Pediatric Cardiac Intensive Care Unit Research Articles

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 <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<0.001), acute kidney injury (p<0.001), low cardiac output (p<0.001), neurological dysfunction (p=0.016), and mortality (p<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.

Intravenous administration of ultrasound contrast to critically ill pediatric patients.

The off-label use of contrast-enhanced ultrasound has been increasingly used for pediatric patients. The purpose of this retrospective study is to report any observed clinical changes associated with the intravenous (IV) administration of ultrasound contrast to critically ill neonates, infants, children, and adolescents. All critically ill patients who had 1 or more contrast-enhanced ultrasound scans while being closely monitored in the neonatal, pediatric, or pediatric cardiac intensive care units were identified. Subjective and objective data concerning cardiopulmonary, neurological, and hemodynamic monitoring were extracted from the patient's electronic medical records. Vital signs and laboratory values before, during, and after administration of ultrasound contrast were obtained. Statistical analyses were performed using JMP Pro, version 15. Results were accepted as statistically significant for P-value<0.05. Forty-seven contrast-enhanced ultrasound scans were performed on 38 critically ill patients, 2 days to 17 years old, 19 of which were female (50%), and 19 had history of prematurity (50%). At the time of the contrast-enhanced ultrasound scans, 15 patients had cardiac shunts or a patent ductus arteriosus, 25 had respiratory failure requiring invasive mechanical oxygenation and ventilation, 19 were hemodynamically unstable requiring continual vasoactive infusions, and 8 were receiving inhaled nitric oxide. In all cases, no significant respiratory, neurologic, cardiac, perfusion, or vital sign changes associated with IV ultrasound contrast were identified. This study did not retrospectively identify any adverse clinical effects associated with the IV administration of ultrasound contrast to critically ill neonates, infants, children, and adolescents.

Development of a clinical prediction tool for extubation failure in pediatric cardiac intensive care unit.

Extubation failure in pediatric patients with congenital or acquired heart diseases increases morbidity and mortality. This study aimed to develop a clinical risk score for predicting extubation failure to guide proper clinical decision-making and management. We conducted a retrospective study. This clinical prediction score was developed using data from the Pediatric Cardiac Intensive Care Unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Thailand, from July 2016 to May 2022. Extubation failure was defined as the requirement for re-intubation within 48 h after extubation. Multivariable logistic regression was used for modeling. The score was evaluated in terms of discrimination and calibration. A total of 352 extubation events from 270 patients were documented. Among these, 40 events (11.36%) were extubation failure. Factors associated with extubation failure included history of pneumonia (OR: 4.14, 95% CI: 1.83-9.37, p = 0.001), history of re-intubation (OR: 5.99, 95% CI: 2.12-16.98, p = 0.001), and high saturation in physiologic cyanosis (OR: 5.94, 95% CI: 1.87-18.84, p = 0.003). These three factors were utilized to develop the risk score. The score showed acceptable discrimination with an area under the curve (AUC) of 0.77 (95% CI: 0.69-0.86), and good calibration. The derived Pediatric CMU Extubation Failure Prediction Score (Ped-CMU ExFPS) could satisfactorily predict extubation failure in pediatric cardiac patients. Employing this score could promote proper personalized care. We suggest conducting further external validation studies before considering implementation in practice.

Comparison of the ultrasound-guided supraclavicular and infraclavicular approaches for subclavian vein cannulation in children with congenital heart disease

Objective(s)Central venous catheterization (CVC) is widely used in pediatric critical patients. We thought to compare the success rate and safety of ultrasound-guided subclavian vein cannulation performed via infraclavicular and supraclavicular approaches. DesignWe compared the success rate of the first puncture and other information for cannulation in the children with congenital heart disease (CHD) requiring central venous catheterization who were randomly assigned to the supraclavicular approach group (Group A) or infraclavicular approach group (Group B). SettingMedical university hospital pediatric cardiac intensive care units (CICUs). ParticipantsPediatric patients diagnosed with CHD in the preoperative period who were admitted to the CICU and required subclavian vein catheterization. InterventionsUltrasound-guided subclavian vein cannulation. Measurements & Main ResultsSixty-seven children were included in the study, with 32 in Group A and 35 in Group B. Notably, there was a significant difference in the success rate of the first puncture between Groups A and B (90.6% vs. 71.4, %, p = 0.047). Furthermore, the access time in Group A was 11.8 (3.2–95) seconds, which was significantly shorter than that in Group B (16.0 [6.5–227] seconds, p = 0.001). In addition, the catheter malposition rate in Group A was significantly lower than that in Group B (0% vs. 11.4%, p = 0.049). Conversely, there were no significant differences in the total access time, overall success rate, and complications (e.g., pneumothorax, hemorrhage, puncture artery, and nerve injury) between the two groups. ConclusionsFor children with congenital heart disease requiring central venous catheterization during the perioperative period, the subclavian vein is a feasible site for catheterization. The supraclavicular approach, especially the left side, has a higher first-puncture success rate, shorter access time, lower complications, and the trend of lower incidence of catheter malposition. However, a larger sample size of randomized controlled study is expected to verify the advantages of ultrasound-guided subclavian catheterization in children.

An evaluation of the outcomes associated with peritoneal catheter use in neonates undergoing cardiac surgery: A multicenter study

ObjectiveThe study objective was to determine if intraoperative peritoneal catheter placement is associated with improved outcomes in neonates undergoing high-risk cardiac surgery with cardiopulmonary bypass. MethodsThis propensity score–matched retrospective study used data from 22 academic pediatric cardiac intensive care units. Consecutive neonates undergoing Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery 3 to 5 cardiac surgery with cardiopulmonary bypass at centers participating in the NEonatal and Pediatric Heart Renal Outcomes Network collaborative were studied to determine the association of the use of an intraoperative placed peritoneal catheter for dialysis or passive drainage with clinical outcomes, including the duration of mechanical ventilation. ResultsAmong 1490 eligible neonates in the NEonatal and Pediatric Heart Renal Outcomes Network dataset, a propensity-matched analysis was used to compare 395 patients with peritoneal catheter placement with 628 patients without peritoneal catheter placement. Time to extubation and most clinical outcomes were similar. Postoperative length of stay was 5 days longer in the peritoneal catheter placement cohort (17 vs 22 days, P = .001). There was a 50% higher incidence of moderate to severe acute kidney injury in the no peritoneal catheter cohort (12% vs 18%, P = .02). Subgroup analyses between specific treatments and in highest risk patients yielded similar associations. ConclusionsThis study does not demonstrate improved outcomes among neonates with placement of a peritoneal catheter during cardiac surgery. Outcomes were similar apart from longer hospital stay in the peritoneal catheter cohort. The no peritoneal catheter cohort had a 50% higher incidence of moderate to severe acute kidney injury (12% vs 18%). This analysis does not support indiscriminate peritoneal catheter use, although it may support the utility for postoperative fluid removal among neonates at risk for acute kidney injury. A multicenter controlled trial may better elucidate peritoneal catheter effects.

Prevalence of Latent Tuberculosis Infection Among Nurses Working in Critical Areas at a Tertiary Care Hospital in Riyadh, Saudi Arabia.

Introduction Tuberculosis is a critical health issue worldwide.Most infected persons are asymptomatic and categorized as having a latent tuberculosis infection (LTBI). Healthcare workers (HCWs) are more prone to being infected with tuberculosis and should be enrolled in a screening program for early detection. Objectives The study aims to estimate the prevalence of LTBI among nurses working in critical areas which include adult intensive care units, pediatric intensive care units, emergency departments, oncology departments, dialysis departments, tuberculosis labs, isolation rooms, and cardiac center intensive care units. Methods A record-based cross-sectional survey measured the prevalence of LTBI among nurses working in critical areas at Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia. We reviewed the occupational health records of all nurses working in critical areas from June 1, 2021, to June 1, 2022. We recorded the data reviewed throughout the year in the Occupational Health Department at PSMMC. We excluded all participants with previously documented positive tuberculin skin test (TST) from the study. We analyzed the sociodemographic data, working years, working location, job title, and TST results. Results We included a total of 771 out of 2025 nurses in this study. Participants were mostly women (88%) and in the 26-35-year age group (67.7%). Most of the participants were originally from the Philippines (66.3%). The overall LTBI prevalence among nurses was 34.5%. The highest prevalence of LTBI was among nurses working in the cardiac intensive care unit (53.5%), and the lowest prevalence was among nurses working in the isolation department (8.9%; p-value <0.0001). Those who worked more in the hospital were significantly more infected with LTBI (p-value <0.04). Conclusion LTBI remains a significant health risk worldwide andin the Middle East as well as among HCWs. This underscores the necessity of comprehensive pre-hiring screening, annual screening, infection control protocols, and active management of HCWs with LTBI.

Mental Health Symptoms in Parents of Infants 3 Months After Discharge Following Neonatal Cardiac Surgery.

Parents of newborns with congenital heart disease (CHD) are at risk for anxiety, depression, and post-traumatic stress. Few studies have examined whether modifiable factors that influence parents' mental health after discharge are present during postoperative care in the pediatric cardiac intensive care unit (PCICU). To describe mental health symptoms of parents of infants with CHD 3 months after PCICU discharge and to determine factors during the PCICU stay that are predictors of such symptoms. A longitudinal cohort pilot study of 56 parents (28 mother-father dyads) of 28 infants with CHD. During the first postoperative week after cardiac surgery, parents completed questionnaires measuring factors potentially influencing mental health. Three months after discharge, 42 parents of 22 infants completed validated measures of anxiety, depression, and posttraumatic stress. Three months after discharge, 26% of parents had clinically elevated levels of anxiety symptoms, 21% had clinically significant levels of depressive symptoms, and 19% had posttraumatic stress symptoms. In multi-variable analysis, parental role alteration in the PCICU was predictive of anxiety (P = .002), depressive (P = .02), and posttraumatic stress (P = .02) symptoms 3 months after discharge. Higher education level was predictive of anxiety symptoms (P = .009). Postnatal CHD diagnosis was predictive of posttraumatic stress symptoms (P = .04). Parental role alteration perceived by parents during the PCICU stay is a modifiable stressor contributing to adverse mental health symptoms 3 months after discharge. Interventions targeting parental role alteration in the PCICU are critically needed.

Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit.

We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.

Prevalence, risk factors, and outcomes of acute kidney injury in a pediatric cardiac intensive care unit: A cross-sectional study.

Acute kidney injury (AKI) is a common complication in pediatric cardiac intensive care unit (CICU). This study aims to identify the prevalence, risk factors, and outcomes of AKI in pediatrics admitted to a CICU unit of a tertiary hospital. We retrospectively gathered the data of 253 randomly selected patients admitted to the CICU unit from March 2018 to March 2022. Data were collected from EHRs. We used the Kidney Disease Improving Global Outcomes (KDIGO) criteria for identifying AKI in patients. Overall, AKI prevalence was 22.9% in our population. In the multivariable analysis, vancomycin intake (odds ratio [OR]: 2.109, 95% confidence interval [CI]: 1.15-3.84), angiography (OR: 4.38, 95% CI: 1.28-14.93), and mechanical ventilation (OR: 2.08, 95% CI: 1.02-4.23) were independent risk factors of AKI development and patients with AKI had a higher in-hospital mortality rate (OR: 5.81, 95% CI: 2.55-13.19), higher need for cardiopulmonary resuscitation(OR: 3.08, 95% CI: 1.17-8.09), and longer ICU length of stay(OR: 6.49, 95% CI: 3.31-9.67). Furthermore, furosemide administration was associated with lower risk of developing AKI (OR: 0.52, 95% CI: 0.27-0.97). AKI is common and is associated with worse outcomes in patients with congenital heart disease. Our results emphasize the importance of early identification and monitoring of AKI in the pediatric CICU setting.

Prevalence and risk factors for prolonged mechanical ventilation in patients with congenital heart diseases undergoing cardiac surgery at a tertiary care center.

Objective: To determine the prevalence and risk factors for prolonged mechanical ventilation (PMV) in patients with CHDs undergoing cardiac surgery at a tertiary care center of Karachi, Pakistan. Study Design: Cross-sectional study. Setting: Paediatric Cardiac Intensive Care Unit (PCICU) at National Institute of Cardiovascular Diseases, Karachi, Pakistan. Period: July 2022 to June 2023. Material &amp; Methods: We analyzed patients who underwent open or closed heart surgery for CHDs. PMV was defined as duration of mechanical ventilation &gt; 72 hours from the time of arrival to PCICU until extubation after cardiac surgery. Peri-operative factors were noted and their association with PMV was documented. Results: In a total of 184 patients who underwent surgeries for CHD, 105 (57.1%) were male while the overall mean age was 7.23±6.49 years. Post-surgery, PMV was documented in 17 (9.2%) patients. PMV was significantly associated with age (p=0.001), weight (p&lt;0.001), cyanosis (p=0.005), TAPSE (p=0.011), and CPB time (p=0.003). Post-surgery, PMV was linked with metabolic acidosis (p=0.003), lactate (p=0.001), AVDO2 (p&lt;0.001), inotropic score (p=0.002), low cardiac output (p=0.005), LV dysfunction (p&lt;0.001), acute kidney injury (p=0.002), sepsis (p&lt;0.001), pneumonia (p=0.004), mortality (p=0.045), and PCICU stay (p&lt;0.001). Conclusion: PMV was documented in 9.2% patients who underwent CHD repair. Age, weight, cyanosis, TAPSE, CPB time, metabolic acidosis, lactate, AVDO2, inotropic score, low cardiac output, LV dysfunction, acute kidney injury, sepsis, and pneumonia were noted to be significant risk factors for PMV.

Innovation in Nurse Staffing Models: Implementing a Tele-Critical Care Nurse Program in a Pediatric Cardiac Intensive Care Unit.

A pediatric tele-critical care nursing program provides an extra layer of surveillance for patients and alerts bedside nurses of abnormal trends to mitigate adverse events. Although workforce turnover combined with patient complexity and acuity in a pediatric cardiac intensive care unit strains the sustainability of a healthy work environment, these variables have also opened the door to an innovative approach to tele-critical care nursing care delivery. In addition to virtual surveillance, a clinical bedside intervention was developed to provide hands-on assistance to bedside nurses. This article describes the evolution of this novel technique for enhancing nursing care delivery.

To Determine the Frequency and Risk Factors for Significant Postoperative Bleeding in Children with Congenital Heart Diseases Undergoing Open Heart Surgery in a Tertiary Care Center

Aim: To determine the frequency and risk factors for significant postoperative bleeding in children with congenital heart diseases undergoing open cardiac surgery in our tertiary care hospital. Methods: A prospective observational study was carried out in the department of Paediatric cardiac intensive care Unit at National Institute of Cardiovascular diseases Karachi between [dates here].Children aged 0-18 years underwent open heart surgery for congenital heart defects. Those patients who had previous palliative surgeries for congenital heart defects were included in the study.The duration of bleeding, recurrence, and treatment given (tranexamic acid bolus/infusion, platelets, FFPs, Packed RBC/WB, Factor 7 concentrates) were also documented. The outcome of bleeding was recorded as either stopped or persistent. If bleeding persisted, any other intervention needed was also noted.

Incidence and risk factors for acute kidney injury in children with congenital heart disease undergoing cardiac surgery in a tertiary care center.

Objective: To determine the incidence and risk factors associated with acute kidney injury (AKI) in children with congenital heart diseases (CHDs) who underwent cardiac surgery in a tertiary care center. Study Design: Cross-sectional study. Setting: Paediatric Cardiac Intensive Care Unit (PCICU) of National Institute of Cardiovascular diseases, Karachi, Pakistan. Period: November 2022 to May 2023. Material &amp; Methods: We included patients of both genders and any age who underwent open or closed heart surgery for congenital heart defects. All patients undergoing CHD repairs were monitored for the total duration of PCICU stay. The development of AKI was labeled as per RIFLE criteria, and management thereafter was performed as per standard institutional protocols. Results: In a total of 93 patients with CHD, there were 50 (53.8%) males and 43 (46.2%) females. The mean age was 9.71±9.14 year ranging between 3 months to 60 years. There were 6 (6.5%) patients who developed AKI post-surgery. Overall, mortality was noted in 7 (7.5%) patients. Cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were significantly higher among patients who developed post-surgery AKI (&lt;0.001). Moreover, post-surgery AKI was significantly associated with intra-operative hypotension (p&lt;0.001), post-operative hypotension (p&lt;0.001), and post-operative sepsis (p&lt;0.001). It was also found that AKI had significant association with higher post-operative inotropic scores (p&lt;0.001), prolonged duration of mechanical ventilation (p&lt;0.001), and length of PCICU stay (p&lt;0.001). Mortality had significant association with AKI (33.3% vs. 5.7%, p=0.013). Conclusion: We noted the incidence of AKI among patient who underwent cardiac repairs to be 6.5%. CPB time and ACC time were significantly higher among patients who developed post-surgery AKI. Post-surgery AKI was significantly associated with intra-operative hypotension, post-operative hypotension, and post-operative sepsis. Mortality was significant high among cases that had AKI.

Abstract 12869: Cardiac Intensive Care Unit Teams and Loved Ones Communicating (CICU TaLC) Intervention is Acceptable and Improves Interprofessional Clinician Communication and Teamwork in Pediatric Pre-Family Meeting Huddles

Introduction: Interprofessional teams often develop a care plan in pre-family meeting huddles before engaging with the family in the pediatric cardiac intensive care unit (CICU)—a process that can affect the course of the family meeting and alter team dynamics but often lacks optimal communication and teamwork. Hypothesis: An interprofessional team intervention for pre-meeting huddles in the CICU is acceptable and positively impacts teamwork. Methods: We enrolled and trained CICU clinicians in interprofessional communication skills with a focus on role clarity, then conducted a quasi-experimental pre-posttest study with clinicians participating in actual pre-family meeting huddles. Clinician acceptability was measured via survey and impact on team communication and teamwork in pre-meeting huddles was assessed using PACT novice, a TeamSTEPPS validated tool, on audio recorded and transcribed huddles. The tool evaluates the domains Team Structure , Leadership , Situation Monitoring , Mutual Support , and Communication on a five-point scale (1 = poor; 3 = average; 5 = excellent). Wilcoxon rank sum test assessed intervention impact on communication and teamwork at the meeting level comparing pre and post-intervention data. Results: 24 Clinicians enrolled in the intervention (92% retention) with 100% completion of training. All trained clinicians recommend CICU TALC to others and 96% believe it improved their participation in family meetings. In 58 huddles (28 pre and 30 post), team performance in all 5 domains were significantly (p&lt; 0.001) higher in post-intervention huddles than in pre-intervention. Median (IQR) comparisons: Team structure [pre 2.00 (1.75, 2.00) vs. post 5.00 (5.00, 5.00)], Leadership [pre 3.00 (2.00, 3.00) vs. post 5.00 (5.00, 5.00)], Situation Monitoring [pre 3.00 (2.75, 3.00) vs. post 5.00 (4.00, 5.00)], Mutual Support [pre 3.00 (2.00, 3.25) vs. post 5.00 (5.00, 5.00)], and Communication [pre 3.00 (2.00, 4.00) vs. post 5.00 (5.00, 5.00)]. Conclusion: It is acceptable to implement an interprofessional team intervention to improve team communication and teamwork in interprofessional pre-family meeting huddles. Future research should assess broader impact of the intervention on clinicians, patients, and families.

Predicting acute kidney injury with an artificial intelligence-driven model in a pediatric cardiac intensive care unit

BackgroundAcute kidney injury (AKI) is among the most common complications following cardiac surgery in adult and pediatric patients, significantly affecting morbidity and mortality. Artificial Intelligence (AI) with Machine Learning (ML) can be used to predict outcomes. AKI diagnosis anticipation may be an ideal target of these methods. The scope of the study is building a Machine Learning (ML) train model with Random Forest (RF) algorithm, based on electronic health record (EHR) data, able to forecast AKI continuously after 48 h in post-cardiac surgery children, and to test its performance.Four hundred nineteen consecutive patients out of 1115 hospital admissions were enrolled in a single-center retrospective study. Patients were younger than 18 years and admitted from August 2018 to February 2020 in a pediatric cardiac intensive care unit (PCICU) undergoing cardiac surgery, invasive procedure (hemodynamic studies), and medical conditions with complete EHR records and discharged after 48 h or more.ResultsThirty-six variables were selected to build the algorithm according to commonly described cardiac surgery-associated AKI clinical predictors. We evaluated different models for different outcomes: binary AKI (no AKI vs. AKI), severe AKI (no-mild vs severe AKI), and multiclass classification (maximum AKI and the most frequent level of AKI, mode AKI). The algorithm performance was assessed with the area under the curve receiver operating characteristics (AUC ROC) for binary classification, with accuracy and K for multiclass classification. AUC ROC for binary AKI was 0.93 (95% CI 0.92–0.94), and for severe AKI was 0.99 (95% CI 0.98–1). Mode AKI accuracy was 0.95, and K was 0.80 (95% CI 0.94–0.96); maximum AKI accuracy was 0.92, and K was 0.71 (95% CI 0.91–0.93). The importance matrix plot demonstrated creatinine, basal creatinine, platelets count, adrenaline support, and lactate dehydrogenase for binary AKI with the addition of cardiopulmonary bypass duration for severe AKI as the most relevant variables of the model.ConclusionsWe validated a ML model to detect AKI occurring after 48 h in a retrospective observational study that could help clinicians in individuating patients at risk of AKI, in which a preventive strategy can be determinant to improve the occurrence of renal dysfunction.

Clinical effects of major aortopulmonary collateral arteries in term neonates diagnosed with transposition of the great arteries.

Transposition of the great arteries is a severe CHD that affects term neonates. The presence of major aortopulmonary collateral arteries in neonatal transposition of the great arteries patients is rare. This study investigated the clinical and haemodynamic implications of the presence of major aortopulmonary collateral arteries in neonatal transposition of the great arteries patients who underwent an arterial switch operation. The study was a retrospective analysis conducted on neonates diagnosed with transposition of the great arteries who underwent arterial switch operation within the period from 1 May 2020 to 1 January 2023 at two high-patient-volume paediatric cardiac surgery centres in Turkey. The patients' demographic characteristics, echocardiographic features, and clinical data were analysed. Additionally, the possible clinical effects of the presence of major aortopulmonary collateral arteries were statistically evaluated. Two hundred cases of neonatal transposition of the great arteries were included in this study, with 55% of the cases male. All the patients underwent arterial switch operation. The median age at the time of arterial switch operation was 5 days (interquartile range 3-7), with a median weight of 3,100 g (interquartile range 2,900-3,400). The median pre-operative saturation level was 76% (interquartile range 70-82%). Prior to arterial switch operation, 32 patients underwent balloon atrial septostomy.In all the patients, the interatrial septum was checked to determine if the atrial septum was intact. A patent foramen ovale (≤ 3 mm) was found in 112 patients, and a non-restrictive atrial septal defect (> 3 mm) was found in 88. Forty-eight patients had ventricular septal defects, and 72 had coronary anomalies. Major aortopulmonary collateral arteries were found in 4 patients pre-operatively and in 12 patients after arterial switch operation (echocardiography, n = 8; angiography, n = 4). Of the patients with post-operative detection of cumulative number of major aortopulmonary collateral arteries were on post-operative day 1 in 2 patients, on post-operative day 3 in 5 patients, on post-operative day 7 in 6 patients, and on post-operative day 14 in 11 patients.Transcatheter closure was performed in 3 cases due to recurrent extubation failure. Major aortopulmonary collateral artery shrinkage was observed in one case under medical treatment. The length of paediatric cardiac intensive care unit stay (10 days versus 8 days; p < 0.005), mechanical ventilator time (4 days versus 2 days; p = 0.02), and inotrope use time (5 days versus 3 days; p = 0.04) were higher in the major aortopulmonary collateral artery cases than patients without major aortopulmonary collateral artery. Major aortopulmonary collateral arteries are frequent in transposition of the great arteries patients and may have clinical effects. The presence of major aortopulmonary collateral arteries should be investigated in patients who do not have a favourable post-operative course after arterial switch operation.

The Inadequate Oxygen Delivery Index and Its Correlation with Venous Saturation in the Pediatric Cardiac Intensive Care Unit.

Continuous monitoring software, T3, has an integrated index called the inadequate oxygen delivery index 50% (IDO2-50) which displays a probability that the mixed venous saturation is below a user-selected threshold of 30-50%. The primary aim of this study was to determine the correlation of the IDO2-50 with a measured venous saturation. The secondary aim of this study was to characterize the hemodynamic factors that contributed to the IDO2-50. This single-center, retrospective study aimed to characterize the correlation between IDO2-50 and inferior vena cava (IVC) saturation. A Bayesian Pearson correlation was conducted to assess the correlation between the collected variables of interest, with a particular interest in the correlation between the IDO2-50 and the IVC saturation. Receiver operator curve (ROC) analysis to assess the ability of the IDO2-50 to identify when the venous saturation was less than 50%. Bayesian linear regression was done with the IDO2-50 (dependent variable) and other independent variables. A total of 113 datasets were collected across 15 unique patients. IDO2-50 had moderate correlation with the IVC saturation (correlation coefficient -0.569). The IDO2-50 had a weak but significant correlation with cerebral near-infrared spectroscopy (NIRS) values, a weak but significant correlation with heart rate, and a moderate and significant correlation with arterial saturation. ROC analysis demonstrated that the IDO2-50 had a good ability to identify a venous saturation below 50%, with an area under the curve of 0.797, cutoff point of 24.5 with a sensitivity of 81%, specificity of 66%, positive predictive value of 44%, and negative predictive value of 91%. Bayesian linear regression analysis yielded the following model: 237.82 + (1.18 × age in months)-(3.31 × arterial saturation)-(1.92 × cerebral NIRS) + (0.84 × heart rate). The IDO2 index has moderate correlation with IVC saturation. It has good sensitive and negative predictive value. Cerebral NIRS does appear to correlate better with the underlying venous saturation than the IDO2 index.

Standardized Treatment andDiagnostic Approach to Reduce Disease burden in the early postoperative phase in children with congenital heart defects—STANDARD study: a pilot randomized controlled trial

To explore the effect of a daily goal checklist on pediatric cardiac intensive care unit (PCICU) length of stay (LOS) after congenital heart surgery. This study is a prospective randomized single-center study. Group characteristics were as follows: STANDARD group: n = 30, 36.7% female, median age 0.9 years; control group: n = 33, 36.4% female, median age 1.1 years. Invasive ventilation time, STAT categories, mean vasoactive-inotropic score (VIS)24h, maximal (max.) VIS24h, mean VIS24–48h, max. VIS24–48h, VIS category, number of sedatives, analgesics, diuretics, number of deployed diagnostic modalities, morbidities, and mortality did not differ between both groups. Median PCICU LOS was 96.0 h (STANDARD group) versus 101.5 h (control group) (p = 0.63). In the overall cohort, univariate regression analysis identified age at surgery (b = −0.02), STAT category (b = 18.3), severity of CHD (b = 40.6), mean VIS24h (b = 3.5), max. VIS24h (b = 2.2), mean VIS24–48h (b = 6.5), and VIS category (b = 13.8) as significant parameters for prolonged PCICU LOS. In multivariate regression analysis, age at surgery (b = −0.2), severity of CHD (b = 44.0), and mean VIS24h (b = 6.7) were of significance. Within the STANDARD sub-group, univariate regression analysis determined STAT category (b = 32.3), severity of CHD (b = 70.0), mean VIS24h (b = 5.0), mean VIS24–48h (b = 5.9), number of defined goals (b = 2.6), number of achieved goals (b = 3.3), number of not achieved goals (b = 10.8), and number of unevaluated goals (b = 7.0) as significant parameters for prolonged PCICU LOS. Multivariate regression analysis identified the number of defined goals (b = 2.5) and the number of unevaluated goals (b = −3.0) to be significant parameters.   Conclusion: The structured realization and recording of daily goals is of advantage in patients following pediatric cardiac surgery by reducing PCICU LOS.What is known:• Communication errors are the most frequent reasons for adverse events in intensive care unit patients.• Improved communication can be achieved by discussion and documentation of the patients’ goals during daily rounds.What is new:• In the overall cohort age at surgery, severity of congenital heart defect and mean vasoactive inotropic score within the first 24 hours had significant impact on pediatric cardiac intensive care unit (PCICU) length of stay (LOS).• In the intervention group, the number of defined goals and the number of unevaluated goals were significant parameters for prolonged PCICU LOS.

Continuous Prostanoid Initiation in Severe Pulmonary Hypertension in the Pediatric Cardiac Intensive Care Unit.

Limited data exists regarding prostanoid (PGI2) use in critically ill patients with pulmonary hypertension. (PH) in the pediatric cardiac intensive care unit (CICU) setting. Single center, retrospective study of patients with diagnosis of PH who received continuous PGI2 and were admitted to CICU from January/2015 to April/2022. Data collected included patient demographics and clinical characteristics including diagnosis, etiology of PH, vasoactive and ventilatory support, length of stay, and survival. Type, initial, maximum, and final dose of PGI2 as well as hemodynamic data was obtained. Data reported as mean ± standard deviation. Significance taken p value < 0.05. 24 patients received PGI2 therapy at a mean age of 3.1years, range (0-16.6years). PGI2 was in the form of IV epoprostenol in 12 patients, IV treprostinil in 6, and SQ treprostinil in 6 patients. Mean initial dose was 2.79ng/kg/min, max dose 18.75ng/kg/min, and mean duration of therapy was 38.5days. At PGI2 initiation, 21 (87.5%) were on vasoactive infusions, 19 (79.2%) mechanically ventilated (MV), and 6 (25%) were on extracorporeal membrane oxygenation (ECMO). The in-hospital mortality rate was 37.5% (n = 9). Patients MV and on ECMO support had higher risk of death (p = 0.04, and < 0.01, respectively). PGI2 therapy was tolerated in approximately 50% of patients with the most common side effect being hypotension leading to discontinuation in 1/3rd of patients. Ongoing evaluation of the benefits of PGI2 for patients in the CICU setting will help better identify patient selection, type, and dosing of PGI2.

Plasma proteoglycan 4: a novel biomarker for acute lung injury after pediatric cardiac surgery.

Identification of biological molecules related to post cardiopulmonary bypass (CPB) lung injury could help diagnose, predict and potentially impact patient's clinical course after cardiac surgery. Proteoglycan 4 (PRG4) initially identified as potential biomarker for patients with prolonged mechanical ventilation following CPB in a prior study. To further validate these findings, we sought to understand the association of lower plasma PRG4 with prolonged mechanical ventilation and worse lung compliance in a larger cohort of pediatric patients post CPB. Retrospective chart review study. Pediatric Cardiac Intensive Care Unit, Tertiary Hospital. Infants <1 year old with tetralogy of Fallot, ventricular septal defect, or atrioventricular septal defect who underwent surgical repair 2012-2020 and had stored plasma samples in our biorepository were screened for inclusion. Patients with mechanical ventilation before surgery were excluded. Patients were divided into quartiles based on postoperative duration of mechanical ventilation (control <25th percentile, study >75th percentile). Preoperative and 48-hour postoperative samples for each cohort (20 patients each) were tested for PRG4 level using enzyme-linked immunosorbent assay (ELISA) technique. Study group had lower lung compliance, higher mean airway pressure and higher oxygen need postoperative when compared to control group. Plasma PRG4 levels before surgery and 48 hours postoperative were lower in study group compared to control group (P=0.0232 preoperative; P=0.0016 postoperative). Plasma PRG4 levels were compared preoperative to PRG4 levels postoperative in both group, there was no statistically significant difference (study group: P=0.0869; control group: P=0.6500). Lower levels of plasma PRG4 is associated with longer duration of mechanical ventilation, worse ventilator compliance and higher oxygen requirement after cardiac surgery in our patient population. Further validation of this finding in a larger and more diverse patient population is necessary prior to its application at the bedside.