Pediatric Cardiac ICU Research Articles

Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care.

Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months. Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU. This study took place at Duke Children's Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021. Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery. Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure. Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures. A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.

Qualitative assessment of nurse satisfaction in the paediatric cardiac ICU.

The objective of this qualitative assessment, utilising the constant comparative method, was to identify satisfiers and dissatisfiers that influence paediatric cardiac ICU nurse retention and recognise areas for improvement. Interviews for this study were performed in a single, large academic children's hospital from March of 2020 through July of 2020. Each bedside paediatric cardiac ICU nurse underwent a single semi-structured interview. Among 12 interviews, four satisfiers were identified: paediatric cardiac ICU patient population, paediatric cardiac ICU care team, personal accomplishment, and respect. Four dissatisfiers were identified: moral distress, fear, poor team dynamics, and disrespect. Through this process of inquiry, grounded theory was developed regarding strategies to improve paediatric cardiac ICU nurse retention. Tactics outlined here should be used to support retention in the unique environment of the paediatric cardiac ICU.

Vasoactive-ventilation-renal score and outcomes in infants and children after cardiac surgery.

There is a need to index important clinical characteristics in pediatric cardiac surgery that can be obtained early in the postoperative period and accurately predict postoperative outcomes. A prospective cohort study was conducted in the pediatric cardiac ICU and ward on all children aged <18 years undergoing cardiac surgery for congenital heart disease from September 2018 to October 2020. The vasoactive-ventilation-renal (VVR) score was analyzed to predict outcomes of cardiac surgeries with a comparison of postoperative variables. A total of 199 children underwent cardiac surgery during the study period. The median (interquartile range) age was 2 (0.8-5) years, and the median weight was 9.3 (6-16) kg. The most common diagnoses were ventricular septal defect (46.2%) and tetralogy of Fallot (37.2%). At the 48th h, area under the curve (AUC) (95% CI) values were higher for the VVR score than those for other clinical scores measured. Similarly, at the 48th h, AUC (95% CI) values were higher for the VVR score than those for the other clinical scores measured for the length of stay and mechanical ventilation. The VVR score at 48 h postoperation was found to best correlate with prolonged pediatric intensive care unit (PICU) stay, length of hospitalization, and ventilation duration, with the greatest AUC-receiver operating characteristic (0.715, 0.723, and 0.843, respectively). The 48-h VVR score correlates well with prolonged ICU, hospital stay, and ventilation.

Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology.

Provider-only, combined surgical, and medical multidisciplinary rounds ("surgical rounds") are essential to achieve optimal outcomes in large pediatric cardiac ICUs. Lean methodology was applied with the aims of identifying areas of waste and nonvalue-added work within the surgical rounds process. Thereby, the goals were to improve rounding efficiency and reduce rounding duration while not sacrificing critical patient care discussion nor delaying bedside rounds or surgical start times. Single-center improvement science study with observational and interventional phases from February 2, 2021, to July 31, 2021. Tertiary pediatric cardiac ICU. Cardiothoracic surgery and cardiac intensive care team members participating in daily "surgical" rounds. Implementation of technology automation, creation of work instructions, standardization of patient presentation content and order, provider training, and novel role assignment. Sixty-one multidisciplinary rounds were observed (30 pre, 31 postintervention). During the preintervention period, identified inefficiencies included prolonged preparation time, redundant work, presentation variability and extraneous information, and frequent provider transitions. Application of targeted interventions resulted in a 26% decrease in indexed rounds duration (2.42 vs 1.8 min; p = 0.0003), 50% decrease in indexed rounds preparation time (0.53 vs 0.27 min; p < 0.0001), and 66% decrease in transition time between patients (0.09 vs 0.03 min; p < 0.0001). The number of presenting provider changes also decreased (9 vs 4; p < 0.0001). Indexed discussion duration did not change (1 vs 0.98 min; p = 0.08) nor did balancing measures (bedside rounds and surgical start times) change (8.5 vs 9 min; p = 0.89 and 38 vs 22 min; p = 0.09). Lean methodology can be effectively applied to multidisciplinary rounds in a joint cardiothoracic surgery/cardiac intensive care setting to decrease waste and inefficiency. Interventions resulted in decreased preparation time, transition time, presenting provider changes, total rounds duration indexed to patient census, and anecdotal improvements in provider satisfaction.

360 - Palliative care referral patterns for patients experiencing death in a pediatric cardiac ICU

360 - Palliative care referral patterns for patients experiencing death in a pediatric cardiac ICU

A survey of current practices in sedation, analgesia, withdrawal, and delirium management in paediatric cardiac ICUs.

To characterise the current approach to sedation, analgesia, iatrogenic withdrawal syndrome and delirium in paediatric cardiac ICUs. A convenience sample survey of practitioners at institutions participating in the Pediatric Cardiac Critical Care Consortium conducted from September to December 2020. Paediatric cardiac ICUs. Survey responses were received from 33 of 42 institutions contacted. Screening for pain and agitation occurs commonly and frequently. A minority of responding centres (39%) have a written analgesia management protocol/guideline. A minority (42%) of centres have a written protocol for sedation. Screening for withdrawal occurs commonly, although triggers for withdrawal screening vary. Only 42% of respondents have written protocols for withdrawal management. Screening for delirium occurs "always" in 46% of responding centres, "sometimes" in 36% of centres and "never" 18%. Nine participating centres (27%) have written protocols for delirium management. Our survey identified that most responding paediatric cardiac ICUs lack a standardised approach to the management of analgesia, sedation, iatrogenic withdrawal, and delirium. Screening for pain and agitation occurs regularly, while screening for withdrawal occurs fairly frequently, and screening for delirium is notably less consistent. Only a minority of centres use written protocols or guidelines for the management of these problems. We believe that this represents an opportunity to significantly improve patient care within the paediatric cardiac ICU.

The effect of clinical and haemodynamic variables on post-operative length of stay immediately upon admission after biventricular repair with Yasui operation following an earlier Norwood operation.

There are a variety of approaches to biventricular repair in neonates and infants with adequately sized ventricles and left-sided obstruction in the presence of a ventricular septal defect. Those who undergo this in a staged manner initially undergo a Norwood procedure followed by a ventricular septal defect closure such that the neo-aorta is entirely committed to the left ventricle and placement of a right ventricular to pulmonary artery conduit (Yasui operation). This study aimed to determine clinical and haemodynamic factors upon paediatric cardiac ICU admission immediately after the two-stage Yasui operation that was associated with post-operative length of stay. This was a retrospective review of patients who underwent the Yasui procedure after the initial Norwood operation between 1 January 2011 and 31 December 2020. Patients with complete data on admission were identified and analysed using Bayesian regression analysis. A total of 15 patients were included. The median age was 9.0 months and post-operative length of stay was 6days. Bayesian regression analysis demonstrated that age, weight, heart rate, mean arterial blood pressure, central venous pressure, pulse oximetry, cerebral near infrared spectroscopy, renal near infrared spectroscopy, pH, pCO2, ionised calcium, and serum lactate were all associated with post-operative length of stay. Discrete clinical and haemodynamic factors upon paediatric cardiac ICU admission after staged Yasui completion are associated with post-operative length of stay. Clinical target ranges can be developed and seem consistent with the notion that greater systemic oxygen delivery is associated with lower post-operative length of stay.

169: SITOSTEROLEMIA PRESENTING WITH SEVERE HYPERTENSION AND CONGESTIVE HEART FAILURE IN A CHILD

Introduction: Sitosterolemia is an autosomal recessive condition caused by pathogenic variants in the ABCG5/ABCG8 genes that prohibit the body from excreting plant sterols, causing build-up in the soft tissues and systemic vasculature. Pediatric vasculopathy secondary to sitosterolemia is poorly described, and there is no clear guidance on the management of complications, including cardiac dysfunction. This case report describes the diagnosis and acute management of a child with severe systemic hypertension, multiple levels of arterial stenosis, and cardiomyopathy presenting in congestive heart failure and ultimately diagnosed with sitosterolemia. Description: An 8-year-old Amish male with no past medical history presented to the emergency department with emesis and associated fatigue and abdominal pain. Vital signs were significant for severe systemic hypertension (BP 220/110), a gallop rhythm, hepatomegaly, cardiomegaly, and mid-aortic narrowing on CT angiogram. Exam was also notable for bilateral knee xanthomas. Laboratory data after admission to the pediatric cardiac ICU showed elevated BNP (peak 4418 pg/mL) and total cholesterol (317 mg/dL) levels. Echocardiogram showed severe mitral and tricuspid valve regurgitation, severely dilated and concentrically hypertrophied and dysfunctional left ventricle, ejection fraction of 30%, and pulmonary hypertension. Consultations included genetics, cardiology, nephrology, and vascular surgery. Initial management included a continuous Milrinone infusion and loop diuretics with improved BP and congestive heart failure symptoms. Cardiac catheterization including coronary and renal angiograms demonstrated severe proximal right coronary artery stenosis and bilateral renal artery stenosis. Right coronary artery and left renal artery angioplasties were performed with good results, and showed significant improvement in parameters of ventricular function and pulmonary arterial hypertension. Genetic testing and positive serum plant sterols confirmed the diagnosis of sitosterolemia. Discussion: Sitosterolemia is a rare genetic disorder and a rare cause of pediatric arteriopathy. Early recognition can prevent the development of life-threatening systemic hypertension, arterial stenosis including coronary artery disease, and cardiomyopathy.

Postextubation stridor in paediatric cardiac surgery patients

Background: Paediatric patients undergoing cardiac surgery are likely to be prone to developing postextubation stridor (PES) due to their airway anatomy and several factors related to surgery, Aim: To examine the incidence and risk factors for PES in paediatric patients undergoing cardiac surgery. Methods: The study was prospectively conducted in the paediatric cardiac postsurgical ICU (PICU) at a tertiary referral hospital from November 2010 to January 2012. All paediatric patients presenting with immediate stridor or its developing within 24 hours after extubation were included. Only those patients who were ventilated for at least 6 hours after surgery, but not more than 7 days and deemed fit for elective extubation were considered. Results: Of the 1328 patients admitted to the PICU, 29 patients (2.18%) met the criteria for PES. Of these, 22 (75.6%) were &lt; 1 year old. Ten patients (34%) did not respond to conservative approach or Noninvasive Ventilation (NIV) and had to be reintubated. Six patients were reintubated within an hour, three in &lt; 6 hours and one after 12 hours of extubation. Conclusion: PES is common in paediatric postcardiac surgical patients. Infants are more prone to develop PES. Majority of them can be successfully managed with conservative measures and noninvasive ventilation. The onset of PES varies from immediately after extubation to 3 hours after extubation. Up to one-third of the patients with PES may require reintubation and is common in the first hour after extubation. Patients who develop PES need close observation in the first few hours after extubation.

Abstract 13282: Towards a Decision Support Tool for Opioid Administration and Sedation Management in the Pediatric Cardiac Intensive Care Unit

Introduction: Opioids are commonly used to treat pain and agitation in the cardiac intensive care unit. However, responsiveness to opioids in pediatric patients is poorly understood, and few guidelines exist for personalized management of sedation. This leads to probable overprescription of opioids in the pediatric ICU, which can extend length of stay and have negative long-term health consequences. In this work, we build a decision support tool to predict a patient’s response to an opioid bolus measured by the state behavior scale (SBS), using available patient data at the time of administration. Methods: We built a dataset including all individual doses of morphine administered to patients admitted to the CICU between 2011-2020. Patients missing critical hemodynamic or SBS data were excluded from the analysis. The change in SBS score before and after morphine administration was converted to a binary outcome, where a decrease in SBS score was considered to be favorable (A). A LASSO regression model was trained to predict SBS response. The predictors utilized in the model included demographics, hemodynamic data, SBS score measurements before morphine, concomitant drug infusions/boluses and morphine response to prior doses. The model was trained on 80% of data and evaluated on 20%. Results: Of 197,242 intravenous boluses, 66,195 boluses administered to 6,021 patients (median age 7.2 mo) were included. The median change in SBS score was 0 (IQR -1 - 0) with 33% of administrations classified as favorable responses. The model coefficients are shown in (B). The model predicts 74% of unfavorable morphine responses with 95% confidence, AUC = 0.899 (C). Conclusions: Nearly three-quarters of ineffective responses to morphine can be predicted with 95% confidence using the prediction models developed. Such models could substantially reduce morphine over-administration for critically ill patients in the pediatric cardiac ICU.

CLABSI Reduction Strategy: Utilizing Weekly Rounds with an Interdisciplinary Team.

Introduction: Central line-associated bloodstream infections (CLABSIs) in pediatric ICU patients lead to a wide variety of adverse outcomes, including increased mortality and morbidity, longer length of stay in the hospital, and greater healthcare costs.1 Pediatric cardiac ICU patients are at a significantly higher risk for these healthcare-associated infections because of an increase in risk factors, such as congenital anomalies, presence of surgical wounds, compromised immune function post cardiopulmonary bypass, and the presence of multiple invasive medical devices.2 After noting an increase in the pediatric cardiac ICU CLABSI rate, an interdisciplinary team was formed to approach the problem. Objectives: The primary aim was to decrease the pediatric cardiac ICU’s CLABSI rate by 25% in 8 months by engaging an interdisciplinary team with identifying and addressing CLABSI maintenance bundle concerns in real time on the unit. Methods: An interdisciplinary team with representatives from nursing, unit leadership, intensive care physicians, infection prevention, nurse practitioners, vascular access team, and quality improvement utilized initial Plan-Do-Study-Act (PDSA) cycles to develop a rounding tool that identified threats to the CLABSI prevention bundle with patient-specific interventions to consider implementing. Weekly interdisciplinary rounds were then conducted on all central lines. Additional PDSA cycles focused on addressing unit-specific gaps in education and increasing awareness of best practices for central line care and maintenance. These included addition and delineation of space to separate clean and dirty supplies, hygiene supplementations to the care bundle, eRecord handoff updates, and both in-person and online educational offerings. Results: Preliminary data suggested a decrease in CLABSI rate during the initial 4-month intervention period (Fig. 1). The focus on central line care has also led to more consistent and robust observations for bundle compliance. In 2021, zero CLABSIs were noted for the initial 4 months after intervention contributing to a unit record of 243 days CLABSI-free. We would like to call attention to 2 points in Figure 1. Point two represents the initiation of weekly interdisciplinary CLABSI rounds. Point three represents 2 premature infants, atypical for unit census, on extracorporeal membrane oxygenation with hemodialysis catheters that required off-label use of Prismaflex. Conclusions: Engagement of a microsystem’s interdisciplinary team to focus efforts on identifying and addressing real-time concerns to central lines has led to a short-term decrease in CLABSI rate. Sustaining this decrease in CLABSIs will require continual reassessment of the effectiveness of strategies utilized. Additional PDSA interventions as a result of the weekly rounds are being investigated, including the use of antimicrobial sheets for high-risk patients, the creation of unit-specific prepackaged sterile central line dressing kits, and transitioning from alcohol to chlorohexidine scrubs for hub accessing.Fig

Development and implementation of a paediatric cardiac intensive care advanced practice provider curriculum.

Education of paediatric advanced practice providers takes a generalist approach which lacks in-depth exposure to subspecialties like paediatric cardiac intensive care. This translates into a knowledge gap related to congenital cardiac physiology and management for APPs transitioning to the paediatric cardiac ICU. A specialised interprofessional peer-reviewed curriculum was created and distributed through the Pediatric Cardiac Intensive Care Society. This curriculum includes a textbook which is complemented by a didactic and simulation review course. Course evaluations were collected following each course, and feedback from participants was incorporated into subsequent courses. Pediatric Cardiac Intensive Care Society partnered with the Pediatric Nursing Certification Board to develop a 200-question post-assessment (exam) bank. From December 2017 to January 2022, 12 review courses were taught at various host sites (n = 314 participants). Feedback revealed that courses improved preparedness for practice, contributed to advanced practice provider empowerment, and emphasised the importance of professional networking. 97% of attendees agreed/strongly agreed that the course improved clinical knowledge, 97% agreed/strongly agreed that the course improved ability to care for patients, and 88% agreed/strongly agreed that the course improved confidence to practice. 49% of participants rated the course as extremely effective, 42% very effective, 6% moderately effective, and 3% as only slightly effective. A standardised subspecialty curriculum dedicated to advanced practice provider practice in cardiac intensive care was needed to improve knowledge, advance practice, and empower APPs managing critically ill patients in the cardiac ICU. The developed curriculum provides standardised learning, increasing advanced practice provider knowledge acquisition, and confidence to practice.

Infection profile of patients with extracorporeal membrane oxygenation in paediatric cardiac surgery ICU.

We investigated the risk of increased nosocomial infections and the associated pathogens in patients who underwent paediatric cardiovascular surgery and were put on extracorporeal membrane oxygenation support. We studied the duration of extracorporeal membrane oxygenation use and other variables that may be associated with increased nosocomial infection risk. Patients who were treated with an extracorporeal membrane oxygenation in paediatric cardiovascular surgery ICU between 2010 and 2020 were included in this retrospective study. We analysed the site of infection and microbiological profile of infections occurring in these patients according to CDC and National Healthcare Safety Network criteria. The onset of infection development in patients after extracorporeal membrane oxygenation was found to be median 8 (3-15, 25-75 IQR) days in the whole group, and median 11 (3-16, 25-75 IQR) days in those who developed infection without being put on extracorporeal membrane oxygenation. When patients were divided into those with and without infection, duration of ICU was found to be 19 (16-28, IQR 25-75) days in patients with infection vs. 8 (2-16, IQR 25-75; p: <0.001) days in patients without infection. Duration of extracorporeal membrane oxygenation support was found to be 14 (10-25, IQR 25-75) days in patients with infection versus 5 (2-10, IQR 25-75; p: <0.001) days in patients without infection and total hospital stay was 26 (18-33, IQR 25-75) days in patients with infection versus 8 (2-23, IQR 25-75) days in those without infection. A total of 24 patients out of the 70 patients experienced 32 infectious episodes during extracorporeal membrane oxygenation support. Culture-positive infections were detected at a single site in 19 patients, and multiple sites in 5 patients. We propose that prolonged extracorporeal membrane oxygenation support is associated with an increased risk of infection. Although extracorporeal membrane oxygenation is a life-saving treatment method, prolonged extracorporeal membrane oxygenation may increase the development of infectious complications and the associated mortality and morbidity of the patient.

Cardiovascular sequelae from COVID-19: perspectives from a paediatric cardiac ICU.

Paediatric ICUs have shared the burden of the COVID-19 pandemic, including subspecialty cardiac ICUs. We sought to address knowledge gaps regarding patient characteristics, acuity, and sequelae of COVID-19 in the paediatric cardiac ICU setting. Retrospective review of paediatric cardiac ICU admissions with COVID-19-related disease. Single centre tertiary care paediatric cardiac ICU. All patients with PCR/antibody evidence of primary COVID-19 infection, and/or Multisystem Inflammatory Syndrome in Children, were admitted between 26 March, 2020 and 31 March, 2021. None. Patient-level demographics, pre-existing conditions, clinical symptoms, and outcomes related to ICU admission were captured from medical records. Among 1064 patients hospitalised with COVID-19/Multisystem Inflammatory Syndrome in Children, 102 patients (9.5%) were admitted to cardiac ICU, 76 of which were symptomatic (median age 12.5 years [IQR 7.5-16.0]). The primary system involved at presentation was cardiovascular in 48 (63%). Vasoactive infusions were required in 62% (n = 47), with eight patients (11%) requiring VA ECMO. Severity of disease was categorised as mild/moderate in 16 (21%) and severe/critical in 60 patients (79%). On univariate analysis, African-American race, presentation with gastrointestinal symptoms or elevated inflammatory markers were associated with risk for severe disease. All-cause death was observed in five patients (7%, n = 5/72) with four patients remaining hospitalised at the time of data query. COVID-19 and its cardiovascular sequelae were associated with important morbidity and significant mortality in a notable minority of paediatric patients admitted to a paediatric cardiac ICU. Further study is required to quantify the risk of morbidity and mortality for COVID-19 and sequelae.

Preload Dependence Fails to Predict Hemodynamic Instability During a Fluid Removal Challenge in Children.

Fluid overload increases morbidity and mortality in PICU patients. Active fluid removal improves the prognosis but may worsen organ dysfunction. Preload dependence in adults does predict hemodynamic instability induced by a fluid removal challenge (FRC). We sought to investigate the diagnostic accuracy of dynamic and static markers of preload in predicting hemodynamic instability and reduction of stroke volume during an FRC in children. We followed the Standards for Reporting of Diagnostic Accuracy statement to design conduct and report this study. Prospective noninterventional cohort study. From June 2017 to April 2019 in a pediatric cardiac ICU in a tertiary hospital. Patients 8 years old or younger, with symptoms of fluid overload after cardiac surgery, were studied. We confirmed preload dependence by echocardiography before and during a calibrated abdominal compression test. We then performed a challenge to remove 10-mL/kg fluid in less than 120 minutes with an infusion of diuretics. Hemodynamic instability was defined as a decrease of 10% of mean arterial pressure. We compared patients showing hemodynamic instability with patients remaining stable, and we built receiver operative characteristic (ROC) curves. Among 58 patients studied, 10 showed hemodynamic instability. The area under the ROC curve was 0.55 for the preload dependence test (95% CI, 0.34-0.75). Using a threshold of 10% increase in stroke volume index (SVi) during calibrated abdominal compression, the specificity was 0.30 (95% CI, 0.00-0.60) and the sensitivity was 0.77 (95% CI, 0.65-0.88). Mean arterial pressure variation and SVi variation were not correlated during fluid removal; r = 0.19; 95% CI -0.07 to 0.43; p = 0.139. Preload dependence is not accurate to predict hemodynamic instability during an FRC. Our data do not support a reduction in intravascular volume being mainly responsible for the reduction in arterial pressure during an FRC in children.

Opioid Weaning Protocol Using Morphine Compared With Nonprotocolized Methadone Associated With Decreased Dose and Duration of Opioid After Norwood Procedure.

Opioids are used to manage pain, comfort, maintain devices, and decrease oxygen consumption around Norwood palliation (NP), but in high dose and prolonged exposure, they increase risk of tolerance and iatrogenic withdrawal syndrome (IAWS). Variability in practice for IAWS prevention potentially increases opioid dose and duration. We hypothesize that protocolized weaning with morphine (MOR) versus nonprotocolized methadone (MTD) is associated with reduction in opioid exposure. A before-versus-after study of outcomes of patients weaned with protocolized MOR versus nonprotocolized MTD including subset analysis for those patients with complications postoperatively. Primary endpoints include daily, wean phase, and total morphine milligram equivalent (MMEq) dose, duration, and, secondarily, length of stay (LOS). Quaternary-care pediatric cardiac ICU. Neonates undergoing single-ventricle palliation. Introduction of IAWS prevention protocol. Analysis included 54 patients who underwent the NP in 2017-2018 including the subset analysis of 34 who had a complicated postoperative course. The total and wean phase opioid doses for the MTD group were significantly higher than that for the MOR group: 258 versus 22 and 115 versus 6 MMEq/kg; p < 0.001. Duration of opioid exposure was 63 days in the MTD group and 12 days in MOR group (p < 0.001). Subanalysis of the complicated subset also identifies higher total and wean dose for MTD group (293 vs 41 and 116 vs 7 MMEq/kg; p < 0.001) with a longer duration (65 vs 22 days; p = 0.001). Within the subset, LOS was 55% longer in the MTD group than that in the MOR group (150 vs 67 d; p = 0.01) and not different in the uncomplicated group. After complex NP, a protocolized opioid weaning using MOR versus MTD is associated with 65% shorter opioid duration, 10-fold decreased dose, and shortened LOS.

Guest Editor’s Memo

The words of Dr. Francis Peabody still ring true almost 100 years after they were first uttered. “The secret of the care of the patient is in caring for the patient.” As providers of patients with pulmonary hypertensive vascular disease (PVHD) we direct the pathway for a patient’s medical care which has considerable impacts on their quality of life. It is imperative that our patients are viewed as people beyond their diagnosis. Pulmonary hypertension (PH) is a disease that affects patients across the lifespan. Each stage in the life of a PH patient presents its own unique challenges which require expert collaboration for holistic care and overall wellbeing. In this issue of Advances in Pulmonary Hypertension we have gathered patients, caregivers, physicians, nurses, social workers, and psychologists to address issues that affect all age groups as they navigate their way through life with PH. Our hope is that this will inspire you to think creatively to care your patients and families beyond their diagnosis with the goal of overall wellbeing and quality of life.In the PHPN Corner, Allison D’Souza, RN offers a personal perspective of how living with PH has empowered her to be a better and more compassionate provider in “From Patient to Provider: How My Diagnosis Makes Me a Better Nurse.” She has transitioned from a teenager adjusting to a new diagnosis to a pediatric cardiac ICU nurse guiding young patients to find hope.Dr. Hilary DuBrock and her team at the Mayo Clinic provide an overview of how PH effects quality of life. They synthesize the evidence regarding palliative care in PH and other cardiopulmonary diseases. DuBrock and team make a strong argument to incorporate palliative care in the longitudinal management of patients with PH.In “Perspectives on Mental Health Evaluation in Pediatric Pulmonary Hypertension: A Call to Action” an argument is made for more robust mental health screening practices integrated within care guidelines for pediatric PH. While providers recognize symptoms of anxiety and depression in their patients, few actually screen for anxiety and depression with intention to connect to mental health services. The authors from the AHP group of the Pediatric Pulmonary Hypertension Network (PPHNet) identify the existing barriers to accessing mental health services in pediatrics.In the current age, social media has been integrated into everyday life. Elise Whalen, NP and her co-authors from Texas Children’s Hospital provide a unique discussion on social media participation as a support system among caregivers of children with PH.Finally in the round table discussion, co-editors Claire Parker, NP and Nancy Bair, CNS gather Maddie Bonpin, a pediatric PH patient and her mother, Liza Bonpin, and Dr. Neal Chaisson to discuss transitions throughout the lifespan of a pulmonary hypertension patient.Thank you to all the authors and participants who contributed to this issue. We are thankful for the PHA and Allen Press for their support and guidance to bring this discussion to publication. We hope this issue encourages you to actively engage in the improvement of quality of life and overall wellbeing of your patients.

Prediction of extubation failure in the paediatric cardiac ICU using machine learning and high-frequency physiologic data.

Cardiac intensivists frequently assess patient readiness to wean off mechanical ventilation with an extubation readiness trial despite it being no more effective than clinician judgement alone. We evaluated the utility of high-frequency physiologic data and machine learning for improving the prediction of extubation failure in children with cardiovascular disease. This was a retrospective analysis of clinical registry data and streamed physiologic extubation readiness trial data from one paediatric cardiac ICU (12/2016-3/2018). We analysed patients' final extubation readiness trial. Machine learning methods (classification and regression tree, Boosting, Random Forest) were performed using clinical/demographic data, physiologic data, and both datasets. Extubation failure was defined as reintubation within 48 hrs. Classifier performance was assessed on prediction accuracy and area under the receiver operating characteristic curve. Of 178 episodes, 11.2% (N = 20) failed extubation. Using clinical/demographic data, our machine learning methods identified variables such as age, weight, height, and ventilation duration as being important in predicting extubation failure. Best classifier performance with this data was Boosting (prediction accuracy: 0.88; area under the receiver operating characteristic curve: 0.74). Using physiologic data, our machine learning methods found oxygen saturation extremes and descriptors of dynamic compliance, central venous pressure, and heart/respiratory rate to be of importance. The best classifier in this setting was Random Forest (prediction accuracy: 0.89; area under the receiver operating characteristic curve: 0.75). Combining both datasets produced classifiers highlighting the importance of physiologic variables in determining extubation failure, though predictive performance was not improved. Physiologic variables not routinely scrutinised during extubation readiness trials were identified as potential extubation failure predictors. Larger analyses are necessary to investigate whether these markers can improve clinical decision-making.

Ultrasound-guided post-pyloric feeding tube insertion in peri-operative cardiac infants.

We carried out a prospective pilot observational experimental study in peri-operative cardiac infants with feeding intolerance between 2019 and 2021. Feeding tube insertion depends on a combination of ultrasound and gastric insufflation with air-saline mixture. Insertion was confirmed by bedside abdominal X-ray. Out of 500 peri-operative cardiac infants, 15 needed post-pyloric feeding tube insertion in median 15 postoperative day. All were under 6 months of age with average weight of 3 ± 0.2 kg. Median Risk Adjustment for Congenital Heart Surgery Categories was 4. Median insertion time was 15 minutes. No complications have been reported. First pass success rate was 87%, while a second successful insertion attempt was needed in 2 cases (13%). Target daily calorie intake was achieved within average of 3.5 ± 0.4 days. Mean post-pyloric feeding tube stay was 20 ± 3 days. Out of 15 infants, 3 patients died, 1 patient needed gastrostomy tube, and 11 patients were discharged home on oral feeds. Ultrasound-guided post-pyloric feeding tube insertion using gastric insufflation with air-saline mixture in peri-operative cardiac infants with feeding intolerance is a useful and practical bedside tool, and it can be performed by a trained paediatric cardiac ICU intensivist. It may have potential positive effects on morbidity and outcome.

Paediatric cardiac rapid response systems: a survey of multicentre practices.

While the efficacy and guidelines for implementation of rapid response systems are well established, limited information exists about rapid response paradigms for paediatric cardiac patients despite their unique pathophysiology. With endorsement from the Paediatric Cardiac Intensive Care Society, we designed and implemented a web-based survey of paediatric cardiac and multidisciplinary ICU medical directors in the United States of America and Canada to better understand paediatric cardiac rapid response practices. Sixty-five (52%) of 125 centres responded. Seventy-one per cent of centres had ∼300 non-ICU beds and 71% had dedicated cardiac ICUs. To respond to cardiac patients, dedicated cardiac rapid response teams were utilised in 29% of all centres (39% and 5% in centres with and without dedicated cardiac ICUs, respectively) [p = 0.006]. Early warning scores were utilised in 62% of centres. Only 31% reported that rapid response teams received specialised training. Transfers to ICU were higher for cardiac (73%) compared to generalised rapid response events (54%). The monitoring and reassessment of patients not transferred to ICU after the rapid response was variable. Cardiac and respiratory arrests outside the ICU were infrequent. Only 29% of centres formally appraise critical deterioration events (need for ventilation and/or inotropes post-rapid response) and 34% perform post-event debriefs. Paediatric cardiac rapid response practices are variable and dedicated paediatric cardiac rapid response systems are infrequent in the United States of America and Canada. Opportunity exists to delineate best practices for paediatric cardiac rapid response and standardise practices for activation, training, patient monitoring post-rapid response events, and outcomes evaluation.