Publications by authors named "Geoffrey L Bird"

20 Publications

  • Page 1 of 1

Predicting and Surviving Prolonged Critical Illness After Congenital Heart Surgery.

Crit Care Med 2020 Jul;48(7):e557-e564

Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI.

Objectives: Prolonged critical illness after congenital heart surgery disproportionately harms patients and the healthcare system, yet much remains unknown. We aimed to define prolonged critical illness, delineate between nonmodifiable and potentially preventable predictors of prolonged critical illness and prolonged critical illness mortality, and understand the interhospital variation in prolonged critical illness.

Design: Observational analysis.

Setting: Pediatric Cardiac Critical Care Consortium clinical registry.

Patients: All patients, stratified into neonates (≤28 d) and nonneonates (29 d to 18 yr), admitted to the pediatric cardiac ICU after congenital heart surgery at Pediatric Cardiac Critical Care Consortium hospitals.

Interventions: None.

Measurements And Main Results: There were 2,419 neonates and 10,687 nonneonates from 22 hospitals. The prolonged critical illness cutoff (90th percentile length of stay) was greater than or equal to 35 and greater than or equal to 10 days for neonates and nonneonates, respectively. Cardiac ICU prolonged critical illness mortality was 24% in neonates and 8% in nonneonates (vs 5% and 0.4%, respectively, in nonprolonged critical illness patients). Multivariable logistic regression identified 10 neonatal and 19 nonneonatal prolonged critical illness predictors within strata and eight predictors of mortality. Only mechanical ventilation days and acute renal failure requiring renal replacement therapy predicted prolonged critical illness and prolonged critical illness mortality in both strata. Approximately 40% of the prolonged critical illness predictors were nonmodifiable (preoperative/patient and operative factors), whereas only one of eight prolonged critical illness mortality predictors was nonmodifiable. The remainders were potentially preventable (postoperative critical care delivery variables and complications). Case-mix-adjusted prolonged critical illness rates were compared across hospitals; six hospitals each had lower- and higher-than-expected prolonged critical illness frequency.

Conclusions: Although many prolonged critical illness predictors are nonmodifiable, we identified several predictors to target for improvement. Furthermore, we observed that complications and prolonged critical care therapy drive prolonged critical illness mortality. Wide variation of prolonged critical illness frequency suggests that identifying practices at hospitals with lower-than-expected prolonged critical illness could lead to broader quality improvement initiatives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316132PMC
July 2020

Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs.

Pediatr Crit Care Med 2018 01;19(1):e41-e50

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.

Design: Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.

Setting: International PICUs.

Patients: Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.

Interventions: tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.

Measurements And Main Results: A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001).

Conclusions: In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000001384DOI Listing
January 2018

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes.

Pediatr Crit Care Med 2017 Apr;18(4):310-318

1Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, NY. 2Department of Pediatrics, Pediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand. 3Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. 4Department of Pediatrics, Columbia University/New York Presbyterian Hospital, New York, NY. 5Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, PA. 6Division of Pediatric Critical Care Medicine, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Providence, RI. 7Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 8Department of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, Bronx, NY. 9Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ. 10Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore. 11Division of Pediatric Critical Care, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY. 12Department of Child Health University of Arizona College of Medicine, Department of Critical Care Phoenix Children's Hospital, Phoenix, AZ. 13Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 14Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC. 15Pediatric Critical Care Medicine, The University of Virginia Children's Hospital, Charlottesville, VA. 16Division of Pediatric Critical Care, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH. 17Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, PA. 18Pediatric Critical Care Medicine, Nicklaus Children's Hospital, Miami Children's Health System, Miami, FL. 19Critical Care Medicine, Department of Pediatrics, Yale Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT. 20Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Louisville, KY. 21Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA. 22Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas College of Medicine, Little Rock, AR. 23Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital Westchester Medical Center, Valhalla, NY. 24Pediatric Critical Care Medicine, Medical City Children's Hospital, Dallas, TX. 25Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada. 26Department of Emergency Medicine, Tokyo Metropolitan Children's Medical Centre, Tokyo, Japan. 27Department of Critical Care Medicine, Children's Hospital of Pittsburgh at University of Pittsburgh Medical Center, Pittsburgh, PA. 28Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA. 29Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR. 30Division of Critical Care, Nationwide Children's Hospital, Columbus, OH. 31Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA. 32Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada. 33Division of Critical Care, Department of Pediatrics, Women & Children's Hospital of Buffalo, Buffalo, NY. 34Division of Pediatric Cardiac Intensive Care, Department of Pediatric Critical Care Medicine, Duke Children's Hospital & Health Center, Durham, NC.

Objective: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality.

Study Design: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%.

Setting: PICUs participating in NEAR4KIDS.

Patients: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed.

Measurements And Main Results: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58-229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1-7 yr and 18% for 8-17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4-21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24-2.60; p = 0.002), after adjusted for patient confounders.

Conclusions: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000001074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5554859PMC
April 2017

Family Presence During Pediatric Tracheal Intubations.

JAMA Pediatr 2016 Mar 7;170(3):e154627. Epub 2016 Mar 7.

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Importance: Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated.

Objective: To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs.

Design, Setting, And Participants: Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs.

Exposures: Family presence and no FP during TI in the PICU.

Main Outcomes And Measures: The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level.

Results: A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders.

Conclusions And Relevance: Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamapediatrics.2015.4627DOI Listing
March 2016

Development and Preliminary Testing of the Coordination Process Error Reporting Tool (CPERT), a Prospective Clinical Surveillance Mechanism for Teamwork Errors in the Pediatric Cardiac ICU.

Jt Comm J Qual Patient Saf 2016 12 16;42(12):562-AP4. Epub 2016 Dec 16.

Formerly Professor, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania; Chief, Division of General Internal Medicine; Professor, Department of Medicine, Massachusetts General Hospital, Boston.

Background: Patient safety reporting systems (PSRSs) may not detect teamwork or coordination process errors that affect all dimensions of quality defined by the Institute of Medicine. This study aimed to develop and observe the performance of a novel tool, the Coordination Process Error Reporting Tool (CPERT), as a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Methods: Providers and parents used the qualitative nominal group technique to identify coordination process error examples. Using categories developed from these discussions, the CPERT was designed and observed to assess agreement among providers and with the PSRS. For each patient at the end of each observed shift, the nurse, frontline clinician, and attending physician were invited to complete the CPERT online. Responses among providers were compared to assess interobserver agreement. Patients with errors identified by the CPERT were matched 1:1 with patients without CPERT errors within the same shift. The PSRS and medical record were reviewed to judge whether a coordination process error occurred and whether patients with CPERT errors differed from controls.

Results: Eight categories of errors were identified and incorporated into the CPERT. During 10 shifts (218 patients), the CPERT completion rate was 74%. Fifty-one patient shifts had errors identified by the CPERT (23%); these patients did not differ significantly from those without CPERT- reported errors. Only 5 CPERT-reported errors (10%) were identified by two or more providers. Of the 51 CPERT- reported errors, 43 (84%) were not documented in the PSRS.

Conclusion: The CPERT detects coordination process errors not identified through PSRS, making it or similar tools potentially useful for improvement efforts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1553-7250(16)30108-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509850PMC
December 2016

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium.

Pediatr Crit Care Med 2015 Nov;16(9):837-45

1Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI. 2Department of Pediatrics, Benioff Children's Hospital and University of California San Francisco School of Medicine, San Francisco, CA. 3Department of Critical Care Medicine and Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, ON, Canada. 4Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 5Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL. 6Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. 7Department of Critical Care Medicine and Cardiology, Children's National Medical Center, Washington, DC. 8Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA. 9Division of Pediatric Cardiac Surgery, Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 10Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 11Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 12Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 13Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan Congenital Heart Center, Ann Arbor, MI. 14The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Objective: To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs.

Design: Retrospective cohort study using prospectively collected clinical registry data.

Setting: Pediatric Cardiac Critical Care Consortium registry.

Patients: All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals.

Interventions: None.

Measurements And Main Results: Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001).

Conclusions: Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000000498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672991PMC
November 2015

A tool to measure shared clinical understanding following handoffs to help evaluate handoff quality.

J Hosp Med 2014 Mar 31;9(3):142-7. Epub 2014 Jan 31.

The Cardiac Center, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Information exchanged during handoffs contributes importantly to a team's shared mental model. There is no established instrument to measure shared clinical understanding as a marker of handoff quality.

Objective: To study the reliability, validity, and feasibility of the pediatric cardiology Patient Knowledge Assessment Tool (PKAT), a novel instrument designed to measure shared clinical understanding for pediatric cardiac intensive care unit patients.

Design: To estimate reliability, 10 providers watched 9 videotaped simulated handoffs and then completed a PKAT for each scenario. To estimate construct validity, we studied 90 handoffs in situ by having 4 providers caring for an individual patient each complete a PKAT following handoff. Construct validity was assessed by testing the effects of provider preparation and patient complexity on agreement levels.

Setting: A 24-bed pediatric cardiac intensive care unit in a freestanding children's hospital.

Results: Video simulation results demonstrated score reliability. Average inter-rater agreement by item ranged from 0.71 to 1.00. During in situ testing, agreement by item ranged from 0.41 to 0.87 (median 0.77). Construct validity for some items was supported by lower agreement rates for patients with increased length of stay and increased complexity.

Discussion: Results suggest that the PKAT has high inter-rater reliability and can detect differences in understanding between handoff senders and receivers for routine and complex patients. Additionally, the PKAT is feasible for use in a real-time clinical environment. The PKAT or similar instruments could be used to study effects of handoff improvement efforts in inpatient settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jhm.2147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049065PMC
March 2014

Results of elective repair at 6 months or younger in 277 patients with tetralogy of Fallot: a 14-year experience at a single center.

J Thorac Cardiovasc Surg 2014 Feb 18;147(2):713-7. Epub 2013 Apr 18.

Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa; Division of Cardiology, Department of Pediatrics, Cardiac Center at the Children's Hospital of Philadelphia, Philadelphia, Pa.

Objective: To report practice and outcomes in infants undergoing elective repair of tetralogy of Fallot.

Methods: A review of a retrospective cohort of elective complete repair of infants age 6 months or younger from 1995 to 2009 was performed. Patients were excluded because of previous interventions, hypercyanotic episodes, intensive care admissions, additional major cardiac defects, or if they were not discharged after birth. Length of stay, mortality, and complications were recorded. Association was determined using logistic or linear regression models and univariate testing determined the multivariate model.

Results: There were 277 patients included. The hospital mortality rate was zero. A total of 87.4% of patients were discharged home within 7 days of repair, and 21.6% of patients were discharged on or before the third postoperative day. The postoperative course was uncomplicated in 245 patients (88.4%). Longer support time was associated independently with increased odds of complications (P < .001). Longer support time, younger age, chromosomal abnormality, and presence of a complication were associated independently with a longer hospital stay (all P < .001). Patients younger than 3 months (n = 110) had a longer median hospital stay (4 vs 3 days; P < .001) and longer support times (77.3 ± 35.1 min vs 66.4 ± 34 min; P < .01).

Conclusions: Elective tetralogy of Fallot repair was performed at 6 months or younger with low morbidity, no hospital mortality, and an 11.6% complication rate. Longer support times, lower weight, chromosomal abnormalities, and complications were associated with a significantly increased duration of hospital stay.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2013.03.033DOI Listing
February 2014

Change in regional (somatic) near-infrared spectroscopy is not a useful indicator of clinically detectable low cardiac output in children after surgery for congenital heart defects.

Pediatr Crit Care Med 2012 Sep;13(5):529-34

Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.

Objective: Near-infrared spectroscopy correlation with low cardiac output has not been validated. Our objective was to determine role of splanchnic and/or renal oxygenation monitoring using near-infrared spectroscopy for detection of low cardiac output in children after surgery for congenital heart defects.

Design: Prospective observational study.

Setting: Pediatric intensive care unit of a tertiary care teaching hospital.

Patients: Children admitted to the pediatric intensive care unit after surgery for congenital heart defects.

Interventions: None.

Measurements And Main Results: We hypothesized that splanchnic and/or renal hypoxemia detected by near-infrared spectroscopy is a marker of low cardiac output after pediatric cardiac surgery. Patients admitted after cardiac surgery to the pediatric intensive care unit over a 10-month period underwent serial splanchnic and renal near-infrared spectroscopy measurements until extubation. Baseline near-infrared spectroscopy values were recorded in the first postoperative hour. A near-infrared spectroscopy event was a priori defined as ≥20% drop in splanchnic and/or renal oxygen saturation from baseline during any hour of the study. Low cardiac output was defined as metabolic acidosis (pH <7.25, lactate >2 mmol/L, or base excess ≤-5), oliguria (urine output <1 mL/kg/hr), or escalation of inotropic support. Receiver operating characteristic analysis was performed using near-infrared spectroscopy event as a diagnostic test for low cardiac output. Twenty children were enrolled: median age was 5 months; median Risk Adjustment for Congenital Heart Surgery category was 3 (1-6); median bypass and cross-clamp times were 120 mins (45-300 mins) and 88 mins (17-157 mins), respectively. Thirty-one episodes of low cardiac output and 273 near-infrared spectroscopy events were observed in 17 patients. The sensitivity and specificity of a near-infrared spectroscopy event as an indicator of low cardiac output were 48% (30%-66%) and 67% (64%-70%), respectively. On receiver operating characteristic analysis, neither splanchnic nor renal near-infrared spectroscopy event had a significant area under the curve for prediction of low cardiac output (area under the curve: splanchnic 0.45 [95% confidence interval 0.30-0.60], renal 0.51 [95% confidence interval 0.37-0.65]).

Conclusions: Splanchnic and/or renal hypoxemia as detected by near-infrared spectroscopy may not be an accurate indicator of low cardiac output after surgery for congenital heart defects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0b013e3182389531DOI Listing
September 2012

Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants.

Pediatrics 2011 Jul 6;128(1):e237-41. Epub 2011 Jun 6.

Interventional Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.

Chylothorax is an uncommon complication of cardiothoracic surgery in children that is traditionally treated with either conservative (diet modification, octreotide administration, and percutaneous drainage) or surgical (thoracic duct ligation, pleurodesis, and pleuroperitoneal shunt) approaches. We report here the cases of 2 children (a 6-month-old and a 1-month-old) with postoperative chylous leaks who were treated successfully by percutaneous thoracic duct embolization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2010-2016DOI Listing
July 2011

Weight change in infants with a functionally univentricular heart: from surgical intervention to hospital discharge.

Cardiol Young 2011 Apr 12;21(2):136-44. Epub 2010 Nov 12.

Department of Pediatrics, The Children's Hospital of Philadelphia and School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States of America.

Objective: The purpose of this study was to assess the pattern of weight change from surgical intervention to home discharge and to determine predictors of poor growth in this population of infants with congenital cardiac disease.

Methods: Neonates with functionally univentricular physiology enrolled in a prospective cohort study examining growth between March, 2003 and May, 2007 were included. Weights were collected at birth, before surgical intervention, and at hospital discharge. In addition, retrospective echocardiographic data and data about post-operative complications were reviewed. Primary outcome variables were weight-for-age z-score at discharge and change in weight-for-age z-score between surgery and discharge.

Results: A total of 61 infants met the inclusion criteria. The mean change in weight-for-age z-score between surgery and hospital discharge was minus 1.5 plus or minus 0.8. Bivariate analysis revealed a significant difference in weight-for-age z-score between infants who were discharged on oral feeds, minus 1.1 plus or minus 0.8 compared to infants with feeding device support minus 1.7 plus or minus 0.7, p-value equal to 0.01. Lower weight-for-age z-score at birth, presence of moderate or greater atrioventricular valve regurgitation, post-operative ventilation time, and placement of an additional central venous line were associated with 60% of the variance in weight-for-age z-score change.

Conclusion: Neonates undergoing staged surgical repair for univentricular physiology are at significant risk for growth failure between surgery and hospital discharge. Haemodynamically significant atrioventricular valve regurgitation and a complex post-operative course were risk factors for poor post-operative weight gain. Feeding device support appears to be insufficient to ensure adequate weight gain during post-operative hospitalisation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S104795111000154XDOI Listing
April 2011

Successful support and separation from veno-venous extracorporeal membrane oxygenation support in a three-month-old patient following bidirectional Glenn procedure.

Interact Cardiovasc Thorac Surg 2010 Oct 30;11(4):496-8. Epub 2010 Jun 30.

Department of Surgery, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Suite 12NW23 Main, 34th and Civic Center Blvd., Philadelphia, PA 19104, USA.

While extracorporeal membrane oxygenation (ECMO) is a useful mechanism of providing support in pediatric patients with cardiopulmonary dysfunction following surgery for congenital heart disease, outcomes have varied dramatically between distinct cardiac diagnoses. Reported outcomes of ECMO support following a bidirectional Glenn procedure in patients with single ventricle physiology are uniformly poor due in part to physiological and anatomical challenges inherent to cannulation in this population. We describe a unique veno-venous cannulation that can be applied to this patient population and has allowed for successful decannulation in our practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1510/icvts.2010.237834DOI Listing
October 2010

Prediction of periventricular leukomalacia. Part II: Selection of hemodynamic features using computational intelligence.

Artif Intell Med 2009 Jul 21;46(3):217-31. Epub 2009 Jan 21.

Department of Mechanical Engineering, Villanova University, PA 19085, USA.

Objective: The objective of Part II is to analyze the dataset of extracted hemodynamic features (Case 3 of Part I) through computational intelligence (CI) techniques for identification of potential prognostic factors for periventricular leukomalacia (PVL) occurrence in neonates with congenital heart disease.

Methods: The extracted features (Case 3 dataset of Part I) were used as inputs to CI based classifiers, namely, multi-layer perceptron (MLP) and probabilistic neural network (PNN) in combination with genetic algorithms (GA) for selection of the most suitable features predicting the occurrence of PVL. The selected features were next used as inputs to a decision tree (DT) algorithm for generating easily interpretable rules of PVL prediction.

Results: Prediction performance for two CI based classifiers, MLP and PNN coupled with GA are presented for different number of selected features. The best prediction performances were achieved with 6 and 7 selected features. The prediction success was 100% in training and the best ranges of sensitivity (SN), specificity (SP) and accuracy (AC) in test were 60-73%, 74-84% and 71-74%, respectively. The identified features when used with the DT algorithm gave best SN, SP and AC in the ranges of 87-90% in training and 80-87%, 74-79% and 79-82% in test. Among the variables selected in CI, systolic and diastolic blood pressures, and pCO(2) figured prominently similar to Part I. Decision tree based rules for prediction of PVL occurrence were obtained using the CI selected features.

Conclusions: The proposed approach combines the generalization capability of CI based feature selection approach and generation of easily interpretable classification rules of the decision tree. The combination of CI techniques with DT gave substantially better test prediction performance than using CI and DT separately.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.artmed.2008.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714881PMC
July 2009

Prediction of periventricular leukomalacia. Part I: Selection of hemodynamic features using logistic regression and decision tree algorithms.

Artif Intell Med 2009 Jul 21;46(3):201-15. Epub 2009 Jan 21.

Department of Mechanical Engineering, Villanova University, PA 19085, USA.

Objective: Periventricular leukomalacia (PVL) is part of a spectrum of cerebral white matter injury which is associated with adverse neurodevelopmental outcome in preterm infants. While PVL is common in neonates with cardiac disease, both before and after surgery, it is less common in older infants with cardiac disease. Pre-, intra-, and postoperative risk factors for the occurrence of PVL are poorly understood. The main objective of the present work is to identify potential hemodynamic risk factors for PVL occurrence in neonates with complex heart disease using logistic regression analysis and decision tree algorithms.

Methods: The postoperative hemodynamic and arterial blood gas data (monitoring variables) collected in the cardiac intensive care unit of Children's Hospital of Philadelphia were used for predicting the occurrence of PVL. Three categories of datasets for 103 infants and neonates were used-(1) original data without any preprocessing, (2) partial data keeping the admission, the maximum and the minimum values of the monitoring variables, and (3) extracted dataset of statistical features. The datasets were used as inputs for forward stepwise logistic regression to select the most significant variables as predictors. The selected features were then used as inputs to the decision tree induction algorithm for generating easily interpretable rules for prediction of PVL.

Results: Three sets of data were analyzed in SPSS for identifying statistically significant predictors (p<0.05) of PVL through stepwise logistic regression and their correlations. The classification success of the Case 3 dataset of extracted statistical features was best with sensitivity (SN), specificity (SP) and accuracy (AC) of 87, 88 and 87%, respectively. The identified features, when used with decision tree algorithms, gave SN, SP and AC of 90, 97 and 94% in training and 73, 58 and 65% in test. The identified variables in Case 3 dataset mainly included blood pressure, both systolic and diastolic, partial pressures pO(2) and pCO(2), and their statistical features like average, variance, skewness (a measure of asymmetry) and kurtosis (a measure of abrupt changes). Rules for prediction of PVL were generated automatically through the decision tree algorithms.

Conclusions: The proposed approach combines the advantages of statistical approach (regression analysis) and data mining techniques (decision tree) for generation of easily interpretable rules for PVL prediction. The present work extends an earlier research [Galli KK, Zimmerman RA, Jarvik GP, Wernovsky G, Kuijpers M, Clancy RR, et al. Periventricular leukomalacia is common after cardiac surgery. J Thorac Cardiovasc Surg 2004;127:692-704] in the form of expanding the feature set, identifying additional prognostic factors (namely pCO(2)) emphasizing the temporal variations in addition to upper or lower values, and generating decision rules. The Case 3 dataset was further investigated in Part II for feature selection through computational intelligence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.artmed.2008.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2745267PMC
July 2009

Neurological complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease.

Cardiol Young 2008 Dec;18 Suppl 2:234-9

Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-4399, USA.

A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrine systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the neurological system. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases. Although neurological injury and adverse neurodevelopmental outcome can follow procedures for congenital cardiac defects, much of the variability in neurological outcome is now recognized to be more related to patient specific factors rather than procedural factors. Additionally, the recognition of pre and postoperative neurological morbidity requires procedures and imaging modalities that can be resource-intensive to acquire and analyze, and little is known or described about variations in "sampling rate" from centre to centre. The purpose of this effort is to propose an initial set of consensus definitions for neurological complications following congenital cardiac surgery and intervention. Given the dramatic advances in understanding achieved to date, and those yet to occur, this effort is explicitly recognized as only the initial first step of a process that must remain iterative. This list is a component of a systems-based compendium of complications that may help standardize terminology and possibly enhance the study and quantification of morbidity in patients with congenital cardiac malformations. Clinicians caring for patients with congenital cardiac disease may be able to use this list for databases, initiatives to improve quality, reporting of complications, and comparing strategies of treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S1047951108002977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742973PMC
December 2008

Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease--the perspective of critical care.

Cardiol Young 2008 Dec;18 Suppl 2:130-6

Department of Paediatric Intensive Care, The Royal Brompton Hospital, London, United Kingdom.

The development of databases to track the outcomes of children with cardiovascular disease has been ongoing for much of the last two decades, paralleled by the rise of databases in the intensive care unit. While the breadth of data available in national, regional and local databases has grown exponentially, the ability to identify meaningful measurements of outcomes for patients with cardiovascular disease is still in its early stages. In the United States of America, the Virtual Pediatric Intensive Care Unit Performance System (VPS) is a clinically based database system for the paediatric intensive care unit that provides standardized high quality, comparative data to its participants [https://portal.myvps.org/]. All participants collect information on multiple parameters: (1) patients and their stay in the hospital, (2) diagnoses, (3) interventions, (4) discharge, (5) various measures of outcome, (6) organ donation, and (7) paediatric severity of illness scores. Because of the standards of quality within the database, through customizable interfaces, the database can also be used for several applications: (1) administrative purposes, such as assessing the utilization of resources and strategic planning, (2) multi-institutional research studies, and (3) additional internal projects of quality improvement or research.In the United Kingdom, The Paediatric Intensive Care Audit Network is a database established in 2002 to record details of the treatment of all critically ill children in paediatric intensive care units of the National Health Service in England, Wales and Scotland. The Paediatric Intensive Care Audit Network was designed to develop and maintain a secure and confidential high quality clinical database of pediatric intensive care activity in order to meet the following objectives: (1) identify best clinical practice, (2) monitor supply and demand, (3) monitor and review outcomes of treatment episodes, (4) facilitate strategic healthcare planning, (5) quantify resource requirements, and (6) study the epidemiology of critical illness in children.Two distinct physiologic risk adjustment methodologies are the Pediatric Risk of Mortality Scoring System (PRISM), and the Paediatric Index of Mortality Scoring System 2 (PIM 2). Both Pediatric Risk of Mortality (PRISM 2) and Pediatric Risk of Mortality (PRISM 3) are comprised of clinical variables that include physiological and laboratory measurements that are weighted on a logistic scale. The raw Pediatric Risk of Mortality (PRISM) score provides quantitative measures of severity of illness. The Pediatric Risk of Mortality (PRISM) score when used in a logistic regression model provides a probability of the predicted risk of mortality. This predicted risk of mortality can then be used along with the rates of observed mortality to provide a quantitative measurement of the Standardized Mortality Ratio (SMR). Similar to the Pediatric Risk of Mortality (PRISM) scoring system, the Paediatric Index of Mortality (PIM) score is comprised of physiological and laboratory values and provides a quantitative measurement to estimate the probability of death using a logistic regression model.The primary use of national and international databases of patients with congenital cardiac disease should be to improve the quality of care for these patients. The utilization of common nomenclature and datasets by the various regional subspecialty databases will facilitate the eventual linking of these databases and the creation of a comprehensive database that spans conventional geographic and subspecialty boundaries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S1047951108002886DOI Listing
December 2008

Risk factors for interstage death after stage 1 reconstruction of hypoplastic left heart syndrome and variants.

J Thorac Cardiovasc Surg 2008 Jul 22;136(1):94-9, 99.e1-3. Epub 2008 May 22.

Division of Cardiology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia 19104, USA.

Objective: The risk of death during the interstage period remains high after stage 1 reconstruction for single ventricle lesions, despite improved surgical results. The purpose of this study is to identify risk factors for interstage death and to describe the events leading to interstage death.

Methods: A nested case-control study was conducted of 368 patients who underwent stage 1 reconstruction at a single center between January 1998 and April 2005.

Results: Among the 313 (85%) hospital survivors, there were 33 (10.5%) interstage deaths. Cases more frequently presented with intact or restrictive atrial septum (9 [27%] vs 4 [4%]; P < .001), were older at the time of surgery (5 [2-40] vs 3 [1-42] days; P = .005), had more postoperative arrhythmias (12 [36%] vs 15 [15%]; P = .01), and a higher incidence of airway or respiratory complications (12 [36%] vs 19 [19%]; P = .04). By multivariate analysis, only intact atrial septum (odds ratio 7.6; 95% confidence intervals 1.9-29.6; P = .003) and age at operation greater than 7 days (odds ratio 3.8; 95% confidence intervals 1.3-11.2; P = .017) were predictors of interstage death.

Conclusions: The presence of intact atrial septum and older age at the time of surgery are associated with a higher risk of interstage death. In addition, postoperative arrhythmia and airway complications are associated with a higher risk of interstage death in univariate analysis. The results of this study provide a focus for interstage monitoring and risk stratification of these high-risk infants, which may improve overall survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2007.12.012DOI Listing
July 2008

Improving safety for children with cardiac disease.

Cardiol Young 2007 Sep;17 Suppl 2:127-32

Cardiac Intensive Care Unit, Children's Hospital Boston, Boston, Massachusetts 02115, United States of America.

The complexity of the modern systems providing health care presents a unique challenge in delivering care of the required quality in a safe environment. Issues of safety have been thrust into the limelight because of adverse events highly publicized in the general media. In the United States of America, improving the safety and quality in health care has been set forth as a priority for improvements in the 21st century in the report from the Institute of Medicine. Many measures have now been initiated for improving the safety of patients at hospital, regional, and national level, and through initiatives sponsored by governments and private organizations. In this review, we summarize known concepts and current issues on the safety of patients, and their applicability to children with congenital cardiac disease. Prior to examining the issues of medical error and safety, it is important to define the terminology. An error is defined as the failure of a planned action to be completed as intended, also known as an execution error, or the use of a wrong plan to achieve an aim, this representing a planning error. An active error is an error that occurs at the level of the frontline operator, and the effects of which are felt immediately. A latent error is an error in the design, organization, training and maintenance, that leads to operator errors, and the effects of which are typically dormant in the system for lengthy periods of time. Latent errors may cause harm given the right circumstances and environment. An adverse event is defined as an injury resulting from medical intervention. A preventable adverse event is an adverse event that occurs due to medical error. Negligent adverse events are a subset of preventable adverse events where the care provided did not meet the standard of care expected of that practitioner. The study of improving the delivery of safe care for our patients is a rapidly growing field. Important components for development of programmes to improve the safety of patients include the leadership for the programme, the implementation of process design based on human limitations, the promotion of teamwork and function, the anticipation of unexpected events, and the creation of a learning environment. Much is yet to be learned about the risk and incidence of adverse events during hospitalization of children with congenital cardiac disease. Errors due to human factors, such as poor communication, poor coordination, and suboptimal team work, have shown to be important causes of adverse outcomes in children undergoing cardiac surgery, and should be a focus for improvement. Future research on evaluating causes and prevention of medical errors and adverse events in this population at high risk, and consuming high resources, is essential. Issues of inadequate safeguards for patients have been prominent in the media, and have been highlighted in reports from the Institute of Medicine. Our review discusses research on the causes of medical error, and proposes concepts to design successful programmes to improve safety for the patients on a local level.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S1047951107001230DOI Listing
September 2007

Postoperative course in the cardiac intensive care unit following the first stage of Norwood reconstruction.

Cardiol Young 2007 Dec 7;17(6):652-65. Epub 2007 Nov 7.

Department of Pediatrics (Division of Pediatric Cardiology), The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.

The medical records of all patients born between 1 September, 2000, and 31 August, 2002, and undergoing the first stage of Norwood reconstruction, were retrospectively reviewed for details of the perioperative course. We found 99 consecutive patients who met the criterions for inclusion. Hospital mortality for the entire cohort was 15.2%, but was 7.3%, with 4 of 55 dying, in the setting of a "standard" risk profile, as opposed to 25.0% for those with a "high" risk profile, 11 of 44 patients dying in this group. Extracorporeal membrane oxygenation was utilized in 7 patients, with 6 deaths. Median postoperative length of stay in the hospital was 14 days, with a range from 2 to 85 days, and stay in the cardiac intensive care unit was 11 days, with a range from 2 to 85 days. Delayed sternal closure was performed in 18.2%, with a median of 1 day until closure, with a range from zero to 5 days. Excluding isolated delayed sternal closure, and cannulation and decannulation for extracorporeal support, 24 patients underwent 33 cardiothoracic reoperations, including exploration for bleeding in 12, diaphragmatic plication in 4; shunt revision in 4, and other procedures in 13. The median duration of total mechanical ventilation was 4.0 days, with a range from 0.7 to 80.5 days. Excluding those who died, the median total duration of mechanical ventilation was 3.8 days, with a range from 0.9 to 46.3 days. Reintubation for cardiorespiratory failure or upper airway obstruction was performed in 31 patients. Postoperative electroencephalographic and/or clinical seizures occurred in 13 patients, with 7 discharged on anti-convulsant medications. Postoperative renal failure, defined as a level of creatinine greater than 1.5 mg/dl, was present in 13 patients. Eleven had significant thrombocytopenia, with fewer than 20,000 platelets per microl, and injury to the vocal cords was identified in eight patients. Risk factors for longer length of stay included lower Apgar scores, preoperative intubation, early reoperations, reintubation and sepsis, but not weight at birth, genetic syndromes, the specific surgeon, or the duration of surgery. Although mortality rates after the first stage of reconstruction continue to fall, the course in the intensive care unit is remarkable for significant morbidity, especially involving the cardiac, pulmonary and central nervous systems. These patients utilize significant resources during the first hospitalization. Further studies are necessary to stratify the risks faced by patients with hypoplasia of the left heart in whom the first stage of Norwood reconstruction is planned, to determine methods to reduce perioperative morbidity, and to determine the long-term implications of short-term complications, such as diaphragmatic paresis, injury to the vocal cords, prolonged mechanical ventilation, and postoperative seizures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S1047951107001461DOI Listing
December 2007

A contemporary comparison of the effect of shunt type in hypoplastic left heart syndrome on the hemodynamics and outcome at stage 2 reconstruction.

J Thorac Cardiovasc Surg 2007 Aug;134(2):297-303

Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pa 19119, USA.

Objective: We compare the hemodynamics and perioperative course of shunt type in hypoplastic left heart syndrome at the time of stage 2 reconstruction and longer-term survival.

Methods: We retrospectively reviewed the echocardiograms, catheterizations, and hospital records of all patients who had a stage 1 reconstruction between January 2002 and May 2005 and performed a cross-sectional analysis of hospital survivors.

Results: One hundred seventy-six patients with hypoplastic left heart syndrome and variants underwent a stage 1 reconstruction with either a right ventricle-pulmonary artery conduit (n = 62) or a modified Blalock-Taussig shunt (n = 114). The median duration of follow-up is 29.1 months (range, 0-57 months). By means of Kaplan-Meier analysis, there is no difference in survival at 3 years (right ventricle-pulmonary artery conduit: 73% [95% confidence limit, 59%-83%] vs modified Blalock-Taussig shunt: 69% [95% confidence limit, 59%-77%]; P = .6). One hundred twenty-four patients have undergone stage 2 reconstruction (78 modified Blalock-Taussig shunts and 46 right ventricle-pulmonary artery conduits). At the time of the stage 2 reconstruction, patients with right ventricle-pulmonary artery conduits were younger (153 days [range, 108-340 days]; modified Blalock-Taussig shunt, 176 days [range, 80-318 days]; P = .03), had lower systemic oxygen saturation (73% [range, 58%-85%] vs 77% [range, 57%-89%], P < .01), and had higher preoperative hemoglobin levels (15.8 g/dL [range, 13-21 g/dL] vs 14.8 g/dL [range, 12-19 g/dL], P < .01) compared with those of the modified Blalock-Taussig shunt group. By means of echocardiographic evaluation, there was a higher incidence of qualitative ventricular dysfunction in patients with right ventricle-pulmonary artery conduits (14/46 [31%] vs 9/73 [12%], P = .02). However, no difference was observed in common atrial pressure or the arteriovenous oxygen difference.

Conclusion: Interim analyses suggest no advantage of one shunt type over another. This report raises concern of late ventricular dysfunction and outcome in patients with a right ventricle-pulmonary artery conduit.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2007.02.046DOI Listing
August 2007