of feed interruption were found to be significant associations with a long duration tracheostomy.

Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study

ObjectiveThe aim of this study was to evaluate efficacy of ultrasound-guided Multiple Injection Costotransverse block (MICB) and compare it with Erector spinae Plane block (ESPB) for post-sternotomy pain relief in paediatric cardiac surgical patients. DesignA prospective, randomized, double-blind, comparative study. SettingSingle-institution tertiary referral cardiac centre. ParticipantsStudy comprised of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy. InterventionsChildren were randomly allocated to 1 of the 3 groups: ESPB (Group1), MICB (Group 2) or Control (Group 3). Participants in Group 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anaesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia and fentanyl/tramadol was used for rescue analgesia. Measurements and Main ResultsModified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. After all exclusions, 84 patients were analysed. MOPS score was found to be significantly lower in ESPB and MICB Group compared to Control Group till 10 hours post extubation (p<0.05), with no statistically significant difference at 12th hour (p=0.2198). Total intraoperative fentanyl consumption (p=0.0005), need for fentanyl supplementation on incision (p<0.0001) and need for rescue opioid requirement in postoperative period (p=0.034) was significantly lower in both ESPB Group and MICB Group than Control Group. There was no statistically significant difference in both primary and secondary outcomes between ESPB and MICB Groups. ConclusionUltrasound guided MICB was effective and comparable to ESPB for post-sternotomy pain management in paediatric cardiac surgical patients.

Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery.

The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group. In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient. A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation. Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

Utility of routine chest radiographs after chest drain removal in paediatric cardiac surgical patients-a retrospective analysis of 1076 patients.

Chest drains are routinely placed in children following cardiac surgery. The purpose of this study was to determine the incidence of a clinically relevant pneumothorax and/or pleural effusion after drain removal and to ascertain if a chest radiograph can be safely avoided following chest drain removal. This single-centre retrospective cohort study included all patients under 18 years of age who underwent cardiac surgery between January 2015 and December 2019 with the insertion of mediastinal and/or pleural drains. Exclusion criteria were chest drain/s in situ ≥14 days and mortality prior to removal of chest drain/s. A drain removal episode was defined as the removal of ≥1 drains during the same episode of analgesia ± sedation. All chest drains were removed using a standard protocol. Chest radiographs following chest drain removal were reviewed by 2 investigators. In all, 1076 patients were identified (median age: 292 days, median weight: 7.8 kg). There were 1587 drain removal episodes involving 2365 drains [mediastinal (n = 1347), right pleural (n = 598), left pleural (n = 420)]. Chest radiographs were performed after 1301 drain removal episodes [mediastinal (n = 1062); right pleural (n = 597); left pleural (n = 420)]. Chest radiographs were abnormal after 152 (12%) drain removal episodes [pneumothorax (n = 43), pleural effusion (n = 98), hydropneumothorax (n = 11)]. Symptoms/signs were present in 30 (2.3%) patients. Eleven (<1%) required medical management. One required reintubation and 2 required chest drain reinsertion. The incidence of clinically significant pneumothorax/pleural effusion following chest drain removal after paediatric cardiac surgery is low (<1%). Most patients did not require reinsertion of a chest drain. It is reasonable not to perform routine chest radiographs following chest drain removal in most paediatric cardiac surgical patients.

Sternal Wound Management in Pediatric Cardiac Surgical Patients: A Novel Strategic Interprofessional Approach: Erratum.

Sternal Wound Management in Pediatric Cardiac Surgical Patients: A Novel Strategic Interprofessional Approach: Erratum.

Sternal wound management in pediatric cardiac surgical patients: implementation of wound care pathways incorporating principles of wound bed preparation paradigm and early-advanced therapy

Sternal wound management in pediatric cardiac surgical patients: implementation of wound care pathways incorporating principles of wound bed preparation paradigm and early-advanced therapy

Sternal Wound Management in Pediatric Cardiac Surgical Patients: A Novel Strategic Interprofessional Approach.

Information on sternal wound management in children after cardiac surgery is limited. The authors formulated a pediatric sternal wound care schematic incorporating concepts of interprofessional wound care and the wound bed preparation paradigm including negative-pressure wound therapy and surgical techniques to expedite and streamline wound care in children. Authors assessed knowledge about sternal wound care among nurses, surgeons, intensivists, and physicians in a pediatric cardiac surgical unit regarding the latest concepts such as wound bed preparation, NERDS and STONEES criteria for wound infection, and early use of negative-pressure wound therapy or surgery. Management pathways for superficial and deep sternal wounds and a wound progress chart were prepared and introduced in practice after education and training. The cardiac surgical unit team members demonstrated a lack of knowledge about the current concepts of wound care, although this improved after education. The newly proposed management pathway/algorithm for superficial and deep sternal wounds and a wound progress assessment chart were introduced into practice. Results in 16 observed patients were encouraging, leading to complete healing and no mortality. Managing pediatric sternal wounds after cardiac surgery can be streamlined by incorporating evidence-based current wound care concepts. In addition, the early introduction of advanced care techniques with appropriate surgical closure further improves outcomes. A management pathway for pediatric sternal wounds is beneficial.

Risk factors of sepsis and prevalence of multidrug-resistant organisms in pediatric cardiac surgery in tertiary care teaching rural hospital in India: A retrospective observational study.

Cardiac surgery and cardiopulmonary bypass result in an immunoparalyzed state in children making them susceptible to sepsis and other hospital-acquired infections. Therefore, identification of the risk factors of sepsis would lead to appropriate management. The current study seeks to evaluate the prevalence of sepsis and risk factors linked to sepsis in pediatric cardiac surgical patients and the subsequent prevalence of multidrug-resistant organisms. A retrospective, single-center observational study was conducted including 100 pediatric patients admitted to the pediatric intensive care unit (ICU) after cardiac surgery between January 2017 and February 2018. All patient data were obtained from the medical record department of the hospital. Patient case report form comprised demography, surgery details, preoperative and postoperative hematological reports, and clinical details. After collecting the data, chi-square test and logistic regression analysis were used to determine the risk factors linked to sepsis. The prevalence of sepsis in our population was 27% and the mortality rate due to sepsis was 1%. The only statistically significant risk factor for sepsis we discovered in this analysis was prolonged ICU stay for more than 5 days. A total of eight patients had blood cultures positive for bacterial infection. The alarming finding was that all eight were infected with multidrug-resistant organisms, demanding the last line of antibacterials. Our study indicates that special clinical care is required when ICU stay is prolonged to lower the risk of sepsis. These new and upcoming infections not only promote high mortality and morbidity rates but also contribute to increased cost of care due to the use of newer broad-spectrum antibiotics and longer hospital stay. The high prevalence of multidrug-resistant organisms is unacceptable in the current scenario and hospital infection and prevention control play a crucial role in minimizing such infections.

Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid

BackgroundUnderstanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. ObjectivesThe purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. MethodsAll Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. ResultsIn 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors’ offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. ConclusionsChildren after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.

Comparison of High-Flow Nasal Cannula Versus Conventional Oxygen Therapy After Extubation in Children Undergoing Cardiac Surgery: A Meta-analysis.

This meta-analysis aims to compare high-flow nasal cannula (HFNC) and conventional oxygen therapy (COT) post-extubation in pediatric cardiac surgical patients.The present meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)guidelines. Two authors independently searched three electronic databases including PubMed, Embase, and the Cochrane Library to identify relevant articles published in English from inception to February 2023. Searching was conducted using keywords and medical subject headings (MeSH), which included "conventional oxygen therapy," "high-flow nasal cannula," "extubation," "pediatrics," and "cardiac surgery." Our primary outcome was extubation failure defined as the need for reintubation within 24 to 72 hours after planned extubation. Secondary outcomes assessed in this meta-analysis included partial pressure of arterial oxygen (PaO2), partial pressure of arterial carbon dioxide (PaCO2), and the ratio of PaO2 and FiO2 (fraction of inspired oxygen). A total of three studies were included in the meta-analysis, with a total of 227 patients. No significant difference was found between the two groups (the HFNC group and the COT group) in terms of reintubation (RR: 0.88, 95% CI: 0.34, 2.30, p-value: 0.80).Pooled meta-analysis showed that PaO2 was significantly greater in patients receiving HFNC at six hours (MD: 33.73, 95% CI: 18.33, 49.14, p-value<0.001), at 12 hours (MD: 44.90, 95% CI: 28.59, 61.22, p-value<0.001) and at 24 hours (MD: 43.53, 95% CI: 29.16, 57.91, p-value<0.001) of extubation. PaCO2 was significantly lower in patients receiving HFNC at six hours (MD: -5.40, 95% CI: -7.94, -2.85, p-value<0.001) and at 12 hours (MD: -5.93, 95% CI: -9.78, -2.09, p-value<0.001) of extubation. However, no significant difference was reported between the two groups after 24 hours of extubation (MD: -0.84, 95% CI: -9.04, 7.37, p-value: 0.84) andPaO2/FiO2 was significantly greater in patients receiving HFNC at six hours (MD: 64.14, 95% CI: 36.10, 92.17, p-value<0.001), at 12 hours (MD: 70.73, 95% CI: 20.46, 121.01, p-value<0.001) and at 24 hours (MD: 82.18, 95% CI: 50.03, 114.32, p-value<0.001) of intubation. In conclusion, the meta-analysis revealed that compared with COT, HFNC significantly increased PaO2and the ratio of PaO2 to FiO2, and decreased PaCO2. No significant differences were observed in the rate of reintubation between the two groups. This is the first meta-analysis comparing HFNC and COT in pediatric cardiac surgical patients.

Pharmacokinetics of dexmedetomidine in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass.

Cardiopulmonary bypass can affect the pharmacokinetics of anesthetic agents. We aimed to evaluate the pharmacokinetics of dexmedetomidine for infants and small children undergoing cardiac surgery with cardiopulmonary bypass based on population pharmacokinetics. We enrolled 30 pediatric cardiac surgical patients in this study. After anesthetic induction with atropine (0.02 mg/kg), thiopental sodium (5mg/kg), and fentanyl (2-3μg/kg), we administered 1μg/kg of dexmedetomidine for 10min, followed by administration of 0.5μg/kg of dexmedetomidine per hour during surgery. At the initiation of cardiopulmonary bypass, 1μg/kg of dexmedetomidine was infused over 5min. Arterial blood was obtained at predefined time points. A pharmacokinetic model was developed using NONMEM. Theory-based allometric scaling with fixed exponents was applied. Weight, age, post-menstrual age, fat-free mass, whether to implement cardiopulmonary bypass and temperature were explored as covariates. A total of 376 blood samples were obtained from 29 children (age: 20.3 ± 19.3months, weight: 9.7 ± 4.1kg). A two-compartment mammillary model with third compartment associated cardiopulmonary bypass procedure best explained the pharmacokinetics of dexmedetomidine. The pharmacokinetic parameter estimates (95% CI) standardized to a 70-kg person were as follows: V1 (L)=31.6 (17.9-39.5), V2 (L)=90.1 (44.0-330), Cl (L/min)=1.08 (0.70-1.25), Q (L/min)=2.0 (1.05-3.46). Volume for third compartment associated cardiopulmonary bypass procedure (L)=39.4 (19.3-50.9). Clearance was not influenced by the presence of cardiopulmonary bypass in this model. When cardiopulmonary bypass is applied, the plasma concentration of dexmedetomidine decreases due to an increase in the volume of distribution, so a loading dose is required to maintain the previous concentration.

Comparision of cardiac output measured by transthoracic echocardiography with continuous cardiac output measured by pressure recording analytical method.

Low cardiac output is a common complication following cardiac surgery and it is associated with higher mortality in the pediatric population. A gold standard method for cardiac output (CO) monitoring in the pediatric population is lacking. The present study was conducted to validate cardiac output and cardiac index measured by transthoracic echocardiography and Pressure recording analytical method, a continuous pulse contour method, MostCareUp in postoperative pediatric cardiac surgical patients. This was a prospective observational clinical study conducted at a tertiary care hospital. A total of 23 pediatric patients weighed between 2 and 20 kg who had undergone elective cardiac surgery were included in the study. Spearman's correlation coefficient of CO between transthoracic echocardiography (TTE) and Pressure Recording Analytical Method (PRAM) showed of positive correlation (r = 0.69, 95% Confidence interval 0.59-0.77, P < 0.0001) Linear regression equations for CO between TTE and PRAM were y = 0.55 + 0.88x (R2 = 0.46, P < 0.0001). (y = PRAM, x = TTE), respectively. Bland- Altman plot for CO between TTE and PRAM showed a bias of -0.397 with limits of the agreement being -2.01 to 1.22. Polar plot analysis showed an angular bias of 6.55° with radial limits of the agreement being -21.46 to 34.58 for CO and angular bias of 6.22° with radial limits of the agreement being -22.4 to 34.84 for CI. PRAM has shown good trending ability for cardiac output. However, values measured by PRAM are not interchangeable with the values measured by transthoracic echocardiography.

Upper airway obstruction and sepsis following endotracheal intubation in paediatric cardiac surgical patients in South Africa

Upper airway obstruction and sepsis following endotracheal intubation in paediatric cardiac surgical patients in South Africa

Sternal Wound Management in Pediatric Cardiac Surgical Patients: A Novel Strategic Interprofessional Approach: Erratum.

The information on sternal wound management in children after cardiac surgery is limited. The authors formulated a pediatric sternal wound care schematic incorporating concepts of interprofessional wound care and the wound bed preparation paradigm including negative-pressure wound therapy (NPWT) and surgical techniques to expedite and streamline wound care in children. Authors assessed knowledge about sternal wound care among nurses, surgeons, intensivists, and physicians in a pediatric cardiac surgical unit regarding the latest concepts such as wound bed preparation, NERDS and STONEES criteria for wound infection, and early use of NPWT or surgery. Management pathways for superficial and deep sternal wounds and a wound progress chart were prepared and introduced in practice after education and training. The cardiac surgical unit team members demonstrated a lack of knowledge about the current concepts of wound care, although this improved after education. The newly proposed management pathway/algorithm for superficial and deep sternal wounds and a wound progress assessment chart was introduced into practice. Results in 16 observed patients were encouraging, leading to complete healing and no mortality. Managing pediatric sternal wounds after cardiac surgery can be streamlined through incorporation of evidence-based current wound care concepts. In addition, the early introduction of advanced care techniques with appropriate surgical closure further improves outcomes. A management pathway for pediatric sternal wounds is beneficial.

Interrogation of Superior Vena Cava by Deep Transgastric Transesophageal Echocardiography Imaging

ABSTRACTThe advantages of intraoperative deep transgastric interrogation by transesophageal echocardiography (TEE) of the superior vena cava (SVC) in comparison to the standard bicaval view was studied in pediatric cardiac surgical cases. The view was found to be helpful in obtaining additional data in pediatric cardiac surgical patients.

Bedside Chest Ultrasound in Postoperative Pediatric Cardiac Surgery Patients: Comparison With Bedside Chest Radiography

The primary objective was to study the degree of agreement between the chest ultrasound (CUS) studies and chest x-ray (CXR) studies in postoperative pediatric cardiac surgical patients regarding the diagnosis of thoracic abnormalities, and also to compare the diagnostic performance of CUS in reference to CXR for the detection of thoracic abnormalities. The secondary objective was to compare the necessity for interventions done on the basis of CUS and CXR findings in the postoperative setting. A prospective observational study. At a postoperative pediatric cardiac surgical intensive care unit in a tertiary-care center. One hundred sixty patients between the age of 2 months to 18 years undergoing elective cardiac surgery for various congenital heart diseases. After obtaining permission from the institutional ethics committee, 160 pediatric cardiac surgical patients were studied prospectively in the postoperative period. On the day of surgery (postoperative day [POD] 0), bedside CXR was done in the immediate postoperative period. After bedside CXR, CUS examination was performed and then interpreted by the principal investigator. The CXR was interpreted by the surgical team. Provisional diagnosis was made by the principal investigator and surgical team. Any intervention required was decided based on CXR or CUS findings or both. The procedure was repeated in the morning of POD 1. The degree of agreement between CUS studies and CXR studies in detecting abnormalities was evaluated by Cohen's kappa (k) statistics. The diagnostic performance of CUS was compared with that of CXR using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy. Overall, kappa analysis (k) showed substantial agreement between the findings of the CUS and CXR studies (k=0.749). The diagnostic performance of CUS, as compared with CXR, was found to have a sensitivity of 96.9%, specificity of 84.75%, PPV of 73.4%, NPV of 98.43%, and diagnostic accuracy of 88.44%. In 94 abnormal findings, the interventions were done based on CUS or CXR findings or both. Overall, there was a substantial agreement (k=0.787) between CUS and CXR regarding the necessity for interventions. The degree of agreement between CUS and CXR studies was substantial for atelectasis, interstitial edema, and diaphragmatic weakness. The degree of agreement between CUS and CXR studies was almost perfect for pneumothorax and fair for pleural effusion. More CUS studies detected intrathoracic pathologies than CXR studies. The CUS also detected abnormalities earlier than CXR and was found to be useful for the early institution of intervention therapy in patients with interstitial edema and atelectasis. It would be reasonable to conclude that CUS may be considered in some instances as an alternative to CXR.