Publications by authors named "Peter C Laussen"

143 Publications

Shock Index, Coronary Perfusion Pressure, and Rate Pressure Product As Predictors of Adverse Outcome After Pediatric Cardiac Surgery.

Pediatr Crit Care Med 2021 Jan;22(1):e67-e78

Department of Cardiology, Boston Children's Hospital, Boston, MA.

Objectives: To determine whether shock index, coronary perfusion pressure, or rate pressure product in the first 24 hours after congenital heart surgery are independent predictors of subsequent clinically significant adverse outcomes.

Design: A retrospective cohort study.

Setting: A tertiary care center.

Patients: All patients less than 18 years old who underwent cardiac surgery at Boston Children's Hospital between January 1, 2010, and December 31, 2018.

Interventions: None.

Measurements And Main Results: Shock index (heart rate/systolic blood pressure), coronary perfusion pressure (diastolic blood pressure-right atrial pressure), and rate pressure product (heart rate × systolic blood pressure) were calculated every 5 seconds, and the median value for the first 24 hours of cardiac ICU admission for each was used as a predictor. The composite, primary outcome was the occurrence of any of the following adverse events in the first 7 days following cardiac ICU admission: cardiopulmonary resuscitation, extracorporeal cardiopulmonary resuscitation, mechanical circulatory support, unplanned surgery, heart transplant, or death. The association of each variable of interest with this outcome was tested in a multivariate logistic regression model. Of the 4,161 patients included, 296 (7%) met the outcome within the specified timeframe. In a multivariate regression model adjusted for age, surgical complexity, inotropic and respiratory support, and organ dysfunction, shock index greater than 1.83 was significantly associated with the primary outcome (odds ratio, 6.6; 95% CI, 4.4-10.0), and coronary perfusion pressure greater than 35 mm Hg was protective against the outcome (odds ratio, 0.5; 0.4-0.7). Rate pressure product was not found to be associated with the outcome. However, the predictive ability of the shock index and coronary perfusion pressure models were not superior to their component hemodynamic variables alone.

Conclusions: Both shock index and coronary perfusion pressure may offer predictive value for adverse outcomes following cardiac surgery in children, although they are not superior to the primary hemodynamic variables.
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http://dx.doi.org/10.1097/PCC.0000000000002524DOI Listing
January 2021

The Lay of the Land: Pediatric Cardiac Critical Care.

Authors:
Peter C Laussen

Pediatr Crit Care Med 2020 09;21(9):835-837

Department of Critical Care Medicine, The Hospital for Sick Children; and Department of Anesthesia, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1097/PCC.0000000000002458DOI Listing
September 2020

Sharing and learning through the Pediatric Cardiac Critical Care Consortium: Moving toward precision care.

Authors:
Peter C Laussen

J Thorac Cardiovasc Surg 2020 Jun 10. Epub 2020 Jun 10.

Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286268PMC
June 2020

A practical approach to storage and retrieval of high-frequency physiological signals.

Physiol Meas 2020 04 20;41(3):035008. Epub 2020 Apr 20.

Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada. School of Biomedical Engineering, University of Sydney, Sydney, New South Wales, Australia.

Objective: Storage of physiological waveform data for retrospective analysis presents significant challenges. Resultant data can be very large, and therefore becomes expensive to store and complicated to manage. Traditional database approaches are not appropriate for large scale storage of physiological waveforms. Our goal was to apply modern time series compression and indexing techniques to the problem of physiological waveform storage and retrieval.

Approach: We deployed a vendor-agnostic data collection system and developed domain-specific compression approaches that allowed long term storage of physiological waveform data and other associated clinical and medical device data. The database (called AtriumDB) also facilitates rapid retrieval of retrospective data for high-performance computing and machine learning applications.

Main Results: A prototype system has been recording data in a 42-bed pediatric critical care unit at The Hospital for Sick Children in Toronto, Ontario since February 2016. As of December 2019, the database contains over 720,000 patient-hours of data collected from over 5300 patients, all with complete waveform capture. One year of full resolution physiological waveform storage from this 42-bed unit can be losslessly compressed and stored in less than 300 GB of disk space. Retrospective data can be delivered to analytical applications at a rate of up to 50 million time-value pairs per second.

Significance: Stored data are not pre-processed or filtered. Having access to a large retrospective dataset with realistic artefacts lends itself to the process of anomaly discovery and understanding. Retrospective data can be replayed to simulate a realistic streaming data environment where analytical tools can be rapidly tested at scale.
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http://dx.doi.org/10.1088/1361-6579/ab7cb5DOI Listing
April 2020

Revisiting oxygen dissociation curves and bedside measured arterial saturation in critically ill children.

Intensive Care Med 2019 12 7;45(12):1832-1834. Epub 2019 Oct 7.

Department of Critical Care Medicine, Hospital for Sick Children, Room 2830A, 2nd Floor Atrium Wing, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

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http://dx.doi.org/10.1007/s00134-019-05792-xDOI Listing
December 2019

Challenges for Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease in the Perioperative Setting.

J Cardiothorac Vasc Anesth 2019 Oct 21;33(10):2618-2621. Epub 2019 Jun 21.

Cardiothoracic Intensive Care Unit, National University Health System, Singapore; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Australia.

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http://dx.doi.org/10.1053/j.jvca.2019.06.024DOI Listing
October 2019

Inadequate oxygen delivery index dose is associated with cardiac arrest risk in neonates following cardiopulmonary bypass surgery.

Resuscitation 2019 09 17;142:74-80. Epub 2019 Jul 17.

Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, Washington University School of Medicine, Saint Louis Children's Hospital, 1 Children's Place St. Louis MO 63110, United States. Electronic address:

Aim: To evaluate the Inadequate oxygen delivery (IDO) index dose as a predictor of cardiac arrest (CA) in neonates following congenital heart surgery.

Methods: Retrospective cohort study in 3 US pediatric cardiac intensive units (1/2011- 8/2016). Calculated IDO index values were blinded to bedside clinicians and generated from data collected up to 30 days postoperatively, or until death or ECMO initiation. Control event data was collected from patients who did not experience CA or require ECMO. IDO dose was computed over a 120-min window up to 30 min prior to the CA and control events. A multivariate logistic regression prediction model including the IDO dose and presence or absence of a single ventricle (SV) was used. Model performance metrics were the odds ratio for each regression coefficient and receiver operating characteristic area under the curve (ROC AUC).

Results: Of 897 patients monitored during the study period, 601 met inclusion criteria: 29 patients had CA (33 events) and 572 patients were used for control events. Seventeen (59%) CA and 125 (26%) control events occurred in SV patients. Median age/weight at surgery and level of monitoring were similar in both groups. Median postoperative event time was 0.73 days [0.05-22.39] in CA patients and 0.82 days [0.08 25.11] in control patients. Odds ratio of the IDO dose coefficient was 1.008 (95% CI: 1.006-1.012, p = 0.0445), and 2.952 (95% CI: 2.952-3.258, p = 0.0079) in SV. The ROC AUC using both coefficients was 0.74 (95% CI: 0.73-0.75). These associations of IDO dose with CA risk remained robust, even when censored periods prior to arrest were 10 and 20 min.

Conclusion: In neonates post-CPB surgery, higher IDO index dose over a 120-min monitoring period is associated with increased risk of cardiac arrest, even when censoring data 10, 20 or 30 min prior to the CA event.
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http://dx.doi.org/10.1016/j.resuscitation.2019.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733252PMC
September 2019

Temporal Variability in the Sampling of Vital Sign Data Limits the Accuracy of Patient State Estimation.

Pediatr Crit Care Med 2019 07;20(7):e333-e341

Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.

Objectives: Physiologic signals are typically measured continuously in the critical care unit, but only recorded at intermittent time intervals in the patient health record. Low frequency data collection may not accurately reflect the variability and complexity of these signals or the patient's clinical state. We aimed to characterize how increasing the temporal window size of observation from seconds to hours modifies the measured variability and complexity of basic vital signs.

Design: Retrospective analysis of signal data acquired between April 1, 2013, and September 30, 2015.

Setting: Critical care unit at The Hospital for Sick Children, Toronto.

Patients: Seven hundred forty-seven patients less than or equal to 18 years old (63,814,869 data values), within seven diagnostic/surgical groups.

Interventions: None.

Measurements And Main Results: Measures of variability (SD and the absolute differences) and signal complexity (multiscale sample entropy and detrended fluctuation analysis [expressed as the scaling component α]) were calculated for systolic blood pressure, heart rate, and oxygen saturation. The variability of all vital signs increases as the window size increases from seconds to hours at the patient and diagnostic/surgical group level. Significant differences in the magnitude of variability for all time scales within and between groups was demonstrated (p < 0.0001). Variability correlated negatively with patient age for heart rate and oxygen saturation, but positively with systolic blood pressure. Changes in variability and complexity of heart rate and systolic blood pressure from time of admission to discharge were found.

Conclusions: In critically ill children, the temporal variability of physiologic signals supports higher frequency data capture, and this variability should be accounted for in models of patient state estimation.
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http://dx.doi.org/10.1097/PCC.0000000000001984DOI Listing
July 2019

Establishing and Sustaining an ECPR Program.

Front Pediatr 2018 6;6:152. Epub 2018 Jun 6.

Department of Critical Care Medicine, Department of Paediatrics, University of Toronto, ON, Canada.

The use of extracorporeal support after failed return of a spontaneous ciruculation during cardiopulmonary resuscitation (ECPR) is well described. There are 4 distinct phases for resuscitation with ECPR and the time spent in each phase is critical for successful outcome. Recommendations for ECPR previously published by the American Heart Association provide the context for implementing a consistent and well-rehearsed system for ECPR, by people with the knowledge, experience and resources to deploy ECPR in the most optimal time frame possible in selected patient populations. In this manuscript we review the current status of ECPR for acute cardiac failure and the components we believe are necessary to develop and sustain a reliable and resilient program.
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http://dx.doi.org/10.3389/fped.2018.00152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998755PMC
June 2018

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association.

Circulation 2018 05 23;137(22):e691-e782. Epub 2018 Apr 23.

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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http://dx.doi.org/10.1161/CIR.0000000000000524DOI Listing
May 2018

A Stewardship Program to Optimize the Use of Inhaled Nitric Oxide in Pediatric Critical Care.

Qual Manag Health Care 2018 Apr/Jun;27(2):74-80

Division of Critical Care Medicine, Montreal Children's Hospital, Montreal, Québec, Canada (Dr Di Genova); and Departments of Respiratory Therapy (Mss Sperling and Gionfriddo and Mr Macartney) and Critical Care Medicine (Dr Laussen) and Division of Neonatology (Mss Da Silva and Davidson, Mr Finelli, and Dr Jankov), The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: Inhaled nitric oxide (iNO) is a pulmonary vasodilator that is approved for use in term and near-term neonates with hypoxic respiratory failure associated with evidence of pulmonary hypertension. However, it is commonly used in infants and children to treat a variety of other cardiopulmonary diseases associated with pulmonary hypertension and hypoxic respiratory failure. In critically ill children, iNO therapy may be continued for a prolonged period, and this increases the risk for adverse consequences including toxicity and unnecessary costs. We implemented an iNO Stewardship Program with the aim of improving adherence to guidelines and reducing unnecessary iNO utilization.

Methods: Between April 1, 2011, and March 31, 2015, a before and after cohort study was conducted at The Hospital for Sick Children. Prospective iNO usage and outcome variables in the poststewardship period were examined.

Results: Patient characteristics and outcomes were similar before and after stewardship implementation. The number of iNO therapy courses were also similar in the before and after period. Inhaled nitric oxide utilization in the pediatric intensive care unit and the cardiac critical care unit decreased from 15 765 hours in the prestewardship period (April 2011 to March 2013) to 10 342 hours in the poststewardship period (April 2013 to March 2015), with significant improvement in adherence to the iNO guideline and a small decrease in expenditure (3%).

Conclusion: Implementation of the iNO Stewardship was successful at reducing overall iNO utilization. This quality improvement initiative helped us optimize practice and subsequently expand the methodology to inform the clinical indication for iNO.
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http://dx.doi.org/10.1097/QMH.0000000000000167DOI Listing
July 2019

Retrospective Application of New Pediatric Ventilator-Associated Pneumonia Criteria Identifies a High-Risk Population.

Pediatr Crit Care Med 2018 06;19(6):507-512

Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.

Objectives: To promote standardization, the Centers for Disease Control and Prevention introduced a new ventilator-associated pneumonia classification, which was modified for pediatrics (pediatric ventilator-associated pneumonia according to proposed criteria [PVAP]). We evaluated the frequency of PVAP in a cohort of children diagnosed with ventilator-associated pneumonia according to traditional criteria and compared their strength of association with clinically relevant outcomes.

Design: Retrospective cohort study.

Setting: Tertiary care pediatric hospital.

Patients: Critically ill children (0-18 yr) diagnosed with ventilator-associated pneumonia between January 2006 and December 2015 were identified from an infection control database. Patients were excluded if on high frequency ventilation, extracorporeal membrane oxygenation, or reintubated 24 hours following extubation.

Interventions: None.

Measurements And Main Results: Patients were assessed for PVAP diagnosis. Primary outcome was the proportion of subjects diagnosed with PVAP. Secondary outcomes included association with intervals of care. Two hundred seventy-seven children who had been diagnosed with ventilator-associated pneumonia were eligible for review; 46 were excluded for being ventilated under 48 hours (n = 16), on high frequency ventilation (n = 12), on extracorporeal membrane oxygenation (n = 8), ineligible bacteria isolated from culture (n = 8), and other causes (n = 4). ICU admission diagnoses included congenital heart disease (47%), neurological (16%), trauma (7%), respiratory (7%), posttransplant (4%), neuromuscular (3%), and cardiomyopathy (3%). Only 16% of subjects (n = 45) met the new PVAP definition, with 18% (n = 49) having any ventilator-associated condition. Failure to fulfill new definitions was based on inadequate increase in mean airway pressure in 90% or FIO2 in 92%. PVAP was associated with prolonged ventilation (median [interquartile range], 29 d [13-51 d] vs 16 d [8-34.5 d]; p = 0.002), ICU (median [interquartile range], 40 d [20-100 d] vs 25 d [14-61 d]; p = 0.004) and hospital length of stay (median [interquartile range], 81 d [40-182 d] vs 54 d [31-108 d]; p = 0.04), and death (33% vs 16%; p = 0.008).

Conclusions: Few children with ventilator-associated pneumonia diagnosis met the proposed PVAP criteria. PVAP was associated with increased morbidity and mortality. This work suggests that additional study is required before new definitions for ventilator-associated pneumonia are introduced for children.
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http://dx.doi.org/10.1097/PCC.0000000000001522DOI Listing
June 2018

Chasing the 6-sigma: Drawing lessons from the cockpit culture.

J Thorac Cardiovasc Surg 2018 02 30;155(2):690-696.e1. Epub 2017 Sep 30.

Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1016/j.jtcvs.2017.09.097DOI Listing
February 2018

Prolonged Dexmedetomidine Infusion and Drug Withdrawal In Critically Ill Children.

J Pediatr Pharmacol Ther 2017 Nov-Dec;22(6):453-460

Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada.

Objective: To characterise the incidence, symptoms and risk factors for withdrawal associated with prolonged dexmedetomidine infusion in paediatric critically ill patients.

Methods: Retrospective chart review in the paediatric intensive care unit and the cardiac critical care unit of a single tertiary children's hospital. Patients up to 18 years old, who received dexmedetomidine for longer than 48 hours were included.

Results: A total of 52 patients accounted for 68 unique dexmedetomidine treatment courses of more than 48 hours. We identified 24 separate episodes of withdrawal in the 68 dexmedetomidine courses (incidence 35%). Of these episodes 38% occurred in patients who were weaned from dexmedetomidine alone while the remaining occurred in patients who had concurrent weans of opioids and/or benzodiazepines. Most common symptoms were agitation, fever, vomiting/retching, loose stools and decreased sleep. The symptoms occurred during the latter part of the wean or after discontinuation of dexmedetomidine. A cumulative dose of dexmedetomidine of 107 mcg/kg prior to initiation of wean was more likely associated with withdrawal (this equates to a dexmedetomidine infusion running at 1 mcg/kg/hr over 4 days). Duration of opioid use was an additional risk factor for withdrawal. The use of clonidine, as a transition from dexmedetomidine, did not protect against withdrawal (p = 1).

Conclusions: A withdrawal syndrome may occur after prolonged infusion of dexmedetomidine. As all our patients were also exposed to opioids this may be affected by the duration of opioid use. We identified a cumulative dose of 107 micrograms/kg of dexmedetomidine beyond which withdrawal symptoms were more likely (which equates to 4 days of use at a dose of 1 mcg/kg/hr). A protocol for weaning should be considered in this circumstance.
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http://dx.doi.org/10.5863/1551-6776-22.6.453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736258PMC
January 2018

Landmark lecture on cardiac intensive care and anaesthesia: continuum and conundrums.

Authors:
Peter C Laussen

Cardiol Young 2017 Dec;27(10):1966-1973

1Department of Critical Care Medicine,The Hospital for Sick Children,Toronto,ON,Canada.

Cardiac anesthesia and critical care provide an important continuum of care for patients with congenital heart disease. Clinicians in both areas work in complex environments in which the interactions between humans and technology is critical. Understanding our contributions to outcomes (modifiable risk) and our ability to perceive and predict an evolving clinical state (low failure-to-predict rate) are important performance metrics. Improved methods for capturing continuous physiologic signals will allow for new and interactive approaches to data visualization, and for sophisticated and iterative data modeling that will help define a patient's phenotype and response to treatment (precision physiology).
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http://dx.doi.org/10.1017/S104795111700213XDOI Listing
December 2017

Distributions and Behavior of Vital Signs in Critically Ill Children by Admission Diagnosis.

Pediatr Crit Care Med 2018 02;19(2):115-124

Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Ontario, Canada.

Objectives: Define the distributions of heart rate and intraarterial blood pressure in children at admission to an ICU based on admission diagnosis and examine trends in these physiologic signs over 72 hours from admission (or to discharge if earlier).

Design: A retrospective analysis of continuously acquired signals.

Setting: A quaternary and primary referral children's hospital with a general PICU and cardiac critical care unit.

Patients: One thousand two hundred eighty-nine patients less than 18 years old were analyzed. Data from individual patient admissions were divided into 19 groups by primary admission diagnosis or surgical procedure.

Interventions: None.

Measurement And Main Results: Distributions at admission are dependent on patient age and admission diagnosis (p < 10(-6)). Heart rate decreases over time, whereas arterial blood pressure is relatively stable, with differences seen in the directions and magnitude of these trends when analyzed by diagnosis group (p < 10(-6)). Multiple linear regression analysis shows that patient age, diagnosis group, and physiologic vital sign value at admission explain 50-63% of the variation observed for that physiologic signal at 72 hours (or at discharge if earlier) with admission value having the greatest influence. Furthermore, the variance of either heart rate or arterial blood pressure for the individual patient is smaller than the variance measured at the level of the group of patients with the same diagnosis.

Conclusions: This is the first study reporting distributions of continuously measured physiologic variables and trends in their behavior according to admission diagnosis in critically ill children. Differences detected between and within diagnostic groups may aid in earlier recognition of outliers as well as allowing refinement of patient monitoring strategies.
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http://dx.doi.org/10.1097/PCC.0000000000001395DOI Listing
February 2018

Universal Follow-Up After Extracorporeal Membrane Oxygenation: Baby Steps Toward Establishing an International Standard of Care.

Pediatr Crit Care Med 2017 11;18(11):1070-1072

Cardiothoracic Intensive Care Unit, National University Health System, Singapore; and Paediatric Intensive Care Unit, Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia Children's Healthcare of Atlanta, Emory University, Atlanta, GA Sophia Children's Hospital, Rotterdam, The Netherlands Department of Critical Care Medicine, Hospital for Sick Children; and Department of Anaesthesia, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1097/PCC.0000000000001317DOI Listing
November 2017

Long-Term Morbidity and Mortality in Children After Cardiac Extracorporeal Membrane Oxygenation.

Pediatr Crit Care Med 2017 08;18(8):811-812

Cardiothoracic Intensive Care Unit, National University Health System Singapore; and Paediatric Intensive Care Unit, Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, VIC, Australia Department of Paediatrics, National University Children's Medical Institute, National University Hospital, Singapore Department of Critical Care Medicine, Hospital for Sick Children; and Department of Anaesthesia, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1097/PCC.0000000000001242DOI Listing
August 2017

The advantage of early plication in children diagnosed with diaphragm paresis.

J Thorac Cardiovasc Surg 2017 11 15;154(5):1715-1721.e4. Epub 2017 Jun 15.

Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: In this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes.

Methods: Patients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay.

Results: DP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care.

Conclusions: Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.
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http://dx.doi.org/10.1016/j.jtcvs.2017.05.109DOI Listing
November 2017

Cerebral Oxygen Saturation in Children With Congenital Heart Disease and Chronic Hypoxemia.

Anesth Analg 2017 07;125(1):234-240

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; †Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; ‡CAS Medical Systems Inc, Branford, Connecticut; §Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and ‖Department of Cardiothoracic Surgery, Stanford Medical Center, Palo Alto, California.

Background: Increased hemoglobin (Hb) concentration accompanying hypoxemia is a compensatory response to maintain tissue oxygen delivery. Near infrared spectroscopy (NIRS) is used clinically to detect abnormalities in the balance of cerebral tissue oxygen delivery and consumption, including in children with congenital heart disease (CHD). Although NIRS-measured cerebral tissue O2 saturation (ScO2) correlates with arterial oxygen saturation (SaO2), jugular bulb O2 saturation (SjbO2), and Hb, little data exist on the interplay between these factors and cerebral O2 extraction (COE). This study investigated the associations of ScO2 and ΔSaO2-ScO2 with SaO2 and Hb and verified the normal range of ScO2 in children with CHD.

Methods: Children undergoing cardiac catheterization for CHD were enrolled in a calibration and validation study of the FORE-SIGHT NIRS monitor. Two pairs of simultaneous arterial and jugular bulb samples were drawn for co-oximetry, calculation of a reference ScO2 (REF CX), and estimation of COE. Pearson correlation and linear regression were used to determine relationships between O2 saturation parameters and Hb. Data were also analyzed according to diagnostic group defined as acyanotic (SaO2 ≥ 90%) and cyanotic (SaO2 < 90%).

Results: Of 65 children studied, acceptable jugular bulb samples (SjbO2 absolute difference between samples ≤10%) were obtained in 57 (88%). The ΔSaO2-SjbO2, ΔSaO2-ScO2, and ΔSaO2-REF CX were positively correlated with SaO2 and negatively correlated with Hb (all P < .001). Although by diagnostic group ScO2 differed statistically (P = .002), values in the cyanotic patients were within the range considered normal (69% ± 6%). COE estimated by the difference between arterial and jugular bulb O2 content (ΔCaO2-CjbO2, mL O2/100 mL) was not different for cyanotic and acyanotic patients (P = .10), but estimates using ΔSaO2-SjbO2, ΔSaO2-ScO2, or ΔSaO2-ScO2/SaO2 were significantly different between the cyanotic and acyanotic children (P < .001).

Conclusions: Children with adequately compensated chronic hypoxemia appear to have ScO2 values within the normal range. The ΔSaO2-ScO2 is inversely related to Hb, with the implication that in the presence of reduced Hb, particularly if coupled with a decreased cardiac output, the ScO2 can fall to values associated with brain injury in laboratory studies.
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http://dx.doi.org/10.1213/ANE.0000000000002073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5476488PMC
July 2017

Heart Rate and Blood Pressure Centile Curves and Distributions by Age of Hospitalized Critically Ill Children.

Front Pediatr 2017 17;5:52. Epub 2017 Mar 17.

Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia, University of Toronto, Toronto, ON, Canada.

Heart rate (HR) and blood pressure (BP) form the basis for monitoring the physiological state of patients. Although norms have been published for healthy and hospitalized children, little is known about their distributions in critically ill children. The objective of this study was to report the distributions of these basic physiological variables in hospitalized critically ill children. Continuous data from bedside monitors were collected and stored at 5-s intervals from 3,677 subjects aged 0-18 years admitted over a period of 30 months to the pediatric and cardiac intensive care units at a large quaternary children's hospital. Approximately 1.13 billion values served to estimate age-specific distributions for these two basic physiological variables: HR and intra-arterial BP. Centile curves were derived from the sample distributions and compared to common reference ranges. Properties such as kurtosis and skewness of these distributions are described. In comparison to previously published reference ranges, we show that children in these settings exhibit markedly higher HRs than their healthy counterparts or children hospitalized on in-patient wards. We also compared commonly used published estimates of hypotension in children (e.g., the PALS guidelines) to the values we derived from critically ill children. This is a first study reporting the distributions of basic physiological variables in children in the pediatric intensive care settings, and the percentiles derived may serve as useful references for bedside clinicians and clinical trials.
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http://dx.doi.org/10.3389/fped.2017.00052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5355490PMC
March 2017

Pediatric Cardiac Intensive Care: A Transition to Maturity.

Pediatr Crit Care Med 2016 08;17(8 Suppl 1):S110-1

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http://dx.doi.org/10.1097/PCC.0000000000000824DOI Listing
August 2016

Modes and Causes of Death in Pediatric Cardiac Intensive Care: Digging Deeper.

Authors:
Peter C Laussen

Pediatr Crit Care Med 2016 05;17(5):461-2

Department of Critical Care Medicine, The Hospital for Sick Children; and, Department of Anaesthesia, University of Toronto, Toronto, ON.

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http://dx.doi.org/10.1097/PCC.0000000000000711DOI Listing
May 2016

Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During Pediatric In-Hospital Cardiopulmonary Arrest Is Associated With Improved Survival to Discharge: A Report from the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry.

Circulation 2016 Jan 3;133(2):165-76. Epub 2015 Dec 3.

From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.).

Background: Although extracorporeal cardiopulmonary resuscitation (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR and continued C-CPR has been reported.

Methods And Results: Consecutive patients <18 years old with CPR events ≥10 minutes in duration reported to the Get With the Guidelines-Resuscitation registry between January 2000 and December 2011 were identified. Hospitals were grouped by teaching status and location. Primary outcome was survival to discharge. Regression modeling was performed, conditioning on hospital groups. A secondary analysis was performed with the use of propensity score matching. Of 3756 evaluable patients, 591 (16%) received E-CPR and 3165 (84%) received C-CPR only. Survival to hospital discharge and survival with favorable neurological outcome (Pediatric Cerebral Performance Category score of 1-3 or unchanged from admission) were greater for E-CPR (40% [237 of 591] and 27% [133 of 496]) versus C-CPR patients (27% [862 of 3165] and 18% [512 of 2840]). Odds ratios (ORs) for survival to hospital discharge and survival with favorable neurological outcome were greater for E-CPR versus C-CPR. After adjustment for covariates, patients receiving E-CPR had higher odds of survival to discharge (OR, 2.80; 95% confidence interval, 2.13-3.69; P<0.001) and survival with favorable neurological outcome (OR, 2.64; 95% confidence interval, 1.91-3.64; P<0.001) than patients who received C-CPR. This association persisted when analyzed by propensity score-matched cohorts (OR, 1.70; 95% confidence interval, 1.33-2.18; P<0.001; and OR, 1.78; 95% confidence interval, 1.31-2.41; P<0.001, respectively].

Conclusion: For children with in-hospital CPR of ≥10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurological outcome compared with C-CPR.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.115.016082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4814337PMC
January 2016

Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future.

World J Pediatr Congenit Heart Surg 2015 Oct;6(4):556-64

The Hospital for Sick Children, University of Toronto, Toronto, Canada.

Background: The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes.

Methods: The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership.

Results: Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges.

Conclusions: Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.
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http://dx.doi.org/10.1177/2150135115596440DOI Listing
October 2015

Pharmacological Manipulation of Peripheral Vascular Resistance in Single Ventricle Patients (Stages I, II, and III of Palliation).

Curr Vasc Pharmacol 2016 ;14(1):58-62

Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada M5G 1X8.

Pharmacological manipulation of afterload is often used in the management of single ventricle patients, both in the acute post-operative setting and more chronically. After the first stage of palliation the pulmonary and systemic circulations are in parallel and afterload reduction is often used to increase total cardiac output and systemic oxygen delivery. The effectiveness of this approach is likely to be dependent on the intrinsic contractile state of the myocardium as well as the post-operative vascular tone. A variety of clinical studies and theoretical models support this approach. The use of afterload reduction in this context must be balanced with the need to maintain a critical systemic blood pressure for organ perfusion and to promote pulmonary blood flow. After the second and third stages of palliation the use of acute afterload reduction is less complex and primarily directed at promoting cardiac output when it is low and/or controlling high blood pressure. Second stage palliation is particularly unique in that the cerebral and pulmonary circulations are in series and respond differently to many manipulations designed to control vascular resistance. The incidence of long-term circulatory failure in single ventricle patients has led to frequent use of afterload reducing agents in this population but data to suggest that this improves overall outcomes is lacking. Newer studies suggest there may be a role for drugs that reduce pulmonary vascular resistance. This chapter will discuss the principles of manipulation of systemic vascular resistance, or afterload, following each of the three stages of single ventricle reconstruction. This article addresses the seventh of eight topics comprising the special issue entitled "Pharmacologic strategies with afterload reduction in low cardiac output syndrome after pediatric cardiac surgery".
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http://dx.doi.org/10.2174/1570161113666151014125556DOI Listing
September 2016

Fractures Related to Metabolic Bone Disease in Children with Congenital Heart Disease.

Congenit Heart Dis 2016 Jan-Feb;11(1):80-6. Epub 2015 Aug 24.

Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.

Objective: Critically ill children with congenital heart disease (CHD) are at risk for metabolic bone disease (MBD) and bone fractures. Our objective was to characterize a cohort of CHD patients with fractures and describe a Fragile Bone Protocol (FBP) developed to reduce fractures.

Design/setting: Patients who developed fractures in the Cardiac Intensive Care Unit (CICU) of Boston Children's Hospital from 3/2008 to 6/2014 were identified via quality improvement and radiology databases. The FBP (initiated July 2011) systematically identifies patients at risk for MBD and prescribes special handling precautions.

Results: Twenty-three fractures were identified in 15 children. Median age at fracture identification was 6.2 months, with a median duration of hospitalization before fracture diagnosis of 2.7 months. Six patients (40%) had single ventricle CHD. Hyperparathyroidism and low 25-OH vitamin D levels were present in 77% and 40% of those tested, respectively. Compared with patients not diagnosed with fractures, fracture patients had increased exposure to possible risk factors for MBD and had elevated parathyroid and decreased calcitriol levels.Six patients (40%) did not survive to hospital discharge, compared with an overall CICU mortality rate of 2.6% (P < .01). The fracture case rate before implementation of the FBP was 2.6 cases/1000 admissions and was 0.7/1000 after implementation of the FBP (P = .04).

Conclusions: Critically ill CHD patients are at risk for fractures. They represent a complex group who frequently has hyperparathyroidism and decreased calcitriol levels, and each may predispose to fractures. FBPs consisting of identification and careful patient handling should be considered in at-risk patients.
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http://dx.doi.org/10.1111/chd.12293DOI Listing
December 2016

Unplanned extubation: securing the tool of our trade.

Intensive Care Med 2015 Nov 12;41(11):1983-5. Epub 2015 Aug 12.

Department of Critical Care Medicine, Hospital for Sick Children, Department of Anaesthesia, University of Toronto, Toronto, Canada.

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http://dx.doi.org/10.1007/s00134-015-4000-1DOI Listing
November 2015

Anaesthesia outside of the operating room: the paediatric cardiac catheterization laboratory.

Curr Opin Anaesthesiol 2015 Aug;28(4):453-7

aDepartment of Anaesthesia bDepartment of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Purpose Of Review: The focus of cardiac catheterization has changed from principally a diagnostic procedure to providing therapeutic options at various stages of childhood and adult congenital heart disease. The paediatric cardiac catheterization laboratory functions as a 'satellite' operating room. Combined ('hybrid') procedures with interventional cardiologists and cardiac surgeons present additional challenges for anaesthesia. The increased patient and procedure complexity represents higher risk for anaesthesia-related adverse events.

Recent Findings: This review concentrates on the recent efforts to determine these patient and procedure-related risks. Multicentre registries have been developed, generating information regarding adverse events and patient outcomes. Standardized adverse events ratios allow comparisons between institutions and providers. Models to identify high-risk groups have been developed.

Summary: Advances in paediatric cardiac catheterization have created significant challenges for delivering anaesthesia in this environment. Anaesthetists need to have an integral role in the cardiac catheterization team, understanding and anticipating the risks for patients and leading the organization of workflow. Techniques used to improve systems in the operating room have been introduced to the cardiac catheterization laboratory to promote patient safety.
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http://dx.doi.org/10.1097/ACO.0000000000000206DOI Listing
August 2015

Learning and evolving.

Authors:
Peter C Laussen

Cardiol Young 2015 Jun 19;25(5):984-90. Epub 2015 Mar 19.

1Department Critical Care Medicine,The Hospital for Sick Children,University of Toronto,Toronto,Ontario,Canada.

It is an honour to present the Anthony Chang lecture at this 10th International Conference of the Pediatric Cardiac Intensive Care Society. I have had the privilege of knowing Dr Chang for over 20 years, and although we only worked for a short period of time together at the Children's Hospital, Boston, in the Cardiac Intensive Care Unit, we have remained close colleagues and friends since that time. The contributions of Dr Chang to the development of paediatric cardiac intensive care are very clear, based on his clinical expertise, research and scholarship, and the development of the Pediatric Cardiac Intensive Care Society in its early days. More than this, Dr Chang is an individual with vision; in many respects, he has been ahead of the curve, anticipating and leading the direction of paediatric cardiac intensive care.
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http://dx.doi.org/10.1017/S1047951115000347DOI Listing
June 2015