Pediatric Cardiac Intensive Care Research Articles

Cardiac Surgery-Associated Acute Kidney Injury in Children after Cardiopulmonary Bypass

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a complication of cardiopulmonary bypass surgery that frequently occurs in children. The increased availability of pediatric cardiac surgery leads to yearly increases in congenital heart disease (CHD) procedures performed worldwide. The number of complications, including pediatric CSA-AKI, has also increased. Children with CSA-AKI have worse postoperative periods and require more complex post-op intensive care. Thus, the timely commencement of interventions to prevent and to treat kidney injury in CHD children are one of a leading goals of pediatric cardiac intensive care.

A Pediatric Interprofessional Cardiac Intensive Care Unit Intervention: CICU Teams and Loved Ones Communicating (CICU TALC) is Feasible, Acceptable, and Improves Clinician Communication Behaviors in Family Meetings.

Parents of children in the pediatric cardiac intensive care unit (CICU) are often unprepared for family meetings (FM). Clinicians often do not follow best practices for communicating with families, adding to distress. An interprofessional team intervention for FM is feasible, acceptable, and positively impacts family preparation and conduct of FM in the CICU. We implemented a family- and team-support intervention for conducting FM and conducted a pretest-posttest study with parents of patients selected for a FM and clinicians. We measured feasibility, fidelity to intervention protocol, and parent acceptability via questionnaire and semi-structured interviews. Clinician behavior in meetings was assessed through semantic content analyses of meeting transcripts tracking elicitation of parental concerns, questions asked of parents, and responses to parental empathic opportunities. Logistic and ordinal logistic regression assessed intervention impact on clinician communication behaviors in meetings comparing pre- and post-intervention data. Sixty parents (95% of approached) were enrolled, with collection of 97% FM and 98% questionnaire data. We accomplished > 85% fidelity to intervention protocol. Most parents (80%) said the preparation worksheet had the right amount of information and felt positive about families receiving this worksheet. Clinicians were more likely to elicit parental concerns (adjusted odds ratio = 3.42; 95%CI [1.13, 11.0]) in post-intervention FM. There were no significant differences in remaining measures. Implementing an interprofessional team intervention to improve family preparation and conduct of FM is locally feasible, acceptable, and changes clinician behaviors. Future research should assess broader impact of training on clinicians, patients, and families.

Clinical Outcomes After Tracheostomy in Children With Single Ventricle Physiology: Collaborative Research From the Pediatric Cardiac Intensive Care Society Multicenter Cohort, 2010-2021.

Multicenter studies reporting outcomes following tracheostomy in children with congenital heart disease are limited, particularly in patients with single ventricle physiology. We aimed to describe clinical characteristics and outcomes in a multicenter cohort of patients with single ventricle physiology who underwent tracheostomy before Fontan operation. Multicenter retrospective cohort study.SETTING: Twenty-one tertiary care pediatric institutions participating in the Collaborative Research from the Pediatric Cardiac Intensive Care Society. We reviewed 99 children with single ventricle physiology who underwent tracheostomy before the Fontan operation at 21 institutions participating in Collaborative Research from the Pediatric Cardiac Intensive Care Society between January 2010 and December 2020, with follow-up through December 31, 2021. None. Death occurred in 51 of 99 patients (52%). Cox proportional hazard analysis was performed to determine factors associated with death after tracheostomy. Results are presented as hazard ratio (HR) with 95% CIs. Nonrespiratory indication(s) for tracheostomy (HR, 2.21; 95% CI, 1.14-4.32) and number of weeks receiving mechanical ventilation before tracheostomy (HR, 1.06; 95% CI, 1.02-1.11) were independently associated with greater hazard of death. In contrast, diagnosis of tricuspid atresia or Ebstein's anomaly was associated with less hazard of death (HR, 0.16; 95% CI, 0.04-0.69). Favorable outcome, defined as survival to Fontan operation or decannulation while awaiting Fontan operation with viable cardiopulmonary physiology, occurred in 29 of 99 patients (29%). Median duration of mechanical ventilation before tracheostomy was shorter in patients who survived to favorable outcome (6.1 vs. 12.1 wk; p < 0.001), and only one of 16 patients with neurologic indications for tracheostomy and 0 of ten patients with cardiac indications for tracheostomy survived to favorable outcome. For children with single ventricle physiology who undergo tracheostomy, mortality risk is high and should be carefully considered when discussing tracheostomy as an option for these children. Favorable outcomes are possible, although thoughtful attention to patient selection and tracheostomy timing are likely necessary to achieve this goal.

Inhaled NO at a crossroads in cardiac surgery: current need to improve mechanistic understanding, clinical trial design and scientific evidence.

Inhaled nitric oxide (NO) has been used in pediatric and adult perioperative cardiac intensive care for over three decades. NO is a cellular signaling molecule that induces smooth muscle relaxation in the mammalian vasculature. Inhaled NO has the unique ability to exert its vasodilatory effects in the pulmonary vasculature without any hypotensive side-effects in the systemic circulation. In patients undergoing cardiac surgery, NO has been reported in numerous studies to exert beneficial effects on acutely lowering pulmonary artery pressure and reversing right ventricular dysfunction and/or failure. Yet, various investigations failed to demonstrate significant differences in long-term clinical outcomes. The authors, serving as an advisory board of international experts in the field of inhaled NO within pediatric and adult cardiac surgery, will discuss how the existing scientific evidence can be further improved. We will summarize the basic mechanisms underlying the clinical applications of inhaled NO and how this translates into the mandate for inhaled NO in cardiac surgery. We will move on to the popular use of inhaled NO and will talk about the evidence base of the use of this selective pulmonary vasodilator. This review will elucidate what kind of clinical and biological barriers and gaps in knowledge need to be solved and how this has impacted in the development of clinical trials. The authors will elaborate on how the optimization of inhaled NO therapy, the development of biomarkers to identify the target population and the definition of response can improve the design of future large clinical trials. We will explain why it is mandatory to gain an international consensus for the state of the art of NO therapy far beyond this expert advisory board by including the different major players in the field, such as the different medical societies and the pharma industry to improve our understanding of the real-life effects of inhaled NO in large scale observational studies. The design for future innovative randomized controlled trials on inhaled NO therapy in cardiac surgery, adequately powered and based on enhanced biological phenotyping, will be crucial to eventually provide scientific evidence of its clinical efficacy beyond its beneficial hemodynamic properties.

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.

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.

Risk Factors and Outcomes for Recurrent Pediatric In-Hospital Cardiac Arrest: Retrospective Cohort Study from the American Heart Association's Get with the Guidelines-Resuscitation Registry

Abstract Objective We aimed to describe the risk factors and outcomes of recurrent in-hospital cardiac arrest (IHCA) in a large pediatric cohort. Methods A retrospective cohort study of patients ≤18 years from the American Heart Association's Get With The Guidelines®-Resuscitation Registry with single or recurrent IHCA who achieved return of spontaneous circulation and were not placed on extracorporeal membrane oxygenation with their initial IHCA were included. Patients were categorized into two groups for analysis: (1) single IHCA or (2) recurrent ICHA. Initial IHCAs from each category were analyzed and compared. Continuous variables were expressed as medians with interquartile ranges and compared via rank sum test. Categorical variables were expressed as percentages and compared via chi square test. Outcomes were assessed in a matched cohort. Results A total of 10,019 patients, 2,225 (22.2%) experienced a recurrent IHCA. Recurrent IHCA patients were more likely to be medical cardiac (21.3 vs. 19%; p = 0.01) or trauma patients (7.5 vs. 5.3%; p &lt; 0.001) and have higher acuity (27.8 vs. 22.7%; p &lt; 0.001). Initial IHCA for recurrent IHCA patients were more likely to occur in the pediatric intensive care unit (44.2 vs. 39.6%; p &lt; 0.001) or cardiac intensive care unit (11.5 vs. 9.5%; p = 0.006) versus other inpatient locations. There was no difference in initial IHCA duration between groups. After matching, patients with a recurrent IHCA had a lower rate of survival to hospital discharge (42.1 vs. 65.3%; p &lt; 0.001). Conclusion In a matched cohort, patients with recurrent IHCA had lower rates of survival compared with those with a single IHCA. Higher acuity and intensive care unit location during initial IHCA event were associated with increased risk for recurrent IHCA.

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.

Cardiac Critical Care Fellowship Training in the United States and Canada: Pediatric Cardiac Intensive Care Society Endorsed Subcompetencies to the 2022 Entrustable Professional Activities.

We aimed to define and map subcompetencies required for pediatric cardiac critical care (PCCC) fellowship education and training under the auspices of the Pediatric Cardiac Intensive Care Society (PCICS). We used the 2022 frameworks for PCCC fellowship learning objectives by Tabbutt et al and for entrustable professional activities (EPAs) by Werho et al and integrated new subcompetencies to the EPAs. This complementary update serves to provide a foundation for standardized trainee assessment tools for PCCC. A volunteer panel of ten PCICS members who are fellowship education program directors in cardiac critical care used a modified Delphi method to develop the update and additions to the EPA-based curriculum. In this process, the experts rated information independently, and repetitively after feedback, before reaching consensus. The agreed new EPAs were later reviewed and unanimously accepted by all PCICS program directors in PCCC in the United States and Canada and were endorsed by the PCICS in 2023. The procedure for defining new subcompetencies to the established EPAs comprised six consecutive steps: 1) literature search; 2) selection of key subcompetencies and curricular components; 3) written questionnaire; 4) consensus meeting and critical evaluation; 5) approval by curriculum developers; and 6) PCICS presentation and endorsement. Overall, 110 subcompetencies from six core-competency domains were mapped to nine EPAs with defined levels of entrustment and examples of simple and complex cases. To facilitate clarity and develop a future assessment tool, three EPAs were subcategorized with subcompetencies mapped to the appropriate subcategory. The latter covering common procedures in the cardiac ICU. This represents the 2023 update to the PCCC fellowship education and training EPAs with the defining and mapping of 110 subcompetencies to the nine established 2022 EPAs. This goal of this update is to serve as the next step in the integration of EPAs into a standardized competency-based assessment framework for trainees in PCCC.

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.